No significant difference in overall mortality and complication rates for three types of gastrectomy procedures

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Key study points:

1. Complication, reoperation, and mortality rates are the same for open, laparoscopic, and robotic gastrectomy.

2. Anastomotic leak occurs more commonly in minimally-invasive approaches to gastrectomy.

Primer: Over 20,000 people are diagnosed with gastric cancer every year in the U.S. alone, and more than 50% of those are expected to die from the disease.  These cancers can present anywhere in the stomach, and mortality has been slowly declining in the last few decades.  5-year survival was 15% in 1977, but has increased to 27% in 2007.  The best chance for survival is surgical resection, with traditional treatment for gastric adenocarcinoma being an open radical gastrectomy with lymph node dissection.  Laparoscopic gastrectomy and robotic-assisted gastrectomy were introduced in 1994 and 2003, respectively. For some cancers, endoscopic resection is appropriate.  This study focuses on the 3 types of approaches to radical gastrectomies and evaluates the rates of complications with each.  Specifically, it focused on a large cohort of patients with proximally located and advanced gastric cancers, which had never been done before.

Background reading:

  1. Saka M, Morita S, Fukagawa T, Katai H. Present and future status of gastric cancer surgery. Jpn J Clin Oncol 2011; 41: 307 – 313.
  2. Mansfield, PF.  Invasive gastric cancer: Surgery and prognosis.  UpToDate 2012.

This [retrospective] study: involved patients undergoing elective radical gastrectomy for histologically-proven stomach adenocarcinoma. Patients were followed using a prospective database, and analyzed retrospectively.  In total, there were 4542 open gastrectomies, 861 laparoscopic gastrectomies, and 436 robotic gastrectomies.  Open gastrectomy patients had higher and more poorly-differentiated tumors.  While intraoperative blood loss was predictably higher in the open gastrectomy group, durations of operations were higher for laparoscopic and robotic gastrectomies.  Of the total 5839 patients, overall complication rate was 10.5%, with no significant difference between groups. However, the rates of different complications were different. For anastomotic leak, 2.1%, 2.3%, and 1.1% were the rates for laparoscopic gastrectomy, robotic gastrectomy, and open gastrectomy, respectively. Rates of post-operative ileus and abscesses were highest after open procedures.

In sum: Overall, this study achieves the goal of evaluating the incidence of complications and the types present in each of the three gastrectomy procedures for gastric adenocarcinoma, and suggests that the three types of procedures are comparable clinically. Specifically, there was no significant difference in the overall complication rate, reoperation rates, and mortality rates in all three types.  The only factors that were different among the complications were the types of complications most prevalent in each: anastomotic leaks were more common in minimally-invasive procedures, and abscesses and obstructions more common after open gastrectomies.

Strengths of this study include a large cohort of patients with similar demographics on many levels.  Limitations include the retrospective nature of the study and that, lacking randomization, demographics such as the rates of hypertension and pulmonary disease were different between study arms.  Moreover, patients with larger, more advanced cancers were more likely to undergo open gastrectomies, and it is unclear if complication rates would have been similar if case complexity was more evenly distributed amongst the study arms.

Click to read the study in [British Journal of Surgery]

By [DM] and [AH]

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