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Blog aimed at residents in surgery
 URL :  www.surgical-oncology.net             e mail surgoncnet@gmail.com
Risk factors for complications following resection of gastric cancer.

Romeo Giuli MD, resident.
School of General and Emergency Surgery.
University of Siena.   Italy.



June 2002.     Review Article.

Viste and associates were the first to evaluate a large number of patients in an attempt to find factors predictive of complications after gastric cancer surgery. This prospective observational study evaluated 1,010 patients who underwent some type of gastric resection. There were 63 deaths for a mortality of 6%, and an overall complication rate of 28%. The most common complications were cardiac and pulmonary, with anastomotic leak, and intraabdominal abscess the next most common. Logistic regression identified five factors that were predictive of complication in this patient population. Male gender (odds ratio [OR] 1.75), age (OR 1.59), type of procedure (subtotal OR 2.24, total OR 3.74, and proximal OR 7.23), the use of antibiotics (not given OR 2.42), and concomitant splenectomy (OR 1.73) were all found to be predictors of complication. A similar regression was run to evaluate predictors of perioperative mortality, with men (OR 2.33) and age (OR 2.24) being the only predictors ( 2, 1 ).
The study of Martin II et al. is very similar to the report by Viste and colleagues, with similar numbers of patients and similar distribution of patients undergoing all type of resections. Their overall complication rate was similar at 31% (404 of 1,283), with fewer perioperative deaths (4%). This study had a similar number of complications in the proximal gastrectomy (30%), and esophagogastrectomy (34%), when compared with the study by Viste and associates (32%). It demonstrates that the overall complication rate is still high with these surgical resections, but with a strong multidisciplinary team including interventional radiology, the perioperative mortality is low.
In particular resection of two or more adjacent organs in advanced gastric adenocarcinoma is associated with a greater risk of developing a complication. The use of a graded surgical complication scale is needed for better reporting and comparison of complications. Complications were categorized by severity on a scale from 0 to 5, 0 being no complication to 5 being death. Chi-square analysis and the logistic regression method were used to compare and estimate factors significantly associated with having a complication.
Logistic regression identified the number of organs resected, two or greater, to be predictive of complications (RR 2.0), as well as age greater than 70 years old (RR 1.57). When excluding minor complications (values 1 and 2), only the number of organs resected (RR 3.8) was a major factor for severe complications (values 3, 4, and 5). Their study, however, did not identify as many predictors of complications as in the Viste and coworkers report. ( 1 ).

In the Grossmann and colleagues study risk factors predicting morbidity and mortality rates at VA hospitals after gastrectomy for gastric cancer are reported by using a prospectively collected, multi-institutional database. Assigning relative weights to factors associated with adverse outcomes may help improve patient care.
The 30-day morbidity rate was 33.3% (236 of 708). The overall 30-day mortality rate was 7.6% (54 of 708). Significant positive predictors of morbidity (P < .05) included current pneumonia, American Society of Anesthesiologists class IV (threat to life), partially dependent functional status, dyspnea on minimal exertion, preoperative transfusion, extended operative time, and increasing age. Significant positive predictors of mortality (P < .05) included do not resuscitate status, prior stroke, intraoperative transfusion, preoperative weight loss, preoperative transfusion, and elevated preoperative alkaline phosphatase level.
In the VA population, 30-day morbidity and mortality rates were not significantly different when total, proximal, and distal gastrectomy were compared. Although their study does not provide information on long-term overall or cancer-specific survival, these data do suggest that the extent of the gastrectomy itself does not have a major impact on short-term survival and morbidity. This is in contrast to several previous studies that have suggested that total gastrectomy is associated with a higher 30-day morbidity or mortality. How the extent of gastric resection and lymphadenectomy affects operative complication rates and cancer-specific outcome has been hotly contested in the literature. Several large series address this topic. The Grossmann's study data sets do not include information on TNM status, extent of lymphadenectomy, involvement of surgical margins, inclusion of the spleen in the resection, and the like. Therefore, they cannot evaluate whether commonly accepted standards of cancer surgery were met, and they cannot report whether the patient cure rate was comparable to that reported elsewhere ( 3, 2, 4, 5, 6, 7).

There are few comprehensive studies evaluating the risk factors for complications after gastrectomy for cancer ( 8, 9, 4 ).
The Yasuda's study divided the clinical parameters into patient-, operation- and tumour-related factors, and identified that factors associated with the presence or absence of postoperative complications were the duration of operation, volume of blood loss, presence of pancreatic invasion and raised serum CEA level in patients with large gastric cancers. Previous studies have also indicated that duration of operation and volume of blood loss are associated with the morbidity after gastrectomy. Volume of blood transfusion may adversely affect the survival of patients after gastrectomy for cancer; therefore, blood loss and transfusion should be minimized by careful operative technique.
In summary overall morbidity and mortality rates were 39 and 7 per cent respectively. The most frequent complication was pleural effusion (17 per cent), followed by anastomotic leakage (14 per cent), abdominal abscess (12 per cent), wound infection (12 per cent), pancreatic leakage (8 per cent) and peritonitis (6 per cent). Risk factors associated with postoperative complications were operating time (400 versus 337 min, P < 001), blood loss (1338 versus 782 ml, P < 001), pancreatic invasion (26 versus 8 per cent, P < 005) and raised serum carcinoembryonic antigen (CEA) level (5 ng/ml or greater) (36 versus 17 per cent, P < 005), independent of patient age, nutritional status, type of gastrectomy, splenectomy or pancreatectomy, extent of lymph node dissection, tumour location, size and stage of disease ( 9 ).

