Postoperative complications and functional results after subtotal gastrectomy with Billroth II reconstruction for primary gastric cancer

Treatment of efferent loop syndrome after pancreatoduodenectomy with a fully covered self‐expandable metal stent: A case report

Efferent loop syndrome is a very rare complication following pancreatoduodenectomy. The treatment of efferent loop syndrome varies depending on the cause of the syndrome. Conservative treatment methods, including nasogastric drainage and enteral nutrition, are adopted that are effective in most of patients; however, surgical treatment is usually required in patients with complete loop obstruction. Herein, we report a case of severe efferent loop obstruction that occurred after pancreatoduodenectomy, which was refractory to conservative treatment and successfully resolved by insertion of a fully covered self‐expandable metal stent.

Long-term postoperative pneumonia in elderly patients with early gastric cancer

Background

Pneumonia is a major cause of death in the elderly population. Considering body weight loss, muscle loss, and reflux after gastrectomy, elderly patients are considered to be at very high risk for pneumonia, which could decrease overall survival because early gastric cancer is mostly curable only by surgery. We aimed to clarify the incidence of pneumonia in the long-term period after gastrectomy in elderly patients who were diagnosed with early gastric cancer and its risk factors.

Methods

We retrospectively examined patients of > 75 years of age who underwent R0 gastrectomy for gastric cancer and who were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. Long-term postoperative pneumonia was diagnosed by chest computed tomography every year until 2 years after surgery. The presence of preoperative sarcopenia was assessed using preoperative L3 skeletal muscle index.

Results

167 patients were included in this study. Long-term postoperative pneumonia was observed in 44 (26%) patients. Of the 44 people diagnosed with long-term postoperative pneumonia, 33 were diagnosed in the 1st year and 11 in the 2nd year. 117 patients (70%) were diagnosed with sarcopenia which was significantly frequently found in the patients who developed long-term postoperative pneumonia (91%) than those without (63%). Preoperative sarcopenia was the only independent risk factor in multivariate analysis. Type of gastrectomy was not a significant risk factor.

Conclusions

Long-term postoperative pneumonia was frequently observed in the elderly patients. Preoperative sarcopenia was associated with long-term postoperative pneumonia in elderly patients who underwent curative surgery for gastric cancer. After gastrectomy, long-term special care would be required for elderly patients, especially with sarcopenia.

A comparison of quality of life between patients with small and large gastric remnant volumes after gastrectomy for gastric cancer

The impact of gastric remnant volumes (GRVs) after gastrectomy on patients' quality of life (QOL) has not yet been clarified. The aim of the present study was to compare QOL after gastrectomy between small and large gastric remnant volume patients.We prospectively collected clinical data from 78 consecutive patients who underwent distal gastrectomy with Billroth II gastrojejunostomy for gastric cancer. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Stomach questionnaire and gastric computed tomography scans were performed. The patients were subdivided into 2 groups by remnant stomach volume (the S group ≤110 mL vs L group >110 mL).The worst scores for most items were observed at postoperative month 1 and usually improved thereafter. There was no difference in the STO22 score except for dysphagia between the S and L groups after gastrectomy (P > .05). The QOL score of dysphagia was different at postoperative 6 months (S vs L, 12.4 vs 22.8, P < .03), but there was no difference at postoperative months 1, 3, 12, 24, or 36 (P > .05).The remnant gastric volume after partial gastrectomy affects neither functional differences nor QOL after 6 months following appropriate radical surgery.

Billroth I, a Viable Alternative in Early Distal Gastric Cancers: Short-Term Results from an Indian Tertiary Care Center

The only hope of cure in carcinoma stomach is gastrectomy; it can be total or partial depending upon the location of the tumor. While there is no controversy in the extent of resection, the choice of anastomosis after partial gastrectomy is a matter of debate. For pyloric lesions, we felt that in spite of the ease of performing surgery, simplicity, being physiological, and time-saving, Billroth I is underutilized. Hence, the study rationale was to compare Billroth I and Billroth II anastomosis post-gastric resection in the surgical management of gastric cancer. This was a retrospective study performed in the Department of Surgical Oncology, Acharya Harihar Regional Cancer Centre (AHRCC), Cuttack, Odisha. A total of 95 patients who underwent distal radical gastrectomy for gastric cancer during 2016 and 2017 were included in the study. Nineteen patients underwent Billroth I reconstruction and 76 patients underwent Billroth II reconstruction. In the case of both groups, no statistically significant differences (p˂0.05) were found in terms of early post-operative complications or long-term post-operative follow-up in our experience. Billroth I reconstruction is a simple, oncologically safe, economical, and physiological procedure. It can be performed when there is availability of large stomach remnant post-gastric resection. However, there is no significant difference between Billroth I and Billroth II in terms of patient's recovery and post-operative complications.

