Skip to main content
Top
Published in: Journal of Gastrointestinal Surgery 9/2016

01-09-2016 | Original Article

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Authors: Allison N. Martin, Deepanjana Das, Florence E. Turrentine, Todd W. Bauer, Reid B. Adams, Victor M. Zaydfudim

Published in: Journal of Gastrointestinal Surgery | Issue 9/2016

Login to get access

Abstract

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01–1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35–2.02, p < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31–2.03, p < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29–1.97, p < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10–3.13, p < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00–1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99–1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p < 0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.
Appendix
Available only for authorised users
Literature
1.
go back to reference Lucas DJ, Pawlik TM. Quality improvement in gastrointestinal surgical oncology with American College of Surgeons National Surgical Quality Improvement Program. Surgery. 2014;155(4):593–601.CrossRefPubMed Lucas DJ, Pawlik TM. Quality improvement in gastrointestinal surgical oncology with American College of Surgeons National Surgical Quality Improvement Program. Surgery. 2014;155(4):593–601.CrossRefPubMed
2.
go back to reference Day RW, Badgwell BD, Fournier KF, Mansfield PF, Aloia TA. Defining the Impact of Surgical Approach on Perioperative Outcomes for Patients with Gastric Cardia Malignancy. J Gastrointest Surg. 2016;20(1):146–53.CrossRefPubMed Day RW, Badgwell BD, Fournier KF, Mansfield PF, Aloia TA. Defining the Impact of Surgical Approach on Perioperative Outcomes for Patients with Gastric Cardia Malignancy. J Gastrointest Surg. 2016;20(1):146–53.CrossRefPubMed
3.
go back to reference Cloyd JM, Ma Y, Morton JM, Kurella Tamura M, Poultsides GA, Visser BC. Does chronic kidney disease affect outcomes after major abdominal surgery? Results from the National Surgical Quality Improvement Program. J Gastrointest Surg. 2014;18(3):605–12.CrossRefPubMed Cloyd JM, Ma Y, Morton JM, Kurella Tamura M, Poultsides GA, Visser BC. Does chronic kidney disease affect outcomes after major abdominal surgery? Results from the National Surgical Quality Improvement Program. J Gastrointest Surg. 2014;18(3):605–12.CrossRefPubMed
4.
go back to reference Kohut AY, Liu JJ, Stein DE, Sensenig R, Poggio JL. Patient-specific risk factors are predictive for postoperative adverse events in colorectal surgery: an American College of Surgeons National Surgical Quality Improvement Program-based analysis. Am J Surg. 2015;209(2):219–29.CrossRefPubMed Kohut AY, Liu JJ, Stein DE, Sensenig R, Poggio JL. Patient-specific risk factors are predictive for postoperative adverse events in colorectal surgery: an American College of Surgeons National Surgical Quality Improvement Program-based analysis. Am J Surg. 2015;209(2):219–29.CrossRefPubMed
5.
go back to reference Epelboym I, Gawlas I, Lee JA, Schrope B, Chabot JA, Allendorf JD. Limitations of ACS-NSQIP in reporting complications for patients undergoing pancreatectomy: underscoring the need for a pancreas-specific module. World J Surg. 2014;38(6):1461–7.CrossRefPubMed Epelboym I, Gawlas I, Lee JA, Schrope B, Chabot JA, Allendorf JD. Limitations of ACS-NSQIP in reporting complications for patients undergoing pancreatectomy: underscoring the need for a pancreas-specific module. World J Surg. 2014;38(6):1461–7.CrossRefPubMed
6.
go back to reference Turrentine FE, Denlinger CE, Simpson VB, Garwood RA, Guerlain S, Agrawal A, et al. Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg. 2015;220(2):195–206.CrossRefPubMed Turrentine FE, Denlinger CE, Simpson VB, Garwood RA, Guerlain S, Agrawal A, et al. Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg. 2015;220(2):195–206.CrossRefPubMed
7.
