Duodenal stump fistula after gastric surgery for malignancies: a retrospective analysis of risk factors in a single centre experience

Double Half Purse-String Sutures Plus "8" Pattern of Stitching for Prevention of Duodenal Stump Fistula after Laparoscopic Gastrectomy

Background: Duodenal stump fistula represents an infrequent but serious complication after laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction for gastric cancer. The present study was designed to evaluate the effectiveness of laparoscopic double half purse-string sutures plus "8" pattern of stitching for reinforcement of duodenal stump. Methods: The data of patients undergoing laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction were retrospectively analyzed between August 2022 and June 2023. According to the different reinforcement methods of duodenal stump, included patients were subdivided into three groups as follows: Group A, duodenal stump was treated with double half purse-string sutures plus "8" pattern of stitching; Group B, duodenal stump was reinforced by continuous suture using a barbed suture; and Group C, duodenal stump without any additional processing. The incidences of duodenal stump fistula between three groups were documented and compared. Moreover, the independent risk factors associated with duodenal stump fistula were analyzed using the logistic regression analysis. Results: No postoperative duodenal stump fistula occurred in Group A, which was significantly different from Group B and Group C (P = .007). In the multivariate analysis, age (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.088-1.303), body mass index (OR, 0.824; 95% CI, 0.727-0.935), and American Society of Anesthesiologists score (OR, 4.495; 95% CI, 1.264-15.992) were the risk factors for duodenal stump fistula. Conclusion: Double half purse-string sutures plus "8" pattern of suture can be conducted in a relatively short operation period and could prevent the incidence of duodenal stump fistula to some extent.

Retrograde drainage for duodenal stump leakage using ileal decompression tube guided by double-balloon endoscopy: a novel case report

BACKGROUND

Duodenal stump leakage is a serious post-gastrectomy complication, and there have been no reports on endoscopic drainage.

CASE PRESENTATION

We report a case of duodenal stump leakage after laparoscopic gastrectomy with Roux-en-Y reconstruction in a 68-year-old man. First-line conservative management was ineffective. Reoperation was performed because of severe abdominal pain and increased ascites. After reoperation, duodenal stump leakage recurred with bleeding from the anterior superior pancreaticoduodenal artery. Coil embolization and pigtail catheter insertion were performed. Furthermore, we retrogradely inserted an ileal tube for tube decompression near the duodenal stump using double-balloon endoscopy for effective drainage. After tube insertion, duodenal stump leakage decreased; on the 47th primary postoperative day, the patient was discharged. The primary postoperative course was uneventful after 1 year and 9 months of follow-up.

CONCLUSIONS

This is the first successful case of duodenal stump leakage treated with retrograde decompression tube insertion near the duodenal stump using double-balloon endoscopy.

Gastrointestinal Fistula in Radical Distal Gastrectomy: Case-Control Study from a High-Volume Hospital

Background: Postoperative gastrointestinal fistula (PGF) is one of the main causes of abdominal infection and perioperative death. This study was designed to investigate the risk factors of PGF, anastomotic fistula (AF), and duodenal stump fistula (DSF) for patients who underwent radical distal gastrectomy. Materials and Methods: In this retrospective observational study, 2652 gastric cancer cases who received radical distal gastrectomy from 2010 to 2020 were selected as research subjects. Subsequently, we adopted the univariate and multivariate logistic regression analysis as statistical method to screen the risk factors for PGF, AF, and DSF, respectively. Results: In univariate analysis, gender (P = .022), operative time (P = .013), intraoperative blood loss (P < .001), tumor diameter (P = .002), and tumor stage (P < .001) were related to PGF. Multivariate logistic regression analysis identified the male (odds ratio [OR] = 2.691, P = .042), massive intraoperative hemorrhage (OR = 1.002, P = .008), and advanced tumor (OR = 2.522, P = .019) as independent predictors for PGF. Moreover, diabetes (OR = 4.497, P = .008) and massive intraoperative hemorrhage (OR = 1.003, P = .010) were proved to be associated with AF, while massive intraoperative hemorrhage (OR = 1.001, P = .050) and advanced tumor (OR = 6.485, P = .005) were independent risk factors of DSF. Conclusions: The gender, intraoperative hemorrhage, tumor stage, and diabetes were expected to be used as predictors of PGF for radical distal gastrectomy.

Reinforcement methods of duodenal stump after laparoscopic gastrectomy for gastric cancer: A review

Duodenal stump fistula is a rare but dangerous complication of gastric cancer surgery. Reinforcement of the duodenal stump was suggested as a useful method to prevent the occurrence of duodenal stump fistula. Although laparoscopic surgery has been established as a safe procedure for gastric cancer, it is acknowledged that the application of duodenal stump reinforcement is a demanding process in laparoscopic radical gastrectomy. This review aims to provide a concise description of the proposed reinforcement methods of duodenal stump after laparoscopic radical gastrectomy for gastric cancer by summarizing the relevant literature written in English. The thorough knowledge of these reinforcement techniques may help surgeons to find the most suitable reinforcement method of duodenal stump for patients.

