Long term survival after total gastrectomy and pancreatoesplenectomy for T4B gastric cancer invading the pancreas in a High-volume Latin American Center

Long term survival after total gastrectomy and pancreatoesplenectomy for T4B gastric cancer invading the pancreas in a High-volume Latin American Center | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long term survival after total gastrectomy and pancreatoesplenectomy for T4B gastric cancer invading the pancreas in a High-volume Latin American Center Marco Ceroni, Enrique Norero, Cristian Martínez, Rodrigo Muñoz, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6290714/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To evaluate postoperative morbidity and mortality up to 90 days and long-term survival in patients with locally advanced gastric cancer (GC) who underwent total gastrectomy with pancreatosplenectomy (TGPS) Summary Background Data: Resection without residual tumor (R0) is the only curative treatment for gastric cancer (GC). TGPS improves the survival of patients with GC with clinical pancreatic invasion (cT4b), however increased postoperative morbidity and mortality. Methods: We enrolled patients with GC who underwent elective TGPS for cT4b between 1996 and 2023. We determined the extent of tumor invasion into the pancreas intraoperatively, and the final pathological stage using delayed biopsy. We used the Clavien–Dindo classification and eighth edition of the TNM staging system and used the Kaplan–Meier survival curves with a log-rank test, descriptive statistics, and univariate and multivariate analyses. Results: Ninety-two patients underwent TGPS for cT4b disease. The morbidity incidence with a Clavien grade ≥3 was 32%. Overall, the mortality rates at 30, 60, and 90 days were 8.7%, 16.3%, and 21,7%, respectively. The rate at 90 days, in the last seven-years, was 7.7%. The 5-year survival rates of patients who underwent curative intent surgery with cT4b, with and without definitive pancreatic invasion were 16.7% and 51.4%, respectively (p =0.0235). Conclusions: TGPS with curative intent in patients with cT4b GC on the pancreas resulted in a long-term survival rate of up to 51.4%. Patients showed decreased postoperative mortality over time. These results support en bloc resection of cT4b on the pancreas. Stomach cancer gastrectomy pancreatectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION The diagnosis and treatment of advanced gastric cancer (GC) with locoregional invasion is challenging. Fundamentally, complete resection with negative margins is used, 1 , 2 with the objective of curing the disease and achieving long-term survival. 3 – 7 However, to minimize postoperative complications, this surgery must be performed by multidisciplinary teams with expertise in oncological digestive surgery in high-complexity centers because of the particularities and technical details of the procedures. 7 Accurate identification of pathological invasion of the pancreas (pT4b) using preoperative radiology is limited because, under normal conditions, the adipose tissue between the stomach and pancreas is minimal, particularly in patients with significant weight loss. Intraoperatively, it is difficult to distinguish between desmoplastic or inflammatory reactions and pT4b pancreatic involvement, which occurs in approximately 50% of patients with clinical pancreatic invasion (cT4b). 8 Therefore, for patients with good functional status and without distant metastasis, resecting the stomach en bloc with any other organs suspected of invasion is the recommended procedure. Subsequently, the pathological report should be reviewed to determine definitive staging, adjuvant treatment, and prognosis. Notably, in our study center, we experience a high volume of cases and maintain a database of several decades of registration with limited access to neoadjuvant therapy. Therefore, we evaluated the surgical results of locally advanced GC treatment in latino American Center. Objective We aimed to evaluate the postoperative morbidity and mortality for up to 90 days and long-term survival in patients with locally advanced GC who underwent total gastrectomy with pancreatosplenectomy (TGPS). METHODS In this retrospective cohort study, we enrolled patients with GC who underwent elective TGPS for cT4b tumors in the pancreas between 1996 and 2023. The absence of a parting plane between the GC and the pancreas confirmed the presence of cT4b (Fig. 1 ), as observed by palpation and visual assessment by the surgeon. 4 pT4b was regarded as the gold standard for invasion. Preoperative Studies All patients underwent upper digestive endoscopy with biopsy-confirmed GC. Until 2001, preoperative staging was performed using chest radiography and abdominal ultrasonography. However, these methods were superseded by computed tomography (CT) scans of the chest, abdomen, and pelvis with intravenous contrast, between 2001 and 2006. General serum tests, albumin level measurements, and electrocardiography were performed. Notably, from 2012, prealbumin levels were monitored, and a tailored nutritional therapy was implemented to achieve a preoperative level of 15 mg/dL. 9 Nevertheless, positron emission tomography (PET) scans, combined with CT, were employed in the diagnosis of gastroesophageal junction (GEJ) cancer, from 2014. Preoperative Preparation The intensive nutritional support unit, in 2005 began to support the nutritional therapy protocols for patients with GC. Accordingly, we referred our patients to the hospital’s oncology committee to record the therapeutic plan. Neoadjuvant chemotherapy is indicated for patients with GC who are positive for node-positive (N), tumor stage 3 (T3), or higher stages. We used 5-fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel (FLOT) neoadjuvant chemotherapy from 2021; however, Capecitabine + Oxaliplatin (CAPEOX) was prescribed previously and, FOLFOX was recommended when neoadjuvant chemotherapy was not administered. From 2017, the kinesiology team performed prehabilitation for the patients, and they were evaluated by the psycho-oncology unit as needed. Surgical Technique (Figs. 2 and 3 ) After exploration time, when pancreas was invaded, we modified surgical plan to en bloc multi-visceral resection. We continued the dissection of the GEJ because approximately one-third of these tumors invade this area. The vagus nerve and esophagus were sectioned, and a contemporaneous biopsy of the esophageal was performed. The right gastroepiploic and gastric vessels, duodenum, left gastric vessels, and the splenic artery at the celiac axis were bound. Next, the pancreas was dissected and sectioned into the neck with either a stapler or a scalpel to locate the pancreatic duct, which was then tied with a non-absorbable suture. The splenic vein was bound 1–2 cm from the portal vein using a vascular linear cutting stapler. Subsequently, the specimen was removed en bloc for a deferred pathological study. A 25 mm circular stapler was used for esophagous-jejunostomy (E-J), with continuous 3 − 0 Monocryl reinforcement around its perimeter. A Roux-en-Y reconstruction was performed. In cases of colon resection, we preferred to perform an ostomy on the proximal end and perform reconstruction 12 months later when the patient has reached a sufficient level of nutritional and functional recovery. One or two tubular drains were placed in the direction of the E-J. In addition, a suction drain was placed relative to the pancreatic section, which ran behind the alimentary limb and was extracted through the left flank. Prior to 2010, Witzel jejunostomy was performed for postoperative nutrition. Surgery with curative intent is one without gross residual tumor or distant metastasis. Palliative surgery is one that is performed in order to alleviate a symptom in which there is a macroscopic residual tumor or metastasis. Postoperative Care We monitored vital signs daily. Serum tests, including complete blood count, biochemical profile, and C-reactive protein levels, were conducted on odd days. High digestive transit using water-soluble contrast was performed between days 5 and 7 to confirm the integrity of the E-J. Since 2015, amylase levels in drainage tubes were measured on days 3 and 5, and the results were compared with serum amylase levels. In the event of altered C-reactive protein or drainage amylase levels, CT scans of the chest, abdomen, and pelvis were performed with oral and intravenous contrast. Once the integrity of the E-J was confirmed, oral feeding was gradually initiated, and the abdominal drainage tubes were removed when the output decreased to less than 200 cc. Postoperative complications and staging We used the Clavien–Dindo classification 10 , major complication was defined as Clavien–Dindo grade ≥ 3. A pancreatic fistula was defined as three times an increase in amylase level or the appearance of pancreatic content of the drain. Since 2011, Bassi et al. 's definition of pancreatic fistula was used; 11 clinically relevant postoperative pancreatic fistula is a drain output of any measurable volume of fluid with an amylase level > 3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. For staging we use the eighth edition of the TNM staging system. 