Safe management of anastomotic leakage after gastric cancer surgery with enteral nutrition via a nasointestinal tube. Langenbecks Arch Surg. 2012;397:737-744. [PMID: 22382705 DOI: 10.1007/s00423-012-0935-7]

Short- and long-term outcomes following perioperative ERAS management in patients undergoing minimally invasive radical gastrectomy after neoadjuvant chemotherapy: A single-center retrospective propensity score matching study

INTRODUCTION

Gastric cancer patients receiving neoadjuvant chemotherapy (NACT) are more vulnerable to perioperative stress. Enhanced recovery after surgery (ERAS) is widely used in surgical patients aiming at reducing stress responses. However, whether this approach is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT remained determined. So, the objective of this study is to investigate the effects of ERAS for this special group of gastric cancer patients.

MATERIAL AND METHODS

The data of gastric cancer patients who underwent minimally invasive radical gastrectomy after NACT were collected. Patients were divided into an ERAS group and a conventional group based on whether they received perioperative ERAS management. Propensity score matching was conducted to eliminate bias. Pre- and postoperative inflammatory and nutritional marker levels, postoperative complications, recovery indices and 3-year OS and RFS were observed.

RESULTS

A total of 252 patients were analyzed after 1:1 PSM, including 126 patients in the ERAS group and 126 in the conventional group. The results showed that the implementation of ERAS significantly reduced the levels of novel inflammatory indicators, improve nutritional status and accelerate postoperative recovery. We found that the 3-year OS (72.2 % vs. 66.7 %) and RFS (67.5 % vs. 61.9 %) in the ERAS group showed an improvement trend compared to those in the traditional group, especially for stage III patients, although these differences were not significant.

CONCLUSION

The perioperative ERAS program is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT.

Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer

Malnutrition, characterized by altered body composition and impaired function, is particularly prevalent among gastric cancer patients, affecting up to 60% of them. Malnutrition in these patients can manifest both before and after surgery, due to factors such as gastric outlet obstruction, cancer cachexia, and anatomical changes. Notably, total gastrectomy (TG) presents the most significant nutritional challenges. However, function-preserving gastrectomy, such as pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG), have shown promise in improving nutritional outcomes. Effective nutritional risk screening and assessment are vital for identifying patients at risk. Nutritional support not only improves nutritional parameters but also reduces complications, enhances quality of life (QoL) and survival rates. Those unable to maintain more than 50% of the recommended intake for over 7 days are recommended for nutritional support. Common methods of nutritional support include oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN) depending on the patient's status. Effect of perioperative nutritional support remains controversial. Preoperative interventions including ONS and PN have shown mixed results, with selective benefits in patients with sarcopenia or hypoalbuminaemia, while impact of EN in gastric outlet obstruction patients have been positive. In contrast postoperative support appears to be consistent. Tube feeding after TG has shown improvements, and ONS have been effective in reducing weight loss and improving nutritional biomarkers. PN was also associated with benefits such as weight maintenance and QoL. This review explores the mechanisms, assessment, and clinical impact of malnutrition, emphasizing the importance of nutritional support in gastric cancer patients undergoing gastrectomy.

Postoperative nutrition in the setting of enhanced recovery programmes

Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.

Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry

BACKGROUND

Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting.

METHODS

To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks.

RESULTS

A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor.

CONCLUSIONS

Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.

Successful management of gastric remnant necrosis after proximal gastrectomy using a double elementary diet tube: a case report

Background

The stomach has many incoming vessels and is resistant to ischemia due to the rich microvascular network within its submucosal layer. Although reports of gastric remnant necrosis after gastrectomy have been rare, mortality rates remain substantially high when present. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression, has been developed for anastomotic leakage and postoperative nutritional management after upper gastrointestinal surgery. The current report presents a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube.

