- Email: [email protected]
Morbidity and mortality rates following gastric cancer surgery and contiguous organ removal, a population based study
EJSO (2005) 31, 1141–1144
www.ejso.com
Morbidity and mortality rates following gastric cancer surgery and contiguous organ removal, a population based study S. Nanthakumarana, E. Fernandesa, A.M. Thompsonb, T. Rapsonc, F.J. Gilbertd, K.G.M. Parka,* a
Department of Upper Gastrointestinal Surgery, Aberdeen Royal Infirmary, Ward 33, Foresterhill, Aberdeen, AB25 2ZD, UK b Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK c Cancer Surveillance, ISD Scotland, Gyle Square, South Gyle, Edinburgh, EH12 9EB, UK d Department of Radiology, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, AB25 2ZD, UK Accepted for publication 23 March 2005 Available online 18 August 2005
KEYWORDS Gastric cancer; Morbidity; Mortality; Survival; Surgical resection
Abstract Background: Complete surgical (R0) resection remains the only potentially curative intervention for patients with localised gastric cancer. To achieve a curative resection, patients may require complex operations with resection of contiguous organs. The aim of this study was to assess how the extent of surgical resection influenced morbidity, mortality and survival in an aged non-selected population with significant comorbid disease. Patients and methods: Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of 1-year follow-up. Results: A total of 646 patients underwent surgical exploration for gastric cancer. A significantly higher incidence of chest infections (18.5 vs 11%, p!0.05) and anastomotic leaks (14.3 vs 2.2%, p!0.05) were associated with total gastrectomy (nZ168) when compared to distal gastrectomy (nZ272) resections. A 9.2% mortality rate and a 60% 1-year survival were associated with gastric resection alone. Removal of the spleen (nZ131), pancreas (nZ30) or liver resection (nZ5) was associated with a significantly higher mortality rates, 18.3, 23.3 and 40%, respectively (p!0.05), and significantly lower 1-year survival rates, 50.9, 39.1 and 20%, respectively (p!0.05). Conclusions: The risk of more extensive resection is not balanced by improved survival in this population based series. Extending gastric resection to involve contiguous organs should be confined to highly selected cases. Q 2005 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: C44 1224 554534; fax: C44 1224 553349. E-mail address: [email protected] (K.G.M. Park).
0748-7983/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2005.03.013
1142
S. Nanthakumaran et al.
Introduction Although there has been a decline in the incidence of carcinoma of the stomach it remains an important cause of cancer death both worldwide and in the UK1–3 with an incidence of 17.7/100,000 (males) and 7.5/100,000 (females) in Scotland.4 The overall 1- and 2-year survival for gastric cancer in Scotland is 35 and 20%, respectively.5 These rates, however, increase following surgical resection which remains the only potentially curative intervention available for patients with localised disease. Following resection, the most important prognostic factor is complete macroscopic and microscopic tumour resection (R0).6,7 However, in striving to achieve a curative resection, patients are exposed to increasingly lengthy and complex procedures where in addition to gastric resection; removal of contiguous organs (such as spleen, pancreas and liver) may also be required. Although good results have been reported from specialist centres8–11 it is clear that these patients are exposed to an increased risk of morbidity and mortality associated with more extensive resections. This may limit the value of such an aggressive approach when dealing with an elderly population with significant comorbid disease. The aim of this study was to assess whether the extent of surgical resection and removal of contiguous organs, was associated with morbidity, mortality or survival in patients undergoing surgery for gastric cancer.
minimum of 1 year. This encompassed all 53 Scottish hospitals in which oesophageal and gastric cancers were diagnosed and/or managed. Data from 1264 consecutive patients diagnosed with gastric cancer during the study period were available (98% of gastric cancer patients identified by Cancer Registry Statistics during this period). Data were collected prospectively, including: patient demographic details, comorbid illness, ASA grades and site of the cancer (fundus, body or antrum). Staging investigations comprised CT scan of abdomen, chest and laparoscopy in addition to routine haematology and biochemistry. At the time of surgery, surgeons were asked to record details of the operation performed and their assessment of the completeness of resection. Peri-operative complications were recorded on a standard proforma. All deaths during the index admission or within 30 days of surgery were considered as postoperative deaths. Patients were followed up until death or for a minimum of 1 year. Data were cross checked by four data managers specifically employed for the study.
