10.1245/s10434-006-9235-1
Annals of Surgical Oncology 14:1288-1294 (2007)
© 2007 Society of Surgical Oncology
Abdominal Shape of Gastric Cancer Patients Influences Short-Term Surgical Outcomes
Jun Ho Lee1,
Yong Hae Paik1,
Jong Seok Lee1,
Keun Won Ryu1,
Chan Gyoo Kim1,
Sook Ryeon Park1,
Young Woo Kim1,
Myeong Cherl Kook1,
Byung-ho Nam2 and
Jae-Moon Bae1,3
1 Research Institute and Hospital, National Cancer Center, 809 Madu1-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do, 411-769, Korea
2 Cancer Biostatistics Branch, Research Institute for National Cancer Control & evaluation, National Cancer Center, 809 Madu1-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do, 411-769, Korea
3 Center for Gastric Cancer, Research Institute & Hospital National Cancer Center, Madu-dong 806 Dongilsan-gu Goyang-si, Gyeonggi-do, 411-764, Korea
Correspondence: Address correspondence and reprint requests to: Jae-Moon Bae. Center for Gastric Cancer, Research Institute & Hospital National Cancer Center, Madu-dong 806 Dongilsan-gu Goyang-si, Gyeonggi-do, 411-764, Korea; E-mail: jmoonbae{at}ncc.re.kr
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ABSTRACT
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Background: There is a prevailing belief that both obesity and abdominal shape influence abdominal accessibility, and thus affect short-term surgical outcomes of gastric cancer surgery.
Methods: We measured the thickness of subcutaneous fat (SCF), abdominal anterior-posterior diameter (APD), transverse diameter (TD), and intra-abdominal fat volume (IFV) at the umbilicus level by using the abdominal CT scans of 291 gastric cancer patients who had undergone subtotal gastrectomy and D2 lymph node dissection. Clinicopathological factors including body mass index (BMI), APD, TD, IFV, and SCF and surgical outcomes, i.e., dissected lymph node number, morbidity, and mortality were analyzed.
Results: SCF thickness, APD, TD, IFV, and BMI mean values were 20.0 mm (range 2.0–64.0), 188.4 mm (range 128.0–332.0), 301.4 mm (range 160.0–651.0), 198.3 mm2 (range 123.4–312.1), and 23.9 kg/m2 (range 16.6–34.6), respectively. In male patients, APD was found to correlate with the number of retrieved lymph nodes (P = 0.045). Whereas in female patients, this was not the case (P = 0.093). Twenty-one patients experienced postoperative complications but no postoperative mortality occurred. Female patients who experienced postoperative complications had higher APD (32.9 ± 10.0 mm versus 26.1 ± 7.9 mm, P = 0.044) and BMI (27.3 ± 4.1 kg/m2 versus 24.3 ± 3.5 kg/m2, P = 0.049) values than those who did not.
Conclusions: We conclude that obesity and abdominal shape of gastric cancer patients both influence the short-term surgical outcomes of subtotal gastrectomy with D2 lymph node dissection.
Key Words: Body shape • Gastric cancer • Lymph node • Dissection
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INTRODUCTION
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Gastric cancer is the most common form of cancer in Korea,1 and the overall age-standardized incidence rates of gastric cancer in 2002 were 69.6 per 100,000 among males and 26.8 per 100,000 among females.2 D2 lymph node dissection remains a standard treatment method for gastric cancer,3–5 and although it increases the radical nature of surgical therapy, it also allows adequate lymph node staging.
Obesity is an expanding problem throughout the world,6 and substantially increases the risks of morbidity and mortality in patients who undergo abdominal surgery.7–10 Moreover, recent data suggests that the survivals of obese patients treated surgically for gastric cancer are compromised.11 Poor accessibility in the obese to lymph nodes deeply embedded in adipose tissues around major abdominal vessels predisposes such patients to unsuccessful lymph node dissection.11,12
However, abdominal shape may also influence accessibility in patients with gastric cancer. For example, a large anterior to posterior abdominal wall diameter may make it difficult to access the abdominal cavity. However, no data is available concerning the effects of abdominal shape on the surgical outcomes of gastric cancer patients.
Thus, we conducted this study to explore the effects of abdominal shape on gastric cancer patient short-term surgical outcomes in both genders, in terms of retrieved lymph node numbers, morbidities, and mortality.
