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

Clinical value of prognostic nutritional index combined with C-reactive protein and albumin in early prediction of anastomotic leakage after radical gastric cancer surgery

OBJECTIVE

To evaluate the predictive value of the Prognostic Nutritional Index (PNI) combined with C-reactive protein (CRP) and albumin (ALB) for anastomotic leakage following radical gastric cancer surgery.

METHODS

A retrospective case-control study was conducted with 275 gastric cancer patients at the Second People's Hospital of Lanzhou City from September 2019 to October 2022. Patients were categorized into an anastomotic leakage group (n=31) or a non-leakage group. Clinical, surgical, and pathological data were analyzed using logistic regression to develop two risk models: a combined clinical-laboratory index (RISK1) and a separate laboratory index (RISK2). Model effectiveness was compared using Receiver Operating Characteristic (ROC) curves.

RESULTS

Anastomotic leakage occurred in 11.27% of patients, predominantly in those with advanced TNM stages (P=0.006). Notably, higher operative times (P=0.049) and increased intraoperative bleeding (P=0.027) were associated with the leakage group. Significant differences in ALB, PNI, and CRP levels were observed between the groups. Both RISK1 and RISK2 identified ALB, CRP, PNI, operative time, and intraoperative bleeding as independent predictors of leakage, demonstrating high predictive accuracy (RISK1 AUC=0.937, RISK2 AUC=0.911), with no significant difference in performance between the models (P=0.245).

CONCLUSION

The combination of ALB, CRP, and PNI effectively predicts the risk of anastomotic leakage in patients undergoing gastric cancer surgery. These biomarkers can significantly enhance postoperative management and improve patient outcomes.

The three-tube method via precise interventional placement for esophagojejunal anastomotic fistula after gastrectomy: a single-center experience

BACKGROUND

Esophagojejunal anastomotic leakage is a serious complication after total gastrectomy. This study evaluated the safety and efficacy of transnasal placement of drainage catheter, jejunal decompression tube, and jejunal nutrition tube under fluoroscopy for treatment of esophagojejunal anastomotic fistula after gastrectomy in gastric cancer patients.

METHODS

This is retrospective review of patients with esophagojejunal anastomotic fistula treated with transnasal placement of abscess drainage catheter, decompression tube, and jejunal nutrition tube under fluoroscopy. Fistula healing time, patient survival, and Eastern Cooperative Oncology Group (ECOG) performance status before and after treatment were evaluated.

RESULTS

Sixty-four patients were included in the study. Insertion of the transnasal abscess drainage catheter, decompression tube, and jejunal nutrition tube was successful on the first attempt in all patients, while 35 patients received transnasal abscess drainage, 13 received percutaneous abscess drainage, and 16 received transnasal drainage plus percutaneous abscess drainage. Immediately after placement of the tube, the mean volume of drainage was 180 mL (range, 10-850 mL); the amount steadily decreased from then on. The clinical success rate was 84.3% (54/64). Median time to fistula healing was 58 days (range, 7-357 days).

CONCLUSIONS

Transnasal insertion of transnasal abscess drainage catheter, jejunal decompression tube, and jejunal nutrition tube under fluoroscopy appears to be a simple, minimally invasive, effective, and safe method for treating esophagojejunal anastomotic fistula after gastrectomy.

Prognostic nomograms for gastric carcinoma after D2 + total gastrectomy to assist decision-making for postoperative treatment: based on Lasso regression

OBJECTIVE

This study aimed to establish novel nomograms that could be used to predict the prognosis of gastric carcinoma patients who underwent D2 + total gastrectomy on overall survival (OS) and progression-free survival (PFS).

METHODS

Lasso regression was employed to construct the nomograms. The internal validation process included bootstrapping, which was used to test the accuracy of the predictions. The calibration curve was then used to demonstrate the accuracy and consistency of the predictions. In addition, the Harrell's Concordance index (C-index) and time-dependent receiver operating characteristic (t-ROC) curves were used to evaluate the discriminative abilities of the new nomograms and to compare its performance with the 8th edition of AJCC-TNM staging. Furthermore, decision curve analysis (DCA) was performed to assess the clinical application of our model. Finally, the prognostic risk stratification of gastric cancer was conducted with X-tile software, and the nomograms were converted into a risk-stratifying prognosis model.

RESULTS

LASSO regression analysis identified pT stage, the number of positive lymph nodes, vascular invasion, neural invasion, the maximum diameter of tumor, the Clavien-Dindo classification for complication, and Ki67 as independent risk factors for OS and pT stage, the number of positive lymph nodes, neural invasion, and the maximum diameter of tumor for PFS. The C-index of OS nomogram was 0.719 (95% CI: 0.690-0.748), which was superior to the 8th edition of AJCC-TNM staging (0.704, 95%CI: 0.623-0.783). The C-index of PFS nomogram was 0.694 (95% CI: 0.654-0.713), which was also better than that of the 8th edition of AJCC-TNM staging (0.685, 95% CI: 0.635-0.751). The calibration curves, t-ROC curves, and DCA of the two nomogram models showed that the prediction ability of the two nomogram models was outstanding. The statistical difference in the prognosis between the low- and high-risk groups further suggested that our model had an excellent risk stratification performance.