go back to reference Merchant SJ, Ituarte PH, Choi A, Sun V, Chao J, Lee B, et al. Hospital Readmission Following Surgery for Gastric Cancer: Frequency, Timing, Etiologies, and Survival. J Gastrointest Surg. 2015;19(10):1769–81.CrossRefPubMed Merchant SJ, Ituarte PH, Choi A, Sun V, Chao J, Lee B, et al. Hospital Readmission Following Surgery for Gastric Cancer: Frequency, Timing, Etiologies, and Survival. J Gastrointest Surg. 2015;19(10):1769–81.CrossRefPubMed
8.
go back to reference Papenfuss WA, Kukar M, Oxenberg J, Attwood K, Nurkin S, Malhotra U, et al. Morbidity and mortality associated with gastrectomy for gastric cancer. Ann Surg Oncol. 2014;21(9):3008–14.CrossRefPubMed Papenfuss WA, Kukar M, Oxenberg J, Attwood K, Nurkin S, Malhotra U, et al. Morbidity and mortality associated with gastrectomy for gastric cancer. Ann Surg Oncol. 2014;21(9):3008–14.CrossRefPubMed
9.
go back to reference Selby LV, Vertosick EA, Sjoberg DD, Schattner MA, Janjigian YY, Brennan MF, et al. Morbidity after Total Gastrectomy: Analysis of 238 Patients. J Am Coll Surg. 2015;220(5):863–71 e2.CrossRefPubMedPubMedCentral Selby LV, Vertosick EA, Sjoberg DD, Schattner MA, Janjigian YY, Brennan MF, et al. Morbidity after Total Gastrectomy: Analysis of 238 Patients. J Am Coll Surg. 2015;220(5):863–71 e2.CrossRefPubMedPubMedCentral
10.
go back to reference Ahmad R, Schmidt BH, Rattner DW, Mullen JT. Factors influencing readmission after curative gastrectomy for gastric cancer. J Am Coll Surg. 2014;218(6):1215–22.CrossRefPubMed Ahmad R, Schmidt BH, Rattner DW, Mullen JT. Factors influencing readmission after curative gastrectomy for gastric cancer. J Am Coll Surg. 2014;218(6):1215–22.CrossRefPubMed
11.
go back to reference Jeong O, Ryu SY, Choi WY, Piao Z, Park YK. Risk factors and learning curve associated with postoperative morbidity of laparoscopic total gastrectomy for gastric carcinoma. Ann Surg Oncol. 2014;21(9):2994–3001.CrossRefPubMed Jeong O, Ryu SY, Choi WY, Piao Z, Park YK. Risk factors and learning curve associated with postoperative morbidity of laparoscopic total gastrectomy for gastric carcinoma. Ann Surg Oncol. 2014;21(9):2994–3001.CrossRefPubMed
12.
go back to reference Newhook TE, LaPar DJ, Lindberg JM, Bauer TW, Adams RB, Zaydfudim VM. Morbidity and mortality of pancreaticoduodenectomy for benign and premalignant pancreatic neoplasms. J Gastrointest Surg. 2015;19(6):1072–7.CrossRefPubMed Newhook TE, LaPar DJ, Lindberg JM, Bauer TW, Adams RB, Zaydfudim VM. Morbidity and mortality of pancreaticoduodenectomy for benign and premalignant pancreatic neoplasms. J Gastrointest Surg. 2015;19(6):1072–7.CrossRefPubMed
13.
go back to reference Newhook TE, LaPar DJ, Lindberg JM, Bauer TW, Adams RB, Zaydfudim VM. Morbidity and mortality of hepatectomy for benign liver tumors. Am J Surg. 2016;211(1):102–8.CrossRefPubMed Newhook TE, LaPar DJ, Lindberg JM, Bauer TW, Adams RB, Zaydfudim VM. Morbidity and mortality of hepatectomy for benign liver tumors. Am J Surg. 2016;211(1):102–8.CrossRefPubMed
14.
go back to reference Kim MC, Kim KH, Jung GJ. A 5 year analysis of readmissions after radical subtotal gastrectomy for early gastric cancer. Ann Surg Oncol. 2012;19(8):2459–64.CrossRefPubMed Kim MC, Kim KH, Jung GJ. A 5 year analysis of readmissions after radical subtotal gastrectomy for early gastric cancer. Ann Surg Oncol. 2012;19(8):2459–64.CrossRefPubMed
15.