Statistics Data were collated on a customised Microsoft Access database (copyright) and transferred to the Statistical Package for Social Sciences (SPSS for Windows) for analysis. For comparisons of patients falling into different categories chi-squared tests were used. Survival analysis was conducted using a Kaplan–Meier plot and log-rank comparisons.
Patients and methods Results Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland (population 5,060,000) over a 2-year period between 1997 and 1999. Patients were followed up until death or a Table 1 Post-operative morbidity and mortality following gastric surgery
Number of cases Mortality Chest infection Cardiac Anastomotic leak
Distal gastrectomy
Total gastrectomy
Gastric bypass
272
168
89
25 (9%) 31 (11%)
26 (15.5%) 31 (18.5%)
22 (25%) 8 (9%)
21 (7.7%) 6 (2.2%)
13 (7.7%) 24 (14.3%)
3 (3%) 0 (0%)
In the 2-year period of data collection, 1264 patients were diagnosed with cancer of the gastric fundus, body or antrum (oesophago–gastric junction cancers were excluded). The male:female ratio was 1.3:1, with a median age of 73.6 years (range 30– 102). In 40% of patients there was severe comorbid disease (ASA grades 3–5) with ischaemic heart disease and respiratory disease most commonly observed. Following initial assessment and staging investigations 646 patients underwent surgical exploration: in 171 (26.5%) patients, non-resectional procedures including 89 gastric bypass operations were performed. Resections were, therefore, performed in 475 (73.5%) patients: distal gastrectomy nZ272, total gastrectomy nZ168 and oesophagogastrectomy nZ33. Of the 475 patients undergoing curative resection, tumour stage was available in 467 cases (no
Morbidity and mortality rates following gastric cancer surgery pathology reported in eight cases): Tx/0Z1 (0.2%), TisZ5 (1.1%), T1Z88 (18.8%), T2Z147 (31.5%), T3Z194 (41.5%) and T4Z32 (6.9%). Following gastric surgery the commonest complications were: chest infections, cardiac complications and anastomotic leaks (Table 1). Significantly fewer chest infections (11 vs 18.5%, p!0.05) and anastomotic leaks (2.2 vs 14.3%, p! 0.05) were reported following distal gastrectomy when compared to total gastrectomy. Patients who developed an anastomotic leak had a mortality of 46% irrespective of the procedure. The overall post-operative mortality rate was 14.1% for all patients undergoing gastric cancer surgery with a 52.1% 1-year survival. Non-resectional surgery resulted in a post-operative mortality rate of 25%, while; resection of the stomach alone (which included concomitant resection of the omentum) resulted in a mortality rate of 9.2% and a 1-year survival of 60%. However, the removal of contiguous organs such as the spleen (nZ131), distal pancreas (nZ30) or liver resection (nZ5), in addition to the stomach for extensive local disease, resulted in a significantly increased mortality and decreased 1-year survival. Peri-operative mortality following associated splenic, pancreatic or hepatic resection were significantly higher at 18.3, 23.3, and 40%, respectively, p!0.05; conversely 1-year survival was significantly lower at 50.9, 39.1 and 20%, respectively, p!0.05, when compared to resection of the stomach alone. For patients undergoing no surgery, the 1-year survival rate was 17.5%.
