1348
Original article
Outcomes of surgical approaches for gastric cancer with portal hypertension Zheng-Yun Zhang, Zun-Qiang Zhou and Guang-Wen Zhou Objective The influence of surgical approaches on patients with gastric cancer with portal hypertension is unknown. The aim of the study was to investigate the outcomes in such patients who had undergone curative surgery for gastric cancer.
independent risk factors for the deterioration of liver function (P < 0.05), and the survival time of patients undergoing simultaneous surgery for portal hypertension was significantly shorter than that of patients undergoing radical gastrectomy alone (P < 0.05).
Patients and methods The clinical data of 60 patients with portal hypertension undergoing curative surgery for gastric cancer or simultaneous surgery for portal hypertension were retrospectively analyzed.
Conclusion Individualized selection of surgical approaches for the treatment of gastric cancer with portal hypertension should be decided by preoperative liver function. Simultaneous management of portal hypertension was not advocated. Eur J Gastroenterol Hepatol 26:1348–1352 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Results Radical gastrectomy alone had no tremendous impact on postoperative liver function, but simultaneous surgery for portal hypertension affected patients’ liver function dramatically (P < 0.001). For those who underwent surgery for portal hypertension simultaneously, the incidence of complications on patients with Child’s B was much higher than that of patients with Child’s A (P < 0.001). However, the incidence of complications did not differ between Child’s A and Child’s B patients who underwent radical gastrectomy alone. In addition, patients undergoing simultaneous surgery for portal hypertension displayed more severe complications than did those who underwent radical gastrectomy alone (P < 0.001). Age, tumor stage, and simultaneous surgery for portal hypertension were the
Introduction Gastric cancer is one of the most frequently diagnosed cancers and the second most common cause of cancerrelated death worldwide [1]. Another major public health problem in China is liver cirrhosis (LC) caused by hepatitis B virus infection. Therefore, LC is not infrequently encountered among surgical candidates for gastric cancer [2]. A radical resection with D2 lymph node dissection is regarded as the standard surgical procedure for gastric cancer. However, LC is considered to be a terminal liver disease, and such an extended surgery is supposed to damage liver function severely and give rise to postoperative morbidity and mortality [3,4]. Therefore, the eradication of tumor and the change in hemodynamics of the portal system must be considered simultaneously during the treatment of gastric cancer with portal hypertension (PHT). Thus, a combined surgery (splenectomy and pericardial devascularization) was once performed by us. However, few reports have described surgical outcomes in patients with gastric cancer with PHT. In this study, we retrospectively analyzed 60 cases of patients who had undergone radical gastrectomy or 0954-691X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
European Journal of Gastroenterology & Hepatology 2014, 26:1348–1352 Keywords: gastric cancer, pericardial devascularization, portal hypertension, radical gastrectomy, splenectomy Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China Correspondence to Guang-Wen Zhou, PhD, MD, Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, 200233 Shanghai, China Tel: + 86 21 6436 9181; fax: + 86 21 6470 1361; e-mail: [email protected] Received 16 July 2014 Accepted 15 August 2014
combined surgery for gastric cancer with LC to explore the influence of surgical procedures on patients.
