Factors for Predicting Morbidity and Mortality of Gastric Cancer Patients After Laparoscopic Surgery: A Retrospective Study

Abstract

Background/Objectives: Gastric cancer is a major global health concern and a leading cause of cancer-related death. While surgical resection remains the cornerstone of curative treatment, postoperative morbidity and mortality are significant issues. This study aimed to identify factors associated with postoperative morbidity and mortality in patients undergoing laparoscopic gastrectomy for gastric adenocarcinoma. Results: The median age was 73 years. Eighteen total gastrectomies (15%) and eighty-eight subtotal gastrectomies (66.6%) were performed. Major complications (Clavien-Dindo ≥ III) occurred in 22.3% of patients, and the hospital mortality rate was 7.5%. Independent predictors of morbidity included anemia (OR 2.49, p = 0.047), extended lymphadenectomy (OR 5.09, p = 0.002), and conversion to open surgery (OR 9.40, p = 0.031). Coagulopathy was a significant predictor of mortality (OR 5.01, p = 0.049). Methods: A retrospective, single-center observational study was conducted on 120 patients who underwent laparoscopic surgery between January 2004 and December 2022. Preoperative assessments included endoscopy, imaging, and staging according to the TNM classification. Risk factors were analyzed using univariate and multivariate logistic regression. Conclusions: Laparoscopic gastrectomy is a technically challenging procedure with substantial risks of morbidity and mortality. Identifying modifiable risk factors, such as anemia and coagulopathy, provides opportunities for improved outcomes through preoperative prehabilitation and optimized patient selection.

1. Introduction

Gastric cancer is a significant global health concern, with its incidence and treatment outcomes varying widely across regions [1]. Approximately one million new cases are diagnosed annually, underscoring its importance. It is the fourth leading cause of cancer-related deaths worldwide [2,3]. Despite a decline in age-adjusted mortality rates, gastric cancer remains a major health challenge due to its high morbidity and mortality rates.

The treatment of gastric cancer is based on three fundamental pillars: neoadjuvant therapy, when necessary; surgical treatment, which is the cornerstone for patients with resectable disease; and adjuvant therapy, which is used to maximize oncological outcomes in selected cases [4,5]. Among surgical interventions, gastrectomy plays a central role, though approaches differ significantly across regions. However, significant differences exist in surgical approaches, with open and laparoscopic techniques being prominent options. Laparoscopic gastrectomy has gained popularity for its potential to reduce postoperative pain, shorten recovery time, and minimize hospital stays compared to open surgery. Nonetheless, these benefits must be weighed against technical challenges and potential risks, especially in complex cases such as total gastrectomy [6,7].

Morbidity and mortality rates show considerable variation across published studies, especially in the case of total gastrectomy [6]. In East Asia, where gastric cancer is highly prevalent, subtotal gastrectomy with D2 dissection is the standard procedure for curable advanced cases [7,8]. This approach, recommended by the Japanese Gastric Cancer Association, has demonstrated superior outcomes compared to those reported in Western countries [9,10]. However, concerns regarding pancreatosplenectomy-related morbidity and mortality have led to evolving surgical practices.

Data from Japan’s National Clinical Database (NCD) show relatively favorable survival outcomes, though further improvements are needed. Notably, limiting mortality assessments to 30 days may underestimate perioperative risks, highlighting the need for more comprehensive evaluations [7,8].

Total gastrectomy, often required for tumors in the upper third of the stomach or in advanced cases, is a complex procedure with substantial risks. Complications such as anastomotic leakage and pancreatic fistula remain significant concerns, particularly in older patients [11,12].

Another key area of focus is neoadjuvant therapy. Given the growing role of perioperative chemotherapy and adjuvant treatments, various methods have been developed to identify factors for risk stratification, with the goal of optimizing treatment sequencing and targeting high-risk patients for neoadjuvant therapy [6,13].

The data from various analyses align with the findings of this study and shed light on the evolving landscape of gastric cancer treatment globally. By examining surgical practices, associated risks, and potential areas for improvement, this study provides a foundation for ongoing efforts to enhance outcomes in laparoscopic gastrectomy for gastric cancer [6,7,8].

