Prognostic Significance of Non-curative Gastrectomy for Incurable Gastric Carcinoma

Background

To date, there is no convincing evidence regarding the benefits of non-curative gastrectomy for gastric carcinoma. In the present study, we reviewed the outcomes of patients who underwent surgery for incurable gastric carcinoma and evaluated the prognostic significance of non-curative gastrectomy.

Methods

Between 2004 and 2011, a total of 197 patients undergoing elective surgery for incurable gastric carcinoma were divided into the gastric resection and non-resection groups. Patient survival was compared between the two groups, and the prognostic significance of non-curative gastrectomy was investigated using multivariate analysis.

Results

Overall, 162 (82.2 %) patients underwent non-curative gastrectomy with morbidity and mortality of 21.0 and 1.2 %, respectively. The median survival of patients undergoing non-curative gastrectomy was significantly longer than that of patients without gastrectomy (12.4 vs. 7.1 months, p = 0.003). Patients who received postoperative chemotherapy also showed significantly better survival than those without chemotherapy (13.2 vs. 4.3 months, p < 0.001). Multivariate analysis revealed that non-curative gastrectomy was an independent prognostic factor (hazard ratio 0.61, 95 % CI 0.40–0.93, p = 0.023) after adjusting for postoperative chemotherapy and other clinical factors. Median survival in patients receiving non-curative gastrectomy combined with postoperative chemotherapy was 13.9 months, which was significantly longer than gastrectomy alone (5.4 months), chemotherapy alone (9.6 months), and no treatment (3.2 months) (p < 0.001).

Conclusion

Primary tumor resection and postoperative chemotherapy are the most important prognostic factors for incurable gastric carcinoma. The survival benefits of non-curative gastrectomy need to be confirmed in a large-scale, randomized trial.     

Significance of the Inflammation-Based Glasgow Prognostic Score for Short- and Long-Term Outcomes After Curative Resection of Gastric Cancer

Background

The Glasgow prognostic score (GPS) is a patient-related measure to determine long-term outcomes in cancer patients. This study examined the impact of GPS on outcomes including postoperative complications after curative resection of gastric cancer.

Methods

The systemic inflammatory response was assessed by GPS, and the severity of postoperative complications was evaluated according to the Clavien?CDindo classification. Survival analysis was performed by the Kaplan?CMeier method and the log rank test. Multivariate analysis was performed to determine significant associations with complications by a logistic regression model and the independent prognostic values by Cox??s proportional hazards model.

Results

Study patients (n?=?1017) were allocated as follows: 904 (88.9?%) to GPS 0, 92 (9.0?%) to GPS 1, and 21 (2.1?%) to GPS 2. One hundred sixty-three patients (16.0?%) had postoperative complications of ?? grade 2. Multivariate logistic analysis identified gender, body mass index, tumor location, tumor depth, blood transfusion, and comorbidity as significantly correlated with postoperative complications. However, GPS was not associated with the incidence of complication. On the other hand, multivariate analysis for overall survival identified GPS as an independent prognostic factor.

Conclusions

GPS is a significant predictor of long-term survival in curable gastric cancer surgery but not of short-term outcomes.     

Prognostic Significance of Antithrombin III Levels for Outcomes in Patients with Hepatocellular Carcinoma After Curative Hepatectomy

Background

Although several studies have shown that serum antithrombin III (ATIII) has anti-inflammatory effects, the prognostic value of ATIII in HCC is unknown. We investigated the influence of preoperative ATIII levels on the outcome of patients who underwent hepatectomy for hepatocellular carcinoma (HCC).

Methods

Data from 440 patients (314 patients with ATIII ??70?% and 126 patients with ATIII <70?%) who underwent curative hepatectomy for HCC were retrospectively collected and analyzed. To overcome bias due to the different distribution of covariates for the 2 groups, propensity score matching was performed on the patients, and outcomes were compared.

Results

The propensity score analysis revealed that 65 patients with ATIII of ??70?% (group 1) and 65 patients with ATIII of <70?% (group 2) had the same preoperative and operative characteristics (excluding the ATIII level). The overall survival rate and the disease-free survival rate was significantly higher in group 1 than in group 2 (P?=?0.005 and 0.011, respectively). Multivariate analysis showed that ATIII was a significant favorable factor for overall survival and disease-free survival of patients with HCC after curative hepatectomy.

