상단 PDF Operative Risk Factors in Gastric Cancer Surgery for Elderly Patients

In conclusion, very elderly patients can recover from ag- gressive gastric cancer surgery without increases in post- operative morbidity and mortality with advanced post- operative intensive care. The long term survival rates of very old patients do not differ from those of young-old pa- tients, especially in early stage disease (I, II, IIIA). There- fore, early diagnosis through regular medical screening and curative gastrectomy with lymph node dissection should be performed in very elderly gastric cancer patients.

cancer. Several researchers have reported that curative surgery for gastric cancer in the elderly is feasible, and has acceptable operative morbidity and mortality. 6,7 Several randomized control trials and meta-analyses have demonstrated the positive effects of adjuvant chemotherapy in patients with advanced gastric cancer, in terms of cancer recur- rence and patient survival. 8-13 However, chemotherapy is toxic, and could result in severe side effects. Furthermore, age is con- sidered a risk factor for increased toxicity and poorer tolerance to chemotherapy. 14 In spite of the elevation in the mean age of patients, until recently the clinical data for elderly patients, es- pecially for those over 75 years of age, have been limited. Even large-scale clinical trials have either included only a small num- ber of elderly patients or excluded extremely elderly patients. 15-18 Thus, management strategies for elderly patients with gastric cancer are still controversial, and till date the treatment guide- lines for these patients are lacking. The aim of this study was to evaluate the tolerance to adjuvant chemotherapy, and to com- pare survival between elderly patient groups (aged ≥75 years) with advanced gastric cancer undergoing surgery only or surgery with adjuvant chemotherapy.

Advances in minimally invasive surgery have benefited patients with stomach cancer. Although the indications for laparoscopy or robotic surgery remain controversial, many studies have shown that in comparison to open gastrectomy, minimally invasive surgery is associated with less postoperative pain, faster return of gastrointestinal function, better pulmonary function, decreased stress response, shorter hospital stay, and better postoperative quality of life. [38,39] In addition, as identified in this study, the risk of SSIs in older adults is also lower in minimally invasive surgery; therefore, this type of surgery could be recommended in older adults even in terms of postoperative infection prevention. And it remained robust after comparing open surgery with minimally invasive surgery in some variables like age, BMI, ASA score and pathological stage. The age, BMI, and ASA score of the patients were not different between 2 groups. Rather, in advanced stage gastric cancer, minimally invasive surgery was performed more than open surgery. Thus, if open gastrectomy is unavoidable, greater attention should be paid to the prevention of SSIs.

DSF is thought to be caused by many factors such as inadequate closure of the duodenal stump, devascularization, cancer involvement or resection, an inflamed duodenal wall, local hematoma, incorrect drain position and postoperative distension of the duodenum [4]. Orsenigo et al. [5] first reported the risk factors associated with postoperative DSF to be heart disease, liver cirrhosis, intraoperative blood loss (>300 mL) and the absence of manual reinforcement. However, that analysis focused on intraoperative factors. The aim of the present study was to analyze the risk factors for DSF that could be revealed during the preoperative evaluation for obtaining informed consent before surgery. By identifying them, we should be Purpose: A duodenal stump fistula is one of the most severe complications after gastrectomy for gastric cancer. We aimed to analyze the risk factors for this problem, and to identify the methods used for its prevention and management.

However, this may help overcome a possible selection bias, as described above. Other limitations included the retrospective design of the study and its relatively short follow-up period. In conclusion, this study showed that deep submucosal invasion, histologic high grade, budding, and vascular invasion are independent risk factors for LNM in patients with T1 CRC, and the incidence of LNM ranges widely according to the type and number of risk factors. If any of these risk factors are present, additional surgery following endoscopic resection should be determined after considering the potential risk of LNM and each patient’s situation.