go back to reference Zhuang CL, Wang SL, Huang DD, Pang WY, Lou N, Chen BC, et al. Risk factors for hospital readmission after radical gastrectomy for gastric cancer: a prospective study. PLoS One. 2015;10(4):e0125572.CrossRefPubMedPubMedCentral Zhuang CL, Wang SL, Huang DD, Pang WY, Lou N, Chen BC, et al. Risk factors for hospital readmission after radical gastrectomy for gastric cancer: a prospective study. PLoS One. 2015;10(4):e0125572.CrossRefPubMedPubMedCentral
16.
go back to reference Migita K, Takayama T, Matsumoto S, Wakatsuki K, Enomoto K, Tanaka T, et al. Risk factors for surgical site infections after elective gastrectomy. J Gastrointest Surg. 2012;16(6):1107–15.CrossRefPubMed Migita K, Takayama T, Matsumoto S, Wakatsuki K, Enomoto K, Tanaka T, et al. Risk factors for surgical site infections after elective gastrectomy. J Gastrointest Surg. 2012;16(6):1107–15.CrossRefPubMed
17.
go back to reference Andreou A, Biebl M, Dadras M, Struecker B, Sauer IM, Thuss-Patience PC, et al. Anastomotic leak predicts diminished long-term survival after resection for gastric and esophageal cancer. Surgery. 2016. Andreou A, Biebl M, Dadras M, Struecker B, Sauer IM, Thuss-Patience PC, et al. Anastomotic leak predicts diminished long-term survival after resection for gastric and esophageal cancer. Surgery. 2016.
18.
go back to reference Sierzega M, Kolodziejczyk P, Kulig J, Polish Gastric Cancer Study G. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg. 2010;97(7):1035–42.CrossRef Sierzega M, Kolodziejczyk P, Kulig J, Polish Gastric Cancer Study G. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg. 2010;97(7):1035–42.CrossRef
19.
go back to reference Samples JE, Snavely AC, Meyers MO. Postoperative Morbidity in Curative Resection of Gastroesophageal Carcinoma Does Not Impact Long-term Survival. Am Surg. 2015;81(12):1228–31.PubMed Samples JE, Snavely AC, Meyers MO. Postoperative Morbidity in Curative Resection of Gastroesophageal Carcinoma Does Not Impact Long-term Survival. Am Surg. 2015;81(12):1228–31.PubMed
20.
go back to reference Doglietto GB, Papa V, Tortorelli AP, Bossola M, Covino M, Pacelli F, et al. Nasojejunal tube placement after total gastrectomy: a multicenter prospective randomized trial. Arch Surg. 2004;139(12):1309–13; discussion 13.CrossRefPubMed Doglietto GB, Papa V, Tortorelli AP, Bossola M, Covino M, Pacelli F, et al. Nasojejunal tube placement after total gastrectomy: a multicenter prospective randomized trial. Arch Surg. 2004;139(12):1309–13; discussion 13.CrossRefPubMed
21.
go back to reference Dhungel B, Diggs BS, Hunter JG, Sheppard BC, Vetto JT, Dolan JP. Patient and peri-operative predictors of morbidity and mortality after esophagectomy: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005–2008. J Gastrointest Surg. 2010;14(10):1492–501.CrossRefPubMed Dhungel B, Diggs BS, Hunter JG, Sheppard BC, Vetto JT, Dolan JP. Patient and peri-operative predictors of morbidity and mortality after esophagectomy: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005–2008. J Gastrointest Surg. 2010;14(10):1492–501.CrossRefPubMed
22.
go back to reference Jeong O, Park YK, Ryu SY. Early experience of duet laparoscopic distal gastrectomy (duet-LDG) using three abdominal ports for gastric carcinoma: surgical technique and comparison with conventional laparoscopic distal gastrectomy. Surg Endosc. 2015. doi:10.1007/s00464-015-4653-4. Jeong O, Park YK, Ryu SY. Early experience of duet laparoscopic distal gastrectomy (duet-LDG) using three abdominal ports for gastric carcinoma: surgical technique and comparison with conventional laparoscopic distal gastrectomy. Surg Endosc. 2015. doi:10.​1007/​s00464-015-4653-4.