Patients and methods Patient selection
We reviewed the medical records of patients with LC who had undergone radical gastrectomy or combined surgery performed by our surgical team between January 2002 and January 2009. Patients with a previous history of abdominal surgery or other malignancies were excluded. This study was conducted in accordance with the Helsinki Declaration and was approved by the Ethics Committee of Shanghai Jiao Tong University. Informed consent was obtained from each patient. Diagnosis of liver cirrhosis and portal hypertension
A diagnosis of LC was made on the basis of clinical findings, abdominal sonogram, endoscopic features, laboratory parameters, or liver biopsy. In patients for whom a pathological diagnosis had not been made before the operation, cirrhosis was confirmed by liver biopsy performed during the operation. To assess the severity DOI: 10.1097/MEG.0000000000000213
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gastric cancer with portal hypertension Zhang et al. 1349
of LC, the Child–Turcotte–Pugh scoring system (Child’s classification) was used. The presence of esophageal–gastric varices, hypersplenism, variceal bleeding, or ascites indicates the presence of PHT. Postoperative mortality was defined as the deaths related to the operation. Severe ascites was defined as postoperative ascites of more than 500 ml per day passing through the drainage tube or needing paracentesis for ascites control. Surgical approaches
Radical gastrectomy was defined as resection with no apparent residual tumors. In such procedure, the degree of lymph node dissection was determined according to the Japanese Classification of Gastric Carcinoma. In D1 lymph node dissection, the perigastric lymph nodes were removed, whereas in D2 lymph node dissection lymph nodes along the common hepatic artery, the splenic artery, and around the celiac axis were also removed. For patients with need of concurrent operation (splenectomy and pericardial devascularization) for PHT along with the resection of gastric cancer, the following prerequisites were required: (a) patients in good condition, with no severe heart, lung, kidney, or other organ lesions; (b) ability to radically remove gastric lesions; (c) history of upper gastrointestinal bleeding in patients; (d) severe splenomegaly (major diameter > 12 cm), platelet count less than 60 × 109/l, and white blood cell count less than 3.0 × 109/l according to the Barcelona Clinic Liver Cancer group criteria. Otherwise, radical gastrectomy was performed alone. Postoperative observations
The occurrence of postoperative complications including ascites, acute liver failure, anastomosis leakage, left inferior phrenic sepsis, pleural effusion, wound infection, and mortality was recorded for every patient. The postoperative Child–Pugh classification of every patient was re-evaluated. Statistical analysis
SPSS 13.0 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. Demographic and clinical data were described using medians (interquartile range) or frequencies. The χ2-test or Fisher’s exact test was used for the comparison of two items. Regression analysis was used to find the influencing factors. Overall survival was measured from the time of operation to the date of death or the latest follow-up. Survival curves were estimated using the Kaplan–Meier method and compared by means of the log-rank test. All statistical tests were assumed to reach statistical significance at P less than 0.05.
Results Patients’ characteristics
A total of 60 patients who underwent curative surgery for gastric cancer were enrolled in this study. Their baseline characteristics are summarized in Table 1. There were
Patients’ demographic findings according to the Child’s classification
Table 1
Characteristics
Child’s A (n = 30)
Age (years) ≤ 50 7 > 50 23 Sex Male 19 Female 11 Tumor stage I 4 II 19 III 7 Etiology of portal hypertension Hepatitis B virus 16 Alcohol 6 Schistosome 8 History of variceal bleeding Yes 9 No 21 White blood cell count (×109/l) < 3.0 12 ≥ 3.0 18 Platelet count (×109/l) ≤ 60 7 ≥ 60 23 Major diameter of spleen (cm) > 12 10 ≤ 12 20
Child’s B (n = 30)
P value
(23.3) (76.7)
8 (26.7) 22 (73.3)
NS
(63.3) (36.7)
22 (73.7) 8 (26.3)
NS
(13.3) (63.3) (23.4)
6 (20.0) 19 (63.3) 5 (16.7)
NS
(53.3) (20.0) (26.7)
30 (100.0) 0 (0.0) 0 (0.0)
< 0.001
(30.0) (70.0)
10 (33.3) 20 (66.7)
NS
(40.0) (60.0)
20 (66.7) 10 (33.3)
< 0.001
(23.3) (76.7)
12 (40.0) 18 (60.0)
< 0.001
(33.3) (66.7)
14 (46.7) 16 (53.3)
NS
41 (68.3%) male and 19 (31.7%) female patients with a median age of 50 years (range 39–62 years). Twenty (33.3%) of these patients were confirmed, by means of liver biopsy performed during operation, to have LC and the remaining 40 (66.7%) patients had been pathologically diagnosed before the operation. Thirty (50%) patients were classified into Child’s class A and 30 (50%) patients into Child’s class B. LC was related to hepatitis B virus infection in 46 (76.7%) patients and to alcohol abuse in six (10%). In the remaining eight patients, schistosome was the cause of cirrhosis. Esophageal or gastric varices were preoperatively identified in all patients, of whom 16 (26.7%) patients had mild varices, 24 (40%) patients had moderate varices, and 20 (33.3%) patients had severe varices. Among them, 19 (31.7%) patients had a history of variceal bleeding at least once. Patients’ demographic findings according to Child’s classification are summarized in Table 1. Surgical approaches
A total of 19 patients with Child’s A liver function underwent a standard radical gastrectomy with D2 lymph node dissection, whereas 15 patients with Child’s B liver function underwent a radical gastrectomy with D1 lymph node dissection. A total of 11 patients with Child’s A liver function and 15 patients with Child’s B liver function underwent gastric surgery with splenectomy and pericardial devascularization simultaneously (Table 2). The median operation time was 184 min (range 120–260 min), and the mean blood loss was 290 ml (range 100–800 ml).
