Abstract
Background
Gastric cancer (GC) is one of the most common causes of cancer-related deaths worldwide. Gastrectomy with lymph node dissection is the standard treatment for GC worldwide. Due to advancements in surgical techniques, the use of laparoscopic gastrectomy (LG) has broadened. However, the incidence of post-operative pancreatic fistula (POPF) after LG is higher than that after open surgery, and the definition and measurement of POPF in gastrectomy have not yet been established. We introduced polyglycolic acid (PGA) sheet to prevent POPF after LG and retrospectively evaluated its effectiveness.
Methods
Between April 2022 and June 2024, surgical interventions were performed for 170 patients with GC. Of these patients, 130 underwent LG. Among them, a PGA sheet was used in 62 patients (PGA group), while the remaining 68 patients did not receive PGA sheet (Control group). After propensity score matching, 44 patients were selected for the PGA group and 46 patients for the Control group.
Results
Statistically significant differences in ascitic amylase levels on post-operative day (POD) 1,3 and 5 between the groups were not observed. However, the PGA group showed a significantly greater reduction in the ascitic amylase levels from POD 1 to POD 5 compared with the Control group (p < 0.01). Additionally, no difference was observed in the incidence of Grade IIIa POPF and no POPF greater than Grade IIIb according to the Clavien-Dindo classification.
Conclusions
The use of PGA sheets in LG for GC more pronounced decrease in ascitic amylase levels over time.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12876-026-04650-7.
Keywords: Gastric cancer, Laparoscopic gastrectomy, Post-operative pancreatic fistula, Polyglycolic acid, Ascitic amylase
Background
Gastric cancer (GC) is one of the most common causes of cancer-related deaths in the world [1]. Surgery is the recommended curative treatment for GC, and gastrectomy with lymph node dissection is generally considered the standard treatment for both early and advanced GC.
The advancements in technology and surgical techniques have resulted in less invasive treatments, and broadened laparoscopic and robotic surgery. Increasing evidence of the benefits of laparoscopic gastrectomy (LG) for GC has established it as a standard procedure [2, 3]. However, Hiki et al. reported that the incidence of post-operative pancreatic fistula (POPF) in laparoscopic distal gastrectomy is higher than in open surgery (2.2% vs 1.0%, respectively) [4]. POPF in gastrectomy has not yet been defined and can lead to fatal complications, such as bleeding, anastomosis leakage, and intra-abdominal abscesses. Currently, the development of POPF cannot be completely prevented. Although clear criteria for amylase levels have not yet been established in gastrectomy, intraperitoneal ascitic amylase levels on post-operative day (POD) 1 and 3 have been associated with POPF [5, 6]. In contrast, in pancreatic surgery, Jang et al. performed a prospective study on the effect of wrapping a polyglycolic acid (PGA) sheet (a bioabsorbable recombinant membrane made of a synthetic polymer with a cellulose-like structure) around the pancreatic resection surface to prevent POPF after distal pancreatectomy (DP) and reported a significant reduction rate of relevant POPF [7].
Based on the findings of these studies, we introduced a PGA sheet to reduce POPF in LG for GC and retrospectively evaluated its effectiveness.
Methods
Patient selection
Between April 2022 and June 2024, 170 surgical interventions were performed for GC. Five cases of anastomosis leakage, one case of postoperative hemorrhage, one case of perioperative death caused by other disease, six cases involving gastric-jejunal bypass surgery, five cases involving staging laparoscopy, fourteen cases involving laparotomy, and eight cases involving simultaneous colorectal cancer surgery were excluded.
After these 40 cases were excluded, 130 involving LG for GC were included (Fig. 1). The pathological stage was diagnosed according to the 8th International Union Against Cancer Tumor-Node-Metastasis classification [8]. A PGA sheet was used for 62 patients who met the criteria described below (PGA group) but not for 68 patients (Control group) (Fig. 1). After propensity score matching (PSM), 44 patients were selected for the PGA group and 46 patients for the Control group (Fig. 1).