Based on the surgical techniques, the patients were di- vided into hemi-arthroplasty group and internal fixation group. Based on the time interval from injury to surgery, the patients were divided into a group within 5 days and a group after 5 days. Based on ASA grades, patients were divided into a lower-grade group (I, II) and a higher- grade group 66 (III, IV). The underlying diseases such as congestive heart failure, ischemic heart disease, de- mentia, chronic kidney disease, hypertension, diabetes, chronic obstructive pulmonary disease, cancer, liver cirrhosis, rheumatoid arthritis, and Parkinson’s disease were also allocated. Based on the number of comorbidi- ties, the patients were divided into 0–2 comorbidities group and 3 and above comorbidities group. Based on

patients, we measured protein C, protein S, antithrombin, homocysteine, factor Va, and antiphospholipid IgG/IgM levels, which are well-known factors related to hypercoagulability. Interestingly, most factors were within normal limits, implying that hereditary causes of coagulopathy are not prominent among Korean patients. On postoperative day 1, 50 patients (46.2%) exhibited elevated D-dimer levels; of these patients, 3 (2.7%) who presented with asymmetric leg swelling underwent duplex ultrasonography to rule out DVT. None of these patients showed DVT.

Comorbidities included diabetes mellitus (DM), hypertension, obstructive lung disease (OLD), heart problem, chronic kidney disease (CKD), cerebrovascular accident (CVA) history, sepsis at the time of surgery, and previous cancer history. OLD included chronic obstructive pulmonary disease, asthma, and pulmonary emphysema. Heart problem included coronary artery disease, congestive heart failure, atrial fibrillation, aortic stenosis, unstable angina, myocardial infarction, severe heart wall hypokinesia, and sick sinus syndrome. Prostate cancer, thyroid cancer, and skin cancer except for melanoma were not included in the category of previous cancer history. Open or laparoscopic appendectomy was not included in the category of previous laparotomy history, but gynecological surgeries such as cesarean section, uterine myomectomy, and total hysterectomy were included.

Additionally, all extracellular mucin pool carcinomas featured larger tumor size, more advanced T stage and N stage, more aggressive lymph node dissection with open surgery, more positive node metastasis, lymphatic invasion, and perineural invasion than NMGC. All extracellular mucin pool gastric adenocarcinomas were in a more advanced state than NMGC, regardless of Lauren classification. Therefore, we can consider all extracellular mucin pool gastric adenocarcinomas included with the diagnostic criteria of MGC. In this study, we analyzed the effect on the prognosis in terms of recurrence of gastric cancer. Univariate analysis showed that tumor size, T stage, N stage, range of lymph node dissection, Lauren classification, WHO classification, lymphatic invasion, vascular invasion, and perineural invasion were significantly correlated with gastric cancer recurrence in all patients treated by curative gastrectomy at our hospital. However, only T stage and N stage were identified as independent prognostic factors for gastric cancer recurrence in the multivariate analysis. It is well known that prognostic factors for gastric cancers are influenced by tumor invasion depth, lymph node metastasis, and complete tumor removal [16-18]. Therefore, we assume extracellular mucin pools affect T stage and N stage, then the prognosis of gastric cancer recurrence

Purpose: The relationship between the prognosis and the age of patients with gastric carcinoma is controversial. This study examined the clinicopathologic features of elderly gastric carcinoma patients with serosal invasion. Methods: We reviewed the hospital records of 136 elderly gastric carcinoma patients with serosal invasion retrospectively to compare the clin- icopathologic findings in the elderly (aged ＞ 70 years) and young (aged ＜ 36 years). Results: The 5-year survival rates of eld- erly and young patients with curative resection did not differ statistically (33.9% vs. 43.3%; P = 0.318). Multivariate analysis showed that two factors were independent, statistically significant parameters associated with survival: histologic type (risk ratio, 1.805; 95% confidence interval [CI], 1.041 to 3.132; P ＜ 0.05) and operative curability (risk ratio, 2.506; 95% CI, 1.371 to 4.581; P ＜ 0.01). Conclusion: This study demonstrated that elderly gastric carcinoma patients with serosal invasion do not have a worse prognosis than young patients. The important prognostic factor was whether the patients underwent curative resection.

