Impact of Induction Chemotherapy and Preoperative Chemoradiotherapy on Operative Morbidity and Mortality in Patients with Locoregional Adenocarcinoma of the Stomach or Gastroesophageal Junction

Background Significant tumor downstaging has been achieved in patients with localized gastric or gastroesophageal adenocarcinoma by induction chemotherapy and preoperative chemoradiotherapy (CTX-CTXRT). However, the influence of CTX-CTXRT on operative morbidity and mortality has not yet been clarified. The aim of the present study was to document the frequency and nature of morbidity and mortality after surgery combined with CTX-CTXRT, and identify factors predictive of postoperative complications in patients with localized gastric or gastroesophageal adenocarcinoma. Methods A prospectively collected database on 71 consecutive patients who underwent CTX-CTXRT at M.D. Anderson Cancer Center between January 1997 and August 2004 was reviewed. Postoperative morbidity and mortality were investigated, and risk factors for overall complications were identified by multivariate logistic regression analysis. Results Overall morbidity and mortality rates were 38.0% (27 patients) and 2.8% (2 patients), respectively. Age greater than 60 years [relative risk 11.3 (95% confidence interval 2.50–50.6)] and body mass index (BMI) of 26 kg/m² or above [relative risk 4.08 (95% confidence interval 1.08 to 15.4)] were significant risk factors for overall complications. Conclusions CTX-CTXRT can be performed safely with an acceptable operative morbidity and a low operative mortality rate in patients with gastric or gastroesophageal cancer, with careful consideration of added risk associated with age and obesity.     

Complications Following D3 Gastrectomy: Post Hoc Analysis of a Randomized Trial

Introduction A single institutional surgical trial for gastric cancer had demonstrated increased morbidity but not mortality. This report analyzes risk factors affecting morbidity. Methods Risk factors for morbidity in 221 patients treated with curative intent were evaluated in a prospective randomized trial comparing D1 and D3 surgery for curable gastric cancer. Results The surgeon’s experience after 25 nodal dissections had no influence on surgical or overall complications, nor did the patients’ co-morbidity (e.g., respiratory system disease, cardiac disease, diabetes mellitus). Distal pancreatectomy negatively affected surgical morbidity [relative risk (RR) 6.21, 95% confidence interval (CI) 1.869–20.626] and overall morbidity (RR 5.50, 95% CI 1.671–18.082). All of the patients with a distal pancreatectomy underwent concomitant splenectomy. Multivariate analysis found splenectomy and nodal dissection to be the only two independent risk factors adversely affecting operative morbidity. The RR of splenectomy for surgical complications was 4.19 (95% CI 1.327–13.208), and for overall complications it was 3.88 (95% CI 1.259–11.973). The RR of nodal dissection for surgical complications was 2.51 (95% CI 1.336–4.730), and for overall complications it was 1.93 (95% CI 1.149–3.255). Conclusions Splenectomy (with or without pancreatectomy) and nodal dissection are risk factors for operative morbidity but not mortality.     

Surgical Complications and the Risk Factors of Laparoscopy-Assisted Distal Gastrectomy in Early Gastric Cancer

Background Information on surgical complications of laparoscopy-assisted distal gastrectomy (LADG) and their risk factors is limited in the literature despite increasing popularity of this procedure. This study was performed to identify the surgical complications and their associated risk factors of LADG in early gastric cancer. Methods LADG was performed in 347 gastric cancer patients from January 2002 to December 2006 at the Korean National Cancer Center by four surgeons with ample experience of open gastric surgery before LADG. LADG indications for cases of gastric cancer at our institution are preoperatively diagnosed cT1N0 or cT1N1, except in cases with an absolute indication for endoscopic resection. Lymph node dissection of more than D1 + β was performed in all patients. Intraoperative and postoperative complications were reviewed and their risk factors were retrospectively analyzed by prospective database information. Results Forty complications occurred in 34 patients (9.8%), but there was no mortality. Intraoperative complications occurred in nine patients (2.6%), and open conversion was performed in eight (2.3%) of these patients. Early and late postoperative complications occurred in 21 (6.1%) and 10 (2.9%) patients, respectively. The most serious complication was vascular injury resulting in bleeding or organ ischemia, which occurred in seven patients. Degree of lymph node dissection and surgical inexperience were found to be risk factors of surgical complication (P = .023, odds ratio 2.832, 95% confidence interval 1.155–6.946 vs. P = .028, odds ratio 2.975, 95% confidence interval 1.127–7.854). Conclusions Lymph node dissection during LADG should be performed cautiously to prevent surgical complications like vascular injuries, especially during the surgeon’s early learning period.     

