Morbidity after Total Gastrectomy: Analysis of 238 Patients

Preoperative Glutamine Supplementation in Gastric Cancer-Thrombocyte Phagocytic Activity and Early Postoperative Outcomes

BACKGROUND

The aim of this study was to determine the phagocytic activity of thrombocytes in patients with gastric cancer and to assess the effect of oral and parenteral preoperative glutamine-based immunonutrition on nutritional status, thrombocyte phagocytic activity, and early postoperative outcomes.

METHODS

Patients suffering from invasive gastric cancer had been treated with preoperative immunonutrition with glutamine, and they were compared to patients without nutritional treatment. Nutritional status, percentage of weight loss, and BMI were assessed. Levels of total protein, albumin, cholesterol, triglycerides, platelets, and their phagocytic ability were measured twice. Postsurgical complications were assessed via the Clavien-Dindo classification.

RESULTS

Group I consisted of 20 patients with an oral glutamine-10 g daily. Group II had 38 patients who received intravenous glutamine, 1.5 mL per kg body weight of Dipeptiven. Group III consisted of 25 patients who did not receive preoperative immunonutrition. In total, 47% of patients in Group I, 54% of patients in Group II, and 33% of patients in Group III were malnourished. In Group I, the percentage of phagocytizing platelet (%PhP) was 1.1 preoperatively and 1.2 postoperatively. The phagocytic index (PhI) was 1.0 and 1.1. In Group II, %PhP was 1.1 and 1.2 and PhI was 1.0 and 1.1. In Group III, the %PhP was 1.0 and 1.2 and PhI was 1.0 and 1.1. An increase in triglyceride level was observed in both immunonutrition groups. There was a decline in total protein and albumin level in Group II. In Group III, there was a decline in total protein, albumin, and cholesterol level. The total platelet count and PhI were increased in both immunonutrition groups. There was also a rise in %PhP in Group II. In Group III, there was a rise in blood platelet level, %PhP, and PhI. The complication rates were 53% in Group I, 29% in Group II, and 40% in Group III.

CONCLUSIONS

In invasive gastric cancer, laboratory nutritional parameters are significantly reduced, causing malnutrition in 44.7% of patients. Oral glutamine supplementation inhibited the postoperative decline in protein metabolism parameters; however, this did not affect the reduction in the percentage of postoperative complications. Glutamine used preoperatively significantly reduced the percentage of serious surgical complications, regardless of the way it was supplemented. Patients with invasive gastric cancer have a significant decrease in platelet phagocytic activity. The administered preoperative parenteral nutrition and the surgical procedure itself influenced the improvement of the phagocytic activity of blood platelets. Glutamine did not have this effect, regardless of the route of administration.

Comparison of the Contracted Accordion, Expanded Accordion, and Clavien-Dindo complication grading scales after ovarian cancer cytoreduction

OBJECTIVE

To compare the ability of current complication reporting scales (Contracted Accordion Scale, Expanded Accordion Scale, Clavien-Dindo Scale) to reflect the severity of patient outcomes after cytoreductive surgery for ovarian cancer.

METHODS

We included all patients undergoing primary debulking surgery for stage IIIC/IV ovarian cancer from 2006 to 2016 at two expert centers for ovarian cancer. Complications within 30 days of surgery were graded according to three scales. Outcomes included length of stay, mortality (90-day), and delayed initiation of chemotherapy (>42 days after surgery). Correlations were assessed using the Spearman rank correlation, and comparisons between groups were evaluated using the Wilcoxon rank-sum test and the χ² test.

RESULTS

Among the 892 patients, 185 (20.7%) patients had a grade 3 or higher complication per all scales. Patients with grade 3 or higher complications (compared with those with none, grade 1 or grade 2) had longer length of stay, higher 90-day mortality, and delayed initiation of chemotherapy. The expanded scales (Expanded Accordion Scale and Clavien Dindo Scale) provided a more refined characterization of outcome compared with the Contracted Accordion Scale. However, mortality was actually found to be as high as 25.0% for grade 5 complications using the Expanded Accordion Scale. Patients with organ failure or requiring an invasive procedure had significantly worse outcomes than those without either complication, highlighting the importance of separating these events.

CONCLUSIONS

All three scales demonstrated general correlation with important outcomes after ovarian cancer surgery. However, the expanded scales (Clavien Dindo Scale and Expanded Accordion Scale) used important events commonly encountered after cytoreductive surgery, provided a more refined view of the severity of complications, and should be used in reporting outcomes in ovarian cancer.

Short and long-term outcomes of prophylactic total gastrectomy in 54 consecutive individuals with germline pathogenic mutations in the CDH1 gene

BACKGROUND

Germline mutation of CDH1 is rare and leads to hereditary diffuse gastric cancer (DGC).

METHODS

Patients (pts) with CDH1 mutation who underwent multidisciplinary counseling followed by open prophylactic total gastrectomy (PTG) by a single surgeon were reviewed.

RESULTS

Fifty-four pts with a median age of 41 years (16-70 years) underwent PTG between 2006 and 2021. Median operative time was 161 min, and median hospital stay was 7 days (range 6-12). There were 5 complications (9.2%) within 30 days, and two complications (pulmonary embolism and pancreatitis) required readmission. There were no anastomotic leaks. The pathologic analysis of the first 10 pts included the entire gastric mucosa, revealing a median of 15 foci of DGC (range 5-136). The subsequent 44 pts with more limited analysis had a median of 2 foci (range 0-5), and two pts (3.7%) had no foci identified. Median maximum weight loss was 19%. In long-term follow-up (median 4.6 years) of 20 pts, median global QOL was 2.0 (very good), the majority had persistent difficulty with certain foods or liquids, and all stated they would again elect PTG over surveillance endoscopy.

CONCLUSIONS

PTG can be performed safely at high-volume referral centers with very good QOL but nutritional sequelae persist.

Minimally invasivE versus open total GAstrectomy (MEGA): study protocol for a multicentre randomised controlled trial (DRKS00025765)

INTRODUCTION

The only curative treatment for most gastric cancer is radical gastrectomy with D2 lymphadenectomy (LAD). Minimally invasive total gastrectomy (MIG) aims to reduce postoperative morbidity, but its use has not yet been widely established in Western countries. Minimally invasivE versus open total GAstrectomy is the first Western multicentre randomised controlled trial (RCT) to compare postoperative morbidity following MIG vs open total gastrectomy (OG).

METHODS AND ANALYSIS

This superiority multicentre RCT compares MIG (intervention) to OG (control) for oncological total gastrectomy with D2 or D2+LAD. Recruitment is expected to last for 2 years. Inclusion criteria comprise age between 18 and 84 years and planned total gastrectomy after initial diagnosis of gastric carcinoma. Exclusion criteria include Eastern Co-operative Oncology Group (ECOG) performance status >2, tumours requiring extended gastrectomy or less than total gastrectomy, previous abdominal surgery or extensive adhesions seriously complicating MIG, other active oncological disease, advanced stages (T4 or M1), emergency setting and pregnancy.The sample size was calculated at 80 participants per group. The primary endpoint is 30-day postoperative morbidity as measured by the Comprehensive Complications Index. Secondary endpoints include postoperative morbidity and mortality, adherence to a fast-track protocol and patient-reported quality of life (QoL) scores (QoR-15, EUROQOL EuroQol-5 Dimensions-5 Levels (EQ-5D), EORTC QLQ-C30, EORTC QLQ-STO22, activities of daily living and Body Image Scale). Oncological endpoints include rate of R0 resection, lymph node yield, disease-free survival and overall survival at 60-month follow-up.

ETHICS AND DISSEMINATION

Ethical approval has been received by the independent Ethics Committee of the Medical Faculty, University of Heidelberg (S-816/2021) and will be received from each responsible ethics committee for each individual participating centre prior to recruitment. Results will be published open access.

TRIAL REGISTRATION NUMBER

DRKS00025765.

