UP TO DATE GASTRIC CANCER SURGERY

Abstract

BACKGROUND: Effective palliation rather than cure is often the most appropriate goal in the management of patients with advanced gastric cancer.The literature to date is limited by the imprecise use of the term palliative and subsequent variable designation of patients into evaluable groups. STUDY DESIGN: Between 2000 and 2007, 303 patients underwent a operation for gastric adenocarcinoma. Patients who received a noncurative (R1/R2) resection were identified. A procedure was defined as palliative if it was performed explicitly to palliate symptoms or improve quality of life. RESULTS: One hundred and ninety five of them (65%) received a noncurative gastric resection. The operation was palliative in 47% (92/195) and nonpalliative in 53% (103/195). Palliative no curative operations aimed preservation of tumor-engaged organ’s function, enhanced quality of patient’s life till dead, but not prolonged his life. No curative no palliative operations aimed cytoreductive effect by removing the organ engaged with primary tumor and improve the results of postoperative complex treatment and prolong the patient’s life. CONCLUSIONS: There are important differences among patients undergoing noncurative operations for gastric cancer. Studies designed to measure palliative interventions would benefit from precise designations of palliative intent in patients receiving noncurative operations. Considerable variation in defining palliative care has complicated the understanding of the role of surgery in managing patients with advanced malignancies.(1) Surgeons commonly use the word palliative to describe a procedure performed in the presence of unresectable disease, a patient with limited survival, or as acknowledgment that a successful curative operation is not possible.(2) Such imprecise and incorrect characterizations of palliation have contributed to varied interpretations of surgical indications and outcomes. Palliative care has been defined by theWorld Health Organization as “the total active care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychologic, social, and spiritual problems is paramount. The goal of palliative care is the achievement of the best quality of life for patients and their families.”(3) Others have further classified surgical palliation to include the evaluation of extent of disease (to include surgical biopsy), control of local disease, control of discharge or hemorrhage, control of pain, reconstruction and rehabilitation, and treatment of procedure-related complications.(4) Although these broad definitions provide a global understanding of the scope of palliative care, they fail to clarify the subject of surgical palliation. For example, inclusion of patients undergoing a surgical biopsy with those undergoing a palliative resection produces such dissimilar groups that the evaluation of important factors such as surgical morbidity and mortality is severely limited. Even in patients with known metastatic disease, it is difficult to make valid comparisons between contrasting clinical scenarios such as elective flap coverage of a complex wound versus an emergency laparotomy for gastrointestinal bleeding. Because ideal palliative care requires an approach defined in terms of a patient’s individual needs and values, identical procedures may play dramatically different roles for each patient.(5) Surgical palliation of malignancy is defined best as a procedure used with the primary intention of improving quality of life or relieving symptoms caused by an advanced malignancy.(1, 2, 5) Palliation is not the opposite of cure. Each term has its own distinct indications and goals and should be evaluated independently. Important considerations relate to the medical condition and performance status of the patient, the extent and prognosis of the cancer, the potential for a curative procedure, knowledge of the natural history of the primary and secondary symptoms, potential durability of the intervention, and the expectancy and quality of life of the patient.(6) By stressing quality of life and symptom control as key elements of palliative care, this definition not only maintains a primary focus on an individualized approach for palliative surgery but also is consistent with the recommendations from the World Health Organization definition, the landmark Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment trial,(7) and the American College of Surgeons Statement on Principles Guiding Care at the End of Life.[8] A survey of The Society of Surgical Oncology members demonstrated a need for clarity in defining palliative surgery. These surgeons strongly acknowledged the importance of quality of life and symptom control in evaluating the effectiveness of palliative surgery.(9)