Longer Operating Time During Gastrectomy Has Adverse Effects on Short-Term Surgical Outcomes

Risk factors for infectious complications after gastrectomy in older patients

The present study aimed to identify preoperative and perioperative risk factors for postoperative infectious complications in older patients with gastric cancer. The present retrospective study included 504 patients with gastric cancer aged >65 years who underwent radical gastrectomy. After determining the cutoff values for various perioperative factors in the receiver operating characteristic curve analysis, preoperative and perioperative risk factors for the development of infectious complications after gastrectomy were examined using logistic regression analysis. Of the 504 patients who underwent gastrectomy, 95 (18.8%) developed infectious complications of grade II-V based on the Clavien-Dindo classification. In an analysis restricted to preoperative factors, male sex, low prognostic nutritional index, high visceral fat area and total gastrectomy were independent risk factors for infectious complications after gastrectomy. Among all perioperative factors, a low prognostic nutritional index and long operative duration were identified as independent risk factors for infectious complications after gastrectomy. The patients were divided into five groups according to the number of positive preoperative risk factors for infectious complications, and the incidence of infectious complications differed among the five groups (0 factors, 6.7%; 1 factor, 10.4%; 2 factors, 18.9%; 3 factors, 27.8%; and 4 factors, 47.6%; P<0.001). Older patients with gastric cancer who have a number of preoperative risk factors require careful consideration of the indication for gastrectomy and a shorter operative time to reduce infectious complications.

Incidence of wound dehiscence in patients undergoing laparoscopy or laparotomy: a systematic review and meta-analysis

Surgical wound dehiscence (SWD) is a serious complication-with a 40% estimated mortality rate-that occurs after surgical intervention. Since the implementation of advanced recovery protocols, the current global incidence of SWD is unknown. This systematic review and meta-analysis estimated the worldwide incidence of SWD and explored its associated factors in general surgical patients. Eligible full-text cross-sectional, cohort and observational studies in English, between 1 January 2010 to 23 April 2021, were retrieved from MEDLINE, CINAHL, EMBASE and the Cochrane Library. Data extraction and quality appraisal were undertaken independently by three reviewers. Random effects meta-analytic models were used in the presence of substantial inconsistency. Subgroup, meta-regression and sensitivity analyses were used to explore inconsistency. Publication bias was assessed using Hunter's plots and Egger's regression test. Of 2862 publications retrieved, 27 studies were included in the final analyses. Pooled data from 741,118 patients across 24 studies were meta-analysed. The 30-day cumulative incidence of SWD was 1% (95% Confidence Interval (CI): 1-1%). SWD incidence was highest in hepatobiliary surgery, at 3% (95% CI: 0-8%). Multivariable meta-regression showed SWD was significantly associated with duration of operation and reoperation (F=7.93 (2-10); p=0.009), explaining 58.2% of the variance. Most studies were retrospective, predated the agreed global definition for SWD and measured as a secondary outcome; thus, our results likely underestimate the scope of the problem. Wider uptake of the global definition will inform the SWD surveillance and improve the accuracy of reporting.

Evaluation of surgical complexity by automated surgical process recognition in robotic distal gastrectomy using artificial intelligence

BACKGROUND

Although radical gastrectomy with lymph node dissection is the standard treatment for gastric cancer, the complication rate remains high. Thus, estimation of surgical complexity is required for safety. We aim to investigate the association between the surgical process and complexity, such as a risk of complications in robotic distal gastrectomy (RDG), to establish an artificial intelligence (AI)-based automated surgical phase recognition by analyzing robotic surgical videos, and to investigate the predictability of surgical complexity by AI.

METHOD

This study assessed clinical data and robotic surgical videos for 56 patients who underwent RDG for gastric cancer. We investigated (1) the relationship between surgical complexity and perioperative factors (patient characteristics, surgical process); (2) AI training for automated phase recognition and model performance was assessed by comparing predictions to the surgeon-annotated reference; (3) AI model predictability for surgical complexity was calculated by the area under the curve.

RESULT

Surgical complexity score comprised extended total surgical duration, bleeding, and complications and was strongly associated with the intraoperative surgical process, especially in the beginning phases (area under the curve 0.913). We established an AI model that can recognize surgical phases from video with 87% accuracy; AI can determine intraoperative surgical complexity by calculating the duration of beginning phases from phases 1-3 (area under the curve 0.859).

CONCLUSION

Surgical complexity, as a surrogate of short-term outcomes, can be predicted by the surgical process, especially in the extended duration of beginning phases. Surgical complexity can also be evaluated with automation using our artificial intelligence-based model.

