The Benefits of Advising Patients of 90-day Risks After Total Gastrectomy

In many patients who have surgery for gastric cancer, total gastrectomy (TG) is necessary to achieve microscopically negative margins. After this complex procedure, patients are at risk of adverse events beyond the standard 30-day follow-up period.

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For esophagectomy and colorectal surgery, the 90-day period after surgery has been proposed as the preferred measure of postoperative outcomes. Selena S. Li, an MD student and researcher, Christina L. Costantino, MD, general surgeon, and John T. Mullen, MD, surgeon in the Department of Surgery at Massachusetts General Hospital, recently reviewed the experience with TG at Mass General.

In the Journal of Gastrointestinal Surgery, they report a substantial incidence of complications, although a low rate of anastomotic leaks.

Patient Characteristics and Operative Details

The study involved 148 patients who underwent TG with curative intent for gastroesophageal cancer at Mass General between 2000 and 2017. The median age was 66, and 61% of the patients were male. Half had pT3 or pT4 disease, and 48% had regional nodal metastases. Fifteen had previously undergone gastric resection. 32% received neoadjuvant chemotherapy and 11% received neoadjuvant radiation therapy.

The vast majority of TGs (93%) were completed via an open approach. All patients had a Roux-en-Y esophagojejunostomy reconstruction. A hand-sewn anastomosis was performed in 65% and a stapled end-to-end anastomosis in 35%. A feeding jejunostomy tube was placed in 40%.

Complications Within 90 Days

• 65 patients (44%) experienced one or more complications
• Most complications (62%) were minor (Clavien–Dindo class I or II)
• 14% of all patients in the cohort had a serious complication (class III or IV and required surgical or radiologic intervention)
• The most common complications, affecting 16% of the entire cohort, were respiratory in nature; the next most common were anemia requiring blood transfusion and new-onset cardiac arrhythmia

Anastomotic Leak

One hundred and sixteen patients had a routine barium swallow study to evaluate for anastomotic leak. Eight of those patients (5.4% of the entire cohort) experienced a leak at the esophageal anastomosis, diagnosed between the fourth and seventh postoperative days. Of those, three leaks were managed conservatively with restriction of oral intake and total parenteral nutrition, and four leaks were additionally managed with percutaneous drain placement by radiology. One patient required reoperation after conservative management proved inadequate, and a drain was placed at the site. There was one death associated with sepsis secondary to anastomotic leak.

Hospital Readmission

Thirty-three patients (22%) were readmitted within 30 days of hospital discharge. The most common reason for readmission was a complication related to the feeding jejunostomy tube (n=4, 12%).

Mortality

• The 30-day mortality rate was 2.0% (n=3)
• The 90-day mortality rate was 3.4% (n=5), nearly a 75% increase from the one-year rate
• Over the last six years of this study (2012–2017), there were no deaths within 90 days

Takeaways for Clinicians

In light of this research, surgeons are advised to consider the following:

• Feeding jejunostomy tubes should be reserved for patients at highest risk of nutritional compromise after TG
• One of the anastomotic leaks was missed on two separate barium swallow studies. For ruling out an anastomotic leak after TG, it may be most reasonable to obtain a more sensitive study, such as computed tomography with oral contrast, for patients who exhibit signs and symptoms that are worrisome for a leak (e.g., fever, tachycardia, pain or leukocytosis)
• The low rate of anastomotic leak and the stellar 90-day survival rate in recent years may be attributable to Mass General's move toward a new policy: Complex surgical procedures such as TG are performed by specialized, high-volume surgeons
• All centers should critically examine their own outcomes after complex surgical procedures, such as TG, because they are critical to the informed consent process and to quality improvement initiatives

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