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.

Recurrent complex incisional hernia repair by enhanced-view totally extraperitoneal (eTEP) technique

OBJECTIVE

Treatment of large recurrent abdominal wall hernias remains a surgical challenge. The enhanced-view totally extraperitoneal (eTEP) approach is an emerging technique used to treat hernias with minimally invasive procedure. This article illustrates a step-by-step eTEP approach, used in a complex recurrent hernia repair.

PATIENTS AND METHODS

A 56-years-old male had a previous epigastric hernia repair with an intraperitoneal onlay mesh (IPOM) technique in 2018. Six months later, he presented a recurrent epigastric protrusion and a new painful ombilical hernia, objectified on the CT-scan.

RESULTS

Four suprapubic trocars were used to dissect the preperitoneal space below the arcuate line and the retromuscular spaces on both sides. On the mid-line, posterior fascia was divided and both hernia sacs were fully dissected. Both anterior and posterior sheats were closed with self-locking non-absorbable threads before placing a Polypropylene self-gripping mesh. The follow-up was uneventful, and the patient was discharged on day 2.

CONCLUSIONS

This case report illustrates that eTEP technique can be used safely and effectively to treat complex recurrent ventral hernias even with a mesh already in place. The potential advantages of the eTEP procedure are multiple, such as improving mobility and esthetic results, reducing pain and shorting hospital length of stay.

Accuracy of preoperative staging for a priori resectable esophageal cancer

This study assessed the accuracy of preoperative staging in patients undergoing oncological esophagectomy for adenocarcinoma and squamous cell carcinoma. All patients undergoing surgery for resectable esophageal cancer in a university hospital from 2005 to 2016 were identified from our institutional database. Patients with neoadjuvant treatment were excluded to avoid bias from down-staging effects. Routinely, all patients had an upper endoscopy with biopsy, a thoracoabdominal CT scan, an 18-FEG PET-CT, and endoscopic ultrasound. Preoperative staging was compared to histopathological staging of surgical specimen that was considered as gold standard. There were 51 patients with a median age of 65 years (IQR: 59.3-73 years) having 21 squamous cell carcinoma and 30 adenocarcinoma, respectively. T- and N-stages were correctly predicted in 26 (51%) and 37 patients (72%), respectively. Overall, 18 patients (35%) were preoperatively diagnosed with a correct T- and N-stage. There was no difference between adenocarcinoma and squamous cell carcinoma. Accuracy of the T-stage was not influenced by the smoking status. The N-stage was not correct in 7/22 smoking patients (32%) and 6/29 nonsmoking patients (21%).The N-stage was underestimated in smoking patients as 6/22 patients (27%) had a histologically confirmed N+ who were preoperatively classified as N0. In conclusion, only 35% of patients had a correct assessment. Separate T- and N-stage prediction was improved with 51% and 72%, respectively. Major efforts are needed for improvement.

[Gastroesophageal cancer: an update on diagnosis and treatment]

Esophago-gastric cancer remains a relatively rare pathology with, however, an ascending tendency in the recent years due to a variety of predisposing factors. An extensive preoperative workup and a thorough multidisciplinary discussion are the key elements to define treatment strategy. Surgery is the cornerstone of treatment for resectable tumors, even if it is associated with morbidity rates of 40-60% in medium and high-volume centers. Long-term consequences (e.g. malnutrition and late anastomotic stenosis) are present in a high proportion of patients and they raise the need for a close follow-up with the collaboration of the general practitioner, surgeon and oncologist. This multidisciplinary treatment and aftercare has the best chance to offer to the patient not only a longer overall survival, but a better quality of life as well.

Critical appraisal of single port access cholecystectomy

BACKGROUND

Single port access (SPA) cholecystectomy is a new concept in laparoscopic surgery. A review of existing results was performed to evaluate critically the current state of SPA with specific reference to feasibility, safety, learning curve, indications and cost-effectiveness.

METHODS

All papers identified in MEDLINE until 15 February 2010 and all other relevant papers obtained from cited references were reviewed, without any language restriction. Case reports and series of fewer than three patients were excluded.

