Risk factors for esophagojejunal anastomotic leakage after elective gastrectomy for gastric cancer

A 10-year experience with anastomotic leaks in upper gastrointestinal surgery-Retrospective cohort study

BACKGROUND

Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge. We seek to identify clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries.

METHODS

592 patients underwent UGI surgeries with an anastomosis between January 2011 and January 2021. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed.

RESULTS

The overall occurrence of AL was 6.4 %. Tachycardia >120 BPM (OR 6.959, 95 % CI 1.856-26.100, p = 0.004) and leukocyte count >19 × 109/L (OR 3.327, 95 % CI 1.009-10.967, p = 0.048) were independent predictors of AL. On multivariate analysis, patients whose anastomosis was deemed high risk and had pre-emptive investigation done postoperatively to exclude a leak were less likely to require intervention and were more likely to be managed conservatively (66.7 % vs 14.3 %, p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had 50.0 %, 20.0 % and 9.1 % false negative results, while esophagogastroduodenoscopy had none. There was no misdiagnosed AL when more than 1 investigation (n = 15, 39.5 %) were performed.

CONCLUSION

Our study demonstrates that the presence of a triad including desaturation, tachycardia and leucocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed. A practice of evaluating high risk anastomosis prior to commencement of feeding decreased the need for surgical intervention and improves success of conservative treatment.

Gastrointestinal Fistula in Radical Distal Gastrectomy: Case-Control Study from a High-Volume Hospital

Background: Postoperative gastrointestinal fistula (PGF) is one of the main causes of abdominal infection and perioperative death. This study was designed to investigate the risk factors of PGF, anastomotic fistula (AF), and duodenal stump fistula (DSF) for patients who underwent radical distal gastrectomy. Materials and Methods: In this retrospective observational study, 2652 gastric cancer cases who received radical distal gastrectomy from 2010 to 2020 were selected as research subjects. Subsequently, we adopted the univariate and multivariate logistic regression analysis as statistical method to screen the risk factors for PGF, AF, and DSF, respectively. Results: In univariate analysis, gender (P = .022), operative time (P = .013), intraoperative blood loss (P < .001), tumor diameter (P = .002), and tumor stage (P < .001) were related to PGF. Multivariate logistic regression analysis identified the male (odds ratio [OR] = 2.691, P = .042), massive intraoperative hemorrhage (OR = 1.002, P = .008), and advanced tumor (OR = 2.522, P = .019) as independent predictors for PGF. Moreover, diabetes (OR = 4.497, P = .008) and massive intraoperative hemorrhage (OR = 1.003, P = .010) were proved to be associated with AF, while massive intraoperative hemorrhage (OR = 1.001, P = .050) and advanced tumor (OR = 6.485, P = .005) were independent risk factors of DSF. Conclusions: The gender, intraoperative hemorrhage, tumor stage, and diabetes were expected to be used as predictors of PGF for radical distal gastrectomy.

Endoscopic treatment of esophagogastric and esophagojejunal anastomotic leaks: A single tertiary center experience

Anastomotic leakage in esophagogastric and esophagojejunal anastomoses after esophagectomy/gastrectomy is a severe complication with a high mortality rate. We aimed to evaluate the technical and clinical success and outcomes of endoscopic placement of fully covered self-expanding metallic stents (FCSEMSs) for treating anastomotic leaks that develop after cancer surgery. All consecutive patients treated at the Gastroenterology Department, Ankara City Hospital, Ankara, Turkey, who underwent endoscopic FCSEMSs for leaks of esophagogastric or esophagojejunal anastomosis between February 2015 and December 2021 were included in the study. We analyzed the data on leak characteristics, technical success, clinical success, stent-related complications, and mortality to investigate the clinical efficacy and safety of endoscopically implanted FCSEMSs. A total of 24 patients, 12 of whom were male were included in the study. The median age of the patients was 60 years (min-max: 38-84). Nineteen patients underwent esophagojejunal anastomosis, and 5 patients underwent esophagogastric anastomosis. The median stent follow-up time was 68.8 (26-190) days, and the median hospital stay was 62.7 (24-145) days. Complications related to stent placement were observed in of 50%. The most common complication was stent migration, occurring at a frequency of 37.5%. The median follow-up period time was 11.4 (2-37) months. While the clinical success rate was 87.5%, 3 patients died. Endoscopic placement of FCSEMSs is a relatively safe and beneficial treatment for esophagojejunal and esophagogastric anastomotic leaks.

Comparison of short-term and long-term clinical effects of modified overlap anastomosis and conventional incision-assisted anastomosis in laparoscopic total gastrectomy

BACKGROUND

To compare short-term and long-term clinical effects of modified overlap anastomosis and conventional incision-assisted anastomosis for laparoscopic total gastrectomy.

METHODS

This retrospective cohort study included patients with gastric cancer admitted to the Second Affiliated Hospital of Fujian Medical University from January 2016 to March 2020. Quality of life, intraoperative and postoperative conditions were analyzed.

RESULTS

Compared with the conventional assisted group, the modified overlap group showed a shorter auxiliary incision, milder postoperative pain, shorter time to the first postoperative anal exhaust, shorter time to the first postoperative liquid food intake, and shorter postoperative stay. There were no differences between the two groups regarding operation time, esophagus-jejunum anastomosis time, intraoperative blood loss, number of lymph nodes dissected, and length of the upper incision margin. There were no differences between the two groups regarding postoperative early and late complications. There were no differences between the two groups regarding the QLQ-C30 scale three years after the operation. The scores of the QLQ-STO22 scale 3 years after the operation showed significantly lower scores for dysphagia and feeding limit in the modified overlap group than those in the conventional assisted anastomosis group. There was no recurrence in the modified overlap group but one patient in the conventional assisted group.

CONCLUSIONS

Patients undergoing totally laparoscopic total gastrectomy with modified overlap anastomosis have better minimal invasiveness and faster post-operative recovery than conventional incision-assisted anastomosis.

Magnetic compression anastomosis for reconstruction of digestive tract after total gastrectomy in beagle model

BACKGROUND

Magnetic compression anastomosis (MCA) is a simple procedure contributing to a reliable anastomosis. However, digestive-tract reconstruction after total gastrectomy using MCA has not yet been reported.

AIM

To investigate the feasibility of MCA for simultaneous esophagojejunostomy and jejunojejunostomy after total gastrectomy using beagle dogs.

METHODS

Sixteen beagles were randomly divided into an MCA group (study group, n = 8) and a manual-suture anastomosis group (control group, n = 8). Two different magnetic anastomosis devices were used in the study group for esophagojejunal and jejunojejunal anastomoses. Both devices included a pair of circular daughter and parent magnets each. The time of esophagojejunostomy and jejunojejunostomy, postoperative complications, and survival rate of the two groups were compared. The dogs were sacrificed one month after the operation and their anastomotic specimens were obtained. Healing was observed by the naked eye and a light microscope.

RESULTS

Digestive-tract reconstruction after total gastrectomy was successfully completed in both groups (survival rate = 100%). In the study group, esophagojejunal and jejunojejunal anastomoses took 6.13 ± 0.58 and 4.06 ± 0.42 min, respectively, significantly lower than those in the control group (15.63 ± 1.53 min, P < 0.001 and 10.31 ± 1.07 min, P < 0.001, respectively). Complications such as bleeding, anastomotic leakage, and anastomotic stenosis were not observed. In the study group, the magnets did not interfere with each other. Discharge time of the jejunojejunal magnetic anastomosis device was 10.75 ± 1.28 d, while that of the esophagojejunal magnetic anastomosis device was 12.25 ± 1.49 d. Residual silk was found in the control group. The study group showed a greater smoothness of the anastomosis than that of the control group. All layers of anastomosis healed well in both groups.

