Postoperative recovery after suspension suture placement at the site of esophagojejunal anastomosis after total gastrectomy: Comparison of two surgical techniques

1. Introduction

Gastric cancer is the fourth most common cause of death from malignant diseases worldwide and the sixth most frequently diagnosed cancer worldwide [1]. Despite improvements, survival rates for gastric cancer remain low, even in developed countries, confirming the role of primary and secondary prevention [2, 3].

There are several histopathologic classifications of gastric cancer, but the most commonly used are Lauren’s classification and the World Health Organization’s classification of gastric cancer [4]. Determining the stage of the disease (staging) is based on the widely accepted TNM classification, which essentially decides the choice of therapeutic approach [5].

Surgery is the most important form of gastric cancer treatment. It consists of resectioning the stomach (subtotal or total gastrectomy) and removing surrounding lymph nodes (lymphadenectomy) in compliance with the R0 D2 principle of resection. There are three levels of lymphadenectomy (D1, D2 and D3) [10, 11].

After a total gastrectomy, in order to establish the continuity of the digestive tube, a Roux-en-Y esophagojejunostomy (EJ) (T end-to-L side type) is created with a circular stapler. The rest of the small intestine, which is isolated by Roux and enters the structure of the anastomosis, is taken care of with a lined stapler. Then an entero-entero (EE) anastomosis, according to Brown, is created manually, which is the standard for reconstructing the alimentary canal after total gastrectomy [10, 11].

A nasogastric tube (NGT) is often placed intraoperatively to the EE anastomosis. Numerous studies have been conducted on the role and actual need for using an NGT after total gastrectomy, but opinions remain divided [11].

Most surgeons traditionally use nasogastric decompression, believing that its use eases the region of the created anastomosis and reduces complications such as nausea, vomiting, postoperative ileus, aspiration, and the creation of a fistula at the anastomosis, i.e., the outflow of the contents of the digestive tube into the abdominal cavity through a defect in the anastomosis. However, numerous studies have shown no significant differences in postoperative complications and the length of hospital treatment when comparing patients with or without NGT application [11, 12, 13].

There are also many controversies about using additional single sutures on the esophagojejunal anastomosis (EJA) created with a circular stapler in patients with gastric cancer who underwent total gastrectomy. In our country and the wider region, we have not found any studies conducted to determine the role and advantage of additional sutures in EJA.

This study aims to demonstrate the role of additional suspension sutures on the esophagojejunal anastomosis (EJA) to strengthen the anastomosis, i.e., relieve the mechanical suture.

2. Patients and methods

A retrospective cohort study was conducted from 2011 to 2022 at the Clinic for Surgery, University Clinical Center Tuzla, Bosnia and Herzegovina. The study was conducted with the approval of the Ethics Committee of the University Clinical Center Tuzla (approval number: 02-09/2-46/22). All patients provided written informed consent before being included in the study.

Patients were divided into two groups based on surgeons’ preference for placement of suspension sutures. The experimental group consisted of patients placed with a suspension suture at the esophagojejunal anastomosis (EJA) site created with a circular stapler after total gastrectomy. The control group was patients without a suspension suture at the site of the EJA created with a circular stapler.

Inclusion criteria were newly diagnosed operable patients with pathologically confirmed gastric cancer after endoscopy and biopsy of suspected lesions. Exclusion criteria were patients with a manually created EJA and previously operated and treated patients for gastric or other digestive tract cancer.

Suspension sutures were placed transversely on the esophagus (for the longitudinal musculature of the esophagus) and transversely on the small intestine (Fig. 1). Six suspension sutures were placed, two from the front, two from the back and two from the side. We used slow resorptive sutures 3-0. Mostly, we used PDS 3-0, Maxon 3-0 and Vicryl plus 3-0. Maxon and PDS were slow-absorbing sutures, and Vicryl plus is an antibacterial resorptive suture.

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The following parameters available from the medical history were analyzed; age, gender, preoperative symptoms (epigastric pain, nausea, vomiting, weight loss, anemia), duration of preoperative complaints, comorbidities (diabetes mellitus, arterial hypertension, ischemic heart disease, bronchitis), preoperative and postoperative pathologic features, placed NGT or oral feeding postoperatively, laboratory findings on the second and seventh postoperative day (hemogram, renal and pancreatic parameters, proteinogram, C reactive protein), X-ray passage (width of anastomosis, bleeding, dehiscence, stenosis of anastomosis), surgical complications of the first seven days and after seven days (esophageal, duodenal, biliary fistula, bleeding, intraabdominal abscess, laparotomy wound infection, revision surgery, other surgical complications), non-surgical complications (pneumonia, myocardial infarction, ARDS, pleural effusion), and the length of hospitalization.

Later, the postoperative course, time of onset of postoperative complications (pain, vomiting, heartburn), postoperative radiological follow-up (CT and MRI) and endoscopic postoperative follow-up (proper anastomosis, stenosis of anastomosis, reflux) were then analyzed.

3. Results

In our study, we compared the postoperative course and a short-term outcome in patients with gastric cancer who underwent total gastrectomy with an EJA circular stapler and placed one suspensory suture at the EJA site in the experimental group. In contrast, no suspensory suture was placed in the control group. The two examined groups were fairly homogeneously distributed, with uniform basic characteristics, comorbidities, symptoms, pathohistological diagnoses, TNM stage and laboratory parameters.

