Simultaneous surgery for coronary artery disease and gastric cancer

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World J. Surg. 18, 879-882, 1994
WORLD
Journal of
SURGERY
9 199d by the Soci~t~
Internationale de Chirurgie
Simultaneous Surgery for Coronary Artery Disease and Gastric Cancer
W a t a r u Kamiike, M.D., Masahiko Miyata, M.D., Masaaki Izukura, M.D., Toshinori Itoh, M.D., Riichiro Nezu, M.D.,
M a k o t o N a k a m u r o , M.D., N o b u t a k a Hatanaka, M.D., Shigeomi Shimizu, M.D., Toshiki Takahashi, M.D.,
Yasuhisa Shimazaki, M.D., S u s u m u Nakano, M.D., H i k a r u Matsuda, M.D.
First Department of Surgery, Osaka University Medical School, 2-2 Yamada-oka, Suita 565, Japan
Abstract. Of 26 patients who underwent both coronary artery bypass
grafting and abdominal surgery at our institution between 1977 and 1992,
nine had severe coronary artery disease associated with UICC stage I
gastric cancer. They were treated by coronary artery bypass grafting
followed by a curative operation for gastric cancer; the initial four
patients underwent two-staged surgery (group A), and the most recent five
patients underwent simultaneous surgery (group B). The cardiac surgery
was performed first in all patients, and in group A the interval between
the two procedures was 2 to 7 weeks. There were no significant differences
between the two groups in terms of preoperative characteristics: sex, age,
preoperative complications, NYHA class, prior myocardial infarction,
ejection fraction, cardiac index, number of vessels diseased, or number of
grafts. There were no significant differences between the two groups in
terms of blood loss during the gastric operation (A: 649 -+ 194 ml; B: 842
-4- 326 ml) or the operating time (A: 371 -+ 106 minutes; B: 343 _+ 46
minutes). Two group A patients had postoperative complications (one had
arrhythmia, and one died of sepsis caused by sutural insufficiency). On
the other hand, four group B patients had complications (three cases of
transient hyperbilirubinemia and one case of postoperative bleeding;
none died). The postoperative hospital stay after gastrectomy was not
prolonged in group B compared with group A (A: 41.7 -+ 22.7 days; B: 46.0
-+ 25.0 days). In conclusion, simultaneous procedure of coronary artery
bypass grafting and gastric surgery can be performed safely, although
careful management is indispensable.
With the aging of our society, it is no longer unusual to encounter
elderly patients with simultaneous critical coronary artery disease
(CAD) and intraabdominal cancer. For such patients, the conventional approach has been to perform coronary artery bypass
grafting (CABG) first, followed by abdominal surgery for the
cancer about 1 month later (two-staged fashion), primarily because of a concern for intraabdominal bleeding from the systemic
heparinization and a fear of depressed left ventricular function
just after CABG. The operative risk has been thought probably to
exceed the risk of the tumor growing. However, our increasing
experience suggests that a simultaneous procedure of CABG and
gastrectomy is possible. Simultaneous CABG and pulmonary
surgery through the same incision have been reported [1, 2].
However, only two cases of simultaneous CABG and surgery for
abdominal cancer have been reported [3]. One was for sigmoid
colon cancer, and the other was for renal cancer.
This report presents our experience of simultaneous CABG and
Correspondence to: W. Kamiike, M.D.
curative surgery for UICC stage I gastric cancer in five patients
since 1989. The influence of these simultaneous operations on the
risk during the perioperative period was studied and compared
with that of four patients with the same stage of gastric cancer who
underwent gastric surgery after CABG in a two-staged fashion.
Patients
Between 1977 and 1992 there were 26 patients who underwent
both CABG and abdominal surgery at our institution. Of the 26,
six patients had benign abdominal diseases, and two underwent
abdominal surgery 4 years or more after CABG. Another 18
patients with intraabdominal cancer, who also had CAD, underwent curative surgery during the same hospital stay. They were
treated with CABG followed by abdominal surgery. Seven patients underwent these two operations in a staged fashion, and 11
patients underwent a simultaneous procedure.
