Unplanned reoperation after radical gastrectomy for gastric cancer: causes, risk factors, and long-term prognostic influence

Figures & data

Figure 1 Flowchart of patient selection.

Abbreviations: AJCC, American Joint Committee on Cancer; URO, unplanned reoperation.

Table 1 Intra-abdominal bleeding position, cause, and treatment

Position	Cases (%)	Mean interval days	Cause	Treatment	Outcome
Splenic artery	4 (19.0)	22.5	Technical failure or anastomotic leakage	Suture, TAE Suture and abdominal drainage	Two patients died of re-bleeding, two recovered
Superior pancreatic vessels	3 (14.2)	0.2	Technical failure	Suture	One patient re-bled, two recovered
Right gastroepiploic vessels	2 (9.5)	9.8	Technical failure or anastomotic leakage	Suture Suture and abdominal drainage	One patient re-bled, the other recovered
Gastroduodenal artery	2 (9.5)	9.5	Anastomotic leakage	Suture and abdominal drainage	One patient died of re-bleeding, one recovered
Transverse mesocolon vessels	1 (4.8)	0.8	Technical failure	Suture	Recovered
Right gastric artery	1 (4.8)	19	Abdominal infection	Suture and abdominal drainage	Re-bled
Spleen	1 (4.8)	4	Technical failure	Splenectomy	Recovered
Abdominal wall muscle	1 (4.8)	8	Technical failure	Suture	Recovered
Gastric wall	1 (4.8)	20	Gastric necrosis	Gastrectomy	Recovered
Unidentified	5 (23.8)	4.5	Technical failure	Suture	Two patients re-bled, three recovered
Total	21 (100.0)	9.7	–	–	–

Note: Mean interval days: the time between the first operation and the unplanned reoperation.

Abbreviation: TAE, transcatheter arterial embolization.

Table 2 Univariate analysis of potential influencing factors for URO

Variables	Non-URO group (n, %)	URO group (n, %)	P-value
Gender			0.005*
Male	2,068 (73.5)	36 (92.3)
Female	745 (26.5)	3 (7.7)
Age (years)			0.088
<60	972 (34.6)	8 (20.5)
≥60	1,841 (65.4)	31 (79.5)
BMI (kg/m^2)			0.094
≤25	2,315 (82.3)	28 (71.8)
>25	498 (17.7)	11 (28.2)
Concomitant diseases			0.700
No	2,174 (77.3)	29 (74.4)
Yes	639 (22.7)	10 (25.6)
Diabetes			0.010*
No	2,680 (95.3)	33 (84.7)
Yes	133 (4.7)	6 (15.3)
Preoperative hypoproteinemia			0.035*
No	2,500 (88.9)	30 (76.9)
Yes	313 (11.1)	9 (23.1)
Preoperative anemia			0.424
No	1,256 (44.6)	20 (51.3)
Yes	1,557 (55.4)	19 (48.7)
Tumor size (cm)			0.480
≤5.0	1,986 (70.6)	30 (76.9)
>5.0	827 (29.4)	9 (23.1)
Type of reconstruction			0.146
Roux-en-Y	979 (34.8)	19 (48.7)
Billroth-I	552 (19.6)	3 (7.7)
Billroth-II	991 (35.2)	12 (30.8)
Esophagogastrostomy	291 (10.4)	5 (12.8)
Type of surgical resection			0.120
Total	979 (34.8)	19 (48.7)
Distal	1,543 (54.8)	15 (38.5)
Proximate	291 (10.4)	5 (12.8)
Surgical approach			0.236
Open	2,234 (79.4)	28 (71.8)
Laparoscopic	579 (20.6)	11 (28.2)
Combined organ resection			0.648
No	2,714 (96.5)	37 (94.9)
Yes	99 (3.5)	2 (5.1)
Neoadjuvant chemotherapy			0.262
No	1,270 (45.1)	14 (35.9)
Yes	1,543 (54.9)	25 (64.1)
AJCC stage			0.130
I	210 (7.5)	4 (10.3)
II	762 (27.1)	5 (12.8)
III	1,841 (65.4)	30 (76.9)

Notes:

* P < 0.05. Fisher’s exact test was used to calculate the P-value.