The main finding of our study is that there was no significant difference between the groups in postoperative surgical and general complications and late postoperative complications.

Our study confirmed that anemia is common in patients with gastric cancer before and after total gastrectomy. Anemia after gastrectomy is common in patients with an advanced stage of the disease and is a poor prognostic factor, as are female gender and diabetes mellitus [14].

Chen et al. analyzed the correlation between preoperative and postoperative leukocyte values. They concluded that elevated preoperative leukocyte values and postoperative leukopenia significantly correlated with the overall survival of gastrectomy patients with gastric cancer and adjuvant chemotherapy [15].

Preoperative leukocyte values correlate with patient gender, TNM stage and nodal status. Postoperative leukopenia is associated with poor tumor differentiation and low leukocytes preoperatively [15].

In our study, leukocytes were significantly lower postoperatively at discharge compared to the values obtained on the second postoperative day in both examined groups.

Mao et al. analyzed the association and significance of C reactive protein (CRP) with clinicopathological characteristics and nutritional status in patients with gastric cancer. They came to the conclusion that the level of CRP significantly correlates with the years of life of patients, tumor diameter, perineural invasion, lymphovascular invasion, depth of tumor invasion, lymph node metastases, TNM stage, weight loss, body mass index, hemoglobin level, total proteins and albumins [16].

In our study, CRP was elevated postoperatively in both examined groups, on the 2nd and 7th postoperative days, while total proteins, albumins, and globulins were decreased.

Wei et al. in their meta-analysis examined the need for nasogastric tube (NGT) after gastrectomy for gastric cancer. They came to the conclusion that there is a significantly shorter time to oral intake of food in patients who did not have NGT and shorter hospitalization time. Time to onset of flatus, anastomotic leakage, pulmonary complications, mortality and morbidity were similar between patients with and without NGT. NGT does not facilitate the recovery of bowel function or reduce the risk of postoperative complications, so routine application of NGT is unnecessary in total gastrectomy after gastric cancer [17]. However, other authors consider that the purpose of placing gastric tube in clinic is to make intraoperative exposure more convenient and intraoperative operation safer, which is helpful for postoperative observation of anastomotic bleeding and other conditions [18].

In our study, half of the patients in both examined groups had a NGT, the average length of time until oral nutrition was 3 days in both groups. The average length of hospitalization was slightly shorter in the experimental group, 8.72 days, while in the experimental group it was 9.88 days, but without a significant difference.

Routine abdominal drainage after gastrectomy is still widely accepted worldwide for the early diagnosis and management of abdominal complications such as postoperative bleeding, anastomotic loosening, and intra-abdominal infections. However, many studies have not shown the benefit of prophylactic abdominal drainage [19]. Placement of drainage even increases postoperative pain, prolongs the use of analgesics and leads to complications related to the drain, which is why some institutions do not place drainage routinely after gastrectomy [19]. The authors of a meta-analysis that combined 21 studies and 5142 patients came to the conclusion that the routine use of drainage after total gastrectomy does not bring benefit, even harm, with increased morbidity, prolonged time to oral intake of food and prolonged hospital stay [19].

In our study, patients were routinely placed abdominal drains, the frequency of complications was not high, considering the extensiveness of the procedure. Surgical complications were more common after the 7th day after surgery. The most common complications in the experimental group were intra-abdominal abscess, while in the control group it was infection of the surgical wound.

Among the long-term complications associated with EJA, anastomotic stenosis is one of the most significant because it impairs the patient’s quality of life and requires invasive treatment with endoscopic dilation. Various factors can lead to stenosis of the EJA, and its frequency in the literature ranges from 4–40% [20]. In our study, the frequency of stenosis at the EJA site was 9.2% in the experimental and 4% in the control group, which can be considered a rather low frequency. The type of stapler can also have an influence on the formation of EJA stenosis, because the circular stapler is determined by the size of the esophagus, so in case of smaller diameters of the esophagus, a linear stapler or manual creation of EJA [20] may be recommended.

Although new studies are constantly being developed in the world that will surely improve the diagnosis and treatment of gastric cancer, one of the interesting studies that we analyzed with interest is the study by He et al., which came to the conclusion that dual-energy CT imaging plays an important role in the preoperative evaluation of the pathological types of gastric cancer and has high clinical application value in patients with gastric cancer [21].

The limiting factors of our study are that the study is retrospective and single-centered. A limiting factor is also the retrospective data analysis. One of the major shortcomings of the study is the lack of randomization of patients, rather the suspension sutures were placed according to the surgeon’s preference, therefore a randomized controlled study is necessary to confirm these data. The advantages are a relatively large sample, the homogeneity of the sample, a long period of patient follow-up (over 10 years), a similar treatment protocol for oncology patients, and a similar surgical technique among the surgeons who performed the operations. EJAs have been performed by several experienced surgeons with impressive results.

5. Conclusion

Our study did not show a statistically significant difference between the two analyzed EJA techniques created with a circular stapler, when it comes to postoperative course and outcome in patients with gastric cancer. Future prospective and multicenter studies are necessary to prove which operative methods are best for optimal outcome and treatment of patients with gastric cancer.