Early complications following total gastrectomy for gastric cancer

Clinical comparison of total gastrectomy with single-vessel transection Roux-en-Y reconstruction vs total gastrectomy with conventional Roux-en-Y reconstruction for proximal gastric cancer

PURPOSE

This study aimed to investigate the clinical benefits of single-vessel transection Roux-en-Y (SR-Y) reconstruction after total gastrectomy.

METHODS

A total of 194 patients with proximal gastric cancer were prospectively recruited at Fudan University Shanghai Cancer Center between January 2021 and September 2022. This study included 97 patients who underwent conventional Roux-en-Y reconstruction and 97 patients who underwent SR-Y reconstruction. Clinicopathologic characteristics, surgical outcomes, and postoperative complications were compared between the conventional and single-vessel transection groups.

RESULTS

There were no significant differences in baseline characteristics between the 2 groups in terms of age (P = .882), gender (P = .595), body mass index (P = .683), tumor location (P = .568), TNM stage (P = .122), tumor size (P = .927), anemia (P = .756), neoadjuvant chemotherapy (P = .730), and surgical approach (P = .592). However, compared with the conventional group, the single-vessel transection group had a shorter operation time (162.5 ± 37.6 vs 178.5 ± 48.3 min, respectively; P = .011) and less intraoperative bleeding (167.2 ± 91.8 vs 207.8 ± 167.5 mL, respectively; P = .037) after complete reservation of the terminal jejunal vascular arches. Nevertheless, there were no significant differences in tensions in the jejunal mesentery, durations of peritoneal drainage, postoperative hospital stay durations, the number of lymph node dissections, and early complications between the 2 groups.

CONCLUSION

SR-Y reconstruction can simplify surgical procedures, reduce operating time, and minimize intraoperative bleeding without increasing tensions in the jejunal mesentery or short-term complications. It is feasible and safe and worth further promotion in clinical practice.

Supradiaphragmatic Jejunal Perforation Following Total Gastrectomy With Esophagojejunostomy Reconstruction for Gastric Adenocarcinoma

Nasogastric tube decompression is a common technique used after abdominal surgery as it is widely accepted to play a role in the management of postoperative ileus and possibly reduce anastomotic leaks after gastrointestinal surgery. However, the routine practice of nasogastric/nasoenteric tube decompression in elective abdominal surgeries has been challenged due to the increased incidence of pulmonary complications and the argued lack of expected benefit. Here, we present a rare complication of nasogastric tube drainage following a routine total gastrectomy for signet-ring cell adenocarcinoma of the cardia in a 43-year-old female. Her postoperative course was complicated with a supradiaphragmatic jejunal perforation presumably from nasogastric tube decompression resulting in a left pleural effusion. The workup included an endoscopy showing the perforation, after which the nasojejunal tube was removed and the patient was managed conservatively. She was eventually discharged on postoperative day 28.

Prediction scores for complication and recurrence after multivisceral resection in gastric cancer

BACKGROUND

Multivisceral resection (MVR) is indicated in T4b gastric cancer (GC) when R0 can be achieved. Patient's selection for MVR is imperative, since it carries an increased risk for postoperative complications (POC) and disease recurrence. This study aims to elaborate prediction scores for POC and recurrence after MVR for cT4b GC.

METHODS

Patients who underwent MVR with curative intent due to cT4b gastric adenocarcinoma were selected from our prospective database. Scoring models were based on the variables identified as risk factors for the studied outcome. Through binary regression the model that best predicted the outcome was created.

RESULTS

From 237 MVRs, 58 fulfilled the inclusion criteria. Males were 70.7%, mean age was 61.8 years. A pT4b was confirmed in 34 patients, 29 had 2 or more adjacent organs removed. Major POC occurred in 25.9%, mortality was 8.6%. Overall survival (OS) and disease-free survival (DFS) were similar for pT4b and non-pT4b. DFS was worse for pN+ and when >2 adjacent organs were removed. Scoring models included 5 and 6 parameters for POC and recurrence, respectively, and their accuracy was 80.6% (95%CI = 0.69-0.92) and 78% (95%CI = 0.66-0.90). The POC and recurrence rates in low- and high-score groups were statistically different (p < 0.001 and p = 0.004, respectively). Patients with high-risk for POC had lower OS (p = 0.036) and DFS was worse in the high-recurrence risk group (p = 0.008).