Case presentation

A 73-year-old male was referred to our hospital for an additional resection after endoscopic submucosal dissection (ESD) for gastric cancer. Endoscopic findings showed an ESD scar on the posterior wall of the upper portion of the stomach, while computed tomography (CT) showed no obvious regional lymph node enlargement and distant metastases. The patient subsequently underwent laparoscopic proximal gastrectomy and esophagogastrostomy but developed candidemia on postoperative day 7. On postoperative day 14, endoscopy revealed gastric ischemic changes around the anastomotic site, suggesting that the patient’s candidemia developed due to gastric necrosis. His vital signs remained normal, while the gastric remnant ischemia was localized. Given that surgery in the presence of candidemia was considered extremely risky, conservative treatment was elected. A W-ED tube was placed nasally, after which enteral feeding was initiated along with gastrointestinal tract decompression. Although the patient subsequently developed anastomotic leakage due to gastric remnant necrosis, local control was achieved and conservative treatment was continued. On postoperative day 52, healing of the gastric remnant necrosis and anastomotic leakage was confirmed, after which the patient started drinking water. Although balloon dilation was required due to anastomotic stenosis, the patient was able to resume oral intake and was discharged on postoperative day 88.

Conclusions

Herein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy, wherein conservative management was achieved using a W-ED tube. In cases involving high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication.

Short-term evaluation of immune levels and nutritional values of EN versus PN in gastric cancer: a systematic review and a meta-analysis

BACKGROUND

Postsurgical patients' oral feeding begins with clear fluids 1-3 days after surgery. This might not be sufficiently nutritious to boost the host immune system and provide sufficient energy in gastric neoplastic patients to achieve the goal of enhanced recovery after surgery (ERAS). Our objective was to analyze the significance of early postoperative feeding tubes in boosting patients' immunity and decreasing incidence of overall complications and hospital stay in gastric cancer patients' post-gastrectomy.

METHODS

From January 2005 to May 24, 2019, PubMed and Cochrane databases were searched for studies involving enteral nutrition (EN) feeding tubes in comparison to parenteral nutrition (PN) in gastric cancer patients undergoing gastrectomy for gastric malignancies. Relative risk (RR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI) were used to estimate the effect sizes, and heterogeneity was assessed by using Q and χ² statistic with their corresponding P values. All the analyses were performed with Review Manager 5.3 and SPSS version 22.

RESULTS

Nine randomized trials (n = 1437) and 5 retrospective studies (n = 421) comparing EN feeding tubes and PN were deemed eligible for the pooled analyses, with a categorized time frame of PODs ≥ 7 and PODs < 7. Ratio of CD4+/CD8+ in EN feeding tubes was the only outcome of PODs < 7, which showed significance (MD 0.22, 95% CI 0.18-0.25, P < 0.00001). Regarding other immune indicators, significant outcomes in favor of EN feeding tubes were measured on POD ≥ 7: CD3+ (SMD 1.71; 95% CI 0.70, 2.72; P = 0.0009), CD4+ (MD 5.84; 95% CI 4.19, 7.50; P < 0.00001), CD4+/CD8+ (MD 0.28; 95% CI 0.20; 0.36, P < 0.00001), NK cells (SMD 0.94; 95% CI 0.54, 1.30; P < 0.00001), nutrition values, albumin (SMD 0.63; 95% CI 0.34, 0.91; P < 0.001), prealbumin (SMD 1.00; 95% CI 0.52, 1.48; P < 0.00001), and overall complications (risk ratio 0.73 M-H; fixed; 95% CI 0.58, 0.92; P = 0.006).

CONCLUSION

EN feeding tube support is an essential intervention to elevate patients' immunity, depress levels of inflammation, and reduce the risk of complications after gastrectomy for gastric cancer. Enteral nutrition improves the innate immune system and nutrition levels but has no marked significance on certain clinical outcomes. Also, EN reduces the duration of hospital stay and cost, significantly.

Safety and Feasibility of Linear Stapling Device with Bioabsorbable Polyglycolic Acid Sheet for Duodenal Closure in Gastric Cancer Surgery: A Multi-institutional Phase II Study

BACKGROUND

Duodenal stump fistula (DSF) after gastrectomy is of low frequency but a critical complication in gastric cancer surgery. Manual oversewing for reinforcement of the duodenal stump is not applicable when free longitudinal margin is short and has technical difficulties in laparoscopic surgery. This trial evaluated the safety and feasibility of using a linear stapler with bioabsorbable polyglycolic acid (PGA) sheet for duodenal stump closure and reinforcement in gastric cancer surgery.

METHODS

This multi-institutional, prospective phase II trial included gastric cancer patients who were scheduled to undergo distal or total gastrectomy with R-Y reconstruction. In all cases, duodenum was transected using a linear stapler with PGA sheet. The primary endpoint was the incidence of postoperative DSF. Sample size was set at 100 patients considering an expected value of 3% and threshold value of 8% with one-sided testing at a 10% significance level.

