Abstract
Aim
This study aimed to evaluate the technical safety and feasibility of gastrectomy for super‐elderly patients ≥85‐y‐old with gastric cancer and to clarify the risk factors for serious postoperative complications in these patients.
Methods
Between 2017 and 2020, 10,203 patients who underwent distal gastrectomy (DG) and 2580 patients who underwent total gastrectomy (TG) were reviewed from the Japanese National Clinical Database. All possible preoperative factors were used to explore the risk factors for serious postoperative complications in the super‐elderly patients with gastric cancer.
Results
For DG, the operative mortality rate was 1.6% (162 patients), and the rate of serious postoperative complications was 7.8% (796 patients). Similarly, the mortality rate was 2.6% (67 patients), and the rate of serious complications was 11.3% (292 patients) for TG. Based on multivariate analysis, body mass index (≥25 kg/m2), activities of daily living (ADL) (partially dependent), ASA‐PS (Grade ≥3), dyspnea, ascites, history of cerebrovascular disease, serum albumin (<4 g/dL), and creatinine (>1.2 mg/dL) in DG, and ADL (partially dependent), ASA‐PS (Grade ≥3), previous percutaneous coronary intervention, dialysis, WBC (>9000 μL), and AST (>35 IU/L) in TG were strong risk factors for serious postoperative complications.
Conclusions
The study findings suggest that gastrectomy for super‐elderly gastric cancer patients is relatively safe and feasible. Surgeons need to pay special attention to physical status and past medical history than tumor factors for preventing serious postoperative complications in super‐elderly gastric cancer patients.
Keywords: elderly patients, gastrectomy, National Clinical Database, postoperative complications, risk factors
The study findings of the Japanese National Clinical Database suggest that gastrectomy for super‐elderly gastric cancer patients is relatively safe and feasible in Japan. Surgeons need to pay special attention to physical status and past medical history than tumor factors for preventing serious postoperative complications in super‐elderly gastric cancer patients.
1. INTRODUCTION
Gastric cancer is the fifth most common cancer type and causes the fourth‐highest number of cancer deaths worldwide. 1 While the incidence of gastric cancer is gradually decreasing around the world, it was ranked as the third most common cancer type in 2019 and the third leading cause of cancer‐related deaths in 2021 in Japan. 2 Moreover, Japan has the most aged society in the world, with 5.5% of the Japanese population aged ≥85 y in 2023. 3 Consequently, the incidence of gastric cancer in elderly patients has been increasing year by year in Japan, with ~17% of gastric cancer patients now aged ≥85 y old in 2019. 2
With the increase in opportunities to treat super‐elderly patients with gastric cancer, we have had more chances to consider how to treat these patients in the clinical setting. Recent systematic reviews and meta‐analyses have reported improved prognosis from surgical treatment, including with laparoscopic gastrectomy (LG), for elderly patients with gastric cancer. 4 , 5 , 6 The National Survey of Endoscopic Surgery conducted by the Japan Society for Endoscopic Surgery found that >38% of the gastrectomies performed in Japan in 2019 were done laparoscopically. 7 Namely, LG has also been rapidly adopted for use in elderly patients with gastric cancer in Japan. However, whether the safety and feasibility of gastrectomy including LG for super‐elderly patients with gastric cancer are applicable in general clinical practice remains unclear. Furthermore, while it is sometimes difficult to avoid serious postoperative complications that can lead to death following gastrectomy in super‐elderly patients, the risk factors for such complications have also not been sufficiently determined. Preoperative recognition of risk factors for serious postoperative complications is especially important when surgically treating super‐elderly patients.
The National Clinical Database (NCD) was begun as a nationwide registry system in 2011 in Japan and covers >95% of the surgeries performed in Japan. In this study we first investigated the technical safety and feasibility of gastrectomy, including LG, in super‐elderly patients with gastric cancer via a large‐scale retrospective cohort analysis of patient data in the Japanese NCD database, and then examined the risk factors for serious postoperative complications following gastrectomy performed in super‐elderly gastric cancer patients.
2. METHODS
2.1. Data source and collection
All data were retrieved from the NCD Gastroenterological section. The details of patient registration in the nationwide web‐based data entry system of the NCD were described previously. 8 , 9 As of 2018, over 5000 institutions have participated in the NCD system, with ~1.4 million surgical cases, corresponding to >95% of all surgeries in Japan, being registered annually. Details input into the system for all surgical cases registered in the NCD include data on comorbidities, preoperative laboratory test results, postoperative complications, and mortality. The study protocol was approved by the Institutional Review Board of Oita University (approval number 2119).
