Follow-up of elderly gastric cancer post-radical surgery: Trauma, complications, and prognosis

Abstract

BACKGROUND

The incidence of gastric cancer in the elderly is increasing; however, standardized surgical approaches are lacking.

AIM

To investigate the effects of radical surgery on the trauma response, postoperative complications, and long-term prognosis in elderly patients with gastric cancer.

METHODS

Between January 2020 and December 2023, 110 gastric cancer patients admitted to the Department of Oncology Jiangnan University Medical Center were categorized into a control group (40 cases) and an observation group (70 cases) based on surgical method differences. The control and observation group received palliative surgery and radical surgery, respectively, and were further divided into open (25 cases) and laparoscopic (45 cases) surgery. Surgical outcomes, trauma indicators, complication rates, and long-term survival at 6 months, 1-, and 2-years were compared.

RESULTS

Laparoscopic surgery showed superior surgical outcomes compared to the open surgery and control groups (P < 0.05). Trauma indicators were lowest in the laparoscopic group and highest in the control group (P < 0.05). No significant difference was observed in the complication rates between the open and laparoscopic groups (P > 0.05), but both were higher than those in the control group (P < 0.05). No significant differences were found in survival rates at different follow-up periods between the laparoscopic and open groups (P > 0.05); however, both groups showed higher survival rates than the control group (P < 0.05).

CONCLUSION

Radical surgery in elderly patients with gastric cancer reduces surgical trauma response, facilitates postoperative recovery, and improves long-term survival rates, albeit with an increased risk of complications. Laparoscopic radical surgery further minimizes postoperative trauma, with no significant difference in complication rates and survival prognosis compared with open radical surgery.

Key Words: Radical surgery; Elderly gastric cancer; Trauma stress response; Complications; Long-term prognosis

Core Tip: Although elderly patients have reduced surgical tolerance, surgery remains the primary treatment for gastric cancer in this population. Selecting appropriate surgical methods can reduce mortality and enhance the quality of life in elderly patients with gastric cancer.

INTRODUCTION

The elderly, characterized by diminished antitumor cell proliferation and immune capabilities, are a high-incidence group for gastric cancer. With the aging of the population, the number of elderly gastric cancer patients has been increasing, with over 70% of patients aged 60 and above[1]. Radical surgery is the primary treatment for gastric cancer, effectively extending survival time. However, owing to the complex anatomical structure of the stomach, the risk of postoperative complications is high. Elderly patients often have multiple chronic systemic diseases that reduce surgical tolerance, increase the risk of complications, and affect postoperative recovery. Moreover, the limited life expectancy of older patients makes it difficult to achieve a significant increase in survival after radical surgery. There is an ongoing debate in the clinical setting regarding the choice of surgical approach for elderly patients with gastric cancer. Because gastric cancer in the elderly is a significant public health issue that is expected to increase with the intensification of aging, identifying efficient and safe surgical methods is crucial to reduce mortality and extend survival[2]. Using patients from the Jiangnan University Medical Center as an example, we explored the efficacy of radical surgery in elderly patients with gastric cancer to provide a basis for clinical surgical decision-making. These findings are reported in this study.

MATERIALS AND METHODS

General information

Patient demographics revealed that the study population consisted of gastric cancer patients treated at the Oncology Department of Jiangnan University Medical Center from January 2020 to December 2023. A total of 110 patients were included in the study after applying the inclusion and exclusion criteria. The patients were categorized into a control group (n = 40) and an observation group (n = 70) based on differences in surgical approaches. The observation group was further divided into laparoscopic (n = 45) and open surgery (n = 25) subgroups.

Control group: Male: 19; Female: 21. Age: 67-81 years (mean 75.31 ± 5.54). Tumor node metastasis (TNM) staging: IB-IIA (10 cases), IIB-IIIA (17 cases), and IIIB-IIIC (13 cases). Pathological examination revealed adenocarcinoma (34 cases), mucinous adenocarcinoma (four cases), and signet ring cell carcinoma (two cases).

Open surgery group: Male: 13; Female: 12. Age: 65-83 years (mean 75.55 ± 5.21). Pathology: Adenocarcinoma (20 cases), mucinous adenocarcinoma (4 cases), and signet ring cell carcinoma (1 case). TNM staging: IB-IIIA (15 cases), IIB-IIIA (six cases), and IIIB-IIIC (four cases).

