麻豆传媒

SAN FRANCISCO -- Palliative surgery for gastric outlet obstruction allowed patients with incurable gastric cancer to resume oral food intake and improved quality of life (QoL) during the last months of life, Japanese investigators reported.

Within 14 days of surgery, a majority of patients had resumed oral food intake, which was maintained through 3 months of follow-up. About a fourth of 104 evaluable patients had early postoperative complications, and six patients died in hospital.

About half of the patients had stable or improved QoL during follow-up after palliative surgery, , of Osaka Prefectural General Medical Center in Japan, reported here at the .

"This is the first prospective multicenter observational study of surgical palliation examining postoperative quality of life in patients with malignant gastric outlet obstruction caused by incurable advanced gastric cancer, and it provides the largest sample of quality-of-life data for this setting," said Fujitani. "Surgical palliation maintained patient quality of life while improving solid food intake with an acceptable surgical toxicity, at least for the first 3 months after surgery."

Studies of gastric resection for advanced gastric cancer have consistently shown improved survival over chemotherapy or supportive care, but close inspection of the studies revealed widespread bias toward selection of healthier patients for surgery. Selection bias could easily explain some of the survival benefit of gastrectomy, said invited discussant , of the University of Chicago.

In contrast, by Fujitani and colleagues showed no improvement in survival with gastrectomy plus chemotherapy versus chemotherapy alone for stage IV gastric cancer. Imbalances in patient selection might have influenced the outcome, but the palliative implications of the surgery were discussed in detail, Posner noted.

A recent evaluation of endoscopic stenting and gastrojejunostomy for malignant gastric outlet obstruction showed that the former was associated with a shorter time to oral food intake, shorter hospital stay, a substantial reduction in the cost of care, but no improvement in survival. Posner suggested that patients treated with stents might have been sicker and had more high-risk characteristics, contributing to the lack of survival benefit.

Posner congratulated Fujitani and colleagues for undertaking a study to address an important issue in the surgical management of advanced gastric cancer, and he lamented the paucity of surgical studies in gastric cancer conducted in the United States.

A second study of surgical intervention in advanced gastric cancer yielded . Bursectomy to prevent metastatic spread failed to reduce the risk of metastasis or improve survival and was associated with an increased incidence of pancreatic fistula, increased blood loss, and increased operative time.

Palliation Trial

Fujitani noted that two types of surgical intervention can be used in advanced gastric cancer. Gastrectomy has a goal of reducing tumor volume, with an associated expectation of improved survival. Palliative resection or bypass surgery, on the other hand, has a goal of reducing serious disease-associated symptoms, such as bleeding or obstruction.

As Posner noted, multiple studies have examined the risks and benefits of gastrectomy. Few studies have evaluated the impact of palliative surgery on patient-reported outcomes, said Fujitani.

In an attempt to inform decision making about palliative surgery for advanced gastric cancer, Japanese investigators performed a multicenter observational study involving patients with incurable (stage 4b) gastric cancer and gastric outlet obstruction. Patients who had any type of surgery for the specific aim of relieving the obstruction were eligible. Patients who received endoscopic stents were excluded.

Patients were assessed at baseline, 2 weeks, 1 month, and 3 months after palliative surgery. The primary endpoint was change in quality of life as assessed by a generic health-status questionnaire and by a QoL questionnaire specific to gastric cancer. Additionally, patients' ability to eat solid food was evaluated by the gastric outlet obstruction scoring system (GOOSS).

Data analysis comprised 104 patients, 77 of whom completed 3 months of follow-up. Gastrojejunostomy (open or laparoscopic) was the predominant form of surgical palliation (70 patients), followed by distal gastrectomy (23) and total gastrectomy (9), and exploratory laparotomy (2).

Overall, scores on the generic QoL instrument changed little from baseline through 3 months. From 14 days to 3 months, 20 to 25 patients reported improvement, and another 20 to 30 patients reported stable QoL.

Chronologic change in the gastric cancer-specific instrument tended to show improvement in several outcomes, including pain, anxiety, and dry mouth. Sense of taste remained stable for most of the follow-up.

At baseline, no patient was able to consume solid food. By 14 days, more than 60% of the total population could eat solid food, and that number remained stable out to three months. Results were similar in patients who underwent gastrectomy or gastrojejunostomy.

Bursectomy Controversy

The study of bursectomy may put to rest the debate over its ability to improve outcomes in advanced gastric cancer. The procedure involves dissection of the peritoneal lining covering the pancreas and anterior plane of the meso colon. When the procedure can prevent peritoneal spread of cancer has remained controversial for years, said , of Shizuoka Cancer Center in Nagaizumi, Japan.

A involving patients with T2-T4a gastric cancer showed a trend toward improved survival in patients who underwent bursectomy, but the results failed to meet statistical criteria for noninferiority or superiority for patients who underwent omentectomy without bursectomy. Nonetheless, the authors concluded that "bursectomy may improve survival and should not be abandoned as a futile procedure until more definitive data can be obtained."

In an attempt to provide the definitive data, members of the Japanese Clinical Oncology Group enrolled 1,200 patients with clinical T3-4b, nonmetastatic gastric cancer to undergo omentectomy with or without bursectomy. The primary endpoint was overall survival, and secondary endpoints included relapse-free survival.

The data and safety monitoring committee recommended ending the trial when a second interim analysis showed a 3-year overall survival of 86.0% for omentectomy without bursectomy and 83.3% with bursectomy. Relapse-free survival also favored the nonbursectomy group. Terashima said 140 patients in the bursectomy group had peritoneal recurrences, compared with 129 in the omentectomy group.

Operative time was about 30 minutes longer with bursectomy, and bursectomy led to about 100 mL more blood loss.

"Bursectomy tended to be worse in almost all subgroups," Terashima said. "Bursectomy is not recommended as standard treatment for cT3 or cT4 gastric cancer, while complete omentectomy remains a part of standard procedure."

Comment