Risk factors and conservative therapy outcomes of anastomotic leakage after gastrectomy: Experience of 3,926 patients from a single gastric surgical unit

Background

Anastomotic leakage (AL) after gastrectomy is one of the severest postoperative complications and is related to increasing mortality. In addition, no consensus guidelines about strategies of AL treatment have been established. This large cohort study aimed to inspect the risk factors and efficacy of the conservative treatment for AL in patients with gastric cancer.

Methods

We reviewed the clinicopathological data of 3,926 gastric cancer patients undergoing gastrectomy between 2014 and 2021. Results contained the rate, risk factors, and conservative therapy outcomes of AL.

Results

In total, 80 patients (2.03%, 80/3,926) were diagnosed with AL, and esophagojejunostomy was the most frequent AL site (73.8%, 59/80). Among them, one patient (2.5%, 1/80) died. Multivariate analysis indicated that low albumin concentration (P = 0.001), presence of diabetes (P = 0.025), laparoscopic method (P &lt; 0.001), total gastrectomy (P = 0.003), and proximal gastrectomy (P = 0.002) were predicting factors for AL. The closure rate for the conservative treatment of AL in the first month after AL diagnosis was 83.54% (66/79), and the median time from leakage diagnosis to the closure of leakage was 17 days (interquartile range 11–26 days). Low level of plasma albumin (P = 0.004) was associated with late leakage closures. In terms of 5-year overall survival, no significant difference was observed between patients with and without AL.

Conclusion

The incidence of AL after gastrectomy is associated with low albumin concentration, diabetes, the laparoscopic method, and extent of resection. The conservative treatment is relatively safe and effective for the AL management in patients after gastric cancer surgery.

Application of the Falciform Ligament Patch for the Prevention of Duodenal Stump Leakage After Gastrectomy: Technical Report on a Case Series

Background: Duodenal stump leakage (DSL) is a serious complication after gastrectomy. In this study, we developed a novel prevention technique using a falciform ligament patch (FLP) to prevent DSL among high-risk patients after gastrectomy. Materials and Methods: From January 2019 to July 2021, 14 patients who were judged to be at high risk for DSL during preoperative examinations or surgery were included in this retrospective study, and the FLP was applied to the duodenal stump. The falciform ligament was separated from the liver after duodenal transection during gastrectomy; the end part was used to cover the duodenal stump and was fixed using nonabsorbable polypropylene sutures. Results: In total, 14 patients who underwent FLP had one or two risk factors that were identified: 5 patients, gastric cancer duodenal invasion; 4 patients, gastric outlet obstruction (GOO); 1 patient, cancer involving the distal resection margin; 1 patient, duodenal gastrointestinal stromal tumor involving the distal resection margin; 1 patient, gastric cancer duodenal invasion and GOO; and 2 patients, cancer involving the distal resection margin and GOO. FLP construction was successful, and no patient developed complications of DSL. The average hospital stay was 11.9 days, and the patients were discharged without any morbidities after surgery. Conclusions: Therefore, the FLP can be used to prevent DSL among high-risk patients after gastrectomy.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

BACKGROUND AND OBJECTIVES

Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy.

METHODS

Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications.

RESULTS

One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001).

CONCLUSIONS

A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

Efficacy of endoscopic management for anastomotic leakage after gastrectomy in patients with gastric cancer

Background

Anastomotic leakage (AL) after gastrectomy in gastric cancer patients is associated with high mortality rates. Various endoscopic procedures are available to manage this postoperative complication. The aim of study was to evaluate the outcome of two endoscopic modalities, clippings and stents, for the treatment of AL.

Patients and methods

There were 4916 gastric cancer patients who underwent gastrectomy between December 2007 and January 2016 at the National Cancer Center, Korea. A total of 115 patients (2.3%) developed AL. Of these, 85 patients (1.7%) received endoscopic therapy for AL and were included in this retrospective study. The endpoints were the complete leakage closure rates and risk factors associated with failure of endoscopic therapy.

Results

Of the 85 patients, 62 received endoscopic clippings (with or without detachable snares), and 23 received a stent insertion. Overall, the complete leakage closure rate was 80%, and no significant difference was found between the clipping and stent groups (79.0% vs. 82.6%, respectively; P = 0.89). The complete leakage closure rate was significantly lower in the duodenal and jejunal stump sites (60%) than esophageal sites (86.1%) and gastric sites (94.1%; P = 0.026). The multivariate analysis showed that stump leakage sites (adjusted odds ratio [aOR], 4.51; P = 0.031) and the presence of intra-abdominal abscess (aOR, 4.92; P = -0.025) were associated with unsuccessful leakage closures.

Conclusions

Endoscopic therapy using clippings or stents is an effective method for the postoperative management of AL in gastric cancer patients. This therapy can be considered a primary treatment option due to its demonstrated efficacy, safety, and minimally invasive nature.

Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery

Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.

Duodenal stump leakage. Lessons to learn from a large-scale 15-year cohort study

BACKGROUND

Duodenal stump leakage is a challenging condition causing significant morbidity and mortality. The aim of this study is to identify the risk factors associated with duodenal leak and advocate modification to prevent the incident.

METHODS

A retrospective cohort study was performed to include patients who had gastrectomy with excluded duodenum in a single surgical centre in the period of Jan 2003-March 2017. Analysis of associated factors was performed. Patients with duodenal leak were further analyzed and the treatment strategy was reviewed.