Factors associated with prolonged stay after laparoscopic cholecystectomy in elderly patients

Background Laparoscopic cholecystectomy in elderly patients has been linked to higher complication rates and longer lengths of stay. The purpose of this study was to identify risk factors associated with prolonged postoperative hospitalization in elderly patients undergoing laparoscopic cholecystectomy. Methods The records of 287 patients aged 65 years or older, who underwent successful laparoscopic cholecystectomy between January 2001 and July 2006, were retrospectively reviewed. Clinical data was abstracted from the chart and compared between patients with a shorter or longer postoperative stay. Results The median postoperative hospital stay was three days (interquartile range 3–5). Forty-eight patients had complications, with an overall morbidity of 16% and mortality of 0.7%. The only independent predictor of prolonged postoperative stay was the occurrence of any major complication [odds ratio, 3.144; 95% confidence interval (CI), 1.882–5.251]. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and underlying chronic obstructive pulmonary disease were independently associated with major complications. Conclusions A major complication is the most important cause of prolonged hospital stay after laparoscopic cholecystectomy in the elderly. No specific comorbidity has direct impact on the duration of hospitalization, but pulmonary disease is associated with increased risk of major complications.     

Secular Trends in the Use,Quality, and Outcomes of Gastrectomy for Noncardia Gastric Cancer in the United States

Background The overall survival with non-cardia gastric adenocarcinoma in the United States has remained poor and relatively unchanged over the past 2 decades. This brings into question the utilization and quality of gastrectomy and lymphadenectomy. We examined the trends, extent, and determinants of surgical treatment and the influence of gastrectomy and adequacy of lymphadenectomy (defined as collection of 15 or more lymph nodes) on non-cardia gastric cancer survival. Methods Data from Surveillance, Epidemiology, and End Results (SEER) registries was used to identify patients with non-cardia adenocarcinoma diagnosed during 1983–2002. Logistic regression was used to examine determinants of gastric resection and adequacy of lymphadenectomy. Cox proportional hazard (PH) models were used to examine determinants of mortality risk for patients treated surgically. All models examined year of diagnosis, age, race, gender, geographic region, and cancer spread. Results There were 16,846 patients with non-cardia gastric cancer of whom 10,534 (62.5%) underwent gastric resection. Approximately 77.9% with localized disease underwent resection. Resection for non-cardia gastric cancer declined 6% for all stages and 20% for local stages between 1983 and 2002. In multivariable models, gastrectomies were less likely to be performed between 1998–2002 (−37% compared to 1983–1987), for localized disease (−78% compared to regional disease), for patients older than 70 (−39% compared to patients younger than 40), and for patients from New Mexico (−45% compared to highest in Hawaii). Wide racial variability was also found (lowest for Whites [−54%] compared to Asians). Adequate LN sampling (15 or more LN) was recorded in only 25% overall and 20% of localized disease. Improvement in LN collection since 1997 has been modest, with only a 7% relative increase. The mortality risk of surgically treated non-cardia cancer patients has been unchanged for 15 years. Adequate lymphadenectomy was associated with a 19% decreased mortality risk in this group. Gender and racial differences in mortality risk were present (up to 13% higher in men compared to women and 22% higher in Whites compared Asians). Conclusion Gastrectomy for non-cardia gastric adenocarcinoma is underutilized, especially for localized disease. In the majority of operations for non-cardia gastric cancer, LN collection is inadequate. Racial and geographic variations with gastric resection and LN sampling are as significant as patient age and stage of the cancer. Disparities based on race and geographic region, as well as surgeon and facility factors need to be investigated and addressed to bring forth improvements in outcomes for non-cardia adenocarcinoma.     

