Surgical Outcomes and Early Postoperative Complications in Locally Advanced Gastric Cancer

Year 2011, , 2 - 3, 01.08.2011

Lütfi Doğan Niyazi Karaman Sevinç Hüseyinova Cihangir Özaslan

https://doi.org/10.5505/aot.2011.29392

Abstract

OBJECTIVE: In Western world, 60 to 65% of the gastric cancer cases are in locally advanced stage at the time of diagnosis and in these patients, extended resections may increase the risk of complications. The aim of this study was to investigate the resectability rates and to determine early morbidity and mortality rates after resections for locally advanced gastric cancer.METHODS: Consecutive non-metastatic locally advanced gastric cancer patients treated between October 2002 and September 2006 were included in this retrospective exploratory analyses study.RESULTS: One hundred and ten patients (49.8%) had additional organ resection due to adjacent organ involvement. R0 resection was achieved in 181 patients (82%), R1 resection in 29 patients (13%), and R2 resection in 11 patients (5%). The morbidity and mortality rates of the all series were 21,7% and 4.5% respectively. More than two additional organ resections (p=0.001), eryhtrocyte transfusions of more than 2 units (p=0.001) and low total protein levels (p=0.008) were determined as the parameters which increase complication rates according to multivariate analysis. The parameters which increase mortality rates were as follows; having two or more additional organ resections (p=0.001), cardiovascular and respiratory comorbidities (p=0.002) and total gastrectomy (p=0.028).CONCLUSION: Additional organ resection rates of the patient with locally advanced gastric cancers that not given neo-adjuvant treatment is high and this occurance increases the morbidity and mortality rates. Altough total gastrectomy has been found to be a factor for increased mortality in locally advanced gastric cancer, D2 dissection is safe for these patients

Keywords

complications, locally advanced gastric cancer, mortality, morbidity

Lokal İleri Evre Mide Kanserinde Cerrahi Sonuçlar ve Erken Postoperatif Komplikasyonlar

Abstract

AMAÇ: Batı ülkelerinde saptanan mide kanserlerinin %60-65'i tanı anında lokal ileri evrededirler. Bu hastalara uygulanan genişletilmiş rezeksiyonlar komplikasyon riskini arttırabilir. Bu çalışmanın amacı lokal ileri evre mide kanserlerinde rezektabilite, erken dönem mortalite ve morbidite oranlarını saptamaktır. YÖNTEMLER: Ocak 2002 ile Eylül 2006 tarihleri arasında rezeksiyon uygulanan non-metastatik, lokal ileri evre mide kanserli hastalarımız geriye dönük olarak incelendi. BULGULAR: Komşu organ invazyonu nedeni ile 110 hastaya (%49.8) ek organ rezeksiyonu uygulanmıştı. Yüzseksen bir hastaya (%82) R0, 29 hastaya (%13) R1 ve 11 hastaya (%5) R2 rezeksiyon yapılabilmişti. Tüm serinin morbidite ve mortalite oranları sırasıyla %21.7 ve % 4.5 olarak bulundu. İkiden fazla ek organ rezeksiyonu (p=0.001), 2 üniteden fazla kan transfüzyonu (p=0.001) ve düşük protein seviyeleri (p=0.008) multivaryant analizlerde komplikasyon oranlarını arttıran parametreler olarak saptandı. İki veya daha fazla ek organ rezeksiyonu (p=0.001), kardiyovasküler ve respiratuar komorbidite (p=0.002) ve total gastrektomi uygulanması (p=0.028) mortaliteyi arttıran faktörler olarak bulundu. SONUÇ: Neo-adjuvan tedavi uygulanmayan lokal ileri evre mide kanserli hastalarda ek organ rezeksiyonu oranları yüksektir ve bu durum morbidite ve mortalite oranlarını arttırır. Total gastrektomi mortaliteyi arttıran bir faktör olarak belirlenmiş ancak D2 diseksiyonun bu hastalarda güvenle uygulanabileceği sonucuna varılmıştır.