RESULTS

Between June 2014 and June 2015, a total of 100 patients were registered in this trial. Postoperative DSF was observed in two cases (2.0%, 90% CI 0.4-6.2%) which was developed on postoperative days 13 and 20. Intraoperative bleeding at the duodenal stump staple line was observed in one case but was easily controlled without additional suturing. Postoperative bleeding was not observed in any of the cases.

CONCLUSION

This study suggested that the use of PGA sheet as a reinforcement material for closure of the duodenal stump during gastrectomy for gastric cancer is both safe and feasible. Trial registration number UMIN 000014398.

Role of nutritional support for postoperative recovery of respiratory function in patients with primary lung cancer

This study explored the role of nutritional support for postoperative recovery of respiratory function in patients with primary lung cancer. Clinical data of 182 patients with primary lung cancer who were admitted to Weifang People's Hospital from January 2013 to December 2015 and underwent lung cancer surgery, were collected and retrospectively analyzed. According to the postoperative diet plan, patients were divided into two groups: General diet group (n=80) and nutrition therapy group (n=102). Patients in the general diet group were given a general diet without any nutritional instruction, whereas the patients in the nutrition therapy group were given an enteral nutritional supplement in addition to a general diet. The changes of nutritional indices, recovery status of respiratory function and incidence of adverse events for patients in the two groups were observed, and the data were analyzed statistically. At day 14 after the therapy started, the body mass index, mid-arm circumference and triceps skinfold of patients in the nutrition therapy group were significantly better than those in the general diet group (P<0.05). More significant improvements in levels of hemoglobin, serum albumin and prealbumin were observed in the nutrition therapy group, and the differences in comparison with levels in the general diet group were statistically significant (P<0.05). The respiratory function was more significantly improved for patients in the nutrition therapy group as well, compared to patients in the general diet group (P<0.05). At the end of 1-year follow-up, incidences of malnutrition, lung infection and mortality in the nutrition therapy group were lower than that of the general diet group (P<0.05). The positive impact of appropriate nutritional support on recovery of postoperative respiratory function improved overall outcomes of patients with lung cancer and reduced mortality as well. The nutrition therapy is worth further clinical study.

Combat with esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer: A critical review of the literature

Esophagojejunal anastomotic leakage (EJAL) is considered to be one of the most serious complications after total gastrectomy (TG), despite improvements in surgical instruments and technique. The occurrence of EJAL would cause poorer quality of life, prolonged hospital stay, and increased surgery-related costs and mortality. Although there is ever-increasing knowledge about EJAL, the optimal management is controversial. In the present review, we aim to demonstrate the effective management by focus on the possible risk factors, potentially useful preventive strategies, and several kinds of treatments in esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer.

Esophagojejunal anastomosis leakage after total gastrectomy for esophagogastric junction adenocarcinoma: options of treatment

BACKGROUND

Esophagojejunal anastomosis leakage after total gastrectomy (TG) for esophagogastric junction (EGJ) adenocarcinoma (ADC) constitutes one of the most serious and sometimes life-threatening complications. Management remains controversial and still challenging.

METHODS

A total of 198 patients operated for type I and II EGJ ADC were reviewed. Diagnosis of leakage was based on a combination of clinical and radiological findings. It was classified including objective endoscopic and clinical parameters requiring different type of treatment.

RESULTS

Anastomotic leakage was diagnosed in 14 patients (7%). Two cases recovered with conservative therapy. Six cases underwent endoscopy with clips placement in 2 and partially covered self-expandable metal stent placement in 4. Other two cases underwent reoperation with reconstruction of anastomosis and primary repair respectively. In the last four cases emergency surgery with total esophagectomy and diversion was required. Mortality occurred only in 3 of these patients and overall treatment was successful in 11 patients (78.5%).

CONCLUSIONS

No consensus has been reached on the best method of esophagojejunal anastomosis leakage management and the rate of failure remains significant. Different options of treatment are available but early detection and multidisciplinary approaches are the keys to obtain successful results irrespective of the employed strategy.

Results of Endoscopic and Surgical Fistula Treatment in Esophagointestinal Anastomosis After Gastrectomy

INTRODUCTION

Intestinal fistulas occur in 4% to 8% of cases of upper gastrointestinal tract surgery. Until now, this type of surgery has been the standard for treating fistulas in esophagointestinal anastomosis. The use of stents and hemoclips is still controversial, but an increasing number of publications have been presenting good results with this type of treatment.

