Management of complications after gastrectomy with extended lymphadenectomy

Types and implications of abdominal fluid collections following gastric cancer surgery

Background: Little data are available for abscess and non-abscess abdominal fluid collections (AFCs) after gastric cancer surgery and their clinical implications. We sought to analyse the natural history of such collections in a population of patients subject to routine postoperative imaging.Methods: From 1996 to 2012, 1381 patients underwent gastric resections and routine postoperative monitoring with abdominal ultrasound. As a unit protocol, examinations were carried out in all patients prior to drain removal, immediately before discharge, and at follow-up visits.Results: AFCs were diagnosed in 134 (9.7%) patients after a median time from surgery of seven days (interquartile range (IQR) 5-11 days). Sixty-four of the 134 AFCs (48%) were asymptomatic and resolved spontaneously after a median follow-up of 26.5 days (IQR 14-91 days). Seventy (52%) AFCs required interventional drainage. A stepwise logistic regression model demonstrated that interventional treatment was much more likely among patients with enteric fistula (odds ratio (OR) 9.542, 95% CI 1.418-46.224, p=.003) and pancreatic fistula (OR 7.157, 95% CI 1.340-39.992, p=.012).Conclusions: About one half of AFCs after gastric surgery were asymptomatic and eventually resolved spontaneously without any intervention. However, the need for interventional drainage was significantly increased by coexisting pancreatic or enteric fistula.

Impact of high amylase level in drainage fluid after gastric cancer surgery: Is it a complication or suspicious biochemical measurement?

Purpose: Pancreatic fistula is a potential postoperative complication with variable definitions, incidences and risk factors. We intended to evaluate its impact after gastric surgery. Materials and Methods: A total of 28 consecutive patients who underwent curative open gastrectomy with lymphadenectomy for gastric adenocarcinoma were retrospectively analyzed. Patients’ demographics, peri-operative and pathological data were collected. Pancreatic fistula that was diagnosed and graded according to International Study Group of Pancreatic Fistula’s system was identified as main variable.Results: Mean age of patients was 58.8±10.1 years with a female to male ratio of 9/19. Grade A pancreatic fistula was diagnosed in six patients (21.4%). There was no grade B and C pancreatic fistula. Drain amylase level was significantly higher in patients with pancreatic fistula (p=0.0001). There was no significant difference with regard to amount of drainage, length of hospital stay and duration of drains in patients with and without fistula. No significant association was shown between development of fistula and patients’ demographics, peri-operative and pathological data. Conclusion: The development of grade A pancreatic fistula after gastric surgery does not appear to be a major complication with clinical consequences. High amylase level in the drainage fluid can be considered as a biochemical measure only.  

Serum level of C-reactive protein on postoperative day 3 is a predictive indicator of postoperative pancreatic fistula after laparoscopic gastrectomy for gastric cancer

INTRODUCTION

Postoperative pancreatic fistula (POPF) is a serious complication after gastrectomy for gastric cancer. It is vitally important to detect signs of POPF in the early postoperative period and perform adequate management to avoid patient death. The aim of this study was to investigate the predictive indicators of POPF after laparoscopic gastrectomy for gastric cancer.

METHODS

The current study included 197 patients who were pathologically diagnosed with adenocarcinoma and underwent laparoscopic gastrectomy between January 2010 and December 2014 in our hospital.

RESULT

Nine patients (5.6%) developed POPF of grade III or higher according to the Clavien-Dindo classification. There was no statistical difference between POPF and various clinicopathological indicators, including age, gender, BMI, extent of lymph node dissection, and operative procedure. With respect to postoperative laboratory data, however, the serum level of C-reactive protein on postoperative day 3 was significantly related to the development of POPF. Receiver-operating characteristic analysis indicated that optimal cut-off value of the serum level of C-reactive protein on postoperative day 3 was 17.0 mg/dL, with a sensitivity of 74.0, specificity of 88.0, positive predictive value of 0.14, and negative predictive value of 0.99.

CONCLUSION

An elevated C-reactive protein level on postoperative day 3 can help physicians predict the likelihood of POPF and facilitate decision making regarding prompt clinical evaluation and therapeutic approaches for POPF.

Gastroenterological surgery in Japan: The past, the present and the future

In the last two centuries, there has been remarkable progress in the field of gastroenterological surgery, including the curative resection of cancers, replacement of failed organs through transplantation, increased safety of undergoing major surgeries and decreased operative morbidity through developments in minimal access surgery. Japan has very much been at the forefront of these advances, as is evident from the present review, from advancing the surgical management of gastric cancer to the pioneering work in live-donor transplantation. This review also highlights many instances where surgical management of the same pathologies has evolved differently between Japan and the West. It is encouraging that many procedures established in Japan are eventually taken up by the West, often after rigorous assessment affirming the quality and applicability of such techniques. In Japan, many of the crucial issues in gastroenterological surgery are increasingly addressed through large multi-institutional prospective control trials, ensuring that Japanese surgeons continue to contribute to the advances in gastroenterological surgery.