Fig. 1.
Flowchart of participant inclusion in the present study
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation, the Declaration of Helsinki of 1964, and later versions. Prior to surgery, written informed consent or equivalent consent to participate in this study was obtained from all patients.
This study was approved by the Institutional Review Board of the Onomichi General Hospital Ethics Review Committee (Approval No. OJH-202438).
Surgical procedure
Preoperative images were used to identify the tumor location and progression in all cases.
We performed laparoscopic proximal gastrectomy (LPG) with double tract reconstruction or modified side overlap esophagogastrostomy (mSOFY), laparoscopic distal gastrectomy (LDG) with Billroth-I (B-I) or Roux-en-Y (RY) reconstruction, and laparoscopic total gastrectomy (LTG) with RY reconstruction according to the Japanese treatment guidelines and recent reports of surgical techniques [2, 9, 10]. At the end of surgery, the abdominal cavity was washed with 1,000 mL of warm saline and a closed suction drain was placed on the upper border of the pancreas.
Gastrointestinal surgeons with more than 15 years of experience served as the operator and first assistant in all surgeries. Each operator and first assistant pair performed more than 40 cases of GC by LG annually, and the combination of operator and first assistant remained consistent all procedures. In addition, three surgeons who each performed at least 60 laparoscopic surgeries for GC or colorectal cancer per year were selected as camera assistant. All surgeries were supervised by the same senior surgeon. While some surgical team members varied, the core techniques and decisions were consistently performed under the direction of this surgeon.
Criteria for PGA sheet application
The 0.15-mm PGA sheet (Neoveil; GUNZE MEDICAL, Japan) is an absorbable reinforcing material and gradually loses its strength through hydrolysis and is absorbed by the body within approximately 15 weeks. This sheet (10 cm × 5 cm) was cut into eight pieces (2.5 cm × 2.5 cm per piece) and applied to cover the surface and upper margin of the parenchyma of pancreatic head and body at the site of lymph node dissection before the placement of the closed suction drain (Fig. 2). The decision to use a PGA sheet was made by the surgical team, including the operator, first assistant, and camera assistant, and it was applied in cases with grossly exposed pancreatic parenchyma, thermal injury caused by energy devices, saponification, or excessive compression of the pancreas during surgery.
Fig. 2.
The PGA sheet was applied to cover the pancreatic head (a) and upper border of the pancreatic parenchyma (b) where lymph node dissection was performed
Analysis of ascitic and serum amylase levels and the POPF grade
The intraperitoneal fluid volume in the closed suction drain was checked daily and ascitic amylase levels of the drainage fluid were measured on POD 1, 3, and 5. Serum amylase levels were also measured in POD 1,3,5, and 7. The decreasing rate of the ascitic amylase levels in drainage fluid from POD 1 to 3 and 1 to 5 was calculated as follows: decreasing rate = (ascitic amylase level on POD 1 − ascitic amylase level on POD 3 or 5)/ascitic amylase level on POD 1 × 100%.
We adopted the Clavien-Dindo (C-D) grading system to determine the POPF grade [11]. POPF classified as Grade III or higher was considered clinically problematic and required invasive intervention.
Criteria for intraperitoneal drain removal and exchange
The suction drain was removed on POD 5 or later when the following criteria were met: no fever elevation, serous ascites in the drain, ascitic amylase levels < 100 U/L in the drain and resumption of oral intake. For patients with intense inflammation and potentially insufficient drainage of the abdominal cavity, the drainage tube was exchanged and its location was adjusted under radiographic guidance to maintain optimal drainage after POD 7.
Statistical analysis
All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). More precisely, it is a modified version of the R commander designed to add statistical functions frequently used in biostatistics [12]. Student’s t-test or Welch`s t-test and the chi-squared test were used to compare baseline characteristics and clinicopathological parameters between the PGA and Control groups (Tables 1, 2 and 3). Welch`s t-test was used to compare the decreasing rates of ascitic amylase levels between the PGA and Control groups (Fig. 3). Statistical significance was defined as P < 0.05. To ensure an accurate analysis of the results, we used PSM to minimize bias between the two groups. One-to-one nearest-neighbour matching was performed using a caliper width of 0.02.