OBJECTIVE

The objective of the study was to investigate the outcome of endoscopic and surgical treatment of fistulas in esophagointestinal anastomosis after gastrectomy.

MATERIALS AND METHODS

Fistulas in esophagointestinal anastomoses were observed in 23 patients (4.8%) over an 18-year period. The indications for endoscopic treatment were small (<50 mL/d) and large (>50 mL/d) fistulas in patients with no symptoms of peritonitis or abscess, who were treated with implantation of a covered stent.Surgical intervention was carried out for large fistulas that resulted in peritonitis and complicated gangrene of margins and/or abscesses.

RESULTS

Four subjects were treated endoscopically with hemoclips, resulting in 50% technical and clinical success. We implanted stents in 12 patients. Technical success was achieved in all patients; yet, permanent closure of the fistula was reported in 8 subjects (66%). Thirty-three percent of patients were operated upon for fistulas. We reported 4 deaths in this group.

CONCLUSIONS

The use of hemoclips in the treatment of small fistulas and of self-expandable covered stents in the treatment of medium and large fistulas is an effective method that shortens the hospitalization period and accelerates the introduction of oral nutrition while reducing the number of fatal complications.

Results of endoscopic and surgical fistula treatment in oesophagointestinal anastomosis after gastrectomy

Introduction

Intestinal fistulas occur in 4–8% of cases of upper gastrointestinal tract surgery. Until now, surgery has been the standard of treating fistulas in oesophagointestinal anastomosis. The use of stents and haemoclips still causes much controversy, but more and more publications present good results with this type of treatment.

Aim

To present results of endoscopic and surgical treatment of fistulas in oesophagointestinal anastomosis after gastrectomy.

Material and methods

A fistula in the oesophagointestinal anastomosis was observed in 23 (4.8%) patients within an 18-year period. The indications for endoscopic treatment were small fistulas (< 50 ml/day), and large (> 50 ml/day) fistulas in subjects with no symptoms of peritonitis or abscess were treated with implantation a of covered stent. Surgical treatment was performed with a large fistula leading to peritonitis and complicated gangrene of margins and/or the presence of abscess.

Results

Four subjects were treated endoscopically with the use of haemoclips, resulting in 50% technical and clinical success. We implanted stents in 12 patients. Technical success was achieved in all the patients, yet permanent closure of the fistula was reported for 8 (66%) subjects. The percentage of patients operated on for fistula was 33%. We recorded 4 deaths in this group.

Conclusions

The use of haemoclips in treatment of small fistulas, and self-expandable, covered stents in treatment of medium and large fistulas, is an effective method that shortens the hospitalisation period and accelerates introduction of oral nutrition while reducing the number of fatal complications.

Treatment of Esophagojejunal Anastomosis Leakage: A Systematic Review from the Last Two Decades

Esophagojejunal anastomosis leakage is one of the major complications after total gastrectomy for gastric cancer and is an independent predictor of survival. Our aim is to systematically review the literature and discuss the reported therapeutic approaches to identify the best therapeutic approach. Pubmed, EMbase, Cochrane Library, CILEA Archive, BMJ Clinical Evidence, and Up ToDate databases were screened limiting the research to articles written in English from January 1992 through December 2013. This way a total of 474 manuscripts were retrieved for furthermore evaluation. Eleven manuscripts were considered eligible and the study is focused on those works. We analyzed a total of 3,893 patients and 114 cases of esophagojejunal anastomosis leakage. Different treatments were grouped into three main categories: conservative approach (66 cases), endoscopic approach (21 cases), and surgical approach (27 cases). The overall mortality rate is 26.32 per cent and surgical approach showed the higher rate. According to the reported data, a complete resolution of the leakage can be achieved in an interval ranging from 7 to 28 days in the group treated conservatively. Conservative approach should always be considered as the treatment of choice. Reoperation may be necessary in case of wide dehiscence or when other treatments fail; therefore, the high mortality rate related to this procedure is due to the comorbidities of patients undergoing relaparotomy. Finally, endoscopic approach with endoclips seems promising but needs furthermore studies.