Amylase concentration in drainage fluid as a predictive factor for severe postoperative pancreatic fistula in patients with gastric cancer

PURPOSE

Postoperative pancreatic fistula (PPF) sometimes occurs after gastrectomy. We examined the risk factors for severe PPF and evaluated the predictive value of amylase concentration in drainage fluid.

METHODS

We retrospectively reviewed 591 patients who underwent curative gastrectomy for gastric cancer. A multivariate analysis was conducted to identify the risk factors for severe PPF. Receiver operating characteristic curves were used to identify the appropriate amylase cut-off value to predict severe PPF.

RESULTS

Severe PPF occurred in 23 (3.9%) cases. The multivariate analysis indicated that splenectomy (P = 0.009) was the only significant risk factor. The area under the curve of amylase in drainage fluid for predicting severe PPF on postoperative day (POD) 3 was much greater than that on POD 1 (0.972 vs. 0.894). When the cut-off values for amylase were determined to be 2900 U/L on POD 1 and 2100 U/L on POD 3, the risk ratio for severe PPF on POD 3 was higher than that on POD 1 (99.2 vs. 30.2).

CONCLUSIONS

Splenectomy was an independent risk factor for severe PPF. An amylase level of 2100 U/L on POD 3 may be a reliable cut-off value for the early diagnosis of patients at high risk of severe PPF.

Management of postoperative complications of lymphadenectomy

Gastric cancer remains a disease with poor prognosis, mainly due to its late diagnosis. Surgery remains as the only treatment with curative intent, where the goal is radical resection with free-margin gastrectomy and extended lymphadenectomy. Over the last two decades there has been an improvement on postoperative outcomes. However, complications rate is still not negligible even in high volume specialized centers and are directly related mainly to the type of gastric resection: total or subtotal, combined with adjacent organs resection and the extension of lymphadenectomy (D1, D2 and D3). The aim of this study is to analyze the complications specific-related to lymphadenectomy in gastric cancer surgery.

Failure to rescue patients from early critical complications of oesophagogastric cancer surgery

'Failure to rescue' is a significant cause of mortality in gastrointestinal surgery. Differences in mortality between high and low-volume hospitals are not associated with large difference in complication rates but to the ability of the hospital to effectively rescue patients from the complications. We reviewed the critical complications following surgery for oesophageal and gastric cancer, their prevention and reasons for failure to rescue. Strategies focussing on perioperative optimization, the timely recognition and management of complications may be essential to improving outcome in low-volume hospitals.

The measurement of amylase in drain fluid for the detection of pancreatic fistula after gastric cancer surgery: an interim analysis

Background

Pancreatic fistula is still one of the most serious and potential complications after D2-D3 distal and total gastrectomy (4% to 6%). Despite their importance, pancreatic fistulas still have not been uniformly defined. Amylase concentration of the drainage fluid after surgery for gastric cancer can be considered as a predictive factor of the presence of pancreatic fistula.

Methods

From January 2009 to April 2013, 53 patients underwent surgery for gastric cancer. Amylase concentration in the drainage fluid was measured on the first postoperative day and if it was ≥1,000 UI, it was measured again on the third postoperative day. Pancreatic fistula occurred in four cases (7.5%). Pancreatic fistulas were classified using the International Study Group on Pancreatic Fistula (ISGPF) criteria into different grades of severity. Two fistulas were Grade A, one was Grade B, and one was Grade C.

Results

Management of drainage tubes is still crucial after gastrectomy, not only for the likelihood of anastomotic leaks but also the eventual diagnosis and management of pancreatic fistula. High amylase drainage content and then the presence of the pancreatic fistula may be due to several causes: the operation itself when it includes splenectomy or pancreatic tail-splenectomy, the extended lymphadenectomy but even the ‘gently and softly’ pancreatic manipulation, according literature, may be a risk factor.

Conclusions

The authors assessed amylase concentration in the drainage fluid collected from the left subphrenic cavity on POD1 and POD3 in 53 patients who had undergone curative gastrectomy for cancer and concluded that amylase drainage content >3 times the serum amylase was a useful predictive risk factor for pancreatic fistula. Our work is an interim analysis and the aim of this study is to increase the accrual of the number of patients to have a significant number. For this reason, a protocol for a multicenter trial will be designed to verify whether the systematic measurement of amylase in drain fluid is better than abdominal ultrasound for the detection of pancreatic fistula after gastric cancer surgery.

