Novel abdominal negative pressure lavage-drainage system for anastomotic leakage after R0 resection for gastric cancer

Table 1 Characteristics of patients who underwent R0 resection for gastric cancer n (%)

Characteristic	All patients (n = 4173)	2009-2013 (n = 2219)	2014-2016 (n = 1954)	P-value
Mean age, yr				0.148
< 65	2701 (64.7)	1414 (63.7)	1287 (65.9)
≥ 65	1472 (35.3)	805 (36.3)	667 (34.1)
Sex				0.002
Male	3083 (73.9)	1683 (75.8)	1400 (71.6)
Female	1090 (26.1)	536 (24.2)	554 (28.4)
Mean BMI, kg/m2 (SD)	22.3 (5.2)	22.0 (3.1)	22.6 (3.7)	< 0.001
History of abdominal surgery				0.436
No	3543 (84.9)	1875 (84.5)	1668 (85.4)
Yes	630 (15.1)	344 (15.5)	286 (14.6)
Tumor site				< 0.001
Upper	1136 (27.2)	590 (26.6)	546 (27.9)
Middle	892 (21.4)	383 (17.3)	509 (26.0)
Lower	1654 (39.6)	958 (43.2)	696 (35.6)
≥ 2 areas	491 (11.8)	288 (13.0)	203 (10.4)
Malnourished				0.277
No	3730 (89.4)	1919 (88.9)	1811 (89.9))
Yes	443 (10.6)	240 (11.1)	203 (10.1)
Mean tumor size, cm (SD)	4.4 (2.6)	4.6 (2.6)	4.0 (2.7)	< 0.001
AJCC-TNM stage, 8th edition				< 0.001
I	1158 (27.7)	598 (26.9)	560 (28.7)
II	1052 (25.2)	487 (21.9)	565 (28.9)
III	1963 (47.0)	1134 (51.1)	829 (42.4)
Comorbidities				0.112
No	2876 (68.9)	1553 (70.0)	1323 (67.7)
Yes	1297 (31.1)	666 (30.0)	631 (32.3)
HB, g/dL				0.317
≥ 90	3718 (89.1)	1967 (88.6)	1751 (89.6)
< 90	455 (10.9)	252 (11.4)	203 (10.4)
ASA				0.641
I-II	4000 (95.9)	2130 (96.0)	1870 (95.7)
III-IV	173 (4.1)	89 (4.0)	84 (4.3)
Operation method				< 0.001
Open	670 (16.1)	469 (21.1)	201 (10.3)
Laparoscopic	3503 (83.9)	1750 (78.9)	1753 (89.7)
Type of resection				0.235
Subtotal gastrectomy	1873 (44.9)	1015 (45.7)	858 (43.9)
Total gastrectomy	2300 (55.1)	1204 (54.3)	1096 (56.1)
Type of reconstruction				< 0.001
Billroth I	1100 (26.4)	782 (35.2)	318 (16.3)
Billroth II	540 (12.9)	160 (7.2)	380 (19.4)
Roux-en-Y	2468 (59.1)	1225 (55.2)	1243 (63.6)
Other	65 (1.6)	52 (2.3)	13 (0.7)
Mean surgical duration, min (SD)	184.7 (67.6)	191.3 (67.8)	177.1 (66.7)	< 0.001
Mean intraoperative blood loss, mL (SD)	94.7 (256.8)	115.0 (335.3)	71.5 (108.6)	< 0.001
Mean length of stay, d (SD)	13.5 (7.8)	13.5 (7.4)	13.4 (8.2)	0.296
AL	83 (2.0)	37 (1.7)	46 (2.4)	0.113

Values represent the number of patients (percentages), unless otherwise indicated. BMI: Body mass index; HB: Hemoglobin; ASA: American Society of Anesthesiologists; AL: Anastomotic leakage.