23.
go back to reference Lee JH, Nam BH, Ryu KW, Ryu SY, Kim YW, Park YK, et al. Comparison of the long-term results of patients who underwent laparoscopy versus open distal gastrectomy. Surg Endosc. 2015. doi:10.1007/s00464-015-4215-9. Lee JH, Nam BH, Ryu KW, Ryu SY, Kim YW, Park YK, et al. Comparison of the long-term results of patients who underwent laparoscopy versus open distal gastrectomy. Surg Endosc. 2015. doi:10.​1007/​s00464-015-4215-9.
24.
go back to reference Bo T, Peiwu Y, Feng Q, Yongliang Z, Yan S, Yingxue H, et al. Laparoscopy-assisted vs. open total gastrectomy for advanced gastric cancer: long-term outcomes and technical aspects of a case–control study. J Gastrointest Surg. 2013;17(7):1202–8.CrossRefPubMed Bo T, Peiwu Y, Feng Q, Yongliang Z, Yan S, Yingxue H, et al. Laparoscopy-assisted vs. open total gastrectomy for advanced gastric cancer: long-term outcomes and technical aspects of a case–control study. J Gastrointest Surg. 2013;17(7):1202–8.CrossRefPubMed
25.
go back to reference Kurita N, Miyata H, Gotoh M, Shimada M, Imura S, Kimura W, et al. Risk Model for Distal Gastrectomy When Treating Gastric Cancer on the Basis of Data From 33,917 Japanese Patients Collected Using a Nationwide Web-based Data Entry System. Ann Surg. 2015;262(2):295–303.CrossRefPubMed Kurita N, Miyata H, Gotoh M, Shimada M, Imura S, Kimura W, et al. Risk Model for Distal Gastrectomy When Treating Gastric Cancer on the Basis of Data From 33,917 Japanese Patients Collected Using a Nationwide Web-based Data Entry System. Ann Surg. 2015;262(2):295–303.CrossRefPubMed
26.
go back to reference Yoshikawa T, Cho H, Rino Y, Yamamoto Y, Kimura M, Fukunaga T, et al. A prospective feasibility and safety study of laparoscopy-assisted distal gastrectomy for clinical stage I gastric cancer initiated by surgeons with much experience of open gastrectomy and laparoscopic surgery. Gastric Cancer. 2013;16(2):126–32.CrossRefPubMed Yoshikawa T, Cho H, Rino Y, Yamamoto Y, Kimura M, Fukunaga T, et al. A prospective feasibility and safety study of laparoscopy-assisted distal gastrectomy for clinical stage I gastric cancer initiated by surgeons with much experience of open gastrectomy and laparoscopic surgery. Gastric Cancer. 2013;16(2):126–32.CrossRefPubMed
27.
go back to reference Hu Y, Huang C, Sun Y, Su X, Cao H, Hu J, et al. Morbidity and Mortality of Laparoscopic Versus Open D2 Distal Gastrectomy for Advanced Gastric Cancer: A Randomized Controlled Trial. J Clin Oncol. 2016;34(12):1350–7.CrossRefPubMed Hu Y, Huang C, Sun Y, Su X, Cao H, Hu J, et al. Morbidity and Mortality of Laparoscopic Versus Open D2 Distal Gastrectomy for Advanced Gastric Cancer: A Randomized Controlled Trial. J Clin Oncol. 2016;34(12):1350–7.CrossRefPubMed
28.
go back to reference Imamura H, Takiguchi S, Yamamoto K, Hirao M, Fujita J, Miyashiro I, et al. Morbidity and mortality results from a prospective randomized controlled trial comparing Billroth I and Roux-en-Y reconstructive procedures after distal gastrectomy for gastric cancer. World J Surg. 2012;36(3):632–7.CrossRefPubMed Imamura H, Takiguchi S, Yamamoto K, Hirao M, Fujita J, Miyashiro I, et al. Morbidity and mortality results from a prospective randomized controlled trial comparing Billroth I and Roux-en-Y reconstructive procedures after distal gastrectomy for gastric cancer. World J Surg. 2012;36(3):632–7.CrossRefPubMed
29.
go back to reference Tran TB, Worhunsky DJ, Squires MH, Jin LX, Spolverato G, Votanopoulos KI, et al. To Roux or not to Roux: a comparison between Roux-en-Y and Billroth II reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer. 2016;19(3):994–1001. Tran TB, Worhunsky DJ, Squires MH, Jin LX, Spolverato G, Votanopoulos KI, et al. To Roux or not to Roux: a comparison between Roux-en-Y and Billroth II reconstruction following partial gastrectomy for gastric cancer. Gastric Cancer. 2016;19(3):994–1001.