Laparoscopic group: Male: 21; Female: 24. Age: 67-80 years (mean 75.43 ± 5.18). Pathological examination revealed adenocarcinoma (27 patients), mucinous adenocarcinoma (14 patients), and signet ring cell carcinoma (4 patients). The TNM staging: IIB-IIIA (21 cases), IIB-IIIA (17 cases), and IIIB-IIIC (7 cases). No statistically significant differences were found in the baseline characteristics among the three groups (P > 0.05), making them eligible for the study.

The inclusion criteria: (1) Diagnosis of gastric cancer according to standard criteria; (2) Age 60 years; (3) No distant metastasis; (4) No previous radiotherapy, chemotherapy, or immunotherapy; (5) No cognitive or communication impairments were observed; and (6) Informed consent was obtained from all patients and their families.

The exclusion criteria: (1) Other concurrent malignancies; (2) Inability to tolerate surgery; (3) Other functional or structural organ impairments; (4) History of abdominal surgery; (5) Immunological disorders; (6) Coagulation dysfunction; and (7) Death from non-tumor-related causes or withdrawal during follow-up.

Surgical methods

The control group was treated with palliative surgery: Patients in the control group underwent palliative surgery, which was initiated with the patient in the supine position under general anesthesia and endotracheal intubation. A midline laparotomy incision was made, and the tumor location, size, and metastatic status were assessed using a systematic approach from the periphery to the center. Palliative surgical options include resectional techniques such as total, proximal, and distal gastrectomy and non-resectional techniques such as jejunostomy.

The observation group was treated with radical surgery interventions: Open surgery subgroup: Patients who underwent conventional open radical gastrectomy with the same anesthetic and positioning protocols as the control group. An incision from the xiphoid process to the umbilicus allows for exploration and vascular control of the gastric area. The stomach was mobilized and the omentum was transected using electrocautery. Lymph node dissection was performed sequentially, followed by resection of the stomach containing the tumor and anastomosis of the stomach and duodenum using standard techniques, such as Billroth I or II, culminating in routine wound closure.

Laparoscopic group underwent laparoscopic radical gastrectomy for gastric cancer: The patients were positioned in a supine position with the head lower than the feet, with legs abducted approximately 30° in a ‘big’ character shape, and the left leg was bent in a ‘jackknife’ manner at approximately 15°. Endotracheal intubation was performed and general anesthesia was administered. The skin on the patient’s gastric wall was secured and punctured to create an artificial pneumoperitoneum. Punctures were made at the umbilical hole, 5 mm to the left of the umbilicus, along the anterior axillary line at the costal margin, and at the right midclavicular line (at the same horizontal level as the umbilicus) to serve as operative ports. Ultrasonic scalpels and other instruments were inserted through the surgical ports. Under laparoscopic visualization, the right gastroepiploic vessels were clamped and the left and right gastric arteries were ligated to interrupt the gastric branches. The mesentery and greater omentum were stripped and the lymph nodes were cleared. A 5 cm incision was made in the midline of the patient’s abdomen, and the duodenum was transected. The surgeon used intestinal forceps to grasp the gastric remnant and proximal jejunum and lifted the stomach out of the abdominal cavity. The stomach was transected using a stapler (the transection site was 5 cm from the cancerous lesion). The jejunum was removed from the abdominal cavity and holes were drilled at the mesenteric edge of the greater curve of the stomach and jejunum. A stapler was used to anastomose the stomach and jejunum, followed by routine suturing.

Patient general information survey

Surgical-related indicators: Operative time, intraoperative blood loss, time to first flatus postoperatively, time to ambulation, and length of postoperative hospital stay were recorded for all three patient groups.

Trauma stress response: Fasting venous blood (5 mL) was collected from patients in all groups preoperatively and 12 hours postoperatively, followed by centrifugation to obtain the serum. Measure serum levels of endothelin (ET), nitric oxide (NO), and C-reactive protein (CRP) using an enzyme-linked immunosorbent assay with kits from Shanghai Lanjing Biotech Co., Ltd., strictly according to the manufacturer’s instructions.

Complications: Monitor and document the incidence of postoperative complications in the two groups including anastomotic leakage, incision infection, pulmonary infection, dumping syndrome, and intra-abdominal infection.

Long-term prognosis follow-up survey: Follow-up surveys were conducted via telephone and outpatient reviews after patient discharge until recurrence or death. The survival rates of the two groups were recorded at 6 months, 1 year, and 2 years after discharge.

