Analysis of postoperative complications and risk factors of Da Vinci robotic total gastrectomy for gastric cancer

Objective To analyze the postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer, and explore the risk factors for postoperative complications. Methods The retrospective case-control study was conducted. The clinicopathological data of 173 patients with gastric cancer who were admitted to the First Affiliated Hospital of Army Medical University from March 2010 to March 2019 were collected. There were 138 males and 35 females, aged from 34 to 76 years, with an average age of 60 years. All the 173 patients underwent Da Vinci robotic total gastrectomy for gastric cancer. Observation indicators: (1) postoperative complications; (2) analysis of risk factors for postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer. Count data were expressed as absolute numbers or percentages. Univariate analysis was performed using the chi-square test or Fisher exact probability. Indicators with P<0.1 were included into multivariate analysis, and multivariate analysis was performed using logistic regression model. Results (1) Postoperative complications: of the 173 patients, 45 had postoperative complications, with a incidence rate of 26.0%(45/173). Among the 45 patients, 5 had gradeⅠpostoperative complications, 31 had grade Ⅱ postoperative complications, 2 had grade Ⅲa postoperative complications, 3 had grade Ⅲb postoperative complications, 1 had grade Ⅳa postoperative complications, 1 had grade Ⅳb postoperative complications, and 2 had grade Ⅴ postoperative complications. The incidence of serious complications was 5.2%(9/173). Of the 5 patients with gradeⅠcomplications, 1 of fever was improved after antipyretic treatment, 2 of incisional fat liquefaction were improved after dressing change, 1 of vomiting was improved after being given antiemetic, and 1 of delayed recovery of gastrointestinal function was improved after symptomatic treatment. Among 31 patients with gradeⅡcomplications, 12 patients had pulmonary infection, including 6 of pulmonary infection alone, 3 combined with pleural effusion, 1 combined with abdominal infection, 2 combined with intestinal obstruction, and all were improved after conservative treatment; 7 of fever were improved after anti-infection treatment; 4 patients had deep venous catheter infection including 1 combined with bilateral pleural effusion, and were improved after removing catheter and anti-infection treatment; 3 patients had anastomotic leakage including 1 with pulmonary infection and abdominal infection, and were improved after conservative treatment; 2 patients had duodenal stump leakage (1 combined with pulmonary infection, 1 combined with pulmonary infection and pleural effusion) , and were improved after conservative treatment; 1 patient had abdominal hemorrhage, and was improved after conservative treatment; 1 patient had intestinal obstruction, and was improved after conservative treatment; 1 patient had abdominal infection, and was improved after conservative treatment. Of the 2 patients with grade Ⅲa complications, 1 had duodenal stump leakage combined with abdominal abscess, and was improved after puncture and drainage; 1 had pleural effusion combined with pulmonary infection, and was improved after puncture and drainage. Among the 3 patients with grade Ⅲb complications, 1 of abdominal hemorrhage was improved after reoperation, 2 of anastomotic leakage were improved after being placed jejunal nutrition tube under painless gastroscopy. Of the 2 cases, 1 combined with abdominal infection and 1 combined with pleural effusion and abdominal infection were improved after puncture and drainage. Among the 2 patients with grade Ⅳ complications, 1 of Ⅳa encountering respiratory failure was improved after treatment due to misinhalation of anesthesia, and 1 of Ⅳb suffered from multiple organ failure and was improved after treatment due to anastomotic leakage. Two patients with grade V complication died, including one with anastomotic leakage, abdominal hemorrhage, and multiple organ failure, and the other with respiratory failure and cardiac insufficiency. In the 173 patients, the incidence of comprehensive complication index (CCI) ≥ 25.2 was 11.0%(19/173). (2) Analysis of risk factors for postoperative complications of Da Vinci robotic total gastrectomy for gastric cancer: univariate analysis showed that body mass index (BMI), volume of intraoperative blood loss, and operation time were the related factors affecting the postoperative complications (χ2=4.275, 5.057, 5.463, P<0.05). BMI and volume of intraoperative blood loss were the related factors affecting the postoperative serious complications (χ2=7.517, 5.537, P<0.05). Age, BMI and Charlson Comorbidity Index were the related factors affecting CCI ≥25.2 (χ2=8.946, 7.890, 4.062, P<0.05). Multivariate analysis showed that tumor diameter ≥ 3 cm and tumor located at esophagogastric junction were independent risk factors for postoperative complications [odds ratio (OR) =4.350, 2.175, 95% confidence interval (CI): 1.352-14.000, 1.018-4.647, P<0.05)]. BMI ≥25 kg/m2 was an independent risk factor for serious complications after operation (OR=5.156, 95%CI: 1.120-23.738, P<0.05). Age ≥60 years, BMI ≥25 kg/m2, and history of abdominal surgery were independent risk factors for CCI≥25.2 (OR=30.928, 3.557, 6.009, 95%CI: 1.485-644.19, 1.082-11.691, 1.358-26.592, P<0.05). Conclusions The Clavien-Dindo classification of patients after Da Vinci robotic total gastrectomy for gastric cancer is mostly gradeⅡ. The main complications are pulmonary-related complications. CCI can better predict the risk factors for serious complications after operation. Tumor diameter ≥ 3 cm and tumor located at esophagogastric junction are independent risk factors for postoperative complications; BMI ≥25 kg/m2 is an independent risk factor for serious complications; age ≥60 years, BMI ≥25 kg/m2, and history of abdominal surgery are independent risk factors for CCI≥25.2. Key words: Gastric neoplasms; Gastric cancer; Da Vinci robotic surgical system; Total gastrectomy; Complications; Comprehensive complication index; Risk factors