Journal of Cancer Therapy, 2013, 4, 1-5
http://dx.doi.org/10.4236/jct.2013.49A1001 Published Online October 2013 (http://www.scirp.org/journal/jct)
1
Estimation of Physiologic Ability and Surgical Stress
Scoring System Appraises Laparoscopy-Assisted and Open
Distal Gastrectomy in Treatment of Early Gastric Cancer*
Hideki Bou1#, Hideyuki Suzuki1, Kentaro Maejima1, Hidetsugu Hanawa1, Masanori Watanabe1,
Eiji Uchida2
1Institute of Gastroenterology, Nippon Medical School Musashi-kosugi Hospital, Kawasaki, Japan; 2Department of Surgery, Nippon
Medical School, Tokyo, Japan.
Received July 24th, 2013; revised August 23rd, 2013; accepted August 30th, 2013
Copyright © 2013 Hideki Bou et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Laparoscopy-assisted distal gastrectomy (LADG) has been widely used to treat early gastric cancer (EGC). The Esti-
mation of Physiologic Ability and Surgical Stress (E-PASS) scoring system predicts the risk of fatal postoperative com-
plications by quantifying the patient’s reserve and degree of surgical stress, but there have been a few reports of use of
the E-PASS scoring system to assess the risk of mortality following special types of surgical procedures such as LADG.
In this study we assessed the feasibility of LADG versus open distal gastrectomy (ODG) by the E-PASS scoring system.
The subjects of this study consisted of 69 stage IA gastric cancer patients who underwent LADG (LADG group) and 69
stage IA gastric cancer patients who underwent ODG (ODG group). The mean age of the patients in the LADG group
was 68.6 years, which was significantly higher than the mean age of 63.4 years in the ODG group. There were no statis-
tically significant differences between the groups in operation time or preoperative risk score, but there were statisti-
cally significant differences in blood loss, surgical stress score, comprehensive risk score, and duration of postoperative
hospital stay. We conclude that using the E-PASS scoring system, LADG appreciates a more beneficial procedure for
the treatment of EGC than ODG.
Keywords: E-PASS; LADG; ODG
1. Introduction
In recent years laparoscopic surgery has become the
main surgical treatment for early gastric cancer (EGC)
[1-5], and the reasons have been standardization of the
procedure, including lymph node dissection [6-8], re-
duced blood loss, and the rapid postoperative recovery
associated with the reduction in size of the wound [5-7,
9]. Surgical stress greatly exceeding a patient’s reserve
capacity often disrupts the homeostasis of the respiratory,
circulatory, metabolic, or immune systems, causing nu-
merous postoperative complications. These postoperative
complications may result from three major factors, name-
ly, the quality of surgical performance, the patient’s phy-
siological status, and the degree of surgical stress applied.
Where the quality of a surgical team has remained stable
for a certain period, the morbidity and mortality rates
after an operation could be estimated by quantification of
the patient`s physiological status and the surgical stress.
The Estimation of Physiologic Ability and Surgical Stress
(E-PASS) was reported by Haga et al. [10]. This system
comprises a preoperative risk score (PRS), a surgical
stress score (SSS), and a comprehensive risk score (CRS)
that is calculated from both the PRS and SSS. The Esti-
mation of Physiologic Ability and Surgical Stress (E-
PASS) scoring system is used to evaluate surgical risk
after elective digestive system surgery [10], and it pre-
dicts postoperative fatal complications [11-14]. More-
over, the E-PASS scoring system is useful for predicting
and recognizing the risk of postoperative complications
and for obtaining a better therapeutic outcome [15]. There
are many reports about the value of general surgical risk
in various surgical operations, but there were few re-
ports concerning the comparison of LADG and ODG
using E-PASS. We wanted to evaluate the feasibility of
*Statement: The authors declare that they have no conflicts of interest.
#Corresponding author.

Estimation of Physiologic Ability and Surgical Stress Scoring System Appraises Laparoscopy-Assisted and Open
Distal Gastrectomy in Treatment of Early Gastric Cancer
2
LADG for EGC by applying this system. We introduced
laparoscopic surgery for the treatment of EGC in 2005.
We therefore used the E-PASS scoring system to conduct
a comparative study of the cases in which EGC treatment
(open distal gastrectomy) was performed to treat stage IA
gastric cancer during the 6-year period from 1999 to
2004 and the cases in which laparoscopy-assisted distal
gastrectomy (LADG) was performed to treat stage IA
gastric cancer cases during the period from 2005, when
we introduced laparoscopic surgery, to 2010.
