Analysis of predictive risk factors for postoperative complications of laparoscopy-assisted distal gastrectomy

Risk factors of postoperative complications and their effect on survival after laparoscopic gastrectomy for gastric cancer

Background

The association between postoperative complications and long-term survival after laparoscopic gastrectomy (LG) for gastric cancer (GC) remains uncertain. This study aimed to determine the incidence and risk factors of postoperative complications and evaluate their impact on survival outcomes in patients undergoing LG.

Methods

A retrospective study was conducted on 621 patients who underwent LG for gastric adenocarcinoma between March 2015 and December 2021. Postoperative complications were classified according to the Clavien-Dindo classification, with major complications defined as Grade III or higher. Logistic regression models with stepwise backward procedure were used to identify risk factors for complications. To assess the impact of postoperative complications on survival, uni- and multi-variable Cox proportional hazard models were used for overall survival (OS) and disease-free survival (DFS).

Results

Overall rate of postoperative complications was 17.6% (109 patients); 33 patients (5.3%) had major complications. Independent risk factors for major complications were Charlson comorbidities index (OR [95% CI], 1.87 [1.09-3.12], p-value = 0.018 for each one score increase), and type of anastomosis (OR [95% CI], 0.28 [0.09-0.91], p-value = 0.029 when comparing Billroth II with Billroth I). Multivariable analysis identified major complications as an independent prognostic factor to reduce OS (HR [95% CI], 2.32 [1.02-5.30], p-value = 0.045) and DFS (HR [95% CI], 2.63 [1.37-5.06], p-value = 0.004). Other prognostic factors for decreased survival outcomes were tumor size, presence of invasive lymph nodes, and T4a stage.

Conclusions

Major complications rate of LG for GC was approximately 5.3%. Charlson comorbidities index and type of anastomosis were identified as risk factors for major postoperative complications. Major complications were demonstrated to pose adverse impact on survival outcomes.

Preoperative weight loss program involving a 20-day very low-calorie diet for obesity before laparoscopic gastrectomy for gastric cancer

INTRODUCTION

The increased visceral fat in patients with obesity can increase the technical difficulty of surgery. This study was performed to evaluate a preoperative 20-day very low-calorie diet for obesity before laparoscopic gastrectomy for gastric cancer.

METHODS

This prospective single-center study involved patients with obesity who were planning to undergo laparoscopic gastrectomy for gastric cancer. Obesity was defined according to the Japanese criteria: BMI ≥25 kg/m² or waist circumference ≥85 cm in men and ≥90 cm in women. The patients underwent a preoperative 20-day very low-calorie diet and received nutritional counseling. Weight loss, body composition, visceral fat mass, and operative outcomes were evaluated.

RESULTS

Thirty-three patients were enrolled from September 2013 to August 2015. Their median age was 71 years, and 78.8% were men. Their median bodyweight and BMI were 72.3 kg (range, 53.8-82.5 kg) and 26.0 kg/m² (range, 23.5-31.0 kg/m² ), respectively. The patients achieved a mean weight loss of 4.5% (95% confidence interval [CI]: 3.8-5.1), corresponding to 3.2 kg (95%CI: 2.7-3.7 kg). Body fat mass was significantly decreased by a mean of 2.5 kg (95%CI: 1.9-3.1), whereas skeletal muscle mass was unaffected (mean: -0.20 kg [95%CI: -0.55-0.15]). The visceral fat mass reduction rate was high as 16.8% (range, 11.6%-22.0%). All patients underwent laparoscopic gastrectomy as planned. Severe postoperative morbidity (Clavien-Dindo grade ≥III) was seen in only one patient (3.0%).

CONCLUSION

The preoperative 20-day very low-calorie diet weight loss program is promising for the treatment of obesity before laparoscopic gastrectomy for gastric cancer.

Body Mass Index and Parotidectomy Outcomes

Multiple specialties have demonstrated increased risk of certain postoperative complications in patients with an increased body mass index (BMI). The goal of this study was to understand the outcomes of patients undergoing parotidectomy with an increased BMI and to identify any other patient risk factors for postoperative complications. This study was a retrospective chart review of 432 patients. Patient variables collected included BMI, age, gender, history of diabetes mellitus, type of parotidectomy, and pathology. Outcomes reviewed included facial nerve weakness, hematoma or seroma formation, and wound infection. The results showed that BMI had no statistically significant effect on complications. However, patients undergoing a total parotidectomy, malignant pathology, and patients with a history of diabetes mellitus had significantly more postoperative facial weakness. In conclusion, BMI does not influence postoperative complications in patients undergoing parotidectomy. Patients with diabetes, those undergoing total parotidectomies, and patients with malignant pathology have significantly more facial weakness and should be counseled accordingly.