Abbreviations: URO, unplanned reoperation; BMI, body mass index; AJCC, American Joint Committee on Cancer.

Table 3 Multivariate logistic regression analysis of risk factors for URO

Variables	Multivariate logistic regression analysis
	OR	95% CI	P-value
Gender	4.630	1.412–15.152	0.011*
Age	1.367	0.452–4.136	0.579
BMI	1.409	0.485–4.095	0.529
Concomitant diseases	1.540	0.480–4.941	0.467
Diabetes	4.189	1.705–10.290	0.002*
Preoperative hypoproteinemia	2.305	1.079–4.923	0.031*
Preoperative anemia	0.798	0.334–1.903	0.611
Tumor size	1.357	0.423–4.355	0.608
Type of reconstruction	1.046	0.230–4.765	0.954
Type of surgical resection	0.465	0.180–1.201	0.114
Surgical approach	0.935	0.345–2.533	0.896
Combined organ resection	0.856	0.233–3.143	0.814
Neoadjuvant chemotherapy	1.387	0.153–12.566	0.771
Postoperative AJCC stage	1.461	0.356–6.002	0.599

* Note: P < 0.05.

Abbreviations: URO, unplanned reoperation; BMI, body mass index; AJCC, American Joint Committee on Cancer.

Table 4 Early surgical outcomes for patients with or without URO

Parameters	Non-URO group (n = 2,813)	URO group (n = 39)	P-value
Hospital stay (days)	15.52 ± 6.16	35.03 ± 14.85	<0.001*
Postoperative complications	423 (15.0%)a	19 (48.7%)b	<0.001*
Mortality rate	6 (0.2%)a	5 (12.8%)b	<0.001*

* Notes: P < 0.05.

a Parameters in the non-URO group refer to data after the initial operation.

b Parameters in the URO group refer to data after the second operation.

Abbreviation: URO, unplanned reoperation.

Figure 2 Kaplan–Meier curves for cancer-specific survival.

Abbreviation: URO, unplanned reoperation.

Table 5 Prognostic factors for cancer-specific survival after curative gastric cancer resection in univariate and multivariable analyses

Prognostic factors	Cancer-specific survival
	Univariate			Multivariate
	Log-rank	P-value	HR	95% CI	P-value
URO
No	1.193	0.275	1.683	0.923–3.071	0.090
Yes
Gender
Female	0.200	0.655	0.853	0.460–1.852	0.615
Male
Age (years)
<60	0.822	0.365	1.049	0.585–1.882	0.873
≥60
BMI
≤25	1.032	0.310	1.187	0.681–2.067	0.546
>25
Concomitant diseases
No	0.147	0.701	0.979	0.523–1.833	0.947
Yes
Diabetes
No	0.656	0.418	0.718	0.272–1.892	0.502
Yes
Preoperative hypoproteinemia
No	4.757	0.029*	1.831	1.126–2.978	0.015*
Yes
Anemia
No	3.650	0.056	1.415	0.878–2.281	0.153
Yes
Tumor size (cm)
<5	0.016	0.900	0.978	0.533–1.793	0.942
≥5
AJCC stage
I	17.920	<0.001*	Reference
II			2.575	0.631–10.510	0.187
III			7.004	2.130–23.034	0.001*
Surgical approach
Open	2.522	0.118	0.893	0.549–1.454	0.649
Laparoscopic
Type of reconstruction
Billroth-I	0.023	0.878	0.716	0.420–1.219	0.219
Billroth-II
Roux-en-Y
Esophagogastrostomy
Combined organ resection
No	1.481	0.224	0.311	0.038–2.526	0.274
Yes

Note:

* P < 0.05.

Abbreviations: URO, unplanned reoperation; BMI, body mass index; AJCC, American Joint Committee on Cancer.