2. Patients and Methods
2.1. Patients
The subjects of this study were the patients who under-
went surgical treatment for stage IA EGC at the Gastro-
intestinal Disease Center of Nippon Medical School
Musasi Kosugi Hospital during the 12-year period from
1999 to 2010. Laparoscopic surgery was introduced in
January 2005 and became the surgical treatment of first
choice. The preoperative evaluations of depth of invasion
and for the presence of lymph node metastasis were bas-
ed on gastroscopy with gastric endoscopic ultrasonogra-
phy, an upper gastrointestinal series, and an abdominal
enhanced CT examination. All of the tumors were ade-
nocarcinomas that had invaded either the mucosa or
submucosa. Ultimately, 138 patients with stage IA gas-
tric cancer were enrolled. Patients who had mucosal le-
sions that were suitable for endoscopic mucosal resection
(lesion size < 20 mm when the elevated type and <10
mm when the depressed type) and patients who required
combined surgery to treat another disease were excluded
from the study. Patients who underwent ODG for stage
IA EGC between 1999 and the end of 2004 were re-
cruited as a control group. ODG was performed by the
traditional procedure. A total of 69 patients were enrolled
in the ODG group.
2.2. Surgical Procedures
LADG was performed by a 5-port technique with the
patient under general anesthesia and in the supine posi-
tion. A carbon dioxide pneumoperitoneum was created,
and the camera was inserted through a 12-mm subum-
bilical port. After the laparoscopic procedure, we made a
single 5-cm incision in the upper epigastric area, and the
stomach, including the omentum and lymph nodes, was
removed through the incision. Anastomosis was per-
formed by a circular stapling technique, reconstructed by
the Billroth-I, and a standard distal gastrectomy with a
D1 + lymph node dissection was performed. Finally, the
abdomen was closed in layers.
ODG plus D1 + lymph node dissection was performed
through an upper midline incision and followed by Bil-
lroth-I reconstruction.
2.3. Methods
All clinical findings were collected retrospectively and
were investigated. Nine factors determined the E-PASS
scores, namely age, severity of heart disease, severity of
pulmonary disease, diabetes mellitus, PS, American
Society of Anesthesiologists physiological status classifi-
cation, blood loss/body weight (g/kg), operation time
(min), and extent of the skin incision. The equation of the
E-PASS scoring system are shown in Table 1. The
preoperative risk score (PRS) is used to evaluate pre-
operative risk, and it is calculated on the basis of age,
whether severe heart disease is present, whether severe
lung disease is present, diabetes, the American Society of
Anesthesiologists (ASA) classification, and performance
status index defined by the Japanese Society for Cancer
Therapy (see Table 1 for the actual calculation method).
The surgical stress score (SSS) is used to evaluate sur-
gical risk, and it is calculated on the basis of the BMI,
operation time, and blood loss (Table 1). The evaluation
is not made based on these individual scores alone, but
by an overall evaluation of the risk of surgery itself per-
Table 1. Statistical analysis of preoperative and surgical va-
riables.
Factors LADG group ODG groupp
No. of subjects 69 69
Sex M:F 48:21 45:24 0.585
Age (yr) 68.6 ± 9.9 63.4 ± 13.7 0.040
Operation time (min)237.5 ± 68.0 228.8 ± 62.4 0.594
Blood loss (ml) 162.1 ± 369.9 476.6 ± 279.0 <0.0001
Hospital stay (days) 14.9 ± 8.8 23.6 ± 6.7 <0.0001
PRS 0.359 ± 0.189 0.327 ± 0.212 0.037
SSS −0.143 ± 0.155 0.275 ± 0.093 <0.0001
CRS −0.127 ± 0.238 0.247 ± 0.208 <0.0001
*Formulas for calculating the Estimation of Physiologic Ability and Surgical
Stress (E-PASS) scores: preoperative risk score (PRS), surgical stress score
(SSS), and comprehensive risk score (CRS): 1) PRS = −0.0686 + 0.00345X1
+ 0.323X2 + 0.205X3 + 0.153X4 + 0.148X5 + 0.0666X6. X1, age (yr); X2,
presence (1) or absence (0) of severe heart disease; X3, presence (1) or ab-
sence (0) of severe pulmonary disease; X4, presence (1) or absence (0) of
diabetes mellitus; X5, performance status index (0 - 4); X6, American Soci-
ety of Anesthesiologists physiological status classification (1 - 5). Severe
heart disease was defined as heart failure that was New York Heart Associa-
tion Class III or IV, or severe arrhythmia requiring mechanical support.
Severe pulmonary disease was defined as any condition with a %VC below
60% and/or an FEV 1.0% below 50%. Performance status index was based
on the definition by the Japanese Society for Cancer Therapy. 2) SSS =
−0.342 + 0.0139X1 + 0.0392X2 + 0.352X3. X1, blood loss/body weight
(g/kg); X2, operation time (h); X3, extent of skin incision (0: minor inci-
sions for laparoscopic or thoracoscopic surgery (including scope-assisted
surgery); a) laparotomy or thoracotomy alone; b) both laparotomy and tho-
racotomy). 3) CRS = −0.328 + 0.936 (PRS) + 0.976 (SSS). VC, vital capac-
ity; FEV, forced expiratory volume.

