Pancreatic fistula as a pivotal prognostic factor among postoperative complications in gastric cancer

Recent studies have identified that postoperative infectious complications (PICs) have contributed to poor prognosis in gastric cancer (GC). In this study, we investigated which complication among PICs most strongly contributes to a poor prognosis. This study included 1,653 consecutive patients who underwent curative gastrectomy for GC between 1997 and 2018. A Clavien-Dindo classification of grade II or higher was used as a cut-off for PICs. PICs occurred in 17.1% of all GC patients. Patients with a PIC had a poorer prognosis than those without [Hazard ratio (HR): 17.5, P < 0.001]. Among PICs, pancreatic fistula (PF) had the strongest effect on poor prognosis (HR: 3.16) compared to anastomotic leakage (HR: 2.41), pneumonia (HR: 2.11) and intra-abdominal abscess (HR: 1.98). Multivariate analysis on pStage II or III GC showed that PF had the strongest poor prognostic effect (P = 0.025, HR: 2.21, 95%-CI: 1.07-3.99). Patients with PF had significantly higher C-reactive protein (CRP) levels on postoperative days 1 (P = 0.039) and 3 (P = 0.044), tended to experience a prolonged period of high inflammation, with CRP levels above 10 mg/dL (P = 0.086), and had the highest incidence of recurrence compared to other PICs. Robotic gastrectomy had no incidence of PF, while open gastrectomy resulted in a 2% occurrence, and laparoscopic gastrectomy had a 1.8% occurrence. In conclusion, PF had the strongest effect on poor prognosis among PICs. Robotic gastrectomy might be the optimal approach for avoiding PF.