Machine learning identifies the risk of complications after laparoscopic radical gastrectomy for gastric cancer

BACKGROUND Laparoscopic radical gastrectomy is widely used,and perioperative complications have become a highly concerned issue.AIM To develop a predictive model for complications in laparoscopic radical gastrectomy for gastric cancer to better predict the likelihood of complications in gastric cancer patients within 30 days after surgery,guide perioperative treatment strategies for gastric cancer patients,and prevent serious complications.METHODS In total,998 patients who underwent laparoscopic radical gastrectomy for gastric cancer at 16 Chinese medical centers were included in the training group for the complication model,and 398 patients were included in the validation group.The clinicopathological data and 30-d postoperative complications of gastric cancer patients were collected.Three machine learning methods,lasso regression,random forest,and artificial neural networks,were used to construct postoperative complication prediction models for laparoscopic distal gastrectomy and laparoscopic total gastrectomy,and their prediction efficacy and accuracy were evaluated.RESULTS The constructed complication model,particularly the random forest model,could better predict serious complications in gastric cancer patients undergoing laparoscopic radical gastrectomy.It exhibited stable performance in external validation and is worthy of further promotion in more centers.CONCLUSION Using the risk factors identified in multicenter datasets,highly sensitive risk prediction models for complications following laparoscopic radical gastrectomy were established.We hope to facilitate the diagnosis and treatment of preoperative and postoperative decision-making by using these models.

Effect of Subcostal Anterior Quadratus Lumborum Block vs.Oblique Subcostal Transversus Abdominis Plane Block after Laparoscopic Radical Gastrectomy

Objective:To evaluate the analgesic effect of ultrasound-guided subcostal anterior quadratus lumborum block(QLB)for laparoscopic radical gastrectomy surgery.Methods:Patients(aged 20-65 years,ASA Ⅰ-Ⅱ,and weighing 40-75 kg)scheduled for elective laparoscopic radical gastrectomy were enrolled in the current study.Sixty patients were randomly assigned to two groups by computer-generated randomization codes:an ultrasound-guided oblique subcostal transversus abdominis plane block(TAPB)group(group T,n=30)or an ultrasound-guided subcostal anterior QLB group(group Q,n=30).In both groups,bilateral ultrasound-guided oblique subcostal TAPB and subcostal anterior QLB were performed before general anesthesia with 0.25% ropivacaine 0.5 mL/kg.For postoperative management,all patients received patient-controlled intravenous analgesia(PCIA)with nalbuphine and sufentanil after surgery,maintaining visual analogue scale(VAS)scores<4 within 48 h.The intraoperative consumption of remifentanil,the requirement for sufentanil as a rescue analgesic,and the VAS scores at rest and coughing were recorded at 1,6,12,24 and 48 h after surgery.The recovery(extubation time after surgery,first ambulation time,first flatus time and length of postoperative hospital stay)and the adverse events(nausea and vomiting,skin pruritus,respiratory depression and nerve-block related complications)were observed and recorded.The primary outcome was the perioperative consumption of opioids.Results:Compared with group T,the intraoperative consumption of remifentanil,requirement for sufentanil and the frequency of PCIA were reduced in group Q.Meanwhile,VAS scores at all points of observation were significantly lower in group Q than in group T.Patients in group Q were also associated with shorter time to first out-of-bed activity and flatus,and shorter length of postoperative hospital stay than group T(P<0.05).There were no skin pruritus,respiratory depression or nerve-block related complications in both groups.Conclusion:Compared with ultrasound-guided oblique subcostal TAPB,ultrasound-guided subcostal anterior QLB provided greater opioid-sparing effect,lower visual analogue scores,and shorter postoperative hospital stay for laparoscopic radical gastrectomy.

Superior pancreatic lymphadenectomy with portal vein priority via posterior common hepatic artery approach in laparoscopic radical gastrectomy

BACKGROUND D2 lymph node dissection for advanced gastric cancer is advocated,and station 8p lymph node should be considered in selected patients,which is,however,technically difficult.AIM To introduce a new and easy-to-perform procedure for dissection of the lymph nodes superior to the pancreas.METHODS A series of patients who underwent laparoscopic gastrectomy for gastric cancer were retrospectively included with utilization of a new procedure for superior pancreatic lymphadenectomy(LND)with portal vein priority via the posterior common hepatic artery approach(SPLD-PPPH)based on a newly defined portal triangle.The surgical outcome of the patients,as well as the efficacy and safety of SPLD-PPPH are reported.RESULTS A total of 51 patients were included with most of them being male(n=34,66.7%).According to the 8th edition of AJCC TNM staging,there were four(7.8%)patients in stage I,13(25.5%)in stage II,33(64.7%)in stage III and one(2.0%)in stage IV.The average duration for LND was about 1 h(67.7±6.9 min).After surgery,four patients developed morbidities,but all were treated successfully with no perioperative mortality.Among the 51 patients included,the percentage of patients who had lymph node metastasis at station 8p was 9.8%.Of note,with a total of 14 lymph nodes harvested at station 8p,the incidence of nodal metastasis was 14.3%.CONCLUSION About one in 10 patients with advanced gastric cancer had nodal metastasis at station 8p.The new approach of SPLD-PPPH is safe and effective for D2+LND during laparoscopic radical gastrectomy.

How to examine anastomotic integrity intraoperatively in totally laparoscopic radical gastrectomy? Methylene blue testing prevents technical defect-related anastomotic leaks

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.

Analgesic effect of ultrasound-guided bilateral transversus abdominis plane block in laparoscopic gastric cancer

BACKGROUND Postoperative complications are important factors affecting the survival time and quality of life of patients undergoing radical gastrectomy.AIM To investigate and compare the anesthetic effects of intravenous general anesthesia combined with epidural anesthesia or ultrasound-guided bilateral transversus abdominal plane block(TAPB)in gastric cancer patients undergoing laparoscopic radical gastrectomy.METHODS The clinical data of 85 patients who underwent laparoscopic radical gastrectomy in our hospital from December 2020 to January 2023 were retrospectively collected and divided into a TAPB group(n=45)and epidural anesthesia group(n=40)according to the different anesthesia and analgesia programs used.The TAPB group received general anesthesia combined with TAPB,and the epidural anesthesia group received general anesthesia combined with epidural anesthesia.The pain status,cognitive status,intestinal barrier indicators,recovery quality,and incidence of complications were compared between the two groups.RESULTS Compared with the epidural anesthesia group,the TAPB group’s visual analog scale scores were significantly lower 6 h,12 h,24 h and 48 h after surgery(P<0.05).The incidence of postoperative cognitive dysfunction(POCD)in the TAPB group was significantly lower than that in the epidural anesthesia group,and the Mini-mental State Examination score 24 h after surgery was significantly higher in the TAPB group than the epidural anesthesia group(P<0.05).The levels of diamine oxidase and plasma D-lactate were significantly lower in the TAPB group than the epidural anesthesia group 24 h after surgery(P<0.05).The agitation score and the incidence of agitation during recovery were significantly lower in the TAPB group than epidural anesthesia group(P<0.05).The total incidence of postoperative complications in the TAPB group was 4.44%,significantly lower than the 20.00%in the epidural anesthesia group(P<0.05).CONCLUSION Compared with epidural anesthesia combined with general anesthesia,TAPB combined with general anesthesia had a good analgesic effect in laparoscopic radical gastrectomy and can further reduce the incidence of POCD and postoperative complications,improve the levels of intestinal barrier indicators,and improve postoperative recovery quality.