2.2. Study population
Cases of gastrectomy registered in the NCD between January 2017 and December 2020 were included. Excluded from this study were patients with emergent surgery and those with multiple tumors registered, as well as those who underwent robotic‐assisted operation, other concurrent procedures except for cholecystectomy, and those with missing values (Figure 1).
FIGURE 1.
Flowchart detailing the patient selection process.
2.3. Study endpoints
The primary endpoints of this study were the incidence of overall serious postoperative morbidity of ≥Grade III according to the Clavien–Dindo classification, 10 such as pancreatic fistula, postoperative pneumonia, and anastomotic leakage, which were evaluated as independent complications, as well as overall complication and mortality (within 30 d after surgery or within 90 d in hospital).
2.4. Study analysis
We tabulated the background factors of the patients undergoing distal and total gastrectomies separately. We estimated the incidences of the outcomes in each procedure group. We also estimated the incidences of the outcome in the subgroups stratified by the background characteristics, and evaluated the strength of these risk factors for severe postoperative complications following gastrectomy by using multivariable logistic regression analysis. The clinical factors included age at surgery (85–90, >90 y), sex (male vs female), body mass index (BMI; <18.5, 18.5 < BMI < 25, ≥25 kg/m2), smoking history (Brinkman index: 0, 400–<600, 600–<1200, ≥1200), drinking habit (no, occasionally, habitual drinking), activities of daily living (independent, partially dependent, totally dependent), American Society of Anesthesiologists physical status (ASA‐PS; Grade ≤2 vs ≥3), preoperative chemotherapy (yes vs no), diabetes mellitus (yes vs no), chronic obstructive pulmonary disease (yes vs no), hypertension (yes vs no), ischemic heart disease (yes vs no), need for preoperative dialysis (yes vs no), previous cerebrovascular disease (yes vs no), long‐term administration of steroid (yes vs no), weight loss (yes vs no), bleeding disorder (yes vs no), preoperative blood transfusion (yes vs no), preoperative laboratory tests (WBC >9000/μL, hemoglobin [men: <13.5 g/dL; women: <11.5 g/dL], hematocrit [men: <37%; women: <32%], platelets <150,000/μL, serum albumin <4 g/dL, total bilirubin >1.2 mg/dL, AST >35 IU/L, ALT >35 IU/L, ALP >340 IU/L, BUN >12 mg/dL, creatinine >1.2 mg/dL, serum Na <138 mEq/L, APTT >40 s, PT‐INR >1.1), clinical T stage (T0/Tis, T1, T2, T3, T4, Tx), clinical N stage (N0, N1, N2, N3, Nx), and clinical M stage (M0, M1). The 7th edition of the American Joint Committee on Cancer TNM classification was used to extract representative tumor depth (T), node metastasis (N), and distant metastasis (M). All statistical analyses were performed with SAS v. 9.4 (SAS Institute, Cary, NC, USA).
3. RESULTS
3.1. Patient characteristics
In total, 12,783 cases of gastrectomy were identified from the NCD between January 2017 and December 2020. Among them, 10,203 underwent distal gastrectomy (DG) and 2580 patients underwent total gastrectomy (TG). Patient and tumor characteristics are shown in Table 1. Distal gastrectomy was performed in 8778 (86%) patients aged 85–90‐y‐old and in 1425 patients (14%) aged ≥90 y. Similarly, TG was performed in 2337 (90.6%) patients aged 85–90‐y‐old and in 243 patients (9.4%) aged ≥90 y. Laparoscopic DG was performed on 4467 patients (43.8%) and laparoscopic TG was performed on 633 patients (24.5%).
TABLE 1.
Patient and tumor characteristics.