Effect of somatostatin in advanced gastric cancer after D2 radical gastrectomy

AIM: To study the effect of somatostatin in patients with advanced gastric cancer who received D2 lymphadenectomy and vagina vasorum dissection.

METHODS: Using a prospective, single-blind, placebo-controlled design, patients with advanced gastric cancer were randomized into a study group (n = 61) and a control group (n = 59). Patients in the study group were given somatostatin for 5-7 d starting 6 h after the operation, and patients in the control group were given normal saline. Preoperative and nonoperative complications in the perioperative period, as well as different types of postoperative drainage in the two groups were compared.

RESULTS: There was no significant difference between the study group and the control group for preoperative clinicopathological indicators. We found no significant difference between the two groups for the overall incidence of complications, but a lower percentage of peritoneal effusion was observed in the treatment group (1.6% vs 10.2%, P < 0.05). There were no significant differences between the two groups in the incidence of postoperative pancreatic dysfunction and chylous fistula. However, there were significant differences in the amylase concentration in drainage fluid, volume and duration of drainage, volume and duration of chylous fistula and peritoneal drainage, and volume and duration of gastric tube drainage. The study group did not show any increase in mean hospitalization cost and the cost reduced when the postoperative complications occurred.

CONCLUSION: Postoperative somatostatin reduces volume and duration of surgical drainage and related complications. Somatostatin may improve safety of gastric cancer surgery, reducing postoperative complications and promoting recovery.

Postoperative pancreatic fistula formation according to ISGPF criteria after D2 gastrectomy in Western patients

BACKGROUND

Limited information is available on the incidence of postoperative pancreatic fistula (POPF) after D2 gastrectomy with the strict use of the International Study Group of Pancreatic Fistula (ISGPF) criteria, particularly so in Western patients.

METHODS

All patients who underwent gastrectomy for adenocarcinoma at the Karolinska University Hospital Huddinge from 2006 until June 2012 were identified via hospital records and reviewed for type of surgical procedure, postoperative morbidity, incidence, and risk factors for POPF.

RESULTS

Ninety-two of 107 cases had a D2 gastrectomy eligible for evaluation of POPF, of which 83 (90 %) also underwent bursectomy. Seven patients fulfilled the criteria for POPF grade A (7.6 %), 5 met the criteria for POPF grade B (5.4 %), and 6 the criteria for POPF grade C (6.5 %). The incidence of POPF grade B or C was 4.9 % among the 82 patients for whom no pancreatic resection was performed and 70 % among 10 cases with concomitant pancreatic resection. The latter (OR 156.2, 95 % CI 8.00-3046.93) and age (OR 1.2, 95 % CI 1.02-1.35) were found to be the only risk factors for POPF after gastrectomy upon a multivariate analysis.

CONCLUSIONS

In this series of Western patients, POPF grade B or C according to the ISGPF criteria was uncommon after D2 gastrectomy without pancreatic resection. Bursectomy was not a risk factor for POPF.

Establishment of a simple predictive scoring system for pancreatic fistula after laparoscopy-assisted gastrectomy

BACKGROUND

The potential severity of postoperative pancreatic fistula (POPF) after laparoscopy-assisted gastrectomy (LAG) necessitates efforts to identify predictive factors for POPF. The aim of the present study was to identify predictive factors for POPF and to establish a predictive scoring system for POPF after LAG.

PATIENTS AND METHODS

Between June 2004 and March 2011, 277 gastric cancer patients who underwent curative resection with LAG were enrolled. POPF was defined according to the International Study Group for Pancreatic Fistula grading system. Risk factors for POPF were evaluated using logistic regression analysis, and a scoring system for POPF was established.

RESULTS

In the derivation cohort, multivariate analysis revealed the risk factors for POPF as patient age ≤70 years (5 points), amylase level of postoperative day 1 drainage fluid >454 IU/L(5 points), total number of retrieved lymph nodes >21 (5 points), body mass index >21.45 kg/m(2) (4 points), and operating time >337 min (2 points). In the validation cohort, at the cut-off point for high risk (score ≥15), the model had a negative predictive value of 94.5%, a positive predictive value of 57.4%, a sensitivity of 88.6%, and a specificity of 75.0% (C statistic = 0.857).

CONCLUSION

This study demonstrated that POPF after LAG is associated with specific preoperative and postoperative factors. With a simple predictive scoring system, patients at high risk for POPF can be accurately identified. This simple predictive scoring system will be useful for many clinicians to assess the risk of POPF after LAG and start treating at-risk patients earlier.

