Impact of Centralizing Gastric Cancer Surgery on Treatment, Morbidity, and Mortality

Abstract

IntroductionCentralization of gastric cancer surgery is thought to improve outcome and has been imposed in the Netherlands since 2012. This study analyzes the effect of centralization in terms of treatment outcome and survival in the Eastern part of the Netherlands.MethodsAll gastric cancer patients without distant metastases who underwent a gastrectomy in six hospitals in the Eastern part of the Netherlands between 2008 and 2011 (pre-centralization) and 2013–2016 (post-centralization) were selected from the Netherlands Cancer Registry. Patient and tumor characteristics and treatment outcomes (duration of surgery, blood loss, resection margin, lymphadenectomy, chemotherapy, postoperative complications and hospital stay, and overall and disease-free survival) were analyzed and compared between pre- and post-centralization.ResultsOne hundred forty-four patients were included pre-centralization and 106 patients post-centralization. Patient and tumor characteristics were almost similar in the two periods. After centralization, more patients were treated with perioperative chemotherapy (25 vs. 42% p < 0.01). The proportion of patients treated with an adequate lymphadenectomy (21 vs. 93% p < 0.01) and laparoscopic surgery (6 vs. 40% p < 0.01) increased significantly (p < 0.01). The amount of cardiac complications (16 vs. 7.5% p < 0.05) decreased; however, complications needing a re-intervention were comparable (42 vs. 40% p = 0.79). Median hospital stay decreased from 10 to 8 days (p < 0.01). A 30-day mortality did not differ significantly (4.2 vs. 1.9%). A 1-year overall (78 vs. 80% p = 0.17) and disease-free survival (73 vs. 74% p = 0.66) remained stable.DiscussionCentralizing gastric cancer treatment in the Eastern part of the Netherlands resulted in improved lymph node harvesting and a successful introduction of laparoscopic gastrectomies. Centralization has not translated into improved mortality, and other variables may also have led to these improved outcomes. Further research using a nationwide population-based study will be needed to confirm these data.

Overall survival before and after centralization of gastric cancer surgery in the Netherlands

“…Other studies 14,15 showed that increased hospital volume was associated with lower postoperative mortality rates and improved survival after gastric cancer surgery. However, a Dutch study 16 , which included patients treated surgically in the eastern part of the country, did not find an improvement in overall survival after gastrectomy following centralization; this was probably related to the small number of patients investigated. Another study 17 also reported no association between hospital volume and long-term survival.…”

“…The results from previous studies investigating the effects of centralization of gastric cancer surgery on outcome are ambiguous. Studies from the UK and Denmark showed that patients who underwent gastrectomy in the period after centralization had a lower postoperative mortality rate and better overall survival than patients treated before centralization.…”

Treatment of gastric adenocarcinoma at a New Zealand centre: meeting the challenges of a low volume country

“…Of the 60 patients who underwent curative gastrectomy the overall operative mortality rate was 1.6%. Compared with countries with larger populations, a higher incidence of gastric cancer and mandated centralized units for the management of gastric cancer, our results benchmark satisfactorily . Two of the most important measures of surgical quality in gastric cancer surgery are the rate of R 0 resection and adequacy of lymph node resection (with at least 15 lymph nodes harvested the accepted standard) .…”

“…We have recently employed a sub‐specialty trained UGI surgeon trained in minimally invasive surgery and aim to offer laparoscopic surgery in between 30% and 50% of patients with gastric malignancy . Similarly, our use of neoadjuvant chemotherapy was also less than observed in overseas units during the study period . This largely reflects local oncology policy operating between 2010 and 2014.…”

“…A key observation from this study is the lack of laparoscopic resections when compared to larger centralized treatment centres. Only 3% of patients at WDHB over a 60‐month period were treated with a laparoscopic approach to gastrectomy compared to 40% in a centralized Dutch gastrointestinal unit . We have recently employed a sub‐specialty trained UGI surgeon trained in minimally invasive surgery and aim to offer laparoscopic surgery in between 30% and 50% of patients with gastric malignancy .…”