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1350
European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 12
The surgical approaches of the patients according to Child’s classification
Table 2
Surgical approaches Radical gastrectomya Subtotal gastrectomy, D1 Subtotal gastrectomy, D2 Total gastrectomy, D1 Total gastrectomy, D2 Combined surgeryb Subtotal gastrectomy, D1, splenectomy and pericardial devascularization Subtotal gastrectomy, D2, splenectomy and pericardial devascularization Total gastrectomy, D1, splenectomy and pericardial devascularization Total gastrectomy, D2, splenectomy and pericardial devascularization
Child’s A (n = 30)
Child’s B (n = 30)
19 (63.3%) 0 17 0 2 11 (36.7%) 0
15 (50.0%) 14 0 1 0 15 (50.0%) 13
9
0
0
2
2
0
a
Gastrectomy with D1 or D2 lymph node dissection. Splenectomy and pericardial devascularization were performed simultaneously.
b
Postoperative liver function
Child’s classification was re-evaluated in each patient 1 week after operation. As compared with the preoperative Child’s score, 35 patients had a similar score after surgery. Meanwhile, the Child’s score in 25 patients deteriorated, among whom 10 patients dropped from Child’s A to Child’s B and 15 patients from Child’s B to Child’s C. In postoperative Child’s classification, 20 patients were in Child’s A, 25 in Child’s B, and 15 in Child’s C. Radical gastrectomy alone had no tremendous impact on postoperative liver function in Child’s B patients, similar to Child’s A patients. In patients undergoing splenectomy and pericardial devascularization simultaneously, those in Child’s B class displayed a more significant deteriorated liver function compared with those in Child’s A class (P < 0.001); meanwhile, such patients displayed a more significant deteriorated liver function compared with those who underwent radical gastrectomy alone, regardless of preoperative Child’s classification (P < 0.001) (Table 3). Perspective follow-up found no rupture of esophageal or gastric varices in any of the patients.
Postoperative complications
Among the 60 patients, 38 (63.3%) developed postoperative complications, including severe ascites, pleural effusion, acute liver failure, anastomosis leakage, wound infection, and left inferior phrenic sepsis. Two (3.3%) patients in stage III with Child’s B classification died in the perioperative period, among whom one died from severe ascites and acute liver failure and another from multiple organ failure due to postoperative anastomosis leakage. None of the patients with Child’s A died of complications in perioperative period. The incidence of acute liver failure, anastomosis leakage, wound infection, and left inferior phrenic sepsis between patients with Child’s A and those with Child’s B was not significantly different regardless of operative approaches. However, the incidence of severe ascites and pleural effusion in patients with Child’s B who underwent combined surgery was much higher than that of patients with Child’s A (P < 0.001). However, the incidence of severe ascites and pleural effusion did not differ between Child’s A and Child’s B patients who underwent radical gastrectomy alone (Table 4). In addition, patients undergoing combined surgery displayed more severe complications compared with those who underwent radical gastrectomy alone, regardless of preoperative Child’s classification (P < 0.001) (Table 4).