Table 2 Postoperative mortality, morbidity, and treatment modality among patients with anastomotic leakage after radical gastrectomy before (2009-2013) and after (2014-2016) implementation of the abdominal negative pressure lavage-drainage system n (%)

Postoperative condition	All patients (n = 83)	2009-2013 (n = 37)	2014-2016 (n = 46)	P-value
Death	7 (8.4)	6 (16.2)	1 (2.2)	0.041
Time of occurrence of AL, d (mean)	5.6	5.4	5.7	0.738
Other complication
Pneumonia	41 (49.3)	16 (43.2)	25 (54.3)	0.315
Abdominal bleeding	8 (9.6)	7 (18.9)	1 (2.2)	0.020
Pancreatic fistula	3 (3.6)	3 (8.1)	0 (0)	0.085
Chylous leak	4 (4.8)	3 (8.1)	1 (2.2)	0.319
Anastomotic bleeding	2 (2.4)	2 (5.4)	0 (0)	0.196
Wound infection	4 (4.8)	2 (5.4)	2 (4.3)	> 0.999
ARF&RI	2 (2.4)	2 (5.4)	0 (0)	0.196
Cardiac event	2 (2.4)	1 (2.7)	1 (2.2)	> 0.999
HF and hypohepatia	2 (2.4)	1 (2.7)	1 (2.2)	> 0.999
Treatment
No invasive	58 (69.9)	18 (48.6)	40 (87.0)	< 0.001
CT-guided puncture drainage	16 (19.3)	11 (29.7)	5 (10.9)	0.030
endoscopy	3 (3.6)	3 (8.1)	0 (0)	0.085
Reoperation	6 (7.2)	5 (13.5)	1 (2.2)	0.084
Length of stay, d (mean)	30.2	31.6	28.4	0.458

AL: Anastomotic leakage; ARF&RI: Acute renal failure and renal insufficiency; CT: Computed tomography.

Table 3 Risk factors predictive of anastomotic leakage after radical gastrectomy

Factor	Multivariate analysis results
	OR (95%CI)	P-value
Age, yr
< 65	Reference	0.006
≥ 65	1.886 (1.195-2.975)
Malnourished
No	Reference	0.005
Yes	2.194 (1.267-3.797)
Comorbidities
No	Reference	0.171
Yes	1.377 (0.871-2.178)
HB, g/dL
≥ 90	Reference	0.221
< 90	1.441 (0.803-2.586)
Type of resection
Subtotal gastrectomy	Reference	0.069
Total gastrectomy	1.534 (0.967-2.434)

HB: Hemoglobin.

Table 4 Risk factors predictive of failure-to-rescue after anastomotic leakage with radical gastrectomy for gastric cancer

Factor	Univariate analysis
	OR (95%CI)	P-value
ANPLDS therapy
No	Reference	0.040
Yes	0.103 (0.012-0.898)
Age, yr
< 65	Reference	0.532
≥ 65	0.607 (0.127-2.900)
Sex
Female	Reference	0.998
Male	/
BMI, kg/m2
< 25	Reference	0.773
≥ 25	1.289 (0.230-7.219)
History of abdominal surgery
No	Reference	0.849
Yes	0.808 (0.090-7.286)
Tumor site
Upper	Reference	0.935
Middle	/	0.998
Lower	0.697 (0.106-4.578)	0.707
≥ 2 areas	1.394 (0.203-9.585)	0.736
Malnourished
No	Reference	0.710
Yes	1.388 (0.247-7.802)
Tumor size, cm
≤ 5	Reference	0.700
> 5	1.361 (0.283-6.535)
AJCC-TNM stage, 8th edition
I-II	Reference	0.115
III	5.692 (0.654-49.570)
Comorbidities
No	Reference	0.448
Yes	1.833 (0.383-8.765)
HB, g/dL
≥ 90	Reference	0.728
< 90	0.678 (0.076-6.063)
ASA
I-II	Reference	0.567
III-IV	1.944 (0.200-18.920)
Operation method
Open	Reference	0.073
Laparoscopic	0.226 (0.044-1.149)
Type of resection
Subtotal gastrectomy	Reference	0.763
Total gastrectomy	1.300 (0.236-7.166)
Type of reconstruction
Billroth I	Reference	0.997
Billroth II	0.817 (0.148-4.520)	0.817
Roux-en-Y	/	> 0.999
Other	/	0.999
Surgical duration, min (SD)
> 180	Reference	0.138
≤ 180	3.629 (0.661-19.914)
Intraoperative blood loss, ml
> 50	Reference	0.997
≤ 50	/

ANPLDS: Abdominal negative pressure lavage-drainage system; BMI: Body mass index; HB: Hemoglobin; ASA: American Society of Anesthesiologists.