How to Examine Anastomotic Integrity Intraoperatively in Totally Laparoscopic Radical Gastrectomy? Methylene Blue Testing Prevents Technical Defect-related Anastomotic Leaks

Overview

Journal World J Gastrointest Surg

Publisher Baishideng Publishing Group

Specialty Gastroenterology

Date 2022 Jun 6

PMID 35664361

Authors

Chun Deng

Yang Liu

Zhen-Yu Zhang

Heng-Duo Qi

Zhi Guo

Xu Zhao

Xiao-Jun Li

Affiliations

Soon will be listed here.

Abstract

Background: Intraoperative methylene blue testing (IMBT), air leak testing, or endoscopy is used to assess the anastomotic integrity of esophagojejunostomy during open total gastrectomy for gastric cancer. Totally laparoscopic radical gastrectomy has been widely used to treat gastric cancer in the last few decades. However, reports on testing anastomotic integrity in totally laparoscopic radical gastrectomy are limited.

Aim: To explore the effects of IMBT on the incidence of postoperative anastomotic leaks (PALs) and identify the risk factors for PALs in totally laparoscopic radical gastrectomy.

Methods: From January 2017 to December 2019, patients who underwent totally laparoscopic radical gastrectomy at the Shaanxi Provincial People's Hospital were retrospectively analyzed. According to whether or not they experienced an IMBT, the patients were divided into an IMBT group and a control group. If the IMBT was positive, an intraoperative suture was required to reinforce the anastomosis. The difference in the incidence of PALs was compared, and the risk factors were investigated.

Results: This study consisted of 513 patients, 211 in the IMBT group and 302 in the control group. Positive IMBT was shown in seven patients (3.3%) in the IMBT group, and no PAL occurred in these patients after suture reinforcement. Multivariate analysis showed that risk factors for predicting positive IMBT were body mass index (BMI) > 25 kg/m (hazard ratio [HR] = 8.357, = 0.009), operation time > 4 h (HR = 55.881, = 0.002), and insufficient surgical experience (HR = 15.286, = 0.010). Moreover, 15 patients (2.9%) developed PALs in 513 patients, and the rates of PALs were significantly lower in the IMBT group than in the control group [2 of 211 patients (0.9%) 13 of 302 patients (4.3%), = 0.0026]. Further analysis demonstrated that preoperative complications (HR = 13.128, = 0.017), totally laparoscopic total gastrectomy (HR = 9.075, = 0.043), and neoadjuvant chemotherapy (HR = 7.150, = 0.008) were independent risk factors for PALs.

Conclusion: IMBT is an effective method to evaluate the integrity of anastomosis during totally laparoscopic radical gastrectomy, thus preventing technical defect-related anastomotic leaks. Preoperative complications, totally laparoscopic total gastrectomy, and neoadjuvant chemotherapy are independent risk factors for PALs.

Citing Articles

A comparison of the postoperative outcomes between intraoperative leak testing and no intraoperative leak testing for gastric cancer surgery: a systematic review and meta-analysis.

Luo H, Liu S, Huang W, Lei Y, Xing Y, Wesemann L Surg Endosc. 2024; 38(4):1709-1722.

PMID: 38413470 DOI: 10.1007/s00464-024-10715-z.

References

. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2016; 20(1):1-19. PMC: 5215069. DOI: 10.1007/s10120-016-0622-4. View

Katai H, Mizusawa J, Katayama H, Kunisaki C, Sakuramoto S, Inaki N . Single-arm confirmatory trial of laparoscopy-assisted total or proximal gastrectomy with nodal dissection for clinical stage I gastric cancer: Japan Clinical Oncology Group study JCOG1401. Gastric Cancer. 2019; 22(5):999-1008. DOI: 10.1007/s10120-019-00929-9. View

Sung H, Ferlay J, Siegel R, Laversanne M, Soerjomataram I, Jemal A . Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021; 71(3):209-249. DOI: 10.3322/caac.21660. View

Schuhmacher C, Gretschel S, Lordick F, Reichardt P, Hohenberger W, Eisenberger C . Neoadjuvant chemotherapy compared with surgery alone for locally advanced cancer of the stomach and cardia: European Organisation for Research and Treatment of Cancer randomized trial 40954. J Clin Oncol. 2010; 28(35):5210-8. PMC: 3020693. DOI: 10.1200/JCO.2009.26.6114. View

Gong W, Li J . Combat with esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer: A critical review of the literature. Int J Surg. 2017; 47:18-24. DOI: 10.1016/j.ijsu.2017.09.019. View

