Achieving R0 Resection for Locally Advanced Gastric Cancer: is It Worth the Risk of Multiorgan Resection?1

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Abstract
In gastric adenocarcinoma, only complete resection (R0) translates into survival benefit. Given the potential for increased morbidity and mortality from multiple organ resection we asked the question as to whether extended (multiple organ) resection was justified for advanced gastric cancer. From July 1985 to July 2000, 1,283 patients underwent gastric resection for adenocarcinoma at Memorial Sloan-Kettering Cancer Center, and were entered and followed in a prospectively recorded database. Four hundred eighteen patients (33%) underwent primary resection and had one or more organs resected in addition to the stomach. Eight hundred twenty-six patients (64%) underwent gastrectomy alone, with 39 patients (3%) not undergoing gastrectomy. Clinicopathologic, operative, and morbidity data were evaluated in this group. Complications were categorized by severity on a scale from 0 to 5, 0 being no complication to 5 being death. Chi-square analysis and the logistic regression method were used to compare and estimate factors significantly associated with having a complication. Three hundred thirty-seven patients had a single additional organ resected, 63 had two organs, and 18 had three organs. Five hundred eighty complications occurred in 33% of patients (404 of 1,283). The perioperative mortality was 4% (48 patients). Logistic regression identified the number of organs resected, two or greater, to be predictive of complications (RR 2.0), as well as age greater than 70 years old (RR 1.57). When excluding minor complications (values 1 and 2), only the number of organs resected (RR 3.8) was a major factor for severe complications (values 3, 4, and 5). Resection of two or more adjacent organs in advanced gastric adenocarcinoma is associated with a greater risk of developing a complication. The use of a graded surgical complication scale is needed for better reporting and comparison of complications. Achieving an R0 resection should still be considered the goal, even in locally advanced gastric cancer, but resection of additional organs should be performed judiciously.