Discussion This study provides a unique population based assessment of surgical outcome for gastric cancer rather than previously reported studies confined to specialist centres.8–11 Patients were prospectively recruited from all 53 specialist and non-specialist centres in Scotland, thus, avoiding referral bias associated with data gathered from single units. Patients presenting with gastric cancer in Scotland had similar demographics to other western series,12–15 in contrast to the Japanese population of gastric cancer patients who are generally both younger and suffer less comorbidity.16,17 This may partially explain the relatively high peri-operative morbidity and mortality observed in our nonselected, population based series in comparison with results from specialist centres,18–22 although our data are comparable to other multicentre studies.12,13
1143
The most frequently observed complications following gastrectomy were anastomotic leaks and chest infections; these were higher in patients undergoing a total compared to a partial gastrectomy. The increased operative time incurred by a total gastrectomy could be one reason for the increased complication rate. Technical aspects related to total gastrectomy maybe another contributing factor. The oesophago-jejunal anastomosis is more prone to leakage, presumably related to the relatively poor blood supply of the distal oesophagus following dissection and resection of the proximal stomach. In addition, total gastrectomy involves hiatal dissection with frequent breach of the pleura resulting in potential contamination of the pleural cavity. As previously reported there was no difference in peri-operative mortality between high volume and low volume units.5 The majority of resected gastric cancers were T3 tumours with a relatively small proportion of tumours invading adjacent organs (T4). Within this study contiguous organ resection was carried out primarily to obtain R0 resection in locally advanced disease. However, mortality after gastrectomy and removal of adjacent organs to achieve R0 resection was significantly increased when compared to gastrectomy alone. Furthermore, 1-year survival was significantly decreased when curative resection involved spleen, pancreas or liver resection. Excess mortality rates have previously been reported with the removal of contiguous organs in patients with gastric cancer, both the MRC12 and the Dutch Gastric Cancer Group.13 Indeed in both these studies, designed to compare, the extent of lymphadenectomy, resection of the spleen and pancreatic tail were associated with the highest morbidity and mortality rates irrespective of whether a D1 or D2 lymphadenectomy was performed.12,13 Similarly, subgroup analysis indicated that removal of the spleen and pancreas were independent indicators of a poor prognosis.12 In both the MRC12 and Dutch13 trials it was concluded that routine pancreatectomy and splenectomy do not offer a significant benefit in terms of survival in patients in whom this was performed in order to achieve a more extended lymphadenectomy and are associated with excess morbidity; our population based data reinforces this message from the two clinical trials. With the poor 1-year survival for patients with removal of contiguous organs only marginally better to that of patients treated without surgery, extending gastric resections to involve contiguous organs should only be confined to highly selected cases. These patients should clearly have no signs of metastatic disease and have good pre-operative
1144 reserve, i.e. younger patients with minimal comorbidity. While surgery remains the principle curative modality for gastric cancer, a realistic surgical approach should comprise resecting only those cancers where macroscopic clearance appears possible given the considerable morbidity and mortality inherent in surgery for gastric cancer in western patients.
Acknowledgements The Scottish Audit of Gastric and Oesophageal Cancer was funded by the Clinical Resources Audit Group of the Scottish Executive. SAGOC Steering Group Membership: F. J. Gilbert (jnt chair) Aberdeen University; M. N. Nicolson, K. G. M. Park (jnt chair), Aberdeen Royal Infirmary; A. M. Thompson, Dundee University; T. J. Crofts, H. Gilmour, A. McGilchrist Royal Infirmary of Edinburgh; D. Prakash, Hairmyres Hospital; H. Yosef, Beatson Oncology Centre, Glasgow; J. Anderson, Southern General Hospital: A. Kirk, Western Infirmary, Glasgow; E. Porterfield, Clinical Resource and Audit Group. D. Charles, P. Aerts, K. Zarins, G. Cowans, M. McKernan, SAGOC Data Co-ordinators. T. Rapson, C. Thomson, D. Stockton, Scottish Cancer Intelligence Unit, Information and Statistics Division, Edinburgh. Disclaimer: although the authors are grateful to the Scottish executive for the funding of this study the views expressed do not necessarily represent the views of the executive.