Table 1.
Comparison of baseline clinical characteristics between PGA and Control groups
| Parameter | Before propensity score matching | After propensity score matching | ||||
|---|---|---|---|---|---|---|
| PGA group n = 62 | Control group n = 68 | p | PGA group n = 44 | Control group n = 46 | p | |
| (%) | (%) | (%) | (%) | |||
| Age | 71.6 ± 1.6 | 71.3 ± 1.3 | 0.928 | 70.6 ± 1.9 | 71.8 ± 1.7 | 0.691 |
| Sex | ||||||
| Male | 47 (75.8) | 46 (67.6) | 0.404 | 32 (72.7) | 31 (67.4) | 0.747 |
| Female | 15 (24.2) | 22 (32.4) | 12 (27.3) | 15 (32.6) | ||
| BMI, kg/m2 | 24.1 ± 0.7 | 21.9 ± 1.0 | 0.289 | 24.6 ± 0.7 | 22.1 ± 1.7 | 0.171 |
| Smoking | ||||||
| Yes | 37 (59.7) | 42 (61.8) | 0.949 | 27 (61.4) | 26 (56.5) | 0.801 |
| No | 25 (40.3) | 26 (38.2) | 17 (38.6) | 20 (43.5) | ||
| Comorbidity | ||||||
| Yes | 41 (66.1) | 40 (58.8) | 0.498 | 27 (61.4) | 28 (60.9) | 1 |
| No | 21 (33.9) | 28 (41.2) | 17 (38.6) | 18 (39.1) | ||
| Energy device | ||||||
| Vessel sealing system | 4 (6.5) | 5 (7.4) | 1 | 1 (2.3) | 3 (6.5) | 0.641 |
| Ultrasonic coagulation cutting device | 58 (93.5) | 63 (92.6) | 43 (97.7) | 43 (93.5) | ||
| Surgical procedure | ||||||
| LPG | 6 (9.7) | 9 (13.2) | 0.802 | 6 (13.6) | 7 (15.2) | 0.799 |
| LDG | 50 (80.6) | 52 (76.5) | 34 (77.3) | 33 (71.7) | ||
| LTG | 6 (9.7) | 7 (10.3) | 4 (9.1) | 6 (13.1) | ||
| Reconstruction | ||||||
| double tract | 2 (3.2) | 4 (5.9) | 0.896 | 2 (4.5) | 2 (4.3) | 0.98 |
| mSOFY | 4 (6.4) | 5 (7.4) | 4 (9.0) | 5 (10.9) | ||
| B-I | 22 (35.5) | 24 (35.3) | 17 (38.6) | 16 (34.8) | ||
| RY | 34 (54.9) | 35 (51.2) | 21 (47.9) | 23 (50) | ||
| Lymph node dissection | ||||||
| D1 | 6 (9.7) | 9 (13.2) | 0.719 | 3 (6.8) | 9 (19.6) | 0.142 |
| D1 +/D2 | 56 (90.3) | 59 (86.8) | 41 (93.2) | 37 (80.4) | ||
| Operation time, min | 320.3 ± 11.2 | 297.8 ± 9.3 | 0.114 | 322.9 ± 14.4 | 306.7 ± 9.2 | 0.342 |
| Bleeding, cc | 38.1 ± 6.5 | 26.8 ± 6.3 | 0.191 | 33.6 ± 6.5 | 29.1 ± 7.4 | 0.651 |
| Length of hospital stay, day | 16.1 ± 1.2 | 17.4 ± 1.7 | 0.617 | 15.2 ± 1.0 | 18.9 ± 2.1 | 0.132 |
Values are mean ± standard deviation
PGA polyglycolic acid, BMI body mass index, LPG laparoscopic proximal gastrectomy, LDG laparoscopic distal gastrectomy
LTG laparoscopic total gastrectomy, mSOFY modified side overlap esophagogastrostomy, B-I Billroth-I, RY Roux-en-Y
Table 2.