An Interval >7 Weeks between Neoadjuvant Therapy and Surgery Improves Pathologic Complete Response and Disease–Free Survival in Patients with Locally Advanced Rectal Cancer

Background  We assessed whether the time interval between neoadjuvant therapy and surgery affects the operative and postoperative morbidity and mortality, the pathologic complete response (pCR) rate, and disease recurrence in locally advanced rectal cancer. Methods  One–hundred and thirty-two patients with locally advanced low– and mid–rectal cancer underwent neoadjuvant chemoradiation followed by radical resection (October 2000 to December 2006). Data on the neoadjuvant regime, neoadjuvant–surgery interval, final pathology, type of operation, operative time, intraoperative blood transfusions, postoperative complications, length of hospital stay, disease recurrence, and mortality were reviewed. The patients were divided into two groups according to the neoadjuvant–surgery interval: ≤7 weeks (group A, n = 48), and >7 weeks (group B, n = 84). Results  The groups were demographically comparable except for the group A patients being younger at operation. The median interval between chemoradiation and surgery was 56 days (range 13–173 days). Thirty-seven patients (28%) had a pCR and near pCR. Fifty three patients (40%) had complications. There was no in-hospital mortality. Surgery type, operative time, number of intraoperative blood transfusions, postoperative complications, and length of hospitalization were not influenced by the interval length. The pCR and near pCR rates were higher with longer interval: 17% in group A, 35% in group B (P = 0.03). Patients operated at an interval >7 weeks had significantly better disease–free survival (P = 0.05). Conclusions  A neoadjuvant–surgery interval >7 weeks was associated with higher rates of pCR and near pCR, decreased recurrence and improved disease–free survival.     

Surgical Mortality, Survival, and Quality of Life after Resection for Gastric Cancer in the Elderly

Although there were some studies on clinicopathologic characteristics, operative morbidity, and mortality in elderly patients with gastric cancer, no reports have specifically focused on survival and quality of life after resection. A total of 433 patients aged ≥ 65 years (1987–1994) who underwent gastric resection for gastric adenocarcinoma were studied. Two groups were considered: patients aged 65 to 74 years and those > 74 years. Most of the patients (78.1%) had advanced diseases, and nearly half (41.3%) had associated chronic disease(s). Resections with curative intention were performed in 362 patients (83.6%). The overall operative morbidity rate was 21.7% and mortality rate 5.1%. Although operative procedures were similar in both groups, patients aged >74 years had a higher mortality rate than those aged 65 to 74 years (10.1% vs. 3.5%; p= 0.034). Age and extent of gastric resection were two independent factors negatively affecting mortality. The cumulative survival rates for patients who underwent curative resection were 86.2%, 72.4%, 67.2%, 62.9%, and 60.0% at 1, 2, 3, 4, and 5 years, respectively. Nearly all patients (96%) after surgery had normal work and daily activities. Some patients appeared to lack energy (16%) or experienced a period of anxiety or depression. There was no statistical difference in survival and quality of life assessed by the Spitzer index after curative resection between the two groups. Therefore resection with curative intention can be performed for the elderly with acceptable morbidity and mortality rates, possible long-term survival, and good quality of life, but a limited operation should be considered in the very elderly patients.     

Surgical Factors Influence the Outcome After Ivor-Lewis Esophagectomy with Intrathoracic Anastomosis for Adenocarcinoma of the Esophagogastric Junction: A Consecutive Series of 240 Patients at an Experienced Center