CONCLUSION

MCA is a safe and feasible procedure for digestive-tract reconstruction after total gastrectomy in this animal model.

Treatment and Prevention of Postoperative Leakage after Gastrectomy for Gastric Cancer

Anastomotic leakage is one of the common causes of serious morbidity and death after gastrectomy. The use of surgical treatment for leakage decreased due to the development of nonsurgical management. However, if nonsurgical management fails to control the spread of intra-abdominal infection, emergency surgical treatment is required. The authors wished to determine in which cases surgical treatment is needed for postoperative leakage and to identify treatment and prevention strategies. If a patient's vital signs are stable, local abscesses can be cured by conservative treatment after percutaneous drain insertion; if there is no improvement in anastomotic leakage, endoscopic treatment such as clipping, vacuum, and stent placement can be performed. If a patient's vital signs are unstable or patient shows diffuse peritonitis, surgical treatment should be performed. A surgical plan can be established according to leakage location. The duodenal stump may first require conservative treatment. It is recommended that surgical treatment be attempted first for anastomotic leakage of gastrojejunostomy site and gastric stump in remnant stomach. In conclusion, the need for surgical treatment is determined depending on vital signs and presence of diffuse peritonitis. During surgical treatment, a strategic approach is required according to the patient's condition and the anatomical location of leakage.

A Novel Intraoperative Leak Test Procedure (GAM Procedure) to Prevent Postoperative Anastomotic Leakage in Gastric Cancer Patients Who Underwent Gastrectomy

BACKGROUND

Anastomotic leakage following a radical gastrectomy is a serious complication of gastric cancer and esophagogastric junction cancer. The benefit of intraoperative leak testing for the prevention of postoperative anastomotic leakage has been controversial. We introduce a new procedure, which combines the techniques of gastroscopy, air, and methylene blue (GAM) for intraoperative leakage testing. Our objective was to evaluate the efficacy and safety of the GAM procedure for intraoperative leak testing and to compare the surgical complications of gastric cancer patients who underwent gastrectomy with and without intraoperative leak testing using the GAM procedure.

MATERIALS AND METHODS

A total of 210 patients who underwent radical gastrectomy for gastric cancer were included. Patients were divided into 2 groups: the intraoperative leak testing group using the GAM procedure (IOLT), and the group for which no intraoperative leak testing was done (NIOLT). Clinical and pathologic characteristics, the incidence of postoperative anastomotic leakage, and other surgical complications were compared between the 2 groups.

RESULTS

There were 82 patients in the IOLT group and 82 patients in the NIOLT group after propensity score matching. In the IOLT group, 4 (4.9%) patients were found to have anastomotic discontinuity during the operation; we repaired these anastomotic discontinuities intraoperatively. The incidence of postoperative anastomotic leakage was higher in the NIOLT group compared with the IOLT group, 6 (7.3%) versus 0 (0%), respectively ( P =0.01). The average time of the GAM procedure was 4.99±1.75 minutes. The surgical time was prolonged by 30 minutes in the IOLT group compared with the NIOLT group, 302.2±79.9 versus 272.1±85.2, respectively ( P =0.02). The length of hospital stay, 15.80±4.55 versus 17.00±6.20 ( P =0.16) was reduced in the IOLT group compared with the NIOLT group. The logistic regression model suggested that IOLT, sex, age, Eastern Cooperative Oncology Group, cT stage, tumor diameter, pT stage, pN stage, and Lauren classification were not risk factors for postoperative complication.

CONCLUSIONS

The GAM procedure of intraoperative leakage testing can effectively reduce the incidence of postoperative anastomotic leakage in gastric cancer patients undergoing gastrectomy.

Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy in patients with gastric cancer

Purpose

Esophagojejunostomy leakage after total gastrectomy for gastric cancer is one of the most serious and sometimes life-threatening adverse events. The purpose of this study was to evaluate complications after total gastrectomy in patients with gastric cancer during the period when Histoacryl (B. Braun) injection was performed. Therapeutic outcome of endoscopic Histoacryl injection for esophagojejunostomy leakage was also determined.

Methods

This was a single-center retrospective study. Between January 2016 and December 2021, clinicopathologic characteristics and surgical outcomes of 205 patients who underwent total gastrectomy were investigated. Baseline characteristics and clinical outcomes of 10 patients with esophagojejunostomy leakage were also investigated.

Results

Postoperative complication and mortality rates of total gastrectomy in 205 patients were 25.4% and 0.9%, respectively. Serious complications more than Clavien-Dindo IIIb accounted for 6.3%. Ten (4.9%) esophagojejunostomy leakages occurred in 205 patients. Among 10 esophagojejunostomy leakage patients, endoscopic Histoacryl injection was performed on eight patients and leakage was successfully managed with endoscopic Histoacryl injection in seven patients (87.5%). Mean postinjection hospital stay of seven successfully managed patients was 13.8 days. They were able to drink water at 1-6 days after injection. Among eight patients with endoscopic Histoacryl injection, six patients were injected once and two patients were injected three times.

Conclusion

Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy can be considered as a useful treatment for some selected cases.

Short-term outcomes of a new gastrointestinal decompression tube combined with conservative treatment in patients with esophagojejunal anastomotic leakage after total gastrectomy

To compare the short-term outcomes of a new gastrointestinal decompression tube combined with conservative treatment in patients with esophagojejunal anastomotic leakage (EJAL) after total gastrectomy. We retrospectively analyzed the data of 81 patients with EJAL who had undergone total gastrectomy and Roux-en-Y reconstruction at Fujian Medical University Union Hospital between January 2014 and December 2021. The patients were divided into experimental (12 patients with new gastrointestinal decompression tube plus conservative treatment) and control (69 patients with conservative treatment) groups, according to the different treatment methods they received. Anatomic defect size linearly correlated with time to clinical success, hospital stay, and hospital cost in the control group. The two groups showed no significant differences in anastomotic defect size, time of defect after surgery, hospitalization cost, and time of antibiotic use. However, the time to clinical success was significantly shorter in the experimental group than in the control group (16.0 ± 8.3 vs. 23.6 ± 17.8, P = 0.04), as was the length of hospital stay (30.1 ± 6.3 vs. 36.8 ± 16.7, P = 0.017). Furthermore, when the defect size was ≥ 4 mm, the time to clinical success, hospital stay, and hospital cost in the experimental group were lower than those in the control group (P < 0.05). Placement of a new gastrointestinal decompression tube is a safe treatment. When the defect size is ≥ 4 mm, the time to clinical success, length of hospital stay, and hospital cost can be reduced.

