Early postoperative anastomotic hemorrhage after gastrectomy for gastric cancer

Endoscopic management of postoperative bleeding

Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.

Efficacy and safety of anastomotic leak testing in gastric cancer: a randomized controlled trial

BACKGROUND

Anastomosis-related complications such as bleeding, leakage, and strictures, continue to be serious complications of gastric cancer surgery. Presently, these complications have yet to be reliably prevented. Here we design a comprehensive leak testing procedure which combines gastroscopy, air, and methylene blue (GAM) leak testing. We aimed to evaluated the efficacy and safety of the GAM procedure in patients with gastric cancer.

METHODS

Patients aged 18-85 years without an unresectable factor as confirmed via CT were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital and were randomly assigned to two groups: intraoperative leak testing group (IOLT) and no intraoperative leak testing group (NIOLT). The primary endpoint was the incidence of postoperative anastomosis-related complications in the two groups.

RESULTS

148 patients were initially randomly assigned to the IOLT group (n = 74) and to the NIOLT group (n = 74) between September 2018 and September 2022. After exclusions, 70 remained in the IOLT group and 68 in the NIOLT group. In the IOLT group, 5 patients (7.1%) were found to have anastomotic defects intraoperatively, which included anastomotic discontinuity, bleeding, and strictures. The NIOLT group had a higher incidence of postoperative anastomotic leakage compared to the IOLT group: 4 patients (5.8%) vs 0 patients (0%), respectively. No GAM-related complications were observed.

CONCLUSION

The GAM procedure is an intraoperative leak test that can be performed safely and efficiently after a laparoscopic total gastrectomy. GAM anastomotic leak testing may effectively prevent technical defect-related anastomotic complications in patients with gastric cancer who undergo a gastrectomy.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT04292496.

Urgent Endoscopy Improves Hemostasis in Patients With Upper Gastrointestinal Bleeding Following Biliary-pancreatic Surgery: A Retrospective Analysis

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a lethal complication of biliary-pancreatic surgery (BPS). The role of endoscopic intervention has not been fully defined in such a critical condition. The aim of this study was to assess the efficacy and safety of endoscopic hemostasis in a retrospective cohort.

MATERIALS AND METHODS

Consecutive patients with acute UGIB after BPS who received interventional endoscopy between January 2007 and August 2020 were included in this study. The clinical characteristics were collected and analyzed to screen for predictive factors significantly associated with successful hemostasis.

RESULTS

Among 37,772 patients who underwent BPS, 26 patients (0.069%) developed acute UGIB. The sites and causes of hemorrhage were as follows: gastroenteric anastomoe (n=17), gastric stump (n=2), jejunal anastomose (n=1), duodenal bulb ulcer (n=2), pancreatojejunal anastomosis hemorrhage (n=1), cholangiojejunal anastomose (n=1), gastroenteric anastomose and gastric stump hemorrhage (n=1), and Dieulafoy lesion (n=1). Successful endoscopic hemostasis was achieved in 19 (73.1%) of the 26 UGIB patients. In the 7 patients who failed endotherapy, 1 patient received a successful radiologic intervention, 6 patients underwent reoperation and achieved hemostasis in 4, and the other 2 patients died after reoperation. Logistic regression analysis showed that presentation-to-endoscopy time (≤12 h) was the only independent predictive factor associated with successful endoscopic hemostasis.

CONCLUSIONS

Endoscopic hemostasis is relatively safe and effective in controlling UIGB after BPS. Prompt intervention (≤12 h) could improve the success rate of endoscopic hemostasis.

Gastrointestinal Bleed After Total Pancreatectomy With Islet Autotransplant

OBJECTIVE

Gastrointestinal bleeding (GIB) is an uncommon complication after abdominal surgery. Given the unique risks in the total pancreatectomy with islet autotransplant (TPIAT) population, we aimed to describe this population's incidence of postoperative GIB.

METHODS

Prospectively collected data on patients who underwent a TPIAT from 2001 to 2018 at the University of Minnesota were reviewed for postoperative GIB. Each GIB patient was matched to a control patient and compared for medical, medication, and social history and for clinical outcomes.

RESULTS

Sixty-eight patients developed a GIB (12.4%) at median time after surgery of 17 months. Etiologies included the following: anastomotic ulcer (35%), Clostridium difficile (4%), gastric or duodenal ulcers (9%), esophagitis/gastritis (10%), hemorrhoids (3%), inflammatory bowel disease (4%), Mallory-Weiss tears (1%), and unknown (29%). During diagnostic workup, 87% had an endoscopic procedure and 3% underwent imaging. Seven patients required an operation (10%), 1 required an open embolization (1%), and 13 required endoscopic treatments (19%). Patients with a GIB were more likely to die (15% vs 5%, P = 0.055).