Safe implementation of robotic distal gastrectomy performed by non-endoscopic surgical skill qualification system-qualified surgeons

PURPOSE

Robotic gastrectomy (RG) for gastric cancer (GC) was approved for national medical insurance coverage in April, 2018, since when its use has increased dramatically throughout Japan. However, the safety of RG performed by surgeons who are not Endoscopic Surgical Skill Qualification System (ESSQS)-qualified has yet to be established. We conducted this study to verify the short-term outcomes of the initial series of RG procedures performed by non-ESSQS-qualified surgeons.

METHODS

Between January, 2020 and December, 2021, 30 patients with clinical Stage I and II GC underwent RG performed by four non-ESSQS-qualified surgeons according to the Japan Society for Endoscopic Surgery guideline. We evaluated, retrospectively, the morbidity rates according to Clavien-Dindo (CD) classification grade II or higher.

RESULTS

Each operating surgeon completed all procedures without any serious intraoperative adverse events. The median operative time, console time, and estimated blood loss were 413 (308-547) min, 361 (264-482) min, and 25.5 (4-167) mL, respectively. No patient required conversion to laparoscopic or open surgery. Three (10%) patients suffered CD grade II complications postoperatively. The median postoperative hospitalization was 11 (8-51) days.

CONCLUSION

Non-ESSQS-qualified surgeons trained by expert RG surgeons could perform robotic distal gastrectomy safely for initial cases.

Correlative Analysis Between Adverse Events of Preoperative Chemotherapy and Postoperative Complications of Gastric Cancer

Background and Objectives: This study aims to explore the safety of preoperative chemotherapy and clarify whether preoperative chemotherapy with oxaliplatin + S-1 (SOX) regimen and its adverse events are associated with higher risks of postoperative complications. Methods: We included consecutive patients with gastric cancer who underwent gastrectomy in our department between July 1 2018, and January 31 2020. Patients with preoperative SOX regimen chemotherapy were included in the analysis. Results: In the 343 included patients, 77 cases underwent preoperative chemotherapy. In total, surgical complications were found in 117 patients (34.1%), and there was no significant difference between the patients with and without preoperative chemotherapy before and after propensity score matching (p > 0.05, respectively). Multivariate analysis showed that preoperative comorbidities (p = 0.026) and the preoperative cT4b (p = 0.028) were independent risk factors in postoperative complications. In patients with preoperative chemotherapy, neither the occurrence of adverse events nor their severity was associated with postoperative complications (p > 0.05). However, the patients who received five to six cycles were more prone to postoperative complications than those who received three to four cycles (62.5 vs. 27.9%, OR = 4.306, 95% Cl = 1.282-14.464, p = 0.018). Conclusions: Occurrence of postoperative complications was not influenced by preoperative SOX chemotherapy. However, increased cycles of chemotherapy may lead to higher incidence of postoperative complications.

E-PASS scoring system serves as a predictor of short- and long-term outcomes in gastric cancer surgery

PURPOSES

This study aimed to evaluate the estimation of the physiological ability and surgical stress (E-PASS) scoring system for predicting the short- and long-term outcomes in gastric cancer (GC) surgery.

METHODS

We analyzed a multi-institutional dataset to study patients who underwent gastrectomy with a curative intent between 2010 and 2014. This study evaluated the associations between the optimal E-PASS score cutoff value and the following outcomes: (1) the incidence of postoperative complications in stage I-III GC patients and (2) the prognosis in stage II-III GC patients.

RESULTS

A total of 2495 GC patients were included. A cutoff value of 0.419 was determined using the ROC curve analysis. Postoperative complications were observed more frequently in the E-PASS-high group than that in the E-PASS-low group (30% vs. 17%, p < 0.0001). Among pStage II-III GC patients (n = 1009), the overall survival time of the E-PASS-high group was significantly shorter than that of the E-PASS-low group (hazard ratio 2.08; 95% confidence interval 1.64-2.65; p < 0.0001). A forest plot revealed that E-PASS-high was associated with a greater prognostic factor for overall survival in most subgroups.

CONCLUSIONS

The E-PASS scoring system may therefore be a useful predictor of the short- and long-term outcomes in patients with GC who have undergone radical gastrectomy.

Impact of the Endoscopic Surgical Skill Qualification System on the safety of laparoscopic gastrectomy for gastric cancer

BACKGROUND

We hypothesized that the Endoscopic Surgical Skill Qualification System (ESSQS) can shorten operative time, resulting in a decrease in postoperative morbidity. Here, we aimed to clarify whether ESSQS-qualified surgeons could decrease the incidence of complications.