Gastric cancer surgery without nasogastric decompression

Nasogastric decompression (ND) has been used worldwide in gastric cancer surgery as a traditional way since Hunter pioneered. Most surgeons believe that using ND in abdominal surgery could relieve the internal pressure of anastomosis and reduce the incidence of anastomotic leakage. However, there has no strict scientific evidence for this obtained from medical studies, especially prospective studies. In recent years, several studies have shown that routine use of ND after surgery could not prevent anastomotic leakage or accelerate the recovery of bowel function, and surgery without ND did not increase the risk of anastomotic leakage. All kinds of gastric cancer surgery could be performed safely without ND, which greatly reduces the suffering of the patients, accelerates postoperative recovery, and reduces the workload significantly. If patients with pyloric obstruction or bleeding receive ND before surgery, nasogastric tube could be removed after they waked up. Gastric cancer surgery without ND is safe and deserves clinical popularization. This review summarizes the safety and significance of gastric cancer surgery without ND.

Advantages of enteral nutrition over parenteral nutrition

It is a strong and commonly held belief among nutrition clinicians that enteral nutrition is preferable to parenteral nutrition. We provide a narrative review of more recent studies and technical reviews comparing enteral nutrition with parenteral nutrition. Despite significant weaknesses in the existing data, current literature continues to support the use of enteral nutrition in patients requiring nutrition support, over parenteral nutrition.

Nahtinsuffizienz intestinaler Anastomosen: Endoskopische und laparoskopische Therapieoptionen

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen die schwerwiegendste septische Komplikation nach viszeralchirurgischen Eingriffen dar. Neben der chirurgischen Therapie sind zunehmend endoskopische Behandlungsoptionen möglich. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Therapieoptionen von Anastomoseninsuffizienzen sind abhängig von der klinischen Symptomatik, der Art der Anastomose, der Defektgröße, den lokalen Gewebeverhältnissen sowie dem Zeitpunkt der Diagnose. Bei einer Nekrose oder Minderdurchblutung der Viszeralorgane müssen diese operativ reseziert werden. Prinzipiell sind alle operativen Revisionseingriffe auch laparoskopisch durchführbar. Bei erhaltener Gewebeperfusion können die Leckagen lokal übernäht oder endoskopisch verschlossen werden. Die Ergebnisse für die Stenttherapie nach Ösophagus- und Magenresektionen sind für moderne Stents sehr Erfolg versprechend. Im Gegensatz dazu sind die Ergebnisse der endoskopischen Stenttherapie bei Insuffizienz nach kolorektalen Eingriffen enttäuschend; dafür steht hier mit der Schwammtherapie eine vielversprechende endoskopische Alternative zur Verfügung. <b><i>Schlussfolgerung: </i></b>Die aktuellen Daten zeigen, dass neue laparoskopische und endoskopische Optionen zur Therapie von Anastomoseninsuffizienzen bestehen, die jedoch noch in prospektiven und randomisierten Studien evaluiert werden müssen.

Cigarette smoke exposure promotes arterial thrombosis and vessel remodeling after vascular injury in apolipoprotein E-deficient mice

BACKGROUND

Cigarette smoking is a major risk factor for the development of cardiovascular disease. However, in terms of the vessel wall, the underlying pathomechanisms of cigarette smoking are incompletely understood, partly due to a lack of adequate in vivo models.

METHODS

Apolipoprotein E-deficient mice were exposed to filtered air (sham) or to cigarette mainstream smoke at a total particulate matter (TPM) concentration of 600 microg/l for 1, 2, 3, or 4 h, for 5 days/week. After exposure for 10 +/- 1 weeks, arterial thrombosis and neointima formation at the carotid artery were induced using 10% ferric chloride.

RESULTS

Mice exposed to mainstream smoke exhibited shortened time to thrombotic occlusion (p < 0.01) and lower vascular patency rates (p < 0.001). Morphometric and immunohistochemical analysis of neointimal lesions demonstrated that mainstream smoke exposure increased the amount of alpha-actin-positive smooth muscle cells (p < 0.05) and dose-dependently increased the intima-to-media ratio (p < 0.05). Additional analysis of smooth muscle cells in vitro suggested that 10 microg TPM/ml increased cell proliferation without affecting viability or apoptosis, whereas higher concentrations (100 and 500 microg TPM/ml) appeared to be cytotoxic.

CONCLUSIONS

Taken together, these findings suggest that cigarette smoking promotes arterial thrombosis and modulates the size and composition of neointimal lesions after arterial injury in apolipoprotein E-deficient mice.