Factors influencing postoperative liver function
To find out the independent factors influencing the postoperative liver function, multivariate regression analysis was used. Age (>50 years), tumor stage, and simultaneous splenectomy and pericardial devascularization were demonstrated as independent risk factors for the deterioration of liver function (P < 0.05) (Table 5). Postoperative complications according to the Child’s classification and the surgical approaches
Table 4
n (%) Child’s A (n = 30)
Complications
Child’s B (n = 30)
P value
P valuea
b
Postoperative changes in liver function of the patients according to the Child’s classification and the surgical approaches
Table 3
n (%) Child’s A (n = 30)
Child’s B (n = 30)
P value
13 (86.7) 2 (13.3)
NS
P valuea
b
Radical gastrectomy Stable 16 (84.2) Deteriorated 3 (15.8) Combined surgeryc Stable 4 (36.4) Deteriorated 7 (63.6) a
2 (13.3) 13 (86.7)
< 0.001
< 0.001 < 0.001
Compared with its counterpart in the radical gastrectomy group. Gastrectomy with lymph node dissection. Splenectomy and pericardial devascularization were performed simultaneously; stable, Child’s score remained unchanged after surgery; deteriorated, Child’s score dropped after surgery.
b c
Radical gastrectomy Severe ascites Pleural effusion Acute liver failure Anastomotic leakage Wound infection Left inferior phrenic sepsis Combined surgeryc Severe ascites Pleural effusion Acute liver failure Anastomotic leakage Wound infection Left inferior phrenic sepsis
4 2 0 0 0 0
(21.1) (10.5) (0.0) (0.0) (0.0) (0.0)
3 2 0 2 1 0
(20.0) (13.3) (0.0) (13.3) (6.7) (0.0)
NS NS NS NS NS NS
4 3 0 1 1 0
(36.4) (27.3) (0.0) (9.1) (9.1) (0.0)
11 7 1 2 0 1
(73.3) (46.7) (6.7) (13.3) (0.0) (6.7)
< 0.001 < 0.001 NS NS NS NS
< 0.001 < 0.001 NS NS NS NS
a
Compared with its counterpart in the radical gastrectomy group. Gastrectomy with lymph node dissection. Splenectomy and pericardial devascularization were performed simultaneously.
b c
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gastric cancer with portal hypertension Zhang et al. 1351
Table 5
Independent factors influencing the deterioration of liver
As abdominal surgery in patients with LC often involves significant fatal complications and mortality has increased up to 30% [8,9], the management of patients with gastric cancer with LC inducing PHT remains a challenge. Recent advances in surgical techniques and postoperative management have reduced the morbidity and mortality associated with gastric cancer surgery. However, there had been limited studies revealing the outcomes of patients with PHT who underwent radical surgery for gastric cancer. In addition, whether the simultaneous management of PHT during gastric surgery for such patients was feasible remained controversial. This study was therefore designed to address these issues.
function Factors Age Tumor stage Management of PHTa
OR (95% CI)
P value
1.59 (1.21–1.71) 1.61 (1.11–1.94) 1.53 (1.17–1.98)
0.017 0.025 0.013
CI, confidence interval; OR, odds ratio; PHT, portal hypertension. a Splenectomy and pericardial devascularization were performed simultaneously.