A prospective feasibility and safety study of laparoscopy-assisted distal gastrectomy for clinical stage I gastric cancer initiated by surgeons with much experience of open gastrectomy and laparoscopic surgery

BACKGROUND

The aim of this prospective study was to evaluate the feasibility and safety of laparoscopy-assisted distal gastrectomy (LADG) initiated by surgeons with much experience of open gastrectomy and laparoscopic surgery.

METHODS

Three surgeons who each had experience with more than 300 cases of open gastrectomy, more than 100 cases of laparoscopic cholecystectomy, more than 5 cases of laparoscopic colectomy, and more than 5 cases of laparoscopic partial gastrectomy were nominated as LADG operators. All three operators received training for LADG with study materials including videotapes, a box simulator, and an animal laboratory, with lectures and assistance from LADG instructors who each had experience of more than 50 LADG operations. Then the nominated LADG operators performed LADG with the instructors, in which their skills were evaluated and certified. Thereafter, they performed LADG without assistance from the instructors. The target of this study was clinical stage I gastric cancer that was resectable by distal gastrectomy. D1 + alpha, D1 + beta, or D2 dissection was performed laparoscopically. Basically reconstruction was done extracorporeally with a Billroth-I gastroduodenostomy. An extramural review board checked the surgical quality of the operations performed by the three surgeons. The primary endpoint was morbidity and mortality.

RESULTS

A total of 193 patients were enrolled in this study between August 2004 and July 2009. The median blood loss was 35 ml and the median operation time was 250 min. Conversion to open surgery was seen in 6 patients; 4 due to bleeding and 2 due to advanced disease. Overall morbidity was 1.6 %, including grade 2 anastomotic leakage in 0.5 % and grade 2 pancreatic fistula in 0.5 %. No mortality was observed. The number of cases required until the LADG operators acted as LADG surgeons without an instructor was 3 for each of the three surgeons. When comparing the data between that in the training period (n = 9) and the operators' data (n = 174), the median operation time was significantly longer in the training period (355 min) than in the latter period (247.5 min) (p = 0.015). Median blood loss was also greater in the training period (150 ml) than the latter period (32.5 ml), but the difference did not reach statistical significance (p = 0.084). During the training period, no patient developed any complications of ≥ grade 2.

CONCLUSION

These results suggested that LADG could be initiated and performed feasibly and safely if surgeons with much experience of open gastrectomy and laparoscopic surgery received adequate training for LADG.

Evaluation of postoperative pancreatic fistula after total gastrectomy with D2 lymphadenectomy by ISGPF classification

INTRODUCTION

Postoperative pancreatic fistula (POPF) is a serious complication of total gastrectomy (TG) with D2 lymphadenectomy (D2). However, the actual incidence and risk factors are not yet completely understood, due in part to the absence of the widely accepted criteria for POPF following gastrectomy.

PATIENTS AND METHODS

One hundred and four patients who underwent TG with D2 between March 2007 and December 2009 were included in this study. The incidence and severity of POPF were evaluated according to the International Study Group on Pancreatic Fistula (ISGPF) classification. In addition, risk factors for POPF of ISGPF grade B or higher were investigated.

RESULTS

POPFs of ISGPF grade B or higher were observed in 23 patients (22.1%). Univariate analysis found that sex, body mass index, and amylase concentration of drainage fluid (D: -AMY) on the first postoperative day (1POD) were significant predictors of POPF grade B or higher. The appropriate cutoff level of D: -AMY on 1POD was calculated as 3398 IU/l. Multivariate analysis showed that D: -AMY ≥3,398 IU/l on 1POD was the only independent risk factor.

CONCLUSIONS

High D: -AMY on 1POD (≥3,398 IU/l) can predict a grade B or higher POPF, and this value may be useful in the early detection of POPF following TG with D2.

Laparoscopy-assisted distal gastrectomy for early gastric cancer with versus without prophylactic drainage

PURPOSE

Little has been reported on routine prophylactic abdominal drainage after gastrectomy, especially after laparoscopy-assisted distal gastrectomy (LADG). We conducted this retrospective study on patients undergoing LADG to evaluate the benefit of routine drainage in LADG procedures.

METHODS

The subjects were 21 patients who underwent surgery for early gastric cancer (EGC) between January 2004 and March 2008. They comprised 10 who underwent LADG with drainage before January 2006 and 11 who underwent LADG without drainage after February 2006. We compared patient and tumor characteristics, operative results, and postoperative outcomes between the groups.

RESULTS

The no-drain group of patients were able to eat their first meal significantly sooner than the drain group patients (P < 0.01); however, the time to start ambulating, passing flatus, and drinking was similar in the two groups. There were no significant differences between the groups in the postoperative complication rate or the postoperative hospital stay. The drain did not seem to add benefit, and no complications due to the lack of drain placement were noted in the no-drain group.