Second, other causes of DGE were anastomosis narrow- ing due to edema or stenosis. Many potential contributing factors to the etiology of anastomotic stenosis with a circu- lar stapler have been proposed. These include tension on the anastomosis, local tissue ischemia, subclinical leak, in- jury from acid exposure, and submucosal hematoma cre- ated during suturing [15,16]. Fisher et al. [17] and Gould et al. [18] reported the risk factor of gastrojejunostomy steno- sis according to circular stapler diameter for laparoscopic Roux-en-Y gastric bypass in morbid obesity. They used 21 mm and 25 mm diameter circular staplers for gastro- jejunostomy. They showed that the 21 mm diameter circu- lar stapler resulted in more stenosis and needed additional endoscopic balloon dilatation. In our study, there were more incidences of DGE in the 25 mm group than in the 28 or 29 mm group. Therefore, we could confirm that circular stapler diameter was the only risk factor of DGE in our univariate and multivariate analysis.

Translational Relevance Gastric cancer is the second leading cause of cancer- related death in the world, and prognosis is difficult to predict for individual patients. Most of gastric cancer patients receive similar treatments, typically surgery followed by chemotherapy because there are no reliable biomarkers to optimize therapy. Our study identified the prognostic gene expression signatures and limited number of prognostic biomarkers. We developed a score based on these 6 genes which significantly asso- ciated with survival and early relapse. This method requires the determination of only 6 genes by using simple reverse transcriptase PCR technology and easily accessible paraffin-embedded tissues, which are routi- nely acquired at diagnosis. This will open up new opportunities to optimize treatment of gastric cancer patients according to molecular subtypes of tumors.

Postoperative cancer surveillance included follow-up visits quarterly for the first 2 years, and biannually thereafter. A chest radiograph and vaginal smears were obtained once a year. The visits included a gynecologic medical history and a gynecologic examination that was further supplemented with biopsies in case of suspicious findings and imaging studies in case of suspicion of distant metastases. If an isolated recurrence was diagnosed, treatment with curative intent was initiated unless precluded by the patient or disease factors. Salvage radiation therapy was defined as the use of any type of RT to any relapse site whether loco-regional or distant. After treatment for relapse, patients were again evaluated every 3 months for the first 2 years and every 6 months thereafter.

DISCUSSION The current retrospective cohort study conducted in a single tertiary reference center in the south of Turkey aimed to evaluate the efficiency and reliability of the laparoscopic approach in different risk groups of ECs. In this study, we showed that laparoscopic surgery was as effective and safe as abdominal approach for the treatment of EC. By comparing the operative results between the LS and LT groups that had similar demographic characteristics, a significant superiority was found in the LS cohort in terms of short-term results such as complications, blood loss, and the length of hospital stay in accordance with the literature [2,9-11]. The benefits of the laparoscopic surgery may be particularly marked in women with obesity and comorbidity. In our laparoscopic cohort, there was a higher rate of obese women (twenty-five percent of the LS group had morbid obesity) and approximately half of the patients had comorbidity. Laparoscopic surgery can substantially reduce the rate of postoperative complications compared to LT surgery in such cases [12]. The most common postoperative complication was wound site infection in our cohort.

Methods We performed a retrospective chart review of patients who underwent oral cancer ablative surgery at the Oral Oncology Clinic at the National Cancer Center in Korea from March 2001 to January 2016. Among all patients who underwent major oral cancer resection with free flap reconstruction, 51 patients who underwent tracheostomy for airway protection were included in this study. Trache- ostomy was indicated for patients who required bilateral neck dissection, patients with tumors positioned at the back of the oral cavity or tongue and those who under- went anterior segmental mandibulectomy or resection of the floor of mouth. These patients were considered at risk of an immediate postoperative airway complication such as upper airway obstruction by postoperative tongue retrusion or sudden glottic edema. Tracheostomy was not usually performed in patients who underwent unilateral neck dissection.

