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INTRODUCTION
Gastric cancer (GC) causes 8.2 % of oncological deaths (787,200) and 5.7 % of new cases (969,000) worldwide; being more frequent in men than women (Ferlay et al., 2019). After lung cancer, it is the second leading cause of cancer death, over 780,000 deaths per year (Bray et al., 2018). The areas with the highest incidence rates (> 40 / 100,000) are East Asia and the Andean regions of South America (Global Burden of Disease Cancer Collaboration et al., 2017).
Despite special protocols for its treatment (Macdonald et al., 2001); GC remains one of the leading causes of cancer death in Chile; with a mortality prediction rate of 17.5 x 100,000 inhabitants and 22.5 x 100,000 in men (Carioli et al., 2019); constituting one of the most frequent malignant tumors in men. In La Araucanía region, the overall mortality rate reaches 24.8 x 105 inhabitants and in men 33.7 x 105 (Tapia et al., 2010). The adjusted rate was estimated at 38.9 and 27.4 x 100,000 inhabitants for men and women respectively for the 1990-2010 period; with a marked decline in the last two decades (Itriago et al., 2013). Despite some stabilization in the general mortality rate from GC, the probability of dying from GC in Chile is approximately 3 %, which makes this disease a public health problem (Ministerio de Salud, 2016).
In Chile, more than 80 % of cases are advanced GC (AGC). These are lesions that infiltrate beyond the submucosa layer. Therefore, a series of strategies have been developed to optimize diagnostic and therapeutic processes (Calderón et al., 2007; Tapia et al, 2011; Ministerio de Salud, 2016).
Surgery remains the mainstay in the treatment of AGC, because, as well as allowing tumor excision, allow to determine a better staging of the disease; In addition, it may be applied as cleaning surgery, for eventual application of adjuvant therapies (Cornejo & Portanova, 2006; Díaz de Liaño et al., 2008; Ruiz et al., 2009; Degiuli et al., 2016).
The aim of this study was to determine postoperative morbidity (POM) and 5-year overall survival (OS) in patients resected by AGC without neoadjuvant.
MATERIAL AND METHOD
The report of this study was written based on the MInCir Declaration for the reporting of descriptive observational studies (Manterola & Astudillo, 2013).
Study design: Case series with follow-up.
Setting: The study was conducted at Clínica RedSalud Mayor Temuco. The recruitment period was between January 2008 and December 2019 (12 years). The minimum follow- up was 7 months.
Participants: All patients with AGC consecutively undergoing gastrectomy with extended lymph node dissection (D2), by the first author (CM), were included. Cases of exploratory laparotomy due to disseminated disease, palliative surgeries and those who received additional treatments in addition to surgery were excluded.
Sample size: Since this is an observational and descriptive study, no sample size was estimated. All patients with AGC undergoing D2-gastrectomy in the period and institution indicated were considered.
Variables: The outcome variables were OS and POM. The latter measured up to 30 days after surgery; it was considered dichotomous (present or absent); severity was estimated applying the Clavien proposal (Clavien et al., 2009). Other variables of interest were age, sex, tumor location, stage of the disease (American Joint Committee on Cancer & American College of Surgeons, 2018), type of surgery, operative mortality and recurrence.
Follow-up protocol: After hospital discharge, all patients were followed up with strict controls at least at months 1, 2, 3 and 6; and after that once a year. During the controls, a clinical evaluation, general laboratory tests and computed tomography of the abdomen and pelvis were realized. In addition, information on death certificates obtained from the Civil Registry and Identification was used, when necessary.
Statistical methods: Data collection was carried out and analyzed with the Stata 11.0 / SE® program. Descriptive statistics was used, applying measures of central tendency and dispersion (averages, standard deviations and extreme values). The SV was calculated applying the Kaplan-Meier method.
Biases: These were reduced with a masked data collection and a complete follow-up of the patients that make up this series for at least 6 months (the last patient recruited).
Ethics: Ethical guidelines for research defined by the Declaration of Helsinki (World Medical Association, 2013), were observed. All patients gave their informed consent in writing.