The Analysis of Surgical Outcomes in Operable Gastric Cancer Patients Presenting With or Without Sarcopenia

We aimed to identify the patients with increased risk of post-operative complications using pre-operative sarcopenia as an indicator of adverse outcome in gastric cancer patients undergoing resection. This study was a prospective observational cohort study including patients with adenocarcinoma of stomach, undergoing gastric resection with curative intent. All the patient underwent pre-operative evaluation of sarcopenia including skeletal muscle index (SMI) measurements and hand grip strength (HGS) analysis. The post-operative parameters assessed were the time to initiate enteral feeding, the time to pass first flatus, post-operative complications, post-operative hospital stay, and histopathological staging of the resected specimen. All these parameters were compared between the sarcopenia and non-sarcopenia arms to obtain the final results. The total number of patients enrolled was 72 (46 male, 26 female). The mean SMI of the study cohort was 47.1 cm2/m2 and the mean HGS was 29.35 kg. Thirty-six patients (24 male, 12 female) were sarcopenic pre-operatively. Sixty-two patients underwent subtotal gastrectomy with D2 lymphadenectomy, and 10 patients underwent total gastrectomy with D2 lymphadenectomy. The median time to pass flatus was 4 days, the median time to initiation of enteral feeding was 4 days, and the median post-operative hospital stay was 12 days. Majority of the study patients had a pT3N1-2 disease. Sarcopenia was significantly associated with worsening ECOG performance status (p = 0.001), delay in passage of first flatus post-operatively (p = 0.017), higher post-operative complications (p = 0.012), higher T stage (p = 0.040), and higher N stage (p = 0.001). But there was no significant association between sarcopenia and time to initiation of enteral feeding and post-operative hospital stay. Sarcopenia is an independent prognostic factor for adverse short-term post-operative outcomes in patients undergoing curative intent resection of gastric cancer.

Phase II Trial Evaluating Esophageal Anastomotic Reinforcement with a Biologic, Degradable, Extracellular Matrix after Total Gastrectomy and Esophagectomy

BACKGROUND

A biologic, degradable extracellular matrix (ECM) has been shown to support esophageal tissue remodeling, which could reduce the risk of anastomotic leak following total gastrectomy and esophagectomy. We evaluated the safety and efficacy of reinforcing the anastomosis with ECM in reducing anastomotic leak as compared to a matched cohort.

STUDY DESIGN

In this single-center, nonrandomized phase II trial, gastric or esophageal adenocarcinoma patients undergoing total gastrectomy or esophagectomy were recruited from November 2013 through December 2018. ECM was surgically wrapped circumferentially around the anastomosis. Anastomotic leak was assessed clinically and by contrast study and defined as clinically significant if requiring invasive treatment (grade 3 or higher). Anastomotic stenosis, other adverse events, symptoms, and dysphagia score were collected by standardized forms at regular follow-up visits at approximately postoperative days (POD) 21 and 90. Patients receiving ECM were compared to a cohort matched for surgery type and age.

RESULTS

ECM placement was not feasible in 9 of 75 patients (12%), resulting in 66 patients receiving ECM. Total gastrectomy was performed in 50 patients (76%) and esophagectomy in 16 (24%). Clinically significant anastomotic leak was diagnosed in 6 of 66 patients (9.1%) (3/50 [6.0%] after gastrectomy, 3/16 [18.8%] after esophagectomy); this rate did not differ from that in the matched cohort (p = 0.57). Stenosis requiring invasive treatment occurred in 8 patients (12.5%), and 10 patients (15.6%) reported not being able to eat a normal diet at POD 90. No adverse events related to ECM were reported.

CONCLUSIONS

Esophageal anastomotic reinforcement after total gastrectomy or esophagectomy with a biologic, degradable ECM was mostly feasible and safe, but was not associated with a statistically significant decrease in anastomotic leak.

Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy: A propensity score matching analysis

BACKGROUND

Laparoscopic total gastrectomy (LTG) has drawn increasing attention over the years. Although LTG has shown surgical benefits compared to open TG (OTG) in early stage gastric cancer (GC), little is known about the surgical and oncological outcomes of LTG for advanced GC following neoadjuvant therapy (NAT).

AIM

To compare the long- and short-term outcomes of advanced GC patients who underwent LTG vs OTG following NAT.

METHODS

Advanced GC patients who underwent TG following NAT between April 2011 and May 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences were enrolled and stratified into two groups: LTG and OTG. Propensity score matching analysis was performed at a 1:1 ratio to overcome possible bias.

RESULTS

In total, 185 patients were enrolled (LTG: 78; OTG: 109). Of these, 138 were paired after propensity score matching. After adjustment for propensity score matching, baseline parameters were similar between the two groups. Compared to OTG, LTG was associated with a significantly shorter length of hospital stay (P = 0.012). The rates of R0 resection, lymph node harvest, and postoperative morbidity did not significantly differ between the two groups. Overall survival (OS) outcomes were comparable between the two groups. Pathological T and N stages were found to be independent risk factors for OS.

CONCLUSION

LTG can be a feasible method for advanced GC patients following NAT, as it appears to be associated with better short- and comparable long-term outcomes compared to OTG.

Surveillance and Surgical Considerations in Hereditary Diffuse Gastric Cancer

Inactivating germline variants in the CDH1 tumor suppressor gene cause the hereditary diffuse gastric cancer syndrome. Total gastrectomy is recommended for prevention, although it is associated with adverse outcomes and chronic health risks. Gastric cancer surveillance is an alternative to surgery; however, upper gastrointestinal endoscopy is limited by poor sensitivity. Cancer surveillance requires accurate detection of early carcinoma and patient-specific disease penetrance estimates. Current clinical care should incorporate up-to-date information on variable disease penetrance, which does not seem to correlate with CDH1 genotype. Affected patients and families warrant a balanced presentation of options for cancer surveillance and prophylaxis.

Surgical and oncological outcome after extended lymph node dissection for carcinoma of the stomach and the esophagogastric junction: a retrospective analysis from an experienced single center

Introduction

Gastric cancer remains the fourth leading cause of cancer-related death in Europe, while the proportion of adenocarcinomas of the esophagogastric junction has risen by more than one third over recent years. In 2018, 14,700 new cases of gastric cancer were estimated in Germany, while the 5-year relative survival rate is reported to be 33% for women and 30% for men; in the USA almost the same rate was reported, with 31% 5-year survival.

Material and methods

Between 2001 and 2014, 590 patients with a diagnosis of gastric cancer underwent surgery in our institution, including 120 Siewert type II/III carcinomas of the esophagogastric junction. All patients underwent distal resection of the stomach, gastrectomy or total gastrectomy combined with transhiatal distal esophageal resection. All operations included D2-D3 lymph node dissection (LND). Data were recorded by the cancer registry of the department of surgery and analyzed retrospectively.

Results

The patients were classified according to the TNM (UICC 2010) and Lauren classification. 29% of the patients underwent primary surgery and 31% received neoadjuvant therapy. The median number of harvested lymph nodes was 33 for patients diagnosed with gastric cancer, and 29 for esophagogastric adenocarcinomas, respectively. The anastomotic leak rate was 3%. In this study, the 5-year overall survival rate was 51% concerning gastric carcinomas, 44% for Siewert type II and 47% for Siewert III cancers of the esophagogastric junction.

Conclusions

Increased survival with low complication rates were achieved after individualized and multimodal treatment concepts combined with consistently applied extended lymphadenectomy.

Establishment of a Fast-Track Gastrectomy Pathway for Patients with Gastric Adenocarcinoma at a U.S. Academic Cancer Center

INTRODUCTION

Implementation of fast-track perioperative care pathways for gastric cancer patients in the U.S. has been challenging due to low disease incidence and limited safety and efficacy data. Our institution recently implemented such a pathway for gastric cancer patients undergoing gastrectomy, and we sought to study its effects.

METHODS

We analyzed data from consecutive patients who underwent gastrectomy for gastric adenocarcinoma from January 2014 to August 2020. Patients who had surgery for recurrence, urgent surgery for obstruction, bleeding, or perforation, or an intrathoracic anastomosis were excluded. The primary predictor was whether the patient had surgery before or after implementation of a perioperative fast-track gastrectomy pathway in July 2018, and the primary outcome was length of stay.

