Optimization of perioperative approaches for advanced and late stages of gastric cancer: clinical proposal based on literature evidence, personal experience, and ongoing trials and research.

BACKGROUND: The high incidence of gastric cancer (GC) and paradoxical high prevalence of advanced stage GC, amounting to around 2/3 at time of diagnosis, have urged doctors and researchers around the world not only to ameliorate the detection rate of GC at early stages but also to optimize the clinical management of GC at advanced stages. CONTENT: We hereby recommend a more goal-oriented multimodality approach with objectives to increase survival rate and improve survival status. Based on precision and accurate clinical staging at diagnosis, we suggest that advanced stage GC (AGC) patients should be channeled into different treatment plans according to their disease status where they can be subjected to comprehensive measures involving chemo, radio, immunological, or target therapies depending on the pathophysiological behavior of their tumor. Patients assessed as potentially resectable cT4N + M0 can undergo neoadjuvant chemotherapy with intent of tumor downsizing and downgrading followed by surgery with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) to decrease the incidence of peritoneal dissemination due to surgical trauma and adjuvant chemotherapy and radiation in cases of bulky nodal metastasis. In cases with distal metastasis, conversion therapy is recommended with the possibility of surgery of curative intent in case of favorable response. The options of alternate treatment options such as trans-catheter arterial chemoembolization (TACE) for limited liver lesions or neoadjuvant intraperitoneal plus systemic chemotherapy (NIPS) for peritoneal carcinomatosis have to be negotiated. With surgery as the cornerstone for cancer treatment, there is acknowledgment of the significance of perioperative comprehensive approaches but there has not been some consensus guiding clinical application. Henceforth, in this review, based on past literature, current guidelines and ongoing clinical trials, we have shared a proposal of the current treatment modalities in practice for the advanced stages of gastric cancer. CONCLUSION: Even though surgery is the golden standard of radical cancer treatment, clinical reality shows that without proper perioperative management, patients undergoing radical resections manifest high rates of recurrence and metastasis. Hence, in this review, we have outlined a clinical agenda to optimize the management of advanced stage GC with objective to improve survival outcome and quality of life of patients.

Why the postoperative mortality rate of gastric cancer is lower in our center?

BACKGROUND/AIMS: There was obvious disparity in postoperative mortality rate of gastric cancer surgery among different centers. We analyzed the postoperative complications of gastric cancer surgery at a pioneer surgical center in China and discussed the possible reason behind lower postoperative mortality rate at this center. METHODOLOGY: A total of 697 patients of gastric cancer surgery were analyzed. The median age of the patients was 58 years. POSSUM (Physiological and operative severity score for the enumeration of morbidity and mortality) was applied to calculate risk adjusted morbidity rate. RESULTS: About 82 percent patients were discharged uneventfully in less than 15 days after surgery. Overall 159 patients had postoperative complications, majority of complication were mild or moderate, only about 4 percent of patients had severe complications. Postoperative anastomotic leak and mortality rate was 1.3 and 0.3 percent respectively. CONCLUSION: The postoperative complications especially the mortality rate was significantly lower in our center. The clinical and surgical experience may have influenced the surgical outcome; however, a well controlled prospective study is necessary to postulate this assumption. Regardless of the reason behind the disparity in postoperative mortality rate among different centers, it is mandatory to minimize the postoperative mortality rate of oncological disease like gastric cancer.

Importance of surgical audit: postop complication of gastric cancer surgery among different units.

BACKGROUND/AIMS: Comparative surgical audit is a very important issue in surgical practice. The POSSUM (Physiological and Operative Severity Score for the enumeration of Morbidity and mortality) system has been proposed as the most efficient risk adjusting tool which can be used to compare surgical outcome among different units. POSSUM was applied for risk-adjusted auditing of different units in a single hospital. METHODOLOGY: In total, 357 gastric cancer patients who underwent radical resection or palliative procedures were analyzed retrospectively to evaluate predictive value of POSSUM scoring system and postop morbidity was compared among 5 different units in a single hospital. RESULTS: POSSUM predicted well by correct analysis; the observed to expected morbidity ratio (O:E ratio) was 1.01 for patients overall. But there were significant differences in complication rates among different units, the O: E ratio ranging from 0.7-1.63. CONCLUSIONS: POSSUM is a credible tool for predicting postop morbidity in gastric surgery. It provides risk-adjusted morbidity which can be compared directly. There was surprising difference in surgical outcome among different units of a single hospital, this demands more prospective researches to evaluate surgical outcome of different units. We conclude gastric cancer surgery should be performed in specialized centers.

Risk adjusted auditing of postop complications in gastric cancer patients by POSSUM.

POSSUM (Physiological and Operative Severity Score for the enUmeration of Morbidity and mortality) has been proposed as a promising system for risk adjusted audit in surgical practice. However it has not been generalized in gastric cancer surgery. Present study evaluates the POSSUM on malignant gastric cases in Chinese hospital where patient population or healthcare system might be different than United Kingdom (UK) where the formula was devised. Total of 389 patients who underwent surgical intervention for gastric cancer and malignant gastric lymphomas during the year 2006 were included in the study. Median age was 58 years, with male:female ratio of 7:3. POSSUM data were collected according to standard criteria described by the original authors. Exponential analysis method was used for morbidity predictions. POSSUM predicted satisfactorily for morbidity, observed morbidity was not significantly different than estimated morbidity (p=0.962). Overall, 176 cases were observed to have postoperative complications (including death). The observed to expect ratio (O:E) was 0.99. There was no significant increase in complication rate with increasing age (chi(2)=3.75, 4 d.f, p=0.44). Overall 176 cases were observed to have postop complications (including death). Age was not a risk factor for early postoperative complication. POSSUM predicted well in this study, which means it is a valid system for gastric cancer surgery. However, overall complication rate considered being higher if it is recorded according to POSSUM criteria. Modification in POSSUM equation with revised morbidity definition may be more feasible for major operations.