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Influence of Overweight on Patients With Gastric Cancer After Undergoing Curative Gastrectomy—Invited Critique

Influence of Overweight on Patients With Gastric Cancer After Undergoing Curative... The World Health Organization projects that by 2015 more than 1.6 billion adults will be overweight and 700 million will be obese.1 In addition, obesity has been demonstrated to be a risk factor for several abdominal malignant neoplasms.2-4 Therefore, the effect of obesity on surgical outcomes in a cancer population is a timely issue.2,5 The article by Ojima et al addresses the issue of obesity and its effects on short-term surgical outcomes and 5-year survival for gastric cancer patients. Despite the fact that only 8 patients in this study were obese (BMI >30.0), the authors demonstrated that overweight patients (BMI ≥25.0) with gastric cancer present a technical challenge to the surgeon. In the hands of a group experienced in gastric surgery, there was an increased need for total gastrectomy and splenectomy in overweight patients. In addition, overweight patients (BMI >25) undergoing D2 lymphadenectomy were noted by others6,7 to have prolonged operative times and increased blood loss. The increased technical difficulty is likely to have contributed to the increased incidence of postoperative surgical complications such as anastamotic leakage, pancreatic fistula, and intra-abdominal abscess seen in the overweight patients who underwent a D2 resection. These data are consistent with those of a previously published randomized study of morbidity comparing D2 and D3 lymphadenectomy from the Japan Clinical Oncology Group.8 Patients are generally older and more overweight and present with more comorbidities in Western series of gastric cancer.9 As a result, the morbidity and mortality for radical gastrectomy have been reported to be higher in Western series.10 Despite the demonstration of a survival benefit for more complete lymph node dissections in patients with gastric cancer,11,12 D2 lymph node dissection is not widely used in the United States. The explanation for this decreased rate of D2 resections in Western populations has, in the past, been attributed to inadequate training in proper surgical technique.13,14 Although this may be 1 explanation, Ojima et al raise the question as to whether it is prudent to recommend D2 lymphadenectomy for all patients. Perhaps, as suggested by Lamb et al,15 it may be more prudent in the Western population to individualize patient care by balancing radicality with safety. By taking into account a patient's risk factors, such as age, location and stage of tumor, obesity, and overall health, perhaps surgeons should customize a sound surgical plan that optimizes the extent of lymphadenectomy while minimizing morbidity. Correspondence: Dr Berger, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030 (dhb@bcm.tmc.edu). Financial Disclosure: None reported. References 1. World Health Organization, Obesity and overweight. http://www.who.int/mediacentre/factsheets/fs311/en/index.html. Accessed May 8, 2008 2. Calle EERodriguez CWalker-Thurmond KThun MJ Overweight, obesity, and mortality from cancer in a prospective studied cohort of US adults. N Engl J Med 2003;348 (17) 1625- 1638PubMedGoogle ScholarCrossref 3. Nock NLThompson CLTucker TCBerger NALi L Associations between obesity and changes in adult BMI over time and colon cancer risk. Obesity (Silver Spring) 2008;16 (5) 1099- 1104PubMedGoogle ScholarCrossref 4. Giovannucci EMichaud D The role of obesity and related metabolic disturbances in cancers of the colon, prostate, and pancreas. Gastroenterology 2007;132 (6) 2208- 2225PubMedGoogle ScholarCrossref 5. Tamakoshi KWakai KKojima M et al. JACC Study Group, A prospective study of body size and colon cancer mortality in Japan: the JACC Study. Int J Obes Relat Metab Disord 2004;28 (4) 551- 558PubMedGoogle ScholarCrossref 6. Kodera YIto SYamamura Y et al. Obesity and outcome of distal gastrectomy with D2 lymphadenectomy for carcinoma. Hepatogastroenterology 2004;51 (58) 1225- 1228PubMedGoogle Scholar 7. Dhar DKKubota HTachibana M et al. Body mass index determines the success of lymph node dissection and predicts the outcome of gastric carcinoma patients. Oncology 2000;59 (1) 18- 23PubMedGoogle ScholarCrossref 8. Tsujinaka TSasako MYamamoto S et al. Gastric Cancer Surgery Study Group of Japan Clinical Oncology Group, Influence of overweight on surgical complications for gastric cancer: results from a randomized control trial comparing D2 and extended para-aortic D3 lymphadenectomy (JCOG9501). Ann Surg Oncol 2007;14 (2) 355- 361PubMedGoogle ScholarCrossref 9. Griffin SM Gastric cancer in the East: same disease, different patient. Br J Surg 2005;92 (9) 1055- 1056PubMedGoogle ScholarCrossref 10. Bonenkamp JJSongun IHermans J et al. Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345 (8952) 745- 748PubMedGoogle ScholarCrossref 11. Volpe CMDriscoll DLDouglass HO Jr Outcome of patients with proximal gastric cancer depends on extent of resection and number of resected lymph nodes. Ann Surg Oncol 2000;7 (2) 139- 144PubMedGoogle ScholarCrossref 12. Volpe CMDriscoll DLMiloro SMDouglass HO Jr Survival benefit of extended D2 resection for proximal gastric cancer. J Surg Oncol 1997;64 (3) 231- 236PubMedGoogle ScholarCrossref 13. Sue-Ling HMJohnston D D1 versus D2 dissection for gastric cancer [letter]. Lancet 1995;345 (8963) 1515- 1516PubMedGoogle ScholarCrossref 14. Bonenkamp JJSongun IHermans J et al. Dutch Gastric Cancer Group, D1 versus D2 dissection for gastric cancer [reply]. Lancet 1995;345 (8963) 1517- 1518PubMedGoogle ScholarCrossref 15. Lamb PSivashanmugam TWhite MIrving MWayman JRaimes S Gastric cancer surgery: a balance of risk and radicality. Ann R Coll Surg Engl 2008;90 (3) 235- 242PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Influence of Overweight on Patients With Gastric Cancer After Undergoing Curative Gastrectomy—Invited Critique

