Anil Degaonkar¹, Sachin H M^2*

¹Associate Professor, ²Junior Resident, Department of General Surgery, Dr Shankarrao Chavan Government Medical College, Vishnupuri, Nanded, INDIA.

Email: sachinhm33@gmail.com, degoankar@yahoo.co.in

Table 5: Distribution according to the type of surgery and complications

There is significant statistical association between complications and outcome (p=0.003).

Table 6: Association between complications and outcome

100% of the participants who underwent distal gastrectomy had ICU stay less than 10 days .45.45% of the participants who underwent palliative gastro jejunostomy and 44.44% of the subjects who underwent sub-total gastrectomy had ICU stay less than 10 days .

Table 7: According to the type of surgery and ICU stay

DISCUSSION

95% of all malignant gastric neoplasms are adenocarcinomas. Other histologic types include squamous cell carcinoma, adenoacanthoma, carcinoid tumors, Gl stromal tumors, and lymphoma. Physical signs develop late in the course of the disease and are most commonly associated with locally advanced or metastatic disease. Patients present may present with a palpable abdominal mass, a palpable supraclavicular (Virchow) or periumbilical (Sister Mary Joseph's) lymph node, peritoneal metastasis palpable by rectal examination (Blummer's shelf), or a palpable ovarian mass (Krukenberg's tumor).⁵ As the disease progresses, patients may develop hepatomegaly secondary to metastasis, jaundice, ascites, and cachexia.⁴In the present study, majority of the study participants were in the age group of 60-65 years (40%) followed by participants in the age group of 56-60 years (20 %) and mean age was 62.24 ± 6.44 years. Dao-Jun Gong et.al.⁶ conducted a study had total 125 patients, out of which 62(49.60%) patients were below 60 years of age and 63(50.40%) patients were above 60 years of age. These findings were similar to present study. A study by Wei Peng et al.⁷ 2013 was conducted on 133 patients, out of which 105 (78.94%) patients were less than 50 years of age and 28 patients were more than 50 years of age. In the present study, 64 % of the study participants were males and the rest 36 % were female participants. In study by Dao-Jun Gong et.al.⁶ 68.8 % patients were male and remaining 31.2 % patients were females. These findings are similar to present study. The optimal surgical management of gastric cancer must be tailored to the extent and location of disease. In the absence of distant metastatic spread, aggressive surgical resection of the gastric tumour is justified.⁸ The extent of gastric resection is determined by the need to obtain a resection margin free of microscopic disease. Because gastric tumours are characterized by extensive intramural spread, a line of resection at least 6 cm from the tumour mass is necessary to ensure a low rate of anastomotic recurrence.⁵ In the present study, 36 % of the study subjects were found to have tumour in the body of stomach and underwent sub-total gastrectomy, where-as 64 % of the participant had tumour in the pylorus and underwent distal gastrectomy and palliative gastro jejunostomy. A study conducted by Dao-Jun Gong et.al. found that, 38.8% patients had tumour at upper site of stomach followed by 30.4% had tumour at lower two third site and 19.20% patients had tumour at middle part of stomach while only 14.40% patients had tumour at lower part of stomach. These findings are quite similar to present study. In study by Wei Peng et al., gastrectomy was done in 66.91% subjects. Site of tumour was not mentioned in this study. In the present study, the most common complication encountered was pneumonia in 20% of the subjects, 16% developed ARDS and 44 % of did not develop any complications after surgery. Dao-Jun Gong et al.⁶ found following post-operative complications; out of 125 patients, 7 had pulmonary infection, 4 had wound infections, arrhythmia, and pleural effusion. Abdominal abscess, intra-abdominal bleeding, duodenal stump leakage, upper digestive tract bleeding, ascites and fungal infection were present in 3 patients each. Whereas, jejunum stump leakage was present in only 1 patient. Pulmonary embolus, chylous leak and urinary track infection was present in 2 patients each. This study had many post-operative complications than the present study. In study by Ilfet Songun,⁹ in which 711 patients underwent surgery, local recurrence was 22% in the D1 group versus 12% in D2, and regional recurrence was 19% in D1 versus 13% in D2. Dao-Jun Gong et al.,⁶ noted overall morbidity in 20.8% patients, mortality in 3.2% (palliative or radical total gastrectomy without combined organ resection) and mean postoperative stay was 18.34 days. Wei Peng et al.⁷ found that, overall survival of the 133 patients ranged from 2 to 70 months. The median overall survival was 16 months and average overall survival was 20 months. Complete resection of the tumour remains the standard treatment whenever possible. Complete endoscopic resection suffices only in special types of carcinoma that are confined to the gastric mucosa. Depending on the histological findings, either a subtotal distal gastrectomy or a total (perhaps extended total) gastrectomy can be performed.¹⁰ In the present study, 100% of the participants who underwent distal gastrectomy had ICU stay less than 10 days .45.45% of the participants who underwent palliative gastro jejunostomy and 44.44% of the subjects who underwent subtotal gastrectomy had ICU stay less than 10 days. A study conducted by Dao-Jun Gong et al.⁶, mean postoperative stay after surgeries was 18.34 days, which was greater than the present study. Wei Peng et al.,⁷ noted that age alone was not an independent factor associated with the outcome of the surgery. The association was statistically not significant as p value was 0.054. Similar findings were noted in present study. In the present study, association between site of tumour and outcome of surgery was found out which showed no statistical association between site of tumour and outcome of surgery, similar findings were noted by Dao-Jun Gong et al. In study by Ilfet Songun,⁹ in which 711 patients underwent surgery for adenocarcinoma stomach. 174 (25%) were alive, all but one without recurrence. Over-all 15-year survival was 21% for the D1 group and 29% for the D2 group (p=0·34). Gastric-cancer-related death rate was significantly higher in the D1 group (48%, 182 patients) compared with the D2 group (37%, 123 patients), whereas death due to other diseases were similar in both groups. A study was conducted by Wei Peng et al.⁷ found that, 63.15% patients had ascites post-operatively while 62.40% had residual diseases post-operatively. These findings are quite different from the present study. Wei Peng et al.⁷ noted that, ascites and residual disease were risk factors correlated with poor survival. Multivariate analysis showed that ascites and no gastrectomy were two independent risk factors associated with poor survival. The median overall survival of the patients with or without ascites was 13 months and 21 months respectively, and the survival of the former was inferior to that of the latter. The median survival of the patients who had or had not undergone gastrectomy was 19 months and 9 months respectively, and the survival of the former was longer than that of the latter. The long-term benefit of systematic D2 lymphadenectomy has now been shown in a randomized trial: the rates of tumour-related death and of local or regional recurrence were found to be significantly lower with D2 than with D1lymphadenectomy.¹¹

CONCLUSION

Majority of the study participants were in the age group of 60-65 years, 64 % were males, 36% had tumor in the body of stomach and underwent subtotal gastrectomy, 64.% had tumor in the pylorus and underwent distal gastrectomy and palliative gastro jejunostomy. Most common complication was pneumonia (20%) followed by ARDS (16%). There was no statistical association between age/ site of tumor/ type of surgery/ TNM staging compared to outcome of surgery. Highly significant statistical association was noted between ICU stay/ complications and outcome of surgery.

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