Abstract
BackgroundSurvival and relapse after gastric cancer surgery are largely attributed to tumor biology and surgical radicality; yet, other prognostic factors have been reported, including respiratory sepsis and anastomotic leakage, but not global morbidity severity score (MSS). The hypothesis tested was that MSS would be associated with both disease-free (DFS) and overall survival (OS). MethodsConsecutive 373 patients undergoing potentially curative surgery for gastric adenocarcinoma between 2004 and 2016 in a UK cancer network were studied. Complications were defined prospectively as any deviation from a pre-determined post-operative course within 30 days of surgery and classified according to the Clavien-Dindo severity classification (CDSC). Primary outcome measures were DFS and OS. ResultsPost-operative complications were identified in 127 (34.0%) patients, which was associated with 9 (2.4%) post-operative deaths. Five-year DFS and OS were 35.9 and 38.5% for patients with a post-operative complication compared with 59.5 and 61.5% in controls (p < 0.001, p = 0.001, respectively). On multivariable DFS analysis, post-operative morbidity [hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.06–2.50, p = 0.026] was independently associated with poor survival. On multivariable OS analysis, post-operative morbidity HR 2.25 (95% CI 1.04–4.85, p = 0.039) and CDSC HR 1.76 (95% CI 1.35–2.29, p < 0.001) were independently associated with poor survival. These associations were also observed in patients with TNM stage I and II disease with morbidity HR 7.06 (95% CI 1.89–26.38, p = 0.004) and CDSC HR 2.93 (95% CI 1.89–4.55, p < 0.001) offering independent prognostic value. ConclusionPost-operative CDSC was an important independent prognostic factor after potentially curative gastrectomy for carcinoma associated with both DFS and OS. Prehabilitation strategies to minimize complications are warranted.
Highlights
Positive versus negative outcomes after surgery are commonly cited as the definitive measure of surgeon level competence, and certainly, any reasonable observer would surely agree that fatal complications, though uncommon, represent an important measure of outcome at the surgeon, hospital unit, and network level
Why anastomotic leakage affects prognosis remains open to speculation; it has been argued that prolonged inflammatory response may promote the metastasis of residual tumor cells
High-risk surgical patients are at greater danger of postoperative complications, prolonged durations of hospital stay, and recovery in general blighted by a compromised quality of life
Summary
Positive versus negative outcomes after surgery are commonly cited as the definitive measure of surgeon level competence, and certainly, any reasonable observer would surely agree that fatal complications, though uncommon, represent an important measure of outcome at the surgeon, hospital unit, and network level. Gastric cancer is the third leading cause of cancer-related death, accounting for some 740,000 deaths annually.[4] Surgery remains the only potentially curative treatment, but recurrence and metastasis occur in as many as 20 to 60% of the patients, and survival remains poor even after curative resection Such surgery is complex major in nature, inherently high risk, with operative morbidity and mortality cited in the most recent UK National Oesophagogastric Cancer Audits[5,6] to be 19.4 and 1.9%, respectively. Survival and relapse after gastric cancer surgery are largely attributed to tumor biology and surgical radicality; yet, other prognostic factors have been reported, including respiratory sepsis and anastomotic leakage, but not global morbidity severity score (MSS).
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