12 We reclassify TNM stages for cases diagnosed before this period. Statistical Analysis We conducted Kaplan–Meier survival curves used to estimate survival probabilities, the log-rank test to compare survival distributions and descriptive statistics to summarise patient characteristics. Univariate analysis concerning binomial variables was performed by means of chi square test. Univariate and multivariate Cox regression analyses were used to determine the risk factors for poor survival in patients with cT4b. Statistical significance was set at p < 0.05. Ethics This study was conducted in accordance with the ethical standards of the research ethics committee of our institution. The study was approved by the ethics committee of the South East Metropolitan Health Service. The requirement for informed consent was waived by the institutional review board. RESULTS Patients’ characteristics Ninety-two patients underwent TGPS. The baseline characteristics of the patients and surgical outcomes are shown in Table 1 . Most patients were male (n = 68; 73.9%), with a median age of 63.9 (range, 27–81 years; standard deviation [SD], 10.1) years, and an American Society of Anesthesiologists classification of 2 (n = 55, 59.8%). The most common comorbidities were hypertension (30.4%) and smoking status (17.4%). The body mass index was 23.7 kg/m 2 (range, 16.5–31.9; SD, 3.7). Most GCs were Borrmann types III (45.6%) or IV (28.2%) and the mean size was 9.3 (SD, 3.8; range, 3–27 cm). The upper third of the stomach was involved in 84.7%, whereas it was the GEJ 34.1%. The p-POSSUM score for morbidity and mortality were 48.1% (range, 39.9–79.4; SD, 9.1) and 10.5% (range, 7.8–26.1; SD, 3.8), respectively. Table 1 Patient Characteristics and surgical outcomes Characteristic N (%) Men 68 (73.9) ASA Classification I II III Unknown 19 (20.7) 55 (59.8) 5 (5.4) 13 (14.1) Comorbidities Hypertension Smoking Type 2 Diabetes Mellitus Coronary Heart Disease/Heart Failure COPD Chronic Kidney Disease Fatty Liver/Chronic Live Damage 28 (30.4) 16 (17.4) 10 (10.9) 8 (8.6) 4 (4.3) 3 (3.3) 3 (3.3) Charlson Score Index 2 3 4 5 6 7 8 (8.7) 17 (18.5) 25 (27.2) 27 (29.3) 13 (14.1) 2 (2.2) Location of Cancer U L M UM ML UML E-U E-UM E-UML Unknown 14 (15.2) 5 (5.4) 7 (7.6) 14 (15.2) 2 (2.2) 10 (10.9) 20 (21.7) 14 (15.2) 5 (5.4) 1 (1.1) Borrmann Classification I II III IV V Unknown 1 (1.1) 3 (3.2) 42 (45.6) 26 (28.2) 3 (3.2) 18 (19.5) Other Resected Organs for local invasion Transverse Colon Diaphragmatic Pillars Left Adrenal Gland Lateral Segment of Liver Celiac Axis Ovaries Left Kidney Total Esophagus Transverse Mesocolon Renal Capsule 13 (14,1) 4 (4.3) 4 (4.3) 4 (4.3) 3 (3.3) 2 (2.2) 2 (2.2) 1 (1.1) 1 (1.1) 1 (1.1) Clavien Classification I II III IV V 19 (20.7) 17 (18.5) 10 (10.9) 10 (10.9) 12 (13) ASA, American Society of Anesthesiologists; COPD, Chronic obstructive pulmonary disease; U, Upper third; M, Middle third; L, Lower third; E, Esophagus; UM, Upper third-Middle third; ML, Middle third-Lower third; UML, Upper third-Middle third-Lower third; E-U, Esophagus-Upper third; E-UM, Esophagus-Upper third-Middle third; E-UML, Esophagus-Upper third-Middle third-Lower third. Surgical outcomes The mean surgical time and volume of blood loss were 318.3 (range, 140–510 min; SD, 86.9 min) and 636 (range, 250–1500 cc; SD, 402 cc), respectively. The mean length of hospitalization was 22.5 (range, 7–149 days; SD, 19 days). Resection of other organs by local invasion was performed in 27,2%, the most frequent being the transverse colon (14,1%). The mean number of dissected lymph nodes were 41.2 (range, 9–133; SD, 23.4). Most patients had curative intent surgery (62%). In total, 10.9% of the patients had a clinical pancreatic fistula, and 8.6% had an E-J fistula. Approximately 32% of the patients had severe complications classified as Clavien-Dindo grade III or above. The mortality rate for complications at 30 and 90 days were 8.7% and 13%, respectively. The mortality rate for complications, divided into seven-year periods, was 21.2% between 1996 and 2002, 5.3% between 2003 and 2009, 11.1% between 2010 and 2016, and 7.7% between 2017 and 2023. Oncological outcomes Of the patients with curative intent surgery, R0 was achieved in 91,9%. pT4b was observed in 53 patients (positive predictive value [PPV], 57.6%). Overall, 41.2 (range, 9–133; SD 23.4) lymph nodes were dissected. In patients with surgery with curative intent, the lymph node groups with metastatic involvement over 20% were: 1, 2, 3, 4 and 7. Stage III of the TNM staging system was the most frequent (64.1%). Table 2 . Of the R1 patients with T4b in the pancreas, four (80%) had esophageal margin involvement, and one (20%) had retroperitoneal involvement. Table 2 Pathological Characteristics Characteristics N (%) Histology Well Differentiated Moderately Differentiated Poorly Differentiated Signet Ring Cell Adenosquamous 2 (2.2) 30 (32.1) 41 (44.6) 18 (19.6) 1 (1.1) Angiolymphatic Invasion 59/65 90.7% Perineural Invasion 35/45 77.7% Number of Dissected Lymph Nodes ≥ 15 ˂15 Unknown 87 (94.6) 3 (3.3) 2 (2.2) Metastatic Lymph Node Groups with Curative Intent 1 2 3 4 5 6 7 8 9 10 11 12 42.2% 34.8% 45.4% 39.3% 13.6% 18.2% 34.8% 10.6% 6% 18.2% 18.2% 4.5% Depth of infiltration (pT) T1 T2 T3 T4a T4b (to any organ) 1 (1.1) 0 8 (8.7) 27 (29.3) 56 (60.9) Lymph node status (pN) N0 N1 N2 N3a N3b Unknown 7 (7.6) 9 (9.8) 13 (14.1) 23 (25) 30 (32.6) 2 (2.2) TNM staging system I II IIIA IIIB IIIC IV 1 (1.1) 4 (4.3) 7 (7.6) 16 (17.3) 36 (39.1) 28 (30.4) From those who underwent palliative surgery, 17 patients (56.6%) showed peritoneal carcinomatosis, four (13.3%) demonstrated hepatic metastases, one had a portal vein tumor thrombus (3.3%), and two exhibited intercaval-aortic lymph node involvement (6.7%). Short and long-term mortality and survival The overall mortality rates at 30, 60, and 90 days were 8.7%, 16.3%, and 21,7%, respectively. Whereas the rate after 90 days, divided into seven-year periods, was 33.3% between 1996 and 2002, 26.3% between 2003 and 2009, 11.1% between 2010 and 2016, and 7.7% between 2017 and 2023. Approximately 26,1% of patients received adjuvant chemotherapy. During the four periods of the analysis, the number of surgeries with curative intent increased (p = 0.024), overall mortality at 90 days reduced (p = 0.017), and the indications for adjuvant chemotherapy increased (p < 0.001). Table 3 . The five-year survival rates of patients who underwent curative intent surgery with cT4b, with and without definitive pancreatic invasion, were 16.7% and 51.4%, respectively (p = 0.0235). Figure 4 . Table 3 Postoperative morbidity and mortality, surgical complications, intention to cure, type of oncological resection, and adjuvant chemotherapy in four 7-year periods. 1996–2002 2003–2009 2010–2016 2017–2023 Total p-value * N (%) 33 19 27 13 92 30-Day Mortality 5 (15.2) 1 (5.3) 2 (7.4) 0 8 (8.7) 0.27 60-Day Mortality 8 (24.2) 3 (15.8) 3 (11.1) 1 (7.7) 15 (16.3) 0.151 90-Day Mortality 11 (33.3) 5 (26.3) 3 (11.1) 1 (7.7) 20 (21.7) 0.017 180-Day Mortality 17 (51.5) 7 (36.8) 4 (14.8) 2 (15.4) 30 (32.6) 0.002 Clavien ≥ 3 12 (36.4) 8 (42.1) 7 (25.9) 5 (38.5) 32 (34.8) 0.398 Clavien 5 7 (21.2) 2 (5.3) 2 (11.1) 1 (7.7) 12 (13) 0.166 E-J Fistula 3 (9.1) 2 (10.5) 1 (3.7) 2 (15.4) 8 (8.7) 0.721 Clinical Pancreatic Fistula 4 (12.1) 3 (15.8) 4 (14.8) 4 (30.7) 10 (10.9) 0.4 Curative Intent Surgery 19 (57.6) 11 (57.9) 21 (77.8) 11 (84.6) 62 (67.4) 0.024 R0 17 (89.6) 10 (90.9) 20 (95.2) 10 (90.9) 57 (91.9) 0.588 R1 2 (10.5) 1 (9.1) 1 (4.8) 1 (9.1) 5 (8.1) 0.588 Stage IV 14 (42.4) 7 (36.8) 6 (22.2) 1 (7.7) 28 (30.4) 0.018 Neoadjuvant Therapy 0 0 0 2 (15.4) 5 (5.4) 0.002 Adjuvant Therapy 1 (3) 5 (26.3) 10 (37) 8 (61.5) 24 (26.1) 0.001 E-J, esophagous-jejunostomy; R0, resection without residual tumor; R1, resection with microscopic residual tumor. * Chi-squared test comparing the two firsts and the two seconds seven-years periods. Prognostic factors of survival The univariate analysis of cT4b to the pancreas revealed that palliative surgery (HR, 3.14; 95% CI, 1.77–5.57), more than 15 lymphadenopathies in the specimen (HR, 3.66; 95% CI, 2.12–6.31), pT4b (HR, 1.94; 95% CI, 1.12–3.36), GEJ involvement (HR, 1.85; 95% CI, 1.09–3.13), stage IV (HR, 0,32; 95% CI, 0.18–0.56), lymph node index ˃ 0.37 (HR, 3.98; 95% CI, 2.24–7.08) and residual disease (HR, 3.74; 95% CI, 2.09–6.69) were poor prognostic factors. The absence of chemotherapy, sex, tumor size > 7 cm, age, and complications were not poor prognostic factors. Similarly, GEJ invasion (HR 1.92, 95% CI 1.09–3.38) and pT4b (HR 1.89, 95% CI 1.01–3.53) were poor prognostic factors in the multivariate analysis. DISCUSSION In Western countries, 90% of GC cases are diagnosed at an advanced stage, 13 necessitating multimodal treatment for most patients. Of the treatment options available, R0 surgery remains the only curative option. 4 , 5 , 8 The objective of surgical oncology for the digestive tract is to achieve locoregional control and minimize perioperative morbidity and mortality, thereby improving survival rates and quality of life. Multi-visceral resection for GC is radical surgery, necessary for 10–30% of patients with GC, to achieve R0 resection. 1 , 2 , 13 However, it may increase the risk of postoperative morbidity and mortality. 4 "Multi-visceral resection in CG involves removing the organs that the tumor has invaded because the tumor grows deeply and significantly increases postoperative morbidity. These surgeries included TGPS, gastrectomy with colectomy, hepatectomy, pancreaticoduodenectomy, and vascular resections. 8 Moreover, TGPS without pancreas invasion, with the aim of achieving a more extensive lymphatic dissection, has not significantly impacted the survival of patients compared with dissection of only group 10 and 11 lymph nodes. Nevertheless, it has caused increased complications and is therefore not currently a viable technique for superior lymphadenectomy outcomes. 14 , 15 T4b in the pancreas should be suspected in patients with tumors > 7 cm in size, those with Borrmann type 3 or 4 involvement of the upper third of the stomach or having Siewert type 3 GEJ cancers. The accuracy of CT in identifying the invasion of adjacent organs ranges from 50–80%. 5, 8 , 16 Differentiating pancreatic invasion in tumors affecting the serosa of the posterior stomach wall is particularly challenging because of the minimal adipose tissue in that plane. Nevertheless, supplementary CT tomography can be used. Here, the patient is repositioned to evaluate the absence of the stomach sliding sign relative to the pancreas. 17 However, the absence of displacement does not rule out inflammatory adhesions. Notably, endosonography has a similar performance to CT in differentiating T4a from T4b but does not provide additional useful information in this context. 