Gastric cancer molecular classification based on immunohistochemistry and in situ hybridization: Analysis in western patients after curative-intent surgery

BACKGROUND

Gastric cancer (GC) is a highly heterogeneous disease, and the identification of molecular subtyping of gastric adenocarcinoma emerged as a promising option to define therapeutic strategies and prognostic subgroups. However, the costs and technical complexity of molecular methodologies remains an obstacle to its adoption, and their clinical significance by other approaches needs further evidence.

AIM

To evaluate the clinicopathological characteristics and long-term survival of GC based on the subgroups of molecular classification by immunohistochemistry (IHC) and in situ hybridization (ISH).

METHODS

We retrospectively evaluated all patients who underwent D2-gastrectomy between 2009 and 2016 in a Western cohort of GC patients treated with curative intent. Microsatellite instability (MSI) status, E-cadherin, and p53 expression were analyzed by IHC, and Epstein-Barr virus (EBV) by ISH. Tissue microarrays were constructed for analysis. Clinicopathological characteristics and survival of GC were evaluated according to subtypes defined by The Cancer Genome Atlas (TCGA) Research Network Group and Asian Cancer Research Group (ACRG) classification systems.

RESULTS

A total of 287 GC patients were included. Based on IHC and ISH analysis, five profiles were defined as follows: E-cadherin aberrant (9.1%), MSI (20.9%), p53 aberrant (36.6%), EBV positivity (10.5%), and p53 normal (31%), which corresponded to tumors that showed no alteration in another profile. A flowchart according to the TCGA and ACRG classifications were used to define the subtypes, where clinical and pathological characteristics associated with GC subtypes were evidenced. Proximal location (P < 0.001), total gastrectomy (P = 0.001), and intense inflammatory infiltrate (P < 0.001) were characteristics related to EBV subtype. MSI subtype was predominantly associated with advanced age (P = 0.017) and the presence of comorbidities (P = 0.011). While Laurén diffuse type (P < 0.001) and advanced stage (P = 0.029) were related to genomically stable (GS) subtype. GS tumors and microsatellite stable/epithelial to mesenchymal transition phenotype subtype had worse disease-free survival (DFS) and overall survival (OS) than other subtypes. Conversely, MSI subtype of GC had better survival in both classifications. Type of gastrectomy, pT and the TCGA subtypes were independent factors associated to DFS and OS.

CONCLUSION

The IHC/ISH analysis was able to distinguish immunophenotypic groups of GC with distinct characteristics and prognosis, resembling the subtypes of the molecular classifications. Accordingly, this method of classification may represent a viable option for use in a clinical setting.

Laparoscopic Completion Total Gastrectomy for Remnant Gastric Cancer

Background: Remnant gastric cancer (RGC) is increasing due to past use of subtotal gastrectomy to treat benign diseases, improvements in the detection of gastric cancer, and increased survival rates after gastrectomy for gastric cancer. Laparoscopic access provides the advantages and benefits of minimally invasive surgery. However, laparoscopic completion total gastrectomy (LCTG) for RGC is technically demanding, even for experienced surgeons. Because of its rarity and heterogeneity, no standard surgical strategy has been established and few surgeons will develop technical expertise to carry out this procedure. Aim: To describe our standard technique, giving surgeons a head start in LCTG and report the early experience with this stepwise approach. Materials and Methods: We detail all the steps involved in the procedure, including trocar placement and surgical description. Results: Between 2009 and 2019, a total of 8 patients with past history of RGC were operated with this technique. All patients had been previously operated by open method, 7 due to peptic ulcer disease and 1 due to gastric cancer. Their mean age at the time of the first surgery was 38.9 years (range 25-56 years) and the mean interval between the first and the second gastrectomy was 32.1 years (range 13.6-49). Billroth II was the previous reconstruction in all cases. A 5-trocar technique was used followed by total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y reconstruction. The mean operation time was 272 minutes (range 180-330) and median blood loss was 247 mL (range 50-500). There was no conversion and no major intraoperative complication. Major postoperative complications occurred in 3 patients. Conclusion: Completion total gastrectomy for RGC is a morbid procedure and laparoscopic access is technically feasible, hopefully carrying the benefits of faster recovery, reduced postoperative pain, and wound complications. By standardizing the approach, the learning curve may be shortened and better results achieved.

Long-term outcomes of endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors

BACKGROUND AND AIM

Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question.

METHODS

A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared.

RESULTS

Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13).

CONCLUSIONS

In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.

ROBOTIC GASTRECTOMY: TECHNIQUE STANDARDIZATION

BACKGROUND

Trocars position for the Si model (position is similar for the Xi, although trocars stay more in line). Robotic gastrectomy is gaining popularity worldwide. It allows reduced blood loss and lesser pain. However, it widespread use is limited by the extensive learning curve and costs.

AIM

To describe our standard technique with reduced use of robotic instruments.

METHODS

We detail the steps involved in the procedure, including trocar placement, necessary robotic instruments, and meticulous surgical description.

RESULTS

After standardizing the procedure, 28 patients were operated with this budget technique. For each procedure material used was: 1 (Xi model) or 2 disposable trocars (Si) and 4 robotic instruments. Stapling and clipping were performed by the assistant through an auxiliary port, limiting the use of robotic instruments and reducing the cost.

CONCLUSION

This standardization helps implementing a robotic program for gastrectomy in the daily practice or in one`s institution.

GASTRECTOMY IN OCTOGENARIANS WITH GASTRIC CANCER: IS IT FEASIBLE?

