Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis

BackgroundThe concept of textbook outcome (TO) has been proposed for analyzing quality of surgical care. This study assessed the incidence of TO among patients undergoing curative gastric cancer resection, predictors for TO achievement, and the association of TO with survival.MethodAll patients with gastric and gastroesophageal junction cancers undergoing curative gastrectomy between January 2014–December 2017 were identified from a population-based database (Spanish EURECCA Registry). TO included: macroscopically complete resection at the time of operation, R0 resection, ≥15 lymph nodes removed and examined, no serious postoperative complications (Clavien-Dindo ≥II), no re-intervention, hospital stay ≤14 days, no 30-day readmissions and no 90-day mortality. Logistic regression was used to assess the adjusted achievement of TO. Cox survival regression was used to compare conditional adjusted survival across groups.ResultsIn total, 1293 patients were included, and TO was achieved in 541 patients (41.1%). Among the criteria, “macroscopically complete resection” had the highest compliance (96.5%) while “no serious complications” had the lowest compliance (63.7%). Age (OR 0.53 for the 65–74 years and OR 0.34 for the ≥75 years age group), Charlson comorbidity index ≥3 (OR 0.53, 95%CI 0.34–0.82), neoadjuvant chemoradiotherapy (OR 0.24, 95%CI 0.08–0.70), multivisceral resection (OR 0.55, 95%CI 0.33–0.91), and surgery performed in a community hospital (OR 0.65, CI95% 0.46–0.91) were independently associated with not achieving TO. TO was independently associated with conditional survival (HR 0.67, 95%CI 0.55–0.83).ConclusionTO was achieved in 41.1% of patients who underwent gastric cancer resection with curative intent and was associated with longer survival.     

Frailty assessment can predict textbook outcomes in senior adults after minimally invasive colorectal cancer surgery

AimColorectal cancer (CRC) surgery can be associated with suboptimal outcomes in older patients. The aim was to identify the correlation between frailty and surgical variables with the achievement of Textbook Outcome (TO), a composite measure of the ideal postoperative course, by older patients with CRC.MethodAll consecutive patients ≥70years who underwent elective CRC-surgery between January 2017 and November 2021 were analyzed from a prospective database. To obtain a TO, all the following must be achieved: 90-day survival, Clavien-Dindo (CD) < 3, no reintervention, no readmission, no discharge to rehabilitation facility, no changes in the living situation and length of stay (LOS) ≤5days/≤14days for colon and rectal surgery respectively. Frailty and surgical variables were related to the achievement of TO.ResultsFour-hundred-twenty-one consecutive patients had surgery (97.7% minimally invasive), 24.9% for rectal cancer, median age 80 years (range 70–92), median LOS of 4 days (range 1–96). Overall, 288/421 patients (68.4%) achieved a TO. CD 3–4 complications rate was 6.4%, 90-day mortality rate was 2.9%.At univariate analysis, frailty and surgical variables (ileostomy creation, p = 0.045) were related to. However, multivariate analysis showed that only frailty measures such as flemish Triage Risk Screening Tool≥2 (OR 1.97, 95%CI: 1.23–3.16; p = 0.005); Charlson Index>6 (OR 1.61, 95%CI: 1.03–2.51; p = 0.036) or Timed-Up-and-Go>20 s (OR 2.06, 95%CI: 1.01–4.19; p = 0.048) independently predicted an increased risk of not achieving a TO.ConclusionThe association between frailty and comprehensive surgical outcomes offers objective data for guiding family counseling, managing expectations and discussing the possible loss of independence with patients and caregivers.     