RESULTS

One hundred sixty patients were identified, 109 pre-pathway implementation and 51 post-pathway implementation. Following pathway implementation, length of stay was significantly shorter (median 6 days versus 9 days, p < 0.001), and there was no significant difference in 30-day complication rates (29% pre versus 24% post, P = 0.56) or readmission rates (18% pre versus 16% post, P = 0.85). Using linear segmented regression analysis adjusting for age, body mass index, tumor stage (early versus late), type of surgery (distal/subtotal versus total gastrectomy), and approach (open versus minimally invasive), pathway implementation was found to be associated with a 31% decreased length of stay (effect size 0.69, 95% confidence interval 0.49 - 0.98, P = 0.04).

CONCLUSIONS

Fast-track gastrectomy care pathways are safe and feasible for U.S. gastric cancer patients undergoing gastrectomy and are associated with decreased length of stay.

Risk factors associated with postoperative morbidity and mortality in D2 radical gastrectomy for gastric cancer

INTRODUCTION AND AIMS

Surgery is the main treatment for gastric cancer. D2 radical gastrectomy is associated with a variable postoperative morbidity and mortality rate worldwide. The aim of the present study was to identify the risk factors associated with the postoperative morbidity and mortality of D2 radical gastrectomy, with curative intent, for gastric cancer.

MATERIALS AND METHODS

A retrospective case series was conducted, in which the medical records were reviewed of patients with gastric cancer that underwent D2 radical gastrectomy, within the time frame of January 2014 and December 2018. Univariate and multivariate analyses were carried out to identify the risk factors related to postoperative morbidity and mortality within 90 days.

RESULTS

The percentages of postoperative morbidity and mortality in 691 patients were 23.3% and 3.3%, respectively. In the multivariate analysis, age ≥70 years (OR = 1.85, 95% CI: 1.25-2.76), ASA III-IV (OR = 2.06, 95% CI: 1.28-3.34), total gastrectomy (OR = 1.96, 95% CI:1.19-3.23), and pancreatosplenectomy (OR = 5.41, 95% CI: 1.42-20.61) were associated with greater postoperative morbidity, and age ≥70 years (OR = 4.92, 95% CI:1.78-13.65), lower BMI (OR = 0.81, 95% CI: 0.71-0.92), and hypoalbuminemia (OR = 0.91, 95% CI: 0.85-0.98) were associated with greater mortality in distal and total D2 radical gastrectomy.

CONCLUSIONS

D2 radical gastrectomy for gastric cancer was shown to be a safe treatment, with low postoperative morbidity and mortality rates. Age ≥70 years, ASA III-IV, total gastrectomy, and pancreatosplenectomy were factors associated with a higher complication rate. Age ≥70 years, lower BMI, and hypoalbuminemia were mortality predictors in distal and total radical gastrectomy.

Can intraoperative endoscopy prevent esophagojejunal anastomotic leakage after total gastrectomy?

BACKGROUND

Esophagojejunostomy (EJ) is frequently performed after total gastrectomy for proximal gastric tumors. Despite evolving surgical techniques and improving perioperative care, the EJ leak is one of the most severe life-threatening complications. This study investigated the preventability of postoperative anastomotic complications by performing intraoperative endoscopy.

METHODS

We included 86 patients who underwent total gastrectomy and Roux-en-Y esophagojejunostomy anastomosis in the study. Patients were divided into two groups and analyzed retrospectively. Group 1 consisted of 43 patients who did not undergo intraoperative endoscopy between 2017 and 2019, and Group 2 included 43 patients who underwent intraoperative endoscopy between 2019 and 2020.

RESULTS

Esophagojejunostomy anastomotic leak (EAL) was observed in 2.3 % of patients in Group 1 but not in Group 2. Anastomosis-related abnormal findings (anastomotic defect, bleeding, air leak, mucosal separation) were recorded in seven patients of Group 2 during endoscopy. When such findings were observed, additional full-thickness sutures were placed on the anastomosis line and strengthened. Complication related to anastomosis was not observed in the postoperative period in Group 2.

DISCUSSION

After a total gastrectomy, the most severe complication affecting mortality, morbidity, and consequently the cost of the disease is esophagojejunal anastomotic leakage. Most of these complications are induced by technical errors not noticed during surgery. The crucial advantage of performing intraoperative endoscopy is the technically detailed evaluation of anastomosis.

CONCLUSION

Intraoperative endoscopy is a safe method to evaluate the strength of anastomosis. This procedure provides detailed information regarding anastomotic integrity. HIPPOKRATIA 2021, 25 (3):108-112.

Double-tract reconstruction for oesofagocardial gastric cancer: A systematic review

The number of people with gastric cardia and distal oesophageal cancers has increased in the last five years. The surgical treatment method of choice is proximal gastrectomy, with an option being reconstruction of the gastrointestinal tract. There are many reconstruction techniques for anastomosis of the oesophagus and distal parts of the digestive tract. However, all can result in complications. This systematic review aims to identify the efficacy of the double-tract reconstruction method after gastric resection. Different operative techniques for gastric reconstruction have been included in this review. The double-tract reconstruction method, which is gaining popularity among surgeons in Asia and Europe, is a promising technique that improves the early and late results of surgical treatment. This method is associated with low complications related to gastroesophageal reflux disease and dysphagia. Double-tract reconstruction is a promising method for the treatment of patients with esofagocardial gastric cancer. However, further studies are required on the long-term complications and side effects.

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.

Impact of Esophagojejunal Reconstruction without Division of the Mesentery for Total Laparoscopic Total Gastrectomy

Purpose

This study aimed to compare the surgical outcomes of total laparoscopic total gastrectomy without mesentery division (LTG without MD) and conventional total laparoscopic total gastrectomy (CLTG), as well as evaluate the appropriate method for esophagojejunostomy (EJ) reconstruction after total laparoscopic total gastrectomy (TLTG).

Materials and Methods

We retrospectively analyzed data from 301 consecutive patients who underwent TLTG for upper or middle third gastric cancer between January 2016 and May 2019. After propensity score matching, 95 patients who underwent LTG without MD and 95 who underwent CLTG were assessed. Data on clinical characteristics and surgical outcomes, including operation time, length of postoperative hospital stay, pathological findings, and postoperative complications were analyzed.

Results

The LTG without MD group showed a shorter time to first flatus (3.26±0.80 vs. 3.62±0.81 days, P=0.003) and a shorter time to soft diet (2.80±2.09 vs. 3.52±2.20 days, P=0.002). The total EJ-related complications in the LTG without MD group were comparable to those in the CLTG group (9.47% vs. 3.16%, P=0.083). EJ-related leakage (6.32% vs. 3.16%, P=0.317) and EJ-related stricture (3.16% vs. 1.05%, P=0.317) rates were not significantly different between the LTG without MD and CLTG groups. No significant differences were found between the two groups in terms of other early surgical outcomes such as early complications, late complications, hospital stay, and readmission rate.

Conclusions

LTG without MD is a safe surgical treatment for upper or middle third gastric cancer. LTG without MD may be an alternative procedure for EJ anastomosis during TLTG.

Risk factors associated with postoperative morbidity and mortality in D2 radical gastrectomy for gastric cancer

INTRODUCTION AND AIMS

Surgery is the main treatment for gastric cancer. D2 radical gastrectomy is associated with a variable postoperative morbidity and mortality rate worldwide. The aim of the present study was to identify the risk factors associated with the postoperative morbidity and mortality of D2 radical gastrectomy, with curative intent, for gastric cancer.

MATERIALS AND METHODS

A retrospective case series was conducted, in which the medical records were reviewed of patients with gastric cancer that underwent D2 radical gastrectomy, within the time frame of January 2014 and December 2018. Univariate and multivariate analyses were carried out to identify the risk factors related to postoperative morbidity and mortality within 90 days.