The long-term outcomes of the patients
Except for two patients who died in the perioperative period, the other 58 patients were followed up as outpatients, among whom 21 patients died within 5 years – eight died of hepatic failure, seven of upper gastrointestinal bleeding, and six of recurrent gastric cancer. The survival time of patients undergoing combined surgery was significantly shorter than that of patients undergoing radical gastrectomy alone, regardless of preoperative Child’s classification (P
Original article
Outcomes of surgical approaches for gastric cancer with portal hypertension Zheng-Yun Zhang, Zun-Qiang Zhou and Guang-Wen Zhou Objective The influence of surgical approaches on patients with gastric cancer with portal hypertension is unknown. The aim of the study was to investigate the outcomes in such patients who had undergone curative surgery for gastric cancer.
independent risk factors for the deterioration of liver function (P < 0.05), and the survival time of patients undergoing simultaneous surgery for portal hypertension was significantly shorter than that of patients undergoing radical gastrectomy alone (P < 0.05).
Patients and methods The clinical data of 60 patients with portal hypertension undergoing curative surgery for gastric cancer or simultaneous surgery for portal hypertension were retrospectively analyzed.
Conclusion Individualized selection of surgical approaches for the treatment of gastric cancer with portal hypertension should be decided by preoperative liver function. Simultaneous management of portal hypertension was not advocated. Eur J Gastroenterol Hepatol 26:1348–1352 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Results Radical gastrectomy alone had no tremendous impact on postoperative liver function, but simultaneous surgery for portal hypertension affected patients’ liver function dramatically (P < 0.001). For those who underwent surgery for portal hypertension simultaneously, the incidence of complications on patients with Child’s B was much higher than that of patients with Child’s A (P < 0.001). However, the incidence of complications did not differ between Child’s A and Child’s B patients who underwent radical gastrectomy alone. In addition, patients undergoing simultaneous surgery for portal hypertension displayed more severe complications than did those who underwent radical gastrectomy alone (P < 0.001). Age, tumor stage, and simultaneous surgery for portal hypertension were the
Introduction Gastric cancer is one of the most frequently diagnosed cancers and the second most common cause of cancerrelated death worldwide [1]. Another major public health problem in China is liver cirrhosis (LC) caused by hepatitis B virus infection. Therefore, LC is not infrequently encountered among surgical candidates for gastric cancer [2]. A radical resection with D2 lymph node dissection is regarded as the standard surgical procedure for gastric cancer. However, LC is considered to be a terminal liver disease, and such an extended surgery is supposed to damage liver function severely and give rise to postoperative morbidity and mortality [3,4]. Therefore, the eradication of tumor and the change in hemodynamics of the portal system must be considered simultaneously during the treatment of gastric cancer with portal hypertension (PHT). Thus, a combined surgery (splenectomy and pericardial devascularization) was once performed by us. However, few reports have described surgical outcomes in patients with gastric cancer with PHT. In this study, we retrospectively analyzed 60 cases of patients who had undergone radical gastrectomy or 0954-691X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
European Journal of Gastroenterology & Hepatology 2014, 26:1348–1352 Keywords: gastric cancer, pericardial devascularization, portal hypertension, radical gastrectomy, splenectomy Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China Correspondence to Guang-Wen Zhou, PhD, MD, Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600, Yishan Road, 200233 Shanghai, China Tel: + 86 21 6436 9181; fax: + 86 21 6470 1361; e-mail: [email protected] Received 16 July 2014 Accepted 15 August 2014
combined surgery for gastric cancer with LC to explore the influence of surgical procedures on patients.
