Intractable ascites following surgery for gastric carcinoma

Outcomes of surgical approaches for gastric cancer with portal hypertension

OBJECTIVE

The influence of surgical approaches on patients with gastric cancer with portal hypertension is unknown. The aim of the study was to investigate the outcomes in such patients who had undergone curative surgery for gastric cancer.

PATIENTS AND METHODS

The clinical data of 60 patients with portal hypertension undergoing curative surgery for gastric cancer or simultaneous surgery for portal hypertension were retrospectively analyzed.

RESULTS

Radical gastrectomy alone had no tremendous impact on postoperative liver function, but simultaneous surgery for portal hypertension affected patients' liver function dramatically (P<0.001). For those who underwent surgery for portal hypertension simultaneously, the incidence of complications on patients with Child's B was much higher than that of patients with Child's A (P<0.001). However, the incidence of complications did not differ between Child's A and Child's B patients who underwent radical gastrectomy alone. In addition, patients undergoing simultaneous surgery for portal hypertension displayed more severe complications than did those who underwent radical gastrectomy alone (P<0.001). Age, tumor stage, and simultaneous surgery for portal hypertension were the independent risk factors for the deterioration of liver function (P<0.05), and the survival time of patients undergoing simultaneous surgery for portal hypertension was significantly shorter than that of patients undergoing radical gastrectomy alone (P<0.05).

CONCLUSION

Individualized selection of surgical approaches for the treatment of gastric cancer with portal hypertension should be decided by preoperative liver function. Simultaneous management of portal hypertension was not advocated.

Treatment selection for gastric cancer with portal hypertension: clinical management

BACKGROUND

Treatment for gastric cancer with portal hypertension must consider the eradication of the tumor and the change of hemodynamics in portal hypertension (PHT). Few reports have described the surgical procedures and postoperative complications of surgery for gastric cancer associated with PHT.

METHODS

The clinical data of 22 patients with PHT undergoing curative surgery for gastric cancer during 5 years were retrospectively analyzed. For 12 patients classified in Child's class A, D2 lymph node (LN) dissection was performed, and 10 patients classified into Child's class B were treated with D1 LN dissection. Surgical treatment included total gastrectomy combined with pericardial devascularization, distal subtotal gastrectomy, distal subtotal gastrectomy combined with splenectomy, and distal subtotal gastrectomy combined with pericardial devascularization with posterior gastric artery and left inferior phrenic artery preserved. A liver biopsy was analyzed in all patients.

RESULTS

Postoperative complications developed in 50 % (11/22 patients) and the mortality rate was 9 % (2/22). The rate of postoperative ascites in patients with Child's class A was much lower than in those with Child's class B (P < 0.05). "Operation time," "volume of hemorrhage," "platelet count," and "treatment of PHT" are all risk factors of liver function deterioration. However, there was no significant difference in liver function deterioration rate between patients with Child's class A and Child's class B (P > 0.05). The occurrence rate of complications in patients with PHT was much higher compared to those without with PHT (P < 0.05).

CONCLUSIONS

Individualized selection of surgical approaches is crucial for treatment of gastric carcinoma accompanied by PHT. Surgical treatment should be based on preoperative TNM stage, liver function, and degree of PHT.

Management of ascites after radical surgery in gastric cancer patients with liver cirrhosis and minimal hepatic dysfunction

A radical lymph node dissection is important for the cure of gastric cancer. However, such a procedure in patients with liver cirrhosis (LC) could develop serious complications such as massive ascites. To determine the management of postoperative ascites, 26 gastric cancer patients with LC were reviewed retrospectively. Child-Pugh status was grade A in all 26 patients. Thirteen (50%) patients had advanced gastric cancer, and a D2 lymph nodes dissection was performed in 25 (96.2%) patients. The mean number of dissected lymph nodes was 33 +/- 11 (range: 11-54). An abdominal closed suction drain was placed in 12 (46.2%) patients, and the average amount of fluid drainage was 463 ml/day. The drainage tube was removed on about the eleventh postoperative day (range: day 6 to day 13), and diuretics were used in 8 (30.8%) patients. A paracentesis was needed in one patient but no postoperative surgical morbidity or mortality was observed. Therefore, an extended lymph node dissection is safe in gastric cancer patients with mild hepatic dysfunction. Liver cirrhosis and postoperative ascites can be managed conservatively without any complications.

Gastric cancer surgery in cirrhotic patients: Result of gastrectomy with D2 lymph node dissection

AIM: To explore the feasibility of performing gastrectomy with D2 lymphadenectomy in gastric cancer patients with liver cirrhosis.

METHODS: A total of 7 178 patients were admitted with a diagnosis of liver cirrhosis from January 1993 to December 2003. We reviewed the records of 142 patients who were diagnosed with liver cirrhosis and gastric adenocarcinoma during the same period. Gastrectomy with D2 lymph node dissection for carcinoma of the stomach was performed in 94 patients with histologically proven hepatic cirrhosis.

RESULTS: All but 12 patients were classified as Child’s class A. Only 35 patients (37.2%) were diagnosed with cirrhosis before operation. Seventy-three patients underwent a subtotal gastrectomy (77.7%) and 21 patients (22.3%) underwent a total gastrectomy, each with D2 or more lymph node dissection. Two patients (3.8%) who had prophylactic intra-operative drain placement, died of postoperative complications from hepatorenal failure with intractable ascites. Thirty-seven patients (39.4%) experienced postoperative complications. The extent of gastric resection did not influence the morbidity whereas serum aspartate aminotransferase level (P = 0.011) and transfusion did (P = 0.008). The most common postoperative complication was ascites (13.9%) followed by wound infection (10.6%).

CONCLUSION: We concluded that the presence of compensated cirrhosis, i.e. Child class A, is not a contraindication against gastrectomy with D2 or more lymph node dissection, when curative resection for gastric cancer is possible. Hepatic reserve and meticulous hemostasis are the likely determinants of operative prognosis.