RESULTS

The percentages of postoperative morbidity and mortality in 691 patients were 23.3% and 3.3%, respectively. In the multivariate analysis, age ≥ 70 years (OR=1.85, 95% CI: 1.25-2.76), ASA III-IV (OR=2.06, 95% CI: 1.28-3.34), total gastrectomy (OR=1.96, 95% CI:1.19-3.23), and pancreatosplenectomy (OR=5.41, 95% CI: 1.42-20.61) were associated with greater postoperative morbidity, and age≥70 years (OR=4.92, 95% CI:1.78-13.65), lower BMI (OR=0.81, 95% CI: 0.71-0.92), and hypoalbuminemia (OR=0.91, 95% CI: 0.85-0.98) were associated with greater mortality in distal and total D2 radical gastrectomy.

CONCLUSIONS

D2 radical gastrectomy for gastric cancer was shown to be a safe treatment, with low postoperative morbidity and mortality rates. Age≥70 years, ASA III-IV, total gastrectomy, and pancreatosplenectomy were factors associated with a higher complication rate. Age≥70 years, lower BMI, and hypoalbuminemia were mortality predictors in distal and total radical gastrectomy.

A Novel Parameter Identified Using Indocyanine Green Fluorescence Angiography may Contribute to Predicting Anastomotic Leakage in Gastric Cancer Surgery

BACKGROUND

Anastomotic leak is one of the most serious postoperative complications, and intraoperative adequate perfusion plays a key role in preventing its development in gastric cancer surgery. This study aimed to investigate the relationships between anastomotic leak and the parameters defined by an assessment of intraoperative anastomotic perfusion using a near-infrared indocyanine green (ICG) fluorescence system and to evaluate the usefulness of this ICG fluorescence assessment in gastric cancer surgery.

METHODS

We retrospectively reviewed data of 100 patients who underwent gastric cancer surgery. In a visual assessment based on fluorescence intensity, we classified ICG fluorescence image patterns as homogeneous, heterogeneous, or faint. In a chronological assessment, the first or second time point of ICG fluorescence appearance on one or the other side of the anastomosis was defined as FT or ST, respectively. The time difference in ICG fluorescence appearance between FT and ST was defined as TD. The relationships between anastomotic leak and the evaluated clinical factors, including the parameters identified by the ICG fluorescence assessment, were evaluated using univariate or multivariate analysis.

RESULTS

Although no signs of leak were found by surgeons' subjective judgments, four patients developed postoperative anastomotic leak of Clavien-Dindo grade III or IV. Multivariate analysis revealed that TD was an independent predictor of anastomotic leak (odds ratio 35.361, 95% confidence interval 1.489-839.923, p = 0.027).

CONCLUSIONS

A novel parameter identified using near-infrared ICG fluorescence assessment may be useful to predict anastomotic leak in gastric cancer surgery.

TRIAL REGISTRATION

UMIN Clinical Trials Registry: #UMIN000030747 ( https://www.umin.ac.jp/ctr/index.htm ).

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents

BACKGROUND

the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option.

AIMS

the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks.

METHODS

a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018.

RESULTS

twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach.

CONCLUSIONS

endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

C-Reactive Protein-Lymphocyte Ratio Identifies Patients at Low Risk for Major Morbidity after Oesophagogastric Resection for Cancer

INTRODUCTION

Complications following oesophagogastric surgery have significant implications for patient recovery.

OBJECTIVE

identify cost-effective biomarkers which can predict morbidity.

METHODS

Analysis of all upper gastrointestinal resections in Galway University Hospital from 2014 to 2018 was performed. The ability of C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), and CRP-lymphocyte ratio (CLR) to predict morbidity, including anastomotic leak (AL), was assessed and compared.

RESULTS

Seventy-one oesophagectomies and 77 gastrectomies were performed. There were 2 (1%) 30-day mortalities and 83 (56%) morbidities of which 30 (20%) were of Clavien-Dindo grade 3 or higher. The rate of major morbidity within the oesophagectomy cohort was 27% and was 14% in the gastrectomy cohort. There were 11 (7%) ALs, 7 in the oesophagectomy cohort, and 4 in the gastrectomy cohort. From post-operative day (POD) 2 onwards, CRP could predict AL (POD2 AUC = 0.705, p = 0.025; POD3 AUC = 0.757, p = 0.005, POD4 AUC = 0.811, p = 0.001; and POD5 AUC = 0.824, p = 0.001). CLR predicted AL on POD2 onwards (POD2 AUC = 0.722, p = 0.005; POD3 AUC = 0.736, p = 0.01; POD4 AUC = 0.775, p = 0.003; and POD5 AUC = 0.817, p = 0.001). CRP level of 218 mg/dL and CLR level of 301 at POD 2 generated negative predictive values of 97 and 98%, respectively, for AL. Post-operative NLR did not display sufficient discriminatory ability for the outcomes.

CONCLUSION

CRP and CLR are reliable negative predictors of major morbidity, including AL, after oesophagogastric resection. Their use can inform patient intervention and recovery.

Optimal Timing of Total Gastrectomy to Prevent Diffuse Gastric Cancer in Individuals With Pathogenic Variants in CDH1

BACKGROUND & AIMS

Carriers of pathogenic variants in CDH1 have a high risk of hereditary diffuse gastric cancer (HDGC). Guidelines recommend prophylactic total gastrectomy (PTG) at age 20-30 years, although there is controversy over the optimal age. We developed a simulation model to analyze the effects of PTG at different ages on quality-adjusted life-years (QALYs), cancer mortality, and life expectancy.

METHODS

We used a Markov model of HDGC progression associated with pathogenic variants in CDH1 to simulate outcomes of hypothetical cohorts with different ages at time of PTG (ages 20-79 years). Model inputs including health state transition probabilities, mortality and complication rates, quality of life utility values, and endoscopic surveillance sensitivity were derived from publications. The primary outcome, used to determine the optimal strategy, was age at which PTG yielded the highest QALYs. Secondary outcomes were cancer mortality and unadjusted life-years.

RESULTS

Our model found that for men, the optimal age for PTG is 39 years, resulting in 32.01 incremental QALYs, 58.81 life-years (biologic age, 72.81 years), and lifetime cancer mortality of 8.5%. Incorporating endoscopic surveillance prior to PTG decreased cancer mortality to 6.7%, but had lower QALYs (31.59). PTG at age 30 reduced cancer mortality to 3.2%, with 31.45 incremental QALYs. For women, the optimal age for PTG was calculated to be 30 years, with 33.09 incremental QALYs, 66.17 life-years (biologic age, 80.17 years), and lifetime cancer mortality of 1.6%. Addition of endoscopic surveillance did not decrease the risk of HDGC mortality in women.

CONCLUSIONS

Using a Markov model of HDGC progression associated with pathogenic variants in CDH1 to simulate outcomes, we found the optimal ages for PTG to be 39 years for men and 30 years for women, when QALYs are the primary endpoint. These ages for PTG are older than those of current recommendations.

Impact of Postoperative Complication and Completion of Multimodality Therapy on Survival in Patients Undergoing Gastrectomy for Advanced Gastric Cancer

BACKGROUND

Postoperative complication (POC) adversely impacts long-term survival in patients with gastric cancer, perhaps due in part to lower rates for receipt of multimodality therapy (MMT). We sought to determine the impact of POC on MMT completion rates and overall survival (OS) in patients with locally advanced gastric cancer.

STUDY DESIGN

We analyzed 206 patients with locally advanced gastric cancer undergoing curative-intent resection from 2001 to 2015. POCs were graded using Clavien-Dindo classification and survival outcomes were compared between groups.

RESULTS

One hundred and twenty patients underwent operation followed by chemoradiation therapy, 58 received perioperative chemotherapy, and 28 received total neoadjuvant therapy (TNT). Minor (Clavien-Dindo grade I to II) and major (Clavien-Dindo grade III to IV) POC occurred in 72 (35.0%) and 39 (18.9%) patients, respectively. At median follow-up of 37 months, the 3-year OS of patients experiencing a major, minor, or no POC were 33.3%, 56.9%, and 62.1% (p = 0.023), respectively. In contrast, there was no difference in 3-year OS rates in patients experiencing POC if they completed all intended MMT. Non-TNT patients who experienced a major POC were less likely to complete MMT (hazard ratio 0.36, p = 0.017), and a major POC in these patients had a significant impact on OS (hazard ratio 2.76, p = 0.011), and it did not in patients who completed MMT (hazard ratio 1.58, p = 0.336).