5 Currently, studies reveal that multi-visceral resection is appropriate for patients with good functional status, aged < 65 years, without distant metastases, 18 , 19 with no more than 15 lymphadenopathies, and who have achieved R0 surgery to control the locoregional factors of GC., 4 , 5 , 7 , 20 – 25 In these cases, the recommendation is to perform an en bloc resection, review the definitive biopsy to define prognosis, and complete perioperative chemotherapy. 26 There are three justifications for performing major resection en bloc involving adjacent organs in cases of suspected GC invasion: 1) long-term survival is achievable in patients with pT4b pancreatic involvement; 2) approximately half of the patients with cT4b to the pancreas have a lower pT stage. 8 In our study, the PPV of cT4b to the pancreas, for pT4b was 56.7%, which is consistent with the findings of other series; 4 , 5 , 13 , 16 3) multi-visceral resection does not decrease long-term survival, the prognosis is dependent on the TNM stage rather than the extent of curative surgery. 7 In our study, patients with cT4b disease in the pancreas and who were not pT4b, observed the greatest benefit of TGPS. The survival rate of these patients was 51.4%, which is consistent with the literature. 1 Additionally, during the surgical procedure, exploring the lesser sac during staging is necessary to confirm the relationship between the tumor and the retroperitoneum. This approach necessitated coloepiploic detachment. Moreover, it isn't advisable to attempt to separate the tumor from the pancreas if cT4b is observed in the pancreas. However, distinguishing between a desmoplastic reaction and genuine invasion is challenging, emphasizing the importance of avoiding adhesion release. 5 Using a pancreas wedge resection is inherently risky because it carries a significant risk of developing a difficult-to-control pancreatic fistula. In addition, attempting to separate the tumor from the pancreas can cause fracturing of the pancreas or rupturing of the tumor in the peritoneal cavity. Meanwhile, it is not advisable to rely on rapid peripheral biopsies to predict the extent of invasion of the most adherent part of the tumor into the pancreas. The most significant technical challenge during the resection phase of TGPS for cT4b is the dissection of the celiac axis. Tumor growth alongside the lesser curvature, extending towards the posterior wall, with lymphadenopathies, was observed in group 7. This configuration made the dissection more challenging. Nonetheless, it is easier to expose the splenic and left gastric arteries when the duodenum and pancreatic neck are sectioned. The primary surgical morbidity is pancreatic fistula, which is an inherent complication of pancreatic resection. Additionally, the rate of E-Js fistulas is high because a significant percentage of cancers invade the GEJ and, therefore, result in anastomoses that remain in the mediastinum. Other studies have reported that intra-abdominal collections and pancreatic fistulas as more frequent complications. 1 , 27 The complications observed in our series were not poor prognostic factors for survival in the univariate analysis. The six-month postoperative mortality rate gradually declined from 51.5–15.4%, despite the comparable postoperative morbidity across the four periods. This suggests that patient preparation, nutritional status, and functional reserves improved over time, enabling better management of complications. Other studies have reported morbidity rates of 20–30% and 30-day mortality rates of 2–15%. 1, 2 , 4 , 13 , 28 – 30 Mortality is not solely dependent on patient-specific factors; the learning curve of the surgical center can also influence it. 2 Our results showed that there was a significant reduction in postoperative mortality as the group of surgeons incorporated the learning and advice of their predecessors. The increase in curative intent surgery in our study can be attributed to enhanced patient staging through superior-quality preoperative radiological investigations. This has also been documented in other studies. 2 Furthermore, It is recommended that radiological studies be subjected to a systematic review at a clinical meeting, as this facilitates more effective surgical planning. Although a little more than a quarter of our patients were resected with palliative intent, in stage IV, this occurred because there were no other palliative resources available in the years that it was performed, however, in the last period only one patient with multivisceral resection had distant compromise. We are clear that this surgery should not be performed in metastatic patients. Currently, complex and high-risk surgical procedures are contraindicated in patients with advanced GC, extensive lymph node involvement or distant metastases without neoadjuvant chemotherapy. 8 , 26 The current regimen is FLOT. 18 In our study, as well as in others, 18 the indication for adjuvant chemotherapy is low, as its indication has been demonstrated since 2006. 21 In our study, its use has increased over time. 2 In our study, univariate analysis revealed that more than 15 lymphadenopathies, GEJ involvement, histopathological confirmation of pancreatic invasion, and palliative surgery were poor prognostic factors for survival. In addition to GEJ invasion and palliative surgery, the definitive TNM stage and oncological prognosis cannot be determined until a final biopsy report of the surgical specimen is available. In the multivariate analysis, definitive pancreatic and GEJ invasion were confirmed as poor prognostic factors for survival. However, these results should be interpreted with caution because our study was retrospective in design. GC involving the GEJ indicates a more advanced tumor with an increased risk of lymph node invasion extending to the lower mediastinum. Definitive pancreatic invasion has also been identified as a poor prognostic factor in other studies. 2 , 31 The main limitation of this study was its retrospective design. As this study encompassed several decades, there were variations in the study, treatment, and surgeons, which may have resulted in a degree of patient selection bias. The inclusion of metastatic patients may limit the interpretation of postoperative morbidity and mortality, because they are more fragile and malnourished patients.There have been notable improvements in the standardization of both study and treatment protocols for GC at our center between 2012 and 2023. Patients with GC classified as cT4b to the pancreas who have undergone TGPS with curative intent have a 51.4% chance of long-term survival. These findings, in conjunction with a sustained decline in postoperative mortality over time, support the use of en bloc resection for cT4b in the pancreas. Abbreviations ASA , American Society of Anesthesiologists CAPEOX , Capecitabine + Oxaliplatin cT4b , clinical invasion CT , computed tomography COPD , Chronic obstructive pulmonary disease E , Esophagus E-U , Esophagus-Upper third E-UM , Esophagus-Upper third-Middle third E-UML , Esophagus-Upper third-Middle third-Lower third. E-J , esophagous-jejunostomy FLOT , 5-fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel GC , Gastric Cancer GEJ , gastroesophageal junction L , Lower third M , Middle third ML , Middle third-Lower third PET , positron emission tomography PPV , positive predictive value pT4b , pathological invasion R0 , resection without residual tumor R1 , resection with microscopic residual tumor TGPS , total gastrectomy with pancreatosplenectomy U , Upper third UM , Upper third-Middle third UML , Upper third-Middle third-Lower third Declarations Conflict of Interest and Source of Funding Norero reported a relationship with AstraZeneca Pharmaceuticals LP that included speaking and lecture fees. The authors have no conflicts of interest to declare. Acknowledgments The authors (s) received no financial support for the research, authorship, or publication of this article. Anita Veloso helped revise the manuscript. We would like to thank Editage (www.editage.com) for English language editing. 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Incomplete resection and linitis plastica are factors for poor survival after extended multiorgan resection in gastric cancer patients. Sci Rep . 2017;7:15800. Zhang X, Wang W, Zhao L, et al. Short-term safety and Long-term efficacy of multivisceral resection in pT4b gastric cancer patients without distant metastasis: a 20-year experience in China National Cancer Center. J Cancer . 2022;13:3113–3120. van der Werf LR, Eshuis WJ, Draaisma WA, et al. Nationwide outcome of gastrectomy with en-bloc partial pancreatectomy for gastric cancer. J Gastrointest Surg . 2019;23:2327–2337. Mita K, Ito H, Katsube T, et al. Prognostic factors affecting survival after multivisceral resection in patients with clinical T4b gastric cancer. J Gastrointest Surg . 2017;21:1993–1999. Martin RCG 2nd, Jaques DP, Brennan MF et al. Achieving RO resection for locally advanced gastric cancer: is it worth the risk of multiorgan resection ? J Am Coll Surg . 2002;194:568–577. Kunisaki C, Akiyama H, Nomura M, et al. Surgical outcomes in patients with T4 gastric carcinoma. J Am Coll Surg . 2006;202:223–230. Jeong O, Choi WY, Park YK. Appropriate selection of patients for combined organ resection in cases of gastric carcinoma invading adjacent organs. J Surg Oncol . 2009;100:115–120. Carboni F, Lepiane P, Santoro R, et al. Extended multiorgan resection for T4 gastric carcinoma: 25-year experience. J Surg Oncol . 2005;90:95–100. Aversa JG, Diggs LP, Hagerty BL, et al. Multivisceral resection for locally advanced gastric cancer. J Gastrointest Surg . 2021;25:609–622. Piso P, Bellin T, Aselmann H, et al. Results of combined gastrectomy and pancreatic resection in patients with advanced primary gastric carcinoma. Dig Surg . 2002;19:281–285. Norero E, Vega EA, Diaz C, et al. Improvement in postoperative mortality in elective gastrectomy for gastric cancer: analysis of predictive factors in 1066 patients from a single centre. Eur J Surg Oncol . 