RESULTS

During the study period, 678 patients had gastrectomy with excluded duodenum. 502 patients had elective gastrectomy and 176 patients had emergency gastrectomy. 52 patients had subsequent duodenal stump leakage (7.7%). The existence of duodenal ulcer, intra-operative contamination, lower pre-operative haemoglobin and duodenostomy were the independent associated factors for duodenal leak.

CONCLUSION

This is the largest cohort in studying associated factors regarding duodenal leak in both emergency and elective gastrectomy. The independent associated factors were identified. We advocate a conservative approach for duodenal leak with adequate drainage, nutrition and antibiotics.

Abdominal Pain After Subtotal Gastrectomy: A First Report of Accessory Pancreatic Fistula

Background

The accessory pancreatic duct (APD) is the main drainage duct of the dorsal pancreatic bud in the embryo and varies greatly during development. An APD fistula is a rare and easily neglected complication. In this case report, the first symptom of the patient was postoperative abdominal pain and fever. He was eventually diagnosed with accessory pancreatic fistula combined with duodenal fistula. Such a case has not been reported in the literature.

Case Summary

A 66-year-old man was emergently hospitalized for abdominal pain. His preliminary diagnosis was perforation of the digestive tract. He developed fever and abdominal pain after emergency subtotal gastrectomy, followed by changes in the colour of the abdominal drainage fluid. An APD fistula and duodenal stump fistula were confirmed by drainage fluid amylase analysis, contrast fistulography and percutaneous transhepatic cholangial drainage (PTCD). After PTCD, nutritional management and drug treatment, the patient recovered well.

Outcome

We found and successfully cured a case of accessory pancreatic duct fistula combined with duodenal stump fistula.

Risk Factors for Duodenal Stump Leakage after Laparoscopic Gastrectomy for Gastric Cancer

Purpose

Duodenal stump leakage (DSL) is a potentially fatal complication that can occur after gastrectomy, but its underlying risk factors are unclear. This study aimed to investigate the risk factors and management of DSL after laparoscopic radical gastrectomy for gastric cancer (GC).

Materials and Methods

Relevant data were collected from several prospective databases to retrospectively analyze the data of GC patients who underwent Billroth II (B-II) or Roux-en-Y (R-Y) reconstruction after laparoscopic gastrectomy from 2 institutions (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, and HwaMei Hospital, University of Chinese Academy of Sciences). The DSL risk factors were analyzed using univariate and multivariate analysis regression.

Results

A total of 810 patients were eligible for our analysis (426 with R-Y, 384 with B-II with Braun). Eleven patients had DSL (1.36%). Body mass index (BMI), elevated preoperative C-reactive protein (CRP) level, and unreinforced duodenal stump were the independent risk factors for DSL. DSL was diagnosed in 2–12 days, with a median of 8 days. Seven patients received conservative treatment, 3 patients received puncture treatment, and only 1 patient required reoperation. All patients recovered successfully after treatment.

Conclusions

The risk factors of DSL were BMI ≥24 kg/m², elevated preoperative CRP level, and unreinforced duodenal stump. Nonsurgical treatments for DSL are preferred.

Safety and feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection for locally advanced upper third gastric cancer: a prospective, multicenter clinical trial

BACKGROUND

Previous retrospective studies have shown that laparoscopic spleen-preserving D2 total gastrectomy (LSTG) for advanced upper third gastric cancer (AUTGC) is safe. However, all previous studies were underpowered. We therefore conducted a prospective, multicenter study to evaluate the technical safety and feasibility of LSTG for patients with AUTGC.

METHODS

Patients diagnosed with AUTGC (cT2-4a, N-/+, M0) underwent LSTG at 19 institutions between September 2016 and October 2017 were included. The number of No. 10 lymph node (LN) dissections, metastasis rates, intraoperative and postoperative complications were investigated.

RESULTS

A total of 251 patients were enrolled in the study, and 242 patients were eligible for the per protocol analysis. The average numbers of No. 10 LN dissections and metastases were 2.4 and 0.1, respectively. Eighteen patients (7.4%) had No. 10 LN metastases, and among patients with advanced gastric cancer, the rate of No. 10 LN metastasis was 8.1% (18/223). pN3 status was an independent risk factor for No. 10 LN metastasis. Intraoperative complications occurred in 7 patients, but no patients required conversion to open surgery or splenectomy. The overall postoperative complication rate was 13.6% (33/242). The major complication and mortality rates were 3.3% (8/242) and 0.4% (1/242), respectively. The number of retrieved No. 10 LNs, No. 10 LN metastasis and TNM stage had no significant influence on postoperative complication rates.

CONCLUSION

LSTG for AUTGC was safe and effective when performed by very experienced surgeons, this technique could be used in patients who needed splenic hilar lymph node dissection.

Duodenal stump reinforcement might reduce both incidence and severity of duodenal stump leakage after laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer

BACKGROUND

Although duodenal stump leakage (DSL) is a relatively rare complication after gastrectomy with Roux-en-Y (R-Y) reconstruction, it is difficult to treat and can be fatal. We investigated the impact of duodenal stump reinforcement on DSL after laparoscopic gastrectomy with R-Y reconstruction for gastric cancer.

