Stratification of operation volumes in planned surgical treatment of gastric diseases as a risk factor for perioperative complications

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INTRODUCTION

Despite the significant advances in modern medical technology, surgical intervention remains the primary method of treating stomach diseases; this is particularly relevant in the case of malignant solid tumors of this organ, the most common of which is stomach cancer. This is due to the fact that tumors in this location rank among the leading causes of cancer incidence both globally and in the Russian Federation. According to data from the International Agency for Research on Cancer for 2022, approximately 38,900 new cases of stomach cancer are registered in Russia each year, and the age-standardized incidence rate is approximately 13.7 per 100,000 population, which exceeds the global average [1]. According to the results of epidemiological studies in Russia for 2012–2021, the incidence and mortality rates for stomach cancer remain at a consistently high level, with a significant proportion of patients still being diagnosed at advanced stages of the disease [2]. Furthermore, according to the Global Burden of Disease (GBD 2021), gastric cancer remains one of the leading causes of cancer mortality, ranking among the top ten most significant malignant tumors in terms of years of life lost and the global burden of disease [3]. This underscores the clinical importance of making an informed choice of surgical approach, determining the optimal extent of intervention, and establishing a strategy for postoperative patient management. The high prevalence of the disease and the continuing severity of perioperative complications have led to sustained interest in the surgical treatment of gastric cancer in both international and Russian scientific literature, as reflected in a number of review and analytical publications [4, 5].

In cases of malignant neoplasms, the extent of surgery can vary considerably. As a rule, radical surgery involves gastric resection or gastrectomy with mandatory lymph node dissection within the regional lymphatic drainage area. The latter is strictly regulated by clinical guidelines depending on the location of the primary lesion and the histological structure of the tumor [6]. In contrast, in benign conditions, limited, organ-preserving resections aimed at eliminating the local pathological process are more commonly performed. In clinical practice, locally advanced tumor spread is also not uncommon, wherein the primary tumor infiltrates adjacent regions. In such cases, resection of the affected organs is required to ensure the radicality of the surgical intervention. Additional resection volumes may include both parenchymal organs and anatomical structures, the removal of which requires the formation of additional anastomoses during the reconstructive phase [7]. These variants of combined and extended procedures directly influence the perioperative risk profile, leading to a higher incidence of intraoperative and early postoperative complications associated with increased surgical trauma and, consequently, increased blood loss and prolonged operative time [7, 8].

In related surgical disciplines—gynecology, urology, colorectal and cardiac surgery—systems for stratifying procedures according to the level of surgical trauma have already been developed, allowing for the objective assessment of risks, standardization of data, and comparison of treatment outcomes [9–11]. However, despite the significant volume of published data, there is currently no unified classification in gastric surgery that allows operations to be systematically ranked according to the level of surgical trauma, the associated technical complexity, and the potential risks of possible complications. This complicates the interpretation of clinical outcomes, limits the ability to predict complications, and hinders the standardization of surgical practice.

It should be emphasized that this study focuses exclusively on elective surgical procedures for gastric conditions. The proposed classification does not apply to emergency surgery and life-threatening conditions (peritonitis, massive hemorrhage), nor to various types of bariatric surgery, as the latter are performed on a morphologically intact stomach and have a different pathophysiological and clinical basis. The analysis of risk factors in this study is based on an assessment of the extent of resection and the degree of surgical trauma, rather than on the characteristics of a specific nosological form.

Consequently, there is a need to develop a structured classification of surgical procedures on the stomach, allowing for the objective stratification of operations according to the level of surgical trauma and the associated risk of perioperative complications.

The objective of this study is to formulate and present the authors’ concept of stratifying the extent of surgical interventions in elective treatment of gastric diseases as a risk factor for perioperative complications, based on an analytical systematization of the literature

RESEARCH METHODS

This study is presented as the author’s perspective, based on an analytical review of contemporary Russian and international literature on the surgical treatment of gastric diseases, the extent of surgical procedures, and the pattern of perioperative complications.