CONCLUSION

Routine prophylactic abdominal drainage after LADG for EGC may not be necessary.

Is routine measurement of amylase concentration in drainage fluid necessary after total gastrectomy for gastric cancer?

BACKGROUND AND OBJECTIVES

Measurement of amylase level in drainage fluid (D-AMY) is often performed for detection of pancreatic fistula (PF) formation after total gastrectomy. However, PF incidence has decreased and PF formation can be judged by changes in drainage fluid properties. The aim of study is to compare the significance of drainage fluid inspection for PF formation with D-AMY measurement.

METHODS

PF incidence, drainage fluid properties, and D-AMY level in drainage fluid were investigated retrospectively in 173 patients undergoing total gastrectomy for gastric cancer. The sensitivity and specificity of changes in fluid properties for PF detection were compared to D-AMY measurement.

RESULTS

PF incidence in patients with dark-red colored drainage fluid (16/51) was higher than in those without dark-red fluid (0/122, P < 0.0001). The sensitivity and specificity of diagnosis by fluid properties were 100% and 77.7%, respectively. PF formation also correlated with D-AMY level, with sensitivity and specificity of diagnosis by D-AMY level of 5,000 U of 100% and 82.2%, respectively. There were no differences in the above parameters between the two diagnostic methods.

CONCLUSIONS

Drainage fluid inspection can provide accurate diagnosis of PF formation, similar to D-AMY measurement, suggesting that routine D-AMY measurement is probably not necessary in every patient.

Amylase concentration of the drainage fluid as a risk factor for intra-abdominal abscess following gastrectomy for gastric cancer

BACKGROUND

Insertion of drainage tubes at gastric cancer surgery could be useful for the prediction and management of postoperative complications. However, drains should be removed as soon as they are deemed unnecessary for various reasons. Amylase concentration of the drainage fluid following total gastrectomy for gastric cancer has been reported to be a useful risk factor for surgical complications.

METHODS

Between January 2002 and December 2008, the authors measured amylase concentration of the drainage fluid on the first postoperative day for 372 patients who underwent gastrectomy with lymphadenectomy for gastric cancer at the Department of Surgery II, Nagoya University. Univariate and multivariate analyses were performed to evaluate the significance of various covariates as risk factors for the pancreas-related complications.

RESULTS

Postoperative complications developed in 111 patients, of which 27 were pancreas-related. Amylase concentration was significantly higher in patients who underwent splenectomy, pancreaticosplenectomy, total/proximal gastrectomies, and extended lymphadenectomy and in those who eventually developed intra-abdominal abscess. Amylase concentration > or =1,000 IU/l on the first postoperative day, along with the body mass index, was an independent risk factor for pancreas-related intra-abdominal abscess.

CONCLUSIONS

With a negative predictive value of 97.7%, pancreas-related complications are highly unlikely to be observed when amylase concentration is less than 1,000 IU/l, and early removal of the drainage tube could be recommended for these patients.

Revisional surgery after gastrectomy for gastric cancer: review of the literature

Recent reports have shown that morbidity and mortality after gastrectomy for gastric cancer vary between authors, countries, and procedures. Common complications related to gastrectomy are postoperative bleeding, anastomotic leakage, pancreatic juice leakage, intra-abdominal abscess, intestinal obstruction, wound dehiscence, and so on. Recently, laparoscopic gastrectomy for gastric cancer has developed, especially in Japan and East Asian countries because it is less invasive. Several retrospective studies have shown that the operative complication rate is similar to that of conventional open surgery. Although most postoperative complications can be successfully treated by conservative therapies, surgical management is occasionally needed to prevent a fatal outcome. This review article provides insight into how surgeons can make efforts to reduce postoperative complications through proper preoperative evaluation and improved surgical skills during the initial gastrectomy. In addition, it reviews guidance for timely revisional surgery to allow salvage of patients with serious acute operative complications based on clinical findings made by a group of experienced surgeons.

Safety and feasibility of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG 0703)

BACKGROUND

Although the number of patients undergoing laparoscopy-assisted distal gastrectomy (LADG) has been increasing, a prospective study with a sample size sufficient to investigate the benefit of LADG has never been reported. We conducted a multi-institutional phase II trial to evaluate the safety of LADG with nodal dissection for clinical stage I gastric cancer patients.

METHODS

The subjects comprised patients with clinical stage I gastric cancer who were able to undergo a distal gastrectomy. LADG with D1 plus suprapancreatic node dissection was performed. The primary endpoint was the proportion of patients who developed either anastomotic leakage or a pancreatic fistula. The secondary endpoints included surgical morbidity and short-term clinical outcome.

