Subtotal versus total gastrectomy for cancer of the distal half of the stomach: surgical morbidity and mortality, nutritional profile, and five-year survival rates

ABSTRACT

There is a controversy as to whether the optimal surgery for gastric cancer in the distal half of the stomach is subtotal or total gastrectomy. The aim of this prospective study was to compare postoperative morbidity and mortality, nutritional status, and long-term survival between the two groups. A total of 32 patients with cancer in the distal half of the stomach were randomized to total gastrectomy [TG] [n=15] or subtotal gastrectomy [SG] [n=l7] provided there was at least 6 cm from the proximal edge of the tumour to the cardia. Both surgical treatments included a second-level lymphadenectomy. Operative data as well as the length of hospital stay were recorded. Postoperative complications were divided into non-fatal and fatal complications. Nutritional profile was evaluated preoperatively at admission and postoperatively at one and six months, respectively. The 5-year survival probability was estimated with regard to type of surgical treatment/tumour characteristics by univariate and multivariate analysis. The duration of the surgical procedure, the amount of operative blood loss, the amount of blood transfused, and the length of hospital stay were statistically significant in favour of the SG group [P<0.01]. Postoperative morbidity rate was 29.4% in the SG group and 66.7% in the TG group [P=0.03].The nutritional profile of patients with SG improved significantly at 6 months compared to the values observed in the TG group [P<0.05]. Median follow-up was 36 months after SG [range 9 to 60] and 28 months after TG [range 6 to 60]. Five-year survival probability was 56.2% for SG and 38.5% for TG [P=0.34]. Analysis using a multivariate Cox regression model showed a statistically significant impact on survival for age, extent of resection to the spleen and/or neighboring organs, tumour spread within the gastric wall, lymph node involvement, and tumour stage. In conclusion, there are several advantages in performing a more conservative operation [SG] in patients with cancer of the lower half of the stomach. This study showed that long-term survival is similar after SG or TG. However, the better postoperative outcome and quality of life of patients with SG suggested that this procedure should be the treatment of choice when a cancer free proximal resection margin can be guaranteed