CONCLUSIONS

Major POC adversely affects long-term survival after gastrectomy for gastric cancer, at least in part via lower completion rates of MMT. Treatment strategy designed to ensure the completion of MMT, such as TNT, might be preferable, particularly for patients at high risk for POCs.

Late postoperative complications in surgical patients: an integrative review

ABSTRACT Objective: to identify the main complications in the late postoperative period of surgical patients. Method: an integrative review from the CINAHL, LILACS, Science direct, Web of Science, SCOPUS, Europe PMC, and MEDLINE databases. Descriptors and keywords were combined without language or time restriction. Results: ten primary studies were included. Infectious complications were the most common, especially surgical site infection, pneumonia and urinary tract infection. The presence of complications was linked to increased mortality, need for reoperations and worse survival. Few studies report on monitoring frequency, follow-up time and/or when complications started to be observed. Conclusion: infectious complications were the most prevalent postoperatively. The scarcity of guidelines that guide the monitoring of complications regarding monitoring frequency, follow-up time and classification makes it difficult to establish an overview of them and consequently propose intervention strategies.

Gastric cancer surgery: historical background and perspective in Western countries versus Japan

Gastrectomy plus D2 lymphadenectomy plays a decisive role in the management of resectable gastric cancer in Japan. Before recent advances in chemotherapy, Japanese surgeons considered that extensive surgery involving extended lymphadenectomy with combined resection of neighboring organ(s) was required to eliminate any possible lymphatic cancer spread and improve patient survival. This approach differs radically from that in Western countries, which aim to improve survival outcomes by multidisciplinary approaches including perioperative chemotherapy and/or radiotherapy with limited lymph node dissection. However, a randomized controlled trial conducted in Japan found that more extensive lymphadenectomy including the para-aortic lymph nodes provided no survival benefit over D2 lymphadenectomy. Splenic hilum dissection with splenectomy also failed to show superiority over the procedure without splenectomy in patients with proximal gastric cancer, except in cases with tumor invasion of the greater curvature. Furthermore, bursectomy recently demonstrated similar outcomes to omentectomy alone. Although "D2 lymphadenectomy" as carried out in Japan contributes to low local recurrence rates and good survival outcomes, the results of randomized controlled trials have led to a decreased extent of surgical resection, with no apparent adverse effects on survival outcome. Notably, gastrectomy with D2 dissection has tended to become acceptable for advanced gastric cancer in Western countries, based on the latest results of the Dutch D1D2 trial. Differences in surgical practices between the West and Japan have thus lessened and procedures are becoming more standardized. Japanese D2 lymphadenectomy for advanced gastric cancer is evolving toward more minimally invasive approaches, while consistently striving to achieve the optimal surgical extent, thereby promoting consensus with Western counterparts.

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.

A high-throughput screen to identify novel synthetic lethal compounds for the treatment of E-cadherin-deficient cells

The cell-cell adhesion protein E-cadherin (CDH1) is a tumor suppressor that is required to maintain cell adhesion, cell polarity and cell survival signalling. Somatic mutations in CDH1 are common in diffuse gastric cancer (DGC) and lobular breast cancer (LBC). In addition, germline mutations in CDH1 predispose to the autosomal dominant cancer syndrome Hereditary Diffuse Gastric Cancer (HDGC). One approach to target cells with mutations in specific tumor suppressor genes is synthetic lethality. To identify novel synthetic lethal compounds for the treatment of cancers associated with E-cadherin loss, we have undertaken a high-throughput screening campaign of ~114,000 lead-like compounds on an isogenic pair of human mammary epithelial cell lines - with and without CDH1 expression. This unbiased approach identified 12 novel compounds that preferentially harmed E-cadherin-deficient cells. Validation of these compounds using both real-time and end-point viability assays identified two novel compounds with significant synthetic lethal activity, thereby demonstrating that E-cadherin loss creates druggable vulnerabilities within tumor cells. In summary, we have identified novel synthetic lethal compounds that may provide a new strategy for the prevention and treatment of both sporadic and hereditary LBC and DGC.

Morbidity and Mortality of Total Gastrectomy: a Comprehensive Analysis of 90-Day Outcomes

BACKGROUND

Total gastrectomy (TG) is a complex procedure that carries a high risk of morbidity and mortality and in which patients may experience post-operative sequelae well past the standard 30-day follow-up period. Large studies from high-volume centers with detailed 90-day follow-up data are needed to provide benchmarks for high-quality care for this complex procedure.

METHODS

Single-institution, retrospective review of a comprehensive gastric cancer database of 148 patients undergoing curative intent TG from 2000 to 2017. Clinicopathologic and treatment factors were analyzed for their impact on 90-day outcomes.

RESULTS

The median age of the cohort was 66 years, and 61% were male. Neoadjuvant chemotherapy and radiation therapy were delivered to 32% and 11% of patients, respectively. Open and laparoscopic TG were performed in 93% (n = 137) and 7% (n = 11) of patients, respectively. Extended lymphadenectomy, pancreatectomy, and splenectomy were performed in 37%, 4.7%, and 19% of patients, respectively. The 30- and 90-day mortality rates were 2.0% and 3.4%, respectively. At least one 90-day complication was experienced by 43.9% (n = 65) of patients, and 14% (n = 21) experienced a Clavien-Dindo grade 3 or 4 complication. Anastomotic leak occurred in 5.4% (n = 8) of patients, half of which required an invasive intervention. Median length of stay was 8 days. The readmission rate was 22%, and most readmissions were due to dehydration and/or nutritional compromise.

CONCLUSIONS

This study defines 30- and 90-day post-operative outcomes after total gastrectomy in a high-volume center. These outcomes data are critical to the improvement of the informed consent process and as benchmarks for future quality improvement initiatives.

Hypophosphatemia as a Predictor of Organ-Specific Complications Following Gastrointestinal Surgery: Analysis of 8034 Patients

BACKGROUND

Organ-specific complications (OSC) remain serious potential sequela of gastrointestinal surgery. Hypophosphatemia correlates with poor outcomes and may be a harbinger of OSC after gastrointestinal surgery. Our goal was to describe and evaluate the relationship between postoperative phosphate levels and OSC.

METHODS

Consecutive patients who underwent pancreatic, colorectal, or gastric resections were analyzed. OSC were defined as those resulting from the failure of at least one anastomosis performed during the primary resection, manifesting as an anastomotic leak, fistula, and/or intra-abdominal abscess. Postoperative serum phosphate levels and other recognized OSC risk factors were compared among patients who did and did not develop OSC.

RESULTS

A total of 8034 patients who underwent pancreatic (n = 397), colorectal (n = 5808), or gastric (n = 1829) resections were included in the study. In each resection group, the majority of patients experienced hypophosphatemia postresection with the nadir on postoperative day (POD) 2, and the subgroups that developed OSC exhibited lower phosphate levels on POD3-7. On multivariate analysis, lower phosphate level on POD3 remained significantly associated with OSC following pancreatic resection [median (interquartile range) mmol/L, 0.65 (0.53-0.76) vs. 0.71 (0.61-0.84), p = 0.045] and colorectal resection [0.71 (0.61-0.87) vs. 0.77 (0.65-0.94), p = 0.006], and lower phosphate level on POD4 remained associated with OSC following gastric resection [0.87 (0.74-1.03) vs. 0.96 (0.81-1.13), p = 0.049].

CONCLUSION

This study identified a consistent trajectory of serum phosphate levels following 3 different gastrointestinal operations and association between early postoperative phosphate levels and OSC. Persistent lower phosphate levels should raise the level of concern for evolving postoperative leak and may lead to earlier radiographic evaluation and treatment.

Sarcopenia and Post-Operative Morbidity and Mortality in Patients with Gastric Cancer

Purpose

Surgical resection for gastric adenocarcinoma is associated with significant post-operative morbidity and mortality. The aim of this study was to assess the prognostic significance of sarcopenia in patients undergoing resection for gastric adenocarcinoma with respect to post-operative morbidity and survival.

