Main Article Content


This study aimed to evaluate the severity of intraoperative and post-operative complications of gastric cancer surgery and to investigate the predictive factors correlated to surgical morbidity.
We included 145 patients operated for gastric cancer. We investigated the risk factors associated with complications, length of hospital stay, operative time, and intraoperative blood transfusion (BT). Significant risk factors were analyzed by multiple logistic regression analysis.
Postoperative complications occurred in 32 patients (22.1 %) and the rate of major complications was 7.6%. The rate of anastomotic fistula was 6.9% and was correlated to diabetes, tumor size, operative time, surgical margin, and extended lymphadenectomy. The mean risk factors for postoperative morbidity were the presence of comorbidities and ASA score (p = 0.021), intraoperative BT (p = 0.045) and prolonged operative time (p = 0.055).
Surgical morbidity of gastric cancer is correlated to the extent of resection as well as the clinical and histological characteristics.


gastric cancer surgery morbidity postoperative complications prognosis

Article Details

How to Cite
Mansouri, H., Zemni, I., Ayadi, M. A., Ben Safta, I., Ben Dhiab, T. ., Mahjoub, N., Achouri, L., & Rahal, K. (2020). Determinants of surgical morbidity in gastric cancer: experience of a single center and literature review. Journal of Gastric Surgery, 2(4), 106–117.