| Characteristic | Distal gastrectomy n (rate %) | Total gastrectomy n (rate %) |
|---|---|---|
| Overall, N | 10,203 | 2580 |
| Age, y | ||
| 85–90 | 8778 (86.0) | 2337 (90.6) |
| >90 | 1425 (14.0) | 243 (9.4) |
| Sex | ||
| Male | 5796 (56.8) | 1817 (70.4) |
| Female | 4407 (43.2) | 763 (29.6) |
| BMI, kg/m2 | ||
| Normal (18.5 to <25) | 6889 (67.5) | 1738 (67.4) |
| Underweight (<18.5) | 1868 (18.3) | 508 (19.7) |
| Overweight (≥25) | 1446 (14.2) | 334 (12.9) |
| Current smoker (within a year) | 638 (6.3) | 207 (8.0) |
| Drinking habit | ||
| No | 7138 (70.0) | 1675 (64.9) |
| Occasionally | 1504 (14.7) | 423 (16.4) |
| Habitual drinking | 1561 (15.3) | 482 (18.7) |
| Preoperative comorbidities and status | ||
| ADL (within 30 d) | ||
| Independent | 8762 (85.9) | 2285 (88.6) |
| Partially dependent | 1232 (12.1) | 266 (10.3) |
| Totally dependent | 209 (2.0) | 29 (1.1) |
| ASA‐PS | ||
| Grade ≤2 | 7278 (71.3) | 1891 (73.3) |
| Grade ≥3 | 2925 (28.7) | 689 (26.7) |
| Preoperative chemotherapy | 56 (0.5) | 26 (1.0) |
| Dyspnea | 343 (3.4) | 85 (3.3) |
| COPD | 607 (5.9) | 161 (6.2) |
| Pneumonia | 81 (0.8) | 22 (0.9) |
| Ascites | 201 (2.0) | 69 (2.7) |
| Diabetes mellitus | 1970 (19.3) | 503 (19.5) |
| Esophageal varices | 26 (0.3) | 6 (0.2) |
| Hypertension | 5945 (58.3) | 1496 (58.0) |
| Heart failure (within 30 d) | 229 (2.2) | 52 (2.0) |
| Myocardial infarction (within 6 mo) | 61 (0.6) | 13 (0.5) |
| Angina pectoris (within 30 d) | 192 (1.9) | 49 (1.9) |
| Previous PCI | 515 (5.0) | 147 (5.7) |
| Previous myocardiac surgery | 227 (2.2) | 52 (2.0) |
| Previous PVD surgery | 79 (0.8) | 16 (0.6) |
| Symptom of PVD | 36 (0.4) | 14 (0.5) |
| Dialysis (within 14 d) | 56 (0.5) | 13 (0.5) |
| History of cerebrovascular disease | 824 (8.1) | 208 (8.1) |
| Disseminated cancer | 103 (1.0) | 45 (1.7) |
| Long‐term administration of steroid | 132 (1.3) | 30 (1.2) |
| Body weight loss | 537 (5.3) | 203 (7.9) |
| Risk factors for bleeding | 631 (6.2) | 180 (7.0) |
| Preoperative blood transfusion (within 72 h) | 666 (6.5) | 170 (6.6) |
| Surgical operation (within 30 d) | 58 (0.6) | 18 (0.7) |
| Preoperative laboratory tests | ||
| WBC >9000/μL | 607 (5.9) | 162 (6.3) |
| Hemoglobin, men: <13.5 g/dL; women: <11.5 g/dL | 7312 (71.7) | 1887 (73.1) |
| Hematocrit, men: <37%; women: <32% | 5343 (52.4) | 1389 (53.8) |
| Platelets <150 000/μL | 894 (8.8) | 207 (8.0) |
| Serum albumin <4 g/dL | 7041 (69.0) | 1834 (71.1) |
| Total bilirubin >1.2 mg/dL | 265 (2.6) | 67 (2.6) |
| AST >35 IU/L | 686 (6.7) | 174 (6.7) |
| ALT >35 IU/L | 411 (4.0) | 104 (4.0) |
| ALP >340 IU/L | 807 (7.9) | 193 (7.5) |
| BUN >12 mg/dL | 2853 (28.0) | 665 (25.8) |
| Creatinine >1.2 mg/dL | 1557 (15.3) | 389 (15.1) |
| Serum Na <138 mEq/L | 1482 (14.5) | 392 (15.2) |
| APTT >40 s | 428 (4.2) | 87 (3.4) |
| PT‐INR >1.1 | 1106 (10.8) | 288 (11.2) |
| Tumor factors | ||
| T factor | ||
| T0, Tis | 36 (0.4) | 3 (0.1) |
| T1 | 3391 (33.2) | 416 (16.1) |
| T2 | 1551 (15.2) | 351 (13.6) |
| T3 | 2495 (24.5) | 740 (28.7) |
| T4 | 2720 (26.7) | 1069 (41.4) |
| N factor | ||
| N0 | 5409 (53.0) | 1038 (40.2) |
| N1 | 1864 (18.3) | 477 (18.5) |
| N2 | 1528 (15.0) | 476 (18.4) |
| N3 | 1294 (12.7) | 560 (21.7) |
| M factor | ||
| M0 | 9582 (93.9) | 2305 (89.3) |
| M1 | 621 (6.1) | 275 (10.7) |
| Surgical approach | ||
| Open | 5736 (56) | 1947 (76) |
| Laparoscopy | 4467 (43.8) | 633 (24.5) |
Abbreviations: ADL, activities of daily living; ALP, alkaline phosphatase; ALT, alanine aminotransferase; APTT, activated partial thromboplastin time; ASA‐PS, American Society of Anesthesiologists physical status; AST, aspartate aminotransferase; BUN, blood urea nitrogen; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention; PT‐INR, prothrombin time‐international normalized ratio; PVD, peripheral vascular disease; WBC, white blood cells.