CONCLUSION

The proposed scoring systems accurately predict POC and recurrence in GC patients undergoing MVR. These models are easy to use and can assist in the adoption of an individualized approach.

Esophagojejunal anastomotic fistula: a major issue after radical total gastrectomy

Gastric cancer surgery has evolved considerably over the past years, with substantial improvement on outcomes. Meanwhile, esophagojejunal anastomotic fistula (EJF) continues to impair postoperative results. This study aimed to assess EJF regarding its incidence, risk factors, management and the impact on overall survival. We retrospectively analyzed 258 consecutive patients who underwent total or completion gastrectomy for GC from 2009 and 2017. Clinicopathological characteristics analysis was performed comparing patients who developed EJF with patients with other clinical or surgical complications, as well as patients without any postoperative complications. Fifteen (5.8%) patients had EJF and 81 (31.4%) had other complications (including other surgical fistulas). The median time of EJF diagnosis was on the eighth postoperative day (range 3-76). Completion gastrectomy (p = 0.048) and longer hospital stay (p < 0.001) were associated with the occurrence of EJF. The surgical mortality of patients with EJF was higher than in non-EJF patients (26.7% vs. 4.5%; p < 0.001). Nine patients were treated conservatively and six required surgery. The mortality rate of EJF was 11.1% and 50% in patients who underwent conservative and surgical treatment, respectively. Patients with other complications and patients with EJF had worse survival compared to patients without any complication (p = 0.004 and p = 0.013, respectively). Completion gastrectomy is the main risk factor for EJF occurrence. Still, EJF is associated with high postoperative mortality, longer hospital stay and has a negative impact on long-term survival.

Intraoperatively Testing the Anastomotic Integrity of Esophagojejunostomy Using Methylene Blue

Background:

Intraoperative testing of gastrointestinal anastomosis effectively ensures anastomotic integrity. This study investigated whether the routine use of methylene blue intraoperatively identified leaks to reduce the postoperative proportion of clinical leaks.

Methods:

This study retrospectively analyzed consecutive total gastrectomies performed from January 2007 to December 2014 in a university hospital setting by a general surgical group that exclusively used the methylene blue test. All surgeries were performed for gastric or junctional cancers (n = 198). All reconstructions (Roux-en Y esophagojejunostomy) were performed using a stapler. The methylene blue test was used in 108 cases (group 1) via a nasojejunal tube. No test was performed for the other 90 cases (group 2). Intraoperative leakage rate, postoperative clinical leakage rate, length of hospitalization, and mortality rate were the outcome measures.

Results:

The intraoperative leakage rate was 7.4% in group 1. The postoperative clinical leakage rate was 8.6%. The postoperative clinical leakage rate was 3.7% in group 1 and 14.4% in group 2 (p = 0.007). There were no postoperative clinical leaks when an intraoperative leak led to concomitant intraoperative repair. The median length of hospital stay was 6 days in group 1 and 8 days in group 2 (p < 0.001). One death occurred in each group. No test-related complications were observed.

Conclusion:

The methylene blue test for esophagojejunostomy is a safe and reliable method for the assessment of anastomosis integrity, especially in cases with difficult esophagojejunostomic construction.

Hiatal Hernia as a Total Gastrectomy Complication

Introduction

According to the Brazilian National Institute of Cancer, gastric cancer is the third leading cause of death among men and the fifth among women in Brazil. Surgical resection is the only potentially curative treatment. The most serious complications associated with surgery are fistulas and dehiscence of the jejunal-esophageal anastomosis. Hiatal hernia refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm, though this occurrence is rarely reported as a complication in gastrectomy.

Case Report

A 76-year-old man was diagnosed with intestinal-type gastric adenocarcinoma. He underwent a total laparoscopic-assisted gastrectomy and D2 lymphadenectomy on May 19, 2015. The pathology revealed a pT4pN3 gastric adenocarcinoma. The patient became clinically stable and was discharged 10 days after surgery. He was subsequently started on adjuvant FOLFOX chemotherapy; however, 9 days after the second cycle, he was brought to the emergency room with nausea and severe epigastric pain. A CT scan revealed a hiatal hernia with signs of strangulation. The patient underwent emergent repair of the hernia and suffered no postoperative complications. He was discharged from the hospital 9 days after surgery.

