Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Apr 27, 2022; 14(4): 315-328
Published online Apr 27, 2022. doi: 10.4240/wjgs.v14.i4.315
How to examine anastomotic integrity intraoperatively in totally laparoscopic radical gastrectomy? Methylene blue testing prevents technical defect-related anastomotic leaks
Chun Deng, Yang Liu, Zhen-Yu Zhang, Heng-Duo Qi, Zhi Guo, Xu Zhao, Xiao-Jun Li
Chun Deng, Yang Liu, Zhen-Yu Zhang, Heng-Duo Qi, Zhi Guo, Xu Zhao, Xiao-Jun Li, Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an 710068, Shaanxi Province, China
Author contributions: Deng C designed and performed the research and wrote the paper; Liu Y, Zhang ZY, and Qi HD designed the research and supervised the report; Guo Z and Zhao X provided clinical advice; Li XJ designed and performed the research and supervised the report.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Shaanxi Provincial People's Hospital.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Xiao-Jun Li, MD, Professor, Surgeon, Department of General Surgery, Shaanxi Provincial People's Hospital, No. 256 Youyi West Road, Xi'an 710068, Shaanxi Province, China. lixiaojun20040912@163.com
Received: November 11, 2021
Peer-review started: November 11, 2021
First decision: January 9, 2022
Revised: January 20, 2022
Accepted: April 4, 2022
Article in press: April 4, 2022
Published online: April 27, 2022
Processing time: 164 Days and 4.7 Hours
Abstract
BACKGROUND

Intraoperative methylene blue testing (IMBT), air leak testing, or endoscopy is used to assess the anastomotic integrity of esophagojejunostomy during open total gastrectomy for gastric cancer. Totally laparoscopic radical gastrectomy has been widely used to treat gastric cancer in the last few decades. However, reports on testing anastomotic integrity in totally laparoscopic radical gastrectomy are limited.

AIM

To explore the effects of IMBT on the incidence of postoperative anastomotic leaks (PALs) and identify the risk factors for PALs in totally laparoscopic radical gastrectomy.

METHODS

From January 2017 to December 2019, patients who underwent totally laparoscopic radical gastrectomy at the Shaanxi Provincial People's Hospital were retrospectively analyzed. According to whether or not they experienced an IMBT, the patients were divided into an IMBT group and a control group. If the IMBT was positive, an intraoperative suture was required to reinforce the anastomosis. The difference in the incidence of PALs was compared, and the risk factors were investigated.

RESULTS

This study consisted of 513 patients, 211 in the IMBT group and 302 in the control group. Positive IMBT was shown in seven patients (3.3%) in the IMBT group, and no PAL occurred in these patients after suture reinforcement. Multivariate analysis showed that risk factors for predicting positive IMBT were body mass index (BMI) > 25 kg/m2 (hazard ratio [HR] = 8.357, P = 0.009), operation time > 4 h (HR = 55.881, P = 0.002), and insufficient surgical experience (HR = 15.286, P = 0.010). Moreover, 15 patients (2.9%) developed PALs in 513 patients, and the rates of PALs were significantly lower in the IMBT group than in the control group [2 of 211 patients (0.9%) vs 13 of 302 patients (4.3%), P = 0.0026]. Further analysis demonstrated that preoperative complications (HR = 13.128, P = 0.017), totally laparoscopic total gastrectomy (HR = 9.075, P = 0.043), and neoadjuvant chemotherapy (HR = 7.150, P = 0.008) were independent risk factors for PALs.

CONCLUSION

IMBT is an effective method to evaluate the integrity of anastomosis during totally laparoscopic radical gastrectomy, thus preventing technical defect-related anastomotic leaks. Preoperative complications, totally laparoscopic total gastrectomy, and neoadjuvant chemotherapy are independent risk factors for PALs.

Keywords: Anastomotic leak; Gastric neoplasms; Totally laparoscopic radical gastrectomy; Methylene blue; Risk factors

Core Tip: We reviewed the outcomes of 513 consecutive patients with gastric cancer who underwent totally laparoscopic radical gastrectomy with and without intraoperative methylene blue testing at Shaanxi Provincial People's Hospital from January 2017 to December 2019. We found that intraoperative methylene blue testing is an effective method to evaluate the integrity of anastomosis during totally laparoscopic radical gastrectomy and could reduce the incidence of postoperative anastomotic leaks. Preoperative complications, totally laparoscopic total gastrectomy, and neoadjuvant chemotherapy are independent risk factors for postoperative anastomotic leaks.