[One-stage reconstructive jejunogastroplasty after previous multiple abdominal surgeries for left-sided diaphragm rupture complicated by gastric incarceration and necrosis]

Acute gastric necrosis is a rare event requiring organ resection. Delayed reconstruction is advisable in patients with peritonitis and sepsis. The most common complication of gastrectomy with reconstruction is failure of esophagojejunostomy and duodenal stump. In case of severe esophagojejunostomy failure, appropriate surgical approach and timing of reconstructive stage should be analyzed. We report one-stage reconstructive surgery in a patient with multiple fistulas after previous gastrectomy. Surgery included reconstructive jejunogastroplasty with jejunal graft interposition. The patient underwent previous several unsuccessful reconstructive procedures complicated by failure of esophagojejunostomy and duodenal stump with external intestinal, duodenal and esophageal fistulas. Nutritional insufficiency, water and electrolyte disorders due to significant loss of proteins and intestinal juice through the drain tubes deteriorated clinical status. Surgical procedures finished reconstruction, provided closure of multiple fistulas and stomas and restored physiological duodenal passage.

Jejunal Mesentery Preservation Reduces Leakage at Esophagojejunostomy After Minimally Invasive Total Gastrectomy for Gastric Cancer: a Propensity Score-Matched Cohort Study

PURPOSE

The mesentery of the jejunum (MJ) of the Roux limb is conventionally divided when Roux-en-Y reconstruction is performed after total gastrectomy for gastric cancer (GC). However, the impact of dividing or preserving the MJ on anastomotic leakage (AL) at the esophagojejunostomy (EJS) site after minimally invasive total gastrectomy for GC is unclear.

METHODS

This retrospective cohort study enrolled 226 patients with GC who underwent EJS after laparoscopic or robotic total gastrectomy, including preservation of the MJ (n = 87) and division of the MJ (n = 137). The prevalence of anastomotic complications at the EJS and short-term outcomes were compared between groups using propensity score (PS) matching.

RESULTS

After PS matching, 69 patients were selected for the preserving and dividing MJ groups. There were no significant intergroup differences in patient backgrounds, including oncological stage, body mass index, and gender ratio. After PS matching, overall and severe complications after surgery were compared between the preserving and dividing MJ groups (21.7% vs. 27.5%, p = 0.554 and 8.7% vs. 13.8%, p = 0.137, respectively). However, the rate of AL at the EJS was significantly lower in the preserving than that in the dividing MJ group (1.4% vs. 13.0%, p = 0.017). In addition, the median postoperative hospital stay was significantly shorter in the preserving than that in the dividing MJ group (13.0 days vs. 16.0 days, p = 0.005).

CONCLUSIONS

Preserving the MJ significantly reduced AL at the EJS after minimally invasive total gastrectomy for GC.

Predictive Factors for Anastomotic Leakage after Laparoscopic and Open Total Gastrectomy: A Systematic Review

The aim of this systematic review is to identify patient-related, perioperative and technical risk factors for esophago-jejunal anastomotic leakage (EJAL) in patients undergoing total gastrectomy for gastric cancer (GC). A comprehensive literature search of PubMed/MEDLINE, Embase and Scopus databases was performed. Studies providing factors predictive of EJAL by uni- and multivariate analysis or an estimate of association between EJAL and related risk factors were included. All studies were assessed for methodological quality, and a narrative synthesis of the results was performed. A total of 16 studies were included in the systematic review, with a total of 42,489 patients who underwent gastrectomy with esophago-jejunal anastomosis. Age, BMI, impaired respiratory function, prognostic nutritional index (PNI), alcohol consumption, chronic renal failure, diabetes and mixed-type histology were identified as patient-related risk factors for EJAL at multivariate analysis. Likewise, among operative factors, laparoscopic approach, anastomosis type, additional organ resection, blood loss, intraoperative time and surgeon experience were found to be predictive factors for the development of EJAL. In clinical setting, we are able to identify several risk factors for EJAL. This can improve the recognition of higher-risk patients and their outcomes.

How to examine anastomotic integrity intraoperatively in totally laparoscopic radical gastrectomy? Methylene blue testing prevents technical defect-related anastomotic leaks

BACKGROUND

Intraoperative methylene blue testing (IMBT), air leak testing, or endoscopy is used to assess the anastomotic integrity of esophagojejunostomy during open total gastrectomy for gastric cancer. Totally laparoscopic radical gastrectomy has been widely used to treat gastric cancer in the last few decades. However, reports on testing anastomotic integrity in totally laparoscopic radical gastrectomy are limited.

AIM

To explore the effects of IMBT on the incidence of postoperative anastomotic leaks (PALs) and identify the risk factors for PALs in totally laparoscopic radical gastrectomy.

METHODS

From January 2017 to December 2019, patients who underwent totally laparoscopic radical gastrectomy at the Shaanxi Provincial People's Hospital were retrospectively analyzed. According to whether or not they experienced an IMBT, the patients were divided into an IMBT group and a control group. If the IMBT was positive, an intraoperative suture was required to reinforce the anastomosis. The difference in the incidence of PALs was compared, and the risk factors were investigated.

RESULTS

This study consisted of 513 patients, 211 in the IMBT group and 302 in the control group. Positive IMBT was shown in seven patients (3.3%) in the IMBT group, and no PAL occurred in these patients after suture reinforcement. Multivariate analysis showed that risk factors for predicting positive IMBT were body mass index (BMI) > 25 kg/m² (hazard ratio [HR] = 8.357, P = 0.009), operation time > 4 h (HR = 55.881, P = 0.002), and insufficient surgical experience (HR = 15.286, P = 0.010). Moreover, 15 patients (2.9%) developed PALs in 513 patients, and the rates of PALs were significantly lower in the IMBT group than in the control group [2 of 211 patients (0.9%) vs 13 of 302 patients (4.3%), P = 0.0026]. Further analysis demonstrated that preoperative complications (HR = 13.128, P = 0.017), totally laparoscopic total gastrectomy (HR = 9.075, P = 0.043), and neoadjuvant chemotherapy (HR = 7.150, P = 0.008) were independent risk factors for PALs.

CONCLUSION

IMBT is an effective method to evaluate the integrity of anastomosis during totally laparoscopic radical gastrectomy, thus preventing technical defect-related anastomotic leaks. Preoperative complications, totally laparoscopic total gastrectomy, and neoadjuvant chemotherapy are independent risk factors for PALs.

Recovery procedure for linear stapler mis-insertion in the esophageal submucosal layer during intracorporeal esophagojejunostomy

INTRODUCTION

Intracorporeal esophagojejunostomy is a technically demanding procedure, with many challenges. This study presents the anastomotic and technical complications associated with the mis-insertion of a linear stapler into the esophageal submucosal layer and the recovery procedure for this complication.

MATERIALS AND SURGICAL TECHNIQUES

Of 100 intracorporeal esophagojejunostomy cases from 2017 to 2020, this complication occurred in three cases-one during functional end-to-end anastomosis and two during the overlap method. To recover, the residual esophageal mucosa was incised from the entry point to the top of the incomplete staple line, which was then reinforced by suturing in full thickness, including the incised mucosa. After reinforcement, the common stab incision was closed by the linear stapler or handsewn. As a result, none of the patients developed anastomotic leakage or stenosis.

DISCUSSION

Mucosal dissection and suturing for recovery for the anastomotic site may be an option to address cases of mis-insertion of a linear stapler into the submucosal layer.

Two-stage esophagojejunal anastomosis: An alternative reconstruction in emergency gastrectomy for high-risk gastric cancer patients

Emergency total gastrectomy for patients with gastric cancer who are in shock carries a high risk of esophagojejunal anastomosis leakage. No alternatives have been reported to reduce this risk. This study reports two patients with gastric cancer who were in shock and underwent emergency gastrectomy and two-stage esophagojejunal anastomosis with good results. In the first stage, immediately after gastrectomy, the esophagus was attached to a Roux-en-Y jejunal loop that prevented retraction of the esophagus into the mediastinum. In the second stage, in a second surgery, the esophagojejunal anastomosis was completed under better clinical conditions.