In the present study, nine patients with UICC stage IA and IB
gastric cancer were selected for both procedures. The initial four
patients underwent the two-staged surgery (group A), and the
more recent five patients underwent the simultaneous procedure
(group B). CABG was performed first in all nine patients, and in
group A the interval between CABG and gastrectomy was a mean
35 days (range 16-49 days). Curative surgery for gastric cancer
included lymph node dissection in compartments 1 and 2. Distal
gastrectomy was performed in three of the four patients in group
A and in all five group B patients, whereas total gastrectomy was
performed in the fourth patient in group A. A gastroduodenostomy was made for the distal gastrectomy and esophagojejunostomy with jejunal interposition for the total gastrectomy.
The preoperative clinical characteristics of the patients are
shown in Table 1. There were three men and one woman with a
mean age of 63.3 years (range 59-72 years) in group A and five
men with a mean age of 60.8 years (range 58-64 years) in group
B. All patients had experienced angina pectoris prior to the
CABG, and two group A patients and three group B patients had
experienced at least one previous myocardial infarction. Diabetes
mellitus requiring oral agents was present in two group A patients
and two group B patients. Two patients in each group had
hypertension (resting blood pressure >160/90 mmHg). Pulmo-
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World J. Surg. Vol. 18, No. 6, Nov./Dec. 1994
Table 1. Preoperative clinical characteristics of patients.
Parameter
Two-staged surgery
Simultaneous
surgery
Sex (male/female)
Age (years)
Interval between the
procedures (days)
Preoperative
complications
NYHA class
Prior MI
Ejection fraction
3:1
59-72 (63.3 -+ 6.0)
16, 32, 43, 49
5:0
58-64 (60.8 _+2.4)
Same day
DM 2, HT 2, pulmonary
fibrosis 1
1, 2, 2, 2
2
58 -+ 13
DM 2, HT 2
Cardiac index (L/
min/m2)
Vessels diseased
no. of patients
No. of grafts
(no. of patients)
2.52 +_0.62
3.21 -+ 0.62
Double 1, triple 3
LMT 1, triple 4
1 (1), 3 (3)
2 (1), 3 (4)
(%)
1, 2, 2, 2, 3
3
54 _+ 16
DM: diabetes mellitus; HT: hypertension; NYHA: New York Heart
Association; MI: myocardial infarction; LMT: left main trunk.
nary fibrosis was present in one group A patient. The left
ventricular ejection fraction ranged from 45% to 74% (average 58
_+ 13%) in group A and from 28% to 67% (average 54 -+ 16%) in
group B. The extent of CAD was two-vessel disease in one patient
and three-vessel disease in three patients in group A and the left
main trunk in one patient and three-vessel disease in four patients
in group B. Coronary revascularization was indicated for coronary
arteries with 75% stenosis or more with viable myocardial in each
region. CABG was performed using cardiopulmonary bypass and
cardioplegic arrest. The number of grafts was one in one patient
and three in three patients in group A and two in one patient and
three in four patients in group B. There were no significant
differences between the two groups in terms of the preoperative
characteristics.
All patients were anesthetized with fentanyl, and epidural
anesthesia was combined in two group B patients. Nitroglycerin
was continuously administered intravenously, and central venous
pressure, pulmonary artery pressure, pulmonary capillary wedge
pressure, and direct arterial pressure were carefully monitored
during the perioperative period.
The statistical significance was determined by Fisher's exact test
and unpaired Student t-test.
Results
The operative results and complications are shown in Table 2. The
curative operation for the gastric cancer was successfully performed in each patient. There was no serious bleeding, although
cardiopulmonary bypass and heparinization were performed just
before the gastric operation in group B. Indeed, there were no
significant differences between the two groups during the curative
surgery for gastric cancer in terms of the blood loss (A: 649 _+ 194
ml; B: 842 +- 326 ml) or the operating time (A: 371 +- 106 minutes;
B: 343 -+ 46 minutes). There were no operative deaths and no
episodes of perioperative myocardial infarction or heart failure
that required administration of a large amount of catecholamine
or mechanical support in either group. Two of the four group A
patients developed postoperative complications. One patient died
of sepsis caused by sutural insufficiency on the 61st postoperative
Table 2. Operative results and complications.
