Impact of positive resection margins (R1) on long-term survival of patients with advanced diffuse type gastric cancer

Objective

Gastric cancer (GC) is a leading cause of cancer-related mortality worldwide. Diffuse type GC have a much worse prognosis compared to intestinal type GC. There is an ongoing debate whether microscopic involvement of the proximal margin (R1 resection) influences overall survival (OS) in advanced gastric cancer.

The aim of this study was to assess OS in patients with diffuse gastric cancers and positive lymph node involvement who underwent oncological gastrectomy with R0 and R1 resections.

Methods

All consecutive patients from two tertiary centers operated with curative intent for diffuse gastric cancer between January 2005 and December 2018 were analyzed. Patients with R2 resections or missing data were excluded. Extracted data included demographics, major comorbidities, ASA score, neo-adjuvant treatment, pre- and postoperative staging (TNM 8th edition), postoperative complication with grading according to Clavien classification, survival data and pattern of recurrence. Lymph node involvement was based on pathology.

Kaplan-Meier curves with log-rank test for comparison were used to evaluate survival between groups.

Results

A total of 94 patients with diffuse gastric cancer were included. Two patients were excluded because of R2 resection and missing data regarding pathology, leaving a cohort of 92 patients (48 male, 44 female, median age 62 years). Sixty-four patients were lymph node positive (pN+); 48 patients (75%) with R0 resection and 16 patients (25%) with R1 resection. No difference in terms of preoperative data and intraoperative characteristics was found between R0 and R1 groups. Median OS was better in the R0 group (27 months, 95% CI 17–37) compared to R1 group (7 months, 95% CI 3–11, p<0.001). Similar results were found with disease-free survival (DSF) (25 vs. 6 months, p=0.002).

On multivariable analysis, T stage and resection margin (R status) were independent factors predicting OS (T stage: HR 4.5, p<0.001, R status: HR 4.2, p<0.001) and DFS (T stage: HR 2.9, p=0.004, R status: HR 3.5, p=0.001) in the cohort of patients with lymph node involvement.

Conclusion

The present series confirmed that patients with negative surgical margins have better OS compared to patients with positive margins in case of locally advanced diffuse GC. Therefore, R0 resections should be the goal of oncological gastrectomies.

Long-term outcomes of ruptured hepatocellular carcinoma: An international multicentric propensity score-matched study

Objective

Long-term outcomes of patients with ruptured hepatocellular carcinoma (rHCC) remain scant. This study aimed to assess disease-free survival (DFS) and overall survival (OS) after surgical resection of rHCC compared to non-ruptured HCC (nrHCC).

Methods

Patients with rHCC and nrHCC were collected from 8 centers in Europe, Asia, and North America. Resected rHCC patients were matched 1:1 to patients undergoing surgery for nrHCC using propensity score and nearest-neighbor method (matching criteria: age, tumor size, cirrhosis, Child-Pugh score, Barcelona Clinic Liver Cancer stage, resection status, grade, and microvascular invasion). Survival rates were calculated using Kaplan-Meier method.

Results

A total of 2033 patients were included: 226 rHCC patients (172 operated: 68 with upfront surgery and 104 after embolization) and 1807 nrHCC patients. Median DFS and OS of rHCC patients (all treatments confounded) were 10 months (95% CI 7–13) and 22 months (95% CI 13–31). Prognostic factors for worse OS among rHCC patients were absence of preoperative arterial embolization (HR 2.3, 95% CI 1.2–4.6, p=0.016), cirrhosis Child B/C (HR 2.4, 95% CI 1.1–5.4, p=0.040), and R1/R2 margins (HR 2, 95% CI 1–5, p=0.049). Survivals were similar between Western and Eastern rHCC patients.

After propensity score matching, 106 rHCC patients and 106 nrHCC patients displayed similar characteristics. Patients with rHCC had shorter median DFS (12 months, 95% CI 7–17 vs. 22 months, 95% CI 12–32, p=0.011), but similar median OS compared to nrHCC patients (43 months, 95% CI 21–65 vs. 63 months, 95% CI 21–105, p=0.060).

Conclusion

In this large dataset including Eastern and Western patients, rHCC was associated with shorter DFS compared to nrHCC, while OS was similar.

Biological impact of an enhanced recovery after surgery programme in liver surgery

BACKGROUND

The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery.

METHODS

A retrospective analysis of patients undergoing liver surgery (2010-2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP.

RESULTS

A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P < 0.001) and major resection (47.5 versus 38.1 per cent; P = 0.035) in the ERAS group. Patients in the ERAS group showed attenuated ΔWBC (2.00 versus 2.75 g/l; P = 0.013), ΔCRP (60 versus 101 mg/l; P <0.001) and Δalbumin (12 versus 16 g/l; P < 0.001) compared with those in the no-ERAS group. Subgroup analysis of open resection showed similar results. Multivariable analysis identified ERAS as the only independent factor associated with high ΔWBC (odds ratio (OR) 0.65, 95 per cent c.i. 0.43 to 0.98; P = 0.038), ΔCRP (OR 0.41, 0.23 to 0.73; P = 0.003) and Δalbumin (OR 0.40, 95 per cent c.i. 0.22 to 0.72; P = 0.002).

CONCLUSION

Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.

Systematic review of the impact of patient death on surgeons

BACKGROUND

The death of a patient is experienced at some time by most surgeons. The aim of this review was to use existing literature to establish how surgeons have dealt with the death of patients.