CONCLUSIONS

Twelve percent of patients developed a GIB after TPIAT. One third of those had an undefined etiology despite endoscopy. The need for intervention was high (30%).

Utility of intra-operative flexible sigmoidoscopy to assess colorectal anastomosis: a systematic review and meta-analysis

BACKGROUND

Anastomotic leak (AL) after colorectal resection leads to increased oncological and non-oncological, morbidity and mortality. Intra-operative assessment of a colorectal anastomosis with intra-operative flexible sigmoidoscopy (IOFS) has become increasingly prevalent and is an alternative to conventional air leak test. It is thought that intra-operative identification of an AL or anastomotic bleeding (AB) allows for immediate reparative intervention at the time of anastomosis formation itself. We aim to assess the available evidence for the use of IOFS to prevent complications following colorectal resection.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature between January 1980 and June 2020 was performed. Comparative studies assessing IOFS versus conventional air leak test were compared, and outcomes were pooled.

RESULTS

A total of 4512 articles were assessed, of which eight were found to meet the inclusion criteria. A total of 1792 patients were compared; 884 in the IOFS arm and 908 in the control arm. IOFS was associated with an increase in the rate of positive leak test (odds ratio (OR) 5.21, P > 0.001), a decrease in AL (OR 0.45, P = 0.006) and a decrease in post-operative AB requiring intervention (OR 0.40, P = 0.037).

CONCLUSION

In a non-randomized meta-analysis, IOFS increases the likelihood of identifying an anastomotic defect or bleeding intra-operatively. This allows for immediate intervention that decreases the rate of AL and AB. This adds impetus for performing routine IOFS after a left-sided colorectal resection with anastomosis and highlights the need for randomized controlled trial to confirm the finding.

Clinical characteristics of and prevention strategies for delayed hemorrhage following radical gastrectomy for gastric cancer

BACKGROUND

Delayed massive hemorrhage after gastric cancer surgery is clinically rare, but it is very dangerous once it occurs.

CASE SUMMARY

The clinical data of three patients who underwent radical gastrectomy for gastric cancer were retrospectively analyzed and the preventive strategies for this rare condition are summarized.

CONCLUSION

The causes of hemorrhage after radical gastrectomy are complicated and the methods of hemostasis should be flexibly chosen according to different causes. Computed tomography, digital substraction angiography, and endoscopy can be used for diagnosis and treatment. Intraoperative meticulous manipulation and postoperative close monitoring and effective support are essential for reducing delayed massive hemorrhage after gastric cancer surgery.

Transarterial embolization of acute iatrogenic hemorrhages: predictive factors for mortality and outcome

OBJECTIVE

Iatrogenic hemorrhages occur in 0.5-16% of medical procedures. A retrospective study was conducted to analyze technical and clinical outcome of transarterial embolization (TAE) used for acute iatrogenic hemorrhage and to identify factors predicting outcome.

METHODS

All patients undergoing TAE for acute iatrogenic bleeding from 2006 to 2013 were retrospectively analyzed. Primary end points were technical and clinical success or failure and 30 day mortality.

RESULTS

A total of 153 patients underwent 182 TAEs. Factors associated with clinical failure were lower blood hemoglobin concentration, use of higher number of units of red blood cell concentrate, TAE performed at night or weekend, embolization of more than one vessel, shock state before digital subtraction angiography (DSA), and intensive care before TAE. In multivariate analysis, independent factors for clinical success were hemoglobin concentration, number of units of red blood cell concentrate, and TAE of more than one vessel. Technical failure was associated with female gender, failure to detect signs of bleeding in DSA, TAE of more than one vessel, and shock state before DSA. Bleeding related to anticoagulation medication resulted in a significantly higher mortality rate compared with bleeding due to the remaining causes (30% vs 15%, p < 0.05).

CONCLUSION

Despite excellent technical success, the mortality rate was significant. The only factors affecting clinical success were bleeding intensity and extent of injury. Bleeding attributed to anticoagulation is related to high mortality and therefore requires special attention.

ADVANCES IN KNOWLEDGE

This study gives insights into morbidity and mortality of iatrogenic bleedings and the technical and clinical success rates of TAE in a large study population.