30.
go back to reference Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet. 1996;347(9007):995–9.PubMed Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet. 1996;347(9007):995–9.PubMed
31.
go back to reference Higgins RM, Kubasiak JC, Jacobson RA, Janssen I, Myers JA, Millikan KW, et al. Outcomes and Use of Laparoscopic Versus Open Gastric Resection. JSLS. 2015;19(4):e2015.00095. Higgins RM, Kubasiak JC, Jacobson RA, Janssen I, Myers JA, Millikan KW, et al. Outcomes and Use of Laparoscopic Versus Open Gastric Resection. JSLS. 2015;19(4):e2015.00095.
32.
go back to reference Jung KH, Kim SM, Choi MG, Lee JH, Noh JH, Sohn TS, et al. Preoperative smoking cessation can reduce postoperative complications in gastric cancer surgery. Gastric Cancer. 2015;18(4):683–90.CrossRefPubMed Jung KH, Kim SM, Choi MG, Lee JH, Noh JH, Sohn TS, et al. Preoperative smoking cessation can reduce postoperative complications in gastric cancer surgery. Gastric Cancer. 2015;18(4):683–90.CrossRefPubMed
33.
go back to reference Squires MH, 3rd, Kooby DA, Poultsides GA, Weber SM, Bloomston M, Fields RC, et al. Effect of Perioperative Transfusion on Recurrence and Survival after Gastric Cancer Resection: A 7-Institution Analysis of 765 Patients from the US Gastric Cancer Collaborative. J Am Coll Surg. 2015;221(3):767–77.CrossRefPubMed Squires MH, 3rd, Kooby DA, Poultsides GA, Weber SM, Bloomston M, Fields RC, et al. Effect of Perioperative Transfusion on Recurrence and Survival after Gastric Cancer Resection: A 7-Institution Analysis of 765 Patients from the US Gastric Cancer Collaborative. J Am Coll Surg. 2015;221(3):767–77.CrossRefPubMed
34.
go back to reference Kim W, Kim HH, Han SU, Kim MC, Hyung WJ, Ryu SW, et al. Decreased Morbidity of Laparoscopic Distal Gastrectomy Compared With Open Distal Gastrectomy for Stage I Gastric Cancer: Short-term Outcomes From a Multicenter Randomized Controlled Trial (KLASS-01). Ann Surg. 2016;263(1):28–35.CrossRefPubMed Kim W, Kim HH, Han SU, Kim MC, Hyung WJ, Ryu SW, et al. Decreased Morbidity of Laparoscopic Distal Gastrectomy Compared With Open Distal Gastrectomy for Stage I Gastric Cancer: Short-term Outcomes From a Multicenter Randomized Controlled Trial (KLASS-01). Ann Surg. 2016;263(1):28–35.CrossRefPubMed
35.
go back to reference Vinuela EF, Gonen M, Brennan MF, Coit DG, Strong VE. Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann Surg. 2012;255(3):446–56.CrossRefPubMed Vinuela EF, Gonen M, Brennan MF, Coit DG, Strong VE. Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann Surg. 2012;255(3):446–56.CrossRefPubMed
Metadata
Title
Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors
Authors
Allison N. Martin
Deepanjana Das
Florence E. Turrentine
Todd W. Bauer
Reid B. Adams
Victor M. Zaydfudim
Publication date
01-09-2016
Publisher
Springer US
Published in
Journal of Gastrointestinal Surgery / Issue 9/2016
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI
https://doi.org/10.1007/s11605-016-3195-y

Other articles of this Issue 9/2016

Journal of Gastrointestinal Surgery 9/2016 Go to the issue