The elderly has been well known as the risk factors for postoperative complication in various surgical fields, because of the loss of physical function. We confirmed the results though the analysis for the records of patients who underwent gastric cancer surgery in single center during two years. Moreover, we obtained additional information in which the patients with comorbidity had only risk for complication in the elderly.
Although the definition of elderly patients varies according the social and economic situation, most developed and developing countries have defined the elderly as those aged 65 years because of the decreased role in the community and society.(HelpAge International. et al., 1999) On the other hand, the elderly is medically defined in accordance with the functional loss of major organs and decreased ability of recovery from severe stress like trauma. In particular, because several clinical researches that patients with the age 75 years have higher frequency of comorbidity and severe loss of physical function,(Neugarten et al., 1965; Wu et al., 2000) the definition of “young elderly” is over aged 65 and “old elderly” as over aged 75 years.(Hazzard and Burton, 1987; Williams, 1998) We assumed that increased complication after gastric cancer surgery may also be effected by increased age, because it requires surgical resection of extensive range and reconstruction in upper abdomen. In present study, we analyzed the correlation between postoperative complications and clinical factors including the patients’ age which was divided by age 65 and 75 years. As a result, age over 75 years was a strongest predicting factor for postoperative complication in gastric cancer surgery.
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There have been several studies reporting that postoperative morbidity and mortality can be increased in the elderly.(Winslet et al., 1996; Katai et al., 2004; Kunisaki et al., 2006) Researchers suggested that the reduced range of surgery and minimally invasive treatment like endoscopic therapy could be applied for the elderly patients as alternative method replacing standard surgery. However, the number of the elderly requiring gastric cancer surgery would be increase following with increased number of the elderly, and we can’t make it avoid standard surgery in all elderly patients. Therefore, it can be important to evaluate the surgical risk of the elderly and find out the elderly who may be suitable for limited surgery or minimally invasive treatment. In subgroup analysis objected to the only elderly, the comorbidity was higher risk factor than the old elderly patients.
We confirmed that the biological age of patients considering the organic function was more informative for postoperative complication after gastric cancer surgery than physical age in our study. Major comorbidity in our study was hypertension, diabetic mellitus and pulmonary problem, and the 58.4% of all patients had one and more kinds of comorbidity. The proportion of patients with comorbidity was increased into 76.4% in the elderly over 65 years. Meanwhile the comorbidity was not predicting factor for postoperative complication in the patients under 65 years, it was only factor for the patients over 65 years. It means that comoribidity can give an more effect on the complication in the elderly patients. To date, there have been several reports about the effect of the comorbidity on the gastric cancer surgery,(Rim et al., 1997; Sorensen et al., 2005; Matsuda et al., 2009) and Kim et al.(Kim et al., 2008b) announced that the comorbidity was significantly related to the postoperative complication after laparoscopic
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surgery for gastric cancer in the multicenter study objected to 1,237 patients. However, there has been no study which analyzed the effect of comorbidity on the increasing age in the postoperative complication objected to the all kinds of gastric cancer surgery.
In present study, 280 (47.5%) of total 590 underwent minimally invasive surgery (MIS) by the laparoscopic or robotic approach. Although recent indication for MIS was early disease of gastric cancer, it is expected its indication to be expended due to the increasing number of early disease and the development of technique and instruments.(Kitagawa et al., 2005) Regarding MIS for the elder, there has been controversy about whether this procedure can be positively or negatively effect on the surgical outcome of the elderly.(Kunisaki et al., 2009) The patients who are performed by MIS in our study showed relatively lower complication rate than open procedure, but it is not statistically significant in the elderly as well as all patients. Therefore, the efficacy of MIS for the elderly could not be confirmative from what our study present.
The development of treatment for gastric cancer has followed with the reducing the range of surgery as well as maintaining the oncologic safety.An JY, Cheong HJ, Hyung WJ, Noh SH : Recent evolution of surgical treatment for gastric cancer in korea. J Gastric Cancer 2011, 11(1):1-6 According to this principle, endoscopic resection for early gastric cancer, and partial gastric resection with limited lymph node dissection using sentinel lymph node navigation has been developed. The absolute indication of endoscopic resection was mucosal cancer under 2 cm considering the metastasis to the perigastric lymph node, (Yamao et al., 1996) but this indication has been recently extended by the effect of precise preoperative diagnosis and developing endoscopic technique (Yokoi et
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al., 2006; Gotoda, 2007). The definite advantage of endoscopic treatment is not requiring the general anesthesia. Therefore, the extended indication of endoscopic treatment could be primarily applied for the elderly which are highly expected the postoperative complication related to the anesthesia, in spite of the possibility of incomplete tumor resection and not confirmative lymph node status. Another option for preventing the postoperative complication is partial gastrectomy with limited lymph node dissection under sentinel node navigation. (Ishii et al., 2008; Lee et al., 2009) Although this procedure did not have confirmative results to apply clinical practice, future studies about it can give the researchers the clue to do it.
The three surgeons in the present study have the experience over 80 gastric cancer surgery per year, and 400 surgeries for gastric cancer patients per year has been performed in the institution. Our result in the view of complication rate is similar with the rate, 10.5 – 14.7% from the large scale studies in Korea.(Kim et al.; Kim et al., 2008a) Therefore, our result may be generally acceptable in other institutions. Merely, our study had the limitation in which long term follow-up did not performed to evaluate survival after cancer surgery. Therefore, the benefit of limited surgery or endoscopic treatment for the elderly did not reach a conclusion.
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