Surgical Tactics of the Gastric Cancer Patients Treatment Depending on the Degree of the Esophageal-intestinal Anastomotic Leak Development Risk

The purpose of the study was to improve the results of treatment for patients with gastric cancer and reduce the frequency of complications of the early postoperative period in a group of patients with high surgical risk by improving preoperative preparation, with prediction of the risk of complications and the introduction of treatment and diagnostic algorithm in these patients. Material and methods. We analyzed the treatment of 74 patients with gastric cancer who underwent gastrectomy. Standard preoperative preparation was supplemented with a definition of the risk group for insolvency of the esophageal-intestinal anastomosis for each patient. Three degrees of risk of insolvency of the esophageal-intestinal anastomosis were identified: degree I (minor risk), degree II (moderate risk), and degree III (high risk). Patients with insignificant deviations in clinical and laboratory studies, without severe concomitant diseases and with an uncommon tumor process were treated as the risk degree I. Patients with risk degree II included patients with significant deviations in clinical laboratory parameters, with comorbidities and moderate spread of the tumor process. Patients who required urgent surgical treatment due to bleeding or perforation of the tumor, a common stage of the tumor process, significant changes in clinical and laboratory parameters, the presence of severe concomitant pathology and the severe somatic condition of the patient were referred to the risk degree III. Results and discussion. According to the intraoperative risk of joint failure, the following surgical tactics were proposed. With a slight risk of insolvency, it was considered possible to perform a gastrectomy with simultaneous anastomosing with one of the known methods. As a recommendation, we suggested resolving the issue in need for decompression of the anastomosis zone. With a moderate risk of suture failure, it was considered mandatory to perform decompression of the anastomosis zone (intubation with a transnasal probe for the anastomosis zone) and also to conduct a course of preoperative and postoperative photodynamic therapy (according to the method developed by us). Preoperative photodynamic therapy was performed in order to reduce the size of tumor and inflammatory infiltration, recanalization with stenosis of the esophageal-gastric junction. Photodynamic therapy was also used in the early postoperative period after receiving a morphological conclusion about the presence of tumor cells at the resection edges. At high risk of suture failure, we performed a gastrectomy with unloading jejunostomy. Among all patients, there were 10 patients with the risk degree I (minor risk), 49 patients with the risk degree II (moderate risk) and 15 patients with the risk degree III (high risk). Conclusions. We developed a comprehensive program of successive measures that significantly reduced the risk of developing an esophageal-intestinal anastomosis, even with a complicated course of gastric cancer, and improved the immediate results of surgical treatment of gastric cancer by reducing the mortality rate in the early postoperative period from 10.8% to 4.2%. The annual, two-year and three-year survival was 93.6%, 75.7% and 47.2%, respectively.