Statistical analysis

Data were analyzed using statistical product and service solutions 20.0 software. Quantitative data conforming to a normal distribution are presented as mean ± SD, with t-tests for comparisons and F-tests for multiple group comparisons. Qualitative data are expressed as frequency and percentage n (%), with χ² tests for analysis; P < 0.05 indicating statistical significance.

RESULTS

Surgical-related metrics

Patients in the open laparotomy group exhibited lower intraoperative blood loss and shorter temporal metrics than those in the control group. The laparoscopic group demonstrated intraoperative blood loss lower than that of the open laparotomy group, and the remaining four temporal metrics were at their lowest levels (P < 0.05). See Table 1.

Table 1 Comparison of surgical-related indicators among three groups of patients, mean ± SD.

Groups	Cases (n)	Intraoperative blood loss (mL)	Surgery duration (minute)	Postoperative time to first flatus (day)	Time to ambulation (day)	Postoperative hospital stay (day)
Control	40	398.14 ± 74.21	301.25 ± 45.15	5.25 ± 1.31	3.94 ± 1.21	16.91 ± 4.23
Open surgery	25	205.13 ± 69.32	265.13 ± 37.43	4.13 ± 1.15	3.06 ± 0.80	15.15 ± 3.71
Laparoscopic surgery	45	177.31 ± 55.15	231.25 ± 27.77	3.43 ± 1.02	2.87 ± 0.74	13.15 ± 3.15
F value		131.998	37.756	26.156	14.486	10.973
P value		0.000	0.000	0.000	0.000	0.000

Quantitative data were compared across multiple groups using the F-test.

Trauma stress response

In the comparison of stress response indicators among the three groups, the control group exhibited the highest levels of ET, NO, and CRP, while the laparoscopic group showed the lowest levels of stress indicators (P < 0.05). See Table 2.

Table 2 Comparison of trauma stress response indicators among three groups of patients, mean ± SD.

Groups	Cases (n)	ET (ng/L)		NO (μmol/L)		CRP (mg/L)
		Before	After 12 hours	Before	After 12 hours	Before	After 12 hours
Control	40	1.05 ± 0.32	1.80 ± 0.58	10.08 ± 3.17	20.13 ± 3.40	21.15 ± 1.21	63.12 ± 12.58
Open surgery	25	1.04 ± 0.39	1.65 ± 0.53	10.11 ± 3.15	18.05 ± 2.45	21.30 ± 1.25	59.12 ± 11.37
Laparoscopic surgery	45	1.01 ± 0.35	1.39 ± 0.51	10.03 ± 3.11	16.13 ± 2.11	21.34 ± 1.18	50.10 ± 10.33
F value		0.149	6.232	0.006	22.925	0.279	14.367
P value		0.862	0.002	0.994	< 0.001	0.757	< 0.001

Quantitative data were compared across multiple groups using the F-test. ET: Endothelin; NO: Nitric oxide; CRP: C-reactive protein.

Incidence of complications

The incidence of complications in the control group was significantly lower than that in both radical surgery groups (P < 0.05), and there was no statistically significant difference in the incidence of complications between the open and laparoscopic surgery groups (P > 0.05). See Table 3.

Table 3 Comparison of complication incidence rates among three groups of patients, n (%).

Groups	Cases (n)	Anastomotic fistula	Incision infection	Pulmonary infection	Dumping syndrome	Abdominal infection	Total incidence
Control	40	2 (5.00)	3 (7.50)	0 (0)	1 (2.50)	2 (5.00)	8 (20.00)
Open surgery	25	3 (12.00)	4 (16.00)	1 (4.00)	2 (8.00)	4 (16.00)	14 (56.00)
Laparoscopic surgery	45	7 (15.56)	1 (2.22)	0 (0)	5 (11.11)	5 (11.11)	18 (40.00)
Control and laparoscopic group χ2/P value							8.904/0.002
Control and laparoscopic group χ2/P value							3.989/0.045
Control and laparoscopic χ2/P value							1.657/0.197

Qualitative data are presented as frequencies and percentages and were analyzed using the χ² test.

Long-term prognosis follow-up survey

At the three postoperative follow-up time points, there was no statistically significant difference in survival rates between the open and laparoscopic groups (P > 0.05). At each of the three follow-up time points, the control group had the lowest survival rates (P < 0.05). See Table 4.