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PATIENTS AND METHODS
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The medical records and the abdominal CT scans of 291 patients who underwent subtotal gastrectomy at the Center for Gastric Cancer, National Cancer Center, Korea between January 1 and June 31, 2004 were reviewed. Subcutaneous fat thickness (SCF), abdominal anterior to posterior diameter (APD), and transverse diameter (TD) were measured and total intra-abdominal fat volume (IFV) at the umbilicus level was calculated using preoperative abdominal CT scans. The potential effects of clinicopathological factors, e.g., age, sex, and body mass index (BMI), on surgical outcome defined in terms of retrieved lymph node numbers, morbidities, and mortalities were investigated.
All the CT scans were performed within 4 weeks before surgery according to gastric cancer CT protocol as follows. CT scans were performed using a four channel multidetector CT (MX-8000, Philips Medical Systems, Highland Heights, OH) using the following parameters; 120 kVp, 250 mAs, 3.2 mm beam collimation, 1.625 pitch, 5 mm slice thickness, prone position with the stomach fully distended with water (a negative contrast medium) 65 s after contrast medium injection (Ultravist, Schering, Berlin, Germany) at a rate of 3 ml/s, and again in the right decubitus position 3 min after contrast medium injection. SCF, APD, and TD were measured using a picture archiving and communication system (Mview, Marotech, Seoul), IFV was measured using a 3D workstation (Rapidia, Infinitt, Seoul) by one person (YHB). SCF, APD, and TD were measured at the umbilicus level. SCF was measured from the anterior abdominal wall to the anterior aspect of the rectus abdominis muscle; APD was defined as the maximum distance between the anterior abdominal skin and the back skin vertically at supine position, and TD was defined as the maximal distance measured at right angles to the APD at supine position. The data used for measuring IFV were transferred using digital imaging and communications in medicine (DICOM) format to a workstation. Fat was defined as any area with Hounsfield intensity of between –250 and –50 HU. Intra-abdominal fat was defined as fat located in muscular abdominal structures (rectus abdominis, oblique muscles, back muscles). The workstation automatically calculated fat area densities inside of abdominal muscles drawn manually.
All patients enrolled in the present study underwent subtotal gastrectomy with D2 lymph node dissection. Four gastric cancer surgeons at our center performed gastric cancer surgery only, and for institutional standardization purposes, each surgeon initially acts as a first assistant during surgery for at least 3 months, regardless of previous fellowship training. Distal subtotal gastrectomy was performed if there was a tumor-free margin of 5 cm in the case of advanced gastric carcinoma or 2 cm in the case of early gastric carcinoma. Lymph node dissection extents are as described by the recommendations of the Japanese Research Society for Gastric Carcinoma.13 Cancers were staged according to the tumor node metastasis (TNM) classification system of the Union Internacional Contra la Cancrum (UICC), and potentially curative resection was defined as R0 resection in accord with the UICC residual tumor classification.14
All the specimens were sent to the department of pathology for pathological examination immediate after resection. Single pathologist (M. Kook) retrieved all the lymph nodes using palpation under gross inspection. All the pathological examinations were performed in a standard manner.
Statistical Analysis
Analysis of covariance was performed to examine the associations between SCF, APD, TD, IFV, and BMI (as independent variables) with outcome variables (the number of retrieved lymph nodes and morbidities). Patients who experienced postoperative complications were compared with those who did not with respect to SCF, APD, TD, IFV, and BMI using the Student’s t test. In addition, we investigated the possibility of an interaction between gender and AP with respect to each outcome variable. SAS ‘PROC GLM’ software was used throughout. P values of <0.05 were considered statistically significant. Bio-statistician (B.H. Nam, Ph.D.) performed all the statistical analysis.
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RESULTS
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Clinicopathological Characteristics of the Patients
Median patient age was 58 years (range 25–85 years), and there were 189 (64.9%) male patients and 102 (35.1%) female patients (Table 1
). Fifty-two tumors (19.6%) were located in the middle third of the stomach. One hundred and fifty-two patients (52.2%) had early gastric cancer and 139 advanced gastric cancer (Table 1). All patients underwent distal subtotal gastrectomy with D2 lymph node dissection. The mean number of lymph nodes retrieved was 34.7 (range 10–79) and the mean operation time was 169.8 min (range 90–340). No difference was found between male and female patients with respect to age, tumor location, TNM stage, or the number of lymph nodes retrieved.
Received for publication November 11, 2005.
Accepted for publication February 21, 2006.
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ABSTRACT
INTRODUCTION