Comparison of pathological characteristics between PGA and Control groups
| Parameter | Before propensity score matching | After propensity score matching | ||||
|---|---|---|---|---|---|---|
| PGA group n = 62 | Control group n = 68 | p | PGA group n = 44 | Control group n = 46 | p | |
| (%) | (%) | (%) | (%) | |||
| Tumor location | ||||||
| E | 0 (0) | 1 (1.5) | 0.593 | 0 (0) | 1 (2.2) | 0.701 |
| U | 10 (16.1) | 14 (20.6) | 8 (18.2) | 10 (21.7) | ||
| M | 35 (56.5) | 39 (57.3) | 26 (59.1) | 27 (58.7) | ||
| L | 17 (27.4) | 14 (20.6) | 10 (22.7) | 8 (17.4) | ||
| Histopathology | ||||||
| intestinal | 17 (27.4) | 30 (44.1) | 0.0357 | 14 (31.8) | 14 (30.4) | 0.591 |
| diffuse | 19 (30.6) | 23 (33.8) | 13 (29.5) | 18 (39.2) | ||
| mixed | 26 (42) | 15 (22.1) | 17 (38.7) | 14 (30.4) | ||
| pT | ||||||
| 1 | 26 (42) | 40 (58.8) | 0.0241 | 25 (56.8) | 22 (48) | 0.647 |
| 2 | 4 (6.4) | 10 (14.7) | 3 (6.8) | 6 (13) | ||
| 3 | 16 (25.8) | 6 (8.8) | 7 (15.9) | 6 (13) | ||
| 4 | 16 (25.8) | 12 (17.7) | 9 (20.5) | 12 (26) | ||
| pN | ||||||
| 0 | 34 (54.8) | 47 (69.1) | 0.134 | 29 (65.9) | 28 (60.9) | 0.782 |
| 1,2,3 | 28 (45.2) | 21 (30.9) | 15 (34.1) | 18 (39.1) | ||
| ly | ||||||
| 0 | 30 (48.4) | 45 (66.2) | 0.0611 | 28 (63.6) | 27 (58.7) | 0.792 |
| 1a,1b,1c | 32 (51.6) | 23 (33.8) | 16 (36.4) | 19 (41.3) | ||
| v | ||||||
| 0 | 54 (87.1) | 61 (89.7) | 0.849 | 39 (88.6) | 41 (89.1) | 1 |
| 1a,1b,1c | 8 (12.9) | 7 (10.3) | 5 (11.4) | 5 (10.9) | ||
| pStage | ||||||
| I | 25 (40.3) | 46 (67.6) | < 0.01 | 25 (56.8) | 24 (52.2) | 0.818 |
| II,III,IV | 37 (59.7) | 22 (32.4) | 19 (43.2) | 22 (47.8) | ||
Table 3.