  1. Baiocchi GL, Giacopuzzi S, Marrelli D. Cutoff values of major surgical complications rates after gastrectomy. Updates in surgery. 2018;70:251-5.
  2. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of surgery. 2004;240:205.
  3. Association JGC. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric cancer. 2011;14:113-23.
  4. Tu R-H, Lin J-X, Li P, Xie J-W, Wang J-B, Lu J, et al. Prognostic significance of postoperative pneumonia after curative resection for patients with gastric cancer. Cancer Med. 2017;6:2757-65.
  5. Migita K, Takayama T, Matsumoto S, Wakatsuki K, Enomoto K, Tanaka T, et al. Risk factors for esophagojejunal anastomotic leakage after elective gastrectomy for gastric cancer. Journal of Gastrointestinal Surgery. 2012;16:1659-65.
  6. Xiao H, Xiao Y, Quan H, Liu W, Pan S, Ouyang Y. Intra-abdominal infection after radical gastrectomy for gastric cancer: incidence, pathogens, risk factors and outcomes. International Journal of Surgery. 2017;48:195-200.
  7. Marrelli D, Pedrazzani C, Neri A, Corso G, De Stefano A, Pinto E, et al. Complications after extended (D2) and superextended (D3) lymphadenectomy for gastric cancer: analysis of potential risk factors. Annals of surgical oncology. 2007;14:25-33.
  8. Cuschieri A, Joypaul V, Fayers P, Cook P, Fielding J, Craven J, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Lancet. 1996;347:995-9.
  9. Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V, et al. Patient survival after D 1 and D 2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. British journal of cancer. 1999;79:1522.
  10. Bonenkamp J, Songun I, Welvaart K, van de Velde C, Hermans J, Sasako M, et al. Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. The Lancet. 1995;345:745-8.
  11. Bonenkamp J, Hermans J, Sasako M, Welvaart K, Songun I, Meyer S, et al. Extended lymph-node dissection for gastric cancer. New England Journal of Medicine. 1999;340:908-14.
  12. McCulloch P, Nita ME, Kazi H, Gama‐Rodrigues J. Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach. Cochrane Database of Systematic Reviews. 2003.
  13. Siewert JR, Böttcher K, Stein HJ, Roder JD. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Annals of surgery. 1998;228:449.
  14. Danielson H, Kokkola A, Kiviluoto T, Sirén J, Louhimo J, Kivilaakso E, et al. Clinical outcome after D1 vs D2–3 gastrectomy for treatment of gastric cancer. Scandinavian Journal of Surgery. 2007;96:35-40.
  15. Wu C-W, Chang I-S, Lo S-s, Hsieh M-C, Chen J-H, Lui W-Y, et al. Complications following D3 gastrectomy: post hoc analysis of a randomized trial. World journal of surgery. 2006;30:12-6.
  16. Butte JM, Kerrigan N, Waugh E, Meneses M, Parad H, Visscher A, et al. Complications and mortality of extended gastrectomy for gastric cancer. Revista medica de Chile. 2010;138:1487-94.
  17. Sano T, Sasako M, Yamamoto S, Nashimoto A, Kurita A, Hiratsuka M, et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy-Japan Clinical Oncology Group study 9501. Journal of clinical oncology. 2004;22:2767-73.
  18. Brady MS, Rogatko A, Dent LL, Shiu MH. Effect of splenectomy on morbidity and survival following curative gastrectomy for carcinoma. Archives of surgery. 1991;126:359-64.
  19. Kwon SJ. Prognostic impact of splenectomy on gastric cancer: results of the Korean Gastric Cancer Study Group. World journal of surgery. 1997;21:837-44.
  20. Csendes A, Burdiles P, Rojas J, Braghetto I, Diaz JC, Maluenda F. A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma. Surgery. 2002;131:401-7.
  21. Yu W, Choi G, Chung H. Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer. British Journal of Surgery: Incorporating European Journal of Surgery and Swiss Surgery. 2006;93:559-63.
  22. Degiuli M, Sasako M, Ponti A. Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer. British Journal of Surgery. 2010;97:643-9.
  23. Qi J, Zhang P, Wang Y, Chen H, Li Y. Does total gastrectomy provide better outcomes than distal subtotal gastrectomy for distal gastric cancer? A systematic review and meta-analysis. PloS one. 2016;11:e0165179.
  24. Claassen Y, Hartgrink H, Dikken J, de Steur W, van Sandick J, van Grieken N, et al. Surgical morbidity and mortality after neoadjuvant chemotherapy in the CRITICS gastric cancer trial. European Journal of Surgical Oncology. 2018;44:613-9.
  25. Nakagawa M, Kojima K, Inokuchi M, Kato K, Sugita H, Otsuki S, et al. Identification of frequency, severity and risk factors of complications after open gastrectomy: Retrospective analysis of prospectively collected database using the Clavien-Dindo classification. Journal of medical and dental sciences. 2016;63:53-9.
  26. Park DJ, Lee HJ, Kim HH, Yang HK, Lee KU, Choe KJ. Predictors of operative morbidity and mortality in gastric cancer surgery. The British journal of surgery. 2005;92:1099-102.
