From April 2009 to April 2019, a total of 398 patients with gastric cancer received curative total gastrectomy combined with D2 lymph node dissection in our unit. Two patients who had duodenal stump leakage and a gastric stromal tumor, respectively, were excluded from the study. Two patients who had positive proximal margins, and four patients who had missing data were also excluded in this study; thus, 390 patients remained eligible for analysis.
The reconstruction method employed after total gastrectomy was the Roux-en-Y esophagojejunostomy. All esophagojejunal anastomoses were performed with a circular stapler. A suitably sized stapler for the esophageal and jejunal lumen was chosen at the surgeon’s discretion. The integrity of the ring of the tissue that was retained by the circular stapler after accomplishment of the anastomosis was also examined. Finally, additional sutures were applied at large to reinforce the anastomosis.
Definitions and variables
The diagnosis of EJAL mainly relies on radiological and/or clinical findings. Contrast upper gastrointestinal angiography was routinely carried out for all patients after a median of six postoperative days in our unit, being feasible and low cost for patients. Radiological leakage was defined as a transudation outside of the lumen as seen on X-ray imaging as the patient was drinking the water-soluble contrast medium. Clinical leakage was defined as the leakage of intestinal fluid or turbid content from the surgical drain accompanied with fever, abdominal pain, and elevated leukocyte count, C-reactive protein (CRP), or procalcitonin (PCT). The definition of EJAL was basing on clinical leakage in present study. One patient with asymptomatic leakage that was only radiological diagnosed was not included in the EJAL group. The definition of an older person was made in accordance with the standards of the World Health Organization (WHO). Pulmonary insufficiency was defined as a forced expiratory volume measured for 1 s FEV1/Force Vital Capacity (FVC) <0.70 (obstructive lung disease) or Total Lung Capacity (TLC) <80% (restrictive lung disease) . Gastric cancer histopathological staging was performed according to the seventh edition of the International Union Against Cancer TNM classification . “Alcohol consumption” was defined as alcohol intake as a limit of 1U/day for women and 2 U/day (1U of alcohol = 12g of alcohol) for men, as stipulated in the Dietary Guidelines For Americans .
Patient-related, surgery-related, and tumor-related variables potentially associated with EJAL were recorded. Table 1 summarizes patient-related variables, including sex (female, male), age (≤65, >65), smoking, alcohol consumption, hypertension, diabetes, body mass index (BMI) (<25, ≥25 kg/m2), neoadjuvant chemotherapy, pulmonary insufficiency, preoperative hemoglobin (<90, ≥90 g/L), preoperative serum albumin (<35, ≥35g/L), and preoperative carcinoembryonic antigen (<5, ≥5 ng/mL). Table 2 summarizes surgery-related variables, including operative approach (open, laparoscopic), duration of operation (<240, ≥240 min), intraoperative blood loss (<200, ≥200 mL), combined resection of other organs (spleen, pancreas, liver), and perioperative blood transfusion. Furthermore, Table 3 summarizes tumor-related variables, including tumor location (lower, middle, upper, whole), tumor size (<4, ≥4cm), lymph node dissection (<16, ≥16), pathology type of tumor (well, moderate, poor, other), depth of invasion (T0–4), and lymph node status (N0–3). In total, 23 potential risk factors were considered and analyzed in the present study.
The interventions for EJAL were as follows: (1) conservative treatment (with or without percutaneous drainage): fasting, antibiotics, nutritional support (enteral or parenteral), and insertion of a nasojejunal tube, and (2) surgical treatment: drainage, repair, or refashion of the anastomosis.
Statistical analyses were performed using the SPSS version 19.0 (IBM Corp., Armonk, NY, USA). The continuous variables were dichotomized according to the clinical situation, standard values stipulated by state-of-the-art guidelines, or using the median value of each variable as the cutoff point. All patients were divided into two groups according to having experienced EJAL or not, and the groups were analyzed using the chi-squared test or Fisher’s exact test. Variables with a probability p value < 0.05 in the univariate analysis and other factors that were thought to have important clinical significance were entered into the multivariate analysis. The multivariate analysis used a logistic regression model to investigate the risk factors associated with the incidence of EJAL, and a p value <0.05 was considered statistically significant; odds ratios (OR) and their 95 % confidence intervals (CI) were also provided.