Conclusions

The prognosis of patients with HCC was found to be associated with preoperative antithrombin III levels. ATIII may be useful for predicting outcomes of patients with HCC after curative hepatectomy.     

Prognostic Significance of Microscopic Positive Margins for Gastric Cancer Patients with Potentially Curative Resection

Background  

Most previous studies concerning the impact of positive margins on patient outcomes were based on patients with D1 lymphadenectomy. The prognostic significance of positive margins for patients with D2/D3 lymphadenectomy has not been investigated.     

Prognostic Significance of Free Peritoneal Tumor Cells in the Peritoneal Cavity Before and After Neoadjuvant Chemotherapy in Patients with Gastric Carcinoma Undergoing Potentially Curative Resection

Background  

Free peritoneal tumor cells (FPTCs) are an independent prognostic factor in patients undergoing curative resection for gastric carcinoma. Whether neoadjuvant chemotherapy (NAC) can eliminate FPTCs in the peritoneal lavage remains unclear. The aim of the study was to determine the effect of NAC on FPTCs.     

Preoperative Multivariate Prediction of Morbidity After Gastrectomy for Adenocarcinoma

Background: Gastrectomy remains the only curative treatment for gastric cancer. However,surgical morbidity and mortality remains high. Our aim was to identify the risk factors thatdetermine operative morbidity and mortality and to describe a simple method for preoperativestratification of morbidity outcome.Methods: Retrospective review of patients who underwent gastrectomy for gastric cancer.Multivariate analysis was used to define risk factors for surgical morbidity and mortality.Results: A total of 208 cases were included. Fifty-one episodes of operative morbidity and 19surgery-related deaths were found. Operative blood loss (risk ratio [RR], 1.0012), serum albumin(RR, 0.42), extent of gastrectomy (RR, 2.8), lymphocyte count (RR, 0.999), and splenectomy (RR,1.51) were the most important risk factors for morbidity. However, location of the tumor, serumalbumin level, and lymphocyte count were the most important preoperative risk factors thatdetermine the appearance of surgical complications. Receiver operating characteristic analysis ofthis model allowed definition of three risk groups in terms of surgical morbidity (11.8%, 28.5%, and52.4%, respectively).Conclusions: A new method for preoperative calculation of the probability of surgical complicationswas developed. It must be validated prospectively and in different settings to be used inpreoperative interventions designed to reduce that risk.     

Analysis of Prognostic Factors Affecting Survival After Initial Recurrence and Treatment Efficacy for Recurrence in Patients Undergoing Potentially Curative Hepatectomy for Hepatocellular Carcinoma

Background Survival analysis in patients with initial recurrence after curative hepatectomy for hepatocellular carcinoma (HCC) has not been well evaluated. In addition, selections of the most effective treatments for patients with recurrent HCC still remain controversial. Methods Three hundred and nineteen patients who underwent potentially curative hepatectomies were followed for initial recurrence, and factors predictive of recurrence were determined. The factors affecting survival including pattern of recurrence and treatment modalities from the time of initial recurrence in 211 patients were retrospectively analyzed. Results The overall 5-year disease-free survival rate of 319 patients was 31.1%. The 5-year survival rate of 211 patients from the time of initial recurrence was 31.9%. In a multivariate analysis, a low indocyanine green retention rate, lack of liver cirrhosis, a long interval before recurrence, the absence of portal vein invasion, and intrahepatic recurrence (≤3 nodules) were shown to be significantly favorable prognostic factors after the initial recurrence. The 5-year survival rate of patients with intrahepatic recurrence (≤3 nodules) was 42.3%, and no survival differences were observed among different treatment modalities. Conclusion When the initial recurrence occurred after a longer interval, and/or with three or fewer intrahepatic recurrent nodules, a favorable prognosis could be expected in those patients with better liver function and no portal vein invasion at the time of the primary hepatectomy. It is important to conduct a randomized controlled trial to clarify a method for selecting optimal treatment in patients with a smaller number of initial intrahepatic recurrences.     