A multi-institutional analysis of Textbook Outcomes among patients undergoing cytoreductive surgery for peritoneal surface malignancies

BackgroundWhile recent studies have introduced the composite measure of a textbook outcome (TO) for measuring postoperative outcomes, the incidence of a TO has not been characterized among patients undergoing cytoreductive surgery (CRS) for peritoneal surface malignancies (PSM).Study designAll patients who underwent CRS ± hyperthermic intraperitoneal chemotherapy (HIPEC) between 1999 and 2017 from 12 institutions were included. A TO was defined as the absence of any of the following criteria: completeness of cytoreduction >1, reoperation within 90-days, readmission within 90-days, mortality within 90-days, any grade ≥2 complication, hospital stay >75th percentile, and non-home discharge.ResultsAmong 1904 patients who underwent CRS, only 30.9% achieved a TO while 69.1% failed to achieve a TO most commonly because of postoperative complications. On multivariable analysis, factors associated with achieving a TO were age <65 years (OR: 1.5), albumin ≥3.5 g/dl (OR: 5.7), receipt of HIPEC (OR: 4.5), PCI ≤14 (OR: 2.2), intravenous fluid volume ≤10,000 ml (OR: 2.1), blood loss ≤1000 ml (OR: 4.2) and operative time <7 h (OR: 1.9); while receipt of neoadjuvant therapy (OR: 0.7) and liver resection (OR: 0.4) were associated with not achieving a TO (all p < 0.05). TO was associated with improved overall survival (median 159 months vs 56 months, p < 0.01) even after controlling for confounders on Cox regression (hazard ratio: 2.5, p < 0.01).ConclusionAmong patients undergoing CRS ± HIPEC for PSM, failure to achieve a TO is common and independently associated with worse overall survival.     

Reappraise role of lymph node status in patterns of recurrence following curative resection of gastric adenocarcinoma

ObjectiveTo examine the association between lymph node status and recurrence patterns in completely resected gastric adenocarcinoma.MethodsWe retrospectively assessed 1,694 patients who underwent curative gastrectomy from January 2010 to August 2014. Patients stratified according to lymph node status and recurrence patterns among different subgroups were compared.ResultsOf all, 517 (30.5%) patients developed recurrent disease, and complete data of recurrence could be obtained in 493 (95.4%) patients. For pN0 patients, the patterns of recurrence were different according to pT stage: locoregional recurrence was most common in patients with pT1−2 disease (57.1%), distant recurrence was most common in patients with pT3 disease (57.1%), and peritoneal recurrence was most common in patients with pT4a disease (66.7%). For pN+ patients, distant metastasis was most common pattern irrespective of pT stage. The site-specific trend of recurrence showed that locoregional recurrence increased within 5 years in patients with pN0−2 disease but plateaued 3 years after surgery in patients with pN3 disease. Time to recurrence was significantly longer for the pN0 patients compared with the pN+ patients (median: 25 vs. 16 months, P=0.001). Moreover, post-recurrence survival was significantly better for the pN0 patients than for the pN+ patients (median: 12 vs. 6 months, P<0.001), especially in patients with non-peritoneal recurrence, late recurrence, single recurrence, and receipt of potential curative treatment. ConclusionsAmong clinicopathologic factors, lymph node status is the most important factor associated with recurrence patterns after curative gastrectomy. Lymph node status may be used as an adjunct in clinical decision-making about postoperative therapeutic and follow-up strategies.     

Short- and long-term predictive power of the preoperative Geriatric Assessment components in older cancer patients undergoing high-risk abdominal surgery

IntroductionThe pathological stage of the cancer and presence of postoperative complications are the most important predictors of survival in older oncologic patients. Therefore, determining biological age, and risks connected with it, should be the key factor in the preoperative assessment. It may be accomplished by using a Geriatric Assessment (GA). However, it is not established which components are most useful for predicting short- and long-term postoperative outcomes in cancer patients undergoing high-risk abdominal surgery.Materials and methodsA total of 334 consecutive cancer patients aged ≥70 years underwent elective abdominal surgery and were followed-up prospectively for 12 months. The preoperative GA consisted of eight domains: functional, physical activity, comorbidity, polypharmacotherapy, nutritional, cognition, mood, and social support. Logistic regression analyses were used to analyse the predictive ability.ResultsAll components of GA were independent risk factors of 30-day major morbidity apart from ADL, BOMC, Polypharmacy (OR 0.6–1.3; p < 0.001). However, ADL, TUG, the polypharmacy and the MOS-SSS turned out to be significant predictors of 30-day mortality (OR 0.72–1.46; p < 0.001). In turn, only ADL, CDT and MOS-SSS were valid predictors of 12-months mortality (OR 0.46–0.85; p < 0.001). Frailty (surrogate of the biological age), not the chronological age, were also independent predictors of all outcomes (OR 4.71–8.56 p < 0.001).ConclusionNot the chronological age but components of GA and frailty are significant predictors of both 30-day postoperative outcome and 12-months mortality in older cancer patients undergoing high-risk abdominal surgery.     