Comparison of postoperative laboratory and drain-related data between PGA and Control groups
| Parameter | Before propensity score matching | After propensity score matching | |||||
|---|---|---|---|---|---|---|---|
| PGA group n = 62 | Control group n = 68 | p | PGA group n = 44 | Control group n = 46 | p | ||
| Drainage volume (cc) | POD 1 | 156.9 ± 18.9 | 126.9 ± 16.3 | 0.215 | 165.9 ± 25.0 | 126.0 ± 20.0 | 0.824 |
| POD 3 | 90.9 ± 11.1 | 80.9 ± 9.8 | 0.482 | 99.2 ± 15.0 | 74.6 ± 8.3 | 0.15 | |
| POD 5 | 54.2 ± 10.8 | 68.2 ± 12.7 | 0.818 | 73.5 ± 14.1 | 68.9 ± 11.9 | 0.804 | |
| Ascitic amylase (U/L) | POD 1 | 585.5 ± 81.5 | 576.4 ± 86.6 | 0.939 | 622.1 ± 104.9 | 657.4 ± 118.3 | 0.824 |
| (35–4259) | (15–3603) | 52–4259 | (15–3603) | ||||
| POD 3 | 182.1 ± 35.8 | 153.1 ± 37.4 | 0.559 | 211.3 ± 49.5 | 124.0 ± 17.1 | 0.094 | |
| (21–1859) | (9–2219) | 21–1859 | (9–512) | ||||
| POD 5 | 74.9 ± 9.2 | 131.0 ± 35.4 | 0.132 | 76.5 ± 11.6 | 101.8 ± 19.7 | 0.265 | |
| (9–350) | (12–1916) | 14–350 | (12–619) | ||||
| Serum amylase (U/L) | POD 1 | 164.2 ± 28.7 | 252.4 ± 62.1 | 0.18 | 181.7 ± 37.9 | 242.8 ± 81.3 | 0.452 |
| POD 3 | 74.5 ± 10.9 | 101.5 ± 16.9 | 0.153 | 81.9 ± 14.4 | 91.5 ± 18.0 | 0.724 | |
| POD 5 | 80.3 ± 11.3 | 91.0 ± 11.6 | 0.524 | 88.3 ± 14.8 | 84.7 ± 18.9 | 0.899 | |
| Clavien-Dindo classification | I/II/IIIa | 30/28/4 | 41/20/7 | 0.166 | 22/19/3 | 27/14/5 | 0.422 |
| Grade | Biochemical Leak/B/C | 4/19/0 | 12/9/0 | 0.574 | 3/14/0 | 9/7/0 | 0.052 |
| Drain removal (POD) | 6.8 ± 0.3 | 6.8 ± 0.3 | 0.946 | 7.1 ± 0.4 | 6.8 ± 0.4 | 0.629 | |
Values are mean ± standard deviation
Biochemical Leak: amylase > 3 times upper limit institutional serum amylase value
Grade B: Persistent drainage > 3 weeks after operation or need to reposition the operatively placed drains through interventional image-guided or signs of infection without organ failure
Grade C: reoperation or organ failure or death
PGA polyglycolic acid, POD post-operative day
Fig. 3.
Comparison of the rate of decrease in ascitic amylase levels between the PGA and Control groups from POD 1 to 3 and POD 1 to 5, both before PSM (a, b) and after PSM (c, d)
This study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [13] and STROBE checklist [14] to ensure transparency and completeness in reporting observational research (Supplement A).
Results
Background and clinicopathological characteristics of patients
The characteristics of the 130 patients included in this study are summarized in Table 1. A comparison between the PGA and Control groups revealed, no clinical differences in age, sex, body mass index (BMI), smoking status, comorbidity, use of energy devices, surgical procedure, reconstruction, lymph node dissection, operative time, bleeding, or length of hospital stay (Table 1). On the other hand, statistical differences were observed in histopathology, tumor depth and stage, while no differences in tumor location, lymph node metastasis, or vascular invasion were observed (Table 2). No adverse effects, including allergic reactions and infection, attributable to the PGA sheet were observed in the PGA group. After PSM, no statistically significant differences were observed.
Intraperitoneal drain-related factors and serum amylase
After PSM, POPF classified as Grade III or higher according to the C-D classification was observed in 8 of 90 patients (8.89%). Grade IIIa POPF was observed in 3 patients (6.82%) in the PGA group and in 5 patients (10.9%) in the Control group, with no statistically significant difference (p = 0.761). The median length of hospital stay for the 3 patients PGA group patients was 22 days (range 22–27), and for the 5 patients Control group was 32 days (range 15–44), also with no statistically significant difference (p = 0.318). In both groups, POPF classified as Grade IIIb or higher was not observed.
