DISCUSSION

In the UICC's TNM classification for gastric cancer, a residual tumor or tumor load after gastric surgery is also listed as 1 of the determinant predictors of survival.(16) After palliative surgery, patients with microscopic residual tumors survived longer than those with macroscopic residual tumors. It is well recognized that palliative resection produces a longer survival than non-resection surgery.(6,17-19) Patients survived longer after a gastrojejunostomy or a laparotomy only compared to those who had intubation surgery in other and our own series,(6,7,17) because intubation surgery is usually performed on patients in a later stage such as those with extensive peritoneal carcinomatosis. However some series failed to show any differences in survival between the two.(12,19)
Symptomatic palliation or quality of life is as an important survival benefit as operative safety in selecting surgical procedures for patients with far-advanced gastric cancer.(12) Resection is currently accepted as the most effective procedure for symptomatic palliation.(5-7) The palliative effect after gastric resection endured longer than that after non-resectional procedures.(12) Whenever feasible, gastric resection should be the first choice. Our study supports distal gastrectomy being the best palliative surgery, but it is indicated only for cancers of the distal stomach.
Non-resectional surgery provides only very limited palliation. Gastric outlet obstruction is the most frequent indication for non-resection procedures. A gastrojejunostomy can effectively relieve the obstruction, allowing resumption of an oral diet following the operation. However, some do not consider it satisfactory palliation, because the bypass function can not be maintained as long as patients will survive.(11) Therefore, it is not recommended whenever gastric resection is feasible.(6,7,11) Intubation is the operation of last choice for gastric outlet obstruction.(6) The feeding function of a jejunostomy can be maintained for only 1.4 months on average, which is too short to render it a worthwhile palliative procedure.
Postoperative gastric stasis following a gastrojejunostomy occurred in a high percentage (14.1%) of patients, most of whom had risk factors like a history of chronic obstruction or malnutrition before the operation.(20) A temporal feeding jejunostomy should be added for cases of chronic gastric outlet obstruction. It can serve as a feeding port for enteral nutrition, once gastric stasis develops.
The mortality and morbidity rates of palliative surgery were significantly greater than those following curative resection in other and our own studies.(6,7,21) Anastomotic leakage is the main cause of operative mortality following gastric resection, whereas disease progression is the most common cause of hospital death following non-resection procedures. For cancers of the distal stomach, a bypass or gastrojejunostomy can be performed to avoid the mortality and morbidity of a gastrectomy in high-risk patients. However, for cancers of the proximal third of the stomach, a bypass operation is seldom performed to take the place of a total gastrectomy for high-risk patients. In the R2-resection group, the percentage of patients with total gastrectomies (41.6%) was much higher than that in the R0 (26.2%) or R1 group (32.7%). This may explain why R2 total gastrectomies had a particularly higher operative mortality than did R1 and R2 distal gastrectomies or R1 total gastrectomies in this series.
From logistic regression analysis, we identified peritoneal seeding, very old age (> 80 years), and severe medical diseases as the most important risk factors influencing the operative mortality of patients who underwent gastric resection (Table 4). The proportion of patients of a very old age or with severe medical diseases did not differ in gastrectomized patients of the various residual tumor groups. However, a higher proportion of peritoneal seeding was particularly noted in patients receiving R2 total gastrectomies. This provides another reason for the high mortality of R2 total gastrectomies among our patients.
Some clinicians disapprove of a total gastrectomy as a palliative procedure due to its high operative mortality and short survival times.(22,23) However, several recent reports did not oppose the use of a palliative total gastrectomy, suggesting that it is a relatively safe procedure compared to a distal gastrectomy.(7,8,19) Nevertheless, it is generally recognized that, for a better postoperative quality of life and nutritional status, total gastrectomies should not be performed en principle for all cases except for cancers of the proximal third of the stomach. The selection of a total gastrectomy must be stringent for R2 patients. We suggest that a total gastrectomy is an acceptable operation for R1 patients with cancers of the proximal third of the stomach, while it should be done selectively for R2 patients because of the high operative mortality. For R2 patients, a gastrectomy is not the only method of treatment for proximal-third cancers; instead, other treatment modalities such as trans-endoscopic stenting, laser therapy, and brachytherapy might be safer alternatives.(24,25)
Postoperative residual or occult tumor cells may continue to grow in patients following palliative surgery. Early aggressive chemotherapy is recommended for these patients.(26,27) A regimen, consisting of a weekly high-dose 5-FU and LV infusion, originally recommended for colon cancer, has been tried in our hospital.(15,28) The result of a phase II prospective trial revealed a partial response in 33.3% of 37 patients, in addition to an acceptable toxicity even in patients with a relatively poor performance status.(15) In this study, postoperative chemotherapy was demonstrated capable of improving the survival of incurable patients regardless of whether gastric resection was performed or not.
Recently some more-aggressive operations have been advocated for patients with distant metastasis to the para-aortic lymph nodes, liver, or peritoneum.(9,29) Para-aortic lymph node dissection prolonged the survival of patients if the number of metastatic para-aortic lymph nodes was m 3.(29) A combined hepatectomy for liver metastasis prolonged the survival time of patients with liver metastasis confined to 1 lobe.(18) For patients with peritoneal seeding, a 5-year survival of 24% was observed in a clinical trial (N=14) that utilized an extensive peritonectomy and perioperative intraperitoneal chemotherapy, in addition to an extended gastrectomy.(10,30) For far-advanced cases, radical or aggressive surgery would certainly increase postoperative mortality and morbidity. Therefore, in the decision-making process for these aggressive operations, one must consider not only the survival benefits, but also the surgical risks and postoperative quality of life.

Acknowledgments

The authors would like to thank the Cancer Unit of Chang Gung Memorial Hospital, Taipei, Taiwan for financially supporting this research. Dr Ting-Chang Chang's contribution to the statistical analysis is also highly appreciated.

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Presentation: A portion of the contents of this paper were presented at the 38th World Congress of Surgery of the International Society of Surgery/Societe Internationale de Chirurgie (ISS/SIC) in Viena, Austria during International Surgical Week ISW99, August 17, 1999.
From the Department of General Surgery, Chang Gung Memorial Hospital, Taipei; Chang Gung University, Taoyuan.
Received: Jun. 10, 2002; Accepted: Sep. 3, 2002
Address for reprints: Dr. Chia-Siu Wang, Department of General Surgery, Chang Gung Memorial Hospital. 6, West Chia-Pu Road, Putzi City, Chiayi, Taiwan 613, R.O.C. Tel.: 886-5-3621000 ext. 2752; Fax: 886-5-3623002; E-mail: wangcs@cgmh.org.tw