The impact of the 30-day postoperative complications on the quality of life following gastrectomy for gastric carcinoma: A prospective study

BackgroundThe effect of postoperative complications on long-term quality of life (QoL) is controversial in abdominal surgery. This study aimed to investigate the impact of 30-day postoperative complications on long-term QoL after gastrectomy.MethodThis is a longitudinal cohort study that enrolled 908 patients undergoing gastrectomy for gastric cancer between 2016 and 2017. QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) generic cancer (QLQ C-30) and gastric module (STO-22) preoperatively and at 1, 6, 12, and 24 months postoperatively. Patients were divided into the morbidity (30-day postoperative complications) and no-morbidity groups, and the postoperative QoL change was compared using a linear mixed model.ResultsThe mean age was 62.5 ± 12.0 years. Subtotal and total gastrectomy was performed in 763 (84.0%) and 145 (16.0%) patients, respectively. There were 189 (20.8%) patients developing postoperative complications. The morbidity group showed worse scores in several functions and symptoms of QoL at the baseline. However, the two groups showed no significant difference in postoperative changes in most functions and symptoms of the QLQ C-30 and STO-22 (P_{group × time} > 0.05). The recovery of global health (P_{group × time} < 0.001) and anxiety (P_{group × time} = 0.008) was slightly better in the morbidity group. The subgroup analysis of patients developing major abdominal complications showed similar results.ConclusionThe morbidity group showed worse QoL in several functions and symptoms at the baseline. However, postoperative complications had little influence on QoL change following gastrectomy for gastric cancer.     

Serious complications of pancreatoduodenectomy correlate with lower rates of adjuvant chemotherapy: Would high-risk patients benefit from neoadjuvant therapy?

IntroductionPatients who suffer a serious complication of pancreatoduodenectomy (PD) may have their adjuvant chemotherapy (AC) delayed or omitted as a result. We aimed to investigate whether PD complications affected AC rates.Materials and methodsA retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (2006–2015) was performed; 90-day mortality patients were excluded. Patients who commenced AC were compared to those who did not (morbidity rates and survival) and patients who developed selected postoperative complications were compared to those who did not (AC rates and survival).Results157 patients were included and 90-day mortality was 3.8%. Of the remaining patients, 102 (68.5%) received AC (AC data unavailable for two patients). Survival was longer in the AC group (p = 0.004). AC patients had less frequently experienced a postoperative chest infection (8.82% vs 34.0%, p = 0.0003) or a postoperative complication which was Clavien-Dindo (CD) grade ≥ II (29.4% vs 57.4%, p = 0.0019) or ≥ III (6.86% vs 21.3%, p = 0.023). Patients who experienced a postoperative chest infection (36.0% vs 75.0%, p = 0.0003) or a postoperative complication which was CD grade ≥ II (48.9% vs 73.1%, p = 0.0099) or ≥ III (29.4% vs 70.3%, p = 0.0018) less frequently commenced AC.ConclusionPatients who received AC had less frequently experienced a serious postoperative complication. Efforts should be made to preoperatively identify those who are high-risk for a serious complication as this cohort may benefit from neoadjuvant therapy.     

Comparison of preoperative assessment tools in older patients undergoing cancer surgery: A prospective study