References 1. Levi F, Lucchini F, Negri E, Boyle P, La Vecchia C. Cancer mortality in Europe, 1995–1999, and an overview of trends since 1960. Int J Cancer 2004;110:155–69. 2. Plummer M, Franceschi S, Munoz N. Epidemiology of gastric cancer. IARC Sci Publ 2004;157:311–26. 3. National Institute of Health, http://www.seer.cancer.gov/ publications/raterisk/index.html 4. Harris V, Sandridge AL, Black RJ, Brewster DH, Gould A. Cancer registration statistics Scotland 1986–95. Edinburgh: ISD Scotland Publications; 1998. ISBN: 1 84134 000 6. 5. Gilbert FJ, Park KGM, Thompson AM. The Scottish Audit of Gastric and Oesophageal Cancer. Edinburgh; 2002 [http:// www.show.scot.nhs.uk/crag/committees/CEPS/reports/ SAGOC_report_Contents.htm].
S. Nanthakumaran et al. 6. Roder JD, Bottcher K, Siewert JR, Busch R, Hermanek P, Meyer HJ. Prognostic factors in gastric carcinoma. Results of the German Gastric Carcinoma Study 1992. Cancer 1993;72: 2089–97. 7. Siewert JR, Bottcher K, Stein HJ, Roder JD. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 1998;228:449–61. 8. Roviello F, Marrelli D, Morgagni P, de Mawzoni G, Di Leo A, Vindigni C. Survival benefit of extended D2 lymphadenectomy in gastric cancer with involvement of second level lymph nodes: a longitudinal multicenter study. Ann Surg Oncol 2002;9:894–900. 9. Maruyama K, Okabayashi K, Kinoshita T. Progress in gastric cancer surgery in Japan and its limit of radicality. World J Surg 1987;11:418–25. 10. Maehara Y, Kakeji Y, Oda S, Takahashi I, Akazawa K, Sugimachi K. Time trends of surgical treatment and the prognosis for Japanese patients with gastric cancer. Br J Cancer 2000;83:986–91. 11. Degiuli M, Sasako M, Ponti A, Calvo F. Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer. Br J Cancer 2004 [Epub ahead of print]. 12. Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V. Patient survival after D1 and D2 resections for gastric cancer: long term results of the MRC randomized surgical trial. Br J Cancer 1999;79:1522–30. 13. Bonekamp JJ, Hermans J, Sasako M, van de Velde CJH, for the Dutch Gastric Cancer Group. Extended lymph-node dissection for gastric cancer. N Engl J Med 1999;340:908–14. 14. McKinney A, Sharp L, MacFarlane GJ, Muir CS. Oesophageal and gastric cancer in Scotland 1960–1990. Br J Cancer 1995; 71:411–5. 15. Allum WH, Powell DJ, McConkey CC, Fielding JW. Gastric cancer: a 25 year review. Br J Surg 1989;76:535–40. 16. Davis PA, Sano T. The difference in gastric cancer between, Japan, USA and Europe: what are the facts? What are the suggestion? Crit Rev Oncol Hematol 2001;40:77–94. 17. Yuasa N, Nimura Y. Survival after surgical treatment of early gastric cancer, surgical techniques and long term survival. Langenbecks Arch Surg 2004 [Epub ahead of print]. 18. Siewert JR, Bottcher K, Roder JD, Busch R, Hermanek P, Meyer HJ. Prognostic relevance of systematic node dissection in gastric carcinoma. Arch Surg 1993;80:1015–8. 19. Smith JW, Shiu MH, Kelsey L, Brennan MF. Morbidity of radical lymphadenectomy in the curative resection of gastric carcinoma. Arch Surg 1991;126:1469–73. 20. Giovanetti M, Brotto AC, Tiberio GA, Campedelli L, Vettoretto N, Ronconi M. D2 lymphectomy in the treatment of gastric cancer: a retrospective view on our experience (1990–97). J Exp Clin Cancer Res 1999;18:455–8. 21. Sue-Ling HM, Johnston D, Martin IG, Dixon MF, Lansdown MR, McMahon MJ. Gastric cancer: a curable disease in Britain. BMJ 1993;307:591–6. 22. Volpe CM, Koo J, Miloro SM, Driscoll DL, Nava HR, Douglas Jr HO. The effect of extended lymphadenectomy on survival in patients with gastric adenocarcinoma. J Am Coll Surg 1995;181:56–64.