Conclusion

Hiatal hernia is not well documented, and its occurrence in the context of gastrectomy is an infrequent complication.

The overlap method is a safe and feasible for esophagojejunostomy after laparoscopic-assisted total gastrectomy

Background

Laparoscopic procedures are increasingly being applied to gastric cancer surgery, including total gastrectomy for tumors located in the upper gastric body. Even for expert surgeons, esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) can be technically challenging. We perform the overlap method of esophagojejunostomy after LATG for gastric cancer. However, technical questions remain. Is the overlap method safer and more useful than other anastomosis techniques, such as methods using a circular stapler? In addition, while we perform this overlap reconstruction after LATG in a deep and narrow operative field, can the overlap method be performed safely regardless of body habitus? This study aimed to evaluate these issues retrospectively and to review the literature.

Methods

From October 2005 to August 2013, we performed LATG with lymph-node dissection and Roux-en-Y reconstruction using the overlap method in 77 patients with gastric cancer. This study examined pre-, intra- and postoperative data.

Results

Mean operation time, time to perform anastomosis, and estimated blood loss were 391.4 min, 36.3 min, and 146.9 ml, respectively. There were no deaths, and morbidity rate was 13%, including one patient (1%) who developed anastomotic stenosis. Mean postoperative hospitalization was 13.4 days. Surgical outcomes did not differ significantly by body mass index.

Conclusions

First, the overlap method for esophagojejunostomy after LATG is safe and useful. Second, this method can be performed irrespective of the body type of the patient. In particular, in a deep and narrow operative field, the overlap method is more versatile than other anastomosis methods. We believe that the overlap method can become a standard reconstruction technique for esophagojejunostomy after LATG.

Prevention of anastomotic leakage after total gastrectomy with perioperative supplemental oxygen administration: a prospective randomized, double-blind, controlled, single-center trial

BACKGROUND

The role of supplemental oxygen therapy in the healing of esophagojejunal anastomosis is still very much in an experimental stage. The aim of the present prospective, randomized study was to assess the effect of administration of perioperative supplemental oxygen therapy on esophagojejunal anastomosis, where the risk of leakage is high.

METHODS

We enrolled 171 patients between January 2009 and April 2012 who underwent elective open esophagojejunal anastomosis for gastric cancer. Patients were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30 % (n = 85) or 80 % (n = 86). Administration commenced after induction of anesthesia and was maintained for 6 h after surgery.

RESULTS

The overall anastomotic leak rate was 14.6 % (25 of 171): 17 patients (20 %) had an anastomotic dehiscence in the 30 % FiO2 group and 8 (9.3 %) in the 80 % FiO2 group (P < 0.05). The risk of anastomotic leak was 49 % lower in the 80 % FiO2 group (relative risk 0.61; 95 % confidence interval 0.40-0.95) versus 30 % FiO2.

CONCLUSIONS

Supplemental 80 % FiO2 provided during and for 6 h after major gastric cancer surgery to reduce postoperative anastomotic dehiscence should be considered part of ongoing quality improvement activities related to surgical care, with few risks to the patient and little associated cost.

Complicações pós-operatórias após gastrectomia total no câncer gástrico: análise de 300 doentes

