Introduction
Materials and methods
Patients and data
Classification and diagnosis of postoperative complications
Surgical procedure and postoperative management
Distal gastrectomy | Total gastrectomy | Proximal gastrectomy | ||
---|---|---|---|---|
Gastrectomy-specific ERAS care | Preoperative nutrition for malnourished patients | ○ | ○ | ○ |
Preoperative oral pharmaconutrion | ||||
Laparoscopic access | ○ | ○ | ○ | |
Transversus abdominis plane block | ○ | ○ | ○ | |
Nasogastric/nasojejunal decompression | ○ | |||
Avoiding the use of abdominal drains | ||||
Early postoperative diet and artificial nutrition | ○ | |||
Audit | ○ | ○ | ○ | |
General ERAS care | Dedicated preoperative counselling | ○ | ○ | ○ |
Abstinence of smoking and alcohol consumption | ○ | ○ | ○ | |
Do not use mechanical bowel preparation | ○ | ○ | ○ | |
Preoperative fasting and preoperative treatment with carbohydrates | ○ | ○ | ○ | |
Optimal anaesthetic management | ○ | ○ | ○ | |
Preanaesthetic medication | ||||
Antithrombotic prophylaxis | ○ | ○ | ○ | |
Antimicrobial prophylaxis and skin preparation | ○ | ○ | ○ | |
Epidural analgesia | ||||
Intravenous analgesia through PCA | ○ | ○ | ○ | |
Multimodal intervention for PONV | ○ | ○ | ○ | |
Avoiding intraoperative hypothermia | ○ | ○ | ○ | |
Postoperative glycemic control | ○ | ○ | ○ | |
Near-zero fluid balance | ○ | ○ | ○ | |
Removing urinary drainage on POD1–2 | ○ | ○ | ○ | |
Stimulation of bowel movement | ○ | ○ | ○ | |
Early and scheduled mobilization | ○ | ○ | ○ |
Statistical analysis
Results
Clinicopathologic characteristics
Characteristics | Total | Major complicationsa | Minor/no complicationsa | p value |
---|---|---|---|---|
N = 240 (%) | n = 41 (%) | n = 199 (%) | ||
Age | ||||
< 65 years | 126 (52.5) | 21 (51.2) | 105 (52.8) | 0.857 |
≥ 65 years | 114 (47.5) | 20 (48.8) | 94 (47.2) | |
Gender | ||||
Male | 164 (68.3) | 30 (73.2) | 134 (67.3) | 0.296 |
Female | 76 (31.7) | 11 (26.8) | 65 (32.7) | |
BMI (kg/m2) | 22.15 (19.71–24.01) | 23.20 (21.78–26.15) | 21.78 (19.38–23.70) | 0.002b |
Preoperative serum albumin level (g/L) | 37.71 ± 4.20 | 38.51 ± 3.32 | 37.55 ± 4.35 | 0.719 |
ASA score | ||||
I | 26 (10.8) | 4 (9.8) | 22 (11.1) | 0.949 |
II | 207 (86.3) | 36 (87.8) | 171 (85.9) | |
III | 7 (2.9) | 1 (2.4) | 6 (3.0) | |
Neoadjuvant chemotherapy | ||||
Yes | 26 (10.8) | 4 (9.8) | 22 (11.1) | 1.000 |
No | 214 (89.2) | 37 (90.2) | 177 (88.9) | |
TNM stage | ||||
I | 79 (32.9) | 16 (39.0) | 63 (31.7) | 0.143 |
II | 58 (24.2) | 5 (12.2) | 53 (26.6) | |
III | 103 (42.9) | 20 (48.8) | 83 (41.7) | |
Type of resection | ||||
Distal gastrectomy | 104 (43.3) | 12 (29.3) | 92 (46.2) | 0.017 |
Total gastrectomy | 121 (50.4) | 23 (56.1) | 98 (49.3) | |
Proximal gastrectomy | 15 (6.3) | 6 (14.6) | 9 (4.5) | |
Combined resection | ||||
Yes | 7 (2.9) | 1 (2.4) | 6 (3.0) | 1.000 |
No | 233 (97.1) | 40 (97.6) | 193 (97.0) | |
Operation time (min) | 312.5 (255–312.5) | 360 (295–442.5) | 300 (250–340) | < 0.001b |
Blood loss (ml) | 50 (30–100) | 100 (50–200) | 50 (30–100) | 0.010b |
Postoperative hospitalization (day) | 8 (6–10) | 8 (6–9) | 19 (11–37.5) | < 0.001b |
Characteristics | Total | Major complicationsa | Minor/no complicationsa | p value |
---|---|---|---|---|
N = 104 (%) | n = 16 (%) | n = 88 (%) | ||
Age | ||||
< 65 years | 63 (60.6) | 8 (50.0) | 55 (62.5) | 0.347 |
≥ 65 years | 41 (39.4) | 8 (50.0) | 33 (37.5) | |
Gender | ||||
Male | 67 (64.4) | 12 (75.0) | 55 (62.5) | 0.406 |
Female | 37 (35.6) | 4 (25.0) | 33 (37.5) | |
BMI (kg/m2) | 21.62 (19.91–24.17) | 22.12 (20.54–25.05) | 21.48 (19.64–23.62) | 0.136b |
Preoperative serum albumin level (g/L) | 38.25 ± 3.86 | 37.76 ± 3.61 | 38.34 ± 3.91 | 0.585 |
ASA score | ||||
I | 11 (10.6) | 1 (6.3) | 10 (11.4) | 0.394 |
II | 89 (85.6) | 15 (93.7) | 74 (84.1) | |