2017;43:1330–1336. Norero E, Quezada JL, Cerda J, et al. Risk factors for severe postoperative complications after gastrectomy for gastric and esophagogastric junction cancers. Arq Bras Cir Dig . 2019;32:e1473. Ozer I, Bostanci EB, Orug T, et al. Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer. Am J Surg . 2009;198:25–30. Min JS, Jin SH, Park S, et al. Prognosis of curatively resected pT4b gastric cancer with respect to invaded organ type. Ann Surg Oncol . 2012;19:494–501. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6290714","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":433429736,"identity":"4551e7fb-b517-4f6a-ad33-804b64886bc8","order_by":0,"name":"Marco Ceroni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYLCDAx+ABBs7KVoOzgBpYSZFCzMPmCSgSrf97MMPHxjs5Mzbew8etvm1TZ6PmYHxw8cc3FrMzqQbS85gSDaWOXMu4XBu323DNmYGZsmZ2/BoOZDGBnTPgcQZEjkGh3N7bjMCtbAx8+LTcv4ZWEs9WItlz217wlpuQGxJkABpYfhxO5EILc+YJWcYJBvO4DljcLC34XZyGzNjM36/nE9j/PChwk5egr3H+MOPP7dt57c3H/zwEY8WCDCA0oxtYLKBkHpk8IcUxaNgFIyCUTBSAABuCEuL+2VvaAAAAABJRU5ErkJggg==","orcid":"","institution":"Complejo Asistencial Sótero del Río","correspondingAuthor":true,"prefix":"","firstName":"Marco","middleName":"","lastName":"Ceroni","suffix":""},{"id":433429737,"identity":"5e7d167f-a9ea-4566-b5e5-db0147cecda3","order_by":1,"name":"Enrique Norero","email":"","orcid":"","institution":"Complejo Asistencial Sótero del Río","correspondingAuthor":false,"prefix":"","firstName":"Enrique","middleName":"","lastName":"Norero","suffix":""},{"id":433429738,"identity":"6235d89d-c4a7-4f81-87ae-57df0204f3c8","order_by":2,"name":"Cristian Martínez","email":"","orcid":"","institution":"Complejo Asistencial Sótero del Río","correspondingAuthor":false,"prefix":"","firstName":"Cristian","middleName":"","lastName":"Martínez","suffix":""},{"id":433429739,"identity":"76d16fa5-fffc-4cfe-b04f-35da63f88f71","order_by":3,"name":"Rodrigo Muñoz","email":"","orcid":"","institution":"Complejo Asistencial Sótero del Río","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"","lastName":"Muñoz","suffix":""},{"id":433429740,"identity":"25006a80-f1a6-4ed4-aa6e-352e50506d07","order_by":4,"name":"Emilio Morales","email":"","orcid":"","institution":"Complejo Asistencial Sótero del Río","correspondingAuthor":false,"prefix":"","firstName":"Emilio","middleName":"","lastName":"Morales","suffix":""},{"id":433429741,"identity":"803a4227-604c-4572-be21-3c50f1ee729f","order_by":5,"name":"Eduardo Pizarro","email":"","orcid":"","institution":"Complejo Asistencial Sótero del Río","correspondingAuthor":false,"prefix":"","firstName":"Eduardo","middleName":"","lastName":"Pizarro","suffix":""},{"id":433429742,"identity":"ddecc954-6e39-4d88-b13f-30faac79087f","order_by":6,"name":"Jaime Cerda","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Jaime","middleName":"","lastName":"Cerda","suffix":""},{"id":433429743,"identity":"3b90f6de-7c05-483e-ab08-1614b1352d40","order_by":7,"name":"Alfonso Díaz","email":"","orcid":"","institution":"Complejo Asistencial Sótero del Río","correspondingAuthor":false,"prefix":"","firstName":"Alfonso","middleName":"","lastName":"Díaz","suffix":""}],"badges":[],"createdAt":"2025-03-24 01:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6290714/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6290714/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79673721,"identity":"59206cf7-8ef9-4353-aa11-4d1f4cd9ea11","added_by":"auto","created_at":"2025-04-01 11:50:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":591373,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical specimen showing gastric cancer with invasion of the pancreas\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6290714/v1/bd292229f5a2beae55b7daeb.png"},{"id":79673722,"identity":"3d253003-2a0e-4b05-84b3-c6b12274788e","added_by":"auto","created_at":"2025-04-01 11:50:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":169914,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of a total gastrectomy with pancreato-splenectomy for gastric cancer with invasion of the pancreas.\u003c/p\u003e\n\u003cp\u003eA, duodenal stump; B, stomach; C, spleen; D, proper hepatic artery; E, common hepatic artery; F, left gastric artery; G, Gastric cancer with pancreatic invasion; H, superior mesenteric vein; I, pancreatic\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6290714/v1/e660b374ffe3a9196950f76f.png"},{"id":79675512,"identity":"dbc97c9b-dec9-4a5e-84ce-2dc5e6dc9145","added_by":"auto","created_at":"2025-04-01 12:06:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":334808,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the laparoscopic view of the surgical site after total gastrectomy with pancreato-splenectomy.\u003c/p\u003e\n\u003cp\u003eA, right gastroepiploic artery; B, duodenal stump; C, proper hepatic artery; D, caudate lobe; E, left gastric artery; F, common hepatic artery; G, portal vein; H, pancreas head; I, splenic vein; J, splenic artery.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6290714/v1/f23c3a4151e3b2a367bf479e.png"},{"id":79674935,"identity":"d96fd3d2-a507-4454-a6eb-a197545f775d","added_by":"auto","created_at":"2025-04-01 11:58:07","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":116748,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival curve of patients with cT4b with R0 surgery, with pathological confirmation of pancreatic invasion (blue) or without (red). p=0.014.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6290714/v1/1eca8b37dd88d38821634b20.png"},{"id":80299485,"identity":"4fae0a4d-6dd5-49c1-b8a1-30fbbd8a2309","added_by":"auto","created_at":"2025-04-10 09:03:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2067582,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6290714/v1/a334091b-52b5-4c5e-b1b5-971e0ace87ed.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long term survival after total gastrectomy and pancreatoesplenectomy for T4B gastric cancer invading the pancreas in a High-volume Latin American Center","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe diagnosis and treatment of advanced gastric cancer (GC) with locoregional invasion is challenging. Fundamentally, complete resection with negative margins is used,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e with the objective of curing the disease and achieving long-term survival.\u003csup\u003e\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e However, to minimize postoperative complications, this surgery must be performed by multidisciplinary teams with expertise in oncological digestive surgery in high-complexity centers because of the particularities and technical details of the procedures.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccurate identification of pathological invasion of the pancreas (pT4b) using preoperative radiology is limited because, under normal conditions, the adipose tissue between the stomach and pancreas is minimal, particularly in patients with significant weight loss. Intraoperatively, it is difficult to distinguish between desmoplastic or inflammatory reactions and pT4b pancreatic involvement, which occurs in approximately 50% of patients with clinical pancreatic invasion (cT4b).\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTherefore, for patients with good functional status and without distant metastasis, resecting the stomach en bloc with any other organs suspected of invasion is the recommended procedure. Subsequently, the pathological report should be reviewed to determine definitive staging, adjuvant treatment, and prognosis.\u003c/p\u003e \u003cp\u003eNotably, in our study center, we experience a high volume of cases and maintain a database of several decades of registration with limited access to neoadjuvant therapy. Therefore, we evaluated the surgical results of locally advanced GC treatment in latino American Center.\u003c/p\u003e\n\u003ch3\u003eObjective\u003c/h3\u003e\n\u003cp\u003eWe aimed to evaluate the postoperative morbidity and mortality for up to 90 days and long-term survival in patients with locally advanced GC who underwent total gastrectomy with pancreatosplenectomy (TGPS).\u003c/p\u003e \n \n\n"},{"header":"METHODS","content":"\u003cp\u003eIn this retrospective cohort study, we enrolled patients with GC who underwent elective TGPS for cT4b tumors in the pancreas between 1996 and 2023. The absence of a parting plane between the GC and the pancreas confirmed the presence of cT4b (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), as observed by palpation and visual assessment by the surgeon.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e pT4b was regarded as the gold standard for invasion.\u003c/p\u003e\u003ch3\u003ePreoperative Studies\u003c/h3\u003e\u003cp\u003eAll patients underwent upper digestive endoscopy with biopsy-confirmed GC. Until 2001, preoperative staging was performed using chest radiography and abdominal ultrasonography. However, these methods were superseded by computed tomography (CT) scans of the chest, abdomen, and pelvis with intravenous contrast, between 2001 and 2006. General serum tests, albumin level measurements, and electrocardiography were performed. Notably, from 2012, prealbumin levels were monitored, and a tailored nutritional therapy was implemented to achieve a preoperative level of 15 mg/dL.\u003csup\u003e9\u003c/sup\u003e Nevertheless, positron emission tomography (PET) scans, combined with CT, were employed in the diagnosis of gastroesophageal junction (GEJ) cancer, from 2014.\u003c/p\u003e\u003ch3\u003ePreoperative Preparation\u003c/h3\u003e\u003cp\u003eThe intensive nutritional support unit, in 2005 began to support the nutritional therapy protocols for patients with GC.\u003c/p\u003e\u003cp\u003e Accordingly, we referred our patients to the hospital’s oncology committee to record the therapeutic plan. Neoadjuvant chemotherapy is indicated for patients with GC who are positive for node-positive (N), tumor stage 3 (T3), or higher stages. We used 5-fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel (FLOT) neoadjuvant chemotherapy from 2021; however, Capecitabine + Oxaliplatin (CAPEOX) was prescribed previously and, FOLFOX was recommended when neoadjuvant chemotherapy was not administered.