Safety and efficacy of post-anastomotic intraoperative endoscopy to avoid early anastomotic complications during gastrectomy for gastric cancer

BACKGROUND

Anastomotic complications such as leaks, bleeding, and stricture remain the most serious complications of surgery for gastric cancer. No perfect method exists for an accurate and reliable prevention of these complications. This study investigated the safety and efficacy of post-anastomotic intraoperative endoscopy (PAIOE) for avoidance of early anastomotic complications during gastrectomy in gastric cancer.

METHODS

This retrospective case-control study enrolled patients from a tertiary care, academic medical center. Routine PAIOE was performed on 319 patients undergoing gastrectomy for gastric cancer between 2015 and 2016. As controls, without PAIOE 270 patients from 2013 to 2014 were used for comparison. Early anastomotic complications and outcomes after PAIOE were determined.

RESULTS

Although there were no differences between the PAIOE and non-PAIOE group in terms of overall complication rates (20.1% vs 26.7%; P > 0.05), there were fewer complications related to anastomosis (3.4% vs 8.9%; P < 0.01) in the PAIOE group. The PAIOE group had rates of 2.5% for anastomotic leakage, 0.9% for intra-luminal bleeding, and 0% for anastomotic stenosis, while the non-PAIOE group exhibited rates of 5.6%, 2.6%, and 0.7%, respectively. Thirty-one abnormalities were detected in 26 PAIOE patients (9.71%) (20 venous bleeding, 7 mucosal tearing, 2 air leaks, 1 arterial bleeding, and 1 anastomotic stricture). All abnormalities were corrected by proper interventions (13 reinforced additional suture, 13 endoscopic hemostasis, and 2 re-anastomosis). There were no morbidities associated with PAIOE.

CONCLUSIONS

PAIOE appears to be a safe and reliable procedure to evaluate the stability of gastrointestinal anastomosis for gastric cancer patients. Further data collection and a well-designed prospective study are needed to confirm the validity of PAIOE.

[Procedure-specific postoperative gastrointestinal hemorrhage]

Gastrointestinal bleeding (GIB) can occur as a complicating issue in the postoperative course after visceral surgery. It can be of varying clinical extent ranging from mild anemia to fatal hemorrhagic shock. Symptomatic manifestations of a GIB are hematemesis, melena and hematochezia. The GIB are fundamentally differentiated into upper and lower GIB. While upper GIB is defined as the occurrence of endoluminal hemorrhage above the ligament of Treitz, correspondingly the definition of lower GIB is intraluminal bleeding distal to the duodenojejunal flexure. Knowledge of their procedure-related incidence during the postoperative course enables a better assessment of the necessary intervention.

Incidence and risk factors for anastomotic bleeding in lower gastrointestinal surgery

Objective

Although major anastomotic bleeding after lower gastrointestinal surgery is considered rare, it can be life-threatening if not properly managed. The objective of this study was to assess the incidence of postoperative lower gastrointestinal intraluminal bleeding and to identify its potential risk factors. This retrospective cohort study used data from charts of 314 patients who underwent digestive surgery of the colon or small intestine. Details are reported for their sociodemographic data, surgical approach, comorbidities, timing and presentation of intraluminal bleeding events, bleeding diagnosis, treatment strategies, hospital length of stay, and clinical complications.

Results

A total of 7 patients (2.3%) experienced intraluminal bleeding in the postoperative period. The average length of hospital stay before discharge was 12 days (median = 13 days). Patients with intraluminal bleeding had a significantly higher percentage of coronary artery diseases compared to patients without intraluminal bleeding (P value = .04), as well as having a cancer diagnosis (P value = .02). The clinical complications that were more likely in patients with intraluminal bleeding included requiring blood transfusions (P value = .01), reduction in hemoglobin (P value = .001), cardiac ischemia (P value = .02), and atrial fibrillations (P value = .02).

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4403-0) contains supplementary material, which is available to authorized users.

A risk prediction system of postoperative hemorrhage following laparoscopy-assisted radical gastrectomy with D2 lymphadenectomy for primary gastric cancer

Objectives

To investigate risk factors of postoperative hemorrhage (PH) following laparoscopy-assisted radical gastrectomy (LARG) with D2 lymphadenectomy for primary gastric cancer (PGC) and to use those risk factors to develop a scoring system for risk assessment.

Materials and Methods

A total of 1789 PGC patients were enrolled in our study. We analyzed the risk factors of PH and constructed a scoring system using 75% of the cases as the experimental group and 25% of the cases as a verification group to demonstrate the effectiveness.