Materials and Methods

A retrospective analysis was conducted on a cohort of consecutive patients who underwent surgical resection for gastric adenocarcinoma between 2008 and 2014. Patient demographics, radiological parameters, and pathological data were collected. OsiriX software (Pixmeo) was used to measure skeletal muscle area, which was normalized for height to calculate skeletal muscle index.

Results

A total of 56 patients (41 male, 15 female; mean age, 68.4 ± 11.9 years) met the inclusion criteria. Of these, 36% (20 of 56) of the patients were sarcopenic pre-operatively. Both sarcopenic and non-sarcopenic patient groups were equally matched with the exception of weight and body mass index (P=0.036 and 0.001, respectively). Sarcopenia was associated with a decreased overall survival (log-rank P=0.003) and was an adverse prognostic predictor of overall survival in multivariate analysis (hazard ratio, 10.915; P=0.001). Sarcopenia was a predictor of serious in-hospital complications in multivariate analysis (odds ratio, 3.508; P=0.042).

Conclusions

In patients undergoing curative resection for gastric cancer, there was a statistically significant association between sarcopenia and both decreased overall survival and serious post-operative complications. The measurement and reporting of skeletal muscle index on pre-operative computed tomography should be considered.

The Impact of Preoperative Low Body Mass Index on Postoperative Complications and Long-term Survival Outcomes in Gastric Cancer Patients

PURPOSE

The aim of this study was to investigate the impact of preoperative low body mass index (BMI) on both the short- and long-term outcomes in patients with gastric cancer.

MATERIALS AND METHODS

A total of 510 patients with gastric cancer were divided into the following 3 groups: low BMI group (≤18.5 kg/m2, n=51), normal BMI group (18.6-24.9 kg/m2, n=308), and high BMI group (≥25.0 kg/m2, n=151).

RESULTS

There were significantly more stage III/IV patients in the low BMI group than in the other groups (P=0.001). Severe postoperative complications were more frequent (P=0.010) and the survival was worse (P<0.001) in the low BMI group. The subgroup analysis indicated that survival was worse in the low BMI group of the stage I/II subgroup (P=0.008). The severe postoperative complication rate was higher in the low BMI group of the stage III/IV subgroup (P=0.001), although the recurrence rate and survival did not differ in the stage III/IV subgroup among all the BMI groups. Low BMI was an independent poor prognostic factor in the stage I/II subgroup (disease-free survival: hazard ratio [HR], 13.521; 95% confidence interval [CI], 1.186-154.197; P=0.036 and overall survival: HR, 5.130; 95% CI, 1.644-16.010; P=0.005), whereas low BMI was an independent risk factor for severe postoperative complications in the stage III/IV subgroup (HR, 17.158; 95% CI, 1.383-212.940; P=0.027).

CONCLUSIONS

Preoperative low BMI in patients with gastric cancer adversely affects survival among those with stage I/II disease and increases the severe postoperative complication rate among those with stage III/IV disease.

Autonomous detection, grading, and reporting of postoperative complications using natural language processing

INTRODUCTION

Natural language processing, a computer science technique that allows interpretation of narrative text, is infrequently used to identify surgical complications. We designed a natural language processing algorithm to identify and grade the severity of deep venous thrombosis and pulmonary embolism (together: venous thromboembolism).

METHODS

Patients from our 2011-2014 American College of Surgeons National Surgical Quality Improvement Project cohorts with a duplex ultrasound or a computerized tomography angiography of the chest performed within 30 days of surgery were divided into training and validation datasets. A "bag of words" approach classified the reports; other electronic health record data classified the venous thromboembolism's severity.

RESULTS

Of the 10,295 American College of Surgeons National Surgical Quality Improvement Project patients, 251 were used in our deep venous thromboses validation cohort (273 total ultrasounds) and 506 in our pulmonary embolisms cohort (552 total computerized tomography angiographies). For deep venous thromboses the sensitivity and specificity were 85.1% and 94.6%, while for pulmonary embolisms they were 90% and 98.7%. Most discordances were due to lack of imaging documentation of a deep venous thrombosis (28/41, 68.3%) or pulmonary embolism (6/6, 100%). Most deep venous thromboses (28 patients, 54.6%) and pulmonary embolisms (25 patients, 75.8%) required administration of therapeutic intravenous or subcutaneous anticoagulation.

CONCLUSION

Natural language processing can reliably detect the presence of postoperative venous thromboembolisms, and its use should be expanded for the detection of other conditions from narrative documentation.

Clinical trends and effects on quality metrics for surgical gastroesophageal cancer care

Background

Surgical therapy of mid-stage gastric cancer (GC) and other neoplastic conditions requiring gastric resection remains at the center of curative outcomes, while epidemiologic changes and multimodality treatment options have evolved rapidly. Putative quality metrics for gastrectomy such as R0 rate, total lymph node (LN) count or postoperative morbidity may depend partly on changing disease and treatment patterns, and deserve evaluation under various practice conditions.

Methods

Data within a U.S.-based single surgical oncologist's practice over 15 years were prospectively recorded and retrospectively analyzed for clinicopathologic factors, operative treatment aspects and outcomes. Trends and spectrum changes over three time intervals were analyzed with contingency analysis and continuous data comparative statistics.

Results

Of 179 patients undergoing gastric resection, 119 were male and 60 female, with a median age of 63 years (range, 24-98 years). Resections included 56 total, 56 subtotal/distal, 30 proximal and 37 segmental gastrectomies. Diagnoses included 96 GCs, 31 gastroesophageal (GE) junction (GEJ) cancers, 21 GI stromal tumors (GISTs), and 31 other conditions. Significant trends from first towards last time interval were observed for resection type (16% to 32% proximal, 9% to 30% segmental, P=0.0003), curative intent (76% to 98%, P=0.002), diagnosis (5% to 42% GEJ cancer, P<0.0001) and preoperative therapy use (0% to 58%, P<0.0001), among others. Intraoperative aspects showed significantly reduced blood loss (median: 500 to 150 mL) and transfusion requirements (39% to 4%), and an increased use of minimally invasive techniques over time (all at P<0.001). Among patients undergoing curative intent GC resection with LN dissection, total LN counts remained steady (mean: 26), while the number of involved LNs decreased (9.0 to 3.7, P=0.0003) and the R0 resection rate increased from 74% to 85% (P=0.05). The number of specimens with >15 LNs examined increased from 69.0% to 92.5% (P=0.022). At the same time, spleen preservation rate (91% overall) and major morbidity (16%) remained unchanged throughout. Postoperative length of stay decreased from a median of 12 to 8 days (P<0.0001).

Conclusions

This experience represents some variable practice patterns within a clinicopathologic spectrum of GE diseases. Postoperative or oncologic quality metrics have been sustained or did improve, which would support their utility for various practice settings; they compare favorably to other published U.S. experiences during the same time period.

Second-look laparostomy for perforated gangrenous gastric volvulus to prevent total gastrectomy

A 42-year-old Caucasian woman presented to the emergency department with severe upper abdominal pain and vomiting. Clinically, she was septic, and abdominal examination suggested peritonitis. Following immediate resuscitation, the patient was stabilised and underwent urgent contrast-enhanced CT of the abdomen and pelvis. This revealed a mesenteroaxial gastric volvulus with traction on the mesentery and a small volume of free fluid. She underwent laparotomy revealing gangrenous gastric fundus perforation complicated by persistent intraoperative hypotension. This mandated a damage-control approach for the patient's safety entailing a limited-sleeve gastrectomy and laparostomy formation. Stabilisation in the intensive care unit allowed for a safer return to the operating room. On second look 24 hours later, previously ischaemic non-viable-looking portions of the stomach had recovered their blood supply. The patient was discharged 31 days postoperatively after recovering from the operations, postoperative wound infections and pleural effusions.

The Impact of Postoperative Enteral Immunonutrition on Postoperative Complications and Survival in Gastric Cancer Patients - Randomized Clinical Trial

BACKGROUND

Immunomodulating enteral nutrition in the perioperative period may reduce postoperative complications in cancer patients. Little is known if this effect translates to the better survival. The aim of study was to assess the impact of postoperative immunomodulating enteral nutrition on postoperative complications and survival of gastric cancer patients.