To establish the conceptual framework of the study, an analysis was conducted of publications available in the PubMed, Scopus, Web of Science, Cochrane Library and RINC databases. Clinical studies, national and international registries, systematic reviews and meta-analyses, as well as international and domestic clinical guidelines reflecting modern approaches to the surgical treatment of gastric diseases, were considered.

In the literature review, priority was given to studies with clearly described surgical procedures, characteristics of their scope and the structure of perioperative complications, as well as publications allowing for the comparison of different types of operations with the level of surgical trauma. The selected literature data were used not for a quantitative assessment of effects, but to identify consistent clinical patterns and provide a conceptual basis for the authors’ proposed classification of gastric surgical procedures according to the level of surgical trauma and the associated risk of perioperative complications.

CLASSIFICATION OF SURGICAL PROCEDURES ON THE STOMACH BASED ON THEIR TRAUMATICITY

Level I. Limited Organ-Preserving Procedures

Surgical treatment of localized gastric lesions of various aetiologias—both neoplastic and non-neoplastic (including early-stage neoplastic forms, benign neoplasms, peptic ulcer disease requiring elective surgery, and other therapeutic conditions)— may be performed as limited organ-preserving procedures, involving resection of the pathological area within the gastric wall without involving adjacent anatomical structures. The choice of the extent of resection is closely linked to the characteristics of the pathological process and the criteria for the oncological appropriateness of organ-preserving surgery. It has been shown that performing local resection for limited gastric tumors, not accompanied by signs of regional metastasis or deep wall infiltration, provides adequate local control of the disease without increasing the incidence of serious early complications or the risk of recurrence. This is confirmed by the findings of Koga et al. (2015), who demonstrated comparable immediate surgical outcomes with strict adherence to indications [12]. Similar results were demonstrated in the series by Ghoneim et al. (2025), where wedge resection for small lesions was associated with a minimal incidence of adverse outcomes and short-term functional impairments [13]. In the studies by Cai et al. (2015), complications were predominantly associated with local hemostatic difficulties and inflammatory reactions in the wound area [14], which is confirmed by the observations of Goh et al. (2015), indicating rare episodes of early bleeding and the need for infusion therapy [15]. These sources note that local operations without regional lymph node dissection are characterized by an extremely low risk of re-intervention.

The most common types of such operations are wedge resection and partial gastrectomy involving up to two-thirds of the organ. Such a scope of intervention is limited to the area of the primary pathological focus and, as a rule, does not require extension of the surgical field to adjacent organs, which ensures a low level of tissue trauma. During limited resections, the main vascular structures are not transected, so no significant disruption to the blood supply to the stomach occurs, and the risk of ischemic complications in the area of the surgical sutures remains minimal. This, in turn, reduces the likelihood of early local postoperative complications, such as anastomotic leakage, obstruction, and transient disturbances in gastric emptying.

Analysis of the clinical data presented revealed that local gastric resections are characterized by favorable immediate surgical outcomes and are classified as minimally invasive procedures.

In a study by Koga et al. (2015), the incidence of clinically significant complications of Clavien–Dindo category III and above following local resections was 8–12% [12]. Similar complication rates were demonstrated by Ghoneim et al. (2025) in an analysis of wedge resections of the stomach [13]. Comparative studies by Cai et al. (2015) showed no increase in the incidence of severe complications with local resections compared to alternative techniques [14]. Similar conclusions are presented in the work of Goh et al. (2015), where local interventions were accompanied predominantly by mild and transient complications [15].

The most common complications are local wound complications and transient changes in gastric emptying function, which, as a rule, resolve with conservative treatment and very rarely require repeat surgical intervention.

Thus, marginal and partial gastric resections demonstrate a minimal level of surgical trauma and a low incidence of clinically significant complications and can be classified into a separate category of surgical trauma—level I. Their distinguishing features are the preservation of the main arterial trunks of the stomach, a minimal reconstructive phase, a limited extent of intraoperative manipulation, and a predictable course of the early postoperative period. Against a background of increased surgical extent, the inclusion of various lymph node dissection options, transection of major vascular structures, and the creation of anastomoses, surgical trauma increases, which naturally raises the risks of perioperative complications and corresponds to a transition to Level II procedures—standard gastrectomy or subtotal gastric resections with regional lymph node dissection (D1+/D2).