Results

Among these 1789 patients, 46 (2.6%) developed PH. Univariate and multivariate analysis in the experimental group indicated that having more than 41 lymph node excisions, combined organ resection, stage III tumor and postoperative digestive fistula were independent risk factors of PH. According to the independent risk factors, we constructed a scoring system to separate patients into low-risk (0–2 points) and high-risk (≥ 3 points) groups. The area under the ROC curve for this scoring system was 0.748. In the verification group, the risk of PH predicted by the scoring system was not significantly different from the actual incidence observed.

Conclusions

This scoring system could simply and effectively predict the occurrence of PH following LARG with D2 lymphadenectomy for PGC. The predictive system will help surgeons evaluate risk and select risk-adapted interventions to improve surgical safety.

Efficacy of Oxidized Regenerated Cellulose, SurgiGuard®, in Porcine Surgery

PURPOSE

Adequate hemostasis is important for postoperative outcomes of abdominal surgery. This study evaluated the hemostatic effects and accompanying histopathological changes of a novel oxidized regenerated cellulose, SurgiGuard®, during abdominal surgery.

MATERIALS AND METHODS

Ten pigs underwent wedge resection of the spleen (1×1 cm) and liver (1.5×1.5 cm). The resected surface was covered with Surgicel® fabric or fibril type (Group A) or SurgiGuard® fabric or fibril type (Group B). Surgicel® and SurgiGuard® were randomized for attachment to the resected surface by fabric type (n=5) or fibril type (n=5). Blood loss was measured 5, 7, and 9 min after resection. Pigs were necropsied 6 weeks postoperatively to evaluate gross and histopathological changes.

RESULTS

There was no significant difference in total blood loss between groups [spleen fabric: Group A vs. Group B, 4.38 g (2.74-6.43) vs. 3.41 g (2.46-4.65), p=0.436; spleen fibril: Group A vs. Group B, 3.44 g (2.82-6.07) vs. 3.60 g (2.03-6.09), p=0.971; liver fabric: Group A vs. Group B, 4.51 g (2.67-10.61) vs. 6.93 g (3.09-9.95), p=0.796; liver fibril: Group A vs. Group B, 3.32 g (2.50-8.78) vs. 3.70 g (2.32-5.84), p=0.971]. Histopathological analysis revealed no significant difference in toxicities related to Surgicel® or SurgiGuard® [inflammation, fibrosis, foreign bodies, and hemorrhage (spleen: p=0.333, 0.127, 0.751, and 1.000; liver: p=0.155, 0.751, 1.000, and 1.000, respectively)].

CONCLUSION

SurgiGuard® is as effective and non-toxic as Surgicel® in achieving hemostasis after porcine abdominal surgery.

Feasibility and Safety of Laparoscopy-Assisted Subtotal Gastrectomy for Gastric Cancer Invading the Upper Stomach

This study evaluated the feasibility and safety of laparoscopy-assisted subtotal gastrectomy preserving a minimal remnant stomach for clinical T1 gastric cancer invading the upper stomach. Forty-three consecutive patients who underwent laparoscopy-assisted subtotal gastrectomy preserving a minimal remnant stomach were examined. In addition to the conventional laparoscopy-assisted distal gastrectomy, some short and posterior gastric arteries were resected. A minimal remnant stomach-jejunum anastomosis was made by using a circular stapler with regular anvil or transoral anvil. Transoral anvil was selected in 19 patients, and regular anvil was used in 24 patients. The median operation time was 288 minutes, and the median blood loss was 50 mL. Conversion to open surgery was required in 2 patients due to bleeding. No patient required conversion to open surgery due to the difficulty of the anastomosis. Nine patients developed postoperative complications, including grade 3 duodenal stump leakage in 1 patient and grade 2 anastomotic bleeding in another patient. No mortality was observed. Laparoscopy-assisted subtotal gastrectomy preserving a minimal remnant stomach is safe and feasible for early gastric cancer invading the upper stomach.

Clinical features of postoperative anastomotic bleeding after gastrectomy and efficacy of endoscopic hemostasis: a case-control study

BACKGROUND

Postoperative anastomotic bleeding (PAB) is relatively rare; however, it can be lethal if not treated immediately. The aim of our study was to investigate the clinical features of PAB and the efficacy of endoscopic hemostasis (EH) for PAB.

METHODS

Between January 2004 and May 2013, 16,591 patients underwent gastrectomy for gastric cancer at Asan Medical Center. Among them, 36 patients who experienced PAB within 2 months after the gastrectomy were enrolled as a case group. Each subject was matched at a ratio of 1:5 with randomly selected patients without bleeding during the same period (n = 180, control group). The clinical outcomes and risk factors for patients with PAB were compared with those of the control group, and the results of EH were evaluated retrospectively.