3.2. Surgical outcomes in DG
For DG, the incidence of serious postoperative complications was 7.8% (796 patients). The incidence of overall postoperative complications was 33.1% (3379 patients) and the operative mortality was 1.6% (162 patients) (Table 2). Serious postoperative complications of pancreatic fistula, postoperative pneumonia, and anastomotic leakage were observed in 69 (0.7%), 174 (1.7%), and 178 (1.7%) patients, respectively.
TABLE 2.
Postoperative events.
| Postoperative event | Distal gastrectomy n (%) | Total gastrectomy n (%) |
|---|---|---|
| Overall, N | 10,203 | 2580 |
| Postoperative death within 30 d | 162 (1.6) | 67 (2.6) |
| Overall postoperative complications | 3379 (33.1) | 951 (36.9) |
| Postoperative severe complications | 796 (7.8) | 292 (11.3) |
3.3. Surgical outcomes in TG
For TG, the rate of serious postoperative complications was 11.3% (292 patients). The incidence rate of overall postoperative complications was 36.9% (951 patients), and the operative mortality was 2.6% (67 patients) (Table 2). Serious postoperative complications of pancreatic fistula, postoperative pneumonia, and anastomotic leakage were observed in 31 (1.2%), 74 (2.9%), and 98 (3.8%) patients, respectively.
3.4. Risk factors for serious postoperative complications in DG
Table 3 shows the results of the multivariable analysis of risk factors associated with serious postoperative complications in DG. BMI ≥25 (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.29–1.93), ADL (partially dependent) (OR 1.28, 95% CI 1.04–1.57), ASA‐PS (Grade ≥3) (OR 1.27, 95% CI 1.08–1.50), dyspnea (OR 2.12, 95% CI 1.55–2.89), ascites (OR 1.70, 95% CI 1.14–2.54), history of cerebrovascular disease (OR 1.34, 95% CI 1.05–1.70), serum albumin (<4 g/dL) (OR 1.39, 95% CI 1.13–1.70), and creatinine (>1.2 mg/dL) (OR 1.26, 95% CI 1.02–1.56) were found to be strong risk factors for serious postoperative complications in DG.
TABLE 3.
Multivariate analysis of risk factors.
| Factors | Distal gastrectomy | Total gastrectomy | ||||
|---|---|---|---|---|---|---|
| Postoperative complication n (event rate %) | Adjusted odds ratio (95% confidence interval) | Postoperative complication n (event rate %) | Adjusted odds ratio (95% confidence interval) | |||
| Age, y | ||||||
| 85–90 | 665 (7.6) | 1 [Reference] | 260 (11.1) | 1 [Reference] | ||
| >90 | 131 (9.2) | 1.17 (0.95–1.43) | 32 (13.2) | 1.13 (0.75–1.71) | ||
| Sex | ||||||
| Male | 534 (9.2) | 1 [Reference] | 223 (12.3) | 1 [Reference] | ||
| Female | 262 (5.9) | 0.66 (0.55–0.79) | 69 (9.0) | 0.72 (0.52–1.01) | ||
| Body mass index, kg/m2 | ||||||
| Normal (18.5 to <25) | 491 (7.1) | 1 [Reference] | 204 (11.7) | 1 [Reference] | ||
| Underweight (<18.5) | 160 (8.6) | 1.08 (0.88–1.31) | 55 (10.8) | 0.87 (0.62–1.22) | ||
| Overweight (≥25) | 145 (10.0) | 1.58 (1.29–1.93) | 33 (9.9) | 0.86 (0.57–1.29) | ||