METHODS

This retrospective study of 965 patients with gastric cancer who underwent laparoscopic distal or total gastrectomy (LDG or LTG) with R-Y reconstruction compared surgical outcomes between two groups, the duodenal stump reinforcement group (reinforcement group) (n = 895) and that without duodenal stump reinforcement (non-reinforcement group) (n = 70).

RESULTS

Mean operative duration was significantly longer in the reinforcement than in the non-reinforcement group (LDG; 291 min versus 258 min, p < 0.001, LTG; 325 min versus 285 min, p < 0.001). DSL occurred less frequently in the reinforcement than in the non-reinforcement group (0.67% vs. 5.71%, p < 0.001). Furthermore, non-reinforcement was an independent risk factor for DSL in multiple logistic regression analysis with adjustment for potential confounding factors. Patients with DSL in the non-reinforcement group all required re-operation, while all but one patient with DSL in the reinforcement group recovered with conservative management.

CONCLUSIONS

Duodenal stump reinforcement in laparoscopic gastrectomy with R-Y reconstruction may reduce the risk of DSL development and minimize its severity.

Management of duodenal stump fistula after gastrectomy for malignant disease: a systematic review of the literature

Background

Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient’s life. DSF is related to high mortality (16–20%) and morbidity (75%) rates. DSF-related morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intra-abdominal abscesses, intra-abdominal bleeding, acute pancreatitis, acute cholecystitis, severe malnutrition, fluids and electrolytes disorders, diffuse peritonitis, and pneumonia. Our systematic review aimed at improving our understanding of such surgical complication, focusing on nonsurgical and surgical DSF management in patients undergoing gastric resection for gastric cancer.

Methods

We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. PubMed/MEDLINE, EMBASE, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.

Results

The 20 included articles covered an approximately 40 years-study period (1979–2017), with a total 294 patient population. DSF diagnosis occurred between the fifth and tenth postoperative day. Main DSF-related complications were sepsis, abdominal abscess, wound infection, pneumonia, and intra-abdominal bleeding. DSF treatment was divided into four categories: conservative (101 cases), endoscopic (4 cases), percutaneous (82 cases), and surgical (157 cases). Length of hospitalization was 21–39 days, ranging from 1 to 1035 days. Healing time was 19–63 days, ranging from 1 to 1035 days. DSF-related mortality rate recorded 18.7%.

Conclusions

DSF is a rare but potentially lethal complication after gastrectomy for gastric cancer. Early DSF diagnosis is crucial in reducing DSF-related morbidity and mortality. Conservative and/or endoscopic/percutaneous treatments is/are the first choice. However, if the patient clinical condition worsens, surgery becomes mandatory and duodenostomy appears to be the most effective surgical procedure.

Effect of High Postoperative Body Temperature on Long-Term Prognosis in Patients with Gastric Cancer After Radical Resection

BACKGROUND

There is a lack of data on the effect of high postoperative body temperature on disease-free survival (DFS) in patients who underwent radical gastrectomy.

METHODS

Patients who underwent radical gastrectomy from January 2006 to December 2011 were selected. The highest body temperature within 1 week after operation was used to establish diagnostic thresholds for high and low body temperature through X-tile software.

RESULTS

A total of 1396 patients were included in the analysis. The diagnostic threshold for high body temperature was defined as 38 °C; 370 patients were allocated to the high-temperature group (HTG), while another 1026 patients were allocated to the low-temperature group (LTG). For all patients, survival analysis showed that 5-year DFS in the HTG was significantly lower than that for the LTG (55.6% vs 63.9%, P = 0.007). Multivariate analysis revealed that high postoperative body temperature was an independent prognostic risk factor for 5-year DFS (HR = 1.288 (1.067-1.555), P = 0.008). For patients without complications, survival analysis showed that the 5-year DFS rate in the HTG was lower than that for the LTG (57.5% vs 64.4%, P = 0.051), especially in patients with stage III gastric cancer (31.3% vs 41.7%, P = 0.037). For patients with complications or infectious complications, there were no significant differences between the HTG and LTG regarding 5-year DFS (49.3% vs 58.2%, P = 0.23 and 49.4% vs 55.1%, P = 0.481, respectively).

CONCLUSION

For stage III gastric cancer patients without complications, high postoperative body temperature can significantly reduce the 5-year DFS. These patients may benefit from more aggressive adjuvant therapy and postoperative surveillance regimens.

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.

Comprehensive Complication Index Predicts Cancer-Specific Survival of Patients with Postoperative Complications after Curative Resection of Gastric Cancer

Objective

To investigate the prognostic impact of postoperative complications for patients with gastric cancer.

Methods

Postoperative complications of patients undergoing radical gastrectomy for gastric cancer were reviewed. The severity of complications was graded by the CCI and C-D classification.

