Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

Background Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding. Methods We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136). Results One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery. Conclusion Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

P109 GEOGRAPHICAL DIFFERENCES IN RESECTION RATES ASSOCIATED WITH SURVIVAL IN SWEDEN-IS SURGERY UNDERUSED?

Aim To investigate associations between resection rates and survival in esophageal and gastroesophageal junctional cancer. Background & Methods Surgical resection is the mainstay of curative treatment for cancer in the esophagus and the gastroesophageal junction. Merely about one third of these patients undergo resectional surgery although proportions vary. We set out to study differences in resection rates by county and their influence, if any, on survival. A national cohort of patients with esophageal- and gastroesophageal junctional cancer, diagnosed 2006-2015, was set up by cross linking several national registries. The annual resection rate of each geographical county was calculated and divided into three groups (low, middle and high). Survival was analyzed with a Cox proportional hazards model including resection rate, sex, age, year of diagnosis, clinical TNM status, relevant comorbidities, neoadjuvant treatment as well as proportion intended curative oncological treatment. Results 6532 patients were diagnosed during the study period whereof 1733 (26.3 %) underwent open or endoscopic resectional surgery. 860 (49.6%) patients received neoadjuvant treatment. In the studied decade, rates ranged from 21% to 33% in the 21 counties. Overall mean survival after diagnosis was 8.1, 9.9 and 12.1 months in the low, middle and high-resection rate groups respectively. In the multivariate Cox analysis, higher resection rate was associated with improved survival (HR 0.87, 95% CI 0.84-0.90, p<0.001). Conclusion In this national population-based cohort study, patients undergoing treatment in counties with higher resection rates had an associated improved survival. Local underuse of the surgical modality cannot be excluded.

Perioperative prehabilitation and rehabilitation in esophagogastric malignancies: a systematic review

SUMMARYCancers of the esophagus and stomach are challenging to treat. With the advent of neoadjuvant therapies, patients frequently have a preoperative window with potential to optimize their status before major resectional surgery. It is unclear as to whether a prehabilitation or optimization program can affect surgical outcomes. This systematic review appraises the current evidence for prehabilitation and rehabilitation in esophagogastric malignancy. A literature search was performed according to PRISMA guidelines using PubMed, EMBASE, Cochrane Library, Google Scholar, and Scopus. Studies including patients undergoing esophagectomy or gastrectomy were included. Studies reporting on at least one of aerobic capacity, muscle strength, quality of life, morbidity, and mortality were included. Twelve studies were identified for inclusion, comprising a total of 937 patients. There was significant heterogeneity between studies, with a variety of interventions, timelines, and outcome measures reported. Inspiratory muscle training (IMT) consistently showed improvements in functional status preoperatively, with three studies showing improvements in respiratory complications with IMT. Postoperative rehabilitation was associated with improved clinical outcomes. There may be a role for prehabilitation among patients undergoing major resectional surgery in esophagogastric malignancy. A large randomized controlled trial is warranted to investigate this further.