Comparison of totally laparoscopic total gastrectomy using an endoscopic linear stapler with laparoscopic-assisted total gastrectomy using a circular stapler in patients with gastric cancer: A single-center experience

AIM

To evaluate the safety and efficacy of totally laparoscopic total gastrectomy (TLTG) with esophagojejunostomy using a linear stapler compared with laparoscopic-assisted total gastrectomy (LATG) using a circular stapler in gastric cancer patients.

METHODS

We retrospectively reviewed 687 patients who underwent laparoscopic total gastrectomy for gastric cancer at a single institution from August 2008 to August 2014. The patients were divided into two groups according to the type of operation: 421 patients underwent TLTG and 266 underwent LATG. Clinicopathologic characteristics and surgical outcomes in the two groups were compared and analyzed.

RESULTS

The TLTG group had higher mean ages at the time of operation (57.78 ± 11.20 years and 55.69 ± 11.96 years, P = 0.020) and more histories of abdominal surgery (20.2% and 12.4%, P = 0.008) compared with the LATG group. Surgical outcomes such as intraoperative and postoperative transfusions, combined operations, pain scores and administration of analgesics, and complications were similar between the two groups. However, compared with the LATG group, the TLTG group required a shorter operation time (149 min vs 170 min, P < 0.001), had lower postoperative hematocrit change (3.49% vs 4.04%, P = 0.002), less intraoperative events (3.1% vs 10.2%, P < 0.001), less intraoperative anastomosis events (2.4% vs 7.1%, P = 0.003), faster postoperative recovery such as median time to first flatus (3.30 d vs 3.60 d, P < 0.001), faster median commencement of soft diet (4.30 d vs 4.60 d, P < 0.001) and shorter length of postoperative hospital stay (6.75 d vs 7.02 d, P = 0.005).

CONCLUSION

The intracorporeal method for reconstruction of esophagojejunostomy using a linear stapler may be considered a feasible procedure comparing with extracorporeal anastomosis using circular stapler because TLTG is simpler and more straightforward than LATG. Therefore, TLTG can be recommended as an appropriate procedure for gastric cancer.

Diagnosis and treatment of duodenal stump leakage after laparoscopic gastrectomy

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

Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer

BACKGROUND

Pylorus-preserving gastrectomy (PPG) has been performed to reduce postprandial symptoms for some early gastric cancer (EGC) cases. The aim of this study was to evaluate the possible advantages after PPG for middle-third EGC in comparison with distal gastrectomy.

MATERIALS AND METHODS

We searched Medline, Embase, and Science Citation Index Expanded for relevant studies. Statistical analyses were conducted to calculate the summary weighted mean differences (WMDs) and odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) using random-effects models.

RESULTS

We identified 15 nonrandomized controlled trials (16 studies) with 1774 patients, which consisted of 11 studies for conventional PPG (CPPG) versus conventional distal gastrectomy (CDG) and 5 studies for laparoscopy-assisted PPG (LAPPG) versus laparoscopy-assisted distal gastrectomy (LADG). Meta-analysis of CPPG versus CDG revealed that CPPG had the advantage of prevention of early dumping syndrome (OR=0.18; 95% CI 0.12, 0.27), gastritis (OR=0.19; 95% CI 0.07, 0.53), duodenal juice reflux (OR=0.20; 95% CI 0.06, 0.66), and regaining of weight (WMD=3.53; 95% CI 2.34, 4.72). However, the incidence of gastric stasis was higher in the CPPG group than in the CDG group (OR=1.70; 95% CI 1.13, 2.57). Meta-analysis of LAPPG versus LADG revealed that LAPPG shortened the operation time (WMD=-21.12; 95% CI -31.33, -10.90) and did not increase the occurrence of postoperative complication (OR=0.72; 95% CI 0.41, 1.27).

CONCLUSIONS

With the benefits of prevention of early dumping syndrome, duodenal juice reflux, gastritis, and regaining of weight, PPG can be an excellent option for middle-third EGC.