Abstract
BackgroundPostoperative complications frequently occur after gastrectomy for gastric cancer and are associated with poor clinical outcomes, such as mortality and reoperations. The aim of study was to identify the clinically most relevantcomplications after gastrectomy, using the population-attributable fraction (PAF).MethodsBetween 2011 and 2017, all patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit. Postoperative outcomes (morbidity, mortality, recovery and hospitalization) were evaluated. The prevalence of postoperative complications (e.g., anastomotic leakage and pneumonia) and of the study outcomes were calculated. The adjusted relative risk and Confidence Interval (CI) for each complication-outcome pair were calculated. Subsequently, the PAF was calculated, which represents the percentage of a given outcome occurring in the population, caused by individual complications, taking both the relative risk and the frequency in which a complication occurs into account.ResultsIn total, 2176 patients were analyzed. Anastomotic leakage and pulmonary complications had the greatest overall impact on postoperative mortality (PAF 29.2% [95% CI 19.3–39.1] and 21.6% [95% CI 10.5–32.7], respectively) and prolonged hospitalization (PAF 12.9% [95% CI 9.7–16.0] and 14.7% [95% CI 11.0–18.8], respectively). Anastomotic leakage had the greatest overall impact on re-interventions (PAF 25.1% [95% CI 20.5–29.7]) and reoperations (PAF 30.3% [95% CI 24.3–36.3]). Intra-abdominal abscesses had the largest impact on readmissions (PAF 7.0% [95% CI 3.2–10.9]). Other complications only had a small effect on these outcomes.ConclusionSurgical improvement programs should focus on preventing or managing anastomotic leakage and pulmonary complications, since these complications have the greatest overall impact on clinical outcomes after gastrectomy.
Highlights
Gastrectomy with lymphadenectomy is the cornerstone of curative treatment for patients diagnosed with adenocarcinoma of the stomach [1] and, if deemed fit enough, patients will receive perioperative chemotherapy [2]
PAF population-attributable fraction a Multivariable poisson regression b Logistic regression-based estimates of confounder-adjusted attributable fractions and bowel injury were associated with the greatest relative risk of both postoperative mortality and reoperations
A large part of the causes of the study outcomes cannot be specified, due to variation in the data that cannot be explained by patient and/or treatment characteristics and complications. These ‘other’ factors, contributed to all clinical postoperative outcomes in large numbers, accounting for 32.9% of postoperative mortality, 50.8% of prolonged hospitalization, 32.5% of re-interventions, 27.3% of reoperations, and 78.7% of hospital readmissions. In this population-based study, the clinically most relevant complications after gastrectomy for gastric cancer were evaluated in a Western population using the PAF
Summary
Gastrectomy with lymphadenectomy is the cornerstone of curative treatment for patients diagnosed with adenocarcinoma of the stomach [1] and, if deemed fit enough, patients will receive perioperative chemotherapy [2]. Gastrectomy is associated with a high risk of postoperative complications (up to 40%) [3], of which pulmonary complications, anastomotic leakage, and wound complications occur most frequently [4,5,6,7,8,9] These complications have a negative influence on postoperative outcomes, such as mortality, length of hospital stay, number of reoperations, and readmissions [10, 11]. The PAF was calculated, which represents the percentage of a given outcome occurring in the population, caused by individual complications, taking both the relative risk and the frequency in which a complication occurs into account. Conclusion Surgical improvement programs should focus on preventing or managing anastomotic leakage and pulmonary complications, since these complications have the greatest overall impact on clinical outcomes after gastrectomy
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