RESULTS

After selection, 24 studies including 895 patients were analysed. None was randomized. Feasibility seems to be established, with a conversion rate of 2 per cent. SPA was not standardized and there was much technical variation. The learning curve could not be determined. Median follow-up time was 3 (range 0.25-12) months. The overall published complication rate was 5.4 per cent and the biliary complication rate 0.7 per cent. The rate of umbilical complications ranged from 2 to 10 per cent.

CONCLUSION

SPA cholecystectomy seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complications.

[NOTES and single port access: surgical or marketing revolution?]

Promising new technologies are emerging in digestive surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Single Port Access Surgery. They both aim to limit the surgical morbidity by decreasing the number of parietal accesses. The feasibility in human is obviously demonstrated, but numerous issues remain concerning the safety of these techniques. Furthermore, the expected advantages are not clearly demonstrated until now in the literature. In the future, it will be advisable to standardize techniques, in order to allow large clinical studies and to limit the potential complications of these approaches.

Transgastric hybrid cholecystectomy

BACKGROUND

Clinical application of natural orifice transluminal endoscopic surgery is under investigation. Preliminary results of transvaginal cholecystectomy in women and associated technical issues have been described. The technique and initial results of hybrid transgastric cholecystectomy are now reported.

METHODS

Five patients aged 18-60 years with uncomplicated cholelithiasis underwent transgastric cholecystectomy in a prospective intention-to-treat study that included the option of transparietal assistance (hybrid technique) if needed. The gastrotomy was created under laparoscopic guidance through a 5-mm umbilical trocar, which also served to expose the gallbladder, clip the cystic pedicle and close the gastrotomy. Cholecystectomy was carried out using flexible instruments through the endoscope, alone or in combination with laparoscopic instruments.

RESULTS

The procedure was successful in all patients with a median operating time of 150 (range 120-180) min. Transparietal assistance was necessary in all patients. There were no intraoperative or postoperative complications.

CONCLUSION

Until technical issues have been resolved, a hybrid procedure with liberal use of transparietal assistance is the safest and most efficient approach for transgastric cholecystectomy. Further studies are essential to evaluate the role of this new approach.

Surgical access to the adrenal gland: the quest for a "no visible scar" approach

Surgery of the adrenal glands has various approaches and remains technically challenging. Many different techniques have been used to decrease morbidity. The most important one is probably laparoscopy which has already quite dramatically improved clinical outcome. The second one is the introduction of posterior endoscopic approach (retroperitoneoscopy), which entirely preserves peritoneal integrity. This concept seems to us to be a fundamental in surgery of the retroperitoneum. Recently, new developments have emerged in the field of abdominal surgery. The most radical concept, known as Natural Orifice Transluminal Endoscopic Surgery (NOTES), consists of the introduction of both endoscope and working instruments through natural orifices in order to eliminate skin incisions and their associated morbidities. Although transperitoneal adrenalectomy has previously been reported in a porcine model, here we report our initial experiences of extra-peritoneal transvaginal NOTES approach of the retroperitoneum, focused on the field of adrenal surgery in both porcine and cadaver models. Whether clinical applications will ultimately be derived of this concept is still not clear certainly it raises new possibilities for interesting developments.

[Cholecystectomy and inguinal repair: frequent laparoscopic interventions]

Laparoscopic cholecystectomy reduces postoperative pain, hospital stay and recovery in comparison with the open procedure. This approach allows to treat most of vesicular pathologies, as acute cholecystitis and choledocal lithiasis, with excellent results. Biliary tract injuries represent however the most feared complication. Concerning groin hernia pathology, two different laparoscopic approaches are described, as the trans-abdominal pre-peritoneal approach (TAPP) and the total extra-peritoneal approach (TEP). The first technique is easier to perform, but associated with more frequent significant intraabdominal morbidity. Results are comparable to the classic open Lichtenstein technique in term of reccurence. Laparoscopic approach could be associated with a lower chronic pain rate, but further studies should confirm this statement.