RACIONAL: A gastrectomia total é considerada um procedimento de alto nível de complexidade, apresenta taxas de complicações elevadas, tanto locais como gerais, pois os doentes na sua maioria estão com as condições clínicas e nutricionais comprometidas pela doença. OBJETIVOS: analisar os resultados imediatos e complicações da gastrectomia total no período de 1972 a 2007. MÉTODOS: Foram revisados os prontuários médicos de 300 doentes portadores de adenocarcinoma gástrico, subdivididos em dois períodos: 1972 a 1992 - compreendendo 108 doentes (36%) e 1993 a 2007 - compreendendo 192 doentes (64%). Eram 67,3% do sexo masculinos, 70,7% brancos e com faixa etária variando de 25 a 86 anos (média de 63,4 anos). As lesões estavam localizadas em cárdia - 40 casos (13,3%); fundo gástrico - 83 casos (27,6%); corpo gástrico - 77 casos (25,6%); linite plástica - 45 casos (15%); côto gástrico - 33 casos (11%) e antro/corpo gástrico - 22 casos (7,3%). A gastrectomia total ampliada com linfadenectomia até nível D2 foi realizada em 246 casos (82%). RESULTADOS: A técnica de reconstrução mais utilizada foi a anastomose esôfago-jejunal término-lateral em Y-Roux em 257 doentes (86,7%). As complicações gerais no período de 1972-92 totalizaram 47 casos (43,5%), compreendendo principalmente as respiratórias (28 casos - 25,9%) e as urinárias (10 casos - 9,2%). No período 1993-2007 totalizaram 48 casos (25%), principalmente complicações respiratórias (27 casos - 14%), seguidas também das urinárias (12 casos - 6,2%). No período de 1972-92 estas complicações locais totalizaram 45 casos (30,8%) e no período de 1993-2007 atingiram 28 casos (14,5%), sendo as fistulas digestivas as mais frequentes. A mortalidade operatória até o 30º dia foi de 18 casos (6%), sendo que no período de 1972-92 totalizou 12 casos (11,1%) e no período de 1993-2007 foi de 7 casos (3,6%). CONCLUSÕES: A gastrectomia total é um procedimento que requer experiência do cirurgião, de sua equipe, empregando técnica cirúrgica aprimorada para minimizar as complicações pós-operatórias. As complicações pós-operatórias requerem cuidados no controle das infecções, das vias aéreas e cuidados nutricionais, diminuindo a mortalidade, aumentando a sobrevida e contribuindo para a qualidade de vida do doente.

Randomized controlled trial of ultrasonic dissection versus standard surgical technique in open left hemicolectomy or total gastrectomy

Background

Ultrasonic dissection devices have been designed for use in open surgery but it is not certain how they compare with standard surgical techniques.

Methods

This was a multicentre randomized controlled trial comparing ultrasonic dissection with the traditional surgical technique for haemostasis and dissection during left hemicolectomy and total gastrectomy. The primary endpoint was duration of operation; secondary endpoints were blood loss and other intraoperative parameters, and patient outcomes. Performance of the two techniques was rated by surgeons and assistants on a ten-point Likert scale.

Results

The analysis included 100 patients in the ultrasonic and 101 in the conventional dissection group. Patient demographics, and clinical and tumour-related parameters were similar in the two groups. There was no significant difference in duration of operation (mean 170 and 178 min in ultrasonic and conventional groups respectively; P = 0·405). Nor were there significant differences in intraoperative blood loss (median 350 and 400 ml respectively; P = 0·882), other intraoperative parameters, oncological or functional outcome. The ultrasonic dissector device was rated one point higher than conventional techniques by the surgeons.

Conclusion

Use of the ultrasonic dissector in open total gastrectomy and hemicolectomy had no impact on the overall operating time or other endpoints studied. Surgeons preferred the ultrasonic device for dissection. Registration number: ISRCTN97779420 (http://www.controlled-trials.com).

Successful enteral nutrition in the treatment of esophagojejunal fistula after total gastrectomy in gastric cancer patients

BACKGROUND

Esophagojejunal fistula is a serious complication after total gastrectomy in gastric cancer patients. This study describes the successful conservative management in 3 gastric cancer patients with esophagojejunal fistula after total gastrectomy using total enteral nutrition.

METHODS

Between January 2004 to December 2008, 588 consecutive patients with a proven diagnosis of gastric cancer were taken to the operation room to try a curative treatment. Of these, 173 underwent total gastrectomy, 9 of them had esophagojejunal fistula (5.2%). In three selected patients a trans-anastomotic naso-enteral feeding tube was placed under fluoroscopic vision when the fistula was clinically detected and a complete polymeric enteral formula was used.

RESULTS

The complete closing of the esophagojejunal fistula was obtained in day 8, 14 and 25 respectively.

