Disparities in Utilization and Outcomes of Minimally Invasive Techniques for Gastric Cancer Surgery in the United States

Background This study investigated national implementation patterns and perioperative outcomes of minimally invasive gastrectomy (MIG) in gastric cancer surgery in the United States. Methods The National Inpatient Sample (NIS) was queried for patients who underwent elective gastrectomy for gastric cancer from 2008-2018. The MIG versus open gastrectomy approach was correlated with hospital factors, patient characteristics, and complications. Results There was more than a fivefold increase in MIG from 5.8% in 2008 to 32.9% in 2018 (nptrend < 0.001). Patients undergoing MIG had a lower Elixhauser Comorbidity Index (p = 0.001). On risk adjusted analysis, black patients (AOR = 0.77, p = 0.024) and patients with income below 25th percentile (AOR = 0.80, p = 0.018) were less likely to undergo MIG. When these analyses were limited to minimally invasive capable centers only, these differences were not observed. Hospitals in the upper tertile of gastrectomy case volume, Northeast, and urban teaching centers were more likely to perform MIG. Overall, MIG was associated with a 0.7-day decrease in length of stay, reduced risk adjusted mortality rates (AOR = 0.58, p = 0.05), and a $4,700 increase in total cost. Conclusions In this national retrospective study, we observe socioeconomic differences in patients undergoing MIG, which is explained by hospital level factors in MIG utilization. We demonstrate that MIG is associated with a lower mortality compared with open gastrectomy. Establishing MIG as a safe approach to gastric cancers and understanding regional differences in implementation patterns can inform delivery of equitable high-quality health care.

How are trial outcomes prioritised by stakeholders from different regions? Analysis of an international Delphi survey to develop a core outcome set in gastric cancer surgery

Background International stakeholder participation is important in the development of core outcome sets (COS). Stakeholders from varying regions may value health outcomes differently. Here, we explore how region, health income and participant characteristics influence prioritisation of outcomes during development of a COS for gastric cancer surgery trials (the GASTROS study). Methods 952 participants from 55 countries participating in a Delphi survey during COS development were eligible for inclusion. Recruits were grouped according to region (East or West), country income classification (high and low-to-middle income) and other characteristics (e.g. patients; age, sex, time since surgery, mode of treatment, surgical approach and healthcare professionals; clinical experience). Groups were compared with respect to how they categorised 56 outcomes identified as potentially important to include in the final COS (‘consensus in’, ‘consensus out’, ‘no consensus’). Outcomes categorised as ‘consensus in’ or ‘consensus out’ by all 3 stakeholder groups would be automatically included in or excluded from the COS respectively. Results In total, 13 outcomes were categorised ‘consensus in’ (disease-free survival, disease-specific survival, surgery-related death, recurrence of cancer, completeness of tumour removal, overall quality of life, nutritional effects, all-cause complications, intraoperative complications, anaesthetic complications, anastomotic complications, multiple organ failure, and bleeding), 13 ‘consensus out’ and 31 ‘no consensus’. There was little variation in prioritisation of outcomes by stakeholders from Eastern or Western countries and high or low-to-middle income countries. There was little variation in outcome prioritisation within either health professional or patient groups. Conclusion Our study suggests that there is little variation in opinion within stakeholder groups when participant region and other characteristics are considered. This finding may help COS developers when designing their Delphi surveys and recruitment strategies. Further work across other clinical fields is needed before broad recommendations can be made.

P-OGC19 The predictive role of cardiopulmonary exercise testing in gastric cancer surgery

Background The role of Cardiopulmonary Exercise Testing (CPET) prior to major surgery has been an area of growing interest over the last two decades. CPET offers an objective and composite measure of physiological functional reserve, and thus can be used to identify patients at highest risk of peri-operative morbidity and mortality. Although the role of CPET has been investigated with respect to outcomes after oesophagectomy, no clear data exist into the predictive role of CPET specifically relating to gastric cancer surgery. The aim of this study was to identify CPET parameters predictive of adverse outcome in patients undergoing curative gastric resections. Methods Patients who underwent CPET followed by curative total or subtotal gastrectomy for gastric or junctional adenocarcinoma between January 2013 and December 2019 in a single high-volume centre were included in retrospective analysis. CPET variables were categorised as per cut-off values from other surgical populations (AT &lt; 11ml.min-1.kg-1, VO2peak&lt;15ml.min-1.kg-1, VE/VCO2 at AT &gt; 34). Associations between these variables and postoperative outcomes were analysed using chi squared or Fisher’s exact test. Results There were 252 patients included in the study. Patients with VE/VCO2&gt;34 were more likely to return to the intensive care unit (ICU) (p = 0.033) and had a higher chance of in-hospital mortality (p = 0.012). AT &lt; 11ml.min-1.kg-1 or VO2peak&lt;15ml.min-1.kg-1 were not associated either with return to ICU (p = 0.243, p = 0.202) or with in-hospital mortality (p = 1.000, p = 1.000). Conclusions Although much has been published on the importance of CPET assessment prior to major abdominal surgery, there is a paucity of literature specifically looking at its role in patients with gastric cancer. Patients with ventilatory inefficiency (VE/VCO2&gt;34) are more likely to return to ICU or to die during hospital stay after total/subtotal gastrectomy for malignant disease. This information should play a more prominent role when assessing patients’ fitness prior to surgery.

The long-term survival outcomes of gastric cancer patients with total intravenous anesthesia or inhalation anesthesia: a single-center retrospective cohort study

Background The relationship between the type of anesthesia and the survival outcomes of gastric cancer patients is uncertain. This study compared the overall outcome of gastric cancer patients after surgery with total intravenous anesthesia (TIVA) or inhalation anesthesia (IHA). Methods Clinicopathological variables of gastric cancer patients were retrieved from the database of the Surgical Gastric Cancer Patient Registry in West China Hospital, Sichuan University. Patients were grouped according to whether they received TIVA or IHA during the operation. Propensity score (PS) matching was used to balance the baseline variables, and survival outcomes were compared between these two groups. In addition, studies comparing survival outcomes between TIVA and IHA used for gastric cancer surgery and published before April 20th, 2020, were identified, and their data were pooled. Results A total of 2827 patients who underwent surgical treatment from Jan 2009 to Dec 2016 were included. There were 323 patients in the TIVA group and 645 patients in the IHA group, with 1:2 PS matching. There was no significant difference in overall survival outcomes between the TIVA and IHA groups before matching the cohort (p = 0.566) or after matching the cohort (p = 0.679) by log-rank tests. In the Cox hazard regression model, there was no significant difference between the TIVA and IHA groups before (HR: 1.054, 95% CI: 0.881–1.262, p = 0.566) or after (HR: 0.957, 95% CI: 0.779–1.177, p = 0.679) PS matching. The meta-analysis of survival outcomes between the TIVA and IHA groups found critical statistical value in the before PS matching cohort (HR 0.74, 95% CI: 0.57–0.96 p < 0.01) and after PS matching cohort (HR: 0.65, 95% CI: 0.46–0.94, p < 0.01). Conclusions Combined with the results of previous studies, total intravenous anesthesia has been shown to be superior to inhalation anesthesia in terms of overall survival for gastric cancer patients undergoing surgical treatment. The selection of intravenous or inhalation anesthesia for gastric cancer surgery should take into account the long-term prognosis of the patient.