腹腔镜胃癌D2根治术在进展期胃癌中的应用探讨

目的探讨腹腔镜下胃癌D2根治术治疗进展期胃癌的可行性。方法对2008年1～8月32例进展期胃癌行腹腔镜下D，根治术，根治性远端胃大部切除术清扫1、3、4、5、6、7、8、9、11p、12a、14v组淋巴结；根治性近端胃大部切除术清扫1、2、3、4、7、8、9、10、11组淋巴结；根治性全胃切除术清扫1、2、3、4、5、6、7、8、9、10、11、12a、14v组淋巴结；所有患者均于上腹部做辅助小切口行病灶移除及消化道重建。结果32例均顺利完成腹腔镜下胃癌D2根治手术，无中转开腹，其中根治性远端胃切除18例，根治性近端胃切除2例，根治性全胃切除12例。远、近端胃根治性切除术时间250～390min，平均325min；全胃根治性切除300—450min，平均347min。术中出血量：远、近端胃根治性切除术50～250ml，全胃根治性切除术60—350ml，术中均未输血。所有标本切缘均阴性。排气时间24—72h，平均38h；进流质时间2～5d，平均2．8d；无吻合口漏等手术相关并发症。30例随访1～8个月，未见复发和转移，亦未发生切口和穿刺口种植。结论腹腔镜下胃癌D2根治术应用于治疗进展期胃癌，安全、可行、有效、创伤小且近期效果良好。     

腹腔镜辅助胃癌D2根治术的临床研究

目的 探讨腹腔镜辅助下胃癌D2根治术治疗胃癌的可行性、安全性和根治性.方法 回顾性分析2011年5月~2012年9月进行的112例胃癌根治术,由患者选择手术方式,腹腔镜组50例,开腹组62例.比较2组手术时间、术中出血量、淋巴结清扫数量、术后肛门排气时间、术后住院时间和术后并发症.结果 腹腔镜组均在腹腔镜辅助下完成根治性胃切除和淋巴结清扫,无中转开腹.腹腔镜组手术时间[（231.8±44.2）min]、清扫淋巴结数[（18.4±5.5）枚]与开腹组[（223.6±36.9）min、（20.5±5.9）枚]比较,差异无显著性（t=1.070,P=0.287;t=-1.930,P=0.056）.腹腔镜组术中出血量[（160.5±136.4）ml]、术后肛门排气时间[（3.0±1.4）d]、术后住院时间[（11.5±2.3）d]均小于开腹组[（231.6±121.7）ml、（4.8±2.3）d、（14.3±3.9）d],差异有显著性（t=-2.912,P=0.004;t=-4.854,P=0.000;t=-4.484,P=0.000）.腹腔镜组术后并发症发生率为12.0%（6/50）,低于开腹组（21.0%,13/62）,但差异无显著性（χ2=1.580,P=0.209）.两组均无围手术期死亡,术后病理分期差异无显著性（χ2=2.064,P=0.356）.结论 熟悉局部解剖与淋巴结清扫技巧,腹腔镜辅助下胃癌D2根治手术是安全可行的,且具有创伤小、并发症少、恢复快等优点.     

Surgical Apgar Score Predicted Postoperative Morbidity After Esophagectomy for Esophageal Cancer

Background

Recently, a simple and easy complication prediction system, the Surgical Apgar Sore (SAS) calculated by three intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate), has been proposed for general surgery. This study aimed to determine if the SAS could accurately predict perioperative morbidity in patients undergoing esophagectomy for esophageal cancer.

Methods

We investigated 399 patients who underwent esophagectomy at the Kumamoto University Hospital between April 2007 and March 2015. Clinical data, including intraoperative parameters, were collected retrospectively. Patients had postoperative morbidities classified as Clavien–Dindo grade III or more. Univariate and multivariate analyses were performed to elucidate factors that affected the development of complications.

Results

The mean age of the study population was 65.7 years, 357 patients (89.5 %) were male. The frequency of any morbidity was 32.3 %. Univariate analyses showed that the SAS as well as preoperative chemotherapy, volume of bleeding, and reconstruction of organs were associated with morbidities. Multivariate analysis showed that a SAS < 5 was found to be an independent risk factor for morbidities.