www.ejso.com
Morbidity and mortality rates following gastric cancer surgery and contiguous organ removal, a population based study S. Nanthakumarana, E. Fernandesa, A.M. Thompsonb, T. Rapsonc, F.J. Gilbertd, K.G.M. Parka,* a
Department of Upper Gastrointestinal Surgery, Aberdeen Royal Infirmary, Ward 33, Foresterhill, Aberdeen, AB25 2ZD, UK b Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK c Cancer Surveillance, ISD Scotland, Gyle Square, South Gyle, Edinburgh, EH12 9EB, UK d Department of Radiology, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, AB25 2ZD, UK Accepted for publication 23 March 2005 Available online 18 August 2005
KEYWORDS Gastric cancer; Morbidity; Mortality; Survival; Surgical resection
Abstract Background: Complete surgical (R0) resection remains the only potentially curative intervention for patients with localised gastric cancer. To achieve a curative resection, patients may require complex operations with resection of contiguous organs. The aim of this study was to assess how the extent of surgical resection influenced morbidity, mortality and survival in an aged non-selected population with significant comorbid disease. Patients and methods: Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of 1-year follow-up. Results: A total of 646 patients underwent surgical exploration for gastric cancer. A significantly higher incidence of chest infections (18.5 vs 11%, p!0.05) and anastomotic leaks (14.3 vs 2.2%, p!0.05) were associated with total gastrectomy (nZ168) when compared to distal gastrectomy (nZ272) resections. A 9.2% mortality rate and a 60% 1-year survival were associated with gastric resection alone. Removal of the spleen (nZ131), pancreas (nZ30) or liver resection (nZ5) was associated with a significantly higher mortality rates, 18.3, 23.3 and 40%, respectively (p!0.05), and significantly lower 1-year survival rates, 50.9, 39.1 and 20%, respectively (p!0.05). Conclusions: The risk of more extensive resection is not balanced by improved survival in this population based series. Extending gastric resection to involve contiguous organs should be confined to highly selected cases. Q 2005 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: C44 1224 554534; fax: C44 1224 553349. E-mail address: [email protected] (K.G.M. Park).
0748-7983/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2005.03.013
1142
S. Nanthakumaran et al.
Introduction Although there has been a decline in the incidence of carcinoma of the stomach it remains an important cause of cancer death both worldwide and in the UK1–3 with an incidence of 17.7/100,000 (males) and 7.5/100,000 (females) in Scotland.4 The overall 1- and 2-year survival for gastric cancer in Scotland is 35 and 20%, respectively.5 These rates, however, increase following surgical resection which remains the only potentially curative intervention available for patients with localised disease. Following resection, the most important prognostic factor is complete macroscopic and microscopic tumour resection (R0).6,7 However, in striving to achieve a curative resection, patients are exposed to increasingly lengthy and complex procedures where in addition to gastric resection; removal of contiguous organs (such as spleen, pancreas and liver) may also be required. Although good results have been reported from specialist centres8–11 it is clear that these patients are exposed to an increased risk of morbidity and mortality associated with more extensive resections. This may limit the value of such an aggressive approach when dealing with an elderly population with significant comorbid disease. The aim of this study was to assess whether the extent of surgical resection and removal of contiguous organs, was associated with morbidity, mortality or survival in patients undergoing surgery for gastric cancer.
minimum of 1 year. This encompassed all 53 Scottish hospitals in which oesophageal and gastric cancers were diagnosed and/or managed. Data from 1264 consecutive patients diagnosed with gastric cancer during the study period were available (98% of gastric cancer patients identified by Cancer Registry Statistics during this period). Data were collected prospectively, including: patient demographic details, comorbid illness, ASA grades and site of the cancer (fundus, body or antrum). Staging investigations comprised CT scan of abdomen, chest and laparoscopy in addition to routine haematology and biochemistry. At the time of surgery, surgeons were asked to record details of the operation performed and their assessment of the completeness of resection. Peri-operative complications were recorded on a standard proforma. All deaths during the index admission or within 30 days of surgery were considered as postoperative deaths. Patients were followed up until death or for a minimum of 1 year. Data were cross checked by four data managers specifically employed for the study.