Safety and efficacy of small-bowel capsule endoscopy examination in patients with Billroth II gastrojejunostomy

BACKGROUND

Small-bowel capsule endoscopy (SBCE) has become an increasingly utilized imaging modality for patients suspected of having small intestinal diseases. However, data regarding the role of SBCE in patients with Billroth II gastrojejunostomy are limited. The objective is to evaluate the safety and efficacy of SBCE in Billroth II gastrojejunostomy patients.

METHODS

We retrospectively studied patients with Billroth II gastrojejunostomy who underwent MiroCam capsule endoscopy between August 2013 and October 2019. Baseline patient characteristics; gastroscopic and SBCE findings; capsule transit time; and the occurrence of adverse events were collected and compared between groups with and without anastomotic lesions.

RESULTS

In total, 30 patients were analyzed in the study. The median age was 59 years, and 26 patients (86.7%) were men. The majority of SBCE positive findings including ulcers (10.0%), angioectasias (6.7%) and polyps (6.7%). In patients with (n = 10) and without (n = 20) anastomotic lesions, the anastomotic lesion was significantly associated with a delayed gastric transit time (GTT) (P = 0.026), but the two groups showed no significant difference in completion (P > 0.05). All patients underwent successful SBCE examinations without adverse events, except device transit into the afferent loop, where it remained for nearly 2 h, occurred in one case with anastomotic ulcers.

CONCLUSIONS

This retrospective study demonstrates that SBCE is a safe and effective diagnostic tool in patients with Billroth II gastrojejunostomy with a favorable gastroscopic evaluation within 7 days prior. The frequently real-time monitoring is suggested due to the risk of retention in the afferent loop, and a delayed food intake is required when a prolonged stay in the afferent loop occurred.

Unplanned reoperation after radical gastrectomy for gastric cancer: causes, risk factors, and long-term prognostic influence

Purpose

Unplanned reoperation (URO) after radical gastrectomy for gastric cancer (GC) mostly results from serious postoperative complications. At present, there is still controversy over the predictive factors for URO. Our goal was to identify the risk factors for URO and to investigate its potential impact on long-term survival.

Patients and methods

We included 2,852 GC patients who underwent a gastrectomy. Multivariate logistic regression analyses were performed to determine the risk factors for URO. Patients were randomly selected from the non-URO group by 1:4 propensity score matching with multiple parameters with patients from the URO group. The survival disparity of 34 URO patients and 136 non-URO patients was examined using the Kaplan-Meier method and the multivariate Cox proportional hazard model.

Results

The incidence of URO was 1.4% (39/2, 852). The primary cause of URO was intra-abdominal bleeding (53.9%, 21/39). Multivariate logistic regression analyses revealed that male gender (OR = 4.630, 95% CI = 1.412-15.152, P = 0.011), diabetes (OR = 4.189, 95% CI = 1.705-10.290, P = 0.002), and preoperative hypoproteinemia (OR = 2.305, 95% CI = 1.079-4.923, P = 0.031) were independent risk factors for URO. With regard to early surgical outcomes, patients undergoing URO had a longer hospital stay (P < 0.001), higher incidence of postoperative complications (P < 0.001), and greater mortality (P < 0.001) compared with the non-URO group. No significant correlation was found between URO and cancer-specific survival in univariate (P = 0.275) and multivariate (P = 0.090) survival analyses.

Conclusion

Male gender, diabetes, and preoperative hypoproteinemia were suggested as independent risk factors for URO. URO was associated with longer hospital stay and increased perioperative mortality, but might not be correlated with long-term mortality.

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.

Evaluation of the POSSUM, p-POSSUM, o-POSSUM, and APACHE II scoring systems in predicting postoperative mortality and morbidity in gastric cancer patients

BACKGROUND/OBJECTIVE

Gastric cancer is the fourth most prevalent cancer worldwide. The ability to accurately predict surgery-related morbidity and mortality is critical in deciding both the timing of surgery and choice of surgical procedure. The aim of this study is to compare the POSSUM, p-POSSUM, o-POSSUM, and APACHE II scoring systems for predicting surgical morbidity and mortality in Chinese gastric cancer patients, as well as to create new scoring systems to achieve better prediction.