Results

A total of 5327 patients were included in the study. Complications were observed in 767 patients. When the C-D classification system was applied, for patients with grade I-II complications, the length of stay (LOS) of those with high CCI (CCI ≥ 26.2) was significantly longer than that of patients with low CCI (CCI < 26.2) (p < 0.001). The 5-year cancer-specific survival rate of patients with complications (52%) was lower than that of patients without complications (61%) (p < 0.001). Analysis of the factors associated with prognosis in patients with gastric cancer revealed that complications were independent risk factors for specific survival. When CCI was used to classify complication severity, the 5-year cancer-specific survival rate of the high-CCI group was 46.3%, which was lower than that of the low-CCI group (54.9%, p = 0.009).

Conclusion

Complication after radical gastrectomy is an independent prognostic factor, and the complication severity as graded by CCI reflects the difference of cancer-specific survival in gastric cancer patients with postoperative complications.

Short- and Long-Term Outcomes in Malnourished Patients After Laparoscopic or Open Radical Gastrectomy

OBJECTIVE

The aim of this study was to compare the short- and long-term outcomes of malnourished gastric cancer patients who underwent laparoscopic or open radical gastrectomy.

BACKGROUND

Preoperative malnutrition is an independent risk factor for postoperative mortality and morbidity in major gastrointestinal surgery. However, whether laparoscopic surgery can improve the short- and long-term outcomes of malnourished gastric cancer patients has not been determined.

METHODS

We reviewed prospectively collected data from 2441 patients with gastric cancer between January 2009 and December 2014 and compared the short- and long-term outcomes in malnourished gastric cancer patients who underwent laparoscopic or open radical gastrectomy. Nutritional risk factors included weight loss >10% within 6 months, body mass index <18.5 kg/m², Subjective Global Assessment Grade C, and serum albumin <3.0 g/dL.

RESULTS

Overall, 501 patients (20.52%) were classified as malnourished. Patients with gastric stump carcinoma, neoadjuvant chemotherapy, distant metastases, palliative operation, or the presence of other malignancies were excluded. Finally, a total of 412 patients were analyzed; 304 in the laparoscopic group and 108 in the open group. There were no significant differences between the two groups regarding the clinicopathological characteristics. However, the operation time (181 ± 53 vs. 253 ± 81 min), intraoperative blood loss (80 ± 116 vs. 322 ± 502 mL), time to first ambulation (2.21 ± 1.04 vs. 2.55 ± 1.50 days), liquid diet (4.91 ± 1.61 vs. 5.72 ± 2.09 days) and semiliquid diet (7.67 ± 1.56 vs. 9.53 ± 2.09 days) as well as the postoperative hospital stay duration (13.00 ± 6.56 vs. 15.22 ± 6.87 days) were significantly lower in the laparoscopic group than those in the open group (p < 0.05). The instances of overall complications (laparoscopic vs. open: 18.4 vs. 30.6%, p = 0.008) and pneumonia (laparoscopic vs. open: 10.9 vs. 19.4%, p = 0.023) were significantly lower in the laparoscopic group. With a median follow-up of 31.0 months (range 1.0-88.0), the 3-year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) rates for the entire cohort were 58.9, 54.0 and 63.0%, respectively. Further analysis showed that the OS (57.5 vs. 59.4%, p = 0.560), RFS (51.8 vs. 54.8%, p = 0.441) and CSS (62.8 vs. 63.0%, p = 0.789) between the laparoscopic and open groups, respectively, were no significantly different. Further analysis showed no significant differences in the OS rates of the two groups of patients stratified by tumor stage (p > 0.05).

CONCLUSION

Compared with open radical gastrectomy, laparoscopy would reduce the postoperative complications especially pneumonia and shorten the postoperative hospital stay for patients with preoperative malnutrition without affecting their long-term survival.

Duodenal fistula: The most lethal surgical complication in a case series of radical gastrectomy

BACKGROUND

Despite all advances regarding the surgical treatment of gastric cancer (GC), duodenal stump fistula (DF) continues to negatively affect postoperative outcomes. This study aimed to assess DF regarding its incidence, risk factors, management and impact on overall survival.

METHODS

We retrospectively analyzed 562 consecutive patients who underwent gastrectomy for GC between 2009 and 2017. Clinicopathological characteristics analysis was performed comparing DF, other surgical fistulas and patients with uneventful postoperative course.

RESULTS

DF occurred in 15 (2.7%) cases, and 51 (9%) patients had other surgical fistulas. Tumor located in the lower third of the stomach (p = 0.021) and subtotal gastrectomy (p = 0.002) were associated with occurrence of DF. The overall mortality rate was 40% for DF and 15.7% for others surgical fistulas (p = 0.043). The median time of DF onset was on postoperative day 9 (range 1-75). Conservative approach was performed in 8 patients and surgical intervention in 7 cases. Age (OR 7.41, p = 0.012) and DF (OR 9.06, p=0.020) were found to be independent risk factors for surgical mortality. Furthermore, patients without fistula had better long-term survival outcomes comparing to patients with any type of fistulas (p = 0.006).

CONCLUSION

DF is related with distal tumors and patients submitted to subtotal gastrectomy. It affects not only the postoperative period with high morbidity and mortality rates, but may also have a negative impact on long-term survival.

Laparoscopic reinforcement suture on staple-line of duodenal stump using barbed suture during laparoscopic gastrectomy for gastric cancer

Purpose

Duodenal stump fistula (DSF) is a serious complication after gastrectomy for gastric cancer. Although risk evaluation and management of DSF were presented by some investigators, there was no technical attempt has been made to prevent DSF during laparoscopic gastrectomy until now.