[Psychiatric and psychosocial emergency situations]

Psychiatric emergencies and crises are unforseeable by nature and can have devastating consequences. They can arise both in the course of chronic mental illness and in people who had not shown any previous signs of mental illness. Conditions that are so similar that they might be confused with one another can be caused by a wide range of internal illnesses, adverse side-effects of medications or intoxication. This is the reason why establishing a psychiatric diagnosis in emergency situations must be primarily driven by the question as to whether the differential diagnosis is an internal illness or rather intoxication. The most prevalent psychiatric emergencies in clinical practice are nervous breakdowns, psychomotor agitation and violence, suicidal tendencies, delirium, psychoses as well as addictions.

[Treatment of alcoholism]

In view of the many non-specific symptoms a diagnosis of alcoholism can only be made by means of a detailed history and a medical checkup. Simple, standardized questions may often be sufficient. After a diagnosis a consultation with a family physician and drugs, such as disulfiram, acamprosate and naltrexone have been proved to be a highly efficient therapy. Therefore, it is worthwhile to treat alcoholics in the general practice setting.

Divergence of ethanol and acetaldehyde kinetics and of the disulfiram-alcohol reaction between subjects with and without alcoholic liver disease

Despite standardization, marked interindividual variation in the severity of the disulfiram-alcohol reaction (DAR) has been observed. We studied the DAR in 51 consecutive alcoholics with (n = 16) and without (n = 35) significant alcoholic liver disease. Clinical signs of the DAR were much weaker in the patients with compared with those patients without liver disease. Because acetaldehyde is thought to be the main cause of the DAR, we studied ethanol and acetaldehyde kinetics in 13 patients (6 females, 7 males) with alcoholic liver disease (documented by biopsy, clinical and/or radiological findings, and by quantitative liver function) [galactose elimination capacity (GEC) 4.2 +/- SD 1.0 mg/min/kg; aminopyrine breath test (ABT) 0.14 +/- 0.10% dose x kg/mmol CO2] and 13 age- and sex-matched controls (alcoholics without significant liver disease, GEC 7.1 +/- 0.7; ABT 0.81 +/- 0.35). Clinical signs of acetaldehyde toxicity during the DAR (flush, nausea, tachycardia, and blood pressure drop) were absent in alcoholic liver disease, but clearly evident in controls. Blood ethanol kinetics were similar in both groups, Cmax and area under the concentration-time curve (AUC) being 6.27 +/- 1.82 and 368.9 +/- 72.9 mmol x min/liter in alcoholic liver disease, and 6.62 +/- 1.71 and 377.6 +/- 124.5 in controls, respectively. In contrast, there was a strong (p < 0.001) difference in Cmax and AUC of acetaldehyde, respective values being 33.46 +/- 21.52 and 1463.8 +/- 762.5 mumol x min/liter in alcoholic liver disease, and 110.87 +/- 56.00 and 4162.0 +/- 2424.6 in controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of food on H2-receptor blockade in normal subjects and duodenal ulcer patients

Two separate studies of 24 hour intragastric acidity were carried out in normal volunteers and duodenal ulcer patients to define the interaction of food and the antisecretory effects of H2-receptor blockers. Both investigations were double blind randomised comparisons using ranitidine 300 mg with either different meal times or ad libitum snacks after an evening meal. Meals taken after drug administration nearly abolished measurable antisectory effects. Median 24 hour pH was 1.3 on placebo, 2.6 when ranitidine was administered after the evening meal and 1.9 when administered before the evening meal. Snacks taken after evening dosing with ranitidine also significantly decreased pharmacodynamic efficacy. During placebo, median night-time pH was 1.3 without snacks and 1.4 with snacks. pH rose to 5.9 during ranitidine treatment when snacks were forbidden but was only 3.1 when snacks were allowed. These findings could be of therapeutic importance and should rationalise dietary advise to patients receiving H2 blockers. The timing of drug administration can be adjusted according to individual life styles.