There were no statistically significant differences between the PGA and Control groups in C-D classification, drain replacement, indwelling period, drainage ascitic volume, or ascitic amylase level on POD1,3, and 5. In addition, no differences in serum amylase levels on POD1,3, and 5 were observed (Table 3).
Decreasing rate of ascitic amylase levels
The rate of decrease in ascitic amylase levels was calculated using the aforementioned formula. Before PSM, there was no statistically significant difference in the rate of decrease in ascitic amylase levels between the PGA and Control groups from POD 1 to 3 (p = 0.0524). However, a statistically significant difference was observed in the rate of decrease from POD 1 to 5 (p < 0.01) (Fig. 3a, b). These findings and trends remained consistent after PSM (Fig. 3c, d).
Discussion
The International Study Group of Pancreatic Fistula proposed the definition of POPF in 2005 and updated the grading of POPF in 2016, which has been used internationally [15]. The definition of POPF after pancreatectomy is as follows: any measurable volume of drain fluid on POD 3 with drain amylase level > 3 times the serum amylase level for each specific institution is the necessary threshold and is graded as Biochemical Leak (BL), Grade B, or Grade C. For reference, when this definition was applied after PSM, the incidence of pancreatic leakage in the PGA group was 38.6% (BL in 3 cases and Grade B in 14 cases), compared with 34.8% in the Control group (BL in 9 cases and Grade B in 7 cases) (Table 3). Although there was a trend toward a higher incidence of Grade B in the PGA group, no statically significant difference was observed (Table 3). In the PGA group, more drain replacements were performed, which may have contributed to the increased incidence of Grade B. However, no clear definition of POPF after gastrectomy exists, and this definition is not directly applicable. Ascitic amylase levels on POD 1 and 3 are associated with POPF in LG [5, 6]; therefore, ascitic amylase levels up to POD 3 influence the extent of POPF in gastrectomy, similar to pancreatectomy cases. Taniguchi et al. reported that an ascitic amylase level > 2100 U/L on POD 3 was a risk factor for POPF classified as C-D Grade II or higher [5]. Meanwhile, Kamiya et al. reported that ascitic amylase levels > 2218 U/L on POD 1 and > 555 U/L on POD 3 are risk factors for POPF classified as C-D Grade III or higher [6]. Therefore, the cut-off values for ascitic amylase levels as a risk factor for POPF vary. In our study, the maximum ascitic amylase levels on POD 1 and 3 were 964 U/L and 230 U/L, respectively for the 4 patients with POPF classified as C-D Grade IIIa in the PGA group. Additionally, the maximum ascitic amylase levels on POD 1 and 3 were 1385 U/L and 614 U/L, respectively for the 7 patients with POPF classified as C-D Grade IIIa in the Control group.
Generally, higher ascitic amylase levels are associated with a greater likelihood of complications such as bleeding, anastomotic leakage, and intra-abdominal abscess. Therefore, methods for reducing ascitic amylase levels are needed. Risk factors for POPF have been reported, including male sex, BMI, smoking, pancreatic morphology (protrusion of the pancreatic head), thermal damage from energy devices and firm compression of the pancreas using forceps [16, 17]. Among these risk factors, male sex, BMI, smoking and pancreatic morphology are patient factors and, therefore, challenging to address preoperatively. However, thermal damage caused by energy devices and firm compression of the pancreas by forceps are surgical factors that can be avoided. For thermal damage by energy devices, Irino et al. reported that the novel “Hit and Away” technique reduced POPF [18], and Tsujiura et al. reported that the novel “Pancreas-Compressionless Gastrectomy” technique for compression of the pancreas using forceps reduced POPF [19]. However, these techniques are not easy to stabilize in terms of surgical outcomes (reducing the incidence of POPF) owing to the different anatomical variations of individual cases and the varying skills of surgeons.
