The incidence of complications after gastrectomy increases significantly when extended lymph node dissection is added.
There are few prospective randomised studies comparing different methods of managing postoperative complications in this group of patients, in whom there are specific risks, such as pancreatic fistula. It is therefore necessary to concede that the superiority of one approach to managing complications cannot be considered scientifically proven. Nevertheless, surgeons remain interested in the results of institutions with large experience of this kind of surgery, because it seems likely that they would have evolved effective methods for dealing with and preventing the complications. This is especially the case where the institutions can show a low incidence of complications, and a low incidence of death and other serious consequences in their patients who do develop complications.
The authors report the collected experience of Japanese surgeons at the National Cancer Center Hospital in Tokyo.
The most frequent major complication after a D2 or more extended lymphadenectomy is pancreatic juice leakage and/or left subphrenic abscess. The incidence of this complication after a total gastrectomy is highest when the distal pancreas is resected together with spleen, and lowest when the spleen is not touched at all. The incidence of pancreas-related complications after the so-called pancreas preserving total gastrectomy (PPTG) is still 15-20%, which is higher than that after simple splenectomy.
Because of the high incidence of pancreas-related complications after D2 or more extended surgery, prophylactic placement of a drainage tube beside the pancreas stump in case of pancreatico-splenectomy (PS) and in the subphrenic space in PPTG is advocated by most Japanese surgeons. Reoperation in the immediate postoperative period after extended surgery usually carries a high risk, especially in patients with septic complications, such as subphrenic abscess.
Pancreas juice leakage is often followed by contamination, resulting in a left subphrenic abscess. Measurement of amylase levels in the drainage fluid is a simple and useful method for the prediction of pancreatic fistula formation, and enables surgeons to plan appropriate management.
If the amount of discharge is large, continuous irrigation is recommended to avoid secondary haemorrhage from major arteries. Unlike anastomotic leakage, the volume of discharge is usually relatively small, but sometimes thick mucinous discharge blocks the tubes and prevents adequate drainage. In such cases also, continuous irrigation is advocated. Such aggressive irrigation should be continued until the discharge becomes clear and small in volume.
Contamination does not seem to be caused by retrograde infection through the drainage tubes but by the contamination of the pancreas juice itself, since even patients who have no drainage tubes often develop contamination. This is presumably caused by simple contamination from bowel flora released during surgery or by retrograde contamination caused by dysfunction of duodenal papilla.
As the incidence of anastomotic leakage has declined in recent years, the argument in favour of the prophylactic use of drainage tubes to guard against the results of anastomotic failure may seem less convincing than previously thought. Once anastomotic leakage occurs, however, it is often fatal, especially in Western patients.
If the risk of anastomotic leakage occurring seems high, then prophylactic use of drainage tubes seems sensible. Leakage or fistula from an esophago- or gastro-jejunostomy leads to the escape of large volumes of intestinal contents with a heavy bacterial load.
Usually, an intra-abdominal abscess related to leakage after gastric surgery is associated with a fistula producing a large volume of intestinal or duodenal contents. These intestinal contents have a high content of digestive enzymes, and are therefore irritating to the granulation tissue and the surrounding organs. It is especially important to protect large arteries skeletonized after lymph node dissection, and for this purpose continuous irrigation is essential.
D2 dissection includes a wide dissection of the retroperitoneum and causes marked edema in the retroperitoneal space. Together with leakage of lymphatic fluid, this causes considerable retention of fluid in the so-called third space. To keep a good circulation, blood pressure and urine volume, transfusion of large amounts of fluid is required. About 2.0-2.3 ml/kg/h should be prescribed on the first and second postoperative days and 1.6-1.8 ml/kg/h thereafter. As the fluid in the third space comes back into the vessels, usually on the third postoperative day, overhydration may easily occur, and acute cardiac failure may follow. Pulmonary complications, mainly pneumonia, often develop as a result ( 1 ).
Su-Shun Lo et al. affirm that total gastrectomy with pancreaticosplenectomy for gastric cancer has been proposed for facilitating lymph node dissection or for resection of direct tumor invasion to the pancreas, especially for T4 lesions. Its effectiveness in improving patient survival is still controversial, and higher morbidity and mortality with this procedure have been reported in several series.
Such risks to patient survival were not observed in the Japanese series. Based on a prospective gastric cancer database maintained from 1987 to 1999 in their institution, the morbidity and mortality were analyzed in their series of pancreaticosplenectomies. 127 patients underwent curative total gastrectomy with pancreaticosplenectomy in order to facilitate lymph node dissection or removal of direct tumor invasion. Operative time, postoperative hospital stay, postoperative complications, and surgical mortality were analyzed.
Compared to another 201 total gastrectomies, longer mean operative time (7.91 ± 2.16 hours vs. 6.67 ± 2.01, p < 0.001) and postoperative hospital stay (median, 24.5 days vs. 17, p < 0.001) for combined organ resection (pancreaticosplenectomy) were shown in this series. The major complication rate, including intraabdominal abscess, anastomotic leak, postoperative bleeding, pancreatitis/fistula, chylous leak, and general complications causing unstable vital signs (26.8% vs. 11.9%, p = 0.001), but not the mortality rate (6.3% vs. 4.8%, p = 0.608), was also shown to be higher in pancreaticosplenectomy patients. The most frequent fatal complication was intraabdominal abscess.
However, more than 50% of complications occurred in the first 40 pancreaticosplenectomies (1987-1991); after adequate accumulation of experience, the total complication rate (57.5% vs. 35.6%, p = 0.021), major complication rate (40% vs. 20.7%, p = 0.022), and mortality rate (17.5% vs. 1.1%, p = 0.001) improved significantly in the remaining 87 patients (1991-1999).
They therefore conclude that total gastrectomy with pancreaticosplenectomy can be performed by experienced surgeons with acceptable risk of morbidity and mortality ( 2 ).
References
1) Mitsuru Sasako, Hitoshi Katai, Takeshi Sano and Keiichi Maruyama. Management of complications after gastrectomy with extended lymphadenectomy. Surgical Oncology 2000, volume 9, issue 1, 31-34.
2) Su-Shun Lo, M.D., Chew-Wun Wu, M.D., King-Han Shen, M.D., Mao-Chie Hsieh, M.D., and Wing-Yiu Lui, M.D. Higher Morbidity and Mortality after Combined Total Gastrectomy and Pancreaticosplenectomy for Gastric Cancer. World Journal of Surgery, 26, 678-682, 2002.
3) Yonemura Y, Kawamura T, Nojima N, et al. (2000) Postoperative results of left upper abdominal evisceration for advanced gastric cancer. Hepato-gastroenterology 47:571-574
4) Wyn G. Lewis, Paul Edwards, Jonathan D. Barry, Saboor Khan, Daljit Dhariwal, Ilias Hodzovic, Miles C. Allison, Kenneth Shute: D2 or not D2? The gastrectomy question. Gastric Cancer 5 (2002) 1, 29-34
5) Degiuli M, Sasako M, Ponti A, et al. (1998) Morbidity and mortality after D2 gastrectomy for gastric cancer: results of the Italian Gastric Cancer Study Group prospective multicenter surgical study. J. Clin. Oncol. 16:1490-1493
6) Kitamura K, Yamaguchi T, Sawai K, et al. (1997) Chronologic changes in the clinicopathologic findings and survival of gastric cancer patients. J. Clin. Oncol. 15:3471-3480