CONCLUSION

In some selected cases it is possible to make a successful enteral nutrition using a feeding tube distal to the leak area inserted with the help of fluoroscopic vision. The specialized management of a gastric surgery unit and nutritional therapy unit are highlighted.

Endoscopic vacuum sponge therapy for esophageal defects

BACKGROUND

Anastomotic insufficiency in esophageal anastomosis and esophageal defects of other etiology are very severe complications. For anastomotic insufficiency in the rectum, endoscopic vacuum therapy has already been used successfully. The authors used vacuum therapy for anastomotic defects and other lesions of the esophagus.

METHODS

Between November 2006 and September 2009, 10 patients (5 men and 5 women, ages 46-82 years) were treated with endoscopic vacuum sponge therapy for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 5), iatrogenic esophageal perforation (n = 2), esophageal wall necrosis (n = 1), Boerhaave's syndrome (n = 1), and perforation of esophageal cancer (n = 1).

RESULTS

After one to seven changes of the sponge at intervals of 2-7 days and a mean therapy duration of 12 days, the defects were healed in all the surviving patients. During treatment, the patients were fed via an intestinal tube or percutaneous endoscopic gastrostomy (PEG), or enterally past the sponge. One patient died of intercurrent severe colitis. In three cases, a revision laparotomy was necessary at the beginning of treatment. No postinterventional stricture or functional relevant scar formation was observed during a follow-up period of 10-380 days after termination of the vacuum therapy.

CONCLUSION

Esophageal anastomotic insufficiency and esophageal wall defects of other causes can be treated successfully with endoscopic vacuum sponge therapy.

D2 gastrectomy -- a safe operation in experienced hands

In the contemporary practice, surgery is the only potentially curative treatment available for gastric cancer. However, there is no consensus on the extent of surgical resection. Advantages of D2 gastrectomy in terms of morbidity, mortality, local recurrence and survival are confirmed in Japanese as well as some European trials. In our hospital, all patients with operable gastric cancer are treated with D2 gastrectomy along with splenectomy and distal pancreatectomy followed by jejunal pouch reconstruction. The study was undertaken to evaluate our practice in terms of postoperative morbidity and mortality. All the patients who had total gastrectomy for gastric carcinoma from January 1995 to December 2000 were included in the study. During this 6-year period, 33 patients underwent potentially curative D2 gastrectomy. Postoperative morbidity and mortality were 18 and 9%, respectively. There were no anastomotic leaks. Three (9%) patients developed dysphasia, of which two (6%) had anastomotic stricture requiring dilatation. We feel D2 gastrectomy with splenectomy and distal pancreatectomy when performed electively is a safe procedure in experienced hands. Oesophago-jejunal anastomosis can be safely performed using circular stapler.

Prospective study of routine contrast radiology after total gastrectomy

BACKGROUND

The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation.

METHODS

Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy.

RESULTS

Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak.

CONCLUSION

There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Postoperative anatomic and pathologic findings at CT following gastrectomy

Helical computed tomography (CT) is useful in identifying postoperative anatomic changes, complications, and tumor recurrence in gastric cancer patients who have undergone gastrectomy. Postoperative anatomic changes can usually be identified on consecutive CT scans. Complications include anastomotic leakage, duodenal stump leakage, intraabdominal bleeding, wound complications, and other less common complications (postoperative pancreatitis, retention of surgical foreign bodies, diffuse peritonitis). The degree and extent of bowel wall thickening is important in diagnosing tumor recurrence; however, CT lacks specificity. Large or conglomerated lymph node metastases can be easily diagnosed at CT; however, small solitary or focal metastases may not be detected or differentiated from nonmetastatic nodes. Ascites, a common finding with peritoneal seeding in gastrointestinal tumors, is well depicted at CT. Hematogenous metastases from gastric carcinoma are most frequently seen in the liver and are best demonstrated with helical CT performed during the portal venous phase of enhancement (sensitivity >90% for the detection of lesions >1 cm). The sophisticated surgical procedures used in gastrectomy can alter normal anatomy and make image interpretation difficult; thus, familiarity with the appearance of postoperative anatomic changes, complications, and tumor recurrence is essential for accurate CT evaluation of affected patients.