Hyung W, Yang H, Han S, Lee Y, Park J, Kim J . A feasibility study of laparoscopic total gastrectomy for clinical stage I gastric cancer: a prospective multi-center phase II clinical trial, KLASS 03. Gastric Cancer. 2018; 22(1):214-222. DOI: 10.1007/s10120-018-0864-4. View

Trapani R, Rausei S, Reddavid R, Degiuli M . Risk factors for esophago-jejunal anastomosis leakage after total gastrectomy for cancer. A multicenter retrospective study of the Italian research group for gastric cancer. Eur J Surg Oncol. 2020; 46(12):2243-2247. DOI: 10.1016/j.ejso.2020.06.035. View

Kawamura Y, Satoh S, Suda K, Ishida Y, Kanaya S, Uyama I . Critical factors that influence the early outcome of laparoscopic total gastrectomy. Gastric Cancer. 2014; 18(3):662-8. DOI: 10.1007/s10120-014-0392-9. View

Gorur M, Sozutek A, Irkorucu O, Karakaya B . The influence of platelet-rich plasma (PRP) on colonic anastomosis healing impaired by intraperitoneal 5-flourouracil application. An experimental study. Acta Cir Bras. 2020; 35(5):e202000504. PMC: 7341987. DOI: 10.1590/s0102-865020200050000004. View

10.

Nishikawa K, Yanaga K, Kashiwagi H, Hanyuu N, Iwabuchi S . Significance of intraoperative endoscopy in total gastrectomy for gastric cancer. Surg Endosc. 2010; 24(10):2633-6. DOI: 10.1007/s00464-010-1007-0. View

11.

Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S . Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clin Nutr. 2015; 34(3):335-40. DOI: 10.1016/j.clnu.2015.03.001. View

12.

. The global, regional, and national burden of stomach cancer in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease study 2017. Lancet Gastroenterol Hepatol. 2019; 5(1):42-54. PMC: 7033564. DOI: 10.1016/S2468-1253(19)30328-0. View

13.

Mortensen K, Nilsson M, Slim K, Schafer M, Mariette C, Braga M . Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Br J Surg. 2014; 101(10):1209-29. DOI: 10.1002/bjs.9582. View

14.

Kim S, Son S, Park Y, Ahn S, Park D, Kim H . Risk Factors for Anastomotic Leakage: A Retrospective Cohort Study in a Single Gastric Surgical Unit. J Gastric Cancer. 2015; 15(3):167-75. PMC: 4604331. DOI: 10.5230/jgc.2015.15.3.167. View

15.

Yanagimoto Y, Omori T, Fujiwara Y, Demura K, Jeong-Ho M, Shinno N . Comparison of the intracorporeal triangular and delta-shaped anastomotic techniques in totally laparoscopic distal gastrectomy for gastric cancer: an analysis with propensity score matching. Surg Endosc. 2019; 34(6):2445-2453. DOI: 10.1007/s00464-019-07025-0. View

16.

Lee J, Nam B, Ryu K, Ryu S, Park Y, Kim S . Comparison of outcomes after laparoscopy-assisted and open total gastrectomy for early gastric cancer. Br J Surg. 2015; 102(12):1500-5. DOI: 10.1002/bjs.9902. View

17.

Son T, Sun J, Choi S, Cho M, Kwon I, Kim H . Multi-institutional validation of the 8th AJCC TNM staging system for gastric cancer: Analysis of survival data from high-volume Eastern centers and the SEER database. J Surg Oncol. 2019; 120(4):676-684. DOI: 10.1002/jso.25639. View

18.

Park J, Kim Y . Uncut Roux-en-Y Reconstruction after Laparoscopic Distal Gastrectomy Can Be a Favorable Method in Terms of Gastritis, Bile Reflux, and Gastric Residue. J Gastric Cancer. 2015; 14(4):229-37. PMC: 4286901. DOI: 10.5230/jgc.2014.14.4.229. View

19.

Ko C, Choi N, Kim B, Yook J, Kim M, Kim B . Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy: A comparative study. World J Gastroenterol. 2021; 27(18):2193-2204. PMC: 8117731. DOI: 10.3748/wjg.v27.i18.2193. View

20.

Celik S, Almali N, Aras A, Yilmaz O, Kiziltan R . Intraoperatively Testing the Anastomotic Integrity of Esophagojejunostomy Using Methylene Blue. Scand J Surg. 2016; 106(1):62-67. DOI: 10.1177/1457496916630652. View