RESULTS

Between November 2007 and September 2008, 176 eligible patients were enrolled. The proportion of patients who developed anastomotic leakage or a pancreatic fistula was 1.7%. The overall proportion of in-hospital grade 3 or 4 adverse events was 5.1%. The short-term clinical outcomes were as follows: 43.2% of the patients requested an analgesic on postoperative days 5-10; the median time from surgery until the first episode of flatus was 2 days; and 88 patients (50.0%) had a body temperature of 38 °C or higher during their hospital stay.

CONCLUSIONS

This trial confirmed the safety of LADG performed by credentialed surgeons in terms of the incidence of anastomotic leakage or pancreatic fistula formation. A phase III trial (JCOG 0912) to confirm the noninferiority of LADG to an open gastrectomy in terms of overall survival is ongoing.

Prognostic Factors of Patients With Transmural Advanced Gastric Carcinoma

Background

The purpose of this study is to evaluate perioperative morbidity, mortality and the prognostic factors that influence survival of the patients with transmural advanced gastric carcinoma after curative surgical therapy.

Methods

Fifty patients with transmural advanced gastric adenocarcinoma underwent curative resection in our clinic. The records of the patients were reviewed and the prognostic factors such as age, gender, location and size of the tumor, type of surgery, blood transfusion, depth of tumor invasion, lymph node metastases, stage of the disease, grading, vascular invasion, lymph vessel invasion, characteristics of the tumor according to Lauren’s classification, and lymph node ratio were evaluated by using statistical methods.

Results

In a total of 12 patients (24%) major morbidities developed, and five patients (10%) died. The overall survival rate was 48% at 1 year, 31% at 3 years, and 19% at 5 years. Lymph node metastases (P = 0.03), lymph vessel invasion (P = 0.001), blood transfusion (P = 0.021), and lymph node ratio (P = 0.006) were the prognostic features identified by univariate analysis. Among the multiple significant prognostic factors in the univariate analysis only one factor, lymph node ratio, proved to be independently significant in the multivariate analysis (RR: 4.47).

Conclusions

Our data showed that we can expect a good survival for patients with a lymph node ratio less than 0.2.

Prevention of postoperative pancreatic fistula after total gastrectomy

BACKGROUND

Pancreatic fistula (PF) is still one of the serious complications after total gastrectomy (TG). The purpose of this study was to identify risk factors for PF after TG and to evaluate our attempts to prevent PF.

METHODS

From August 1992 to July 2006, 740 consecutive patients with gastric neoplasm underwent TG at the National Cancer Center Hospital East. Univariate and multivariate analyses of potential risk factors for the development of PF and the effectiveness of operative procedures to prevent PF were performed.

RESULTS

Postoperative PF was identified in 130 patients (18%). On multivariate analysis, body mass index (P < 0.001) and the operative procedure (TG with pancreaticosplenectomy) (P = 0.001) were independent risk factors. In TG with splenectomy (pancreas-preserving method), total preservation of the splenic artery was significantly correlated with a lower incidence of PF (P < 0.001). In TG with pancreaticosplenectomy, the use of a linear stapling device was an effective surgical technique for closure of the cut end of the pancreas, but there was no significant difference from conventional methods. Recently, the incidence decreased significantly for TG overall and TG with splenectomy.

CONCLUSIONS

PF after TG is more likely to occur in obese patients undergoing TG with pancreaticosplenectomy. When TG with splenectomy (pancreas-preserving method) is performed, the splenic artery should be totally preserved. If TG with pancreaticosplenectomy is performed, the use of a linear stapling device for closure of the cut end of the pancreas should be suggested. These improvements in surgical techniques are useful to prevent PF.

Risk factors and management of intra-abdominal infection after extended radical gastrectomy

BACKGROUND

This study elucidated risk factors and management for intra-abdominal infection after extended radical gastrectomy.

METHODS

From 1988 to 2004, 2,076 patients with gastric cancer underwent extended radical gastrectomy at Taipei Veterans General Hospital. Risk factors for intra-abdominal infection were determined by analyzing clinicopathological factors, operative procedure, combined organ resection, operative time, blood loss, and associated disease(s). Management modalities were summarized.

RESULTS

The overall complication rate was 18.7%. Eighty (3.9%) patients were found to have intra-abdominal infections. Age, prolonged operation time, and combined organ resection were the precipitating factors. These patients were categorized into 3 groups: intra-abdominal abscess with adequate drainage, intra-abdominal abscess without anastomotic leakage, and intra-abdominal abscess because of leakage. Adequate drainage was the primary treatment. Mortality rate was 22.5% (18), and the most common cause of mortality was intra-abdominal abscess caused by leakage.