MATERIALS AND METHODS 1. Patients The present study was carried out using data of patients with FIGO stage IB1 cervical cancer for whom tumor diam- eter/volume were preoperatively confirmed by magnetic resonance imaging (MRI), and radical hysterectomy or radical trachelectomy was performed. Eligible patients underwent re- section of bilateral parametrial tissues. A total of 421 patients with invasive cervical cancer were treated in the National Hospital Organization Hokkaido Cancer Center from January 2008 to June 2014 (Table 1). Of 140 patients who had FIGO stage IB1 disease, eight were treated with radiotherapy. One patient refused to receive any treatment. Of 131 patients who underwent surgical treatment, nine underwent conization or simple hysterectomy instead of radical surgery. Two patients received systemic chemotherapy before surgical treatment.

Statistical analysis Statistical analyses were performed using PASW version 18.0 (SPSS Inc., Chicago, IL, USA). Continuous variables (age, BMI, and operative time) were dichotomized, using the mean value of each variable. Chi-square or Fisher exact test for categorical variables was used for statistical comparisons of clinical parameters, operative time, operative methods, preoperative nutritional status and NRS 2002. Multivariate analysis to detect risk factors for postoperative complications was conducted with a logistic regression model. Chi-square tests were also used to analyze morbidity variables associated with weight loss. A value of P < 0.05 was deemed statistically significant.

follow-up endoscopy. The clinical implications of AG and RA remain to be established. Although AG and RA show similar features, inflammation is more common in RA than in AG. A Spanish single center study reported the microscopic and histopathologic results of the atypical gastric epithelium. Of 44 patients, 3 (2.7%) received a final diagnosis of early gastric cancer, and most of them were intestinal metaplasia. 27 However, several recent Korean studies reported that approximately 25% of subjects with IFND are diagnosed as carcinoma. 10,15-19 Another study reported that approximately 75% of IFND patients are diagnosed with carcinoma including only AG. 20 Despite the variability in the reported risk of carcinoma in cases of IFND, which may be attributed to differences in methodology, AG is associated with a higher risk of malignancy than RA. To the best of our knowledge, there are no studies addressing RA alone, and its clinical implications have not been clarified until now.

Although hypoalbuminemiais well known marker of malnutrition or a risk factor of postoperative complica- tions, the benefit of albumin replacement to correct pre- operative hypoalbuminemia in patients with CD are unclear. Several studies have shown that albumin replace- ment therapy did not decrease the rates of death or major complications [20,21]. However, others found that treat- ment of hypoalbuminemic patients with exogenous hu- man albumin solution resulted in a greater than twofold decrease in major complications [22,23]. A recent meta- analysis of 71 randomized trials showed that albumin ad- ministration significantly reduced overall morbidity among acutely ill hospitalized patients [24]. Few studies, however, have assessed the clinical relevance of these properties, especially in CD patients who underwent surgery. Nevertheless, characteristics of albumin con- tributing normal oncotic pressure, innate immune re- sponse may help to explain the possible benefits observed after correction of hypoalbuminemia

The role and theoretical bases of cytoreductive surgery are well established in the treatment of primary epithelial ovarian cancer. The prognostic effect of primary surgical cytor- eduction was first reported by Griffiths, who found improved survival in patients with no residual tumor after primary sur- gery, compared to patients with persistent tumor load. 2 Many investigators have since reproduced and confirmed this ob- servation, and a meta-analysis summarizing data from 1989 to 1998 revealed that maximal cytoreduction was one of the most powerful determinants of survival in patients with ad- vanced epithelial ovarian cancer. 3 Although randomized in- vestigations evaluating the role of primary cytoreductive sur- gery are lacking due to the difficulties involved in conducting such trials, the value of debulking a large tumor mass during primary surgery for ovarian cancer has been generally ac- cepted, and primary cytoreductive surgery followed by che- motherapy is considered to be a standard treatment procedure for patients with advanced ovarian cancer.