Level II. Subtotal Resections and Gastrectomies with Regional Lymph Node Disection

Operations classified at this level are characterized by a significant extent of gastric resection and differ fundamentally from Level I procedures in both the amount of tissue removed and the nature of the surgical trauma. This level includes both subtotal (distal and proximal) resections and total gastrectomies. Despite differences in the extent of the organ removed, these procedures have key common features: the need to transect major arterial branches, perform regional lymph node dissection, and include a reconstructive phase involving the creation of anastomoses. These very features of the procedure—regardless of the specific extent of resection—fundamentally distinguish Level II operations from limited Level I resections and determine the higher level of surgical trauma. Standard subtotal resection or gastrectomy with lymph node dissection is the standard oncological procedure for gastric cancer and involves subtotal or total gastrectomy with D1+ or D2 regional lymph node dissection. These operations aim to achieve R0 resection with removal of the primary tumor and regional lymph nodes in accordance with international and national clinical guidelines. Despite the standardization of the technique, gastrectomy is accompanied by significant anatomical and physiological changes and is considered a procedure with a higher level of surgical trauma compared to limited resections performed for localized gastric lesions.

In recent years, the international classification of complications by the Gastrectomy Complications Consensus Group (GCCG) has been proposed, designed to standardize the assessment of adverse events following gastrectomy. An analysis of the NEO/Dutch Upper GI Cancer Audit national registry shows that the overall incidence of postoperative complications following gastrectomy reaches 24–38%, whilst serious complications (Clavien–Dindo ≥III) occur in 6–12% of patients. In the study by Visser et al. (2024), the most common complications were intra-abdominal abscesses, anastomotic leakage and postoperative infections, with a mortality rate of approximately 2% [16].

Similar results are presented in the Finnish national retrospective analysis by Putila et al. (2023), which included patients with gastric adenocarcinoma. The overall complication rate was 32.5%, serious complications (Clavien–Dindo ≥IIIa) were observed in 10.4% of cases, and the 30-day mortality rate reached 3% [17]. These data are comparable with the results of studies from other regions of the world and emphasize that standard gastrectomy remains a procedure with a moderate level of surgical trauma and a significant risk of adverse outcomes [18].

Earlier studies (Zilberstein et al., 2004) demonstrated an even higher complication rate, reaching 20–40%, which is partly explained by the absence of modern principles of intraoperative monitoring, ERAS approaches and laparoscopic techniques [19]. Recent studies (Yu et al., 2024; Van Hootegem et al., 2025) confirm a downward trend in the overall incidence of complications; however, the risk of serious events remains stable at around 8–12% [20–21].

Postoperative complications following gastrectomy include a wide range of conditions, the most clinically significant of which are:

• duodenal stump insufficiency, the incidence of which, according to Paik et al. (2016), is 1.1–5%; this complication is associated with high mortality and requires comprehensive management [22];
• chylous ascites, occurring in 1.0–2.7% of patients, predominantly following D2 lymphadenectomy, due to damage to the lymphatic vessels [23];
• intra-abdominal abscesses, the incidence of which reaches 4–8% in large registries;
• inconsistency of esophagojejunal anastomosis following total gastrectomy, characterized by a severe course and prolonged treatment; according to Jeong et al. (2023), this occurs in 4–9% of cases [24];
• bleeding and early infectious complications, accounting for up to 10–15% of all adverse events according to the GCCG.
• postoperative pancreatitis, which reaches 9% according to Wu Zong et al. (2023) [25].

Stomel et al. (2016) point out that the development of severe postoperative complications, such as anastomotic leakage or infected intra-abdominal fluid collections (abscesses), not only has short-term clinical consequences but also is associated with poorer long-term treatment outcomes. This underscores the clinical importance of preventing and detecting complications early, the frequency and severity of which are largely determined by the extent and technical complexity of the surgical procedure [26].