METHODS

Data from 612 gastric cancer patients undergoing gastrectomy between January 2007 and December 2011 were included in this study. The predictive abilities of the four scoring systems were compared by examining observed-to-expected (O/E) ratios, the receiver operating characteristic curve, Student t test, and χ² test results.

RESULTS

The observed complication rate of 34% (n = 208) did not differ significantly from the rate of 36.6% (n = 208) predicted by the POSSUM scoring system (O/E ratio = 0.93). The observed mortality rate was 2.9% (n = 18). For predicting mortality, POSSUM had an O/E ratio of 0.34 as compared with p-POSSUM (O/E ratio = 0.91), o-POSSUM (O/E ratio = 1.26), and APACHE II (O/E ratio = 0.28).

CONCLUSION

The POSSUM scoring system performed well with respect to predicting morbidity risk following gastric cancer resection. For predicting postoperative mortality, p-POSSUM and o-POSSUM exhibited superior performance relative to POSSUM and APACHE II.

Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review

AIM: To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.

METHODS: A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients’ characteristics, type of treatment, short and long-term outcomes were extracted and analyzed.

RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d.

CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.

Management of post-gastrectomy anastomosis site obstruction with a self-expandable metallic stent

Post-gastrectomy anastomosis site obstruction is a relatively rare complication after a subtotal gastrectomy. We present a case of a 75-year-old man who underwent a truncal vagotomy, omental patch, gastrojejunostomy, and Braun anastomosis for duodenal ulcer perforation and a gastric outlet obstruction. Following the 10^th postoperative day, the patient complained of abdominal discomfort and vomiting. We diagnosed post-gastrectomy anastomosis site obstruction by an upper gastrointestinal series and an upper endoscopic examination. We inserted a self-expandable metallic stent (SEMS) at the anastomosis site. The stent was fully expanded after deployment. On the day following the stent insertion, the patient began to eat, and his abdominal discomfort was resolved. This paper describes the successful management of post-gastrectomy anastomosis site obstruction with temporary placement of a SEMS.

Numerical and experimental analysis of factors leading to suture dehiscence after Billroth II gastric resection

The main goal of this study was to numerically quantify risk of duodenal stump blowout after Billroth II (BII) gastric resection. Our hypothesis was that the geometry of the reconstructed tract after BII resection is one of the key factors that can lead to duodenal dehiscence. We used computational fluid dynamics (CFD) with finite element (FE) simulations of various models of BII reconstructed gastrointestinal (GI) tract, as well as non-perfused, ex vivo, porcine experimental models. As main geometrical parameters for FE postoperative models we have used duodenal stump length and inclination between gastric remnant and duodenal stump. Virtual gastric resection was performed on each of 3D FE models based on multislice Computer Tomography (CT) DICOM. According to our computer simulation the difference between maximal duodenal stump pressures for models with most and least preferable geometry of reconstructed GI tract is about 30%. We compared the resulting postoperative duodenal pressure from computer simulations with duodenal stump dehiscence pressure from the experiment. Pressure at duodenal stump after BII resection obtained by computer simulation is 4-5 times lower than the dehiscence pressure according to our experiment on isolated bowel segment. Our conclusion is that if the surgery is performed technically correct, geometry variations of the reconstructed GI tract by themselves are not sufficient to cause duodenal stump blowout. Pressure that develops in the duodenal stump after BII resection using omega loop, only in the conjunction with other risk factors can cause duodenal dehiscence. Increased duodenal pressure after BII resection is risk factor. Hence we recommend the routine use of Roux en Y anastomosis as a safer solution in terms of resulting intraluminal pressure. However, if the surgeon decides to perform BII reconstruction, results obtained with this methodology can be valuable.

Endoscopic closure of postoperative anastomotic leakage with endoclips and detachable snares

Anastomotic leakage, although uncommon, is a life-threatening complication and requires prompt recognition and treatment. Surgical closure has been recommended for defects that are large and symptomatic. However, recent reports on successful endoscopic closure of anastomotic leakage suggest that endoscopic techniques may be a feasible alternative to surgical approaches in patients with comorbid conditions that are not suitable for undergoing second operation or for those who refuse to be reoperated. Herein, we describe a case of postoperative gastrojejunal anastomotic leakage that was successfully treated with endoscopic closure using endoclips and detachable snares.