Application value of overlap guiding tube (OGT) in assisting overlap esophagojejunostomy during laparoscopic total gastrectomy for gastric/gastroesophageal junction (G/GEJ) tumors

BACKGROUND

The overlap guiding tube (OGT) method, which was designed by our team to assist in overlap esophagojejunostomy, could potentially provide new perspectives for esophagojejunostomy. The application of the OGT-assisted method was first explored by our team and has not yet been reported.

METHODS

This cohort study analyzed the 3 month outcomes of 38 gastric/gastroesophageal junction (G/GEJ) tumor patients who underwent OGT-assisted overlap esophagojejunostomy.

RESULTS

There were 27 males and 11 females, aged 40-82 years. All patients underwent surgery successfully. The success rate of inserting anvil fork into esophageal lumen at first attempt was 97.4%. The total operation time, esophagojejunostomy time, volume of intraoperative blood loss, and length of surgical incision were 317.6 ± 51.5 min, 20.8 ± 3.8 min, 50.0 (range 15.0-200.0) ml, and 5.0 (range 4.0-8.0) cm, respectively. No procedures were converted to other laparoscopic anastomosis techniques or open approaches. The time to postoperative initial flatus, liquid diet intake, soft diet intake, and length of postoperative hospital stay were 3.0 (range 1.0-6.0) days, 4.0 (range 2.0-9.0)days, 6.0 (range 3.0-11.0) days, and 8.5 (range 6.0-16.0) days, respectively. Overall, postoperative complications were observed in 8 (21.1%) patients. Among them, one patients developed esophagojejunal anastomotic leakage. After 3 months of follow-up, none of the patients developed anastomotic stenosis or experienced unplanned secondary surgery or perioperative death.

CONCLUSIONS

OGT-assisted overlap esophagojejunostomy for patients with G/GEJ tumors is safe and feasible, with good short-term effects. OGT method has a satisfactory success rate of inserting anvil fork into esophageal lumen at first attempt and could prevent from developing esophageal submucosa pseudocanals.

Self-expanding Metal Stents for Anastomotic Leaks After Upper Gastrointestinal Cancer Surgery

BACKGROUND

Anastomotic leakage (AL) is a common and severe complication after upper gastrointestinal (UGI) surgery. Although evidence is scarce, endoscopic deployed self-expanding metal stents (SEMS) are well-established for the management of AL in UGI surgery. The present study aimed to evaluate the feasibility, effectiveness, and safety of SEMS in terms of success, mortality, and morbidity in patients with AL after UGI cancer surgery.

MATERIALS AND METHODS

Patients with AL after primary UGI cancer surgery were retrospectively analyzed with regard to demographics, disease, surgical and endoscopic procedures, and complications. Stent treatment success was divided into technical, primary (within 72 hours of stent deployment), sustained (after 72 hours of stent deployment), and sealing success.

RESULTS

In a total of 63 patients, 74 stents were used and 11 were deployed in endoscopic reinterventions. Stent deployment was successful in all patients. Primary and sustained success rates were 68.3% (n = 43) and 65.1% (n = 41), respectively. Of the primarily successfully treated patients, 87.8% remained successfully treated. If primary treatment was unsuccessful, it remained unsuccessful in 66.6% of the patients (P = 0.002). Final sealing of the leakage was observed in 65.1% of patients (n = 41). Longer stent shafts and wider stent end widths were correlated with successful stent treatment (P < 0.05).

CONCLUSION

SEMS are a safe and sufficient tool in the treatment of AL after UGI cancer surgery. Treatment success is improved with longer stent shafts and wider stent end widths. Switching to alternative treatments is strongly suggested if signs of persistent leakage are present beyond 72 hours after stent placement, as this is highly indicative of sustained stent failure.

Aorta Calcification Increases the Risk of Anastomotic Leakage After Gastrectomy in Gastric Cancer Patients

Purpose

The purpose of the present study was to evaluate whether vascular calcification is a risk factor for anastomotic leakage after gastrectomy in gastric cancer patients.

Methods

Patients with confirmed gastric cancer were collected from the database of a single clinical center from January 2013 to January 2019. The calcification score and anastomotic leakage were recorded, and predictors of anastomotic leakage were analyzed.

Results

A total of 856 patients were included in this study; 818 patients had no anastomotic leakage, and 38 patients had anastomotic leakage. The ratio of hypertension status (p=0.011), open gastrectomy (p=0.012), postoperative length of stay (p=0.000), aorta calcification score (p=0.000) and celiac axis calcification (p=0.000) were higher in the anastomotic leakage group than in the nonanastomotic leakage group. In multivariate analysis, aorta calcification (p=0.029, odds ratio =2.425, 95% CI=1.095–5.491) was an independent predictor of the anastomotic leakage.

Conclusion

Aorta calcification is an independent risk factor for anastomotic leakage after gastrectomy in gastric cancer patients.

Risk factors for esophagojejunal anastomotic leakage after curative total gastrectomy combined with D2 lymph node dissection for gastric cancer

OBJECTIVE

To explore the risk factors associated with esophagojejunal anastomotic leakage (EJAL) after curative total gastrectomy combined with D2 lymph node dissection for gastric cancer.

METHODS

We reviewed the data for 390 consecutive patients undergoing Roux-en-Y esophagojejunostomy reconstruction after total gastrectomy. Multivariate analysis was performed using a logistic regression model to identify the independent risk factors for EJAL.

RESULTS

Of the 390 patients enrolled in this study, EJAL occurred in 10 patients (2.6%), and one patient (1/10) with EJAL died. Univariate analysis identified age, alcohol consumption, pulmonary insufficiency, and intraoperative blood loss as risk factors for EJAL. Of these four risk factors, age and alcohol consumption were retained as independent risk factors by multivariate analysis.

CONCLUSION

Surgeons should be very careful regarding anastomotic leakage after esophagojejunal anastomosis, perioperatively, especially in patients with advanced age and a history of alcohol consumption. Pulmonary insufficiency and intraoperative blood loss, although not identified as independent risk factors, should also be considered.

Prognosis of hemodialysis patients undergoing surgery for gastric cancer: Results of a multicenter retrospective study

BACKGROUND

Little is known about the survival outcomes of and predictive factors for survival in hemodialysis patients undergoing surgery for gastric cancer.

METHODS

We performed a multicenter retrospective study from 9 institutions to investigate the survival outcomes of 75 hemodialysis patients with gastric cancer. Patient characteristics included demographic data, hemodialysis- and gastric cancer-related variables. Multivariate Cox hazards models were applied to determine independent predictors of poor overall survival and non-gastric cancer related death.