Statistics Data were collated on a customised Microsoft Access database (copyright) and transferred to the Statistical Package for Social Sciences (SPSS for Windows) for analysis. For comparisons of patients falling into different categories chi-squared tests were used. Survival analysis was conducted using a Kaplan–Meier plot and log-rank comparisons.
Patients and methods Results Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland (population 5,060,000) over a 2-year period between 1997 and 1999. Patients were followed up until death or a Table 1 Post-operative morbidity and mortality following gastric surgery
Number of cases Mortality Chest infection Cardiac Anastomotic leak
Distal gastrectomy
Total gastrectomy
Gastric bypass
272
168
89
25 (9%) 31 (11%)
26 (15.5%) 31 (18.5%)
22 (25%) 8 (9%)
21 (7.7%) 6 (2.2%)
13 (7.7%) 24 (14.3%)
3 (3%) 0 (0%)
In the 2-year period of data collection, 1264 patients were diagnosed with cancer of the gastric fundus, body or antrum (oesophago–gastric junction cancers were excluded). The male:female ratio was 1.3:1, with a median age of 73.6 years (range 30– 102). In 40% of patients there was severe comorbid disease (ASA grades 3–5) with ischaemic heart disease and respiratory disease most commonly observed. Following initial assessment and staging investigations 646 patients underwent surgical exploration: in 171 (26.5%) patients, non-resectional procedures including 89 gastric bypass operations were performed. Resections were, therefore, performed in 475 (73.5%) patients: distal gastrectomy nZ272, total gastrectomy nZ168 and oesophagogastrectomy nZ33. Of the 475 patients undergoing curative resection, tumour stage was available in 467 cases (no
Morbidity and mortality rates following gastric cancer surgery pathology reported in eight cases): Tx/0Z1 (0.2%), TisZ5 (1.1%), T1Z88 (18.8%), T2Z147 (31.5%), T3Z194 (41.5%) and T4Z32 (6.9%). Following gastric surgery the commonest complications were: chest infections, cardiac complications and anastomotic leaks (Table 1). Significantly fewer chest infections (11 vs 18.5%, p!0.05) and anastomotic leaks (2.2 vs 14.3%, p! 0.05) were reported following distal gastrectomy when compared to total gastrectomy. Patients who developed an anastomotic leak had a mortality of 46% irrespective of the procedure. The overall post-operative mortality rate was 14.1% for all patients undergoing gastric cancer surgery with a 52.1% 1-year survival. Non-resectional surgery resulted in a post-operative mortality rate of 25%, while; resection of the stomach alone (which included concomitant resection of the omentum) resulted in a mortality rate of 9.2% and a 1-year survival of 60%. However, the removal of contiguous organs such as the spleen (nZ131), distal pancreas (nZ30) or liver resection (nZ5), in addition to the stomach for extensive local disease, resulted in a significantly increased mortality and decreased 1-year survival. Peri-operative mortality following associated splenic, pancreatic or hepatic resection were significantly higher at 18.3, 23.3, and 40%, respectively, p!0.05; conversely 1-year survival was significantly lower at 50.9, 39.1 and 20%, respectively, p!0.05, when compared to resection of the stomach alone. For patients undergoing no surgery, the 1-year survival rate was 17.5%.