In conclusion, standard gastrectomy with lymph node dissection is a procedure involving moderate surgical trauma, accompanied by a moderate but consistent risk of postoperative complications. The incidence of serious complications (Clavien–Dindo ≥III) is reported in the literature to be 6–12%, which is significantly higher compared with Grade I procedures. The specific features of the technique, the need to create anastomoses, and the performance of extended lymph node dissection determine the nature of the complications and justify classifying gastrectomy with D1+/D2 lymph node dissection as a separate category of surgical trauma (level II).

Level III. Extended Resections Involving Adjacent Organs

In locally advanced gastric cancer (T4b), accompanied by tumor invasion into neighboring organs or the peritoneum, as well as in cases of marked adhesions, the risk of perioperative complications and mortality increases significantly. This is due to the increased volume of tissue to be resected, the need for more extensive mobilization of the stomach, disruption of anatomical landmarks and the associated technical complexity of the procedure. In such situations, a standard gastrectomy is often insufficient, and there is a need for extended resection with removal of affected adjacent structures or total viscerolysis [27].

The most common variants of extended resection for gastric cancer include splenectomy, distal pancreatectomy and limited liver resections, performed as a single unit with the stomach in the presence of direct tumor invasion. These procedures do not require the creation of additional intestinal anastomoses; however, they are inevitably associated with increased trauma and a higher risk of potential complications.

A systematic review by Schizas et al. (30 studies, 3,362 patients) showed that extended resections of adjacent organs in locally advanced gastric cancer are associated with an overall complication rate of approximately 30–50%, with severe complications (Clavien–Dindo ≥III) occurring on average in 20–35% of cases [28]. In a review by Brar et al. (2012), the incidence of postoperative complications following multi-organ resections ranged from 11.8% to 90.5%, and mortality from 0% to 15%, highlighting the wide variation in outcomes across different anatomical patterns of invasion [29].

In a multicenter Italian study by Pacelli et al. (112 patients with T4b), the overall complication rate was 33.9% and the postoperative mortality rate was 3.6%, with splenectomy, pancreatic tail resection and limited liver resections being the most frequently performed procedures [30]. In the study by Radovanović et al., complications occurred in 26.5% of patients following extended resections, compared with 11.4% following standard gastrectomy, and mortality reached 14.7% (compared with 4.8%) [31].

The study by Dias et al. confirms a significant increase in the risk of severe complications with extended procedures: according to the authors, resection of one or more organs was associated with a significant increase in adverse outcomes (Clavien–Dindo ≥III), which highlights the impact of the increased extent of the procedure on the risk [32]. Recent studies by He et al. (2025) and Vladov et al. also demonstrate an increase in the incidence of complications following resection of adjacent organs, mainly due to pancreatic fistulas, intra-abdominal abscesses and hemorrhage [33, 34].

Splenectomy for gastric cancer is associated with a moderate increase in the incidence of infectious complications and bleeding, with severe complications occurring in an average of 15–20% of cases. Pancreatic resection is traditionally regarded as a higher-risk procedure due to the potential for pancreatic fistulae; in various studies, the incidence of this group of complications reaches up to 30–40%. Limited liver resections lead to increased blood loss and longer operative times, and the overall complication rate is approximately 25–35%, with severe complications occurring in up to 10–15% of cases [29, 30, 34].

In addition, in Level III procedures, pancreatic inflammatory complications, including acute postoperative pancreatitis, play a significant role; this is associated with trauma to the pancreatic parenchyma during extensive resections in the upper abdomen. Pancreatic complications following gastrectomy, including episodes of acute pancreatitis, have been described in clinical studies and highlight the contribution of the trauma associated with the procedure to the pattern of adverse outcomes [25, 35].

Total viscerolysis is another option for extending the scope of the procedure and may be required both in cases of tumor infiltration of the peritoneum and as a result of severe adhesions following previous operations.

According to ten Broek et al. (2013), the performance of adhesiolysis during repeat abdominal procedures is an independent risk factor for perioperative complications and is associated with an increase in the incidence of severe surgical complications to 23–30% compared with 16–18% in operations without adhesiolysis [36].