IntroductionSurgery in older adults with cancer is complex due to multiple age related confounding factors. There are many scoring systems available for preoperative risk stratifications of older patients. Currently very few prospective studies comparing the various commonly used scales are available. This is the first study which compares the established preoperative risk assessment tools of Eastern Cooperative Oncology Group Performance Scale (ECOG) and American Society of Anaesthesiologists Physical Status Scale (ASA) with frailty scores of Modified Frailty Index (MFI) and Clinical Frailty Scale (CFS).Material and MethodsThis is a prospective observational study of older patients with cancer who underwent oncosurgery in a tertiary cancer centre during the one-year study period. Patients were scored on the CFS, MFI, ASA and ECOG scales. All patients were followed up for 30 days immediately following surgery and their post operative complications were documented. Univariate and multivariate analyses were done and a p value of ≤0.05 was considered statistically significant.ResultsOf the 820 patients studied, 15.6% had prolonged hospital stay, 9.1% had 30-day morbidity, 0.7% had readmission, and mortality was 1.1%. High-risk scores on the ASA and CFS were significantly associated with prolonged postoperative stay, readmission, morbidity, and mortality (p < 0.05). High-risk scores on the ECOG was significantly associated with prolonged hospital stay (p = 0.027), 30-day morbidity (p = 0.003), and mortality (p = 0.001), but not with readmission. There was no significant association between MFI score and the postoperative variables studied (p > 0.05). On multivariate analysis, morbidity was significantly associated only with male gender (p = 0.015), higher cancer stage (p = 0.005), higher ASA score (p = 0.029), and prolonged hospital stay (p = 0.001). Mortality was significantly associated only with emergency surgery (p = 0.012) and prolonged hospital stay (p = 0.004), and prolonged hospital stay was significantly associated with advanced cancer stage (p = 0.001) and emergency surgery (p = 0.02).ConclusionsIn older patients undergoing cancer surgery, ASA and CFS are predictors of prolonged postoperative stay, morbidity, mortality, and readmission. A high-risk ECOG score is predictive of prolonged post operative stay, 30-day morbidity, and mortality, but not of readmission. Score on MFI is not a predictor of postoperative outcomes. Newer predictive tools which include cancer- specific factors are required for better management of these patients.     

Immediate Adjuvant Chemotherapy in Non-Metastatic Colon Cancer: Phase I Trial Evaluating a Novel Treatment Protocol

BackgroundThe optimal timing of adjuvant chemotherapy (AC) in non-metastatic colon cancer is poorly defined. Delays in AC result in decreased survival. Effective cytotoxic treatments should be considered during the perioperative phase of care. The immediate adjuvant chemotherapy (IAC) concept intends to capitalize on the therapeutic benefits that can be achieved in the perioperative period. We aim to demonstrate that IAC is safe and tolerable.Patient and MethodsMicrosatellite stable invasive adenocarcinomas were treated with intravenous Leucovorin 20 mg/m2 and single dose of 5-Flurouracil 400mg/m2 at the time of surgery. High-risk stage II and stage III received the first dose of standard AC at 14 days after surgery. Serial measurements of blood-based biomarkers were measured. Quality of life (QOL) was measured using EORTC QLQ-C30.ResultsOf the 20 patients recruited, 40% had final pathology of stage III, 40% stage II and 20% stage I. All patients received intra-operative chemotherapy with no associated morbidity. Median length of stay was 2 days (range of 2-4). There was no intraoperative morbidity with 5% (N = 1) grade 3 complication. AC was administered to 65% of patients. The median time to AC was 14 days (range 14-36). Overall quality of life and health scores were similar before surgery and at 30-day postoperatively (P < .05).ConclusionsA protocol based on IAC starting at the time of surgical resection was found to be safe and feasible with no adverse effects on surgical morbidity or quality of life. Further prospective studies are needed to explore the oncologic benefit of this novel systemic treatment approach.     

The association between body mass index and postoperative complications, 30-day mortality and long-term survival in Dutch patients with colorectal cancer

IntroductionThis retrospective study aims to examine the association between body mass index (BMI) and serious postoperative complications, 30-day mortality and overall survival in colorectal cancer (CRC) patients.Materials and methodsAll CRC patients diagnosed between 2008 and 2013 in the south-eastern part of the Netherlands were included. Patients were categorized into four BMI groups: underweight (<18.5), normal weight (18.5 ≥ BMI<25), overweight (25 ≥ BMI<30), and obese (≥30).ResultsA total of 7371 CRC patients were included (underweight 133 (1.8%); normal weight 2054 (41.4%); overweight 2955 (40.1%); obesity 1229 (16.7%)). Underweight patients were more likely to have postoperative complications (18.8% vs. 11.7%, adjusted OR 1.95, 95% CI 1.08–3.49) and had a worse 30-day mortality (9.8% vs. 3.3%, adjusted OR 4.37, 95% CI 2.03–9.42) compared to normal weight patients. After stratification for stage (stage I-III and stage IV), underweight was associated with a worse overall survival in both groups compared to normal weight (stage I-III: HR 2.06, 95%CI 1.51–2.80; stage IV: HR 1.65, 95% CI 1.11–2.45). Overweight was associated with an improved overall survival compared to normal weight in both stage groups. Only in stage IV patients obesity was associated with a significant better overall survival compared to stage IV normal weight patients.ConclusionUnderweight CRC patients were more likely to have postoperative complications and a worse 30-day mortality compared to patients in other BMI categories. The underweight population also has a worse long-term survival while overweight CRC patients and obese stage IV CRC patients were associated with an improved survival compared to normal weight patients.     

Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study

Background

Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer.

Methods

Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression.

Results

In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%, p = 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26, p < 0.001), while no difference was found in the rate of tumor-free resection margins. Better overall survival was observed after laparoscopic gastrectomy (HR 0.63, p < 0.001).

Conclusions

Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.

     

Adjuvant chemotherapy with cisplatin and gemcitabine versus chemotherapy at relapse in patients with muscle-invasive bladder cancer submitted to radical cystectomy: an Italian,multicenter, randomized phase III trial

BackgroundThe purpose of the study was to evaluate the benefit of adjuvant chemotherapy (AC) versus surgery alone in patients with muscle-invasive bladder cancer (MIBC).Patients and methodsOne hundred and ninety-four patients with pT2G3, pT3–4, N0–2 transitional cell bladder carcinoma were randomly allocated to control (92 patients) or to four courses of AC (102 patients). These latter patients were further randomly assigned to receive gemcitabine 1000 mg/m² days 1, 8 and 15 and cisplatin 70 mg/m² day 2 or gemcitabine as above plus cisplatin 70 mg/m² day 15, every 28 days.ResultsAt a median follow-up of 35 months, the 5-year overall survival (OS) was 48.5%, with no difference between the two arms [P = 0.24, hazard ratio (HR) 1.29, 95% confidence interval (CI) 0.84–1.99]. Mortality hazard was significantly correlated with Nodes (N) and Tumor (T) stage. The control and AC arms had comparable disease-free survival (42.3% and 37.2%, respectively; P = 0.70, HR 1.08, 95% CI 0.73–1.59). Only 62% of patients received the planned cycles. A significant higher incidence of thrombocytopenia was observed in patients receiving cisplatin on day 2 (P = 0.006). A similar global quality of life was observed in the two arms.ConclusionThe study was underpowered to demonstrate that AC with cisplatin and gemcitabine improves OS and disease-free survival in patients with MIBC.     

Successful Treatment of Incidental Prostate Cancer by Radical Transurethral Resection of Prostate Cancer

BackgroundTo evaluate the rationale for RTUR-PCa against pT1a/b cancer, we analyzed oncological and functional outcomes.Patients and MethodsFifty-six patients with incidental prostate cancer were included and the age ranged from 66 to 91 years (mean, 76.6; median, 75.0). Preoperative prostate specific antigen (PSA) levels were between 0.70 and 44.1 ng/mL (mean, 5.90; median, 4.60). We performed 69 RTUR-PCa's by resecting and fulgurating the residual prostate tissues after previous transurethral resection of the prostate. Prostate specific antigen nonrecurrence rate was calculated by Kaplan–Meier method.ResultsFollow-up duration of 51 patients was mean ± SD 64.1 ± 21.6 months (median, 67.8 months; range, 13.8-99.8) excluding 5 patients that were lost to follow-up. Prostate specific antigen failure developed in 3 patients (5.9%). In the other 48 patients, PSA stabilized as follows: PSA ≤ 0.01, 24 cases; ≤ 0.02, 5 cases; ≤ 0.03, 6 cases; ≤ 0.04, 3 cases; ≤ 0.1, 7 cases; and ≤ 0.4, 3 cases. Prostate specific antigen nonrecurrence rates were 100% for pT2a and 91.3% for pT2b at the mean follow-up period of 64.1 months. Nonrecurrence rate grouped by D'Amico classification system were 100% in the low-risk group, 94.7% in the intermediate-risk group, and 88.2% in the high-risk group, respectively. Water intoxication did not develop and no patients required transfusion. Bladder neck contracture, which developed in 22 out of 51 patients (43.1%), was the most frequent postoperative complication. Postoperative incontinence was temporary and disappeared within 3 months in all patients.ConclusionSatisfactory oncologic and functional results suggest that RTUR-PCa could be a promising option for radical treatment against incidental prostate cancer.     