METHODS

Between January 2009 and June 2019, 1042 patients diagnosed with both clinical and pathological Stage ≤ III gastric cancer and undergoing LG were enrolled. In all LG procedures involving ESSQS-qualified surgeons, these served as the operator or the instructive assistant. The short-term outcomes were retrospectively compared between the ESSQS-qualified and the non-ESSQS-qualified surgeons using a propensity-score matched analysis.

RESULTS

After propensity-score matching, 321 patients were included in each group. No significant differences were observed in morbidity rate, and length of hospitalization following surgery, although the non-ESSQS-qualified surgeon group had a significantly longer total operative time (Non-ESSQS-qualified group, 368 [170-779] min vs. ESSQS-qualified group, 316 [147-772] min; p < 0.001), and larger estimated blood loss (Non-ESSQS-qualified group, 28 [0-702] mL vs. ESSQS-qualified group 25, [0-1069] mL; p = 0.042). Multivariate analysis revealed that operative time ≥ 360 min (OR 1.818 [1.069-3.094], p = 0.027) was identified as the only significant independent risk factor determining morbidity.

CONCLUSIONS

The incidence of postoperative morbidity did not differ between patients operated by the qualified and nonqualified surgeons, as long as ESSQS-qualified surgeons provide intraoperative instructions.

Predictive value of the surgical Apgar score on postoperative complications in advanced gastric cancer patients treated with neoadjuvant chemotherapy followed by radical gastrectomy: a single-center retrospective study

Background

The surgical Apgar score (SAS) or modified SAS (mSAS) has been reported as a simple and easy risk assessment system for predicting postoperative complications in primary surgery for gastric cancer. However, few studies have described the SAS’s utility in gastric surgery after neoadjuvant chemotherapy (NAC).

Methods

One hundred and fifteen patients who received NAC and radical gastrectomy from 2008 and 2015 were included in this study. The SAS was determined by the estimated blood loss (EBL), lowest intraoperative mean arterial pressure, and lowest heart rate. The mSAS was determined by the EBL reassessed using the interquartile values. The predictive values of the SAS/mSAS for postoperative complications were assessed with univariate and multiple logistic regression analyses.

Results

Among the 115 patients, 41 (35.7%) developed postoperative complications. According to analyses with receiver operating characteristic curves of the SAS and mSAS for predicting postoperative complications, the cut-off value of the mSAS was set at 8. The rates of anastomotic leakage, pancreatic fistula, and arrhythmia in patients with high mSAS (> 8) values were higher than in those with low (0–3) and moderate [1–4] mSAS values. A multiple logistic regression analysis showed that the operation time, body mass index, and diabetes mellitus were independent risk factors for postoperative complications. The mSAS was not a significant predictor.

Conclusion

The predictive value of SAS or mSAS for morbidity may be limited in patients who undergo gastric cancer surgery after NAC. Future prospective studies with a large sample size will be needed to confirm the present results.

Risk Factors Related to Operative Duration and Their Relationship With Clinical Outcomes in Pediatric Patients Undergoing Roux-en-Y Hepaticojejunostomy

Background: Operative duration might be important for perioperative morbidity, and its involvement has not been fully characterized in pediatric patients. We identified perioperative variables associated with operative duration and determined their influence on clinical outcomes in pediatric patients. Methods: We retrospectively reviewed 701 patients who underwent elective removal of choledochal cysts followed by Roux-en-Y hepaticojejunostomy. The patients were separated into the long operative time group (>165 min) and short operative time group (<165 min) based on the median operative time (165 min). Propensity score matching was performed to adjust for any potential selection bias. The independent risk factors for operative time were determined using multivariable logistic regression analyses. Results: The operative time was often increased by excision difficulty caused by a larger choledochal cyst size (OR = 1.56; 95% CI, 1.09-2.23; p < 0.001), a greater BMI (OR = 1.02; 95% CI, 1.00-1.15; p = 0.018), and older age (OR = 1.17; 95% CI, 1.02-1.39; p = 0.012) in the multivariate analysis. A long surgical duration was associated with delayed gastrointestinal functional recovery, as measured using the time to first defecation (p = 0.027) and first bowel movement (p = 0.019). Significantly lower levels of serum albumin were found in the long operative time group than in the short operative time group (p = 0.0035). The total length of postoperative hospital stay was longer in patients in the long operative time group (7.51 ± 2.03 days) than in those in the short operative time group (6.72 ± 1.54 days, p = 0.006). Conclusions: Our data demonstrated that a short operative time was associated with favorable postoperative results. The influencing factors of operative time should be ameliorated to achieve better outcomes.