CONCLUSION

We reported the first risk stratification and nomogram for gastric carcinoma patients with total gastrectomy in Chinese population. Our model could potentially be used to guide treatment selections for the low- and high-risk patients to avoid delayed treatment or unnecessary overtreatment.

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

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

Computer tomography-guided negative pressure drainage treatment of intrathoracic esophagojejunal anastomotic leakage: A case report

BACKGROUND

Esophagojejunal anastomotic leakage (EJAL) is a serious and potentially crucial complication of total gastrectomy and represents the major cause of postoperative death, with a mortality rate of up to 50%. However, treatment remains challenging and controversial. We report here the case of a patient whose intrathoracic EJAL was successfully treated with computer tomography (CT)-guided negative pressure drainage treatment.

CASE SUMMARY

A 69-year-old male patient complained of difficulty swallowing within the last six months. He was diagnosed with esophagogastric junction carcinoma, Siewert II, cT3N0M0 stage II. Total gastrectomy and Roux-en-Y esophagojejunostomy were performed. High fever, left chest pain and dyspnea appeared on postoperative day 5, and EJAL was confirmed by CT, gastroscopy and oral blue-dimethylene tests. Conservative treatment measures were applied immediately, including antibiotics, nasojejunal tubes, and repeated thoracic puncture and drainage under ultrasound guidance. However, without sufficient and effective drainage, the thoracic infection and systemic condition continued to deteriorate. With the cooperation of multiple departments, percutaneous CT-guided drainage (24 Fr 7 mm) in the thoracic cavity was successfully placed near the anastomotic leakage. Because of continuous negative pressure suction, the infection symptoms were effectively controlled and the general situation gradually recovered. Subsequent follow-up examination showed that the patient was in good condition.

CONCLUSION

Negative pressure drainage via CT may represent an effective minimally invasive approach to treating intrathoracic EJAL.

Machine Learning-based Correlation Study between Perioperative Immunonutritional Index and Postoperative Anastomotic Leakage in Patients with Gastric Cancer

Backgrounds: The immunonutritional index showed great potential for predicting postoperative complications in various malignant diseases, while risk assessment based on machine learning (ML) methods is becoming popular in clinical practice. Early detection and prevention for postoperative anastomotic leakage (AL) play an important role in prognosis improvement among patients with gastric cancer (GC). Methods: This retrospective study included 297 patients with gastric cancer receiving gastrectomy between 2018 and 2021 in general surgery department of Xinhua Hospital. Perioperative clinical variables were collected to evaluate the predictive value for postoperative AL with 5 ML models. Then, AUROC was applied to identify the optimal perioperative clinical index and ML model for predicting postoperative AL. Results: The incidence of postoperative AL was 6.1% (n=18). After the training of 5 ML classification models, we found that immunonutritional index had significantly better classification ability than inflammatory or nutritional index alone separately (AUROC=0.87 vs. 0.83, P=0.01; AUROC=0.87 vs. 0.68, P<0.01). Next, we found that support vector machine (SVM), one of the ML methods, with selected immunonutritional index showed significantly greater classification ability than optimal univariant parameter [CRP on postoperative day 4 (AUROC=0.89 vs.0.86, P=0.02)]. Also, statistical analysis revealed multiple variables with significant relevance to postoperative AL, including serum CRP and albumin on postoperative day 4, NLR and SII etc. Conclusion: This study showed that perioperative immunonutritional index could act as an indicator for postoperative AL. Also, ML methods could significantly enhance the classification ability, and therefore, could be applied as a powerful tool for postoperative risk assessment for patients with GC.

The Contribution of a Collagen Patch Coated With Fibrin Glue in Sealing Upper Gastrointestinal Defects: An Experimental Study

BACKGROUND/AIM

We aimed to evaluate the safety and efficacy of sealing primary upper gastrointestinal (GI) perforations with a collagen patch coated with fibrin glue (Tachosil^®).

MATERIALS AND METHODS

Thirty New Zealand rabbits were used in this study. An iatrogenic gastric perforation was created, and primary repair was performed on the control group. Tachosil^®, without suturing the deficit, was used in the intervention group.

RESULTS

Leakage was observed in 3 (20%) and 2 rabbits (13.3%) in the control and intervention group, respectively; however, the difference was not statistically significant (p=0.62). Moreover, adhesions formed in 10/15 and all rabbits in the intervention and control group, respectively (p=0.014); however, based on the Zuhlke adhesion's classification, there was no statistically significant difference between the two groups.

CONCLUSION

A collagen patch coated with fibrin glue is not a replacement but can be considered a safe option for the reinforcement of suturing, preventing leakages in the upper GI tract.