Patients and methods Patient selection
We reviewed the medical records of patients with LC who had undergone radical gastrectomy or combined surgery performed by our surgical team between January 2002 and January 2009. Patients with a previous history of abdominal surgery or other malignancies were excluded. This study was conducted in accordance with the Helsinki Declaration and was approved by the Ethics Committee of Shanghai Jiao Tong University. Informed consent was obtained from each patient. Diagnosis of liver cirrhosis and portal hypertension
A diagnosis of LC was made on the basis of clinical findings, abdominal sonogram, endoscopic features, laboratory parameters, or liver biopsy. In patients for whom a pathological diagnosis had not been made before the operation, cirrhosis was confirmed by liver biopsy performed during the operation. To assess the severity DOI: 10.1097/MEG.0000000000000213
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gastric cancer with portal hypertension Zhang et al. 1349
of LC, the Child–Turcotte–Pugh scoring system (Child’s classification) was used. The presence of esophageal–gastric varices, hypersplenism, variceal bleeding, or ascites indicates the presence of PHT. Postoperative mortality was defined as the deaths related to the operation. Severe ascites was defined as postoperative ascites of more than 500 ml per day passing through the drainage tube or needing paracentesis for ascites control. Surgical approaches
Radical gastrectomy was defined as resection with no apparent residual tumors. In such procedure, the degree of lymph node dissection was determined according to the Japanese Classification of Gastric Carcinoma. In D1 lymph node dissection, the perigastric lymph nodes were removed, whereas in D2 lymph node dissection lymph nodes along the common hepatic artery, the splenic artery, and around the celiac axis were also removed. For patients with need of concurrent operation (splenectomy and pericardial devascularization) for PHT along with the resection of gastric cancer, the following prerequisites were required: (a) patients in good condition, with no severe heart, lung, kidney, or other organ lesions; (b) ability to radically remove gastric lesions; (c) history of upper gastrointestinal bleeding in patients; (d) severe splenomegaly (major diameter > 12 cm), platelet count less than 60 × 109/l, and white blood cell count less than 3.0 × 109/l according to the Barcelona Clinic Liver Cancer group criteria. Otherwise, radical gastrectomy was performed alone. Postoperative observations
The occurrence of postoperative complications including ascites, acute liver failure, anastomosis leakage, left inferior phrenic sepsis, pleural effusion, wound infection, and mortality was recorded for every patient. The postoperative Child–Pugh classification of every patient was re-evaluated. Statistical analysis
SPSS 13.0 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. Demographic and clinical data were described using medians (interquartile range) or frequencies. The χ2-test or Fisher’s exact test was used for the comparison of two items. Regression analysis was used to find the influencing factors. Overall survival was measured from the time of operation to the date of death or the latest follow-up. Survival curves were estimated using the Kaplan–Meier method and compared by means of the log-rank test. All statistical tests were assumed to reach statistical significance at P less than 0.05.
Results Patients’ characteristics
A total of 60 patients who underwent curative surgery for gastric cancer were enrolled in this study. Their baseline characteristics are summarized in Table 1. There were
Patients’ demographic findings according to the Child’s classification
Table 1
Characteristics
Child’s A (n = 30)
Age (years) ≤ 50 7 > 50 23 Sex Male 19 Female 11 Tumor stage I 4 II 19 III 7 Etiology of portal hypertension Hepatitis B virus 16 Alcohol 6 Schistosome 8 History of variceal bleeding Yes 9 No 21 White blood cell count (×109/l) < 3.0 12 ≥ 3.0 18 Platelet count (×109/l) ≤ 60 7 ≥ 60 23 Major diameter of spleen (cm) > 12 10 ≤ 12 20
Child’s B (n = 30)
P value
(23.3) (76.7)
8 (26.7) 22 (73.3)
NS
(63.3) (36.7)
22 (73.7) 8 (26.3)
NS
(13.3) (63.3) (23.4)
6 (20.0) 19 (63.3) 5 (16.7)
NS
(53.3) (20.0) (26.7)
30 (100.0) 0 (0.0) 0 (0.0)
< 0.001
(30.0) (70.0)
10 (33.3) 20 (66.7)
NS
(40.0) (60.0)
20 (66.7) 10 (33.3)
< 0.001
(23.3) (76.7)
12 (40.0) 18 (60.0)
< 0.001
(33.3) (66.7)
14 (46.7) 16 (53.3)
NS
41 (68.3%) male and 19 (31.7%) female patients with a median age of 50 years (range 39–62 years). Twenty (33.3%) of these patients were confirmed, by means of liver biopsy performed during operation, to have LC and the remaining 40 (66.7%) patients had been pathologically diagnosed before the operation. Thirty (50%) patients were classified into Child’s class A and 30 (50%) patients into Child’s class B. LC was related to hepatitis B virus infection in 46 (76.7%) patients and to alcohol abuse in six (10%). In the remaining eight patients, schistosome was the cause of cirrhosis. Esophageal or gastric varices were preoperatively identified in all patients, of whom 16 (26.7%) patients had mild varices, 24 (40%) patients had moderate varices, and 20 (33.3%) patients had severe varices. Among them, 19 (31.7%) patients had a history of variceal bleeding at least once. Patients’ demographic findings according to Child’s classification are summarized in Table 1. Surgical approaches
A total of 19 patients with Child’s A liver function underwent a standard radical gastrectomy with D2 lymph node dissection, whereas 15 patients with Child’s B liver function underwent a radical gastrectomy with D1 lymph node dissection. A total of 11 patients with Child’s A liver function and 15 patients with Child’s B liver function underwent gastric surgery with splenectomy and pericardial devascularization simultaneously (Table 2). The median operation time was 184 min (range 120–260 min), and the mean blood loss was 290 ml (range 100–800 ml).