Conclusion

The SAS is considered to be useful for predicting the development of postoperative morbidities after esophagectomy for esophageal cancer.

     

Prognostic Factors and Optimal Treatment Strategy for Intrahepatic Nodular Recurrence After Curative Resection of Hepatocellular Carcinoma

Background Intrahepatic recurrence is a major problem after curative resection of hepatocellular carcinoma. However, the most effective treatments for patients with intrahepatic recurrence still remain unclear. In addition, the selection of various treatment modalities such as repeat resection, local ablation therapy, and transarterial chemoembolization is only applicable to patients with intrahepatic nodular recurrence. Methods Of 353 patients who underwent curative resection, 97 patients with intrahepatic nodular recurrence were retrospectively studied. The prognostic factors for survival after recurrence and treatment modalities were analyzed. The patients were divided into two groups, a control group and a progression group, according to their response to initial treatment for recurrent tumors. Results The 1-, 3-, and 5-year overall survival rates after recurrence in patients with intrahepatic nodular recurrence were 91.0%, 71.0%, and 37.5%, respectively. Multivariate analysis revealed that early recurrence (≤12 months), Child-Pugh class B or C at diagnosis of recurrence, and serum albumin level of ≤3.5 g/dL at diagnosis of recurrence were poor prognostic factors for survival after recurrence. With regard to the response to the initial treatment, time to recurrence of ≤12 months was found to be the only statistically significant risk factor for progression of disease in multivariate analysis. Conclusions Time to recurrence, which usually corresponds with the cellular origin of recurrence, seems to be more important when determining the prognosis of patients with recurrent disease and treatment response than treatment modality. Therefore, different treatment methods should be selected according to the time to recurrence of intrahepatic nodular recurrence.     

Prognostic Impact of Underlying Liver Fibrosis and Cirrhosis After Curative Resection of Hepatocellular Carcinoma

Background  

In the case of hepatocellular carcinoma (HCC), underlying liver pathology may not only determine the feasibility of surgery but may also affect the postsurgical outcome. We report our experience after curative liver resection for HCC in patients with normal liver, liver fibrosis, and liver cirrhosis.     

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N?=?2,799, 76.1 %) and had resection for malignancy (N?=?2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR?=?1.01, 95 % CI?=?1.01–1.02, p?=?0.001), preoperative malnutrition (OR?=?1.65, 95 % CI?=?1.35–2.02, p?<?0.001), total gastrectomy (OR?=?1.63, 95 % CI?=?1.31–2.03, p?<?0.001), benign indication for resection (OR?=?1.60, 95 % CI?=?1.29–1.97, p?<?0.001), blood transfusion (OR?=?2.57, 95 % CI?=?2.10–3.13, p?<?0.001), and intraoperative placement of a feeding tubes (OR?=?1.28, 95 % CI?=?1.00–1.62, p?=?0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR?=?1.23, 95 % CI?=?0.99–1.53, p?=?0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p?<?0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

     

Prognostic Significance of Vascular Endothelial Growth Factor D in Gastric Carcinoma

The angiogenic factor called vascular endothelial growth factor (VEGF)-D is a ligand for VEGF receptor-2 (VEGFR-2/KDR) and receptor-3 (VEGFR-3/Flt-4). It is implicated in the development of lymphatic vessels and promotion of lymphatic metastasis. The purpose of this study was to investigate the prognostic significance of VEGF-D expression in patients with gastric carcinoma. We assessed the expression of VEGF-D in gastric carcinoma by immunohistochemistry on 143 consecutive patients’ stored sections and evaluated the lymphatic vessel count (LVC) in tumors using the novel selective lymphatic endothelium marker D2-40. VEGF-D expression was observed in 55 (39%) tumor sections. The expression of VEGF-D correlated significantly with tumor size, T of the TNM classification, lymphatic and venous system invasion, LVC, lymph node metastasis, M of TNM, and pTNM stage. Multivariate analysis indicated that VEGF-D expression was an independent prognostic factor for both relapse-free survival (RFS) and overall survival (OS). Our data indicate the involvement of VEGF-D in tumor progression via lymphoangiogenic pathways. Practically, VEGF-D expression can be useful for predicting RFS and OS in patients with gastric carcinoma.     

