When Eastern Surgeons Meet Western Patients: A Pilot Study of Gastrectomy with Lymphadenectomy in Caucasian Patients at a Single Korean Institute

The standard curative treatment for gastric cancer (GC) in East Asia is gastrectomy with D2 lymphadenectomy.1, 2 To date, however, it remains unclear whether the East Asian approach to gastrectomy with lymphadenectomy is feasible and safe in Western patients and whether it is reproducible in terms of mortality and morbidity. Thus, in the present study, we examined a series of Caucasian patients (CPs) subjected to gastrectomy with lymphadenectomy at a single institution with the intent of addressing this issue from the point of view of both surgeon-related and patient-related factors.

Between June 2011 and April 2014, 12 CPs underwent gastrectomy for GC at Yonsei University Severance Hospital, Seoul, Korea. In all patients, tumor depth, nodal status, and disease stage were classified in accordance with the American Joint Committee on Cancer Staging (7th edition).3 Based on the Japanese Gastric Cancer Treatment Guidelines (3rd edition),4 the extent of each lymphadenectomy was also stipulated.

Complication data were prospectively evaluated according to the Clavien-Dindo Classification.5 Major complications corresponded with grade IIIa or greater. All surgeons at our institute had performed more than 200 gastrectomies with D2 lymphadenectomy procedures prior to the current cohort and perform over 150 gastrectomies for GC annually. This project was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Yonsei University Severance Hospital (4-2014-0499).

Baseline characteristics and perioperative results of all patients are summarized in Table 1, and pathological characteristics are shown in the Supplementary Table 1 (only online). The details of the clinicopathological characteristics and perioperative results of each patient are shown in Tables 2 and 3. The median age of CPs (males, 8; females, 4) was 62.5 years (range, 40–71 years), with a median body mass index of 24.8 kg/m² (range, 18.6–45.9 kg/m²). The native countries of CPs were as follows: Russia, 7; the United States, 2; Ukraine, 2; and Kazakhstan, 1. All were considered medical tourists, defined as non-resident travelers to Korea for GC treatment. Minimally invasive surgery was performed in six CPs (50%). The types of procedures performed included total gastrectomy (7 of 12, 58%), distal gastrectomy (4 of 12, 33%), and completion total gastrectomy (1 of 12, 8%). Nine patients (75%) underwent D2 lymphadenectomy, with the remaining three (25%) undergoing D1+ dissections. Combined resection was performed in four patients (33%): one cholecystectomy for gallbladder stone, one partial colectomy for direct tumor invasion of the transverse colon, one thyroidectomy for thyroid cancer, and one thymectomy for thymoma. Median values of surgical parameters were as follows: operative time, 266.5 min (range, 120–586 min); estimated blood loss, 90 mL (range, 37–350 mL); retrieved lymph node count, 37.5 (range, 22–63); and postoperative hospital stay, 8 days (range, 5–63 days). No mortality occurred, although two patients (17%) developed anastomotic leakages (both Clavien-Dindo classification grade IIIa).

Table 1
Baseline Characteristics and Perioperative Results of Enrolled Patients

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Table 2
Clinicopathological Characteristics of Each Patient

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Table 3
Perioperative Results of Each Patient

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To our knowledge, the present article is the first patient series addressing short-term results when East Asian surgeons performed gastrectomy with lymphadenectomy in CPs. Our findings suggest that acceptable short-term outcomes are achievable in CPs through standard East Asian procedures.

Although the clinicopathological characteristics of our cohort did approximate those of previously reported Western studies (albeit a younger age range in the current study), current morbidity and mortality rates were lower than those of the earlier Western reports (morbidity, 23.6–46%; mortality, 2–13%).6, 7, 8, 9, 10, 11

The results of this case series suggest that morbidity and mortality rates in CPs undergoing gastrectomy with lymphadenectomy may be reduced if performed by experienced surgeons. According to the US Graduate Medical Education General Surgery Report (2012), current graduates performed 3.4 partial gastrectomies and 0.9 total gastrectomies during 5-year training programs.12 It is well known that mortality rates of high-volume hospitals are lower than those of hospitals where surgeons have less exposure to procedures.13, 14, 15 One potential strategy to overcome this shortcoming is the centralization of GC patients to specific centers, enabling surgeons to boost their experience through intensive short-term training.

On the other hand, morbidity and mortality rates of the present series seemed to be slightly higher than those of prior East Asian studies where East Asian patients were exclusively enrolled.16, 17 Additionally, in our previous article, which included 5839 Korean patients between 2005 and 2010, overall-complication, major-complication (Clavien-Dindo classification IIIa or greater), and mortality rates were 10.5% (612 of 5839), 5.8% (337 of 5839), and 0.4% (25 of 5839), respectively. This implies that surgical expertise is not the sole factor in observed morbidity and mortality differences of East Asian and Western countries. Patient-related factors are critical as well.

Western patients tend to be more obese than East Asian patients,7 and obesity typically raises the risk of complications.18, 19 Anteroposterior girth in Western patients is often sizeable, creating a deep operative field that makes procedures more demanding. Furthermore, obese patients are prone to multiple comorbidities, such as cardiovascular disease and diabetes, which arguably increase morbidity and mortality.20 In the present article, Patient 2 was of normal weight, whereas Patient 1 was an extremely obese and visibly high-risk patient, the likes of which are seldom seen in East Asian countries. It is thus easy to appreciate why morbidity and mortality increase when such patients are surgically treated, thus underscoring that patient factors cannot be ignored in this setting.

The present case series had two major limitations. First, the number of patients analyzed was clearly insufficient for conclusive results. We merely showed a possibility of achieving our procedure in CPs with less morbidity and mortality, and it is impossible to draw any further conclusions. Second, we focused only on short-term outcomes. Further investigations involving large numbers of patients and long-term monitoring are needed to confirm the feasibility, safety, and efficacy of standard East Asian surgery of GC, and such studies may elucidate the unique risk factors for complications in CPs who were treated by East Asian surgeons.

In conclusion, although patient-related factors are crucial and cannot be ignored, acceptably low mortality and morbidity rates were achieved in CPs when gastrectomy with lymphadenectomy was performed by experienced East Asian surgeons. Provided that experienced surgeons perform gastrectomy with lymphadenectomy in CPs, there is a possibility that the East Asian approach is feasible and safe.

Supplementary Table 1

Pathological Characteristics of Enrolled Patients