Thus, identifying preoperative and intraoperative factors that significantly impact the morbidity and mortality of patients undergoing surgical treatment for gastric cancer is crucial.

This study aims to address these gaps by analyzing preoperative and intraoperative factors that significantly impact morbidity and mortality in patients undergoing laparoscopic gastrectomy for gastric cancer. By examining the evolving landscape of surgical practices and identifying risk factors, this research seeks to contribute to optimizing outcomes and improving the global management of gastric cancer.

2. Results

Patient characteristics are summarized in

Table 1. Descriptive data.

Variables	N = 120
Age (years) mean IQR	73.0 (63.0–79.0)
Males	63 (52.5%)
Female	57 (47.5%)
High blood pressure	54 (45%)
Cardiac disease	30 (25%)
Diabetes	24 (20%)
Chronic respiratory disease	13 (10.8%)
Coagulopathy	10 (8.3%)
Immunosuppression	8 (6.7%)
Previous abdominal surgery	37 (30.8%)
ASA II–III	103 (86%)

. A total of 120 patients met the inclusion criteria. The median age was 73 years (IQR 63–79), with a slight predominance of males (52.5%). The most common preoperative comorbidities included hypertension (45.0%), cardiopathy (25.0%), diabetes mellitus (20.0%), chronic respiratory disease (10.8%), coagulopathy (8.3%), and immunosuppression (6.7%). According to the ASA classification, 43.0% of patients were classified as ASA II, and 43.0% as ASA III. Thirty-seven patients (30.8%) had a history of previous abdominal surgery.

Regarding the surgical procedures, they began with a laparoscopic exploration to determine resectability. Based on the findings, resective or bypass surgery was performed, or the procedure was terminated. With these strategy, 80 patients (66.6%) underwent subtotal gastrectomy, 18 patients (15.0%) had total gastrectomy, 8 patients (6.7%) underwent bypass surgery, and 14 patients (11.7%) had exploratory laparoscopy due to advanced disease. Conversion to open surgery occurred in seven patients (5.8%).

The median operative time was 240 min (IQR 162.5–288.75). Pathological staging revealed T4 lesions in 32.5% of patients and T3 lesions in 31.7%. Stage IV disease was identified in 18.3% of patients (

Table 2. Operative data.

Variables	N = 120
Subtotal gastrectomy	80 (66.6%)
Total gastrectomy	18 (15%)
Exploratory laparoscopy	14 (11.7%)
Bypass surgery	8 (6.7%)
Median operative time (min)	240
T4	39 (32.5%)
T3	38 (31.7%)
Stage IV	22 (18.3%)
Conversion to open surgery	7 (5.8%)
Clavien–Dindo I–II	19 (15.7%)
Clavien–Dindo III–IV	27 (22.3%)

). The median postoperative hospital stay was 11 days (IQR 8–16). Major postoperative complications, defined as Clavien–Dindo grade III or higher, occurred in 27 patients (22.3%), while minor complications (Clavien–Dindo grades I and II) were observed in 19 patients (15.7%). Morbidity and mortality were mainly related to reconstruction problems: four anastomosis leakages, and two duodenal stump dehiscence.

In the univariate analysis, factors associated with postoperative morbidity included age, preoperative anemia (hemoglobin < 12 g/dL; serum-iron < 11 µmol/L), conversion to open surgery, extended lymphadenectomy, and disease stage > III C (

Table 3. Univariate and multivariate analysis of risk factors for morbidity.

Variables	Univariate Analysis
	Odds Ratio	95%CI	p Value
Age	1.04	(1.00–1.07)	0.046
Diabetes M.	2.80	(1.12–7.00)	0.028
Iron-deficiency Anemia	2.03	(0.95–4.35)	0.067
Conversion	4.39	(0.82–23.65)	0.085
Lymphadenectomy D1–D2	5.56	(2.24–13.78)	<0.001
T3	2.04	(0.93–4.47)	0.076
N1	3.15	(1.06–9.36)	0.039
Stage IIIC	4.39	(0.82–23.65)	0.085
Palliative surgery	0.31	(0.12–0.84)	0.021
Intervention time (minute)	1.01	(1.00–1.01)	0.001
Subtotal gastrectomy	2.41	(1.08–5.37)	0.032
Unresectable tumor	0.10	(0.01–0.83)	0.032
	Multivariate Analysis (Wald)
Variables	Odds Ratio	95%CI	p Value
Anemia	2.49	(1.01–6.13)	0.047
Conversion	9.40	(1.22–72.36)	0.031
Lymphadenectomy	5.09	(1.86–13.97)	0.002

).