A study by Stommel et al. (2016) showed that the need for extensive visceral adhesiolysis is associated with a significant increase in the incidence of intraoperative injuries to the intestine and other organs, increased blood loss, and the overall trauma of the procedure [26].

In the most technically challenging clinical situations, the overall incidence of complications following procedures involving extensive adhesiolysis can reach 30–40%, highlighting the high level of surgical risk associated with this category of operations [37, 38].

In view of the above, extended procedures for locally advanced gastric cancer, including resection of adjacent parenchymal organs or total visceral dissection without the formation of additional anastomoses, which correspond to level III, are characterized by a significantly higher incidence of postoperative complications and mortality compared with standard gastrectomy. The literature confirms that tumor invasion into adjacent structures and an increased extent of resection are key factors determining increased technical complexity and the risk of adverse outcomes.

Level IV. Combined Procedures Involving a Reconstructive Stage

Performing gastric surgery involving resection of adjacent organs, which requires the creation of various types of additional anastomoses during the reconstructive stage, fundamentally alters the nature of the operation and warrants classification as Level IV. The level of surgical trauma and the associated operative complexity of these procedures is determined by the need to mobilize several anatomical areas, the risk of damage to the mesenteric vascular arches, an increase in the volume of resected tissue, as well as a significant increase in blood loss and the duration of the operation. Multicenter studies have noted that resections involving the creation of an intestinal anastomosis are associated with significantly longer operative times and greater intraoperative trauma compared with extended resections without intestinal reconstruction [30, 32, 34].

The overall incidence of complications in this group of operations varies between 30% and 60% across different studies, reflecting the high burden associated with the reconstructive phase and the specific features of MVR. The most significant severe complications (Clavien–Dindo ≥III) are:

• intra-abdominal abscesses—8–15%,
• massive postoperative hemorrhage—up to 10%,
• severe cardiopulmonary complications—10–12%.

Level IVA. Gastrointestinal Tract Reconstruction

Suture failure of formed anastomoses occupies a special place among the complications of Level IV procedures. According to Jeong et al. (2023), the incidence of postoperative failure following gastrectomy accompanied by a reconstructive phase ranges from 6–12% and is one of the leading causes of severe septic complications and re-interventions [24].

The overall incidence of Clavien–Dindo complications ≥III in contemporary sources is 15–30%, reaching peak values following resection of various segments of the colon or multiple single-stage resections [29, 30, 34].

Less severe complications (Clavien–Dindo II and below), including wound infections, prolonged intestinal paralysis and drug-correctable metabolic disorders, occur significantly more frequently and account for up to 50% of all adverse events [28, 34].

According to data from various centers, perioperative mortality in combined resections involving the creation of an additional intestinal anastomosis ranges from 3% to 10%, increasing primarily due to severe septic complications and fatal anastomotic leaks. In highly specialized centers, this figure remains closer to the lower end of the range [29, 30, 34].

Thus, combined resections with the creation of interintestinal anastomoses are characterized by high surgical trauma and a significant risk of complications, which allows them to be classified as a separate subcategory—level IVA.

Level IVB. Reconstruction of Pancreatic and Biliary Drainage

A fundamentally different level of surgical trauma arises when the pancreaticoduodenal region is involved and reconstruction of the drainage of bile and pancreatic secretions is required. In the most severe cases of locally advanced gastric cancer, accompanied by extensive invasion into the duodenum, the head of the pancreas or the pancreaticoduodenal complex, standard gastrectomy and even extended resections prove insufficient. In such situations, removal of the affected structures is required, followed by the creation of pancreatico-enteric and biliary-digestive anastomoses, aimed at restoring the continuity of the gastrointestinal tract and the outflow of pancreatic and biliary secretions.

