Abstract
Background
Gastric cardia cancer is currently treated with several operations. The purpose of the current study was to compare outcomes associated with three common operative approaches.
Methods
The ACS-NSQIP Participant Use File was searched to identify all patients with gastric cardia malignancy who underwent total gastrectomy (TG), transhiatal esophagectomy (THE), or thoraco-abdominal esophagectomy (TAE) between 2005 and 2012. Demographic, perioperative risk factors, and outcomes were analyzed.
Results
Overall, there were 982 patients identified in the database who met inclusion criteria. The median age was 65 years (range 20–88) and 807 (82.2 %) were male. The number of patients allocated to each approach was 204 TGs (20.8 %), 271 THE (27.6 %), and 507 TAE (51.6 %). All approaches had similar major morbidity, cardiopulmonary morbidity, and 30-day mortality, however, TAE was associated with the highest overall morbidity (TAE 49.9 % vs. TG 40.7 % and THE 43.5 %, p = 0.048). The independent risk factors predicting mortality were age greater than 65 years, history of myocardial infarction, and postoperative cardiopulmonary morbidity.
Conclusions
For patients with proximal gastric cancer, the three most common operative approaches were associated with clinically-significant rates of overall and major morbidity. Approach-associated morbidity should be considered along with tumor location and extent when choosing a technique for resection of gastric cardia malignancy.
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Kyle A. Perry, M.D. (Columbus, OH)
Thank you for sharing this nicely presented study examining the surgical approaches utilized to manage proximal gastric cancers. Proximal gastric cancer presents a challenging clinical dilemma, and consideration of oncologic outcome, the rate of return to normal functional status postoperatively, and perioperative risk all play an important role in planning the operative approach. This study aimed to identify predictive factors that predispose patients to major morbidity following esophagectomy or extended total gastrectomy in order to guide clinical decision making. In light of this, why was the decision made to combine the total gastrectomy and transhiatal esophagectomy groups in the multivariate analysis? These operations are associated with different risks and consequences, and it seems that analyzing them separately may identify different predictors for postoperative complications. Also, you noted significant differences between the patient populations undergoing esophagectomy and gastrectomy. Is it possible that a subset of the total gastrectomy patients was undergoing palliative surgery for inability to tolerate oral intake rather than a curative operation? If so, how might this influence the interpretation of the results. Congratulations again on an excellent presentation, and thank for the opportunity to discuss it.
Closing Discussant
Dr. Day
We thank the Dr. Perry for these insightful comments and questions.
Regarding the grouping of cases, initially each of the approaches was separately analyzed. However, there was recognition that the combined abdomino-thoracic approach may have a different complication profile compared to the two non-thoracotomy approaches (total gastrectomy and transhiatal esophagogastrectomy). The separate analysis yielded similar results to the combined analysis, but due to the small number of some comorbidities, the 95 % confidence intervals were very large. Since both groups had similar outcomes for the same disease, the decision was made to combine the analysis for increased power in the face of small numbers, allowing the potential to specifically comment on the morbidity of thoracotomy.
Regarding the use of total gastrectomy as a palliative maneuver, it is possible that some individuals underwent surgery without curative intent. Unfortunately, oncologic intent and stage of disease cannot be obtained from the NSQIP PUF. This having been said, we believe that most patients undergoing palliation for gastric cardia cancer would not have a total gastrectomy as the operation of choice in that scenario. Given the contemporary cohort, stenting, partial gastrectomy, bypass, or palliative feeding tube placement, which were excluded from the analysis, seem to be more likely surgical palliation options for this disease.
NSQIP Disclaimer
The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in it represent the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or for the conclusions derived by the authors.
This manuscript was presented in a plenary session at the Annual Meeting of the SSAT on May 18th, 2015.
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Day, R.W., Badgwell, B.D., Fournier, K.F. et al. Defining the Impact of Surgical Approach on Perioperative Outcomes for Patients with Gastric Cardia Malignancy. J Gastrointest Surg 20, 146–153 (2016). https://doi.org/10.1007/s11605-015-2949-2
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DOI: https://doi.org/10.1007/s11605-015-2949-2