\u003c/p\u003e\u003cp\u003eFrom 2017, the kinesiology team performed prehabilitation for the patients, and they were evaluated by the psycho-oncology unit as needed.\u003c/p\u003e\u003cp\u003e \u003cem\u003eSurgical Technique\u003c/em\u003e (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAfter exploration time, when pancreas was invaded, we modified surgical plan to en bloc multi-visceral resection. We continued the dissection of the GEJ because approximately one-third of these tumors invade this area. The vagus nerve and esophagus were sectioned, and a contemporaneous biopsy of the esophageal was performed. The right gastroepiploic and gastric vessels, duodenum, left gastric vessels, and the splenic artery at the celiac axis were bound. Next, the pancreas was dissected and sectioned into the neck with either a stapler or a scalpel to locate the pancreatic duct, which was then tied with a non-absorbable suture. The splenic vein was bound 1–2 cm from the portal vein using a vascular linear cutting stapler. Subsequently, the specimen was removed en bloc for a deferred pathological study. A 25 mm circular stapler was used for esophagous-jejunostomy (E-J), with continuous 3 − 0 Monocryl reinforcement around its perimeter. A Roux-en-Y reconstruction was performed. In cases of colon resection, we preferred to perform an ostomy on the proximal end and perform reconstruction 12 months later when the patient has reached a sufficient level of nutritional and functional recovery. One or two tubular drains were placed in the direction of the E-J. In addition, a suction drain was placed relative to the pancreatic section, which ran behind the alimentary limb and was extracted through the left flank. Prior to 2010, Witzel jejunostomy was performed for postoperative nutrition. Surgery with curative intent is one without gross residual tumor or distant metastasis. Palliative surgery is one that is performed in order to alleviate a symptom in which there is a macroscopic residual tumor or metastasis.\u003c/p\u003e\u003ch3\u003ePostoperative Care\u003c/h3\u003e\u003cp\u003eWe monitored vital signs daily. Serum tests, including complete blood count, biochemical profile, and C-reactive protein levels, were conducted on odd days. High digestive transit using water-soluble contrast was performed between days 5 and 7 to confirm the integrity of the E-J. Since 2015, amylase levels in drainage tubes were measured on days 3 and 5, and the results were compared with serum amylase levels. In the event of altered C-reactive protein or drainage amylase levels, CT scans of the chest, abdomen, and pelvis were performed with oral and intravenous contrast. Once the integrity of the E-J was confirmed, oral feeding was gradually initiated, and the abdominal drainage tubes were removed when the output decreased to less than 200 cc.\u003c/p\u003e\u003ch3\u003ePostoperative complications and staging\u003c/h3\u003e\u003cp\u003eWe used the Clavien–Dindo classification\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, major complication was defined as Clavien–Dindo grade ≥ 3. A pancreatic fistula was defined as three times an increase in amylase level or the appearance of pancreatic content of the drain. Since 2011, Bassi et al. 's definition of pancreatic fistula was used;\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e clinically relevant postoperative pancreatic fistula is a drain output of any measurable volume of fluid with an amylase level \u0026gt; 3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. For staging we use the eighth edition of the TNM staging system.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e We reclassify TNM stages for cases diagnosed before this period.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eWe conducted Kaplan–Meier survival curves used to estimate survival probabilities, the log-rank test to compare survival distributions and descriptive statistics to summarise patient characteristics. Univariate analysis concerning binomial variables was performed by means of chi square test. Univariate and multivariate Cox regression analyses were used to determine the risk factors for poor survival in patients with cT4b. Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e\u003ch3\u003eEthics\u003c/h3\u003e\u003cp\u003e This study was conducted in accordance with the ethical standards of the research ethics committee of our institution. The study was approved by the ethics committee of the South East Metropolitan Health Service. The requirement for informed consent was waived by the institutional review board.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; characteristics\u003c/h2\u003e \u003cp\u003eNinety-two patients underwent TGPS. The baseline characteristics of the patients and surgical outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most patients were male (n\u0026thinsp;=\u0026thinsp;68; 73.9%), with a median age of 63.9 (range, 27\u0026ndash;81 years; standard deviation [SD], 10.1) years, and an American Society of Anesthesiologists classification of 2 (n\u0026thinsp;=\u0026thinsp;55, 59.8%). The most common comorbidities were hypertension (30.4%) and smoking status (17.4%). The body mass index was 23.7 kg/m\u003csup\u003e2\u003c/sup\u003e (range, 16.5\u0026ndash;31.9; SD, 3.7). Most GCs were Borrmann types III (45.6%) or IV (28.2%) and the mean size was 9.3 (SD, 3.8; range, 3\u0026ndash;27 cm). The upper third of the stomach was involved in 84.7%, whereas it was the GEJ 34.1%. The p-POSSUM score for morbidity and mortality were 48.1% (range, 39.9\u0026ndash;79.4; SD, 9.1) and 10.5% (range, 7.8\u0026ndash;26.1; SD, 3.8), respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Characteristics and surgical outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (73.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA Classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eII\u003c/p\u003e \u003cp\u003eIII\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (20.7)\u003c/p\u003e \u003cp\u003e55 (59.8)\u003c/p\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003cp\u003e13 (14.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003cp\u003eType 2 Diabetes Mellitus\u003c/p\u003e \u003cp\u003eCoronary Heart Disease/Heart Failure\u003c/p\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003cp\u003eChronic Kidney Disease\u003c/p\u003e \u003cp\u003eFatty Liver/Chronic Live Damage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (30.4)\u003c/p\u003e \u003cp\u003e16 (17.4)\u003c/p\u003e \u003cp\u003e10 (10.9)\u003c/p\u003e \u003cp\u003e8 (8.6)\u003c/p\u003e \u003cp\u003e4 (4.3)\u003c/p\u003e \u003cp\u003e3 (3.3)\u003c/p\u003e \u003cp\u003e3 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlson Score Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (8.7)\u003c/p\u003e \u003cp\u003e17 (18.5)\u003c/p\u003e \u003cp\u003e25 (27.2)\u003c/p\u003e \u003cp\u003e27 (29.3)\u003c/p\u003e \u003cp\u003e13 (14.1)\u003c/p\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eU\u003c/p\u003e \u003cp\u003eL\u003c/p\u003e \u003cp\u003eM\u003c/p\u003e \u003cp\u003eUM\u003c/p\u003e \u003cp\u003eML\u003c/p\u003e \u003cp\u003eUML\u003c/p\u003e \u003cp\u003eE-U\u003c/p\u003e \u003cp\u003eE-UM\u003c/p\u003e \u003cp\u003eE-UML\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (15.2)\u003c/p\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003cp\u003e7 (7.6)\u003c/p\u003e \u003cp\u003e14 (15.2)\u003c/p\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003cp\u003e10 (10.9)\u003c/p\u003e \u003cp\u003e20 (21.7)\u003c/p\u003e \u003cp\u003e14 (15.2)\u003c/p\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorrmann Classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eII\u003c/p\u003e \u003cp\u003eIII\u003c/p\u003e \u003cp\u003eIV\u003c/p\u003e \u003cp\u003eV\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003cp\u003e42 (45.6)\u003c/p\u003e \u003cp\u003e26 (28.2)\u003c/p\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003cp\u003e18 (19.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Resected Organs for local invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransverse Colon\u003c/p\u003e \u003cp\u003eDiaphragmatic Pillars\u003c/p\u003e \u003cp\u003eLeft Adrenal Gland\u003c/p\u003e \u003cp\u003eLateral Segment of Liver\u003c/p\u003e \u003cp\u003eCeliac Axis\u003c/p\u003e \u003cp\u003eOvaries\u003c/p\u003e \u003cp\u003eLeft Kidney\u003c/p\u003e \u003cp\u003eTotal Esophagus\u003c/p\u003e \u003cp\u003eTransverse Mesocolon\u003c/p\u003e \u003cp\u003eRenal Capsule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (14,1)\u003c/p\u003e \u003cp\u003e4 (4.3)\u003c/p\u003e \u003cp\u003e4 (4.3)\u003c/p\u003e \u003cp\u003e4 (4.3)\u003c/p\u003e \u003cp\u003e3 (3.3)\u003c/p\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien Classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eII\u003c/p\u003e \u003cp\u003eIII\u003c/p\u003e \u003cp\u003eIV\u003c/p\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (20.7)\u003c/p\u003e \u003cp\u003e17 (18.5)\u003c/p\u003e \u003cp\u003e10 (10.9)\u003c/p\u003e \u003cp\u003e10 (10.9)\u003c/p\u003e \u003cp\u003e12 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eASA, American Society of Anesthesiologists; COPD, Chronic obstructive pulmonary disease; U, Upper third; M, Middle third; L, Lower third; E, Esophagus; UM, Upper third-Middle third; ML, Middle third-Lower third; UML, Upper third-Middle third-Lower third; E-U, Esophagus-Upper third; E-UM, Esophagus-Upper third-Middle third; E-UML, Esophagus-Upper third-Middle third-Lower third.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSurgical outcomes\u003c/h2\u003e \u003cp\u003eThe mean surgical time and volume of blood loss were 318.3 (range, 140\u0026ndash;510 min; SD, 86.9 min) and 636 (range, 250\u0026ndash;1500 cc; SD, 402 cc), respectively. The mean length of hospitalization was 22.5 (range, 7\u0026ndash;149 days; SD, 19 days). Resection of other organs by local invasion was performed in 27,2%, the most frequent being the transverse colon (14,1%). The mean number of dissected lymph nodes were 41.2 (range, 9\u0026ndash;133; SD, 23.4). Most patients had curative intent surgery (62%).