National trends in total vs subtotal gastrectomy for middle and distal third gastric cancer

Background: To identify trends in total and subtotal gastrectomy for middle and distal third gastric adenocarcinoma in the U.S. Methods: NCDB was queried for patients with stage 0-III middle or distal gastric adenocarcinoma treated with total or subtotal gastrectomy. Statistical analysis including cox proportional hazards model was performed to examine overall survival by stage. Results: 1,628 (85%) underwent subtotal gastrectomy and 283 (15%) underwent total. 1113 patients (58%) had distal tumors and 798 (42%) had middle tumors. Total gastrectomy patients more often had poor tumor grade (60% vs 50%,p < 0.01), larger size (46.3 mm vs 37.8 mm,p < 0.0001), had positive nodes (3.6 ± 5.9 vs 2.2 ± 4.1,p < 0.0001), underwent chemoradiation (13% vs 6%,p < 0.0001), and were higher clinical stage (p < 0.05). An overall survival curve showed an adjusted HR of 2.7 for total vs subtotal gastrectomy at clinical stage 3 (p < 0.05). Conclusions: Total gastrectomy is performed for larger, more aggressive tumors with higher stage. Subtotal gastrectomy may have a survival benefit for stage III gastric cancers.