Impact of postoperative complications on long-term survival after radical resection for gastric cancer

AIM: To investigate the potential impact of complications in gastric cancer patients who survive the initial postoperative period.

METHODS: Between January 1, 2005 and December 31, 2006, 432 patients who received curative gastrectomy with D2 lymph node dissection for gastric cancer at our department were studied. Associations between clinicopathological factors [age, sex, American Society of Anesthesiologists grade, body mass index, tumor-node-metastases (TNM) stage and tumor grade], including postoperative complications (defined as any deviation from an uneventful postoperative course within 30 d of the operation and survival rates) and treatment-specific factors (blood transfusion, neoadjuvant therapy and duration of surgery). Patients were divided into 2 groups: with (n = 54) or without (n = 378) complications. Survival curves were compared between the groups, and univariate and multivariate models were conducted to identify independent prognostic factors.

RESULTS: Among the 432 patients evaluated, 61 complications occurred affecting 54 patients (12.50%). Complications included anastomotic leakages, gastric motility disorders, anastomotic block, wound infections, intra-abdominal abscesses, infectious diarrhea, bleeding, bowel obstructions, arrhythmias, angina pectoris, pneumonia, atelectasis, thrombosis, unexplained fever, delirium, ocular fungal infection and multiple organ failure. American Society of Anesthesiologists grade, body mass index, combined organ resection and median duration of operation were associated with higher postoperative complications. The 1-, 3- and 5-year survival rates were 83.3%, 53.2% and 37.5%, respectively. In the univariate analysis, the size of lesions, TNM stage, blood transfusion, lymphovascular invasion, perineural invasion, neoadjuvant chemotherapy, and postoperative complications were significant predictors of overall survival. In the multivariate analysis, only TNM stage and the presence of complications remained significant predictors of reduced survival.

CONCLUSION: The occurrence of in-hospital postoperative complications was an independent predictor of worse 5-year overall survival rate after radical resection of gastric cancer.

Late anastomotic perforation following surgery for gastric neuroendocrine tumor complicated by perforated duodenal ulcer: a case report

Neuroendocrine tumors (NETs) are a group of neoplasms that are characterized by the secretion of a variety of hormones and diverse clinical syndromes. NETs are considered to be rare, but the incidence of NETs has increased rapidly in recent years. NETs provide a clinical challenge for physicians because they comprise a heterogeneous group of malignancies with a wide range of morphological, functional, and behavioral characteristics. Subtotal gastrectomy with Billroth II reconstruction is the mainstay of therapy in the management of gastric NETs complicated by perforated duodenal ulcer. Late perforation of anastomotic stoma as a long-term complication has been rarely reported. Here, we report a case of anastomotic perforation 5 years after subtotal gastrectomy due to perforated duodenal ulcer and gastric NETs.

Outcomes of intensive care unit admissions after elective cancer surgery

BACKGROUND

Postoperative care for major elective cancer surgery is frequently provided on the Intensive Care Unit (ICU).

OBJECTIVE

To analyze the characteristics and outcome of patients after ICU admission following elective surgery for different cancer diagnoses.

METHODS

We analyzed all ICU admissions following elective cancer surgery in the Netherlands collected in the National Intensive Care Evaluation registry between January 2007 and January 2012.

RESULTS

28,973 patients (9.0% of all ICU admissions; 40% female) were admitted to the ICU after elective cancer surgery. Of these admissions 77% were planned; in 23% of cases the decision for ICU admission was made during or directly after surgery. The most frequent malignancies were colorectal cancer (25.6%), lung cancer (18.5%) and tumors of the central nervous system (14.3%). Mechanical ventilation was necessary in 24.8% of all patients, most frequently after surgery for esophageal (62.5%) and head and neck cancer (50.2%); 20.7% of patients were treated with vasopressors in the acute postoperative phase, in particular after surgery for esophageal cancer (41.8%). The median length of stay on the ICU was 0.9 days (interquartile ranges [IQR] 0.8-1.5); surgery for esophageal cancer was associated with the longest ICU length of stay (median 2.0 days) with the largest variation (IQR 1.0-4.8 days). ICU mortality was 1.4%; surgery for gastrointestinal cancer was associated with the highest ICU mortality (colorectal cancer 2.2%, pancreatico-cholangiocarcinoma 2.0%).