\u003c/p\u003e \u003cp\u003eIn total, 10.9% of the patients had a clinical pancreatic fistula, and 8.6% had an E-J fistula. Approximately 32% of the patients had severe complications classified as Clavien-Dindo grade III or above. The mortality rate for complications at 30 and 90 days were 8.7% and 13%, respectively. The mortality rate for complications, divided into seven-year periods, was 21.2% between 1996 and 2002, 5.3% between 2003 and 2009, 11.1% between 2010 and 2016, and 7.7% between 2017 and 2023.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eOncological outcomes\u003c/h2\u003e \u003cp\u003eOf the patients with curative intent surgery, R0 was achieved in 91,9%. pT4b was observed in 53 patients (positive predictive value [PPV], 57.6%). Overall, 41.2 (range, 9\u0026ndash;133; SD 23.4) lymph nodes were dissected. In patients with surgery with curative intent, the lymph node groups with metastatic involvement over 20% were: 1, 2, 3, 4 and 7. Stage III of the TNM staging system was the most frequent (64.1%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Of the R1 patients with T4b in the pancreas, four (80%) had esophageal margin involvement, and one (20%) had retroperitoneal involvement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathological Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWell Differentiated\u003c/p\u003e \u003cp\u003eModerately Differentiated\u003c/p\u003e \u003cp\u003ePoorly Differentiated\u003c/p\u003e \u003cp\u003eSignet Ring Cell\u003c/p\u003e \u003cp\u003eAdenosquamous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003cp\u003e30 (32.1)\u003c/p\u003e \u003cp\u003e41 (44.6)\u003c/p\u003e \u003cp\u003e18 (19.6)\u003c/p\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngiolymphatic Invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59/65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerineural Invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35/45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Dissected Lymph Nodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;15\u003c/p\u003e \u003cp\u003e˂15\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (94.6)\u003c/p\u003e \u003cp\u003e3 (3.3)\u003c/p\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastatic Lymph Node Groups with Curative Intent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e11\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.2%\u003c/p\u003e \u003cp\u003e34.8%\u003c/p\u003e \u003cp\u003e45.4%\u003c/p\u003e \u003cp\u003e39.3%\u003c/p\u003e \u003cp\u003e13.6%\u003c/p\u003e \u003cp\u003e18.2%\u003c/p\u003e \u003cp\u003e34.8%\u003c/p\u003e \u003cp\u003e10.6%\u003c/p\u003e \u003cp\u003e6%\u003c/p\u003e \u003cp\u003e18.2%\u003c/p\u003e \u003cp\u003e18.2%\u003c/p\u003e \u003cp\u003e4.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepth of infiltration (pT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003cp\u003eT2\u003c/p\u003e \u003cp\u003eT3\u003c/p\u003e \u003cp\u003eT4a\u003c/p\u003e \u003cp\u003eT4b (to any organ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e8 (8.7)\u003c/p\u003e \u003cp\u003e27 (29.3)\u003c/p\u003e \u003cp\u003e56 (60.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph node status (pN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003cp\u003eN1\u003c/p\u003e \u003cp\u003eN2\u003c/p\u003e \u003cp\u003eN3a\u003c/p\u003e \u003cp\u003eN3b\u003c/p\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7.6)\u003c/p\u003e \u003cp\u003e9 (9.8)\u003c/p\u003e \u003cp\u003e13 (14.1)\u003c/p\u003e \u003cp\u003e23 (25)\u003c/p\u003e \u003cp\u003e30 (32.6)\u003c/p\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNM staging system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eII\u003c/p\u003e \u003cp\u003eIIIA\u003c/p\u003e \u003cp\u003eIIIB\u003c/p\u003e \u003cp\u003eIIIC\u003c/p\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003cp\u003e4 (4.3)\u003c/p\u003e \u003cp\u003e7 (7.6)\u003c/p\u003e \u003cp\u003e16 (17.3)\u003c/p\u003e \u003cp\u003e36 (39.1)\u003c/p\u003e \u003cp\u003e28 (30.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFrom those who underwent palliative surgery, 17 patients (56.6%) showed peritoneal carcinomatosis, four (13.3%) demonstrated hepatic metastases, one had a portal vein tumor thrombus (3.3%), and two exhibited intercaval-aortic lymph node involvement (6.7%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eShort and long-term mortality and survival\u003c/h2\u003e \u003cp\u003eThe overall mortality rates at 30, 60, and 90 days were 8.7%, 16.3%, and 21,7%, respectively. Whereas the rate after 90 days, divided into seven-year periods, was 33.3% between 1996 and 2002, 26.3% between 2003 and 2009, 11.1% between 2010 and 2016, and 7.7% between 2017 and 2023.\u003c/p\u003e \u003cp\u003eApproximately 26,1% of patients received adjuvant chemotherapy. During the four periods of the analysis, the number of surgeries with curative intent increased (p\u0026thinsp;=\u0026thinsp;0.024), overall mortality at 90 days reduced (p\u0026thinsp;=\u0026thinsp;0.017), and the indications for adjuvant chemotherapy increased (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The five-year survival rates of patients who underwent curative intent surgery with cT4b, with and without definitive pancreatic invasion, were 16.7% and 51.4%, respectively (p\u0026thinsp;=\u0026thinsp;0.0235). Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative morbidity and mortality, surgical complications, intention to cure, type of oncological resection, and adjuvant chemotherapy in four 7-year periods.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1996\u0026ndash;2002\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2003\u0026ndash;2009\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2010\u0026ndash;2016\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2017\u0026ndash;2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value *\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-Day Mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60-Day Mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90-Day Mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e180-Day Mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE-J Fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Pancreatic Fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurative Intent Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (57.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e62 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (89.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (95.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eE-J, esophagous-jejunostomy; R0, resection without residual tumor; R1, resection with microscopic residual tumor. * Chi-squared test comparing the two firsts and the two seconds seven-years periods.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePrognostic factors of survival\u003c/h2\u003e \u003cp\u003eThe univariate analysis of cT4b to the pancreas revealed that palliative surgery (HR, 3.14; 95% CI, 1.77\u0026ndash;5.57), more than 15 lymphadenopathies in the specimen (HR, 3.66; 95% CI, 2.12\u0026ndash;6.31), pT4b (HR, 1.94; 95% CI, 1.12\u0026ndash;3.36), GEJ involvement (HR, 1.85; 95% CI, 1.09\u0026ndash;3.13), stage IV (HR, 0,32; 95% CI, 0.18\u0026ndash;0.56), lymph node index ˃ 0.37 (HR, 3.98; 95% CI, 2.24\u0026ndash;7.08) and residual disease (HR, 3.74; 95% CI, 2.09\u0026ndash;6.69) were poor prognostic factors. The absence of chemotherapy, sex, tumor size\u0026thinsp;\u0026gt;\u0026thinsp;7 cm, age, and complications were not poor prognostic factors. Similarly, GEJ invasion (HR 1.92, 95% CI 1.09\u0026ndash;3.38) and pT4b (HR 1.89, 95% CI 1.01\u0026ndash;3.53) were poor prognostic factors in the multivariate analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn Western countries, 90% of GC cases are diagnosed at an advanced stage,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e necessitating multimodal treatment for most patients. Of the treatment options available, R0 surgery remains the only curative option.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe objective of surgical oncology for the digestive tract is to achieve locoregional control and minimize perioperative morbidity and mortality, thereby improving survival rates and quality of life. Multi-visceral resection for GC is radical surgery, necessary for 10\u0026ndash;30% of patients with GC, to achieve R0 resection.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e However, it may increase the risk of postoperative morbidity and mortality.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\"Multi-visceral resection in CG involves removing the organs that the tumor has invaded because the tumor grows deeply and significantly increases postoperative morbidity. These surgeries included TGPS, gastrectomy with colectomy, hepatectomy, pancreaticoduodenectomy, and vascular resections.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, TGPS without pancreas invasion, with the aim of achieving a more extensive lymphatic dissection, has not significantly impacted the survival of patients compared with dissection of only group 10 and 11 lymph nodes. Nevertheless, it has caused increased complications and is therefore not currently a viable technique for superior lymphadenectomy outcomes.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eT4b in the pancreas should be suspected in patients with tumors\u0026thinsp;\u0026gt;\u0026thinsp;7 cm in size, those with Borrmann type 3 or 4 involvement of the upper third of the stomach or having Siewert type 3 GEJ cancers. The accuracy of CT in identifying the invasion of adjacent organs ranges from 50\u0026ndash;80%.