Early postoperative complications

E. Strong (ed.). Gastric cancer. Principles and practice. Springer (2015)


Overall morbidity and mortality rates

Clinical trials often provide some of the highest quality data on morbidity and mortality rates for surgery. Several prospective trials in gastric cancer contain early postoperative outcomes and have reported fairly consistent morbidity and mortality rates. Many of these randomized trials compared regional and extended lymphadenectomy, although some studies regarded resection of the spleen and the tail of the pancreas as necessary for removing the D2 lymph nodes. The Dutch trial of 711 patients undergoing resection with curative intent reported morbidity and mortality rates of 25 and 4%, respectively, in patients undergoing D1 dissection and 43 and 10% in patients undergoing D2 dissection [1]. The Medical Research Council Gastric Cancer Surgical Trial, in a similar study to the Dutch trial, compared early complications after D1 dissection with those after D2 dissection. Morbidity and mortality rates in the D1 dissection group were 28 and 7%, respectively, compared with morbidity and mortality rates of 46 and 13% in the D2 dissection group [2]. The Italian Gastric Cancer Study Group, in a prospective multicenter trial evaluating complications after pancreas-preserving D2 lymph node dissection, reported a postoperative morbidity rate of 21% and a hospital mortality rate of 3% [3]. Important findings from this study, in addition to the low overall morbidity rate, were variable hospital mortality rates of 1% after subtotal gastrectomy and 7% after total gastrectomy. The Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) Trial of perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer included postoperative complications as outcome measures. Morbidity and mortality rates for patients in this trial were 45 and 6%, respectively, and these rates were similar in patients treated with chemotherapy or with surgery alone [4]. Table 17.1 summarizes the overall complication rates for gastrectomy in gastric cancer trials and provides an overview to guide more in-depth discussion of specific complications. In addition, a recent Cochrane review has summarized four randomized clinical trials evaluating the need for abdominal drainage after gastrectomy. This review reported a low 30-day overall mortality rate (1.4%), with no difference in the rate of complications between patients with or without drain placement at surgery [5].

Table 17.1. Postoperative morbidity and mortality in clinical trials of surgery for gastric cancer

Gastric cancer. Principles and practice (2015) T 17.1

Programmatic databases such as The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database and The Veterans Affairs National Surgical Quality Improvement Program (VA NSQIP) can also provide high-quality data on 30-day morbidity and mortality after gastrectomy for cancer. In a recent study that used the ACS NSQIP participant use file from 2005 through 2010, overall postgastrectomy serious morbidity occurred in 24% of patients and the 30-day mortality rate was 4% [6]. Patients undergoing total gastrectomy had serious morbidity and mortality rates of 29 and 5%, respectively, and patients undergoing partial gastrectomy had serious morbidity and mortality rates of 20 and 3%, respectively (Table 17.2). An older VA NSQIP study of patients undergoing gastrectomy for cancer from 1991 through 1998 reported 30-day morbidity and mortality rates of 33 and 8%, respectively [7].

Surgical site infections

Superficial, deep, and organ space infections occur in approximately 6, 1, and 7%, respectively, of patients undergoing gastrectomy for cancer, with only slightly higher rates of organ space infection in patients undergoing total gastrectomy than in those undergoing subtotal gastrectomy [6].

Table 17.2. Postoperative 30-day morbidity and mortality rates in patients undergoing total and partial gastrectomy for gastric cancer in ACS NSQIP from 2005 to 2010 [6]

Gastric cancer. Principles and practice (2015) T 17.2

Wound disruption

Wound dehiscence occurs in 1–2% of patients.

Pulmonary complications

Postoperative pneumonia occurs in about 7% of patients but can be as high as 12% in high-risk populations, such as patients receiving care in the United States Department of Veterans Affairs hospital system [6, 7]. Failure to wean from ventilator assistance after 48 h and reintubation occur in 6% of patients, with higher rates in patients undergoing total gastrectomy.

Bleeding

Postoperative hemorrhage or requirement of transfusion of more than 4 units of blood occur in approximately 3% of patients [7].

Cardiac complications

Cardiac arrest and myocardial infarction occur in 1–3% of patients.

Deep vein

Thrombosis and Pulmonary Embolism Venous thrombosis occurs in 1–2% of patients. Pulmonary embolism also occurs in 1% of patients undergoing partial gastrectomy and in 2% of patients undergoing total gastrectomy [6].

Urinary tract infection

Urinary tract infection occurs in up to 6% of patients.

Reoperation

Reoperation is needed and occurs in 6–10% of patients and occurs more often in patients undergoing total gastrectomy.

Delayed gastric emptying

Early delayed gastric emptying after subtotal gastrectomy is not infrequent and is likely exacerbated by regional lymph node dissection along the lesser curvature of the stomach with resection of the vagus nerve branches. Medical management includes supplementing the patient’s nutrition through total parenteral nutrition or tube feedings and prescribing promotility agents such as metoclopramide and erythromycin. Surveillance endoscopy findings from patients after overnight fasting have shown food retention in 14–38% of patients after subtotal gastrectomy, but this finding is often not associated with symptoms of delayed gastric emptying [8].

Anastomotic leaks

Anastomotic leakage occurs in 5–10% of patients undergoing total gastrectomy for gastric cancer [2, 9, 10]. The majority of leaks can be treated conservatively without reoperation. Anastomotic leakage significantly increases mortality and also appears to be associated with poor oncologic prognosis [10, 11]. In a large series of over 1000 total gastrectomies performed over a 30-year period, the associated mortality rates were 19% in patients with anastomotic leakage treated without surgery and 64% in patients treated with surgery [9]. The increased mortality rates associated with reoperative surgery have led to efforts to manage leaks nonoperatively. Endoscopic stent placement has been shown to be a safe procedure to manage anastomotic leaks conservatively after gastrectomy and esophagectomy. Although most series are small, successful healing rates for patients with an anastomotic leak treated with stent placement range from 75 to 90% [12, 13].

Duodenal stump leak

The duodenal stump is a relatively infrequent site of leakage after subtotal or total gastrectomy, with reported frequency rates of 2–3% [3, 14, 15]. Leakage from the duodenal stump with resultant inflammation has also been reported as a negative prognostic factor for overall survival after surgery for gastric cancer [14]. Management may be nonoperative with percutaneous drain placement or may require reoperation with drain placement, although further attempts at duodenal stump closure are rarely successful. Figure 17.1 shows a computed tomography (CT) image of a patient with a duodenal stump leak after subtotal gastrectomy.

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