METHODS

A group of 98 gastric cancer patients was randomly assigned for postoperative immunomodulating enteral nutrition n = 44 (Reconvan, Fresenius Kabi, Bad Homburg, Germany), or standard enteral nutrition n = 54 (Peptisorb, Nutricia, Schipol, The Netherlands). Postoperative complications, mortality, 6-mo and 1-yr survival were analyzed.

RESULTS

The overall postoperative morbidity did not differ between the groups. The rate of pulmonary complications (excluding pneumonia) was significantly lower in immunomodulation group (0% vs 9.3%, p = 0.044), as well as 60-day mortality (0% vs. 11.1%, p = 0.037). There was no difference in 6-mo and 1-yr survival between the groups.

CONCLUSIONS

Postoperative immunomodulating enteral nutrition may reduce respiratory complications and postoperative mortality in comparison to standard enteral nutrition. Despite this effect, it did not improve 6-mo and 1-yr survival in immunomodulation group. Probably the beneficial effect of immunomodulating enteral nutrition is too weak to be significant in such a number of patients.

Predictors of 30-day readmissions after gastrectomy for malignancy

BACKGROUND

The objective of this study is to identify risk factors associated with readmission after gastrectomy to potentially identify potential areas for targeted improvements. Hospital readmission after surgery is a topic of interest in health-care policy among hospitals, payers, and providers. Readmissions are associated with increased costs, morbidity, and mortality. Readmission rates have been proposed as a quality metric for hospitals and quality indicator of individual surgeon's performance. In addition, the Centers for Medicare and Medicaid Services has reduced payments to hospitals with excessive readmissions for certain diagnoses.

MATERIALS AND METHODS

All gastrectomy procedures for malignancy in patients aged ≥18 y from 2005 to 2011 were queried from the California State Inpatient Database. Patients who died during index admission were excluded. Descriptive statistics were examined between all baseline variables and readmission status. Logistic regression models were adjusted for age, race, sex, and insurance status.

RESULTS

A total of 6985 patients underwent gastrectomy for malignancy; 16.5% of the patients were readmitted after postoperative discharge. Readmission rate did not change significantly over time. Multivariable analysis demonstrated that the occurrence of any postoperative complications, postoperative length of stay greater than 10 d, discharge to skilled nursing facility or home health care, combined resection with distal pancreatectomy and/or splenectomy, and patient comorbidities like diabetes mellitus and renal failure were independently associated with readmissions.

CONCLUSIONS

The findings suggest that focusing on quality improvement efforts by targeting reduction of postoperative complications may reduce readmission rates.

Total Gastrectomy for Hereditary Diffuse Gastric Cancer at a Single Center: Postsurgical Outcomes in 41 Patients

OBJECTIVE

The aim of this study was to describe postoperative outcomes of total gastrectomy at our institution for patients with hereditary diffuse gastric cancer (HDGC).

BACKGROUND

HDGC, which is mainly caused by germline mutations in the E-cadherin gene (CDH1), renders a lifetime risk of gastric cancer of up to 70%, prompting a recommendation for prophylactic total gastrectomy.

METHODS

A prospective gastric cancer database identified 41 patients with CDH1 mutation who underwent total gastrectomy during 2005 to 2015. Perioperative, histopathologic, and long-term data were collected.

RESULTS

Of the 41 patients undergoing total gastrectomy, median age was 47 years (range 20 to 71). There were 14 men and 27 women, with 25 open operations and 16 minimally invasive operations. Median length of stay was 7 days (range 4 to 50). In total, 11 patients (27%) experienced a complication requiring intervention, and there was 1 peri-operative mortality (2.5%). Thirty-five patients (85%) demonstrated 1 or more foci of intramucosal signet ring cell gastric cancer in the examined specimen. At 16 months median follow-up, the median weight loss was 4.7 kg (15% of preoperative weight). By 6 to 12 months postoperatively, weight patterns stabilized. Overall outcome was reported to be "as expected" by 40% of patients and "better than expected" by 45%. Patient-reported outcomes were similar to those of other patients undergoing total gastrectomy.

CONCLUSION

Total gastrectomy should be considered for all CDH1 mutation carriers because of the high risk of invasive diffuse-type gastric cancer and lack of reliable surveillance options. Although most patients have durable weight loss after total gastrectomy, weights stabilize at about 6 to 12 months postoperatively, and patients report outcomes as being good to better than their preoperative expectations. No patients have developed gastric cancer recurrence after resections.

Association of Hospital Costs With Complications Following Total Gastrectomy for Gastric Adenocarcinoma

Importance

Postoperative complications are associated with increased hospital costs following major surgery, but the mechanism by which they increase cost and the categories of care that drive this increase are poorly described.

Objective

To describe the association of postoperative complications with hospital costs following total gastrectomy for gastric adenocarcinoma.

Design, Setting, and Participants

This retrospective analysis of a prospectively collected gastric cancer surgery database at a single National Cancer Institute-designated comprehensive cancer center included all patients undergoing curative-intent total gastrectomy for gastric adenocarcinoma between January 2009 and December 2012 and was conducted in 2015 and 2016.

Main Outcomes and Measures

Ninety-day normalized postoperative costs. Hospital accounting system costs were normalized to reflect Medicare reimbursement levels using the ratio of hospital costs to Medicare reimbursement and categorized into major cost categories. Differences between costs in Medicare proportional dollars (MP $) can be interpreted as the amount that would be reimbursed to an average hospital by Medicare if it paid differentially based on types and extent of postoperative complications.

Results

In total, 120 patients underwent curative-intent total gastrectomy for stage I through III gastric adenocarcinoma between 2009 and 2012. Of these, 79 patients (65.8%) were men, and the median (interquartile range) age was 64 (52-70) years. The 51 patients (42.5%) who underwent an uncomplicated total gastrectomy had a mean (SD) normalized cost of MP $12 330 (MP $2500), predominantly owing to the cost of surgical care (mean [SD] cost, MP $6830 [MP $1600]). The 34 patients (28.3%) who had a major complication had a mean (SD) normalized cost of MP $37 700 (MP $28 090). Surgical care was more expensive in these patients (mean [SD] cost, MP $8970 [MP $2750]) but was a smaller contributor to total cost (24%) owing to increased costs from room and board (mean [SD] cost, MP $11 940 [MP $8820]), consultations (mean [SD] cost, MP $3530 [MP $2410]), and intensive care unit care (mean [SD] cost, MP $7770 [MP $14 310]).

Conclusions and Relevance

Major complications were associated with tripled normalized costs following curative-intent total gastrectomy. Most of the excess costs were related to the treatment of complications. Interventions that decrease the number or severity of postoperative complications could result in substantial cost savings.

Gastric Adenocarcinoma: A Multimodal Approach

Despite its declining incidence, gastric cancer (GC) remains a leading cause of cancer-related deaths worldwide. A multimodal approach to GC is critical to ensure optimal patient outcomes. Pretherapy fine resolution contrast-enhanced cross-sectional imaging, endoscopic ultrasound and staging laparoscopy play an important role in patients with newly diagnosed ostensibly operable GC to avoid unnecessary non-therapeutic laparotomies. Currently, margin negative gastrectomy and adequate lymphadenectomy performed at high volume hospitals remain the backbone of GC treatment. Importantly, adequate GC surgery should be integrated in the setting of a multimodal treatment approach. Treatment for advanced GC continues to expand with the emergence of additional lines of systemic and targeted therapies.

Anastomotic Leakage after Upper Gastrointestinal Surgery: Surgical Treatment

BACKGROUND

Anastomotic leakage after upper gastrointestinal surgery is associated with major morbidity and mortality. In recent years, there was a major paradigm shift in the management of leakage after upper gastrointestinal surgery from surgical towards conservative and endoscopic treatment approaches as first-line treatment options.

METHODS

We conducted a PubMed literature search using combinations of the keywords 'leakage', 'complication', 'esophagectomy', 'gastrectomy', and 'pancreatectomy' to identify relevant publications.

