Clinical usefulness of extending the proximal margin in total gastrectomies for gastric adenocarcinoma

Abstract

Introduction and aims: Surgical resection with negative margins is part of the curative treatment of gastric adenocarcinoma. Positive surgical margins are associated with worse outcome. The aim of the present study was to determine the clinical usefulness of extending the proximal surgical margin in patients undergoing total gastrectomy for gastric adenocarcinoma. Materials and methods: A retrospective analysis of patients that underwent total gastrectomy within the time frame of 2002 and 2017 was conducted. Patients diagnosed with adenocarcinoma that underwent curative surgery were included. Patients were divided into three groups, depending on proximal surgical margin status: negative margin (R0), positive margin with additional resection to achieve negative margin (R1-R0), and positive margin (R1). Demographic and clinical variables were analyzed. The outcome measures to evaluate were recurrence, disease-free survival, and overall survival. Results: Forty-eight patients were included in the study. Thirty-seven were classified as R0, 9 as R1-R0, and 2 as R1. Fifty-two percent of the patients had clinical stage III disease. The overall surgical mortality rate was 2% and the morbidity rate was higher than 29%. The local recurrence rate was 0% in the R1-R0 group vs. 50% in the R1 group (p = 0.02). Disease-free survival was 49 months in the R1-R0 group vs. 32 months in the R1 group (p = 0.6). Overall survival was 51 months for the R1-R0 group vs. 35 months for the R1 group (p = 0.5). Conclusions: Intraoperative extension of the positive surgical margin improved the local recurrence rate but was not associated with improvement in overall survival or disease-free survival and could possibly increase postoperative morbidity. Resumen: Introducción y objetivos: La resección quirúrgica con márgenes negativos es parte del tratamiento curativo del adenocarcinoma gástrico. Los márgenes quirúrgicos positivos se asocian a un peor pronóstico. Determinar la utilidad clínica de ampliar el margen quirúrgico proximal en pacientes sometidos a gastrectomía total por adenocarcinoma gástrico. Material y métodos: Análisis retrospectivo de pacientes sometidos a gastrectomía total entre los años 2002 a 2017. Se incluyeron pacientes con diagnóstico de adenocarcinoma operados con intención curativa. Tres grupos establecidos dependiendo del estado del margen quirúrgico proximal: margen negativo (R0), margen positivo con resección adicional para alcanzar margen negativo (R1-R0) y margen positivo (R1). Se analizaron variables demográficas y clínicas. El desenlace a evaluar fue recurrencia, sobrevida libre de enfermedad (SLE) y sobrevida global (SG). Resultados: Se incluyeron 48 pacientes. Treinta y siete se clasificaron como R0, 9 como R1-R0 y 2 como R1. El 52% se encontraban en un estadio clínico III. Se encontró una mortalidad quirúrgica global de 2% y morbilidad mayor de 29%. La recurrencia local fue 0% en el grupo R1-R0 vs. 50% en el grupo R1 (p 0.02). La SLE fue 49 meses en el grupo R1-R0 vs. 32 meses en el grupo R1 (p 0,6). La SG fue de 51 meses para el grupo R1-R0 vs. 35 meses para el grupo R1 (p 0.5). Conclusiones: La ampliación intraoperatoria del margen quirúrgico proximal positivo mejora la tasa de recurrencia local, pero no se asocia a una mejoría en la SG o SLE y podría aumentar la morbilidad posquirúrgica. Keywords: Gastric adenocarcinoma, Proximal surgical margin, Palabras clave: Adenocarcinoma gástrico, Margen quirúrgico proximal