CONCLUSIONS

Although expert surgical skills can minimize the incidence of intra-abdominal infection, management also requires experience and training.

Upper abdominal body shape is the risk factor for postoperative pancreatic fistula after splenectomy for advanced gastric cancer: a retrospective study

Background

Postoperative pancreas fistula (POPF) is a major complication after total gastrectomy with splenectomy. We retrospectively studied the effects of upper abdominal shape on the development of POPF after gastrectomy.

Methods

Fifty patients who underwent total gastrectomy with splenectomy were studied. The maximum vertical distance measured by computed tomography (CT) between the anterior abdominal skin and the back skin (U-APD) and the maximum horizontal distance of a plane at a right angle to U-APD (U-TD) were measured at the umbilicus. The distance between the anterior abdominal skin and the root of the celiac artery (CAD) and the distance of a horizontal plane at a right angle to CAD (CATD) were measured at the root of the celiac artery. The CA depth ratio (CAD/CATD) was calculated.

Results

POPF occurred in 7 patients (14.0%) and was associated with a higher BMI, longer CAD, and higher CA depth ratio. However, CATD, U-APD, and U-TD did not differ significantly between patients with and those without POPF. Logistic-regression analysis revealed that a high BMI (≥25) and a high CA depth ratio (≥0.370) independently predicted the occurrence of POPF (odds ratio = 19.007, p = 0.002; odds ratio = 13.656, p = 0.038, respectively).

Conclusion

Surgical procedures such as total gastrectomy with splenectomy should be very carefully executed in obese patients or patients with a deep abdominal cavity to decrease the risk of postoperative pancreatic fistula. BMI and body shape can predict the risk of POPF simply by CT.

Linfadenectomia ampliada (D2) no tratamento do carcinoma gástrico: análise das complicações pós-operatórias

OBJETIVO: Descrever e analisar as principais complicações pós-operatórias e mortalidade dos pacientes submetidos à ressecção gástrica por câncer gástrico com linfadenectomia D2. MÉTODO: Foi realizada uma coorte histórica onde as principais variáveis em estudo foram: idade, localização do tumor, estadiamento, complicações do procedimento cirúrgico, padrão de recidiva tumoral, análise da sobrevida livre de doença e sobrevida total. RESULTADOS: Foram avaliados 35 pacientes submetidos à dissecção linfonodal D2 no período de Janeiro de 2000 a Dezembro de 2004. A média de idade foi 57 anos. Apenas um (2,9%) paciente apresentava tumor precoce e o local mais comum do tumor foi no terço médio do estômago. O número de linfonodos ressecados por paciente variou de 15 a 80 linfonodos (média 28,8). Vinte e seis (74,3%) pacientes apresentaram linfonodos metastáticos, sendo a média de 13,4 (±11,8) linfonodos comprometidos por paciente. Seis (17,1%) pacientes apresentaram complicações no período pós-operatório, sendo duas pneumonias, uma fístula pancreática, uma fístula do coto duodenal e duas deiscências da anastomose esôfago-jejunal. Apenas um (2,86%) paciente morreu devido a complicações operatórias. O tempo de seguimento médio foi de 26 meses. Vinte e dois pacientes apresentavam-se vivos no fechamento do estudo, com uma sobrevida atuarial de 62,9%. CONCLUSÃO: Os resultados deste estudo sugerem que, em centros especializados, a linfadenectomia D2 é um procedimento com nível de complicações aceitável e pode ser realizada sem aumento da mortalidade operatória.

Gastric cancer surgery--a balance of risk and radicality

INTRODUCTION

The aim of this study was to determine whether tailoring the extent of resection would allow radical gastric cancer surgery to be performed safely in a UK population.

PATIENTS AND METHODS

A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1) undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent of lymphadenectomy was based upon pre-operative and intra-operative staging, and balanced against the patient's age and fitness.

RESULTS

In the study group, 83 patients underwent subtotal or distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy. Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas pre-serving) D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n = 3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37). Of the patients, 48 developed postoperative complications including 17 patients with a major surgical complication. The in-hospital mortality was 1.7% (3 of 180). Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%, respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and 6.9%.

CONCLUSIONS

By tailoring the extent of resection and balancing risk and radicality, gastric cancer surgery can be performed with low mortality in Western patients.

Is prophylactic placement of drains necessary after subtotal gastrectomy?

AIM: To determine the evidence-based values of prophylactic drainage in gastric cancer surgery.

METHODS: One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups.

