Discussion
tumor, pneumonia, blood loss, tumors, TG, gastric cancer
TUMOR, PNEUMONIA, POSTOPERATIVE COMPLICATIONS, BLOOD LOSS, MINOR, LEAKAGE, ATRIAL FIBRILLATION, TUMORS, COMPLICATIONS, GASTRIC CANCER
This study aimed to determine the role of DG for Western gastric cancer patients by comparing surgical and oncological outcomes including quality of life after DG versus TG, in particular in a population where the vast majority of patients was treated with neoadjuvant chemotherapy. Patients selected to undergo DG experienced significantly fewer and less severe postoperative complications, also after correcting for baseline differences. Furthermore, DG-patients had better intraoperative surgical outcomes, shorter hospital and ICU stay, and quicker postoperative recovery compared to TG-patients. Moreover, the reported quality of life after DG was significantly better in most functional and symptom scales at one or all time points, and the significant differences were also clinically relevant based on previous guidelines.In the present study, both DG and TG were oncologically effective and oncological outcomes were concordant with current standards.Importantly, our results demonstrate that DG resulted in fewer and less severe postoperative complications (overall, anastomotic leakage, pneumonia, and atrial fibrillation), less blood loss and splenectomy, shorter operating time and hospital and ICU stay, quicker postoperative recovery, and better quality of life compared to TG. This is in line with a previous nationwide evaluation.Patients in the current study experienced significantly better quality of life after DG versus TG regarding most functional and symptom scales at one or all time points in the 1-year follow-up (predominantly ≥ 10 points difference), possibly as a consequence of functional preservation of part of the stomach. Importantly, all significant differences were also clinically relevant and categorized in medium (41%) or small differences (59%) based on previous guidelines, without any trivial (0%) differences.To complement the abovementioned, several recommendations for surgical decision making can be stated. The surgical strategy (DG or TG) should primarily be based upon achieving a radical D2-gastrectomy, and may secondarily be adjusted to ensure safety of surgery. It should be noted that there is not always a “choice” for surgeons between performing DG or TG; for instance, proximal tumors are not eligible for distal gastrectomy. In the current study, the differences in baseline characteristics reflect this surgical selection process. Notably, the R0-resection rates after DG and TG (98% versus 91%) should be interpreted within the context of these baseline differences, since the TG-group contained proximal tumors and had larger tumor diameters (The costs of surgery are not always incorporated when clinically considering distal or total gastrectomy; however, this is highly relevant for hospital management. In the LOGICA-trial, we had previously assessed the cost-effectiveness of D2-gastrectomy in detail: the mean total costs of D2-gastrectomy including costs associated with surgery (e.g., hospitalization, diagnostic modalities, complications, re-interventions, medication, emergency visits, rehabilitation and nursing homes, and productivity loss) noted €21,939 per distal and €31,583 per total D2-gastrectomy.Since patients selected for DG differ in baseline from TG-patients by definition as described, this limits statistical comparison to some extent. However, the baseline differences are inherent to the indication per surgical procedure (DG/TG), and our findings consistently support DG in alignment with previously mentioned studies. Furthermore, several details of the Roux-en-Y reconstruction, including length of Roux-limbs and antecolic/retrocolic position and jejunal pouch formation and size, were not standardized in the LOGICA-trial, which could have resulted in (minor) differences in QoL-results between DG and TG.In conclusion, Western gastric cancer patients selected for DG experienced fewer and less severe complications (overall, anastomotic leakage, pneumonia, atrial fibrillation), demonstrated quicker postoperative recovery, and reported substantial better quality of life, also after neoadjuvant chemotherapy, while oncological effectiveness after DG was safeguarded. Therefore, in selected patients where DG is oncologically feasible, DG should be preferred over TG. Alternatively, TG is safe and effective if adequate oncological control cannot be achieved with DG. To determine the optimal surgical strategy for each gastric cancer patient, it is crucial to individually balance radicality, surgical morbidity and quality of life.