RESULTS

Stage I disease was predominant (58.7%) in our series. The overall morbidity and the 30-day mortality rates were 25.3% and 1.3%, respectively. The 5-year overall survival rates of patients with pStages I, II, III, and IV disease were 59.2%, 42.9%, 32.3%, and 0%, respectively. Eleven (14.7%) patients died of gastric cancer, whereas many more (40.0%) died owing to causes other than gastric cancer. Non-gastric cancer-related death was especially prevalent in patients with pStages I (95.2%) and II (75.0%) disease. Multivariable analysis revealed advanced age, long duration of hemodialysis (> 5 years), total gastrectomy, and pStage IV disease to be independently associated with poor overall survival. Notably, advanced age, long duration of hemodialysis, and the presence of cardiovascular disease were all independent predictors of non-gastric cancer-related death. Patients with all 3 factors had very poor survival outcomes (3-year overall survival; 14.3%).

CONCLUSION

The survival outcomes of hemodialysis patients with gastric cancer, especially those with early-stage gastric cancer, were clearly poor, largely owing to the increased risk of non-gastric cancer-related death. Preoperative comorbidities and hemodialytic features were useful for predicting long-term outcomes of this vulnerable population.

Risk Factors for the Severity of Complications in Minimally Invasive Total Gastrectomy for Gastric Cancer: a Retrospective Cohort Study

Purpose

Minimally invasive gastrectomy is a promising surgical method with well-known benefits, including reduced postoperative complications. However, for total gastrectomy of gastric cancers, this approach does not significantly reduce the risk of complications. Therefore, we aimed to evaluate the incidence and risk factors for the severity of complications associated with minimally invasive total gastrectomy for gastric cancer.

Materials and Methods

The study included 392 consecutive patients with gastric cancer who underwent either laparoscopic or robotic total gastrectomy between 2011 and 2019. Clinicopathological and operative characteristics were assessed to determine the features related to postoperative complications after minimally invasive total gastrectomy. Binomial and multinomial logistic regression models were used to identify the risk factors for overall complications and mild and severe complications, respectively.

Results

Of 103 (26.3%) patients experiencing complications, 66 (16.8%) and 37 (9.4%) developed mild and severe complications, respectively. On multivariate multinomial regression analysis, independent predictors of severe complications included obesity (OR, 2.56; 95% CI, 1.02−6.43; P=0.046), advanced stage (OR, 2.90; 95% CI, 1.13−7.43; P=0.026), and more intraoperative bleeding (OR, 1.04; 95% CI, 1.02−1.06; P=0.001). Operation time was the only independent risk factor for mild complications (OR, 1.06; 95% CI, 1.001−1.13; P=0.047).

Conclusions

The risk factors for mild and severe complications were associated with surgery, indicating surgical difficulty. Surgeons should be aware of these potential risks that are related to the severity of complications so as to reduce surgery-related complications after minimally invasive total gastrectomy for gastric cancer.

A Comparison of the Short-Term Clinical Effects Between Totally Laparoscopic Radical Gastrectomy With Modified Roux-en-Y Anastomosis and Laparoscopic-Assisted Radical Gastrectomy With Roux-en-Y Anastomosis

Objective:

To compare the short-term clinical effects between totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis, and laparoscopic-assisted radical gastrectomy with Roux-en-Y anastomosis; to explore the safety, feasibility and short-term effect of totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis.

Methods:

Data of 75 patients who underwent totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis, and 95 patients who underwent laparoscopic-assisted radical gastrectomy with Roux-en-Y anastomosis by the same surgical team were analyzed. During the modified Roux-en-Y anastomosis, the stomach separation and regional lymph node dissection were completed under a laparoscope; the specimen was placed in a bag; gastrojejunostomy was completed; the subumbilicus hole was enlarged to 3 cm; the specimen was taken out; then, the proximal and distal ends of the small intestine were moved outside of the abdominal wall to complete the small intestine-small intestine end-to-side anastomosis.

Results:

All 170 operations were successful. The differences in the time of anastomosis and the number of dissected lymph nodes between the 2 groups were not statistically significant (P > 0.05), but in the totally-MA group the amount of bleeding and the length of incision significantly decreased (P < 0.05). The recovery time as measured by breathing unassisted, drinking fluids and getting out of bed was significantly shorter than those in the laparoscopic-assisted group (P < 0.05), and the pain score 1 day after surgery was significantly lower than that of the laparoscopic-assisted group (P < 0.05). One case of duodenal stump leakage and 1 case of esophagojejunostomy leakage were found in the laparoscopic-assisted group. In the totally-MA group, there were no complications such as anastomotic leakage, anastomotic stenosis or anastomotic bleeding, but 2 patients with double primary carcinoma underwent joint radical resection.

Conclusion:

Compared with laparoscopic-assisted surgery, totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis has the advantages of being safer and less traumatic, with associated reductions in bleeding and pain.

Tubular anastomosis with full-thickness discontinuous tension-reduction suture can reduce incidence of cervical anastomotic fistula after surgery for esophageal cancer

BACKGROUND

Anastomotic fistula is the most common serious complication after operation for esophageal cancer. This study retrospectively analyzed the clinical data of patients undergoing radical resection of esophageal carcinoma at our department, identified the relevant risk factors for anastomotic fistula, and investigated the effects of tubular anastomosis with full-thickness discontinuous tension-reduction suture for the prevention of anastomotic fistula.

AIM

To analyze the risk factors affecting the occurrence of cervical anastomotic fistula after surgery of esophageal cancer, and to explore the safety and effectiveness of tubular anastomosis with full-thickness discontinuous tension-reduction suture on anastomotic fistula.

METHODS

The clinical data of 544 patients with esophageal squamous cell carcinoma undergoing radical surgery from May 2014 to December 2018 at the Department of Thoracic Surgery, Anyang Tumor Hospital were retrospectively analyzed, and possible factors related to the occurrence of cervical anastomotic fistula were identified. Single-factor and multi-factor Logistic regression analyses were performed to determine the independent risk factors for the occurrence of cervical anastomotic fistula.

RESULTS

The patient's age, diabetes history, duration of operation (> 300 min), and full-thickness discontinuous suture after tubular anastomosis were independent risk factors for the occurrence of postoperative anastomotic fistula. Among them, tubular anastomosis with full-thickness discontinuous tension-reduction suture was beneficial to reduce the incidence of postoperative cervical anastomotic fistula (6.1% vs 13.1%, P < 0.05).

CONCLUSION

It is safe and effective to prevent cervical anastomotic fistula by using tubular anastomosis with full-thickness discontinuous tension-reduction suture.

Mixed Type Histology as a Predictive Factor for Esophagojejunostomy Leak in Advanced Gastric Cancer

Since esophagojejunostomy leak (EJL) after gastrectomy is a potentially fatal complication and may impact the survival of patients with advanced gastric cancer (GC), it is important to establish risk factors for the EJL and to prevent this surgical complication. The aim of this study was analysis of predictors for the postoperative clinically apparent EJL. All patients operated for advanced GC between October 2016 and December 2019 were analyzed from a prospectively maintained database. The evaluation of the EJL and postoperative complications according to the demographic and clinical (categorized) variables was performed with odds ratio test (multivariate analysis was performed with the use of logistic regression method). Among the 114 patients included in the study, 71.1% received neoadjuvant chemotherapy and 19.3% underwent gastrectomy followed by the hyperthermic intraperitoneal chemotherapy (HIPEC). Postoperative EJL was found in 4.6% patients. The risk of EJL was significantly higher for mixed-type GC (OR = 12.45, 95% CI: 1.03-150.10; p = 0.0472). The risk of other postoperative complications was significantly higher in patients undergoing HIPEC (OR = 3.88, 95% CI: 1.40-10.80, p = 0.0094). The number of lymph nodes removed (>38) was characterized by 80% sensitivity and 79.6% specificity in predicting EJL (AUC = 0.80, 95% CI: 0.72-0.87; p < 0.0001). Mixed histological type of GC is a tumor-related risk factor for the EJL. HIPEC was confirmed to be a risk factor for postoperative complications after gastrectomy.