These procedures are among the most traumatic and, consequently, technically complex in gastric cancer surgery. Unlike operations involving intestinal reconstruction limited to inter-intestinal anastomoses, they involve the removal of the pancreaticoduodenal complex, leading to a significant increase in surgical trauma, duration of the procedure, and blood loss. The average duration of such operations exceeds 7 hours, and intraoperative blood loss reaches 1000–1200 ml, reflecting a fundamentally different level of technical complexity.

A key factor determining the high incidence of complications is the formation of the pancreatoenteric anastomosis, which remains the most vulnerable element of the reconstruction. The incidence of pancreatic fistulas ranges from 13 to 44%, and in some series reaches 37.5%, which is associated with the development of peritonitis, intra-abdominal abscesses and severe septic complications. The overall incidence of Clavien–Dindo complications ≥III in operations of this type is often 30–40% and, in some studies, exceeds 40%, which is significantly higher than the rates typical of Level IVA procedures, and justifies classifying operations involving a pancreatoduodenal stage into a separate subcategory of surgical complexity—Level IVB. An additional adverse outcome is persistent exocrine pancreatic insufficiency, requiring long-term enzyme replacement therapy [28, 39, 40].

Furthermore, in procedures involving a pancreatoduodenal phase, acute postoperative pancreatitis occupies a significant place among complications. According to clinical studies and systematic reviews, inflammatory pancreatic damage following such operations is one of the leading complications after procedures involving the pancreatoduodenal segment and is associated with a marked increase in severe complications and mortality [35, 41].

Perioperative mortality in Level IVB procedures remains the highest among all variants of extended gastric resections and reaches 13% in international studies. In the Russian literature, this figure is approximately 11.5%, which is almost double the mortality rate for combined operations without a pancreatic component. Thus, it is precisely the inclusion of the pancreaticoduodenal stage that is the determining factor increasing the risk of complications and mortality in the surgical treatment of locally advanced gastric cancer [39, 40].

PRINCIPLES FOR DEVELOPING A CLASSIFICATION SYSTEM FOR SURGICAL PROCEDURES

Classification systems are already in use across many surgical disciplines, enabling the extent of a procedure to be assessed based on its invasiveness and allowing the risk of complications to be predicted. In gynecology, the Surgical Complexity Score (SCS) for ovarian cancer demonstrates a direct correlation between the extent of the operation and the frequency of adverse events [42]. In colorectal surgery, multi-level complexity systems, including robot-assisted procedures, also confirm an increase in the number of complications as the surgical class increases. In cardiac surgery, scales such as RACHS-1 are used for risk stratification and standardization of outcomes [43]. However, in gastric cancer surgery, there is no such standardized system, which makes it difficult to compare results and predict complications. This justifies the need to develop a structured classification that reflects the actual relationship between the extent of surgical procedures and the frequency and severity of perioperative complications.

Due to the lack of a standardized system for stratifying surgical procedures in gastric cancer, this study proposes a classification comprising four levels of surgical invasiveness. Level I encompasses limited resections (wedge, marginal and partial) not exceeding two-thirds of the stomach volume and performed without lymph node dissection. Level II corresponds to both subtotal (distal and proximal) gastric resections and total gastrectomies with regional lymphadenectomy (D1/D2) without an extended resection volume, accompanied by ligation of regional vascular structures. Level III includes procedures involving total viscerolysis and/or resection of parenchymal organs without the formation of additional anastomoses. Level IV reflects the most complex operations requiring reconstructive anastomoses and is subdivided into IV (A) (intestinal anastomoses) and IV (B) (pancreatic-digestive and biliary-digestive anastomoses). This structure allows procedures to be compared according to the level of surgical trauma and the associated operative complexity, and enables a reasonable prediction of the potential risks of perioperative complications. The ranking of the risk of perioperative complications based on the classification is presented in Supplement 1. It should be noted that the nosological form of the disease, whilst being an indication for surgical intervention, does not always determine the profile of early postoperative complications. In most clinical situations, the extent of the operation is of decisive importance, which forms the basis of the proposed classification. In this context, it is rightly noted: ‘Surgical trauma is often referred to as the “forgotten stepchild” of global surgery in terms of patient numbers, mortality, morbidity and costs’— which further emphasizes the significance of surgical trauma as a key factor in clinical outcomes [44].