Methods

Consecutive 99 patients were enrolled from April 2014 to February 2016 in 2 institutes. All patients were performed laparoscopic gastrectomy for gastric cancer. After cutting of duodenal stump, laparoscopic reinforcement suture (LARS) commenced with continuous invagination method or interrupted method by barbed suture. Clinicopathologic features and postoperative outcomes were analyzed.

Results

Fifty-six patients had comorbidity including 5 patients with duodenal ulcer. Most patients were performed distal gastrectomy with B-II, and 10 patients total gastrectomy with Roux en Y esophagojejunostomy. Although there were 2 esophagojejunostomy leakage and 1 artificial lesser curvature leakage, DSF did not occurred at all in this study. Mean operation time was 3 hours and mean LARS procedure time was 8 minutes.

Conclusion

LARS of duodenal stump can be considered as one of prevention methods of DSF during laparoscopic gastrectomy for gastric cancer. So this new technique will be necessary to appropriately evaluate by prospective randomized controlled trial in the future.

Comparison of 3D laparoscopic gastrectomy with a 2D procedure for gastric cancer: A phase 3 randomized controlled trial

OBJECTIVE

To determine the relative safety and efficacy of 3D laparoscopic gastrectomy and 2D laparoscopic surgery in patients with gastric cancer.

BACKGROUND

There is still a lack of randomized controlled trials regarding the safety and efficacy of 3D versus 2D laparoscopic surgery for gastric cancer.

METHODS

A large-scale, phase 3, prospective, randomized controlled trial was conducted. (ClinicalTrials.gov number NCT02327481).

RESULTS

A total of 438 patients were randomized (3D group: 219 cases; 2D group: 219 cases) between January 1, 2015, and April 1, 2016; 19 patients were excluded. Finally, data from 419 patients were analyzed (3D group: 211 cases; 2D group: 208 cases). There were no differences between the 2 groups regarding the operation time (3D versus 2D, 176 ± 35 min vs. 174 ± 33 min, P = .562). The intraoperative blood loss in the 3D group was somewhat less than in the 2D group (61 ± 83 mL vs. 82 ± 119 mL, P = .045). Further analysis suggested that the use of 3D laparoscopic surgery was a protective factor against excessive blood loss (≥200 mL).

CONCLUSION

3D laparoscopic gastrectomy did not shorten the operation time compared with 2D laparoscopic gastrectomy, but provided the benefit of less intraoperative blood loss and a lesser occurrence of excessive bleeding than the conventional 2D laparoscopic gastrectomy; the clinical value of the difference is limited.

Effects of Preoperative Malnutrition on Short- and Long-Term Outcomes of Patients with Gastric Cancer: Can We Do Better?

BACKGROUND

The effects of preoperative malnutrition and preoperative correction of hypoalbuminemia (PCH) on the short- and long-term outcomes in patients with gastric cancer are unclear.

OBJECTIVE

This study aimed to examine the effect of preoperative nutritional status on short- and long-term outcomes in patients who underwent radical gastrectomy, and also explored the role of PCH in malnourished patients with gastric cancer.

METHODS

We prospectively reviewed data from patients with gastric cancer who were treated in our department between January 2009 and December 2014. The effect of preoperative nutritional status on short- and long-term outcomes in patients who underwent radical gastrectomy was investigated, and we explored whether PCH could improve the short- and long-term outcomes of these patients.

RESULTS

A total of 1976 patients were analyzed, including 412 patients in the malnourished group and 1564 in the well-nourished group. The overall incidence of complications in the malnourished group was significantly higher than the well-nourished group (21.4 vs. 15.5%, p = 0.005). Except for incision infection (3.2 vs. 1.6%, p = 0.041), there were no significant differences for other complications. In the malnourished group, 98 cases of preoperative hypoproteinemia were corrected (PCH group), whereas 314 cases were not (NPCH group). The incidence of incision infection in the PCH group was significantly lower than in the NPCH group (0 vs. 4.1%, p = 0.041). The median follow-up time was 39 months (1.0-88.0 months), and the 3-year overall survival (OS; 59.1 vs. 75%, p < 0.001) and disease-free survival (DFS; 54.8 vs. 72.5%, p < 0.001) rates were significantly lower in the malnourished group than in the well-nourished group. A multivariate Cox regression analysis showed that malnutrition was an independent prognostic factor for 3-year OS (hazard ratio [HR] 1.211, 95% confidence interval [CI] 1.01-1.452, p = 0.039) and DFS (HR 1.168, 95% CI 1.013-1.398, p = 0.043). For the malnourished group with stage I gastric cancer, the PCH and NPCH groups showed no significant differences in 3-year OS (90.0 vs. 89.0%, p = 0.227) or DFS (90.0 vs. 87.3%, p = 0.363); however, for the malnourished group with stages II-III gastric cancer, the 3-year OS (69.9 vs. 47.6%, p = 0.013) and DFS (55.4 vs. 43.6%, p = 0.046) rates were significantly higher in the PCH group than in the NPCH group.