Radiological appearances of Anastomotic Leakage after Radical Gastrectomy.. [DOI: 10.1101/2020.04.25.20080093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Anastomotic leakage is a critical postoperative complication after gastric cancer surgery. Previous studies have not specified radiological findings of anastomotic leakage. We investigated the potential burden caused by postoperative anastomotic leakage and explored the objective appearances of anastomotic leakage on computed tomography (CT) examination.

Methods

Gastric cancer patients who underwent curative gastrectomy and had a CT examination after surgery were included in this study. Propensity score (PS) matching generated 70 cases (35 cases of anastomotic leakage and 35 cases of no anastomotic leak) among 210 eligible cases. Univariate and multivariate analyses were used to identify the predictive variables of CT findings.

Results

More severe postoperative complications were observed in patients who had an anastomotic failure than those without anastomotic leakage(p<0.05). The median number of postoperative days (PODs) was 18 days for patients with no anastomotic leak, but the length of stay was almost three times longer (50 days) in patients with anastomotic leakage(p<0.05). In the univariate analysis, we observed a significant association between anastomotic leakage and five CT variables, including pneumoperitoneum, pneumoseroperitoneum (intra-abdominal accumulation of mixed gas and fluid), accumulation of extraluminal gas at the anastomosis site, seroperitoneum and extraluminal fluid collection at the anastomosis site (p<0.05). The multivariate analysis of the CT parameters revealed that the accumulation of extraluminal gas at the anastomosis site is the independent diagnostic parameters of a postoperative anastomotic leakage (p<0.05).

Conclusions

The occurrence of an anastomotic leakage significantly compromises the patients and increases the treatment burden. The CT variables of this study are beneficial to rule out anastomotic leakage after gastric cancer surgery. Extraluminal gas at the anastomosis site is highly suggestive of anastomotic leakage.

Prehabilitation: how to prepare our patients for elective major abdominal surgeries?

Surgical approach is the main form of treatment for several diseases of the abdominal cavity. However, surgical procedure itself is a stressor that may lead to adverse effects unrelated to the treatment goal. Prehabilitation has emerged as a multifactorial preoperative health conditioning program, which promotes improvement in functional capacity and postoperative evolution. The present study reviews literature using MEDLINE, Ovid, Google Scholar, and Cochrane databases in order to determine the concept of prehabilitation program and the indications and means of patient selection for it, as well as to suggest ways to implement this program in cases of major abdominal surgeries.

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.

The Preoperative Geriatric Nutritional Risk Index Predicts Postoperative Complications in Elderly Patients with Gastric Cancer Undergoing Gastrectomy

BACKGROUND/AIM

The relationship between the preoperative Geriatric Nutritional Risk Index (GNRI) and morbidity of patients with gastric cancer (GC) undergoing gastrectomy has not yet been reported. Our study aimed to investigate whether preoperative GNRI is associated with short-term outcomes in elderly patients with GC.

PATIENTS AND METHODS

This study enrolled 348 elderly patients with GC who were more than 75 years old and underwent curative gastrectomy for GC at our Institution between January 2006 and December 2015. GNRI was invoked to stratify patients as high (GNRI≥92; n=190) or low (GNRI<92; n=158) GNRI nutritional status. The clinicopathologic features and short-term outcomes were compared.

RESULTS

In multivariate analysis, low GNRI emerged as an independent predictor of postoperative complications (Clavien Dindo classification grade II≤). Low GNRI demonstrated significantly more frequent extra-surgical complications than high GNRI. Significantly more patients with low GNRI suffered from postoperative pneumoniae than patients with high GNRI (p=0.013). On the other hand, the incidence of surgical field complications such as leakage, pancreatic fistula and intraabdominal abscess did not differ significantly between the groups.

CONCLUSION

GNRI is useful in predicting postoperative complications of elderly patients with GC undergoing gastrectomy. Preoperative GNRI has merit as a gauge of postoperative complications in the extra-surgical field, especially pneumonia. There was no relationship between preoperative GNRI and surgical field complications in this setting.

Novel abdominal negative pressure lavage-drainage system for anastomotic leakage after R0 resection for gastric cancer

BACKGROUND

Anastomotic leakage (AL) is a severe complication associated with high morbidity and mortality after radical gastrectomy (RG) for gastric cancer (GC). We hypothesized that a novel abdominal negative pressure lavage-drainage system (ANPLDS) can effectively reduce the failure-to-rescue (FTR) and the risk of reoperation, and it is a feasible management for AL.

AIM

To report our institution’s experience with a novel ANPLDS for AL after RG for GC.

METHODS

The study enrolled 4173 patients who underwent R0 resection for GC at our institution between June 2009 and December 2016. ANPLDS was routinely used for patients with AL after January 2014. Characterization of patients who underwent R0 resection was compared between different study periods. AL rates and postoperative outcome among patients with AL were compared before and after the ANPLDS therapy. We used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with AL and FTR after AL.

RESULTS

AL occurred in 83 (83/4173, 2%) patients, leading to 7 deaths. The mean time of occurrence of AL was 5.6 days. The AL rate was similar before (2009-2013, period 1) and after (2014-2016, period 2) the implementation of the ANPLDS therapy (1.7% vs 2.3%, P = 0.121). Age and malnourishment were independently associated with AL. The FTR rate and abdominal bleeding rate after AL occurred were respectively 8.4% and 9.6% for the entire period; however, compared with period 1, this significantly decreased during period 2 (16.2% vs 2.2%, P = 0.041; 18.9% vs 2.2%, P = 0.020, respectively). Moreover, the reoperation rate was also reduced in period 2, although this result was not statistically significant (13.5% vs 2.2%, P = 0.084). Additionally, only ANPLDS therapy was an independent protective factor for FTR after AL (P = 0.04).

CONCLUSION

Our experience demonstrates that ANPLDS is a feasible management for AL after RG for GC.

Risk factors and laboratory markers used to predict leakage in esophagojejunal anastomotic leakage after total gastrectomy

Objectives

Esophagojejunal anastomotic leakages, which occur in the reconstruction procedures performed after total or proximal gastrectomy, still account for one of the most significant causes of morbidity and mortality in spite of the developments seen in perioperative management and surgical techniques in gastric cancer surgery. The aim of the present study was to ascertain the risk factors for Esophagojejunal anastomotic leakages.

Material and Methods

A total of 80 patients with gastric cancer, who had total gastrectomy +D2 lymph node dissection and Esophagojejunal anastomotic between January 2013 and December 2016, were retrospectively evaluated. Patients who did not have anastomotic leakages during their clinical follow-ups were allocated to Group 1, whereas those who had anastomotic leakages were allocated to Group 2.

Results

A total of 58 (72.5%) out of 80 patients were males, whereas 22 (27.5%) were females. Mean age of the patients was 61.2 ± 11.2 years. There were no demographic differences between the groups. Postoperative recurrent fever (p= 0.001), C-reactive protein values on postoperative days 3 and 5 (p= 0.01), and neutrophil-to-lymphocyte ratio on postoperative day 5 (p= 0.022) were found to be statistically significant with regard to Esophagojejunal anastomotic leakages and other postoperative complications. The duration of operation (p= 0.032) and combined organ resection (p= 0.008) were ascertained as risk factors for Esophagojejunal anastomotic leakages.