| Current smoker (within a year) | 57 (8.9) | 0.98 (0.73–1.32) | 25 (12.1) | 0.98 (0.61–1.57) | ||
| Drinking habit | ||||||
| No | 535 (7.5) | 1 [Reference] | 195 (11.6) | 1 [Reference] | ||
| Occasionally | 135 (9.0) | 1.11 (0.90–1.37) | 46 (10.9) | 0.90 (0.62–1.29) | ||
| Habitual drinking | 126 (8.1) | 0.97 (0.78–1.20) | 51 (10.6) | 0.86 (0.60–1.22) | ||
| Preoperative comorbidities and status | ||||||
| ADL | ||||||
| Independent | 626 (7.1) | 1 [Reference] | 238 (10.4) | 1 [Reference] | ||
| Partially dependent | 141 (11.4) | 48 (18.0) | 1.55 (1.06–2.26) | |||
| Totally dependent | 29 (13.9) | 1.43 (0.93–2.18) | 6 (20.7) | 1.76 (0.66–4.65) | ||
| ASA‐PS | ||||||
| Grade ≤2 | 489 (6.7) | 1 [Reference] | 181 (9.6) | 1 [Reference] | ||
| Grade ≥3 | 307 (10.5) | 1.27 (1.08–1.50) | 111 (16.1) | 1.38 (1.04–1.84) | ||
| Preoperative chemotherapy | 2 (3.6) | 0.36 (0.09–1.48) | 4 (15.4) | 1.41 (0.46–4.37) | ||
| Dyspnea | 66 (19.2) | 2.12 (1.55–2.89) | 19 (22.4) | 1.42 (0.77–2.62) | ||
| COPD | 74 (12.2) | 1.17 (0.89–1.55) | 23 (14.3) | 1.02 (0.61–1.70) | ||
| Pneumonia | 11 (13.6) | 1.05 (0.54–2.04) | 3 (13.6) | 0.78 (0.21–2.90) | ||
| Ascites | 32 (15.9) | 1.70 (1.14–2.54) | 15 (21.7) | 1.53 (0.81–2.88) | ||
| Diabetes mellitus | 172 (8.7) | 1.04 (0.87–1.25) | 65 (12.9) | 1.09 (0.79–1.49) | ||
| Esophageal varices | 4 (15.4) | 1.97 (0.65–5.93) | 1 (16.7) | 0.98 (0.10–9.45) | ||
| Hypertension | 485 (8.2) | 1.06 (0.91–1.24) | 182 (12.2) | 1.18 (0.90–1.54) | ||
| Heart failure (within 30 d) | 27 (11.8) | 0.92 (0.59–1.43) | 10 (19.2) | 1.16 (0.53–2.50) | ||
| Myocardial infarction (within 6 mo) | 5 (8.2) | 0.73 (0.28–1.89) | 4 (30.8) | 2.01 (0.55–7.32) | ||
| Angina pectoris (within 30 d) | 13 (6.8) | 0.77 (0.43–1.38) | 8 (16.3) | 1.00 (0.44–2.31) | ||
| Previous PCI | 53 (10.3) | 1.11 (0.81–1.54) | 30 (20.4) | 1.74 (1.07–2.85) | ||
| Previous myocardiac surgery | 20 (8.8) | 0.88 (0.54–1.42) | 4 (7.7) | 0.37 (0.12–1.11) | ||
| Previous PVD surgery | 12 (15.2) | 1.54 (0.80–2.97) | 3 (18.8) | 1.32 (0.30–5.80) | ||
| Symptom of PVD | 7 (19.4) | 2.08 (0.86–5.01) | 2 (14.3) | 0.68 (0.13–3.65) | ||
| Dialysis (within 14 d) | 10 (17.9) | 1.63 (0.78–3.41) | 5 (38.5) | 4.28 (1.24–14.75) | ||
| History of cerebrovascular disease | 94 (11.4) | 1.34 (1.05–1.70) | 26 (12.5) | 0.97 (0.61–1.54) | ||
| Disseminated cancer | 15 (14.6) | 1.57 (0.86–2.85) | 10 (22.2) | 1.25 (0.55–2.81) | ||
| Long‐term administration of steroid | 11 (8.3) | 0.92 (0.48–1.75) | 4 (13.3) | 0.97 (0.32–2.94) | ||
| Body weight loss | 66 (12.3) | 1.28 (0.96–1.70) | 33 (16.3) | 1.24 (0.80–1.91) | ||
| Risk factors for bleeding | 59 (9.4) | 0.93 (0.69–1.25) | 24 (13.3) | 0.82 (0.49–1.37) | ||
| Preoperative blood transfusion (within 72 h) | 69 (10.4) | 0.99 (0.75–1.31) | 27 (15.9) | 0.92 (0.57–1.50) | ||