Prognostic Factors and 10-Year Survival in Patients with Hepatocellular Carcinoma After Curative Hepatectomy

Purpose  

There were contrary results about the effects of hepatitis B e antigen (HBeAg) positivity on the long-term survival in patients with hepatocellular carcinoma (HCC) after curative resection.     

Severity of Complications After Gastrectomy in Elderly Patients With Gastric Cancer

Background

The risk of surgery for gastric cancer has not been fully evaluated, and this study aimed to assess the severity of postoperative complications after D2 or modified D2 gastrectomy in elderly patients.

Methods

Eligible patients were retrospectively selected from the Kanagawa Cancer Center database between 1990 and 2009 based on the following criteria: age ≥80?years and D2 or modified D2 gastrectomy as a primary treatment for gastric cancer. The severity of complications was evaluated using the Clavien–Dindo classification.

Results

A total of 83 patients with a median age of 82?years (range 80–88?years) were entered in this study. Sixty (72?%) had at least one co-morbid condition. American Society of Anesthesiologists scores were 2 in 66 patients and 3 in 17 patients. The extent of gastrectomy was distal in 65 (78?%) and total in 18 (22?%) patients. The procedure used for lymphadenectomy was modified D2 in 38 (46?%) and D2 in 45 (54?%) patients. Altogether, 18 complications were observed in 15 patients. The overall morbidity rate was 18?% [95?% confidence interval (CI) 9.7–26.2?%], and the mortality rate was 3.6?% (95?% CI 0–7.6?%). Complications were classified as grade 2 (n?=?9), grade 3a (n?=?1), grade 3b (n?=?4), grade 4 (n?=?1), and grade 5 (n?=?3). Severe complications (≥ grade 3) occurred in 8.4?% (95?% CI 2.4–14.4?%).

Conclusions

The morbidity rate was acceptable, but that of severe complications was high, suggesting that surgery for gastric cancer in elderly patients is risky and should be limited.     

Gastric Emptying After Pylorus-Preserving Gastrectomy in Comparison with Conventional Subtotal Gastrectomy for Early Gastric Carcinoma

(Received for publication on Oct. 14, 1996; accepted on May 12, 1997)     

AGMA Score: A Novel Prognostic Score for Patients Undergoing Liver Transplant for Hepatocellular Carcinoma

BackgroundHepatocellular carcinoma (HCC) in cirrhosis represents one of the leading indications for liver transplant. In an effort to expand the listing criteria, a variety of scoring systems have been suggested, mainly based on the tumor number/size criterion. The objective of our study was to evaluate the feasibility of proposing a transplant score for HCC excluding the tumor number/size criterion.Patients and MethodsData corresponding to patients who received transplants because of HCC were reviewed for the purposes of this study. Deceased donor and living donor liver transplants were included. Demographic, clinical and tumor-related parameters were evaluated. Uni- and multivariate regression analyses and survival analysis were performed.ResultsOne hundred patients were included in the study. Fifty-five patients underwent deceased donor liver transplant, and 45 patients received living donor liver transplants. Tumor differentiation (G1/2 vs G3), alpha-fetoprotein levels (AFP), recipient age, and recipient laboratory Model for End-Stage Liver Disease Score (MELD) showed statistical significance. A scoring system was developed, with prognostic points assigned as follows: age 60 years or younger:age older than 60 years = 1:0 points, tumor grading well or moderate:tumor grading poor = 1:0 points, MELD score ≤22:MELD score >22 = 1:0 points, and AFP level ≤400 ng/mL:AFP level >400 ng/mL = 1:0 points. This stratification delineated 3 separate population samples corresponding to patients with scores of 4, 3, and 1 to 2, respectively. The calculated 5-year survival for scores 4, 3, and 1 to 2 was 76%, 47%, and 20%, respectively (P < .001).ConclusionThe AGMA score (age, grading, MELD, AFP) showed prognostic value in this single-center analysis and may find clinical implication avoiding the tumor number/size criterion.