METHODS

A systematic review of the medical literature was performed. MEDLINE/PubMed, Ovid, Web of Science, Embase, and Google Scholar were searched for qualitative and quantitative studies on surgeon reactions when facing death or a dying patient. This systematic review was performed following the recommendations of the Cochrane collaboration and reported following the PRISMA guidelines. Individual and interview-based opinions were summarized and synthesized.

RESULTS

An initial search found 652 articles. After exclusion of articles that did not satisfy the inclusion criteria, 20 articles remained and seven were included. Two of these articles were personal opinion of the author and five were interviews or surveys. The main findings were that facing death routinely induces a strong psychological burden and that surgeons are more at risk than the general population to develop psychological morbidity.

CONCLUSION

Although it is a frequent and emotional subject in the surgical world, the impact of patient death on surgeons is not abundantly studied in the literature. Dealing with patient death or taking care of a dying patient might have long-lasting psychological impact on surgeons.

Ischemic stroke and ST-elevation myocardial infarction revealing infective endocarditis

In this clinical scenario, we report the case of a patient who presented multiple embolic complications due to mitral infective endocarditis (IE). A 68-year-old woman had extended right hepatectomy for hilar cholangiocarcinoma. Unfortunately, she had multiple postoperative complications and had to be transferred to the Intensive Care Unit. During this stay, we have diagnosed an Enterococcus faecium IE after the occurrence of multiple embolic complications (myocardial infarction, ischemic stroke, digital emboli, splenic emboli, and renal emboli). The case is presented hereunder with illustrative imagings. While embolism is a known complication of IE, the presence of multiple emboli in various organs is rare.

Complicated thoraco-abdominal aortic dissection presenting with lower limb ischemia in a patient with bovine arch and arteria lusoria

We report the case of a 58-year-old man who presented with thoraco-abdominal pain and right lower limb ischemia due to type B aortic dissection. Moreover, the patient was discovered to have several concomitant aortic arch anomalies (bovine arch, arteria lusoria, and left vertebral artery arising from the aortic arch). Taking into account this complex anatomy, emergent femoral exploration with fenestration and thrombectomy was performed. The blood flow to the right lower limb was restored. A few days later the aortic dissection spread proximally, and the aortic arch dilatation enlarged. Before total arch replacement could be performed, the aorta ruptured and the patient unfortunately died.

Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost-effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy.

METHODS

ERAS for pancreaticoduodenectomy was implemented in October 2012. All consecutive patients who underwent pancreaticoduodenectomy until October 2014 were recorded. This group was compared in terms of costs with a cohort of consecutive patients who underwent pancreaticoduodenectomy between January 2010 and October 2012, before ERAS implementation. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration. A bootstrap independent t test was used for comparison. ERAS-specific costs were integrated into the model.

RESULTS

The groups were well matched in terms of demographic and surgical details. The overall complication rate was 68 per cent (50 of 74 patients) and 82 per cent (71 of 87 patients) in the ERAS and pre-ERAS groups respectively (P = 0·046). Median hospital stay was lower in the ERAS group (15 versus 19 days; P = 0·029). ERAS-specific costs were €922 per patient. Mean total costs were €56 083 per patient in the ERAS group and €63 821 per patient in the pre-ERAS group (P = 0·273). The mean intensive care unit (ICU) and intermediate care costs were €9139 and €13 793 per patient for the ERAS and pre-ERAS groups respectively (P = 0·151).

CONCLUSION

ERAS implementation for pancreaticoduodenectomy did not increase the costs in this cohort. Savings were noted in anaesthesia/operating room, medication and laboratory costs. Fewer patients in the ERAS group required an ICU stay.

[Acute sigmoid diverticulitis: toward a more and more conservative treatment]

Acute diverticulitis of the colon is a frequent pathology especially among elderly people and people of Caucasian origin. The prevalence is higher among sedentary people and in people with low-fiber diet. Its diagnosis is mainly based on computed tomography (CT) that allows guiding the therapeutic management. Over the last few years the treatment of acute diverticulitis has passably changed with in particular an evolution toward a restriction of the elective and emergency surgery indications and a reduction of the antiobiotherapy and hospitalization number. This article reviews the epidemiology, the diagnostic tools, and the management of this frequent digestive pathology.

Multidisciplinary approach to uncommon, widely metastatic breast cancer

Worldwide, breast cancer represents the most common malignancy in women. Most diagnoses can be made relatively early. However, aggressive metastatic disease is still possible. We report an unusual case of a neglected 69-year-old woman with an intensely malodorous right breast, back pain, and shooting pain in both of her legs. After obtaining history, clinical examination, magnetic resonance imaging and CT scan, she was found to have widely metastatic breast cancer (ER/PR positive, HER-2 negative, 43% Ki-67), with metastases in vertebral bodies of T1/T4, pleura, lungs, liver, mediastinal and axillary lymph nodes, compression pathological fractures of T12/L3, and an expansive, destructive sacral metastasis. She underwent a thoracolumbar surgical fixation for her lower spine and radiotherapy for the T1 metastasis. She received aromatase inhibitor therapy followed by palliative mastectomy. Here, we reviewed the diagnostic steps, management, multidisciplinary approach and the relevant literature of this rare presentation of a destructive, multi-metastatic breast cancer.