Multivariate analysis identified preoperative anemia (OR 2.49, p = 0.047), extended lymphadenectomy (>D1) (OR 5.09, p = 0.002), and conversion to open surgery (OR 9.40, p = 0.031) as independent predictors of morbidity.

The hospital mortality rate was 7.5%. In the univariate analysis, factors associated with mortality included preoperative coagulopathy, previous abdominal surgery, ASA stage, reoperation, and antral tumor localization (

Table 4. Univariate and multivariate analysis of risk factors for mortality.

Variables	Univariate Analysis
	Odds Ratio	95%CI	p Value
Reintervention	0.18	(0.48–0.66)	0.010
Coagulopathy	4.00	(0.92–17.50)	0.065
ASA	2.70	(1.05–6.91)	0.039
Previous abdominal surgery	0.34	(0.10–1.14)	0.080
Variables	Multivariate Analysis (Wald)
	Odds Ratio	95%CI	p Value
Coagulopathy	5.01	(1.00–25.10)	0.049

). Multivariate logistic regression analysis revealed preoperative coagulopathy as an independent predictive factor for mortality (OR 5.01, p = 0.049).

3. Materials and Methods

This single-center, retrospective observational study included all patients with gastric adenocarcinoma who underwent laparoscopic procedures with curative intent between January 2004 and December 2022. Exclusion criteria were patients deemed unfit for surgery and those with gastric neoplasms other than adenocarcinoma.

Preoperative evaluations comprised laboratory tests, upper digestive endoscopy with biopsy, computed tomography (CT) scans, and endoscopic ultrasound. Patients were classified according to the American Society of Anesthesiologists (ASA) physical status classification system during the preoperative workup [14]. The extent of gastric resection and lymphadenectomy was determined by tumor location. Informed consent was obtained from all patients.

Tumor staging was performed according to the TNM classification system of the College of American Pathologists [15]. Postoperative complications were graded using the Clavien–Dindo classification system [16]. Hospital mortality was defined as death occurring within 30 days post-surgery or during the hospital stay. Variables such as length of hospital stay, age, sex, comorbidities, extent of surgery, and pathological TNM (pTNM) stage were analyzed.

Statistical analyses were conducted using SPSS version 25.0 (SPSS Inc., Chicago, IL, USA). Quantitative variables are presented as numbers and percentages, as well as medians with interquartile ranges (IQRs). Univariate logistic regression was performed for each variable, regardless of its association with morbidity and mortality. Variables with p values < 0.1 were included in a multivariate analysis using the Wald selection method. Statistical significance was set at p values < 0.05.

Data were collected from clinical records and anonymized in accordance with the Spanish Organic Law 15/1999 of December 13, 1999, on Personal Data Protection (LOPD). All methods adhered to the ethical guidelines outlined in the Declaration of Helsinki (1964, revised 1983), the Spanish Royal Decree 1090/2015 of December 4 (regulating clinical trials with drugs), the Research Ethics Committees, and the Spanish Registry of Clinical Studies.

Informed consent was obtained from all participants following the standard operating procedures of our center. The study was approved by the Ethics Committee of Valladolid University (reference number PI 20-1964).

4. Discussion

Identifying risk factors for complications associated with specific surgical procedures is essential for optimal preoperative planning, particularly in older patients, as is often the case with gastric carcinoma [8,17]. Another consideration is the potential benefits of minimally invasive surgery (MIS) [18].