The effect of age at diagnosis on prostate cancer mortality: A grade-for-grade and stage-for-stage analysis

ObjectiveTo evaluate the effect of advancing age on cancer-specific mortality (CSM) after radical prostatectomy (RP).Materials and methodsOverall, 205,551 patients with PCa diagnosed between 1988 and 2009 within the Surveillance Epidemiology and End Results (SEER) database were included in the study. Patients were stratified according to age at diagnosis: ≤50, 51–60, 61–70, and ≥71 years. The 15-year cumulative incidence CSM rates were computed. Competing-risks regression models were performed to test the effect of age on CSM in the entire cohort, and for each grade (Gleason score 2–4, 5–7, and 8–10) and stage (pT2, pT3a, and pT3b) sub-cohorts.ResultsAdvancing age was associated with higher 15-year CSM rates (2.3 vs. 3.4 vs. 4.6 vs. 6.3% for patients aged ≤50 vs. 51–60 vs. 61–70 vs. ≥71 years, respectively; P < 0.001). In multivariable analyses, age at diagnosis was a significant predictor of CSM. This relationship was also observed in sub-analyses focusing on patients with Gleason score 5–7, and/or pT2 disease (all P ≤ 0.05). Conversely, age failed to reach the independent predictor status in men with Gleason score 2–4, 8–10, pT3a, and/or pT3b disease.ConclusionsAdvancing age increases the risk of CSM. However, when considering patients affected by more aggressive disease, age was not significantly associated with higher risk of dying from PCa. In high-risk patients, tumor characteristics rather than age should be considered when making treatment decisions.     

Prognostic value of D-dimer levels in patients with gastric cancer undergoing gastrectomy

BackgroundPlasma D-dimer levels have been associated with tumor progression and oncological outcomes in several cancers. This study assessed the relationships of D-dimer levels with clinicopathological features and survival outcomes in patients with gastric cancer undergoing gastrectomy.MethodsData from 666 patients with gastric cancer who underwent gastrectomy between June 2012 and December 2015 were collected and analyzed; these data were acquired during a previous randomized clinical trial (PROTECTOR trial, NCT01448746). Optimal cut-off values of preoperative, immediate postoperative, postoperative-day 1, postoperative-day 4, and postoperative-day 30 D-dimer levels for predicting overall survival (OS) and disease-free survival (DFS) were determined using Contal and O'Quigley's method. The optimal cut-off value of the immediate postoperative D-dimer level for predicting OS was 3.33. Patients were divided into D-dimer high and low groups based on these cut-off values.ResultsHigh immediate postoperative D-dimer levels were significantly associated with advanced T stage and TNM stage (P = 0.001 and P = 0.006, respectively). OS and DFS were significantly lower for patients in the D-dimer high group than for patients in the D-dimer low group; this relationship was consistent for preoperative, immediate postoperative, postoperative-day 1, and postoperative-day 30 D-dimer levels. Multivariate analysis identified the immediate postoperative D-dimer level as an independent prognostic factor for OS (hazard ratio, 2.52; P = 0.010).ConclusionsElevated immediate postoperative D-dimer level was predictive of poor long-term outcomes in patients with gastric cancer after gastrectomy. Immediate postoperative D-dimer levels may offer simple and inexpensive clinical decision-making guidance for patients with gastric cancer after gastrectomy.     