Table 4 Comparison of long-term prognosis follow-up survey among three groups of patients, n (%).

Group	Cases (n)	6 months post-discharge	1 year after discharge	2 years after discharge
Control	40	36 (90.00)	28 (70.00)	22 (55.00)
Open surgery	25	24 (96.00)	23 (92.00)	20 (80.00)
Laparoscopic surgery	45	44 (97.78)	41 (91.11)	34 (75.56)
Control and open χ2/P value		0.780/0.377	4.406/0.035	4.205/0.040
Control and laparoscopic χ2/P value		2.313/0.128	6.176/0.012	3.980/0.046
Open and laparoscopic χ2/P value		0.183/0.668	0.016/0.898	0.180/0.671

Qualitative data are presented as frequencies and percentages and were analyzed using the χ² test.

DISCUSSION

China’s aging population has led to an increase in the number of elderly patients with gastric cancer. Despite medical advancements, a universal cure for gastric cancer remains elusive. Surgery, particularly radical surgery, is one of the primary treatments for prolonging life and removing cancerous lesions, and has shown significant efficacy[3]. However, elderly patients often have reduced physical reserves and lower tolerance to surgery, leading to higher risks and prolonged recovery times, which can increase medical costs and potentially reduce prognosis.

This study analyzed 110 elderly patients with gastric cancer who underwent palliative, open radical, or laparoscopic radical surgery. The palliative surgery group exhibited the highest blood loss and longest time indicators (surgery duration, first flatus, ambulation, and hospital stay) (P < 0.05), indicating greater trauma and prolonged recovery compared to the radical surgeries. Radical surgeries employ sharp dissection principles, reducing the handling of vascular branches, thus decreasing blood loss[4]. In contrast, palliative surgeries that do not aim for complete lesion removal involve more extensive dissection of tumor interfaces, which increases blood loss and operation time[5].

Compared with conventional surgical approaches, laparoscopic surgery, aided by visualization through a lens, effectively addresses the technical challenge of obtaining a clear view of the lesion, which is often difficult using traditional methods. The laparoscopic group showed lower stress response indicators than the open group, with the control group showing the highest levels (P < 0.05). ET, NO, and CRP are key indicators of the stress response, with ET and NO levels positively correlated with traumatic stress, and CRP is rapidly released after tissue damage[6-8]. Palliative surgery induces a stronger stress response owing to longer operation times and greater blood loss, whereas laparoscopic radical surgery, which is minimally invasive, reduces surgical trauma and stress levels[9,10].

The palliative surgery group had a lower incidence of complications than the radical surgery groups (P < 0.05), with no significant difference between the laparoscopic and open radical surgery groups (P > 0.05). Palliative surgery, aimed at improving symptoms without complete tumor removal, preserves more vascular tissue, leading to better blood supply, faster mucosal regeneration, and reduced risk of infection[11,12]. Anastomotic leakage, a common complication of gastrointestinal surgery, is mitigated by palliative surgery because of the enhanced blood supply and reduced inflammatory mediator secretion[13]. However, the technical challenges of laparoscopic lymph node dissection and anastomosis may affect the quality of the surgery and increase the risk of complications if not performed correctly.

Studies have increasingly indicated that patients with gastric cancer who undergo radical-intent gastrectomy after responding to several regimens of combined chemotherapy can achieve good survival outcomes. This study found that, compared with radical surgery, the palliative surgery group had lower survival rates at 6 months, 1 year, and 2 years postoperatively (P < 0.05), while there was no significant difference between the laparoscopic and open radical surgery groups (P > 0.05). Radical surgery effectively removes potentially metastatic lymph nodes and infiltrated tissues, thereby reducing the risk of tumor cell spread and residual lesions[14-17].

CONCLUSION

Palliative surgery in elderly patients with gastric cancer is associated with more severe traumatic impact and extended recovery period. Notably, the incidence of postoperative complications is lower after curative surgery. Conversely, curative surgery is associated with improved long-term survival rates. The use of laparoscopic techniques for curative procedures further mitigate surgical trauma. However, our data indicate that this minimally invasive approach does not significantly influence the rate of postoperative complications or the long-term survival outcomes in these patients. In summary, this study provides specific recommendations and references for clinicians when selecting surgical approaches for elderly patients with gastric cancer, thereby enhancing the clinical applicability of this research.