Therefore, based on animal experimental models using PGA sheet in pancreatectomy [20] and prospective studies that demonstrated the efficacy of PGA sheet for POPF after DP [7], we used PGA sheet in LG when the risk of POPF was considered high. PGA sheet causes an inflammatory response immediately after insertion and hydrolyzes, infiltrating granulation tissue and covering the wound site of the pancreatic parenchyma [7, 21]. A recent multicenter prospective study demonstrated the efficacy of PGA sheet for laparoscopic or robotic DP in preventing severe POPF [22]. In addition, the effectiveness of PGA sheet has also been reported in various areas of surgery; for example, these sheets reduce bile leakage and hemorrhage after hepatectomy [23] or air leakage after lung wedge resection [24]. In this study, the PGA sheet was applied to cover the pancreatic head and the surface and upper border of the pancreatic parenchyma (Fig. 2). No statistically significant difference was found in the rate of decrease in ascitic amylase levels from POD 1 to 3 (p = 0.211); however, a statistically significant difference was observed from POD 1 to 5 (p < 0.01) (Fig. 3c, d). These results suggest that a PGA sheet may not completely prevent POPF but may reduce ascitic amylase levels. The use of a PGA sheet is simple and can be easily introduced as a preventive measure for POPF. Recently, Iwasaki et al. reported the effectiveness of PGA sheet for the prevention of POPF; however, no contributing factors were identified in their study [25]. In the present report, we hypothesized that the use of PGA sheets promotes a more rapid decrease in ascitic amylase levels, thereby reducing the incidence of severe pancreatic fistula-related complications. To the best of our knowledge, this is the first report to demonstrate the effectiveness of PGA sheets in reducing ascitic amylase levels in LG for GC.
This study had some limitations. First, this was a retrospective, single-center study with a small sample size. Second, POPF classified as C-D classification IIIb or higher was not included; therefore, we could not prove whether PGA sheet is effective for more severe POPF. Third, the decision to use a PGA sheet was made intraoperatively, at the discretion of the surgeons, and the criteria for its use were not standardized of quantified, which may introduce selection bias. A larger multicenter prospective trial is needed to reduce selection bias and determine its efficacy. However, PGA sheet is considered a viable option for preventing POPF in LG.
Conclusions
The use of a PGA sheet in LG has been shown to contribute to greater reduction in ascitic amylase levels. However, studies with larger populations are needed to confirm its effectiveness in preventing POPF classified as C-D Grade IIIb or higher.
Supplementary Information
Acknowledgements
We would like to thank Editage (www.editage.com) for English language editing.
Abbreviations
- GC
Gastric cancer
- LG
Laparoscopic gastrectomy
- POPF
Post-operative pancreatic fistula
- POD
Post-operative day
- PGA
Polyglycolic acid
- PSM
Propensity score matching
- STROBE
Strengthening the Reporting of Observational Studies in Epidemiology
- DP
Distal pancreatectomy
- LPG
Laparoscopic proximal gastrectomy
- mSOFY
Modified side overlap esophagogastrostomy
- LDG
Laparoscopic distal gastrectomy
- B-I
Billroth-I
- RY
Roux-en-Y
- LTG
Laparoscopic total gastrectomy
- C-D
Clavien-Dindo
- BMI
Body mass index
- BL
Biochemical Leak
Authors’ contributions
Conceptualization, S.Y. and Y.Y.; methodology, S.Y. and Y.Y.; formal analysis, S.Y.; investigation, S.Y. and Y.Y.; resources, S.Y. and Y.Y. and T.N and M.Y. and S.S. and K.T. and M.N.; data duration, S.Y. and Y.Y.; writing-original draft preparation, S.Y.; writing review and editing, S.Y. and Y.Y. and T.N. and M.Y. and S.S. and K.T. and M.N. and T.N.; visualization, S.Y.; supervision, T.N.; project administration Y.Y. All authors read and approved the final manuscript.
Funding
This research received no external funding.
Data availability
The data analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Written informed consent to use PGA sheet (Neoveil) was obtained from all patients before surgery.
This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the Onomichi General Hospital Ethics Review Committee (OJH-202438).
Consent for publications
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data analyzed during the current study are available from the corresponding author on reasonable request.