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1350
European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 12
The surgical approaches of the patients according to Child’s classification
Table 2
Surgical approaches Radical gastrectomya Subtotal gastrectomy, D1 Subtotal gastrectomy, D2 Total gastrectomy, D1 Total gastrectomy, D2 Combined surgeryb Subtotal gastrectomy, D1, splenectomy and pericardial devascularization Subtotal gastrectomy, D2, splenectomy and pericardial devascularization Total gastrectomy, D1, splenectomy and pericardial devascularization Total gastrectomy, D2, splenectomy and pericardial devascularization
Child’s A (n = 30)
Child’s B (n = 30)
19 (63.3%) 0 17 0 2 11 (36.7%) 0
15 (50.0%) 14 0 1 0 15 (50.0%) 13
9
0
0
2
2
0
a
Gastrectomy with D1 or D2 lymph node dissection. Splenectomy and pericardial devascularization were performed simultaneously.
b
Postoperative liver function
Child’s classification was re-evaluated in each patient 1 week after operation. As compared with the preoperative Child’s score, 35 patients had a similar score after surgery. Meanwhile, the Child’s score in 25 patients deteriorated, among whom 10 patients dropped from Child’s A to Child’s B and 15 patients from Child’s B to Child’s C. In postoperative Child’s classification, 20 patients were in Child’s A, 25 in Child’s B, and 15 in Child’s C. Radical gastrectomy alone had no tremendous impact on postoperative liver function in Child’s B patients, similar to Child’s A patients. In patients undergoing splenectomy and pericardial devascularization simultaneously, those in Child’s B class displayed a more significant deteriorated liver function compared with those in Child’s A class (P < 0.001); meanwhile, such patients displayed a more significant deteriorated liver function compared with those who underwent radical gastrectomy alone, regardless of preoperative Child’s classification (P < 0.001) (Table 3). Perspective follow-up found no rupture of esophageal or gastric varices in any of the patients.
Postoperative complications
Among the 60 patients, 38 (63.3%) developed postoperative complications, including severe ascites, pleural effusion, acute liver failure, anastomosis leakage, wound infection, and left inferior phrenic sepsis. Two (3.3%) patients in stage III with Child’s B classification died in the perioperative period, among whom one died from severe ascites and acute liver failure and another from multiple organ failure due to postoperative anastomosis leakage. None of the patients with Child’s A died of complications in perioperative period. The incidence of acute liver failure, anastomosis leakage, wound infection, and left inferior phrenic sepsis between patients with Child’s A and those with Child’s B was not significantly different regardless of operative approaches. However, the incidence of severe ascites and pleural effusion in patients with Child’s B who underwent combined surgery was much higher than that of patients with Child’s A (P < 0.001). However, the incidence of severe ascites and pleural effusion did not differ between Child’s A and Child’s B patients who underwent radical gastrectomy alone (Table 4). In addition, patients undergoing combined surgery displayed more severe complications compared with those who underwent radical gastrectomy alone, regardless of preoperative Child’s classification (P < 0.001) (Table 4).