Keywords

komplikasyon, lokal ileri evre mide kanseri, mortalite, morbidite

References

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• Two or more additional organ resections were
• determined as a factor that increases mortality,
• morbidity and anastomotic dehiscence in
• multivariate analysis. In a study by Ozer et al.,
• more than two additional organ resections are
• also related to morbidity (13).
• Splenectomy was added to the primary
• procedures of 87 patients. Only 9 of the
• splenectomies were performed for iatrogenic
• injuries. The other reasons for splenectomies were
• implantations on splenic capsule and lymph
• node involvement in splenic hilus. tumoral
• In the last few years, the results of
• different neo-adjuvant chemotherapy regimes
• given to the patients with radiologically proven
• invasion to the adjacent structures have been
• published in the literature. In a series by Wang
• et al., 87 patients with T4 tumor treated with
• neoadjuvant chemotherapy and operated with
• 7% R0 resection rate without any need for
• adjacent organ resection (24). In a series of 49
• patients by Ott et al., this rate was 76% (25).
• Seventeen of 18 patients presented by Newman
• (26)and 19 of 22 patients presented by Guo
• (27) could have been operated with R0
• resection without requiring adjacent organ
• resection. In none of these studies, neoadjuvant chemotherapy
• operative morbidity and mortality. In our series
• of locally advanced tumors, not treated with
• neo-adjuvant chemotherapy, additional organ
• resection had to be applied in 50% of the cases.
• At the same time our R1 and R2 resection rates
• are also high (13% and 5%). In literature, there
• are some other studies stating that R0 resection
• rates of locally advanced gastric tumors, not
• treated with neo-adjuvant chemotherapy, are
• low (28). But now, there is increasing evidence
• that neo-adjuvant chemotherapy potentially
• down-stages the tumor and therefore may
• improve the resectability rate with negative
• surgical margins (29,30). to increase
• In literature, the morbidity and
• mortality rates for locally advanced gastric
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• 10% respectively (31,32). The mortality rate
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• (13). Similarly, neo-adjuvant treatment may
• decrease morbidity and mortality rates by
• decreasing the need for additional organ
• resection (16). Patient characteristics can effect mortality and morbidity rates besides the surgical procedures. Advanced age, male sex, blood loss during operation, low total protein and hemoglobin levels and duration of operation were determined as a factors which effect the morbidity rates negatively (33-36).
• Age, hemoglobin and lymphocyte counts were
• not found as significant factors for the
• morbidity in our series. In multivariate
• analysis, low total protein levels and blood
• transfusions of more than 2 units were
• significant factors for the morbidity, whereas
• cardiac and respiratory comorbidities were
• significant for the mortality. Low total protein levels
• necessity lead to immunosuppression and
• problems in wound healing. Blood transfusions
• increase intracellular adhesion molecules and
• this may be the reason for high predisposition
• to infective complications. In patients with
• locally advanced gastric cancers, the need for
• blood transfusion either preoperatively or
• postoperatively was also high. Cardiac and
• respiratory problems are the most important
• causes of early mortality in upper abdominal surgery. blood transfusion Conclusion
• Additional organ resection rates of the patient
• with locally advanced gastric cancers that not
• given neo-adjuvant treatment is high and this
• occurrence increases the morbidity and
• mortality rates. While total gastrectomy was
• preferred surgical option for locally advanced
• gastric cancers, D2 dissection was used less
• frequently in this series of patients.
• If the subtotal gastrectomy is the
• suitable procedure according to the tumor
• localization, surgeon should not insist on
• performing total gastrectomy. D2 dissection is
• a safe procedure in the treatment of locally
• advanced gastric carcinoma. Gastric cancer
• patients who have cardiac and respiratory
• comorbidities must be prepared to surgery
• carefully. Immunity and nutritional levels of
• the patients must be evaluated preoperatively.
• Conflict of Interest: None.
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