III | 4 (3.8) | 0 (0.0) | 4 (4.5) | |
Neoadjuvant chemotherapy | ||||
Yes | 12 (11.5) | 2 (12.5) | 10 (11.4) | 1.000 |
No | 92 (88.5) | 14 (87.5) | 78 (88.6) | |
TNM stage | ||||
I | 39 (37.5) | 3 (18.8) | 36 (40.9) | 0.213 |
II | 30 (28.8) | 6 (37.5) | 24 (27.3) | |
III | 35 (33.7) | 7 (43.7) | 28 (31.8) | |
Type of resection | ||||
Distal gastrectomy | 45 (43.3) | 4 (25.0) | 41 (46.6) | 0.090 |
Total gastrectomy | 52 (50.0) | 9 (56.3) | 43 (48.9) | |
Proximal gastrectomy | 7 (6.7) | 3 (18.7) | 4 (4.5) | |
Combined resection | ||||
Yes | 1 (1.0) | 0 (0.0) | 1 (1.1) | 1.000 |
No | 103 (99.0) | 16 (100.0) | 87 (98.9) | |
Operation time (min) | 300 (270–345) | 345 (277.5–405) | 300 (266.25–335) | 0.030b |
Blood loss (ml) | 50 (50–100) | 50 (50–150) | 50 (50–100) | 0.184b |
Postoperative hospitalization (day) | 8 (6–10) | 29.5 (11.5–38.5) | 7 (6–9) | < 0.001b |
Relationship between major PCs and clinical characteristics
Type of postoperative complications | No. (%) | Clavien-Dindo classification | |||
---|---|---|---|---|---|
II | III | IV | V | ||
Anastomotic leakage | 24 (7.0) | 4 | 12 | 6 | 2 |
Pneumonia and pleural effusion | 10 (2.9) | 6 | 4 | ||
Ileus | 7 (2.0) | 5 | 2 | ||
Bleeding | 4 (1.2) | 1 | 2 | 1 | |
Duodenal stump leakage | 2 (0.6) | 1 | 1 | ||
Abdominal abscess | 4 (1.2) | 1 | 3 | ||
Chylous fistula | 1 (0.3) | 1 | |||
Surgical site infection | 1 (0.3) | 1 | |||
Other | 4 (1.2) | 1 | 2 | 1 | |
Total | 57 (16.6) | 21 | 26 | 8 | 2 |
The variation tendency of serum CRP level
Diagnostic accuracy of different predictive models for major PCs
Characteristics | Univariate logistical analysis | Multivariate logistical analysis | ||||
---|---|---|---|---|---|---|
OR | 95% CI | p value | OR | 95% CI | p value | |
Age | ||||||
< 65 years | Reference | |||||
≥ 65 years | 1.216 | 0.688–2.149 | 0.500 | |||
Gender | ||||||
Female | Reference | Reference | ||||
Male | 1.452 | 0.767–2.748 | 0.252 | 0.989 | 0.423–2.314 | 0.980 |
BMI | ||||||
< 25 kg/m2 | Reference | Reference | ||||
≥ 25 kg/m2 | 2.872 | 1.478–5.580 | 0.002 | 2.936 | 1.088–7.928 | 0.034 |
Preoperative serum albumin level | ||||||
≥ 40 g/L | Reference | |||||
< 40 g/L | 0.867 | 0.469–1.602 | 0.648 | |||
ASA score | 0.681 | |||||
I | Reference | |||||
II | 1.332 | 0.495–3.584 | 0.570 | |||
III | 0.640 | 0.067–6.142 | 0.699 | |||
Neoadjuvant chemotherapy | ||||||
No | Reference | |||||
Yes | 0.891 | 0.373–2.358 | 0.891 | |||
T stage | ||||||
T1–2 | Reference | |||||
T3–4 | 1.003 | 0.562–1.790 | 0.992 | |||
N stage | ||||||
N0 | Reference | |||||
N1–3 | 1.259 | 0.706–2.244 | 0.435 | |||
Type of resection | 0.002 | 0.148 | ||||
Distal gastrectomy | Reference | Reference | ||||
Proximal gastrectomy | 5.755 | 2.126–15.575 | 0.001 | 4.933 | 0.931–26.124 | 0.061 |
Total gastrectomy | 1.887 | 0.990–3.596 | 0.054 | 1.309 | 0.430–3.982 | 0.636 |
Combined resection | ||||||
No | Reference | |||||
Yes | 0.714 | 0.086–5.920 | 0.755 | |||
Operation time | ||||||
≤ 300 min | Reference | Reference | ||||
> 300 min | 3.009 | 1.614–5.608 | 0.001 | 2.108 | 0.706–6.293 | 0.181 |
Blood loss | ||||||
< 100 ml | Reference | Reference | ||||
≥ 100 ml | 1.751 | 0.988–3.105 | 0.055 | 0.958 | 0.374–2.452 | 0.928 |
POD3/2 CRP | ||||||
≤ 1.0 | Reference | |||||
> 1.0 | 37.422 | 15.971–87.687 | < 0.001 | 42.548 | 16.967–106.700 | < 0.001 |
Characteristics | Sensitivity | Specificity | Youden’s index |
---|---|---|---|
Ratio | |||
POD3/2 = 1.08 | 0.812 | 0.852 | 0.664 |
POD3/1 = 2.13 [18] | 0.938 | 0.523 | 0.461 |
Value | |||
167 mg/L on POD5 [13] | 0.455 | 1.000 | 0.455 |
168 mg/L on POD4 [14] | 0.385 | 0.963 | 0.348 |
177 mg/L on POD3 [11] | 0.563 | 0.909 | 0.472 |
114 mg/L on POD3 [12] | 0.981 | 0.602 | 0.583 |
177 mg/L on POD2 [15] | 0.438 | 0.830 | 0.268 |