| Surgical operation (within 30 d) | 7 (12.1) | 1.29 (0.56–2.93) | 5 (27.8) | 2.92 (0.91–9.34) | ||
| Preoperative laboratory tests | ||||||
| WBC >9000/μL | 62 (10.2) | 1.17 (0.88–1.55) | 36 (22.2) | 2.08 (1.36–3.17) | ||
| Hemoglobin, men: <13.5 g/dL; women: <11.5 g/dL | 638 (8.7) | 1.04 (0.82–1.33) | 240 (12.7) | 1.40 (0.93–2.11) | ||
| Hematocrit, men: <37%; women: <32% | 504 (9.4) | 1.09 (0.88–1.34) | 183 (13.2) | 0.94 (0.67–1.33) | ||
| Platelets <150,000/μL | 73 (8.2) | 1.00 (0.77–1.31) | 33 (15.9) | 1.41 (0.92–2.17) | ||
| Serum albumin <4 g/dL | 634 (9.0) | 1.39 (1.13–1.70) | 229 (12.5) | 1.00 (0.71–1.41) | ||
| Total bilirubin >1.2 mg/dL | 24 (9.1) | 1.15 (0.74–1.79) | 9 (13.4) | 1.19 (0.56–2.53) | ||
| AST >35 IU/L | 71 (10.3) | 1.25 (0.89–1.74) | 30 (17.2) | 1.77 (1.03–3.04) | ||
| ALT >35 IU/L | 40 (9.7) | 0.86 (0.56–1.32) | 14 (13.5) | 0.58 (0.27–1.23) | ||
| ALP >340 IU/L | 76 (9.4) | 1.09 (0.84–1.42) | 25 (13.0) | 0.91 (0.56–1.48) | ||
| BUN >12 mg/dL | 238 (8.3) | 0.89 (0.75–1.07) | 83 (12.5) | 0.90 (0.66–1.24) | ||
| Creatinine >1.2 mg/dL | 164 (10.5) | 1.26 (1.02–1.56) | 51 (13.1) | 0.94 (0.64–1.39) | ||
| Serum Na <138 mEq/L | 157 (10.6) | 1.15 (0.94–1.40) | 62 (15.8) | 1.18 (0.84–1.65) | ||
| APTT >40 s | 50 (11.7) | 1.24 (0.90–1.71) | 19 (21.8) | 1.69 (0.94–3.05) | ||
| PT‐INR >1.1 | 109 (9.9) | 0.98 (0.78–1.23) | 47 (16.3) | 1.25 (0.85–1.82) | ||
| Tumor factors | ||||||
| T factor | ||||||
| T0, Tis | 4 (11.1) | 1.95 (0.67–5.68) | 0 (0.0) | <0.001 (<0.001‐ > 999.99) | ||
| T1 | 209 (6.2) | 1 [Reference] | 32 (7.7) | 1 [Reference] | ||
| T2 | 115 (7.4) | 1.04 (0.82–1.34) | 31 (8.8) | 1.01 (0.59–1.73) | ||
| T3 | 208 (8.3) | 1.04 (0.83–1.31) | 93 (12.6) | 1.43 (0.90–2.29) | ||
| T4 | 259 (9.5) | 1.13 (0.88–1.45) | 136 (12.7) | 1.36 (0.84–2.22) | ||
| N factor | ||||||
| N0 | 375 (6.9) | 1 [Reference] | 94 (9.1) | 1 [Reference] | ||
| N1 | 156 (8.4) | 1.07 (0.87–1.32) | 58 (12.2) | 1.16 (0.79–1.70) | ||
| N2 | 122 (8.0) | 0.94 (0.74–1.20) | 66 (13.9) | 1.24 (0.84–1.82) | ||
| N3 | 132 (10.2) | 1.20 (0.93–1.55) | 69 (12.3) | 1.09 (0.72–1.64) | ||
| M factor | ||||||
| M0 | 741 (7.7) | 1 [Reference] | 251 (10.9) | 1 [Reference] | ||
| M1 | 55 (8.9) | 0.79 (0.57–1.09) | 41 (14.9) | 1.21 (0.79–1.85) | ||
| Surgical approach | ||||||
| Open | 531 (9.3) | 1 [Reference] | 53 (2.7) | 1 [Reference] | ||
| Laparoscopy | 265 (5.9) | 0.71 (0.60–0.84) | 74 (11.7) | 1.16 (0.86–1.56) | ||
Abbreviations: ADL, activities of daily living; ALP, alkaline phosphatase; ALT, alanine aminotransferase; APTT, activated partial thromboplastin time; ASA‐PS, American Society of Anesthesiologists physical status; AST, aspartate aminotransferase; BUN, blood urea nitrogen; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention; PT‐INR, prothrombin time‐international normalized ratio; PVD, peripheral vascular disease; WBC, white blood cells.