Background  Despite a considerable number of randomized studies, the surgical approach to locally advanced adenocarcinoma of the esophagogastric junction (AEG) I and II is still discussed controversially. Thus, we evaluated the surgical risk and outcome after an abdominothoracic esophagectomy (Ivor-Lewis) with intrathoracic anastomosis as standard procedure. Methods  Between 1998 and 2006, a total of 240 consecutive patients underwent standardized right thoracoabdominal esophagectomy with two-field lymphadenectomy and intrathoracic anastomosis (Ivor-Lewis operation) for AEG I (n = 206) or AEG II (n = 34). A total of 157 patients (65.4%) had neoadjuvant chemotherapy. Results  Postoperative morbidity occurred in 17.9% (43 of 240). Overall mortality was 3.8% (9 of 240). The majority of patients (4 of 9) died because of severe pulmonary complications (44.4%) irrespective of surgical complications. Neoadjuvant chemotherapy did not increase morbidity or mortality. The median overall survival was 51 months. Multivariate analysis including age >75 years, clinical response to chemotherapy, complications, R-category and N-category revealed R-category (P = .005; relative risk [RR] 0.32, 95% confidence interval [95% CI] 0.14–0.70) and complications (P < .001, RR 0.16, 95% CI 0.08–0.35) as independent prognostic factors for all patients. Complications was the only independent prognostic factor (P < .001, RR 0.09, 95% CI 0.08–0.35) for the R0 resected patients. Conclusions  At an experienced center, Ivor-Lewis resection is a safe surgical procedure. Outcome of patients was significantly influenced by surgical factors such as complete resection and complications. Neoadjuvant chemotherapy did not lead to higher morbidity and mortality. The high mortality from non-surgery–related complications emphasizes the importance of careful preoperative evaluation of comorbidities and patient selection.     

Association of Splenectomy With Postoperative Complications in Patients With Proximal Gastric and Gastroesophageal Junction Cancer

Background: Splenectomy has been associated with increased morbidity after gastrectomy for gastric cancer. Resection of proximal versus distal tumors is associated with a higher morbidity. Because splenectomy is more commonly performed in resection of proximal tumors, these analyses may be biased. The aim of this study was to describe the association of splenectomy with complications in patients undergoing resection of proximal gastric and gastroesophageal junction (GEJ) cancers.Methods: From July 1985 to August 2001, 335 patients underwent resection of proximal gastric or GEJ (type II and III) cancers. Clinical and pathologic factors were retrieved from a prospective database.Results: Overall morbidity was 59% (infectious complications, 41%; noninfectious complications, 36%), and mortality was 4.5%. Splenectomy was associated with a higher rate of infectious complications (57% vs. 33%; P < .01) but not of noninfectious complications (39% vs. 34%; not significant) or mortality (4% vs. 5%; not significant). Splenectomy was also associated with a higher rate of infectious complications on multivariate analysis (hazard ratio, 2.4; P < .01).Conclusions: Morbidity after resection of proximal gastric and GEJ cancer is significant; splenectomy is associated with increased morbidity, but not mortality, in these patients. Because these complications can be managed without an increase in mortality, splenectomy should be performed when indicated by the extent of the tumor.     

Surgery for stage IV gastric cancer

BACKGROUND: Surgical treatment for stage IV gastric cancer is controversial. METHODS: We analyzed the surgical experience with advanced gastric carcinoma in a tertiary referral center in Mexico City from 1995 through 2000. We analyzed surgical morbidity, mortality, and factors associated with prognosis. Survival was analyzed with the Kaplan-Meier method, and the curves were compared with the log-rank test. Significance was assigned at P <0.05. RESULTS: Seventy-six cases were identified. Mean patient age was 56 +/- 14.5 years. Thirty-nine patients (51.3%) were women. Patients were grouped according to surgical procedure: group 1 underwent resection (40 patients), group 2 underwent bypass procedures (10 patients), and group 3 underwent either celiotomy and biopsy alone or jejunostomy placement (26 patients). Twenty patients (26%) developed operative complications, but most were minor. There was no difference in morbidity between surgical groups and no difference according to patient's age. Operative mortality was 2.6%. Good palliation of symptoms was significantly more common in group 1 patients (82%) than in group 2 patients (60%) (P = 0.0001). Median survival was 8 months (95% confidence interval 4 to 12) for the entire cohort and 13, 5, and 3 months for groups 1, 2, and 3, respectively (P = 0.00001 for group 1 vs groups 2 and 3). CONCLUSIONS: Surgical resection for stage IV gastric cancer can be done with low operative mortality and acceptable morbidity rates, and it provides patients with good symptomatic relief. Advanced patient age is not a contraindication for surgical treatment.     