CONCLUSION

Elective cancer surgery represents a significant part of all ICU admissions, with a short length of stay and low mortality.

Epidemiology, surgical management and early postoperative outcome in a cohort of gastric cancer patients of a tertiary referral center in relation to multi-center quality assurance studies

The aim of the study was to analyze epidemiologic parameters, treatment-related data and prognostic factors in the management of gastric cancer patients of a university surgical center under conditions of routine clinical care before the onset of the era of multimodal therapies. By analyzing our data in relation with multi-center quality assurance trials [German Gastric Cancer Study - GGCS (1992) and East German Gastric Cancer Study - EGGCS (2004)] we aimed at providing an instrument of internal quality control at our institution as well as a base for comparison with future analyses taking into account the implementation of evolving (multimodal) therapies and their influence on treatment results.

MATERIAL AND METHODS

Retrospective analysis of prospectively gathered data of gastric cancer patients treated at a single institution during a defined 10-year time period with multivariate analysis of risk factors for early postoperative outcome.

RESULTS

From 04/01/1993 through 03/31/2003, a total of 328 gastric cancer patients were treated. In comparison with the EGGCS cohort there was a larger proportion of patients with locally advanced and proximally located tumors. 272 patients (82.9%) underwent surgery with curative intent; in 88.4% of these an R0 resection was achieved (EGGCS/GGCS: 82.5%/71.5%). 68.2% of patients underwent preoperative endoluminal ultrasound (EUS) (EGGCS: 27.4%); the proportion of patients undergoing EUS increased over the study period. Diagnostic accuracy of EUS for T stage was 50.6% (EGGCS: 42.6%). 77.2% of operated patients with curative intent underwent gastrectomy (EGGCS/GGCS: 79.8%/71.1%). Anastomotic leaks at the esophagojejunostomy occurred slightly more frequently (8.8%) than in the EGGCS (5.9%) and GGCS (7.2%); however, postoperative morbidity (36.1%) and early postoperative mortality (5.3%) were not increased compared to the multi-center quality assurance study results (EGGCS morbidity, 45%); EGGCS/GGCS mortality, 8%/8.9%). D2 lymphadenectomy was performed in 72.6% of cases (EGGCS: 70.9%). Multivariate analysis revealed splenectomy as an independent risk factor for postoperative morbidity and ASA status 3 or 4 as an independent risk factor for early postoperative mortality. The rate of splenectomies performed during gastric cancer surgery decreased substantially during the study period.

CONCLUSIONS

Preoperative diagnostics were able to accurately predict resectability in almost 90% of patients which is substantially more than the corresponding results of both the EGGCS and the GGCS. In the future, more wide-spread use of EUS will play an increasing role as stage-dependent differentiation of therapeutic concepts gains acceptance. However, diagnostic accuracy of EUS needs to be improved. Our early postoperative outcome data demonstrate that the quality standard of gastric cancer care established by the EGGCS is being fulfilled at our institution in spite of distinct characteristics placing our patients at higher surgical risk. Besides being a valuable instrument of internal quality control, our study provides a good base for comparison with ongoing analyses on future developments in gastric cancer therapy.

Postgastrectomy syndromes

The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed. The indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient's long-term follow-up and care. The article does not deal with the sequelae of bariatric surgery.

Postgastrectomy nutrition

Gastric resection, whether partial or total gastrectomy, often results in nutrition-related complications including weight loss, diet intolerances, and micronutrient deficiencies. The physiology of normal and postgastrectomy digestion is the basis for most of the current diet recommendations after gastric surgery. A careful review reveals that there is not sufficient literature to support a standard postgastrectomy diet. Rather, individualized diet manipulation for symptom relief is recommended. This review highlights the physiology behind common postgastrectomy complications, provides guidelines for the medical and nutrition management of these complications, and presents a basic approach to postgastrectomy gastrointestinal symptoms.

IL-6 serum levels predict postoperative morbidity in gastric cancer patients

BACKGROUND

Despite progress in surgical techniques and perioperative care, gastrectomy remains a procedure of significant morbidity. Several scoring systems and clinical measures have been adopted to predict postoperative complications in gastric cancer patients. The aim of this study was to investigate whether high serum levels of interleukin 6 (IL-6) in the early postoperative period may be a prognostic factor of postoperative morbidity.

