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Is Gastrectomy Necessary?

Abeezar I. Sarela, MB, BS, MSc, MS, FRCS; Shashidhar Yelluri, MB, BS; for the Leeds Upper Gastrointestinal Cancer Multidisciplinary Team

Arch Surg. 2007;142(2):143-149.

Hypothesis  For distant metastatic (M1) gastric adenocarcinoma, a policy to maximally avoid resection of the primary tumor is safe and efficacious.

Design  Cohort study.

Setting  Academic tertiary care center.

Patients  Sixty-seven (32%) of 211 consecutive patients with adenocarcinoma of the stomach or gastroesophageal junction had synchronous M1 disease on computed tomography or laparoscopy. Sixty-three patients with M1 disease were treated nonoperatively, and complete data sets were available for 40 men and 15 women (median age, 73 years). Pretreatment functional performance status was good in 67%. The primary tumor was at the gastroesophageal junction in 20% and was poorly differentiated in 60%. The M1 disease involved the peritoneum in 80% or was exclusively nonperitoneal in 20%. Systemic chemotherapy was administered to 67%.

Main Outcome Measures  Incidence of subsequent invasive intervention for primary tumor–related complications and survival in 55 nonoperatively managed patients with M1 disease.

Results  Fourteen patients (25%) had intervention a median of 5 months after diagnosis. Eight patients had more than 1 intervention. Intervention was for gastric obstruction (20%), bleeding (7%), or perforation (2%). No patient underwent gastrectomy. Laparotomy was performed in 9%; the remainder had endoscopic or radiologic procedures or radiotherapy. There was no intervention-related mortality. Median survival was 7 months (95% confidence interval, 4-10 months). In Cox regression univariate analysis, good functional performance status, exclusively nonperitoneal metastasis, nonpoor differentiation, and chemotherapy predicted significantly longer survival; chemotherapy was the only independently significant predictive factor.

Conclusions  Palliative interventions were performed in 25% of patients, with no mortality. Survival characteristics were similar to those of previous series of noncurative gastrectomy for M1 disease.

Author Affiliations: The Leeds Teaching Hospitals NHS Trust and The University of Leeds School of Medicine, Leeds, England.

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Gastric Adenocarcinoma With Distant Metastasis—Invited Critique
Wilbur B. Bowne and Michael E. Zenilman
Arch Surg. 2007;142(2):149.
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