Discussion This study provides a unique population based assessment of surgical outcome for gastric cancer rather than previously reported studies confined to specialist centres.8–11 Patients were prospectively recruited from all 53 specialist and non-specialist centres in Scotland, thus, avoiding referral bias associated with data gathered from single units. Patients presenting with gastric cancer in Scotland had similar demographics to other western series,12–15 in contrast to the Japanese population of gastric cancer patients who are generally both younger and suffer less comorbidity.16,17 This may partially explain the relatively high peri-operative morbidity and mortality observed in our nonselected, population based series in comparison with results from specialist centres,18–22 although our data are comparable to other multicentre studies.12,13
1143
The most frequently observed complications following gastrectomy were anastomotic leaks and chest infections; these were higher in patients undergoing a total compared to a partial gastrectomy. The increased operative time incurred by a total gastrectomy could be one reason for the increased complication rate. Technical aspects related to total gastrectomy maybe another contributing factor. The oesophago-jejunal anastomosis is more prone to leakage, presumably related to the relatively poor blood supply of the distal oesophagus following dissection and resection of the proximal stomach. In addition, total gastrectomy involves hiatal dissection with frequent breach of the pleura resulting in potential contamination of the pleural cavity. As previously reported there was no difference in peri-operative mortality between high volume and low volume units.5 The majority of resected gastric cancers were T3 tumours with a relatively small proportion of tumours invading adjacent organs (T4). Within this study contiguous organ resection was carried out primarily to obtain R0 resection in locally advanced disease. However, mortality after gastrectomy and removal of adjacent organs to achieve R0 resection was significantly increased when compared to gastrectomy alone. Furthermore, 1-year survival was significantly decreased when curative resection involved spleen, pancreas or liver resection. Excess mortality rates have previously been reported with the removal of contiguous organs in patients with gastric cancer, both the MRC12 and the Dutch Gastric Cancer Group.13 Indeed in both these studies, designed to compare, the extent of lymphadenectomy, resection of the spleen and pancreatic tail were associated with the highest morbidity and mortality rates irrespective of whether a D1 or D2 lymphadenectomy was performed.12,13 Similarly, subgroup analysis indicated that removal of the spleen and pancreas were independent indicators of a poor prognosis.12 In both the MRC12 and Dutch13 trials it was concluded that routine pancreatectomy and splenectomy do not offer a significant benefit in terms of survival in patients in whom this was performed in order to achieve a more extended lymphadenectomy and are associated with excess morbidity; our population based data reinforces this message from the two clinical trials. With the poor 1-year survival for patients with removal of contiguous organs only marginally better to that of patients treated without surgery, extending gastric resections to involve contiguous organs should only be confined to highly selected cases. These patients should clearly have no signs of metastatic disease and have good pre-operative
1144 reserve, i.e. younger patients with minimal comorbidity. While surgery remains the principle curative modality for gastric cancer, a realistic surgical approach should comprise resecting only those cancers where macroscopic clearance appears possible given the considerable morbidity and mortality inherent in surgery for gastric cancer in western patients.
Acknowledgements The Scottish Audit of Gastric and Oesophageal Cancer was funded by the Clinical Resources Audit Group of the Scottish Executive. SAGOC Steering Group Membership: F. J. Gilbert (jnt chair) Aberdeen University; M. N. Nicolson, K. G. M. Park (jnt chair), Aberdeen Royal Infirmary; A. M. Thompson, Dundee University; T. J. Crofts, H. Gilmour, A. McGilchrist Royal Infirmary of Edinburgh; D. Prakash, Hairmyres Hospital; H. Yosef, Beatson Oncology Centre, Glasgow; J. Anderson, Southern General Hospital: A. Kirk, Western Infirmary, Glasgow; E. Porterfield, Clinical Resource and Audit Group. D. Charles, P. Aerts, K. Zarins, G. Cowans, M. McKernan, SAGOC Data Co-ordinators. T. Rapson, C. Thomson, D. Stockton, Scottish Cancer Intelligence Unit, Information and Statistics Division, Edinburgh. Disclaimer: although the authors are grateful to the Scottish executive for the funding of this study the views expressed do not necessarily represent the views of the executive.