Estimation of Physiologic Ability and Surgical Stress Scoring System Appraises Laparoscopy-Assisted and Open
Distal Gastrectomy in Treatment of Early Gastric Cancer
3
formed on the basis of the PRS, the SSS, and the com-
prehensive risk score (CRS), which is calculated by add-
ing the PRS and SSS together (Table 1). Postoperative
complications were included only when medical or inter-
ventional treatment had been carried out. Complications
included wound infection, anastomotic leakage, intraab-
dominal abscess, ileus, intra-abdominal bleeding, pneu-
monia, cardiac ischemic change, and organ dysfunction.
2.4. Statistical Analysis
All statistical analyses were performed using the JMP 9.0
statistical software program (SAS, Cary, NC, USA). P
values less than 0.05 were considered statistically signi-
ficant.
3. Results
Stage IA EGC was treated by LADG in 72 patients in our
series, and by ODG in 69 patients. Three cases in the
LADG group were excluded as mentioned below. Two of
the three cases in the LADG group were excluded be-
cause they were ultimately diagnosed as stage IB, and the
third case was excluded because it was ultimately diag-
nosed as stage II. The procedure in 4 other cases in the
LADG group was converted to open laparotomy, because
of severe adhesions in three cases and because of bleed-
ing due to left liver lobe damage in the other case. Ulti-
mately, 69 cases were enrolled in the LADG group.
There were no complications in the LADG group. Mean
age was 68.6 years in the LADG group and 63.4 years in
the ODG group. The results of the statistical analysis
showed no significant differences between the groups in
sex or operation time (Table 1), but there were signifi-
cant differences between them in age (Table 1), PRS
(Table 1 and Figure 1), blood loss (Table 1), SSS (Ta-
ble 1 and Figure 2), CRS (Table 1 and Figure 3), and
length of postoperative hospital stay (Table 1).
4. Discussion
The E-PASS has been proposed as a means of predicting
postoperative complications [10,14,15]. Recently, it is
said that the E-PASS scoring system is useful for assess-
ing the risk of surgical procedure and surgical decision
making [16-18]. Laparoscopic surgery has been widely
adopted to treat EGC in recent years [1,2], and its advan-
tages have been pointed out by many papers [3-5]. The
greatest benefit it has provided to patients is the speed of
postoperative recovery, the main reason being the small
size of the surgical wound. The advantages of laparo-
scopic surgery have certainly been said to lie in the small
size of the surgical wound and the small volume of blood
loss, and there was significantly less blood loss in the
LADG group according to the results of the present study
Figure 1. There was a si gnificant diffe rence in PRS betwee n
the ODG group and LADG group. The quantile box plot is
shown in the form of a red line. *p = 0.037.
Figure 2. There was a significant difference in SSS between
the ODG group and LADG group. **p < 0.0001.
Figure 3. There was a significant difference in CRS between
the ODG group and LADG group. ***p < 0.0001.
as well. However, the drawback of laparoscopic surgery
in the form of the long operation time has become a
problem. We thought that this problem could be over-
come by striving to standardize the surgical procedure,
establish a regular surgical team, and introduce appropri-
ate surgical instruments, and, actually, no significant

Estimation of Physiologic Ability and Surgical Stress Scoring System Appraises Laparoscopy-Assisted and Open
Distal Gastrectomy in Treatment of Early Gastric Cancer
4
difference in operation time was observed in this study,
and as a result the SSS was significantly lower in the
LADG group. On the other hand, surgical risk cannot be
concluded to be decreased just because the PRS is lower,
because in elderly patients and patients who have high-
risk complications the operation sometimes ends in pal-
liative surgery rather than seeking curative surgery [16-
18]. In our present study mean age was higher in the
LADG group, and the PRS was higher. This means that
the preoperative risk was higher in the LADG group, but
since the aforementioned SSS was lower, the overall
evaluation in the form of the CRS was significantly
lower in the LADG group. This also seems to suggest
that laparoscopic surgery is more beneficial as a treat-
ment for EGC, even if there is some risk. A CRS of 1.0 is
said to be the threshold score for postoperative fatal com-
plications increasing [10]. In the present study the CRS
was significantly lower in the LADG group, but neither
score exceeded the threshold. Moreover, the postopera-
tive hospital stay was also significantly shorter in the
LADG group. Laparoscopic surgery has been described
as more beneficial in many papers [1-4], but few of them
have reported a comparative study in which the E-PASS
was used. In the present study we used the E-PASS to
perform an overall evaluation of the surgical treatment
for EGC, and based on the results we concluded that sur-
gical treatment in the LADG group was more beneficial.
This corroborates what has been widely claimed, and it is
a result that it was obtained according to an overall eval-
uation of the patients’ risk and the risk of surgery itself, a
different viewpoint from the past. Based on the above,
the E-PASS scoring system is useful for assessing the
risks of the operation procedure of EGC. We appreciate
that LADG is more feasible than ODG as a surgical
treatment for EGC.
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