THE IMPACT OF SURGICAL APPROACH

Specific complications associated with the type of surgical approach (laparotomy, laparoscopic or robot-assisted approach) may influence the profile of perioperative complications; however, in most clinical situations, this is less significant than the extent of gastric resection, the involvement of vascular and adjacent anatomical structures, and the need for a reconstructive phase. Furthermore, minimally invasive and robot-assisted technologies are currently used routinely primarily in large specialized and high-volume centers, which limits their universal reproducibility. Consequently, within the proposed classification, the type of surgical approach is not considered as an independent classification criterion, and the assessment of surgical trauma is based on the extent of the procedure and the nature of the resected tissues.

CONCLUSION

A review of the literature has shown that the frequency and nature of postoperative complications in the surgical treatment of gastric diseases are directly dependent on the extent of the procedure and its surgical invasiveness. Minimally invasive resections (level I) demonstrate minimal tissue damage and a low incidence of serious adverse events. Standard gastrectomy with lymph node dissection (level II) is associated with a high rate of complications, including 6–12% of severe cases, reflecting the increased anatomical and physiological demands of the procedure. In locally advanced gastric cancer, the need for resection of adjacent organs or total visceral resection (level III) leads to a significant increase in the complication rate to 30–50%, whilst the addition of a reconstructive phase involving the creation of intestinal, pancreatic or biliodigestive anastomoses (level IV) results in the highest risk of severe complications and perioperative mortality.

A comparison of data across different levels of intervention demonstrates a consistent and progressive increase in surgical trauma and the incidence of adverse outcomes as the extent of the operation increases. These results highlight the clinical significance of stratifying the extent of procedures according to the level of surgical trauma. The four-level model presented here allows for the systematic ranking of gastric operations, reflects their actual technical complexity, and corresponds to the spectrum of typical complications. Such a structured classification can serve as a basis for unifying surgical practice, standardizing reporting, and improving the accuracy of predicting the risk of perioperative complications in both clinical trials and routine surgical practice. It should be noted that the proposed classification applies to elective surgical procedures for gastric diseases and is not intended for the assessment of emergency operations performed in life-threatening conditions, nor for bariatric procedures performed on a morphologically intact stomach.

Additional information

Supplement 1. Risk ranking of perioperative complications depending on the level of surgical trauma during gastric surgeries.

doi: 10.17816/clinpract701970-4415220

Author contributions: V.S. Lavrenyuk, working with data, data analysis, writing a draft of the manuscript; R.Yu. Khlobystin, definition of the concept, visualization, research management; S.I. Petrushko, validation, revision and editing of the manuscript, project administration. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding source: No funding.

Disclosure of interests: The authors declare that they have no competing interests.

Statement of originality: This manuscript is an original work of the authors. The article was prepared independently based on a critical analysis of published literature sources, all of which are appropriately cited in the References section.

Data availability statement: All the data used in this work are presented in the text of the article and in the list of references.

Generative AI: Generative AI tools were used exclusively for language editing, stylistic improvement, and text translation. Scientific data, results, interpretations, and conclusions were not generated using AI. The authors are solely responsible for the content of the manuscript.

About the authors

Ruslan Yu. Khlobystin

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University; Federal Siberian Research Clinical Center of the Federal Medical Biological Agency

Email: oncolog_hr@list.ru
ORCID iD: 0009-0009-6959-6619
SPIN-code: 9132-1460

MD, PhD

Russian Federation, Krasnoyarsk; Krasnoyarsk

Vladimir S. Lavrenyuk

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University

Author for correspondence.
Email: lavrinyuk36@gmail.com
ORCID iD: 0009-0003-6714-5482
SPIN-code: 7379-3550
Russian Federation, Krasnoyarsk

Stanislav I. Petrushko

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University

Email: petrushko.66@mail.ru
ORCID iD: 0000-0001-9990-7574
SPIN-code: 6835-0679

MD, PhD, Professor

Russian Federation, Krasnoyarsk

References

Supplementary files