\u003csup\u003e5, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Differentiating pancreatic invasion in tumors affecting the serosa of the posterior stomach wall is particularly challenging because of the minimal adipose tissue in that plane. Nevertheless, supplementary CT tomography can be used. Here, the patient is repositioned to evaluate the absence of the stomach sliding sign relative to the pancreas.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e However, the absence of displacement does not rule out inflammatory adhesions. Notably, endosonography has a similar performance to CT in differentiating T4a from T4b but does not provide additional useful information in this context.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCurrently, studies reveal that multi-visceral resection is appropriate for patients with good functional status, aged\u0026thinsp;\u0026lt;\u0026thinsp;65 years, without distant metastases,\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e with no more than 15 lymphadenopathies, and who have achieved R0 surgery to control the locoregional factors of GC.,\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e In these cases, the recommendation is to perform an en bloc resection, review the definitive biopsy to define prognosis, and complete perioperative chemotherapy.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are three justifications for performing major resection en bloc involving adjacent organs in cases of suspected GC invasion: 1) long-term survival is achievable in patients with pT4b pancreatic involvement; 2) approximately half of the patients with cT4b to the pancreas have a lower pT stage.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In our study, the PPV of cT4b to the pancreas, for pT4b was 56.7%, which is consistent with the findings of other series;\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e 3) multi-visceral resection does not decrease long-term survival, the prognosis is dependent on the TNM stage rather than the extent of curative surgery.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn our study, patients with cT4b disease in the pancreas and who were not pT4b, observed the greatest benefit of TGPS. The survival rate of these patients was 51.4%, which is consistent with the literature.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdditionally, during the surgical procedure, exploring the lesser sac during staging is necessary to confirm the relationship between the tumor and the retroperitoneum. This approach necessitated coloepiploic detachment. Moreover, it isn't advisable to attempt to separate the tumor from the pancreas if cT4b is observed in the pancreas. However, distinguishing between a desmoplastic reaction and genuine invasion is challenging, emphasizing the importance of avoiding adhesion release.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Using a pancreas wedge resection is inherently risky because it carries a significant risk of developing a difficult-to-control pancreatic fistula. In addition, attempting to separate the tumor from the pancreas can cause fracturing of the pancreas or rupturing of the tumor in the peritoneal cavity. Meanwhile, it is not advisable to rely on rapid peripheral biopsies to predict the extent of invasion of the most adherent part of the tumor into the pancreas.\u003c/p\u003e \u003cp\u003eThe most significant technical challenge during the resection phase of TGPS for cT4b is the dissection of the celiac axis. Tumor growth alongside the lesser curvature, extending towards the posterior wall, with lymphadenopathies, was observed in group 7. This configuration made the dissection more challenging. Nonetheless, it is easier to expose the splenic and left gastric arteries when the duodenum and pancreatic neck are sectioned.\u003c/p\u003e \u003cp\u003eThe primary surgical morbidity is pancreatic fistula, which is an inherent complication of pancreatic resection. Additionally, the rate of E-Js fistulas is high because a significant percentage of cancers invade the GEJ and, therefore, result in anastomoses that remain in the mediastinum. Other studies have reported that intra-abdominal collections and pancreatic fistulas as more frequent complications.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e The complications observed in our series were not poor prognostic factors for survival in the univariate analysis.\u003c/p\u003e \u003cp\u003eThe six-month postoperative mortality rate gradually declined from 51.5\u0026ndash;15.4%, despite the comparable postoperative morbidity across the four periods. This suggests that patient preparation, nutritional status, and functional reserves improved over time, enabling better management of complications. Other studies have reported morbidity rates of 20\u0026ndash;30% and 30-day mortality rates of 2\u0026ndash;15%.\u003csup\u003e1, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMortality is not solely dependent on patient-specific factors; the learning curve of the surgical center can also influence it.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Our results showed that there was a significant reduction in postoperative mortality as the group of surgeons incorporated the learning and advice of their predecessors.\u003c/p\u003e \u003cp\u003eThe increase in curative intent surgery in our study can be attributed to enhanced patient staging through superior-quality preoperative radiological investigations. This has also been documented in other studies.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Furthermore, It is recommended that radiological studies be subjected to a systematic review at a clinical meeting, as this facilitates more effective surgical planning. Although a little more than a quarter of our patients were resected with palliative intent, in stage IV, this occurred because there were no other palliative resources available in the years that it was performed, however, in the last period only one patient with multivisceral resection had distant compromise. We are clear that this surgery should not be performed in metastatic patients.\u003c/p\u003e \u003cp\u003eCurrently, complex and high-risk surgical procedures are contraindicated in patients with advanced GC, extensive lymph node involvement or distant metastases without neoadjuvant chemotherapy.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e The current regimen is FLOT.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In our study, as well as in others,\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e the indication for adjuvant chemotherapy is low, as its indication has been demonstrated since 2006.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In our study, its use has increased over time.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In our study, univariate analysis revealed that more than 15 lymphadenopathies, GEJ involvement, histopathological confirmation of pancreatic invasion, and palliative surgery were poor prognostic factors for survival. In addition to GEJ invasion and palliative surgery, the definitive TNM stage and oncological prognosis cannot be determined until a final biopsy report of the surgical specimen is available. In the multivariate analysis, definitive pancreatic and GEJ invasion were confirmed as poor prognostic factors for survival. However, these results should be interpreted with caution because our study was retrospective in design. GC involving the GEJ indicates a more advanced tumor with an increased risk of lymph node invasion extending to the lower mediastinum. Definitive pancreatic invasion has also been identified as a poor prognostic factor in other studies.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe main limitation of this study was its retrospective design. As this study encompassed several decades, there were variations in the study, treatment, and surgeons, which may have resulted in a degree of patient selection bias. The inclusion of metastatic patients may limit the interpretation of postoperative morbidity and mortality, because they are more fragile and malnourished patients.There have been notable improvements in the standardization of both study and treatment protocols for GC at our center between 2012 and 2023.\u003c/p\u003e \u003cp\u003ePatients with GC classified as cT4b to the pancreas who have undergone TGPS with curative intent have a 51.4% chance of long-term survival. These findings, in conjunction with a sustained decline in postoperative mortality over time, support the use of en bloc resection for cT4b in the pancreas.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e, American Society of Anesthesiologists\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCAPEOX\u003c/strong\u003e, Capecitabine + Oxaliplatin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ecT4b\u003c/strong\u003e, clinical invasion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCT\u003c/strong\u003e, computed tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOPD\u003c/strong\u003e, Chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e, Esophagus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE-U\u003c/strong\u003e, Esophagus-Upper third\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE-UM\u003c/strong\u003e, Esophagus-Upper third-Middle third\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE-UML\u003c/strong\u003e, Esophagus-Upper third-Middle third-Lower third.