RESULTS: No significant differences were observed between the drain group and no-drain group in terms of operating time (171 ± 42 min vs 156 ± 39 min), number of post-operative days until passage of flatus (3.7 ± 0.5 d vs 3.5 ± 1.0 d), number of post-operative days until initiation of soft diet (4.9 ± 0.7 d vs 4.8 ± 0.8 d), length of post-operative hospital stay (9.3 ± 2.2 d vs 8.4 ± 2.4 d), mortality rate (5.4% vs 3.8%), and overall post-operative complication rate (21.4% vs 19.2%).

CONCLUSION: Prophylactic drainage placement is not necessary after subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.

Laparoscopy-assisted gastrectomy for early gastric cancer in young and elderly patients

Open gastric surgery in elderly patients is associated with higher morbidity and mortality rates than those reported among younger individuals. Therefore, minimally invasive surgery may have a larger impact on the elderly compared to the younger age group. The objective of this study was to evaluate the experience of laparoscopy-assisted distal gastrectomy (LADG) in patients with early gastric cancer and compare the results in patients 70 years of age and older to those in patients younger than 70 years of age. From January 1998 to October 2004, a total of 103 patients underwent LADG. Of these patients, 30 who were older than 70 years were compared with 73 who were younger. Preoperative co-morbidity, operative results, postoperative outcomes, and survival were analyzed. Furthermore, as a standard control of this study, we reviewed 54 distal gastrectomy cases with open surgery (open distal gastrectomy; ODG) in the same term with the same background factors, categorized into elder (n = 16) and younger (n = 38). The mean age of the elderly patients was 75 years in the LADG group. A significantly higher proportion of elderly patients had concurrent diseases in both groups. Blood loss was significantly less in the elderly than in younger patients undergoing LADG, and it was less in the LADG group than in the ODG group. The overall 5-year survival rates in the LADG group were not significantly different between elderly and younger patients. Laparoscopy-assisted distal gastrectomy is a safe and effective treatment for early gastric cancer in the elderly. Therefore, chronological age alone should not be considered a contraindication in selecting patients for LADG.

Risk factors for pancreas-related abscess after total gastrectomy

BACKGROUND

European clinical trials of gastrectomy have shown that pancreas-related complications are the major cause of mortality. The aim of this study was to determine the risk factors for pancreas-related abscess after gastrectomy and to evaluate the effects of the abscess on postoperative mortality.

METHODS

Between 1992 and 1999, 663 consecutive patients with gastric carcinoma underwent total gastrectomy. Data from these patients were analyzed, to identify the predictors of pancreas-related abscess caused by pancreatic juice leakage, by a multiple logistic regression model.

RESULTS

On multivariate analysis, increasing age (P = 0.018) and body mass index (P = 0.006) were independent preoperative risk factors. Dissection along the distal splenic artery was an intraoperative risk factor. The hazard ratios were increased 9.13-fold (P = 0.000) with a pancreas-preserving operation and 16.72-fold (P = 0.000) by distal pancreatectomy. Patients with the abscess had a higher postoperative mortality rate (P = 0.008), and a higher re-operation rate (P < 0.001) than patients without the abscess.

CONCLUSION

Pancreas-related abscess is more likely to occur in older, obese patients undergoing node dissection along the distal splenic artery. Abscess formation is associated with a higher mortality and re-operation rate. Spleen preservation should be evaluated in Japan.

Gastric cancer surgery in the elderly without operative mortality

BACKGROUND

Surgeons are increasingly being faced with the problem of treating elder gastric carcinoma patients. Recent improvements in the techniques for preoperative diagnosis and perioperative management have been made. The purpose of this study was to elucidate whether these improvements have produced a decrease in postoperative complications and mortality and resulted in a better clinical outcome.

METHODS

Between 1993 and 2003, 141 elderly patients (aged 80 years or above) with gastric cancer underwent operation under the care of dedicated staff surgeons. The results of treatment were analysed.

RESULTS

52 (36.9%) patients had a diagnosis of gastric cancer during a health-check. Only 19 patients (13.5%) had no preoperative risk factors. The ASA score was II in 80%. Approximately 35% of the patients had early gastric cancer. Nodal metastasis was observed in 56% of the patients. The proportion of stage I patients was 40%. Resection rate was 95.7%. Reduced nodal dissection (<D2) was common (47%). The surgery-related complication rate was as low as 8% and the number of operation-related deaths was zero. The 3 (5) year survival rates were 59.0 (48.2-69.8), 48.8 (36.0-61.6) % overall, and 70.0 (58.3-81.7), 56.6 (41.4-71.8) % after curative resection. The 3 (5) year survival rate was 80.3 (63.9-96.7), 73.6 (54.0-93.2) % for early gastric cancer.

CONCLUSIONS

Gastrectomy for elder patients can be carried out very safely by specialists with an excellent patient prognosis.