Conclusion

Surgeons should be careful about Esophagojejunal anastomotic leakages which are significant postoperative complications seen especially in cases where the duration of operation is prolonged, and additional organ resections are performed. Recurrent fever, high C-reactive protein levels, and neutrophil-to-lymphocyte ratio may serve as warnings for complications in postoperative follow-ups.

Endoscopic Full-Thickness Defects and Closure Techniques

PURPOSE OF REVIEW

Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects.

RECENT FINDINGS

The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.

Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer

Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.

Long-Term Nutritional Outcomes of Near-Total Gastrectomy in Gastric Cancer Treatment: a Comparison with Total Gastrectomy Using Propensity Score Matching Analysis

Purpose

This study sought to examine whether near total gastrectomy (nTG) confers a long-term nutritional benefit when compared with total gastrectomy (TG) for the treatment of gastric cancer.

Materials and Methods

Patients who underwent nTG or TG for gastric cancer were included (n=570). Using the 1:2 matched propensity score, 25 patients from the nTG group and 50 patients from the TG group were compared retrospectively for oncologic outcomes, including long-term survival and nutritional status.

Results

The length of the proximal resection margin, number of retrieved lymph nodes and tumor nodes, metastasis stage, short-term postoperative outcomes, and long-term survival were not significantly different between the groups. The body mass index values, and serum total protein and hemoglobin levels of the patients decreased significantly until postoperative 6 months, and then recovered slightly over time (P<0.05); however, there was no difference in the levels between the groups. The prognostic nutritional index values and serum albumin levels decreased significantly until postoperative 6 months and then recovered (P<0.05); the levels decreased more in the nTG group than in the TG group (P<0.05). The mean corpuscular volumes and serum transferrin levels increased significantly until postoperative 1 year and then recovered slightly over time (P<0.05); however, there was no difference between the groups. Serum vitamin B₁₂, iron, and ferritin levels of the patients did not change significantly over time, and no difference existed between the groups.

Conclusions

A small remnant stomach after nTG conferred no significant nutritional benefits over TG.

Towards optimal intraoperative conditions in esophageal surgery: A review of literature for the prevention of esophageal anastomotic leakage

BACKGROUND

Esophageal anastomotic leakage (EAL) is a severe complication following gastric and esophageal surgery for cancer. Several non-modifiable, patient or surgery related risk factors for EAL have been identified, however, the contribution of modifiable intraoperative parameters remains undetermined. This review provides an overview of current literature on potentially modifiable intraoperative risk factors for EAL.

MATERIALS AND METHODS

The PubMed, EMBASE and Cochrane databases were searched by two researchers independently. Clinical studies published in English between 1970 and January 2017 that evaluated the effect of intraoperative parameters on the development of EAL were included. Levels of evidence as defined by the Centre of Evidence Based Medicine (CEBM) were assigned to the studies.

RESULTS

A total of 25 articles were included in the final analysis. These articles show evidence that anemia, increased amount of blood loss, low pH and high pCO2 values, prolonged duration of procedure and lack of surgical experience independently increase the risk of EAL. Supplemental oxygen therapy, epidural analgesia and selective digestive decontamination seem to have a beneficial effect. Potential risk factors include blood pressure, requirement of blood products, vasopressor use and glucocorticoid administration, however the results are ambiguous.

CONCLUSION

Apart from fixed surgical and patient related factors, several intraoperative factors that can be modified in clinical practice can influence the risk of developing EAL. More prospective, observational studies are necessary focusing on modifiable intraoperative parameters to assess more evidence and to elucidate optimal values of these factors.

Ketorolac and Other NSAIDs Increase the Risk of Anastomotic Leakage After Surgery for GEJ Cancers: a Cohort Study of 557 Patients

OBJECTIVE

The objective of this study is to investigate the impact of ketorolac and other nonsteroidal anti-inflammatory drugs on anastomotic leakage after surgery for gastro-esophageal-junction cancer. Within the last two decades, the incidence of gastro-esophageal-junction cancer has increased in the western world and surgery is the curative treatment modality of choice. Anastomotic leakage is a feared complication of gastro-esophageal surgery, as it increases recurrence, morbidity, and mortality. Nonsteroidal anti-inflammatory drugs are widely used for postoperative pain relief. Nonsteroidal anti-inflammatory drugs have, however, in colorectal surgery, been shown to increase the risk of anastomotic leakage.

METHOD

In a historical cohort study, we investigated the impact of nonsteroidal anti-inflammatory drugs on anastomotic leakage in 557 patients undergoing surgery for gastro-esophageal-junction cancer. Data were collected from a prospective maintained database, the Danish National Patient Registry, and patient medical records. Data were analyzed using univariate and multivariate statistical models and were stratified for theoretical confounders.

RESULTS

In univariate analysis, we did not observe any difference in age, gender, tobacco exposure, or comorbidity status between patients experiencing anastomotic leakage and those without. In multivariate analysis, gender, histology, and type of anastomosis proved to affect odds ratios for anastomotic leakage. After adjustment for possible confounders, we found an odds ratio of 6.05 (95% confidence interval 2.71; 13.5) for ketorolac use and of 5.24 (95% confidence interval 1.85; 14.8) for use of other nonsteroidal anti-inflammatory drugs for anastomotic leakage during the first seven postoperative days.

CONCLUSION

In the present study, we found a strong association between the postoperative use of ketorolac and other nonsteroidal anti-inflammatory drugs and the risk for anastomotic leakage after surgery for gastro-esophageal-junction cancers.

Outcomes following the main treatment options in patients with a leaking esophagus: a systematic literature review

Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368) and the in-hospital mortality was 17% (61/368). The current literature suggests that a SEMS-based therapy can be successfully applied as an alternative therapeutic strategy in esophageal perforation rupture.

Combat with esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer: A critical review of the literature

Esophagojejunal anastomotic leakage (EJAL) is considered to be one of the most serious complications after total gastrectomy (TG), despite improvements in surgical instruments and technique. The occurrence of EJAL would cause poorer quality of life, prolonged hospital stay, and increased surgery-related costs and mortality. Although there is ever-increasing knowledge about EJAL, the optimal management is controversial. In the present review, we aim to demonstrate the effective management by focus on the possible risk factors, potentially useful preventive strategies, and several kinds of treatments in esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer.

Anastomotic complications after laparoscopic total gastrectomy with esophagojejunostomy constructed by circular stapler (OrVil™) versus linear stapler (overlap method)

BACKGROUND

Esophagojejunostomy after laparoscopic total gastrectomy (LTG) is the most technically difficult type of anastomosis; thus, anastomotic complications such as leakage and stenosis sometimes occur. Identification of the safest anastomotic procedure is important for successful LTG. We have performed LTG since 2004 either with a circular stapler using an OrVil^™ anvil or via the overlap Orringer method with a linear stapler. This retrospective study aimed to determine which method results in a lower incidence of anastomotic complications in patients undergoing LTG.

METHODS

Data on 188 consecutive patients who underwent LTG between April 2004 and August 2016 were retrospectively reviewed. Patients were divided into those who underwent esophagojejunostomy performed via a circular stapler using an OrVil^™ anvil (group C, n = 49) or via the overlap method (group L, n = 139).

