Aorta Calcification Increases the Risk of Anastomotic Leakage After Gastrectomy in Gastric Cancer Patients

Figures & data

Figure 1 Inclusion criteria and exclusion criteria of patients who underwent gastrectomy.

Table 1 Definitions of Arterial Calcification on Preoperative CT Images

Artery	Score 0	Score 1	Score 2
Aorta*	Absent	Minor calcifications: ≤ 9 foci and ≤ 3 foci extending over ≥ 3 sections	Major calcifications: > 9 foci and > 3 foci extending over ≥ 3 sections
Celiac axis	Absent	Minor calcifications: Extending over < 3 sections or MCSD of single focus ≤ 10mm	Major calcifications: Extending over ≥ 3 sections and MCSD of single focus ≥ 10 mm or involving both the proximal (aortoceliac) and distal (hepatosplenic bifurcation) parts
Left postceliac arteries†	Absent	≥ 1 calcification	Not applicable
Right postceliac arteries‡	Absent	≥ 1 calcification	Not applicable

Notes: *Aorta defined as descending part of thoracic aorta and abdominal part of aorta above celiac level; † right postceliac arteries defined as common hepatic artery, gastroduodenal artery, and right gastroepiploic artery; ‡ left postceliac arteries defined as splenic artery and left gastroepiploic artery; MCSD, maximum cross-sectional diameter. Table was adapted with permission from van Rossum PS, Haverkamp L, Verkooijen HM et al Calcification of arteries supplying the gastric tube: a new risk factor for anastomotic leakage after esophageal surgery. Radiology. 2015; 274(1): 124–132. ¹³

Figure 2 Examples of calcification on preoperative CT images in patients with gastric cancer. (A) Image showing the descending aorta with a plaque and calcified foci (arrow). (B) Image showing calcification of the celiac axis (arrow). (C) Image showing calcification of the splenic artery (arrow). (D) Image showing calcification of the common hepatic artery (arrow). A calcification score of 1 was assigned to the above four images.

Table 2 Baseline Characteristics

Characteristics	Anastomotic Leakage (n=38)	Nonanastomotic Leakage (n=818)	P value
Sex			0.537
Male	30	601
Female	8	217
Age (year)	62.6 ± 9.8	59.2 ± 10.7	0.053
BMI (kg/m^2)	23.0 ± 3.7	22.2 ± 3.1	0.114
ASA			0.343
1	32	677
2	6	102
3	0	39
COPD			1.000
Yes	0	17
No	38	801
Diabetes mellitus			1.000
Yes	2	45
No	36	773
Smoking			0.512
Yes	22	427
No	16	391
Drinking			0.867
Yes	21	469
No	17	349
Coronary artery disease			0.356
Yes	2	26
No	36	792
Hypertension			0.011*
Yes	11	102
No	27	716
Renal insufficiency			1.000
Yes	0	4
No	38	814
Peripheral vascular disease			1.000
Yes	0	9
No	38	809

Notes: Variables are expressed as the mean ± SD, *P-value <0.05.

Abbreviations: BMI, body mass index; ASA, the American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease.

Table 3 Surgical Information

Characteristics	Anastomotic Leakage (n=38)	Nonanastomotic Leakage (n=818)	P value
Approach			0.012*
Open	6	39
Laparoscopic	32	779
Procedure			0.523
Total gastrectomy	8	210
Subtotal gastrectomy	30	608
Combined organ resection			1.000
Yes	0	20
No	38	798
Operation time (minutes)	210.3 ± 65.3	219.5 ± 64.0	0.387
Estimated blood loss (mL)	123.2 ± 89.9	167.0 ± 377.2	0.475
Transfusion			0.765
Yes	2	76
No	36	742
Retrieved lymph nodes	22.3 ± 9.7	22.1 ± 9.6	0.853
Type of anastomosis			0.321
B-I	22	374
B-II	6	187
R-Y	10	257
TNM stage			0.518
I	15	240
II	5	144
III	18	424
IV	0	10
Postoperative length of stay (day)	27.4 ± 17.0	11.4 ± 5.4	0.000*

Notes: Variables are expressed as the mean ± SD, *P-value <0.05.

Abbreviations: B-I, Billroth I reconstruction; B-II, Billroth II reconstruction; R-Y, Roux-en-Y reconstruction; TNM, tumor-node-metastasis.

Table 4 Calcification Score of Patients with/without Anastomotic Leakage

Artery	Anastomotic Leakage (n=38)	Nonanastomotic Leakage (n=818)	P value
Aorta			0.000*
0	16	559
1	19	182
2	3	77
Celiac axis
0	26	664	0.000*
1	12	154
2	0	0
Left postceliac arteries			0.541
0	37	802
1	1	16
Right postceliac arteries			0.422
0	37	807
1	1	11

Note: *P-value <0.05.

Table 5 Multivariate Logistic Regression Analysis Revealed Independent Factors Associated with Anastomotic Leakage

Variable	OR	95% CI	P value
Aorta calcification (1 and 2 VS 0)	2.425	1.095–5.491	0.029*
Celiac axis calcification (1 VS 0)	1.024	0.443–2.365	0.956
Hypertension (yes VS no)	1.511	0.657–3.476	0.331
Surgical approach (open VS laparoscopic)	2.672	0.985–7.244	0.053
Age	1.005	0.968–1.043	0.799
BMI	1.075	0.971–1.190	0.166

Note: *P-value <0.05.

van Rossum PSN , Haverkamp L , Verkooijen HM , van Leeuwen MS , van Hillegersberg R , Ruurda JP . Calcification of arteries supplying the gastric tube: a new risk factor for anastomotic leakage after esophageal surgery. Radiology . 2015;274(1):124–132. doi:10.1148/radiol.14140410 25119021

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