Parameter
Two-stage
surgery
(n = 4)
Blood loss (ml)
Operation time (min)
Postoperative
complications
649 _+ 194
371 +- 106
Died of sepsis 1,
VPB 1
Hospital stay after
gastrectomy (days)
41.7 -+ 22.7~
Simultaneous surgery
(n = 5)
842 +_ 326
343 _+46
Hyperbilirubinemia 3,
postoperative
bleeding 1
46.0 _+25.0
VPB: ventricular premature beat.
aExcluding one case of hospital death on the 61st postoperative day.
day. The second patient developed a ventricular premature beat
(VPB), but it was controllable with drugs. In contrast, four of the
five group B patients had complications. Three patients developed
transient hyperbilirubinemia with a serum bilirnbin level of more
than 5 mg/dl, which decreased gradually to a normal level within
2 weeks. One patient had postoperative hemorrhage with a loss of
400 ml over 2 hours through the abdominal drain just after
surgery; it was easily controlled by protamine administration and
fresh blood transfusion. There were no hospital deaths in group B.
The length of hospital stay after gastric surgery in group B was not
prolonged compared to that in group A, excluding one group A
case of hospital death on the 61st postoperative day (A: 41.7 -+
22.7 days; B: 46.0 -+ 25.0 days).
All patients were satisfactorily followed in this study. Three
patients in group A are presently alive 73 to 97 months after the
gastric operation. Four in group B are alive 32 to 41 months after
the simultaneous operations; one patient died of strangulation of
the small intestine 12 months postoperatively. The seven surviving
patients are free of any recurrent gastric cancer. All nine patients
have been free of cardiac events, such as angina pectoris, myocardial infarction, or cardiac death, during the follow-up period.
Discussion
Cardiac evaluation of the patients with CAD who are facing major
surgery for intraabdominal malignancy is important because the
risk of both general anesthesia and the operative procedure is
increased [4]. If severe CAD is present, CABG is recommended
before the curative operation for the malignancy [5, 6]. Traditionally, abdominal surgery, especially in intraabdominal cancer patients, has not been simultaneously performed with open heart
surgery. However, if a simultaneous procedure of CABG and
curative surgery for intraabdominal cancer is possible, the patients
who undergo the procedure can avoid the wound pain and risks
associated with a second operation. Furthermore, a simultaneous
procedure allows expeditious treatment of the neoplasm, a fact
that could be important in tumors with a rapid doubling time.
Indeed, we experienced an unfortunate case in which a tumor of
the stomach showed rapid growth endoscopically during the
waiting period for gastric surgery after CABG. Such rapid growth
of a cancer might be due to depression of the immune mechanisms related to the cardiopulmonary bypass operation [7, 8].
Thus since 1989 we performed a simultaneous surgical procedure
in 11 cases with intraabdominal cancer.
The present study was done to determine if the simultaneous
Kamiike et al.: CABG and Gastrectomy
procedure achieves superior results to the staged operation. We
selected nine patients of stage-matched gastric cancer. No severe
complications occurred in the group with simultaneous surgery,
and there was no significant differences in blood loss or the
operating time of the curative gastric surgery. There were no
episodes of infection in either group, and the hospital stay after
the gastric operation was not prolonged in the simultaneous
surgery group. Our observations suggest that a simultaneous
procedure of CABG and operation for stage ! gastric cancer can
be safely performed.
In our series, the parameters of cardiac function after CABG
were satisfactory, and no severe bleeding episodes were encountered. However, heart failure that requires high doses of catecholamine or mechanical circulatory assistance and a serious bleeding
tendency after CABG are thought to be definite contraindications
for the simultaneous procedure, and such cases should be subjected to a two-stage procedure.
In conclusion, it may be advantageous to undertake simultaneous procedures than separate major surgical operations for
patients with concomitant critical coronary artery disease and
gastric cancer. The simultaneous procedure can be applied to
patients with invasive cancer if a curative operation is possible.