Barrett’s esophagus with high grade dysplasia: Surgical results and long-term outcome— An update

We updated our surgical results and long-term outcome for prophylactic esophagectomy in patients with Barrett’s esophagus and high-grade dysplasia (HGD) and determined the incidence of occult adenocarcinoma. Sixty consecutive patients with HGD who underwent esophagectomy had pre- and postoperative pathology examined at our institution from 1982 to 2001. We reviewed medical records to determine patient characteristics, surgical approach, operative morbidity and mortality, pathology, and length of stay. Patients and/or referring physicians were contacted to determine long-term outcome. Fifty-three men (88%) and 7 women (12%) were followed up for a median of 4.6 years. Transhiatal esophagectomy was performed in the majority of patients (82%). There was one operative death (1.7%) and 15 complications (29%). Median length of stay was 9 days. In 18 patients (30%), invasive adenocarcinoma was detected in the resected specimen. When examined by time periods, 43% (13/30) of patients were diagnosed with occult cancer from 1982–1994, whereas 17% (5/30) harbored occult malignancy from 1994–2001. All patients with adenocarcinoma in the recent interval had stage I disease, as opposed to only 61.5% of patients from the earlier study. Operative mortality declined from 3.3% to 0% over the two intervals as did mean length of stay from 14 days to 10 days. Five-year survival was excellent at 88%. Age and amount of preoperative weight loss were preoperative predictors of survival, whereas major postoperative complications and stage were postoperative predictors of outcome. Barrett’s esophagus with high-grade dysplasia continues to be an indication for prophylactic esophagectomy. Overall prevalence of occult adenocarcinoma remains high. We have demonstrated a declining incidence of occult cancer and treatment of earlier stage adenocarcinoma when found in this population of patients treated with esophagectomy. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Predictors for Complications after Loop Stoma Closure in Patients with Rectal Cancer

Purpose This unmatched case control study was undertaken to evaluate factors contributing to surgery-related complications of loop stoma closure in patients with rectal cancer. Methods Cases were consecutive patients with complications identified from a local registry. Complications were defined as surgery-related and included 30 days overall mortality. Controls were all other patients with stoma closure from the same population of the registry without the endpoint. Results Of the 243 patients, 47 (19%) patients experienced a surgery-related complication, including 5 patients who died within 30 days after surgery. Significant risk factors in the univariate analysis were supervised operation (odds ratio 0.50; 95% confidence interval 0.27–0.95; P = 0.04), stapled anastomosis (odds ratio 0.40; 95% confidence interval 0.17–0.91; P = 0.04) and using a soft silicone drain (odds ratio 2.03; 95% confidence interval 1.07–3.85; P = 0.04). Using a soft silicone drain (odds ratio 2.17; 95% confidence interval 1.10–4.26; P = 0.03) and stapled anastomosis (odds ratio 0.38; 95% confidence interval 0.15–0.98; P = 0.04) were the only significant predictors in the multivariate analysis. Conclusions The present study in a homogeneous group of patients with rectal cancer as elective indication for temporary loop stoma construction confirms the high complications rate and mortality rate associated with stoma closure. Intraperitoneal drains should be omitted after loop stoma closure.     

