Improving the outcomes in gastric cancer surgery Tegels, Juul J W; De Maat, Michiel F G; Hulsewé, Karel W E ...
World journal of gastroenterology,
10/2014, Volume:
20, Issue:
38
Journal Article
Open access
Gastric cancer remains a significant health problem worldwide and surgery is currently the only potentially curative treatment option. Gastric cancer surgery is generally considered to be high risk ...surgery and fiveyear survival rates are poor,therefore a continuous strive to improve outcomes for these patients is warranted. Fortunately,in the last decades several potential advances have been introduced that intervene at various stages of the treatment process. This review provides an overview of methods implemented in pre-,intra- and postoperative stage of gastric cancer surgery to improve outcome. Better preoperative risk assessment using comorbidity index(e.g.,Charlson comorbidity index),assessment of nutritional status(e.g.,short nutritional assessment questionnaire,nutritional risk screening- 2002) and frailty assessment(Groningen frailty indicator,Edmonton frail scale,Hopkins frailty) was introduced. Also preoperative optimization of patients using prehabilitation has future potential.Implementation of fast-track or enhanced recovery after surgery programs is showing promising results,although future studies have to determine what the exact optimal strategy is.Introduction of laparoscopic surgery has shown improvement of results as well as optimization of lymph node dissection.Hyperthermic intraperitoneal chemotherapy has not shown to be beneficial in peritoneal metastatic disease thus far.Advances in postoperative care include optimal timing of oral diet,which has been shown to reduce hospital stay.In general,hospital volume,i.e.,centralization,and clinical audits might further improve the outcome in gastric cancer surgery.In conclusion,progress has been made in improving the surgical treatment of gastric cancer.However,gastric cancer treatment is high risk surgery and many areas for future research remain.
In gastric cancer patients chronological and biological age might vary greatly between patients. Age as well as American Society of Anaesthesiologists-physical status classifications are very ...non-specific and do not adequately predict adverse outcome. Improvements have been made such as the introduction of Charlson Comorbidity Index. Geriatric frailty is probably a better measure for patients resistance to stressors and physiological reserves. An increasing amount of evidence shows that geriatric frailty is a better predictor for adverse outcome after surgery, including gastric cancer surgery. Geriatric frailty can be assessed in a number of ways. Questionnaires such as the Groningen Frailty Indicator provide an ease and low cost method for gauging the presence of frailty in gastric cancer patients. This can then be used to provide a better preoperative risk assessment in these patients and improve decision making.
Complications can be classified using the most-severe Clavien-Dindo-Classification (CDC) per patient or the total complication burden per patient expressed in the Comprehensive Complication Index ...(CCI). This study determined the additional value of CCI to CDC in examining the impact of complications after gastric cancer surgery.
The CCI and CDC were determined in the multicenter randomized LOGICA-trial comparing laparoscopic versus open D2-gastrectomy for cancer (cT1-4aN0-3M0). Differences in median CCI between laparoscopic and open gastrectomy were compared for overall postoperative complications and cardiovascular, gastrointestinal, infectious, pulmonary, and other complications. CCI and CDC were correlated to hospitalization, ICU-stay and reoperations using Spearman's rho-test and compared with standard Fisher's z-transformation.
Between 2015 and 2018, 211 patients underwent laparoscopic (n = 106) or open (n = 105) D2-gastrectomy, and 157 (74%) received neoadjuvant chemotherapy. Median CCI was comparable between laparoscopic versus open gastrectomy regarding overall complications (CCI 0 IQR 0-23.5 versus 0 IQR 0-22.6; p = 0.755) and subgroups of complications (p > 0.05). Both CCI and CDC showed moderate positive correlations for hospitalization (r
= 0.646 versus r
= 0.628; p = 0.001, difference clinically irrelevant), and reoperations (r
= 0.590 versus r
= 0.599; p = 0.070), and weak correlations for ICU-stay (r
= 0.446 versus r
= 0.440; p = 0.189).
The CCI is a composite scoring system based on the CDC and reflects a subjective interpretation of complication burden from the perspectives of both physicians and patients, following abdominal surgery other than gastrectomy. Implementing CCI showed no clinically relevant benefit and caused additional workload compared to CDC for assessing complication burden. Therefore, using the CCI alongside the CDC after gastric cancer surgery is not recommended.
Quality of gastric cancer surgery is crucial for favorable prognosis. Generally, prospective trials lack quality control measures. This study assessed surgical quality and a novel D2-lymphadenectomy ...photo-scoring in the LOGICA-trial.
The multicenter LOGICA-trial randomized laparoscopic versus open total/distal D2-gastrectomy for resectable gastric cancer (cT1-4aN0-3M0) in 10 Dutch hospitals. During the trial, two reviewers prospectively analyzed intraoperative photographs of dissected nodal stations for quality control, and provided centers weekly feedback on their D2-lymphadenectomy, as continuous quality-enhancing incentive. After the trial, these photographs were reanalyzed to develop a photo-scoring for future trials, rating the D2-lymphadenectomy dissection quality (optimal-good-suboptimal-unevaluable). Interobserver variability was calculated (weighted kappa). Regression analyses related the photo-scoring to nodal yield, recurrence and 5-years survival.
Between 2015 and 2018, 212 patients underwent total/distal D2-gastrectomy (n = 122/n = 90), and 158 (75%) received neoadjuvant chemotherapy. R0-resection rate was 95%. Rate of ≥15 retrieved lymph nodes was 95%. Moderate agreement was obtained in stations 8 + 9 (κ = 0.522), 11p/11d (κ = 0.446) and 12a (κ = 0.441). Consensus was reached for discordant cases (30%). Stations 8 + 9, 11p/11d and 12a were rated ‘optimal’ in 76%, 63% and 68%. Laparoscopic photographs could be rated better than open (2% versus 12% ‘unevaluable’; 73% versus 50% ‘optimal’; p = 0.042). The photo-scoring did not show associations with nodal yield (p = 0.214), recurrence (p = 0.406) and survival (p = 0.988).
High radicality and nodal yield demonstrated good quality of D2-gastrectomy. The prospective quality control probably contributed to this. The photo-scoring did not show good performance, but can be refined. Laparoscopic D2-gastrectomy was better suited for standardized surgical photo-evaluation than open surgery.
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