Long-term survival estimates in older patients with pathological stage I gastric cancer undergoing gastrectomy: Duocentric analysis of simplified scoring system

BackgroundOur aim was to determine factors predictive of long-term post-gastrectomy outcomes in older adults with pathological stage I gastric cancer (GC).MethodsA total of 175 patients with resected pathological stage I GC at two institutions were reviewed, each ≥75 years old at the time of gastrectomy and full participants in a 5-year follow-up program. The procedures were undertaken between January 2006 and December 2011. Patients were divided into two groups: survivors and non-survivors at postoperative Year 5. Univariate and multivariate analyses were applied to identify independent predictors of 5-years survival, including preoperative, surgical, and histopathologic variables.ResultsMultivariate analysis of overall survival (OS) at 5 years indicated that prognostic nutritional index (PNI) <45 and the American Society of Anesthesiologists physical status (ASA-PS) 3 were independently associated with unfavorable outcomes. A clinical score consisting of 1-point each for these two variables proved useful in predicting survival after gastrectomy (5-year OS: 0 point, 86.6%; 1-point, 51.6%; 2-point, 33.3%; p < .001, area under the curve [AUC] = 0.757).ConclusionsLong-term survival of older adults with pathological stage I GC is unfavorable in patients displaying both ASA-PS 3 and PNI < 45. A simple scoring method, based on combined ASA-PS/PNI determinations, provides an accurate prognostic prediction for these patients.     

Systematic review of the surgical strategies of adenocarcinomas of the gastroesophageal junction

IntroductionThe optimal surgical treatment of patients with adenocarcinoma of the gastroesophageal junction has not been established yet.ObjectiveTo evaluate the surgical strategies to treat adenocarcinoma of the gastroesophageal junction.MethodsDatabases Pubmed, Cochrane, and Embase were searched for “adenocarcinoma of the gastroesophageal junction” AND (“surgery” OR “esophagectomy” OR “gastrectomy”) or its synonyms or abbreviations. Only comparative studies that evaluated gastrectomy versus esophagectomy were included.ResultsIn total 10 cohort studies comparing esophagectomy versus gastrectomy fulfilled the quality criteria. The R0 resection rates varied between 72–93% for esophagectomy and 62%–93% for gastrectomy. Morbidity was 33–39% after esophagectomy versus 11–54% after gastrectomy. The 30-day mortality ranged between 1.0–2.3 after esophagectomy and 1.8–2.7% after gastrectomy. At 6 months after surgery, health-related quality of life was higher after total gastrectomy than after esophagectomy. The 5-year survival rates varied between 30–42% for esophagectomy and 18–38% for gastrectomy, but were not significantly different.ConclusionNo clear oncologic benefit of either esophagectomy or gastrectomy in patients with adenomacarcinoma of gastroesophageal junction could be observed. However, gastrectomy seems to be accompanied with better quality of life. Future research should preferably consist of a multicenter RCT comparing esophagectomy and gastrectomy for adenocarcinomas of the gastroesophageal junction.     

Pre- and post-operative low prognostic nutritional index influences survival in older patients with gastric carcinoma

ObjectivesThe survival impact of the preoperative prognostic nutritional index (PNI) has been investigated in older patients with gastric carcinoma (GC), while that of the postoperative PNI has yet to be addressed. We evaluated the significance of PNI before and after surgery in older GC patients (≥75 years).Materials and MethodsIn total, 309 older GC patients undergoing radical gastrectomy between 2006 and 2016 were retrospectively reviewed. The PNI was evaluated before and at six months after gastrectomy. Patients were divided into low (<45) and high (≥45) PNI groups. The impact of low PNI on overall survival (OS), cancer-specific survival (CSS), and non-GC-related death were investigated.ResultsLow PNI was present in 134 patients (43.4%) preoperatively and 121 (39.2%) postoperatively. Low pre-PNI was independently associated with poor overall survival (P < .001). Similarly, OS was significantly stratified by post-PNI (P < .001). The significant survival difference according to post-PNI was present only in pStage I disease (P < .001). Low post-PNI independently increased the risk of non-GC-related death in a multivariable analysis (P = .002). In contrast, CSS was not stratified by post-PNI (P = .45). In the high pre-PNI group, total gastrectomy and super-older age (≥80 years) independently increased the risk of low post-PNI, which was significantly associated with poor survival outcomes.ConclusionsPre- and post-operative PNI are useful for predicting long-term outcomes in older patients with GC. Low postoperative PNI is a powerful determinant of mortality due to other diseases. Optimal perioperative management is required for those at high risk of malnutrition postoperatively.