Attempted Salvage Resection for Recurrent Gastric or Gastroesophageal Cancer

The purpose of this study was to determine the outcome of surgery for patients with recurrent gastric or gastroesophageal cancer. We queried records from 7,459 patients who presented with gastric or gastroesophageal cancer to our institution from 1973 through 2005 to identify those for whom resection of recurrent disease had been attempted. We assessed the associations between various clinicopathologic factors and resectability with logistic regression analysis and between clinicopathologic factors and overall survival (OS) with the Cox proportional hazards model. Sixty patients underwent attempted resection for recurrent cancer. In 31 cases (52%), recurrent disease proved unresectable at laparotomy. Factors associated with the ability to undergo re-resection included neoadjuvant treatment prior to initial resection [odds ratio (OR) 12.2, 95% confidence interval (CI) 1.9–75.6] and having an isolated local recurrence (OR 5.1, 95% CI 1.3–20.5). Of the 29 patients who underwent re-resection, 14 required adjacent organ resection, and 6 required interposition grafting. Three- and 5-year OS rates for all 60 patients were 21% and 12%, respectively; median follow-up time was 23 months. Median OS for patients undergoing resection was 25.8 months (95% CI 17.1–49.8) versus 6.0 months (95% CI 4.0–10.5) for unresectable patients (P < 0.001). Initial tumor location at the gastroesophageal junction was associated with diminished OS [hazard ratio (HR) 2.8, 95% CI 1.2–6.5] and ability to undergo resection of recurrence was associated with improved OS (HR 0.2, 95% CI 0.1–0.6). We conclude that surgical resection of select patients with recurrent gastric or gastroesophageal cancer can result in improved OS but often requires adjacent organ resection or interposition graft placement.     

Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula

A significant fraction of patients undergoing pancreaticoduodenectomy develop a postoperative pancreaticocutaneous fistula. To identify risk factors for this complication and to delineate its impact on patient outcomes, we conducted a retrospective review of 1891 patients undergoing pancreaticoduodenectomy between 1981 and 2002. Overall, 216 patients (11.4%) developed a postoperative pancreaticocutaneous fistula. In univariate analysis, gender, coronary disease, diabetes mellitus, operative times, blood loss, radical lymphadenectomy, gland texture, and specimen pathology correlated with fistula rates. In a multivariate model, however, only gland texture and coronary disease were statistically predictive. A soft gland was associated with a 22.6% fistula rate, a 20.4-fold increase in fistula risk over those patients with a medium or firm gland (95% confidence interval, 4.7–90.9). No patient with a firm gland developed a fistula. Although 30-day postoperative mortality was not different between those patients with and those without fistula (1.4% versus 1.5%), the mean length of stay was longer (26.0 days versus 13.2 days) and the rates of certain complications were increased in those patients with fistula. In this single-institution experience, pancreaticocutaneous fistula was most strongly predicted by pancreatic texture. Choice of anastomotic technique did not correlate with fistula rates. Pancreaticocutaneous fistula increases postoperative length of stay and morbidity but was not directly associated with increased postoperative mortality. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 Supported in part by National Institutes of Health grant T32-DK-077130.     

Gastric Adenocarcinoma: Reduction of Perioperative Mortality by Avoidance of Nontherapeutic Laparotomy

National trends indicate a longstanding decline in gastric adenocarcinoma due presumably to a decreasing prevalence of Helicobacter pylori infection. Nonetheless, surgical outcomes continue to include relatively high morbidity and mortality rates owing to the advanced stage of disease encountered. We hypothesize that recent immigration patterns are responsible for a leveling off or even reversal of the declining incidence of gastric cancer associated with H. pylori infection. Furthermore, advances in preoperative tumor staging and nonoperative palliation currently permit better patient selection for operation with lower perioperative morbidity and mortality. A retrospective review of a consecutive case series at a public teaching hospital located in an area of high immigration was conducted that included all patients presenting, from 1995 through 2004, with gastric adenocarcinoma. For time comparison purposes, patients were divided into early (1995–1999) and recent (2000–2004) periods. There was no decline in the frequency of gastric adenocarcinoma among the study population over the 10 years. A total of 260 patients were treated of whom 137 (53%) underwent operation. The operation rate decreased and the gastric resection rate increased from the early period to the recent period as fewer incurable advanced stage (M1) patients underwent exploratory laparotomy and were palliated by nonoperative means. Perioperative morbidity and mortality rates also declined over time. Of the four total perioperative deaths, two followed 11 nontherapeutic laparotomies (18% mortality), whereas the only two additional deaths followed 122 curative or palliative laparotomies (2% mortality) (p = 0.034). We conclude that in an area of high immigration there has been no decline in gastric adenocarcinoma rates over the past decade, and the marked reduction in perioperative mortality was due to near elimination of nontherapeutic laparotomy.     