CONCLUSIONS

The incidence of incision infection was significantly higher in patients with malnutrition than in well-nourished patients. The 3-year OS and DFS rates were significantly lower in malnourished patients than in well-nourished patients. PCH may both reduce the incidence of incisional infection in patients with malnutrition and improve 3-year OS and DFS rates for malnourished patients with stages II-III gastric cancer; however, to confirm our findings, further studies are warranted.

Complications and failure to rescue following laparoscopic or open gastrectomy for gastric cancer: a propensity-matched analysis

BACKGROUND

To investigate the incidence of and factors associated with postoperative complications and failure to rescue following laparoscopic and open gastrectomy for gastric cancer.

STUDY DESIGN

We analyzed the records of 4124 patients who underwent a laparoscopic or open gastrectomy for gastric cancer. One-to-one propensity score matching was performed to compare the difference between the two groups.

RESULTS

A total of 4124 patients were included in the study, 627 of whom (15.2 %) developed postoperative complications. Postoperative deaths occurred in 23 (0.6 %) patients with serious complications. In the propensity score matching analysis with 1361 pairs, no significant differences in the rates of overall complications (14.2 vs. 16.5 %, p = 0.093) were observed between laparoscopic and open gastrectomy group. In-hospital mortality decreased in patients who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy (0.3 vs. 1.2 %, p = 0.004). Failure to rescue rates were lower in patients who underwent laparoscopic gastrectomy (2.1 vs. 7.6 %, p = 0.008). Multivariate analysis showed that older age, tumor location, TNM stage classification, extent of gastric resection, operative time and intra-operative blood loss were adverse risk factors for postoperative complications. Laparoscopic gastrectomy was found to be a protective factor for failure to rescue. Complications associated with failure to rescue included abdominal bleeding, anastomotic leakage and cardiac events. In-hospital mortality increased as the number of complications per patient increased.

CONCLUSIONS

Assuming equal competence with open and laparoscopic approaches of a surgeon, the proportion of patients with postoperative complications were similar among those who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy. However, when complications occurred, patients with open gastrectomy were more likely to die.

Duodenal stump fistula after gastrectomy for gastric cancer: risk factors, prevention, and management

Purpose

A duodenal stump fistula is one of the most severe complications after gastrectomy for gastric cancer. We aimed to analyze the risk factors for this problem, and to identify the methods used for its prevention and management.

Methods

We retrospectively reviewed the clinical data of 716 consecutive patients who underwent curative gastrectomy with a duodenal stump for gastric cancer between 2008 and 2013.

Results

A duodenal stump fistula occurred in 16 patients (2.2%) and there were 2 deaths in this group. Univariate analysis revealed age >60 years (odds ratio [OR], 3.09; 95% confidence interval [CI], 0.99–9.66), multiple comorbidities (OR, 4.23; 95% CI, 1.50–11.92), clinical T stage (OR, 2.91; 95% CI, 1.045-8.10), and gastric outlet obstruction (OR, 8.64; 95% CI, 2.61–28.61) to be significant factors for developing a duodenal stump fistula. Multivariate analysis identified multiple comorbidities (OR, 3.92; 95% CI, 1.30–11.80) and gastric outlet obstruction (OR, 5.62; 95% CI, 1.45–21.71) as predictors of this complication.

Conclusion

Multiple comorbidities and gastric outlet obstruction were the main risk factors for a duodenal stump fistula. Therefore, preventive methods and aggressive management should be applied for patients at high risk.

Duodenal fistula after gastrectomy: Retrospective study of 13 new cases

INTRODUCTION

Duodenal stump fistula (DSF) after gastrectomy has a low incidence but a high morbidity and mortality, and is therefore one of the most aggressive and feared complications of this procedure.

MATERIAL AND METHODS

We retrospectively evaluated all DSF occurred at our hospital after carrying out a gastrectomy for gastric cancer, between January 1997 and December 2014. We analyzed demographic, oncologic, and surgical variables, and the evolution in terms of morbidity, mortality and hospital stay.

RESULTS

In the period covered in this study, we performed 666 gastrectomies and observed DSF in 13 patients (1.95%). In 8 of the 13 patients (61.5%) surgery was the treatment of choice and in 5 cases (38.5%) conservative treatment was carried out. Postoperative mortality associated with DSF was 46.2% (6 cases). In the surgical group, 3 patients developed severe sepsis with multiple organ failure, 2 patients presented a major hematemesis which required endoscopic haemostasis, 1 patient had an evisceration and another presented a subphrenic abscess requiring percutaneous drainage. Six patients (75%) died despite surgery, with 3 deaths in the first 24 hours of postoperative care. The 2 patients who survived after the second surgical procedure had a hospital stay of 45 and 84 days respectively. In the conservative treatment group the cure rate was 100% with no significant complications and an average postoperative hospital stay of 39.5 days (range, 26-65 days).

CONCLUSION

FMD is an unusual complication but it is associated with a high morbidity and mortality. In our experience, conservative management has shown better results compared with surgical treatment.

Surgical management of duodenal stump fistula after elective gastrectomy for malignancy: an Italian retrospective multicenter study

BACKGROUND

Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome.

METHODS

We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics.