RESULTS

Surgical re-intervention after esophagectomy, gastrectomy, or pancreatectomy is still indicated in selected patients, depending on the severity of symptoms, the condition of the patient, and failure of initiated treatment. Furthermore, surgical revision after esophagectomy and gastrectomy is indicated for early leakage and depends on the extent of anastomotic disruption and the condition of tissue.

CONCLUSION

Surgical re-intervention still plays a crucial role in the management of leakage after upper gastrointestinal surgery, especially in critically ill patients and after failure of conservative or endoscopic treatment.

Linear-Stapled Side-to-Side Esophagojejunostomy with Hand-Sewn Closure of the Common Enterotomy After Prophylactic and Therapeutic Total Gastrectomy

After total gastrectomy, anastomosis-related complications such as leak or stricture can be highly morbid. Between July 2005 and December 2015, a linear-stapled side-to-side esophagojejunostomy with hand-sewn closure of the common enterotomy (modified Orringer technique) was used for Roux-en-Y reconstruction after prophylactic total gastrectomy in 22 germline CDH1 mutation carriers and after therapeutic total gastrectomy in 18 patients diagnosed with gastric adenocarcinoma. All operations were performed by the same surgeon. No patient in either cohort developed a clinically evident anastomotic leak, one patient (2.5%) developed a contained radiographic leak that healed without intervention, and one patient (2.5%) developed an anastomotic stricture treated by endoscopic dilatation 7 months after operation. These rates were lower than radiographic leak and stricture rates in a comparison group of 32 patients who received a completely hand-sewn esophagojejunostomy (6.3 and 3.1%, respectively). Here, we describe how to perform the linear-stapled esophagojejunostomy anastomosis.

Minimally Invasive Surgical Approaches to Gastric Resection

Minimally invasive gastric resections carry several advantages, including less intraoperative blood loss, faster recovery time, reduced pain, and decreased hospital length of stay and quicker return to work. Numerous trials have proved that laparoscopic and robotic-assisted gastrectomy provides equivalent surgical and oncologic outcomes to open approaches. As with any minimally invasive approach, advanced minimally invasive training and good judgment by a surgeon are paramount in selecting patients in whom a minimally invasive approach is feasible. With increasing research in patient populations with more advanced disease, the indications are likely to continue to expand.

Improvement in postoperative mortality in elective gastrectomy for gastric cancer: Analysis of predictive factors in 1066 patients from a single centre

BACKGROUND

Gastrectomy represents the main treatment for gastric adenocarcinoma. This procedure is associated with substantial morbidity and mortality. The aim of this study was to evaluate the postoperative mortality changes across the study period and to identify predictive factors of 30-day mortality after elective gastrectomy for gastric cancer.

METHODS

This was a retrospective cohort study of a prospective database from a single centre. Patients treated with an elective gastrectomy from 1996 to 2014 for gastric adenocarcinoma were included. We compared postoperative mortality between four time periods: 1996-2000, 2001-2005, 2006-2010, and 2011-2014. Univariate and multivariate analyses were applied to identify predictors of 30-day postoperative mortality.

RESULTS

We included 1066 patients (median age 65 years; 67% male). The 30-day mortality rate was 4.7%. Mortality decreased across the four time periods; from 6.5% to 1.8% (P = 0.022). In the univariate analysis, age, ASA score, albumin <3.5, multivisceral resection, splenectomy, intrathoracic esophagojejunal anastomosis, R status, and T status were significantly associated with postoperative mortality. In the multivariate analysis, ASA class 3 (OR 10.06; CI 1.97-51.3; P = 0.005) and multivisceral resection (OR 1.6; CI 1.09-2.36; P = 0.016) were associated with higher postoperative 30-day mortality; surgery between 2011 and 2014 was associated with lower postoperative 30-day mortality (OR 0.55; CI 0.33-0.15; P = 0.030).

CONCLUSION

There was a decrease in postoperative 30-day mortality during this 18-year period at our institution. We have identified ASA score and multivisceral resection as predictors of 30-day mortality for elective gastrectomy for cancer.

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

BACKGROUND

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

METHODS

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

RESULTS

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p < 0.001).

CONCLUSIONS

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

Ratio of intra-operative fluid to anesthesia time and its impact on short term perioperative outcomes following gastrectomy for cancer: A retrospective cohort study

BACKGROUND

This study evaluates the short-term impact of fluid administration during gastrectomy for cancer.

METHODS

A multi-institutional database of patients undergoing gastrectomy for cancer from three tertiary centers was reviewed. Logistic and linear regression analyses were performed.

RESULTS

205 patients were included. The majority of patients (n = 116, 57%) underwent proximal or total gastrectomy. Median anesthesia time was 280 min (range 95-691 min). Median intraoperative crystalloid administration was 2901 ml (range 500-10,700 ml). Median colloid administration was 0 (range 0-3835 ml), although only 66 patients (32%) received colloid. On multivariate analysis, patients who received <10.0 ml total fluid per minute of anesthesia had a significantly higher risk of complications (OR 4.12, p = 0.010). Crystalloid and total fluid administration ratios did not significantly affect LOS or discharge disposition.

CONCLUSIONS

Restricting intra-operative fluid resuscitation to <10 ml total fluid per minute anesthesia is associated with an increased risk of complications in patients undergoing gastrectomy for cancer.

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.

Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS)

INTRODUCTION

Anastomotic or staple-line leak after foregut surgery presents a formidable management challenge. In recent years, with advancement of endoscopy, self-expanding covered stents have been gaining popularity. In this study, we aimed to determine the safety and effectiveness of self-expanding covered stents in management of leak after foregut surgery.

METHODS

Consecutive patients who received a fully covered self-expandable metal stent (SEMS) due to an anastomotic leak after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and removal, clinical success, time to resolution, and complications were collected. Predictive factors for clinical success rate were assessed.

RESULTS

A total of 20 consecutive patients underwent placement of fully covered SEMS for anastomotic leak, following esophagectomy (n = 5), esophageal diverticulectomy (n = 1), gastric sleeve (n = 4), gastric bypass (n = 3), partial gastrectomy (n = 4), and total gastrectomy (n = 3). All the stents were removed successfully, and clinical resolution was achieved in 18 patients (90 %) after a median of two (range 1-3) procedures and a mean of 6.2 weeks (range 0.4-14). Complications presented in 12 patients (60 %), including stent migration (n = 8), mucosal friability (n = 4), tissue integration (n = 2), and bleeding (n = 2). Two (10 %) patients' treatment was complicated by aorto-esophageal fistula formation resulting in one death. Demographic factors, comorbidities, and type of surgery were not predictive of clinical success rate or time to resolution.

CONCLUSION

SEMS are effective tools for the management of leaks after foregut surgery. The biggest challenge with this approach is stent migration. Caution is warranted due to the risk of fatal complications such as aorto-esophageal fistula formation. No type of surgery or particular patient factor, including age, sex, BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with success rate. Larger studies are needed to determine factors predictive of clinical success.

Decreased length of stay and earlier oral feeding associated with standardized postoperative clinical care for total gastrectomies at a cancer center

BACKGROUND

Standardization of postoperative care has been shown to decrease postoperative length of stay.

METHODS

In June 2009, we standardized postoperative care for all gastrectomies at our institution. Four years' worth of total gastrectomies (2 years prior to standardization and 2 years after standardization) were reviewed to determine the effect of standardization on postoperative care, length of stay, complications, and readmissions.

RESULTS

Between June 2007 and July 2011, 99 patients underwent curative intent open total gastrectomy: 51 patients prior to standardization, and 48 patients poststandardization. Patients were predominantly male (70%); median age was 63; and median body mass index was 26. Standardization of postoperative care was associated with a decrease in median time to beginning both clear liquids and a postgastrectomy diet, earlier removal of epidural catheters, earlier use of oral pain medication, less time receiving intravenous fluids, and decreased length of stay (all P < .01). Groups showed no differences in complication rates, complication severity, diet intolerance, return to our Urgent Care Center, or readmission.

CONCLUSION

Institution of standardized postoperative orders for total gastrectomy was associated with a significantly decreased length of stay and earlier oral feeding without increasing postoperative complications, early postoperative outpatient visits, or readmissions.