3.5. Risk factors for serious postoperative complications in TG
Table 3 also shows the results of the multivariable analysis of risk factors associated with serious postoperative complications in TG. ADL (partially dependent) (OR 1.55, 95% CI 1.06–2.26), ASA‐PS (Grade ≥3) (OR 1.38, 95% CI 1.04–1.84), previous percutaneous coronary intervention (PCI) (OR 1.74, 95% CI 1.07–2.85), dialysis (OR 4.28, 95% CI 1.24–14.75), WBC (>9000 μL) (OR 2.08, 95% CI 1.36–3.17), and AST (>35 IU/L) (OR 1.77, 95% CI 1.03–3.04) were the strong risk factors for serious postoperative complications in TG.
4. DISCUSSION
The safety and feasibility of gastrectomy in super‐elderly patients with gastric cancer have not been sufficiently studied. The rates of operative mortality and serious postoperative complications in the super‐elderly patients with gastric cancer in the present study were 1.6% and 7.8% for DG and 2.6% and 11.3% for TG, respectively. Furthermore, the strong risk factors for serious postoperative complications were BMI, ADL, ASA‐PS, dyspnea, ascites, history of cerebrovascular disease, serum albumin, and creatinine for DG and ADL, ASA‐PS, previous PCI, dialysis, WBC, and AST for TG. To the best of our knowledge, this large multihospital study is the first to clarify the safety and feasibility of gastrectomy in super‐elderly patients with gastric cancer.
Some previous studies on gastric surgery in elderly patients reported the adverse effect of age on postoperative mortality rates. 11 , 12 , 13 Lee et al 14 showed that advanced age (>70 y) was an independent risk factor for postoperative death in patients with gastric cancer undergoing gastrectomy from a large sample size using the US National Inpatient Sample database. In contrast, Omichi et al 15 reported that the postoperative mortality rate in patients aged >80 y was relatively lower than those of previous similar studies. Our rates were more than one‐half lower than their rates (1.6% vs 3.6% for DG and 2.6% vs 5.7% for TG, respectively). These favorable results suggest that surgeons in Japan have been paying more careful attention to surgical indications, perioperative management, and less‐invasive operative procedures, including limited surgery to avoid postoperative death in super‐elderly patients. We thus consider that gastrectomy for super‐elderly gastric cancer patients is relatively safe and feasible.
Many previous studies showed that advanced age was associated with the incidence of postoperative complications in elderly patients. 15 , 16 , 17 , 18 Conversely, Xu et al 19 indicated in their meta‐analysis that the risk of postoperative complications for octogenarian patients was the same as that for younger patients, except for those of abscess and anastomotic leakage. Thus, the relationship between age and postoperative complications remains controversial. The risk factors for postoperative complications in super‐elderly patients with gastric cancer have been reported in only a few previous studies. 20 , 21 , 22 However, most of them were small‐scale, single‐center studies in which the severity of postoperative complications was not considered. It is well known that serious postoperative complications are directly related to life or death in super‐elderly patients. Furthermore, postoperative complications also affect the incidence of death from other disease rather than from gastric cancer itself, not only in the nonelderly but elderly gastric cancer patients. 23 , 24 Thus, we focused on serious postoperative complications of Clavien–Dindo Grade ≥ III, pancreatic fistula, postoperative pneumonia, and anastomotic leakage. In the present study, BMI, ADL, ASA‐PS, dyspnea, and a history of cerebrovascular disease in DG, in addition to previous PCI in TG, remain the strong risk factors for serious postoperative complications. These findings suggest that the cause of serious postoperative complications in super‐elderly gastric cancer patients may not be independently age‐specific, but rather physical status such as frailty and past medical history.
The mortality and morbidity rates in TG are also well known to be higher than those in DG in elderly gastric cancer patients. Our results showed that not only mortality rates but also incidence rates of serious postoperative complications for TG were higher than those for DG (11.3% vs 7.8%). TG itself is a known risk factor for postoperative complications. 20 , 25 , 26 Especially in elderly patients, TG is a risk factor for postoperative pneumonia due to aspiration of esophageal reflux contents. 27 , 28 In the present study, not only the incidences of postoperative pneumonia but also those of pancreatic fistula and anastomotic leakage were almost twice as high for TG than for DG. We consider that the choice of TG for super‐elderly patients with gastric cancer may be avoided as much as possible.