RESULTS

The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30%, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28% and was related to the presence of vascular disease (P = 0.04), more than one reoperation (P = 0.05), sepsis (P < 0.001), and renal failure (P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations (P < 0.01) and the presence of an abdominal abscess (P < 0.01) led to an increase in healing time.

CONCLUSIONS

Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF.

Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review

AIM: To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.

METHODS: A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients’ characteristics, type of treatment, short and long-term outcomes were extracted and analyzed.

RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d.

CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.

A scoring system to predict the risk of postoperative complications after laparoscopic gastrectomy for gastric cancer based on a large-scale retrospective study

To investigate the risk factors for postoperative complications following laparoscopic gastrectomy (LG) for gastric cancer and to use the risk factors to develop a predictive scoring system.Few studies have been designed to develop scoring systems to predict complications after LG for gastric cancer.We analyzed records of 2170 patients who underwent a LG for gastric cancer. A logistic regression model was used to identify the determinant variables and develop a predictive score.There were 2170 patients, of whom 299 (13.8%) developed overall complications and 78 (3.6%) developed major complications. A multivariate analysis showed the following adverse risk factors for overall complications: age ≥65 years, body mass index (BMI) ≥ 28 kg/m, tumor with pyloric obstruction, tumor with bleeding, and intraoperative blood loss ≥75 mL; age ≥65 years, a Charlson comorbidity score ≥3, tumor with bleeding and intraoperative blood loss ≥75 mL were identified as independent risk factors for major complications. Based on these factors, the authors developed the following predictive score: low risk (no risk factors), intermediate risk (1 risk factor), and high risk (≥2 risk factors). The overall complication rates were 8.3%, 15.6%, and 29.9% for the low-, intermediate-, and high-risk categories, respectively (P < 0.001); the major complication rates in the 3 respective groups were 1.2%, 4.7%, and 10.0% (P < 0.001).This simple scoring system could accurately predict the risk of postoperative complications after LG for gastric cancer. The score might be helpful in the selection of risk-adapted interventions to improve surgical safety.

Repeated Duodenal Stump Perforation Using a Stapling Device Following Subtotal Gastrectomy With Roux-en-Y Reconstruction for Advanced Gastric Cancer: Lessons From a Rare Case

Closure of the duodenal stump using a stapling device is commonly applied in Roux-en-Y reconstruction after gastrectomy. However, serious and possibly fatal duodenal stump perforation can develop in extremely rare cases. We describe a case of subtotal gastrectomy with Roux-en-Y reconstruction followed by repeated duodenal stump perforations. A 79-year-old man with a long history of diabetes and hypertension was admitted to our institution with epigastralgia and right hypochondralgia. Computed tomography and an upper gastrointestinal imaging series revealed remarkable wall thickening of the gastric antrum and corpus. Upper endoscopy also showed a giant ulcerative lesion in the same area. The lesion was confirmed by histology to be poorly differentiated adenocarcinoma. The patient underwent open subtotal gastrectomy with Roux-en-Y reconstruction. However, duodenal stump perforation occurred repeatedly on postoperative days 1, 3, and 19, which caused peritonitis. The patient was kept alive through duodenal stump repair, an additional resection using a stapling device, and repeated drainage treatments; but he suffered considerable morbidity due to these complications. We report a case of a life-threatening duodenal stump perforation after subtotal gastrectomy, highlighting lessons learned from the profile and clinical course. Abdominal surgeons should be aware of the possibility of this serious complication of duodenal stump perforation, and be able to perform immediate interventions, including life-saving reoperation.

Delayed duodenal stump blow-out following total gastrectomy for cancer: Heightened awareness for the continued presence of the surgical past in the present is the key to a successful duodenal stump disruption management. A case report

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Duodenal stump disruption is not a surgical anachronism, because it still remains one of the most dreadful postgastrectomy complications.

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Postgastrectomy duodenal stump disruption poses an overwhelming therapeutic challenge.

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Historical surgical sense and familiarity with the various well established methods for the treatment of duodenal stump disruption can provide to the surgical team the ability to successfully manage this devastating complication.

INTRODUCTION

Duodenal stump disruption remains one of the most dreadful postgastrectomy complications, posing an overwhelming therapeutic challenge.

PRESENTATION OF CASE

The present report describes the extremely rare occurrence of a delayed duodenal stump disruption following total gastrectomy with Roux-en-Y esophagojejunostomy for cancer, because of mechanical obstruction of the distal jejunum resulting in increased backpressure on afferent limp and duodenal stump. Surgical management included repair of distal jejunum obstruction, mobilization and re-stapling of the duodenum at the level of its intact second part and retrograde decompressing tube duodenostomy through the proximal jejunum.

DISCUSSION

Several strategies have been proposed for the successful management post-gastrectomy duodenal stump disruption however; its treatment planning is absolutely determined by the presence or not of generalized peritonitis and hemodynamic instability with hostile abdomen. In such scenario, urgent reoperation is mandatory and the damage control principle should govern the operative treatment.

CONCLUSION

Considering that scientific data about duodenal stump disruption have virtually disappeared from the current medical literature, this report by contradicting the anachronism of this complication aims to serve as a useful reminder for gastrointestinal surgeons to be familiar with the surgical techniques that provide the ability to properly manage this dreadful postoperative complication.