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE-J\u003c/strong\u003e, esophagous-jejunostomy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFLOT\u003c/strong\u003e, 5-fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGC\u003c/strong\u003e, Gastric Cancer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGEJ\u003c/strong\u003e, gastroesophageal junction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eL\u003c/strong\u003e, Lower third\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM\u003c/strong\u003e, Middle third\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eML\u003c/strong\u003e, Middle third-Lower third\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePET\u003c/strong\u003e, positron emission tomography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPV\u003c/strong\u003e, positive predictive value\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003epT4b\u003c/strong\u003e, pathological invasion\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR0\u003c/strong\u003e, resection without residual tumor\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR1\u003c/strong\u003e, resection with microscopic residual tumor\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTGPS\u003c/strong\u003e, total gastrectomy with pancreatosplenectomy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eU\u003c/strong\u003e, Upper third\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUM\u003c/strong\u003e, Upper third-Middle third\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUML\u003c/strong\u003e, Upper third-Middle third-Lower third\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest and Source of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNorero reported a relationship with AstraZeneca Pharmaceuticals LP that included speaking and lecture fees. The authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors (s) received no financial support for the research, authorship, or publication of this article. Anita Veloso helped revise the manuscript. We would like to thank Editage (www.editage.com) for English language editing.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePacelli F, Cusumano G, Rosa F, et al. Multivisceral resection for locally advanced gastric cancer: an Italian multicenter observational study\u003cem\u003e. JAMA Surg\u003c/em\u003e. 2013;148:353\u0026ndash;360.\u003c/li\u003e\n\u003cli\u003eTran TB, Worhunsky DJ, Norton JA, et al. Multivisceral resection for gastric cancer: results from the US gastric cancer collaborative\u003cem\u003e. Ann Surg Oncol\u003c/em\u003e. 2015;22 Suppl 3:S840\u0026ndash;S847.\u003c/li\u003e\n\u003cli\u003eDias AR, Pereira MA, Oliveira RJ, et al. Multivisceral resection vs standard gastrectomy for gastric adenocarcinoma\u003cem\u003e. J Surg Oncol\u003c/em\u003e. 2020;121:840\u0026ndash;847.\u003c/li\u003e\n\u003cli\u003eDias AR, Pereira MA, Ramos MFKP, et al. Prediction scores for complication and recurrence after multivisceral resection in gastric cancer. \u003cem\u003eEur J Surg Oncol\u003c/em\u003e. 2020;46:1097\u0026ndash;1102.\u003c/li\u003e\n\u003cli\u003eVladov N, Trichkov T, Mihaylov V, et al. Аre multivisceral resections for gastric cancer acceptable: experience from a high volume center and extended literature review? \u003cem\u003eSurg J (N Y).\u003c/em\u003e 2023;9:e28\u0026ndash;e35.\u003c/li\u003e\n\u003cli\u003eKorenaga D, Okamura T, Baba H, et al. Results of resection of gastric cancer extending to adjacent organs. \u003cem\u003eBr J Surg\u003c/em\u003e. 1988;75:12\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eMartin RCG 2nd, Jaques DP, Brennan MF, et al. Extended local resection for advanced gastric cancer: increased survival versus increased morbidity\u003cem\u003e. Ann Surg\u003c/em\u003e. 2002;236:159\u0026ndash;165.\u003c/li\u003e\n\u003cli\u003eYang Y, Hu J, Ma Y, et al. Multivisceral resection for locally advanced gastric cancer: A retrospective study. \u003cem\u003eAm J Surg\u003c/em\u003e. 2021;221:1011\u0026ndash;1017.\u003c/li\u003e\n\u003cli\u003eZhou J, Hiki N, Mine S, et al. Role of prealbumin as a powerful and simple index for predicting postoperative complications after gastric cancer surgery. \u003cem\u003eAnn Surg Oncol\u003c/em\u003e. 2017;24:510\u0026ndash;517.\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. \u003cem\u003eAnn Surg\u003c/em\u003e. 2004;240:205\u0026ndash;213. \u003c/li\u003e\n\u003cli\u003eBassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. \u003cem\u003eSurgery.\u003c/em\u003e 2005;138:8\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eAmerican Joint Committee on Cancer. AJCC Cancer Staging Manual. 8th ed., Springer International Publishing, 2016.\u003c/li\u003e\n\u003cli\u003eBobrzyński Ł, Pach R, Szczepanik A et al. What determines complications and prognosis among patients subject to multivisceral resections for locally advanced gastric cancer? \u003cem\u003eLangenbecks Arch Surg.\u003c/em\u003e 2023;408:442.\u003c/li\u003e\n\u003cli\u003eKasakura Y, Fujii M, Mochizuki F, et al. Is there a benefit of pancreaticosplenectomy with gastrectomy for advanced gastric cancer? \u003cem\u003eAm J Surg\u003c/em\u003e. 2000;179:237\u0026ndash;242.\u003c/li\u003e\n\u003cli\u003eTakeuchi K, Tsuzuki Y, Ando T, et al. Total gastrectomy with distal pancreatectomy and splenectomy for advanced gastric cancer. \u003cem\u003eJ Surg Res\u003c/em\u003e. 2001;101:196\u0026ndash;201.\u003c/li\u003e\n\u003cli\u003eColen KL, Marcus SG, Newman E, et al. Multiorgan resection for gastric cancer: intraoperative and computed tomography assessment of locally advanced disease is inaccurate. \u003cem\u003eJ Gastrointest Surg\u003c/em\u003e. 2004;8:899\u0026ndash;902.\u003c/li\u003e\n\u003cli\u003eJeon K, Kim SH, Yoo J, et al. Added value of the sliding sign on right down decubitus CT for determining adjacent organ invasion in patients with advanced gastric cancer\u003cem\u003e. J Korean Soc Radiol\u003c/em\u003e. 2022;83:1312\u0026ndash;1326.\u003c/li\u003e\n\u003cli\u003eXiao H, Ma M, Xiao Y, et al. Incomplete resection and linitis plastica are factors for poor survival after extended multiorgan resection in gastric cancer patients. \u003cem\u003eSci Rep\u003c/em\u003e. 2017;7:15800.\u003c/li\u003e\n\u003cli\u003eZhang X, Wang W, Zhao L, et al. Short-term safety and Long-term efficacy of multivisceral resection in pT4b gastric cancer patients without distant metastasis: a 20-year experience in China National Cancer Center. \u003cem\u003eJ Cancer\u003c/em\u003e. 2022;13:3113\u0026ndash;3120.\u003c/li\u003e\n\u003cli\u003evan der Werf LR, Eshuis WJ, Draaisma WA, et al. Nationwide outcome of gastrectomy with en-bloc partial pancreatectomy for gastric cancer. \u003cem\u003eJ Gastrointest Surg\u003c/em\u003e. 2019;23:2327\u0026ndash;2337.\u003c/li\u003e\n\u003cli\u003eMita K, Ito H, Katsube T, et al. Prognostic factors affecting survival after multivisceral resection in patients with clinical T4b gastric cancer. \u003cem\u003eJ Gastrointest Surg\u003c/em\u003e. 2017;21:1993\u0026ndash;1999.\u003c/li\u003e\n\u003cli\u003eMartin RCG 2nd, Jaques DP, Brennan MF et al. Achieving RO resection for locally advanced gastric cancer: is it worth the risk of multiorgan resection\u003cem\u003e? J Am Coll Surg\u003c/em\u003e. 2002;194:568\u0026ndash;577.\u003c/li\u003e\n\u003cli\u003eKunisaki C, Akiyama H, Nomura M, et al. Surgical outcomes in patients with T4 gastric carcinoma. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e. 2006;202:223\u0026ndash;230.\u003c/li\u003e\n\u003cli\u003eJeong O, Choi WY, Park YK. Appropriate selection of patients for combined organ resection in cases of gastric carcinoma invading adjacent organs. \u003cem\u003eJ Surg Oncol\u003c/em\u003e. 2009;100:115\u0026ndash;120.\u003c/li\u003e\n\u003cli\u003eCarboni F, Lepiane P, Santoro R, et al. 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Prognosis of curatively resected pT4b gastric cancer with respect to invaded organ type. \u003cem\u003eAnn Surg Oncol\u003c/em\u003e. 2012;19:494\u0026ndash;501.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stomach cancer, gastrectomy, pancreatectomy","lastPublishedDoi":"10.21203/rs.3.rs-6290714/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6290714/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To evaluate postoperative morbidity and mortality up to 90 days and long-term survival in patients with locally advanced gastric cancer (GC) who underwent total gastrectomy with pancreatosplenectomy (TGPS)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSummary Background Data: \u003c/strong\u003eResection without residual tumor (R0) is the only curative treatment for gastric cancer (GC). TGPS improves the survival of patients with GC with clinical pancreatic invasion (cT4b), however increased postoperative morbidity and mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We enrolled patients with GC who underwent elective TGPS for cT4b between 1996 and 2023. We determined the extent of tumor invasion into the pancreas intraoperatively, and the final pathological stage using delayed biopsy. We used the Clavien–Dindo classification and eighth edition of the TNM staging system and used the Kaplan–Meier survival curves with a log-rank test, descriptive statistics, and univariate and multivariate analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eNinety-two patients underwent TGPS for cT4b disease. The morbidity incidence with a Clavien grade ≥3 was 32%. Overall, the mortality rates at 30, 60, and 90 days were 8.7%, 16.3%, and 21,7%, respectively. The rate at 90 days, in the last seven-years, was 7.7%. The 5-year survival rates of patients who underwent curative intent surgery with cT4b, with and without definitive pancreatic invasion were 16.7% and 51.4%, respectively (p =0.0235).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e TGPS with curative intent in patients with cT4b GC on the pancreas resulted in a long-term survival rate of up to 51.4%. Patients showed decreased postoperative mortality over time. These results support en bloc resection of cT4b on the pancreas.\u003c/p\u003e","manuscriptTitle":"Long term survival after total gastrectomy and pancreatoesplenectomy for T4B gastric cancer invading the pancreas in a High-volume Latin American Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 11:50:02","doi":"10.21203/rs.3.rs-6290714/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82aa3043-8156-40df-a1da-b15c85ba1e3a","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-14T18:23:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-01 11:50:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6290714","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6290714","identity":"rs-6290714","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}