References 1. Levi F, Lucchini F, Negri E, Boyle P, La Vecchia C. Cancer mortality in Europe, 1995–1999, and an overview of trends since 1960. Int J Cancer 2004;110:155–69. 2. Plummer M, Franceschi S, Munoz N. Epidemiology of gastric cancer. IARC Sci Publ 2004;157:311–26. 3. National Institute of Health, http://www.seer.cancer.gov/ publications/raterisk/index.html 4. Harris V, Sandridge AL, Black RJ, Brewster DH, Gould A. Cancer registration statistics Scotland 1986–95. Edinburgh: ISD Scotland Publications; 1998. ISBN: 1 84134 000 6. 5. Gilbert FJ, Park KGM, Thompson AM. The Scottish Audit of Gastric and Oesophageal Cancer. Edinburgh; 2002 [http:// www.show.scot.nhs.uk/crag/committees/CEPS/reports/ SAGOC_report_Contents.htm].
S. Nanthakumaran et al. 6. Roder JD, Bottcher K, Siewert JR, Busch R, Hermanek P, Meyer HJ. Prognostic factors in gastric carcinoma. Results of the German Gastric Carcinoma Study 1992. Cancer 1993;72: 2089–97. 7. Siewert JR, Bottcher K, Stein HJ, Roder JD. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 1998;228:449–61. 8. Roviello F, Marrelli D, Morgagni P, de Mawzoni G, Di Leo A, Vindigni C. Survival benefit of extended D2 lymphadenectomy in gastric cancer with involvement of second level lymph nodes: a longitudinal multicenter study. Ann Surg Oncol 2002;9:894–900. 9. Maruyama K, Okabayashi K, Kinoshita T. Progress in gastric cancer surgery in Japan and its limit of radicality. World J Surg 1987;11:418–25. 10. Maehara Y, Kakeji Y, Oda S, Takahashi I, Akazawa K, Sugimachi K. Time trends of surgical treatment and the prognosis for Japanese patients with gastric cancer. Br J Cancer 2000;83:986–91. 11. Degiuli M, Sasako M, Ponti A, Calvo F. Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer. Br J Cancer 2004 [Epub ahead of print]. 12. Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V. Patient survival after D1 and D2 resections for gastric cancer: long term results of the MRC randomized surgical trial. Br J Cancer 1999;79:1522–30. 13. Bonekamp JJ, Hermans J, Sasako M, van de Velde CJH, for the Dutch Gastric Cancer Group. Extended lymph-node dissection for gastric cancer. N Engl J Med 1999;340:908–14. 14. McKinney A, Sharp L, MacFarlane GJ, Muir CS. Oesophageal and gastric cancer in Scotland 1960–1990. Br J Cancer 1995; 71:411–5. 15. Allum WH, Powell DJ, McConkey CC, Fielding JW. Gastric cancer: a 25 year review. Br J Surg 1989;76:535–40. 16. Davis PA, Sano T. The difference in gastric cancer between, Japan, USA and Europe: what are the facts? What are the suggestion? Crit Rev Oncol Hematol 2001;40:77–94. 17. Yuasa N, Nimura Y. Survival after surgical treatment of early gastric cancer, surgical techniques and long term survival. Langenbecks Arch Surg 2004 [Epub ahead of print]. 18. Siewert JR, Bottcher K, Roder JD, Busch R, Hermanek P, Meyer HJ. Prognostic relevance of systematic node dissection in gastric carcinoma. Arch Surg 1993;80:1015–8. 19. Smith JW, Shiu MH, Kelsey L, Brennan MF. Morbidity of radical lymphadenectomy in the curative resection of gastric carcinoma. Arch Surg 1991;126:1469–73. 20. Giovanetti M, Brotto AC, Tiberio GA, Campedelli L, Vettoretto N, Ronconi M. D2 lymphectomy in the treatment of gastric cancer: a retrospective view on our experience (1990–97). J Exp Clin Cancer Res 1999;18:455–8. 21. Sue-Ling HM, Johnston D, Martin IG, Dixon MF, Lansdown MR, McMahon MJ. Gastric cancer: a curable disease in Britain. BMJ 1993;307:591–6. 22. Volpe CM, Koo J, Miloro SM, Driscoll DL, Nava HR, Douglas Jr HO. The effect of extended lymphadenectomy on survival in patients with gastric adenocarcinoma. J Am Coll Surg 1995;181:56–64.