Bursectomy in gastric cancer surgery: surgical technique and operative safety

Abstract

Although there is little evidence that bursectomy has clinical benefit, its continuing practice imposes evaluation of bursectomy-related adverse effects, especially pancreatic fistula and intestinal obstruction. The aims of this study were to provide a detailed description of the technique of bursectomy as standardized by the authors and determine if extended surgery for gastric cancer with additional bursectomy can be performed safely in Western population. A total of 72 consecutive patients of median age 76.4 years and mean ASA score grade 2.1, who submitted to D2 or D2+ gastrectomy with additional bursectomy for gastric adenocarcinoma, were prospectively studied. Bursectomy was associated with a median additional operative time of 41 min and a median additional blood loss of 65 ml. The post-operative morbidity rate was 19.4 %. Among various adverse events, pancreatic fistula was observed in three patients (4.2 %) and intestinal obstruction was observed in eight patients (11.1 %) including two cases of delayed gastric emptying, one case of afferent loop syndrome, one case of early postoperative adhesions and four cases of prolonged postoperative ileus. The in-hospital mortality rate was 1.4 %. D2 or D2+ gastrectomy with additional bursectomy can be safely performed in Western patients. Although the incidence of pancreatic fistula that we reported was low, the incidence of bursectomy-related intestinal obstruction was high and should always be kept in mind when performing extended surgery for gastric cancer.

Changing Trends in Gastric Cancer Surgery

“…Bursectomy refers to a surgical procedure that includes removal of the anterior leaf of the transverse mesocolon and the peritoneal lining of the pancreas via omentectomy. During gastric cancer surgery, bursectomy is performed to remove free cancer cells and microscopic tumour deposits in the lesser sac and greater omentum, for complete resection of disease from the pancreas, complete dissection of the subpyloric lymph nodes and a regular coeliac-based lymphadenectomy ( 22 , 23 ). However, there is no clear evidence of its clinical benefit and the performance of bursectomy is controversial.…”

“…The most important cause of morbidity is a leak due to pancreatic injury (pancreatic fistula). In addition, skeletonization of the mesocolon and pancreas may lead to adhesion formation, which may cause intestinal obstruction, afferent loop syndrome and delayed gastric emptying ( 22 ). Blouhos et al ( 22 ) observed five intraoperative complications (spleen injury in two patients, common bile duct injury in one patient and portal vein injury in two patients) in their prospective cohort study that included 72 patients.…”

“…In addition, skeletonization of the mesocolon and pancreas may lead to adhesion formation, which may cause intestinal obstruction, afferent loop syndrome and delayed gastric emptying ( 22 ). Blouhos et al ( 22 ) observed five intraoperative complications (spleen injury in two patients, common bile duct injury in one patient and portal vein injury in two patients) in their prospective cohort study that included 72 patients. The authors reported a post-operative complication rate of 19.4% and they observed three pancreatic fistulas (two grade As, one grade B) ( 22 ).…”

“…Blouhos et al ( 22 ) observed five intraoperative complications (spleen injury in two patients, common bile duct injury in one patient and portal vein injury in two patients) in their prospective cohort study that included 72 patients. The authors reported a post-operative complication rate of 19.4% and they observed three pancreatic fistulas (two grade As, one grade B) ( 22 ). There are various studies concerning the safety of bursectomy in the literature.…”

Total meso-esophagogastrectomy in surgically resectable Siewert type II-III junctional gastric cancer: Safety and long term oncologic outcome

“…Yet, it remains a complex surgical procedure, requiring meticulous dissection along anatomo-embryological avascular surgical planes, especially in bursectomy, which is the main source of morbidity [25,26].…”