METHODS

A group of 99 consecutive patients with resectable gastric cancer were enrolled. The mean age was 62.9 years and the male/female ratio was 72:27. Subtotal gastric resection was performed in 22 patients and total gastric resection in 77. The IL-6 serum level was measured on the 1st postoperative day (POD).

RESULTS

Complications were recorded in 28 patients (28.3%). The observed case-fatality rate was 3.03%. An IL-6 serum level of >288.7 pg/ml on the 1st POD in univariate and multivariate Cox proportional hazard models was an independent prognostic factor for overall complications and infective complications.

CONCLUSION

Our study showed an association between perioperative IL-6 serum levels and postoperative morbidity in gastric cancer patients. The IL-6 serum level on the 1st POD was shown to be an independent prognostic factor for both overall complications and infective complications.

Early postoperative anastomotic hemorrhage after gastrectomy for gastric cancer

BACKGROUND

Postoperative anastomotic hemorrhage is a relatively rare complication, but it is lethal if not treated immediately.

METHODS

Of 1400 patients with gastric cancer who underwent gastrectomy between September 2002 and December 2007, postoperative anastomotic hemorrhage was observed in 6 patients. The surgical procedures, bleeding sites, methods of hemostasis, and clinical courses of these 6 patients were analyzed.

RESULTS

Of the 1400 patients, 878, 72, and 450 underwent distal, proximal, and total gastrectomy, respectively. The bleeding sites were as follows: transection line of the stomach using a linear stapler (n = 1); gastroduodenostomy using a circular stapler (n = 3); gastrojejunostomy by hand-suture (n = 1); and esophagojejunostomy using a circular stapler (n = 1). Five patients achieved complete hemostasis with endoscopic treatment. One patient underwent re-operation for anastomotic hemorrhage without endoscopic therapy. Two patients had delayed gastric emptying, and one patient developed an intraabdominal abscess after hemostatic treatment.

CONCLUSION

Postoperative anastomotic hemorrhage is an infrequent but potentially life-threatening complication. Endoscopy appears to be useful for both the confirmation of bleeding and therapeutic intervention.

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM: To investigate the occurrence of postoperative complications of gastric cancer surgery, and analyze the potential causes of reoperation for early postoperative complications.

METHODS: A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study. The study endpoint was the analysis of postoperative complications in inpatients.

RESULTS: About 31% of patients had early postoperative complications, and complications of infection occurred most frequently. Intra-abdominal hemorrhage and anastomotic leak were the main causes of reoperation, which accounted for about 2.2%. Mortality was 11.1% in the reoperation group, but was only 0.8% in other patients. The duration of postoperative stay in hospital was significantly longer and the total expenditure was markedly higher in the patients who underwent reoperation (P < 0.001). There was no significant association of any available factors in this study with the high rate of reoperation.

CONCLUSION: Reoperation significantly increases the mortality rate and raises the burden of the surgical unit. More prospective studies are required to explore the potential risk factors.

Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy?

Background

The selection of an anastomosis method after a distal gastrectomy is a highly debatable topic; however, the available documentation lacks the necessary research based on a comparison of early postoperative complications. This study was conducted to investigate the difference of early postoperative complications between Billroth I and Billroth II types of anastomosis for distal gastrectomies.

Methods

A total of 809 patients who underwent distal gastrectomies for gastric cancer during four years were included in the study. The only study endpoint was analysis of in-patients' postoperative complications. The risk adjusted complication rate was compared by POSSUM (Physiological and operative severity score for enumeration of morbidity and mortality) and the severity of complications was compared by Rui Jin Hospital classification of complication.

Results

Complication rate of Billroth II type of anastomosis was almost double of that in Billroth I (P = 0.000). Similarly, the risk adjusted complication rate was also higher in Billroth II group. More severe complications were observed and the postoperative duration was significantly longer in Billroth II type (P = 0.000). Overall expenditure was significantly higher in Billroth II type (P = 0.000).

Conclusion

Billroth II method of anastomosis was associated with higher rate of early postoperative complications. Therefore, we conclude that the Billroth I method should be the first choice after a distal gastrectomy as long as the anatomic and oncological environment of an individual patient allows us to perform it. However more prospective studies should be designed to compare the overall surgical outcomes of both anastomosis methods.