Factors influencing postoperative liver function
To find out the independent factors influencing the postoperative liver function, multivariate regression analysis was used. Age (>50 years), tumor stage, and simultaneous splenectomy and pericardial devascularization were demonstrated as independent risk factors for the deterioration of liver function (P < 0.05) (Table 5). Postoperative complications according to the Child’s classification and the surgical approaches
Table 4
n (%) Child’s A (n = 30)
Complications
Child’s B (n = 30)
P value
P valuea
b
Postoperative changes in liver function of the patients according to the Child’s classification and the surgical approaches
Table 3
n (%) Child’s A (n = 30)
Child’s B (n = 30)
P value
13 (86.7) 2 (13.3)
NS
P valuea
b
Radical gastrectomy Stable 16 (84.2) Deteriorated 3 (15.8) Combined surgeryc Stable 4 (36.4) Deteriorated 7 (63.6) a
2 (13.3) 13 (86.7)
< 0.001
< 0.001 < 0.001
Compared with its counterpart in the radical gastrectomy group. Gastrectomy with lymph node dissection. Splenectomy and pericardial devascularization were performed simultaneously; stable, Child’s score remained unchanged after surgery; deteriorated, Child’s score dropped after surgery.
b c
Radical gastrectomy Severe ascites Pleural effusion Acute liver failure Anastomotic leakage Wound infection Left inferior phrenic sepsis Combined surgeryc Severe ascites Pleural effusion Acute liver failure Anastomotic leakage Wound infection Left inferior phrenic sepsis
4 2 0 0 0 0
(21.1) (10.5) (0.0) (0.0) (0.0) (0.0)
3 2 0 2 1 0
(20.0) (13.3) (0.0) (13.3) (6.7) (0.0)
NS NS NS NS NS NS
4 3 0 1 1 0
(36.4) (27.3) (0.0) (9.1) (9.1) (0.0)
11 7 1 2 0 1
(73.3) (46.7) (6.7) (13.3) (0.0) (6.7)
< 0.001 < 0.001 NS NS NS NS
< 0.001 < 0.001 NS NS NS NS
a
Compared with its counterpart in the radical gastrectomy group. Gastrectomy with lymph node dissection. Splenectomy and pericardial devascularization were performed simultaneously.
b c
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gastric cancer with portal hypertension Zhang et al. 1351
Table 5
Independent factors influencing the deterioration of liver
As abdominal surgery in patients with LC often involves significant fatal complications and mortality has increased up to 30% [8,9], the management of patients with gastric cancer with LC inducing PHT remains a challenge. Recent advances in surgical techniques and postoperative management have reduced the morbidity and mortality associated with gastric cancer surgery. However, there had been limited studies revealing the outcomes of patients with PHT who underwent radical surgery for gastric cancer. In addition, whether the simultaneous management of PHT during gastric surgery for such patients was feasible remained controversial. This study was therefore designed to address these issues.
function Factors Age Tumor stage Management of PHTa
OR (95% CI)
P value
1.59 (1.21–1.71) 1.61 (1.11–1.94) 1.53 (1.17–1.98)
0.017 0.025 0.013
CI, confidence interval; OR, odds ratio; PHT, portal hypertension. a Splenectomy and pericardial devascularization were performed simultaneously.
The long-term outcomes of the patients
Except for two patients who died in the perioperative period, the other 58 patients were followed up as outpatients, among whom 21 patients died within 5 years – eight died of hepatic failure, seven of upper gastrointestinal bleeding, and six of recurrent gastric cancer. The survival time of patients undergoing combined surgery was significantly shorter than that of patients undergoing radical gastrectomy alone, regardless of preoperative Child’s classification (P