The present study also revealed that the risk factors of serious postoperative complications were different for DG and TG, although the reason why these risk factors differed between the two procedures is not known. Also, for previous studies using the NCD data, the risk factors for morbidities were different for DG and TG. 29 , 30 These differences may be due to differences in these operation procedures itself. TG is relatively difficult for surgeons, and a more invasive procedure for patients than DG. Thus, these differences in risk factors may reflect differences in surgical stress and postoperative complications after the two types of gastrectomy. Only ADL and ASA‐PS were selected as strong risk factors for serious postoperative complications common in the two procedures. In addition, the strength of the association between tumor factors and serious postoperative complications was weak for either procedure. The general condition of super‐elderly patients, as revealed by factors such as ADL and ASA‐PS, might be a more important risk factor for serious postoperative complications than are tumor factors.
Although LG is more beneficial than open gastrectomy for elderly patients, as reported previously, 31 , 32 its usefulness in super‐elderly patients with gastric cancer is still unclear. Lin et al 33 indicated that older age was an independent risk factor for postoperative complications after LG in elderly patients. However, Inokuchi et al 34 found that LG reduced postoperative complication in elderly patients in a Japanese nationwide study. Kamiya et al 35 also indicated that LG independently reduced the occurrence of noncancer‐related death in elderly patients with gastric cancer. The present study also showed that LG was not a positive risk factor in either DG or TG for serious postoperative complications in our super‐elderly patients. We thus consider that LG is not contraindicated for even super‐elderly patients with gastric cancer.
This study had several limitations. First is the lack of evaluation of oncological and long‐term outcomes because these relevant data are not available in the NCD. Second, due to the retrospective nature of this study, selection bias, which could potentially affect the decision to treat these patients surgically, cannot be excluded. Third, this analysis did not have information on some of the important determinants of the clinical outcomes following gastrectomy, such as the degree of lymphadenectomy and the type of reconstruction methods used. Fourth, the effects of perioperative management on the prevention of postoperative complications, such as prerehabilitation, preoperative breathing training, and enhanced recovery after surgery, were not evaluated in this study, also due to lack of information in this surgical registry. Finally, the association between surgical outcomes and hospital volume was not examined in this study because the NCD database includes a large number of cases from >5000 institutions ranging from high‐volume cancer centers to low‐volume community hospitals in Japan. Future studies are needed to address these points.
In conclusion, our results of real‐world practice in Japan show that gastrectomy performed in super‐elderly gastric cancer patients over 85 y of age is relatively safe and feasible. We believe that age alone is not a contraindication to gastrectomy, including LG for gastric cancer in even this age group. Surgeons and medical staff should pay more special attention to physical status and past medical history when treating super‐elderly gastric cancer patients. Further, surgeons need to consider safer operations, even if they are not standard surgeries, to prevent serious postoperative complications in super‐elderly patients.
AUTHOR CONTRIBUTIONS
Study conception and design: Y.U., S.N., M.I., T.A., H.K. Acquisition of data: S.N., H.K., H.U., Y.K. Analysis and interpretation of data: Y.U., S.N., M.I., T.A., H.K. Drafting of manuscript: Y.U., S.N., T.A., H.S., T.S., H.K. Critical revision of manuscript: Y.U., M.I., S.T., Y.S., H.U., Y.K.
5. FUNDING INFORMATION
This study was carried out without funding.
CONFLICT OF INTEREST STATEMENT
HK reports receiving a consultation fee from EPS Corporation, and a speaker fee from Chugai Pharmaceutical Co., Ltd. HK reports receiving research funding from Amgen K.K. for an unrelated research project. HK and SN are affiliated with the Department of Healthcare Quality Assessment at the University of Tokyo, a social collaboration department supported by the National Clinical Database, Johnson & Johnson K.K., Nipro Corporation, and Intuitive Surgical Sàrl. Masafumi Inomata is an editorial member of the Annals of Gastroenterological Surgery dealing with the lower digestive tract. Hideki Ueno is an Associate Editor of the Annals of Gastroenterological Surgery dealing with the lower digestive tract. Yuko Kitagawa is an Editor‐in‐Chief of the Annals of Gastroenterological Surgery. The remaining authors declare no conflicts of interest for this article.
ETHICS STATEMENT
Approval of research protocol: The study protocol was approved by the Institutional Review Board of Oita University (approval number: 2119).
Informed consent: N/A.
Registry and the registration no. of the study/trial: N/A.
Animal studies: N/A.
Ueda Y, Nishimura S, Inomata M, Akagi T, Shiroshita H, Etoh T, et al. Risk factors for serious postoperative complications following gastrectomy in super‐elderly patients ≥85‐years‐old with gastric cancer: A National Clinical Database study in Japan. Ann Gastroenterol Surg. 2025;9:79–88. 10.1002/ags3.12843
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