Post-operative complications of gastric cancer surgery: female gender at high risk

We applied physiological and operative severity score for the enumeration of morbidity and mortality (POSSUM) to evaluate overall surgical outcome and investigated the role of gender for early post-operative complications in gastric cancer surgery. The data from a total of 357 patients of gastric cancer were analysed by univariate and multivariate analysis. Post-operative complications were recorded according to definition of POSSUM. Post-operative complications of male and female patients were compared separately. The observed to estimated morbidity ratio (O:E) was 1.01. Among the pre-operative variables, patient gender was one of the independent risk factors for a higher rate of post-operative complications (risk ratio 1.777, P = 0.024). Post-operative complication was significantly higher in female patients. Similarly, post-operative length of stay was significantly longer and more severe complications were observed in female patients (P = 0.03). In conclusion, POSSUM system is a valid algorithm for risk-adjusted surgical audit. We conclude that a patient's gender influences the early post-operative complications after gastric cancer surgery. A detailed understanding on disparity of early post-operative complications between men and women may provide valuable information to improve surgical outcome of gastric cancer. However, results of this study need further confirmation by a prospective study involving a larger cohort.

Computer simulation of flow and mixing at the duodenal stump after gastric resection

AIM: To investigate the flow and mixing at the duodenal stump after gastric resection, a computer simulation was implemented.

METHODS: Using the finite element method, two different Billroth II procedure cases (A and B) were modeled. Case A was defined with a shorter and almost straight duodenal section, while case B has a much longer and curved duodenal section. Velocity, pressure and food concentration distribution were determined and the numerical results were compared with experimental observations.

RESULTS: The pressure distribution obtained by numerical simulation was in the range of the recorded experimental results. Case A had a more favorable pressure distribution in comparison with case B. However, case B had better performance in terms of food transport because of more continual food distribution, as well as better emptying of the duodenal section.

CONCLUSION: This study offers insight into the transport process within the duodenal stump section after surgical intervention, which can be useful for future patient-specific predictions of a surgical outcome.

Deep venous thrombosis after gastrectomy for gastric carcinoma: A case report

The treatment of gastric carcinoma consists of neoadjuvant chemoradiation, partial gastrectomy, subtotal gastrectomy, total gastrectomy, extended resection, and postoperative chemotherapy. Currently, gastrectomy and extended lymphadenectomy is the optimal choice for late gastric carcinoma. Postoperative complications are common after total gastrectomy including hemorrhage, anastomotic leakage, fistula, and obstruction. However, deep venous thrombosis (DVT) is an uncommon complication after gastrectomy for gastric carcinoma. We describe a case of a 68-year-old female patient with DVT after gastrectomy for gastric carcinoma. The patient was treated with anticoagulants and thrombolytics and subjected to necessary laboratory monitoring. The patient recovered well after treatment and was symptom-free during a 3-mo follow-up. We conclude that correct diagnosis and treatment of DVT are crucial.

Effect of surgical work volume on postoperative complication: superiority of specialized center in gastric cancer treatment

PURPOSE

We investigated the risk factors for early postoperative complications after gastric cancer surgery.

MATERIALS AND METHODS

The data from a total of 273 patients with gastric cancer were analyzed by univariate and multivariate analysis. We applied physiological and operative severity score for the enumeration of morbidity and mortality (POSSUM) to compare risk-adjusted surgical outcomes among different surgical units.

RESULTS

Among the preoperative variables, patient gender, chronic obstructive pulmonary disease, surgical unit, and intraoperative blood loss were independent risk factors for a higher rate of postoperative complications. There were significant differences in complication rates among different surgical units (P = 0.001). The observed-to-expected morbidity ratio (O-to-E ratio) ranged from 0.81 to 1.63. Units with low surgical work volume had higher complication rates. Postoperative length of stay was significantly shorter (P = 0.000) and the rate of moderate and severe complications was significantly lower (P = 0.001) in specialized unit.

CONCLUSIONS

POSSUM is a valid system for risk-adjusted evaluation of surgical outcomes. We conclude that surgical experience and work volume greatly influence the outcome, with overall surgical outcome in specialized centers superior to that in other units. Hence, gastric cancer surgery should be performed in specialized centers. Risk factors identified in this study need further confirmation by a prospective study involving a larger cohort.