Archives of Surgery , Volume 144 (4) – Apr 20, 2009

Influence of Overweight on Patients With Gastric Cancer After Undergoing Curative Gastrectomy—Invited Critique

Abstract

The World Health Organization projects that by 2015 more than 1.6 billion adults will be overweight and 700 million will be obese.1 In addition, obesity has been demonstrated to be a risk factor for several abdominal malignant neoplasms.2-4 Therefore, the effect of obesity on surgical outcomes in a cancer population is a timely issue.2,5 The article by Ojima et al addresses the issue of obesity and its effects on short-term surgical outcomes and 5-year survival for gastric cancer patients....
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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2009.15
Publisher site
See Article on Publisher Site

Abstract

The World Health Organization projects that by 2015 more than 1.6 billion adults will be overweight and 700 million will be obese.1 In addition, obesity has been demonstrated to be a risk factor for several abdominal malignant neoplasms.2-4 Therefore, the effect of obesity on surgical outcomes in a cancer population is a timely issue.2,5 The article by Ojima et al addresses the issue of obesity and its effects on short-term surgical outcomes and 5-year survival for gastric cancer patients. Despite the fact that only 8 patients in this study were obese (BMI >30.0), the authors demonstrated that overweight patients (BMI ≥25.0) with gastric cancer present a technical challenge to the surgeon. In the hands of a group experienced in gastric surgery, there was an increased need for total gastrectomy and splenectomy in overweight patients. In addition, overweight patients (BMI >25) undergoing D2 lymphadenectomy were noted by others6,7 to have prolonged operative times and increased blood loss. The increased technical difficulty is likely to have contributed to the increased incidence of postoperative surgical complications such as anastamotic leakage, pancreatic fistula, and intra-abdominal abscess seen in the overweight patients who underwent a D2 resection. These data are consistent with those of a previously published randomized study of morbidity comparing D2 and D3 lymphadenectomy from the Japan Clinical Oncology Group.8 Patients are generally older and more overweight and present with more comorbidities in Western series of gastric cancer.9 As a result, the morbidity and mortality for radical gastrectomy have been reported to be higher in Western series.10 Despite the demonstration of a survival benefit for more complete lymph node dissections in patients with gastric cancer,11,12 D2 lymph node dissection is not widely used in the United States. The explanation for this decreased rate of D2 resections in Western populations has, in the past, been attributed to inadequate training in proper surgical technique.13,14 Although this may be 1 explanation, Ojima et al raise the question as to whether it is prudent to recommend D2 lymphadenectomy for all patients. Perhaps, as suggested by Lamb et al,15 it may be more prudent in the Western population to individualize patient care by balancing radicality with safety. By taking into account a patient's risk factors, such as age, location and stage of tumor, obesity, and