R6sum6
Parmi les 26 patients qui avaient eu un pontage coronarien associ6
/tune chirurgie abdominale dans notre institution entre 1977 et
1992, neuf avaient une maladie coronarienne s6v6re associ6e fi un
cancer gastrique stade I UICC. Le pontage coronarien a 6t6 suivi
d'une gastrectomie fi visde curatrice soit en un (premier dans
l'ordre chrouologique, groupe A = 4), soit en deux temps (groupe
B = 5). La chirurgie cardiaque a pr6c6d6 la chirurgie gastrique
darts tous les cas, et dans le groupe B, l'intervalle entre les deux
interventions a 6t6 de 2 g 7 semaines. I1 n'y avait aucune diff6rence
significative entre les deux groupes en ce qui concerne l'fige, le
sexe, l'6tat pr6opdratoire, la classification NYHA, les ant6c6dents
d'infarctus du myocarde, la fraction d'djection, l'indexe cardiaque,
le nombre de vaisseaux atteints ou le nombre de greffons utilis6s.
I1 n'y avait aucune diff6rence entre les deux groupes en ce qui
concerne la perte sanguine pendant l'intervention gastrique (A:
649 -+ 194 ml; B; 842 _+ 326 ml) ou la dur6e de l'intervention (A:
371 -+ 106 min; B: 343 _+ 46 min). Deux patients dans le groupe
A ont eu une complication postop6ratoire (un cas d'arythmie, et
un autre cas, fatal, de fuite anastomotique). I1 y a eu quatre
complications chez les patients du groupe B (trois cas
d'hyperbilirubin6mie transitoire, un cas d'h6morragie postop6ratoire, sans aucune mortalit6). La dur6e d'hospitalisation postop6ratoire n'a pas 6t6 significativement plus longue chez les patients
du groupe B (A: 41.7 + 22.7 jours; B: 46.0 _+ 25.0 jours). En
conclusion, la chirurgie coronarienne et gastrique peut 6tre faite
simultan6ment avec sdcurit6, mais une surveillance et une th6rapeutique p6riopdratoire rigoureuse sont n6cessaires.
881
Resumen
De 26 pacientes sometidos tanto a "bypass" coronario y a cirugfa
abdominal en nuestra instituci6n entre 1977 y 1992, 9 exhibfan
severa enfermedad coronaria asociada con c~incer gfistrico en
estadfo I (UICC). Estos casos fueron tratados con "bypass"
coronado seguido de operaci6n curativa para su cfincer gfistrico;
los primeros 4 pacientes recibieron cirugia en dos etapas (Grupo
A), en tanto que los filtimos cinco pacientes recibieron cirugia
simult~inea (Grupo B). La cirugfa cardfaca fue realizada primero
en todos los pacientes, y e n los del Grupo A el intervalo entre los
dos procedimientos rue de 2-7 semanas. No se encontraron
diferencias significativas entre los dos Grupos en cuanto a caracteristicas preoperatorias: sexo, edad, complicaciones preoperatorias, clase N Y H A (New York Heart Association), infarto miocfirdico previo, fracci6n de eyecci6n, fndice cardfaco, nfimero de
vasos afectados o mimero de injertos. No se hallaron diferencias
significativas entre los dos Grupos en cuanto a p6rdida de sangre
durante la operaci6n gfistrica (A: 649 -+ 194 ml; B: 842 _+ 326 ml)
o el tiempo operatorio (A: 371 -+ 106 min; B: 343 + 46 min). Dos
pacientes del Grupo A presentaron complicaciones postoperatorias (1 caso de arritmia, y i muri6 de sepsis por falla de la sutura).
Pot el contrario, 4 pacientes del Grupo B desarrollaron complicaciones (3 casos de hiperbilirrubinemia y 1 caso de hemorragia
postoperatoria: ninguno muri6). La estancia postoperatoria
despu6s de la gastrectomfa no result6 prolongada en el Grupo B,
en comparacidn con el Grupo A (A: 41.7 _+ 22.7; B: 46.0 _+ 25.0
dfas). En conclusidn, se pueden realizar en forma segura el
procedimiento de "bypass" coronario y de cirugfa gfistrica,
aunque es indispensable un cuidadoso manejo del paciente.
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