As in other studies, we found three main groups of variables associated with morbidity and mortality in patients undergoing surgery for gastric cancer: patient-related factors (e.g., age and comorbidities), disease-related factors (e.g., tumor stage at diagnosis), and surgery-related factors (e.g., extent of lymphadenectomy, reoperation, and conversion to open surgery).

Several studies have examined mortality and morbidity in patients undergoing distal and total gastrectomy for gastric cancer [6,7,8]. Advanced age and preoperative weight loss are frequently associated with higher risks of postoperative complications [17,19]. In our study, univariate analysis identified advanced age as a risk factor for morbidity.

Bartlett et al. [6] conducted a study involving 1165 patients who underwent total gastrectomy for gastric malignancies at ACS NSQIP-participating hospitals in the United States. This study identified age over 70, weight loss, prior splenectomy, and prior pancreatectomy as significant predictors of 30-day morbidity. Additionally, age over 70, weight loss, low albumin levels, and prior pancreatectomy were linked to increased 30 day mortality. Their findings underscored a 36% morbidity rate after gastrectomy, even in patients without high-risk features.

Similarly, Watanabe et al. [7], using data from the Nationwide Database of Japan (33,917 cases from 1737 hospitals), developed risk models for 30-day and operative mortality. The ASA score emerged as the most significant factor associated with 30-day mortality, alongside other variables such as patient condition and disease extent. Our findings, which show that preoperative anemia and coagulopathy are predictive of morbidity and mortality, respectively, align with these results. Previous studies have also highlighted laboratory variables such as white blood cell count and serum albumin level as predictors of both early and late mortality, reinforcing the importance of presurgical prehabilitation, particularly for elderly patients [6].

Reported overall morbidity rates for gastric adenocarcinoma surgery range from 20% to 40% [6,8,9,17], while morbidity associated with laparoscopic gastrectomy (LG) ranges from 6% to 25% [20,21]. This supports the growing consensus that laparoscopic surgery offers advantages in reducing complications. In our study, the morbidity rate (Clavien–Dindo grade ≥ III) was 22.3%, similar to rates reported by other Western studies [6,17,22], but higher than those observed in Eastern countries [7,23,24]. Differences in patient factors likely explain these disparities [22,25].

The extent of surgery is another factor influencing morbidity [7]. We found that extended lymphadenectomy was associated with an increased risk of complications, which may explain why advanced-stage disease consistently correlates with higher morbidity rates, as reflected in our results. However, good results have recently been reported, with low morbidity and mortality rates, with a more aggressive therapeutic approach, superextended D2 lymphadenectomy after neoadjuvance with chemotherapy [26].

Conversion to open surgery, which has been reported at rates ranging from 0% to 12% [27], occurred in 5.8% of the cases in our series. Conversion was associated with longer operative times and was an independent predictor of increased postoperative morbidity.

Surgical mortality rates following laparoscopic gastrectomy range between 0% and 7% [6,7,17]. Our mortality rate was 7.5%, with 6.2% in the subtotal gastrectomy group and 11.1% in the total gastrectomy group. Consistent with previously reported data [4,8,11], we found that coagulopathy was associated with higher mortality rates.

The mean length of hospital stay in our study was 11 days, which is in line with data from other authors [11,23]. This finding supports the view that laparoscopic gastrectomy is beneficial for reducing the invasiveness of surgery for gastric cancer. Our study highlights the critical role of prehabilitation, particularly in elderly patients, by addressing modifiable factors such as anemia and hypoalbuminemia. It underscores the importance of tailoring surgical strategies to individual risk profiles to enhance outcomes. Consistent with findings from other studies, our results reaffirm the significance of preoperative prehabilitation in optimizing the surgical treatment of gastric adenocarcinoma.

5. Conclusions

Laparoscopic gastrectomy for gastric cancer is a complex procedure requiring meticulous planning and execution. This study highlights the significant impact of preoperative factors, such as anemia and coagulopathy, on postoperative morbidity and mortality. These findings emphasize the potential value of targeted prehabilitation strategies to mitigate these risks. Comprehensive risk stratification and patient selection remain paramount to optimizing surgical outcomes. Future efforts should focus on integrating prehabilitation protocols into standard care for high-risk patients to improve perioperative safety and long-term prognosis.