Clinicopathological profile and long-term outcome in young adults with gastric cancer: multicenter evaluation of 214 patients

Background and aims Gastric cancer (GC) is usually diagnosed in the sixth and seventh decade of life, although it may also be found in younger patients. The aim of this study was to analyse the potential differences in demographic and clinicopathological factors between the younger (40 years of age and less) and older (above 40 years) population of GC. Materials and methods An electronic database covering all gastric cancer patients treated between 1977 and 1998 at eight university surgical centres was reviewed. Results Of 3,431 patients treated, 214 (6.2%) were 40 years of age or younger. No differences in tumour staging or location could be identified, but the diffuse type lesions were more common in the younger patients (52.6 vs 29.8%). No differences were found in morbidity and mortality rates, except a higher incidence of cardiopulmonary complications in older patients undergoing stomach resection (6.6 vs 12.3%). Median survival of patients after gastrectomy was 24.7 months (95% confidence interval [CI] 22.7–26.6) and was insignificantly longer in younger (30.8 months, 95%CI 21.0–40.5) than older (24.1 months, 95%CI 22.1–26.1) patients (P = 0.056). Median survival for unresectable cases was 5.4 months (95%CI 5.1–5.7) and was comparable in the younger (median 5.5 months, 95%CI 5.2–5.8) and older (median 4.4 months, 95%CI 3.7–5.1) groups. Conclusion GC in young adults demonstrates only minor deviations from the general population with a similar long-term outcome. R. Bandurski, A. Czupryna, A. Dabrowski, M. Drews, M. Fraczek, H. Jaroszewicz-Heigelmann, A. Jeziorski, M. Krawczyk, A. Kubisz, W. Laszewicz, K. Marlicz, J. Swirkowicz, M. Tenderenda, G. Wallner are members of the Polish Gastric Cancer Study Group.     

Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns

Background Local recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns. Methods Forty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted. Results Morbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8–28]), a local disease–free interval of <12 months (4.2 [1.8–9.8]), and pain radiating to the buttock or further (4.2 [1.6–11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4–40]). Of the patients with recurrence, 56% had failures confined locally or to the lung. Conclusions ASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease–free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences. Presented at the Annual Meeting of the Society of Surgical Oncology, San Diego, California, March 23–26, 2006.     

Comparing Surgical Outcomes in Obese Women Undergoing Laparotomy,Laparoscopy, or Laparotomy With Panniculectomy for the Staging of Uterine Malignancy

Background Limiting surgical morbidity while maintaining staging adequacy is a primary concern in obese patients with uterine malignancy. The goal of this study was to compare the surgical adequacy and postoperative morbidity of three surgical approaches to staging the disease of obese women with uterine cancer. Methods The records of all patients with a body mass index (BMI) of ≥35 undergoing primary surgery for uterine corpus cancer at our institution from January 1993 to May 2006 were reviewed. Patients were assigned to three groups on the basis of planned surgical approach—standard laparotomy, laparoscopy, or laparotomy with panniculectomy. Standard statistical tests appropriate to group size were used to compare the three groups. Results In all, 206 patients with a BMI of ≥35 were grouped as follows: laparotomy, 154 patients; laparoscopy, 25 patients; and laparotomy with panniculectomy, 27 patients. Median BMI was 41 (range, 35–84). Regional lymph nodes were removed in 45% of the laparotomy patients, 40% of the laparoscopy patients, and 70% of the panniculectomy patients (P = .04). Compared with laparotomy, both laparoscopy and panniculectomy yielded higher median pelvic and total lymph node counts (P = .001). Operative time was shortest after standard laparotomy, and blood loss was greatest after panniculectomy. The incidence of all incisional complications was lower for panniculectomy (11%) and laparoscopy (8%) compared with standard laparotomy (35%) (P = .002). On multivariate analysis, a significantly lower risk of total incisional complications was seen for patients undergoing panniculectomy (risk ratio, .25; 95% confidence interval, .071–.88) and laparoscopy (risk ratio, .19; 95% confidence interval, .04–.94). Conclusions Both laparoscopic staging and panniculectomy in a standardized fashion were associated with an improved lymph node count and a lower rate of incisional complications than laparotomy alone. Although definitive conclusions are limited by low patient numbers, the substantial decrease in wound complications suggests that these two approaches should be considered for obese patients undergoing uterine cancer staging. Presented in part at the Society of Gynecologic Oncologists Winter Meeting; Beaver Creek, CO; February 1–3, 2007.     