RESULTS
During the study period, 38 patients were operated for AGC, with a median age of 65 (34-87) years, 71.1 % of which were male. 78.9 % of the series had some type of comorbidity (Tables I and II).
Table I Distribution of clinical variables in patients under study. (N = 38).
*: Some patients had more than one comorbidity. AHT: Arterial hypertension. II-DM: Type II diabetes mellitus.
The most frequent location of the lesions was subcardial (50.0 %). All cases were stage III or IV according to TNM classification (mainly IIIA, 39.5 %); and 55.3 % were Lauren's diffuse type. With 100 % resectability of the series, the most common type of resection was D2-total gastrectomy (60.5 %) (Table I, Figs. 1 and 2).
The medians of the surgical time, number of resected lymph nodes, and hospital stay were 190 min, 32 y 6 days respectively (Table II).
POM was 18.4 % (7 cases), all of which were Clavien & Dindo type I or II (Table III). There was no operative mortality.
With a median follow-up of 28 months, a recurrence of 44.7 % was verified (Table III). On the other hand, the 5- year OS for stages IIIA, IIIB and IV was 53.3 %, 46.1 % and 20.0 % (p=0,007) respectively (Figs. 3 and 4).
Fig. 1 D2-subtotal gastrectomy. The gastric remnant, the Y-Roux gastrojejunal reconstruction, and pancreas can be observed.
Fig. 2 Surgical specimen of subtotal gastrectomy for AGC. An extensive and proliferative tumor that involves a large part of the gastric body.
DISCUSSION
Novelty of the proposal: The novelty of the proposal is that it is a single-center and regional casuistry of patients of a private health institution; with comparable results with different series from national and international referral centers (Cornejo & Portanova; Díaz de Liaño et al., 2008, 2009; Ruiz et al.; Tapia et al., 2010, 2011; Valenti et al., 2011; de Steur et al., 2013; Chen et al., 2016; Degiuli et al.; Randle et al., 2016; Tóth et al., 2016; Yang et al., 2016; Bhandare et al., 2017; Uslu et al., 2018; Wang et al., 2018).
Comment on observed results: Surgery is essential in the treatment of GC and is considered curative when all macroscopic disease is removed, followed by the histological demonstration of the absence of neoplasia on the margins of the surgical specimen. Thus, R0 resection will be considered when in-block excision of the tumor with disease-free histological margins was performed (Bhandare et al.; Uslu et al.; Wang et al.).
Non-Communicable Disease is a denominator used by WHO for oncological diseases (Porta, 2014). It represents a public health problem and will have a sustained increase over time. So, it is projected that by 2030, they will account for almost 70 % of the total deaths in the world (WHO, 2004).
Thus, GC is responsible for the loss of 15 million years of healthy life (DALYs); either due to premature death or disability (Salomon, 2010).
In relation to the burden of cancer disease, oncological diseases ranked 7th in importance of DALYs in 2004; which translated into an immense 221,529 years of life loss, affecting 6 % of the total DALYs of the population, ranking first in men (followed by prostate and lung cancer), and fourth in women (after cancers of the breast, gallbladder, and uterine cervix) (Ministerio de Salud, 2008).
The 5-year OS observed in this study, in the 3 stages measured, is similar to that reported in other series in which only patients with AGC treated with protocols that did not consider neoadjuvant were included (Al-Moundhri et al., 2006; Alici et al., 2006; Garrido et al., 2007; Bhandare et al.; Uslu et al.; Wang et al.). Applying the surgery and adjuvant therapy modality is due to the strong evidence regarding the inappropriate internal and external validity of the Macdonald protocol (Manterola et al., 2006), used as a national protocol for treating GC in our country (Macdonald et al.); that it has only undergone cosmetic modifications by Ministerio de Salud in its application in the last 15 years.
Limitations of the study: Among the limitations, it should be noted that this is a small series, in which all patients underwent surgery by the same surgeon. On the other hand, in the last cases, the follow-up is brief.