overall health, perhaps surgeons should customize a sound surgical plan that optimizes the extent of lymphadenectomy while minimizing morbidity. Correspondence: Dr Berger, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030 (dhb@bcm.tmc.edu). Financial Disclosure: None reported. References 1. World Health Organization, Obesity and overweight. http://www.who.int/mediacentre/factsheets/fs311/en/index.html. Accessed May 8, 2008 2. Calle EERodriguez CWalker-Thurmond KThun MJ Overweight, obesity, and mortality from cancer in a prospective studied cohort of US adults. N Engl J Med 2003;348 (17) 1625- 1638PubMedGoogle ScholarCrossref 3. Nock NLThompson CLTucker TCBerger NALi L Associations between obesity and changes in adult BMI over time and colon cancer risk. Obesity (Silver Spring) 2008;16 (5) 1099- 1104PubMedGoogle ScholarCrossref 4. Giovannucci EMichaud D The role of obesity and related metabolic disturbances in cancers of the colon, prostate, and pancreas. Gastroenterology 2007;132 (6) 2208- 2225PubMedGoogle ScholarCrossref 5. Tamakoshi KWakai KKojima M et al. JACC Study Group, A prospective study of body size and colon cancer mortality in Japan: the JACC Study. Int J Obes Relat Metab Disord 2004;28 (4) 551- 558PubMedGoogle ScholarCrossref 6. Kodera YIto SYamamura Y et al. Obesity and outcome of distal gastrectomy with D2 lymphadenectomy for carcinoma. Hepatogastroenterology 2004;51 (58) 1225- 1228PubMedGoogle Scholar 7. Dhar DKKubota HTachibana M et al. Body mass index determines the success of lymph node dissection and predicts the outcome of gastric carcinoma patients. Oncology 2000;59 (1) 18- 23PubMedGoogle ScholarCrossref 8. Tsujinaka TSasako MYamamoto S et al. Gastric Cancer Surgery Study Group of Japan Clinical Oncology Group, Influence of overweight on surgical complications for gastric cancer: results from a randomized control trial comparing D2 and extended para-aortic D3 lymphadenectomy (JCOG9501). Ann Surg Oncol 2007;14 (2) 355- 361PubMedGoogle ScholarCrossref 9. Griffin SM Gastric cancer in the East: same disease, different patient. Br J Surg 2005;92 (9) 1055- 1056PubMedGoogle ScholarCrossref 10. Bonenkamp JJSongun IHermans J et al. Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345 (8952) 745- 748PubMedGoogle ScholarCrossref 11. Volpe CMDriscoll DLDouglass HO Jr Outcome of patients with proximal gastric cancer depends on extent of resection and number of resected lymph nodes. Ann Surg Oncol 2000;7 (2) 139- 144PubMedGoogle ScholarCrossref 12. Volpe CMDriscoll DLMiloro SMDouglass HO Jr Survival benefit of extended D2 resection for proximal gastric cancer. J Surg Oncol 1997;64 (3) 231- 236PubMedGoogle ScholarCrossref 13. Sue-Ling HMJohnston D D1 versus D2 dissection for gastric cancer [letter]. Lancet 1995;345 (8963) 1515- 1516PubMedGoogle ScholarCrossref 14. Bonenkamp JJSongun IHermans J et al. Dutch Gastric Cancer Group, D1 versus D2 dissection for gastric cancer [reply]. Lancet 1995;345 (8963) 1517- 1518PubMedGoogle ScholarCrossref 15. Lamb PSivashanmugam TWhite MIrving MWayman JRaimes S Gastric cancer surgery: a balance of risk and radicality. Ann R Coll Surg Engl 2008;90 (3) 235- 242PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Apr 20, 2009

Keywords: gastrectomy,gastric cancer,overweight

References