Advanced gastric cancer. Are there still indications for palliative surgical interventions

BACKGROUND AND METHODS: Based on data obtained in the prospective multicenter observational study on the surgical treatment of gastric cancer "East German Gastric Cancer Study 2002 (EGGCS)", the cohort of patients with gastric cancer who underwent palliative surgical interventions during the study period from 1(st) January to 31(st) December 2002 was investigated. RESULTS: Out of 1,139 documented patients with gastric cancer, 1,031 underwent a surgical intervention (operation rate 90.5%). In 70.4% (n=726) of the patients with surgical interventions, R0 resection status could be achieved whereas in 305 patients (29.6%), only a palliative (R1/2 resection status) result was possible using resection and non-resection procedures in 165 and 140 cases, respectively. The hospital mortality rate was 7.3% (n=53) in the group of curative R0 resection patients and was almost identical with 7.8% (n=13) in the group of R1/2 resection patients. The highest hospital mortality of 14.4% (n=20) was found in subjects who primarily underwent palliative surgical interventions (R2 resection or non-resection procedures). In the subgroup analysis the highest overall morbidity of 57.1% was found in the group of palliative (R2) resection patients. Curatively intended but palliatively operated patients (from the perspective of the final histopathological result) showed a significantly longer overall survival time (11 months) compared with patients who primarily underwent a surgical intervention with palliative intention (6.3 months). Even patients who underwent tumor resection with palliative intention were observed to have a longer survival time of 2.3 months (in total, 6.9 months) compared with patients with non-resection surgical intervention (4.6 months). In the group of R2 resection patients with a preoperatively detected pyloric stenosis/dysphagia, an increased overall morbidity (62.5% with stenosis versus 47.7% without stenosis) and an increased hospital mortality rate (25% versus 11.6%, respectively) were seen. This favors more interventional endoscopic procedures if possible considering the only marginal prolongation in survival time. In contrast, palliative resection in cases without stenosis is associated with an acceptable rate of postoperative complications (47.7%) and mortality (11.6%) resulting in the recommendation of a palliative resection under specific conditions considering the improved oncosurgical long-term outcome. CONCLUSION: Radical tumor resection with palliative intentions (if possible from a technical point of view) resulted in a prolongation of the median survival time of 3 months with an acceptable postoperative morbidity and mortality compared with non-resection procedures. According to the results of individual analysis of each tumor resection intervention, palliative gastrectomy showed a significant prolongation of survival time of 5 months compared with more limited subtotal resection (6 versus 11 months).