Resection can be a potentially curative treatment for perforated gastric cancer provided that the patient's condition is stable during surgery.
Age greater than 65 years and haemoglobin level less than 10 g/dl on admission are predictive factors for postoperative complications. Hypotension on admission and development of postoperative pulmonary and cardiac complications significantly increase the operative mortality risk. As surgery for these patients carries a high risk of death and morbidity, it may be better managed by surgeons with a special interest in this area, as surgical experience is a well known predictive factor for complications in upper gastrointestinal surgery ( 10 ).

Onate Ocana et al affirm that gastrectomy remains the only curative treatment for gastric cancer. However surgical morbidity and mortality remains high.
Operative blood loss, serum albumin, extent of gastrectomy, lymphocyte count, and splenectomy were the most important risk factors for morbidity. However location of the tumor, serum albumin level and lymphocyte count were the most important preoperative risk factors that determine the appearance of surgical complications. Receiver operating characteristic analysis of this model allowed definition of three groups in terms of surgical morbidity ( 11,8%, 28,5% and 52,4% respectively) ( 13 ).

According to the Msika et al study the stage at diagnosis was associated with operative mortality by univariate and multivariate analysis. The stage at the time of diagnosis is more relevant than tumor size and can be considered an indipendent risk factor for operative mortality. Weight loss, anorexia, and poor nutrition are probably more profound in those with advanced tumors and therefore contribute to the higher morbidity and mortality ( 15 ).

References

1) Robert C. G. Martin II, David P. Jaques, Murray F. Brennan , and Martin Karpeh. Achieving R0 resection for locally advanced gastric cancer: is it worth the risk of multiorgan resection? J Am Coll Surg.194, 5, May 2002, Pages 568-577

2) A. Viste, T. Haugstvedt, G.E. Eide and O. Soreide , Postoperative complications and mortality after surgery for gastric cancer. Ann Surg 207 (1988), pp. 7-13.

3) Erik M. Grossmann, Walter E. Longo, Katherine S. Virgo, Frank E. Johnson, Charles A. Oprian, William Henderson, Jennifer Daley, Shukri F. Khuri. Morbidity and mortality of gastrectomy for cancer in Department of Veterans Affairs Medical Centers. Surgery 2002;131:484-90.

4) Adachi Y, Mimori K, Mori M, Maehara Y, Sugimachi K. Morbidity after D2 and D3 gastrectomy for node-positive gastric cancer. J Am Coll Surg 1997;184:240-4.

5) Wu CW, Hsieh MC, Lo SS, Wang LS, Hsu WH, Lui WY, et al. Morbidity and mortality after radical gastrectomy for patients with carcinoma of the stomach. J Am Coll Surg 1995;181:26-32.

6) Cuschieri A, Fayers P, Fielding J, Craven J, Banacewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomized controlled surgical trial. Lancet 1996;347:995-9.

7) Bonenkamp JJ, Songun I, Hermans J, Sasako M, Welvaart K, Plukker JTM, et al. Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745-8.

8) K. Yasuda, N. Shiraishi, Y. Adachi, M. Inomata, K. Sato and S. Kitano. Risk factors for complications following resection of large gastric cancer. BJS 2001, 88, 873-877.

9) Sasako M, for the Dutch Gastric Cancer Study Group. Risk factors for surgical treatment in the Dutch gastric cancer trial. Br J Surg 1997; 84: 1567-71.

10) J. B. Y. So, A. Yam, W. K. Cheah, C. K. Kum and P. M. Y. Goh. Risk factors related to operative mortality and morbidity in patients undergoing emergency gastrectomy. BJS 2000, 87,1702-1707.

11) Adachi, Y, Mori, M, Maehara, Y, Matsumata, T, Okudaira, Y, Sugimachi, K. Surgical results of perforated gastric carcinoma: an analysis of 155 Japanese patients. Am J Gastroenterol 1997; 92, 516 18.

12) Gertsch, P, Yip, SKH, Chow, LWC, Lauder, IJ. Free perforation of gastric carcinoma. Results of surgical treatment. Arch Surg 1995; 130, 177 81.

13) L.F. Onate-Ocana, S.A. Cortes-Cardenas, V. Aiello-Crocifoglio et al., Preoperative multivariate prediction of morbidity after gastrectomy for adenocarcinoma. Ann Surg Oncol 7 (2000), pp. 281-288.

14) Bottcher K, SiewertJR, Roder JD, Bush R, Hermanek P, Meyer HJ. Risk of surgical therapy of stomach cancer in Germany: results of the German 1992 Stomach Cancer Study: German stomach cancer study Group (92). Chirur 1994; 65: 298-306.

15)Simon Msika et al. Improvement of operative mortality after curative resection for gastric cancer: population-based study. World Journal Surgery, 24, 1137-1142, 2000.

16) Sasako M. Invited Commentary. World Journal Surgery, 24, 1142, 2000.



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