Value of MELD and MELD-Based Indices in Surgical Risk Evaluation of Cirrhotic Patients: Retrospective Analysis of 190 Cases

Background  Recent studies have suggested that the Model for End-Stage Liver Disease (MELD) may represent a promising alternative to the Child-Turcotte-Pugh classification as a predictive factor of operative mortality and morbidity. This study was designed to evaluate the value of MELD and four MELD-based indices (iMELD: integrated MELD; MESO: MELD to sodium ratio; MELD-Na: MELD with incorporation of sodium; MELD-XI: MELD excluding the International Normalized Ratio) in the quantification of surgical risk for patients with cirrhosis and compare its prognostic value with the Child-Turcotte-Pugh classification and two derived scores (proposed by Huo and Giannini, respectively). Methods  A retrospective study of 190 patients with cirrhosis, operated on in our department between 1993 and 2008, was undertaken. Results  Forty-three percent of patients were included in Child-Turcotte-Pugh A class, and their mean MELD score was 12.2 ± 4.9 (range, 6.4–35.2). Mortality and morbidity rates were 13% and 24%, respectively. In global analysis of mortality, MELD-based indices presented an acceptable prognostic performance (auROC = 71–77%), similar to the three analyzed Child-Turcotte-Pugh-derived scores. iMELD demonstrated the highest prognostic capacity (auROC = 77%; 95% confidence interval (CI), 66–88; p = 0.0001); operative death probability was 4% (95% CI, 3.6–4.4) when the score was inferior to 35, 16.1% (95% CI, 14.4–17.9) between 35 and 45, and 50.1% (95% CI, 42.2–58.1) when superior to 45. In elective surgical procedures, iMELD represented a useful prognostic factor of operative mortality (auROC = 80%; 95% CI, 63–97; p = 0.044) with significant correlation and better accuracy then MELD and Child-Turcotte-Pugh-derived indices. Conclusions  In this study, iMELD was a useful predictive parameter of operative mortality for patients with cirrhosis submitted to elective procedures. Further studies are necessary to define the relevance of MELD-based indices in the individual surgical risk evaluation.     

Improvement of Operative Mortality after Curative Resection for Gastric Cancer: Population-based Study

It is not well known if the improvement in operative mortality after surgery for gastric cancer reported in hospital series can be extrapolated to the whole population. The aim of this study was to determine trends in operative mortality over a 20-year period in a nonselected community-based series of patients. A database of 648 patients with gastric cancer resected with curative intent between 1976 and 1995 in a region with a half-million population was divided into two periods: 1976–1983 and 1984–1995. Nonconditional logistic regression was performed to estimate the independent effects of the studied factors. Operative mortality was higher during the 1976–1983 period than during the 1984–1995 period (17.1% vs. 7.1%; p < 0.0001). When comparing the two study periods, operative mortality decreased dramatically from 26.2% to 10.0% in patients over age 70, from 31.8% to 7.9% after total gastrectomy, and from 30.7% to 6.3% after proximal esophagogastrectomy. Operative mortality after total gastrectomy was nearly the same as that after distal gastrectomy (7.9% vs 5.9%) during the second study period. During the first study period, operative mortality was independently associated with age at diagnosis, type of gastrectomy, and to a lesser degree stage at diagnosis; during the second study period, only age and stage at diagnosis were associated with the risk of operative mortality. This study indicates that in this well defined population operative mortality after curative resection for gastric cancer has decreased during the last 20 years. The results should encourage aggressive management of patients with gastric cancer, even in patients over 70 years of age.