RESULTS

Anastomotic complications occurred in five of 188 esophagojejunostomies (2.7%). They comprised three cases of leakage (1.6%), and two of stenosis (1.1%). There was no significant difference in patient characteristics or hematological variables between groups C and L. There was no significant difference between groups in operation time, blood loss, lymph node dissection, and intraoperative anastomotic problems. The rate of anastomotic complications was significantly lower in group L (0.7%, 1/139) than in group C (8.2%, 4/49; p = 0.005). In particular, anastomotic leakage in group L tended to be lower (0.7% 1/139) than in group C (4.1% 2/49), although this difference was not significant. The rate of anastomotic stenosis in group L was significantly lower (0%, 0/139) than in group C (4.1%, 2/49; p = 0.017). Furthermore multivariate analysis showed anastomotic procedure was an independent factor for anastomotic complication.

CONCLUSIONS

There were fewer anastomotic complications after overlap esophagojejunostomy than after esophagojejunostomy via the OrVil^™ procedure, especially regarding anastomotic stenosis. We therefore recommend the overlap technique when performing esophagojejunostomy.

Anastomotic leaks in gastrointestinal surgery and their prevention

Anastomotic leak in the gastrointestinal tract is one of the most important complications of resection. They are the main cause of reoperation, their occurrence worsens the prognosis of the patient, increasing the proportion of direct mortality, as well as being a significant risk factor for recurrence of cancer. The risk of leaks within the gastrointestinal tract is greatly varied, depending on the location and extent of the resection, but also on patient, disease or a surgical procedure, including surgeon. To determine the potential risk of leakage can be significant for introduction some prophylactic actions. Some of them have the character of general recommendations, as proper nutrition of the patient in the perioperative period, while another part is directly connected to the surgical procedure. The second group includes protective stoma, the use of tissue glues, insertion transrectal drain for rectal anastomosis decompression, the use of stents or the use of collagen matrix coated with fibrinogen and thrombin. Important to reduce the proportion of leaks can be more precise and targeted prophylactic recommendations, based on the individualized determination of risk factors leaks. Further research for this purpose are necessary for this purpose, the big hope can be associated with data obtained through mobile applications.

Diagnosis and treatment of duodenal stump leakage after laparoscopic gastrectomy

Duodenal stump fistula is a severe early postoperative complication of laparoscopic gastrectomy. It may cause the leakage of a large amount of digestive juices, which contain pancreatic juice and bile, into the abdominal cavity, thus leading to intra-abdominal hemorrhage and intra-abdominal infection, or even threatening the life. The most effective treatment for duodenal stump fistula is establishing effective and sufficient drainage as soon as possible. We recommend that effective operative treatment should be employed once duodenal stump fistula is diagnosed. After operation, Li's drainage tube is used for continuous drainage of the abdominal cavity. Proper antibiotics, symptomatic therapy, and effective nutrition support are the key to the treatment of duodenal stump fistula. If possible, a nasointestinal tube should be placed for enteral nutrition as soon as possible. In addition to these treatments, somatostatin and growth hormone can promote the healing of intestinal fistula.

Perioperative blood transfusions increases the risk of anastomotic leakage after surgery for GEJ-cancer

OBJECTIVE

To investigate the effect of blood transfusions on the risk of anastomotic leakage (AL) in patients with gastro-esophageal-junction (GEJ) cancer.

BACKGROUND

The incidence of GEJ cancer is increasing in the western world. Surgery is the curative treatment of choice. AL increases mortality and morbidity, and increases the risk cancer reoccurrence. In colo-rectal surgery a relation between AL and blood transfusions have been demonstrated.

METHOD

The risk of AL in relation to blood transfusions was investigated in a cohort study. 253 consecutive patients undergoing surgery for GEJ cancer was included. Data was based on a prospective maintained database and analyzed using logistic regressions models adjusting for multiple confounders.

RESULTS

We found an increased risk of AL when blood was transfused OR: 3.47, (1.51; 7.99). This relation was consistent after adjustment for multiple confounders OR: 4.60, (1.29; 16.4). Increasing number of blood units did not increase risk of AL further.

CONCLUSION

We present data demonstrating a strong correlation between receiving blood transfusions and the risk of AL after surgery in GEJ cancers patients.

Development of a nomogram for predicting the risk of anastomotic leakage after a gastrectomy for gastric cancer

AIMS

To investigate the incidence of and factors associated with anastomotic leakage (AL) following gastrectomy for gastric cancer.

METHODS

We retrospectively analyzed 3632 patients who underwent a laparoscopic gastrectomy or open gastrectomy for gastric cancer. A logistic regression model was used to identify the determinant variables, and a nomogram for AL was developed.

RESULTS

A total of 3632 patients were included in the study, 50 of whom (1.4%) developed AL. Postoperative deaths occurred in 6 (0.2%) patients with AL failure to rescue. Esophagojejunal AL (27/50) and Billroth I AL (20/50) were the most common types of AL. Gastrografin swallow was the main diagnostic method. The diagnosis was made a median of 9 days postoperatively. The median healing time for AL was 34.5 days. Of the 50 AL patients, 56% of patients could be managed nonsurgically, whereas 28% of patients required percutaneous radiologic drainage, 6% of patients were treated by endoscopy, and 10% of patients required a second surgery. A multivariate analysis showed the following adverse risk factors for AL: age ≥65 years, hemoglobin ≤8.0 g/dL and malnourishment. A multivariable model for AL showed a strong optimism-adjusted discrimination (concordance index, 0.675). The 5-year overall survival rates for patients without or with AL were 59.4% and 67.4%, respectively (p = 0.354).

CONCLUSIONS

AL was infrequent but was more prevalent in patients with age ≥65 years, hemoglobin ≤8.0 g/dL and malnourishment. We created a novel nomogram that can provide individualized prediction of AL in patients after a gastrectomy for gastric cancer, which may help clinicians in making treatment decisions.

Esophagojejunal anastomosis leakage after total gastrectomy for esophagogastric junction adenocarcinoma: options of treatment

BACKGROUND

Esophagojejunal anastomosis leakage after total gastrectomy (TG) for esophagogastric junction (EGJ) adenocarcinoma (ADC) constitutes one of the most serious and sometimes life-threatening complications. Management remains controversial and still challenging.

METHODS

A total of 198 patients operated for type I and II EGJ ADC were reviewed. Diagnosis of leakage was based on a combination of clinical and radiological findings. It was classified including objective endoscopic and clinical parameters requiring different type of treatment.

RESULTS

Anastomotic leakage was diagnosed in 14 patients (7%). Two cases recovered with conservative therapy. Six cases underwent endoscopy with clips placement in 2 and partially covered self-expandable metal stent placement in 4. Other two cases underwent reoperation with reconstruction of anastomosis and primary repair respectively. In the last four cases emergency surgery with total esophagectomy and diversion was required. Mortality occurred only in 3 of these patients and overall treatment was successful in 11 patients (78.5%).

CONCLUSIONS

No consensus has been reached on the best method of esophagojejunal anastomosis leakage management and the rate of failure remains significant. Different options of treatment are available but early detection and multidisciplinary approaches are the keys to obtain successful results irrespective of the employed strategy.

Recent improvements in the management of esophageal anastomotic leak after surgery for cancer

Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage. Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures. Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed. Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer.

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.