  27. Persiani R, Antonacci V, Biondi A, Rausei S, La Greca A, Zoccali M, et al. Determinants of surgical morbidity in gastric cancer treatment. Journal of the American College of Surgeons. 2008;207:13-9.
  28. Sun C, Wang Y, Yao HS, Hu ZQ. Allogeneic blood transfusion and the prognosis of gastric cancer patients: systematic review and meta-analysis. International journal of surgery (London, England). 2015;13:102-10.
  29. Gockel I, Pietzka S, Gönner U, Hommel G, Junginger T. Subtotal or total gastrectomy for gastric cancer: impact of the surgical procedure on morbidity and prognosis—analysis of a 10-year experience. Langenbeck's archives of surgery. 2005;390:148-55.
  30. Papenfuss WA, Kukar M, Oxenberg J, Attwood K, Nurkin S, Malhotra U, et al. Morbidity and mortality associated with gastrectomy for gastric cancer. Annals of surgical oncology. 2014;21:3008-14.
  31. Brar SS, Seevaratnam R, Cardoso R, Yohanathan L, Law C, Helyer L, et al. Multivisceral resection for gastric cancer: a systematic review. Gastric Cancer. 2012;15:100-7.
  32. Pacelli F, Cusumano G, Rosa F, Marrelli D, Dicosmo M, Cipollari C, et al. Multivisceral resection for locally advanced gastric cancer: an Italian multicenter observational study. JAMA surgery. 2013;148:353-60.
  33. Tran TB, Worhunsky DJ, Norton JA, Squires MH, Jin LX, Spolverato G, et al. Multivisceral resection for gastric cancer: results from the US gastric cancer collaborative. Annals of surgical oncology. 2015;22:840-7.
  34. Xiao H, Quan H, Pan S, Yin B, Luo W, Huang G, et al. Impact of peri-operative blood transfusion on post-operative infections after radical gastrectomy for gastric cancer: a propensity score matching analysis focusing on the timing, amount of transfusion and role of leukocyte depletion. Journal of cancer research and clinical oncology. 2018;144:1143-54.
  35. Ojima T, Iwahashi M, Nakamori M, Nakamura M, Naka T, Katsuda M, et al. Association of allogeneic blood transfusions and long-term survival of patients with gastric cancer after curative gastrectomy. Journal of Gastrointestinal Surgery. 2009;13:1821.
  36. Lee K-G, Lee H-J, Yang J-Y, Oh S-Y, Bard S, Suh Y-S, et al. Risk factors associated with complication following gastrectomy for gastric cancer: retrospective analysis of prospectively collected data based on the Clavien–Dindo system. Journal of Gastrointestinal Surgery. 2014;18:1269-77.
  37. Songun I, Putter H, Kranenbarg EM-K, Sasako M, van de Velde CJ. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. The lancet oncology. 2010;11:439-49.
  38. Sah B, Zhu Z, Wang X, Yang Q, Chen M, Xiang M, et al. Post‐operative complications of gastric cancer surgery: female gender at high risk. European journal of Cancer care. 2009;18:202-8.
  39. Cunningham-Rundles S, McNeeley DF, Moon A. Mechanisms of nutrient modulation of the immune response. Journal of Allergy and Clinical Immunology. 2005;115:1119-28.
  40. Zheng H-L, Lu J, Li P, Xie J-W, Wang J-b, Lin J-X, et al. Effects of preoperative malnutrition on short-and long-term outcomes of patients with gastric cancer: can we do better? Annals of surgical oncology. 2017;24:3376-85.
  41. Ojima T, Iwahashi M, Nakamori M, Nakamura M, Naka T, Ishida K, et al. Influence of overweight on patients with gastric cancer after undergoing curative gastrectomy: an analysis of 689 consecutive cases managed by a single center. Archives of Surgery. 2009;144:351-8.
  42. Kang SC, Kim HI, Kim MG. Low Serum Albumin Level, Male Sex, and Total Gastrectomy Are Risk Factors of Severe Postoperative Complications in Elderly Gastric Cancer Patients. J Gastric Cancer. 2016;16:43-50.
  43. Gil-Rendo A, Hernandez-Lizoain JL, Martinez-Regueira F, Sierra Martinez A, Rotellar Sastre F, Cervera Delgado M, et al. Risk factors related to operative morbidity in patients undergoing gastrectomy for gastric cancer. Clinical & translational oncology : official publication of the Federation of Spanish Oncology Societies and of the National Cancer Institute of Mexico. 2006;8:354-61.
  44. Yu X, Hu F, Li C, Yao Q, Zhang H, Xue Y. Clinicopathologic characteristics and prognosis of proximal and distal gastric cancer. OncoTargets and therapy. 2018;11:1037-44.
  45. Liu K, Zhang W, Chen X, Chen X, Yang K, Zhang B, et al. Comparison on Clinicopathological Features and Prognosis Between Esophagogastric Junctional Adenocarcinoma (Siewert II/III Types) and Distal Gastric Adenocarcinoma: Retrospective Cohort Study, a Single Institution, High Volume Experience in China. Medicine. 2015;94:e1386.
  46. Wang X, Wan F, Pan J, Yu GZ, Chen Y, Wang JJ. Tumor size: a non-neglectable independent prognostic factor for gastric cancer. Journal of surgical oncology. 2008;97:236-40.
  47. Zhou HY, Yi W, Wang J, Zhang J, Wang WJ, Hu ZQ. Association of perioperative allogeneic blood transfusions and prognosis of patients with gastric cancer after curative gastrectomy. American journal of surgery. 2014;208:80-7.

Most read articles by the same author(s)