RESULTS

The incidence of PAB was 0.22% (n = 36), and the median duration from gastrectomy to PAB was 34.5 h (interquartile range, 12.3-132.8 h). EH was attempted in 25 patients (69.4%); surgery was performed in 6 patients (16.7%); and conservative management was applied in 5 patients (13.9%). PAB-related death occurred in three patients (8.3%; one in each treatment modality). Among 25 patients with primary EH, 16 were treated successfully (64%) and hemoclip was the most commonly used endoscopic tool (52%). In the multivariate analysis, the type of gastrectomy was found to be a risk factor for PAB (odds ratio 3.448, 95% confidence interval, 1.138-10.448, p = .029).

CONCLUSIONS

Although PAB is an infrequent and potentially life-threatening complication, endoscopy can be considered as a useful method to avoid additional surgery in properly selected patients.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

Postoperative Morbidity and Mortality Following D2 Gastrectomy-an Audit of 456 Cases

BACKGROUND

D2 gastrectomy is routinely performed in Japanese centres for carcinoma stomach with low morbidity and mortality. There were concerns in Western centres with regard to D2 gastrectomy in view of high morbidity and mortality rates. This study was aimed to study the postoperative morbidity and mortality following D2 gastrectomy for carcinoma stomach in a high volume centre in India.

METHODS

It was a retrospective analysis of all the patients who underwent D2 gastrectomy from 1991 to 2010.

RESULTS

D2 gastrectomy was performed in 456 patients during this period. Respiratory events were the most common cause of morbidity in the study group (2.4 %). Male gender (p = 0.007), presence of gastric outlet obstruction (p = 0.01) and pathological T4 (p = 0.05) independently predicted increased post operative morbidity in multivariate analysis. The morbidity and mortality rates declined with increase in hospital volume and experience of the surgeon.

CONCLUSION

D2 gastrectomy for carcinoma stomach can be performed safely in specialized centres with low morbidity and mortality rates.

Gastrointestinal bleeding in patients with gastrointestinal tumors after surgery: Causes and treatments

AIM: To investigate the causes and treatments of postoperative gastrointestinal bleeding in patients with gastrointestinal tumors.

METHODS: A retrospective study was performed on 21 patients with gastrointestinal tumors who developed gastrointestinal bleeding after surgery for gastrointestinal tumors between January 2009 and January 2014 at the Third Affiliated Hospital of Anhui Medical University. Among them, 19 patients had early and 2 patients had late gastrointestinal hemorrhage.

RESULTS: Eighteen patients recovered after appropriate treatments such as conservative therapy, endoscopic treatment, digital subtraction angiography and reoperation. One patient abandoned treatment and 2 patients died after the reoperation.

CONCLUSION: There are many reasons for postoperative hemorrhage in patients with gastrointestinal tumors. Effective treatments and standard surgery technique are key solutions for gastrointestinal bleeding after surgery for gastrointestinal tumors.

Transarterial embolization for massive gastrointestinal hemorrhage following abdominal surgery

AIM: To evaluate the clinical results of angiography and embolization for massive gastrointestinal hemorrhage after abdominal surgery.

METHODS: This retrospective study included 26 patients with postoperative hemorrhage after abdominal surgery. All patients underwent emergency transarterial angiography, and 21 patients underwent emergency embolization. We retrospectively analyzed the angiographic features and the clinical outcomes of transcatheter arterial embolization.

RESULTS: Angiography showed that a discrete bleeding focus was detected in 21 (81%) of 26 patients. Positive angiographic findings included extravasations of contrast medium (n = 9), pseudoaneurysms (n = 9), and fusiform aneurysms (n = 3). Transarterial embolization was technically successful in 21 (95%) of 22 patients. Clinical success was achieved in 18 (82%) of 22 patients. No postembolization complications were observed. Three patients died of rebleeding.

CONCLUSION: The positive rate of angiographic findings in 26 patients with postoperative gastrointestinal hemorrhage was 81%. Transcatheter arterial embolization seems to be an effective and safe method in the management of postoperative gastrointestinal hemorrhage.

Postoperative gastrointestinal hemorrhage

Significant gastrointestinal (GI) bleeding in the postoperative period is an uncommon complication of surgery. The management of GI bleeding within the postoperative period is complex because of a larger differential for the source of bleeding and a more complex risk/benefit analysis. There is minimal published literature specific to the management of postoperative GI bleeding, and the infrequency, complexity, and variability of the clinical setting of this complication confound simplistic consideration of its cause and therapy. This article outlines a systematic evaluation of the patient, treatment options, and assessment of risk/benefit ratio for various treatment options.