BACKGROUND

The octogenarian population is expanding worldwide and demand for gastrectomy due to gastric cancer in this population is expected to grow. However, the outcomes of surgery with curative intent in this age group are poorly reported and it is unclear what matters most to survival: age, clinical status, disease´s stage, or the extent of the surgery performed.

AIM

Evaluate the results of gastrectomy in octogenarians with gastric cancer and to verify the factors related to survival.

METHODS

From prospective database, patients aged 80 years or older with histologically confirmed adenocarcinoma who had undergone gastrectomy with curative intent were selected. Factors related to postoperative complications and survival were studied.

RESULTS

Fifty-one patients fulfilled the inclusion criteria. A total of 70.5% received subtotal gastrectomy and in 72.5% D1 lymphadenectomy was performed. Twenty-five (49%) had complications, in eleven major complications occurred (seven of these were clinical complications). Hospital length of stay was longer (8.5 vs. 17.8 days, p=0.002), and overall survival shorter (median of 1.4 vs. 20.5 months, p=0.009) for those with complications. D2 lymphadenectomy and the presence of postoperative complications were independent factors for worse overall survival.

CONCLUSION

Octogenarians undergoing gastrectomy with curative intent have high risk for postoperative clinical complications. D1 lymphadenectomy should be the standard of care in these patients.

Does a history of head and neck cancer affect outcome of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma?

Background and study aims  Esophageal squamous cell carcinoma (ESCC) is the most common secondary tumor in patients with head and neck squamous cell cancer (HNSCC). Currently, endoscopic submucosal dissection (ESD) is the preferred approach to manage superficial ESCC, however, it remains to be elucidated whether patients with HNSCC and early ESCC managed by ESD have different outcomes. Patients and methods  We retrospectively analyzed esophageal ESD for early ESCC from September 2009 to September 2017 and the following variables: demographics, tumor and specimen size, Paris classification, location, en bloc and R0 resection rates, overall survival (OS) and adverse events (AEs). To reduce selection bias, propensity score matching was applied to compare the results. Results  Eighty-nine ESDs were performed in 81 consecutive patients (47 with HNSCC and 34 without HNSCC). Patients with HNSCC who developed superficial ESCC were found to be younger and to refer a more frequent history of alcohol ingestion and smoking. There was no difference in lesion size, number of lesions, procedure time, en bloc resection rate, R0 resection rate, local recurrence and adverse event rate between the two groups. The histological depth of invasion for patients with HNSCC was significantly shallower before ( P  = 0.016) and after ( P  = 0.047) matching. The overall survival rate was similar in both groups. Conclusions  Patients with HNSCC have earlier detection of ESCC, probably due to endoscopic screening. Previous history of chemoradiation and surgery for HNSCC does not affect procedure time, AEs and OS.

Validation and improvement of the predictive equation for resting energy expenditure in advanced gastrointestinal cancer

OBJECTIVES

The usual predictive equations for estimating resting energy expenditure (REE) seem to be associated with significant inaccuracy in patients with advanced cancer. Recently, our group developed a predictive equation for patients with advanced head and neck cancer, showing a better accuracy when compared with indirect calorimetry. The aim of this study was to validate this predictive equation and, if necessary, to elaborate a new predictive equation for patients with advanced gastrointestinal (GI) cancer.

METHODS

This was a retrospective, unicentric observational study. Data regarding the characteristics of the study were collected using an electronic medical record from June 2016 to January 2018. The nutritional status was calculated by the body mass index (BMI). Patients with nutritional risk, by the Nutritional Risk Screening 2002, were subjectively evaluated in relation to the nutritional status by the Patient-Generated Subjective Global Assessment (PG-SGA). Sarcopenia was defined as fat-free mass index ≤17.4 kg/m² for men and ≤15 kg/m² for women. Body composition and phase angle values were evaluated by electrical bioimpedance. REE was measured by indirect calorimetry.

RESULTS

The study included 109 patients with advanced GI tract cancer. Most were male (72.5%), ≥60 y of age (61.5%), and had cancer in the esophagus region (62.4%). Most patients had not undergone any treatment at the time of the examination. Regarding nutritional characteristics, the majority of the patients were malnourished by BMI (71.6%), with a deficit of lean mass (79.8%), sarcopenia (83.5%), and a phase angle below the fifth percentile for age, sex, and BMI, showing in addition to a poor nutritional condition, an impaired cellular integrity. Most of the patients were hypermetabolic (56.9%) and their caloric intake in the preceding 3 d was insufficient in 43.1%. Through the intraclass correlation coefficient (ICC), it was possible to observe the satisfactory agreement between the REE measured by the gold standard (calorimetry) versus the Souza-Singer's formula (ICC, 0.730; 95% confidence interval, 0.659-0.789; P < 0.001). When we did the multiple linear regression model, we figured that in this group of patients with GI cancer, only lean mass, phase angle, and sex were the age-adjusted independent variables that influenced REE, which was different from the Souza-Singer formula. This way a new prediction formula for this population has been created and needs to be validated.

CONCLUSION

A new equation considering phase angle and body composition can improve the accuracy of the predictive equation.

TRANSHIATAL ESOPHAGECTOMY IS NOT ASSOCIATED WITH POOR QUALITY LYMPHADENECTOMY

Background:

Esophageal cancer neoadjuvant therapy followed by surgery increases the likelihood of treatment success.

Aim:

To evaluate variables that can influence the number of retrieved lymph nodes, the number of retrieved metastatic lymph nodes and lymphnodal recurrence in esophagectomy after neoadjuvant chemoradiotherapy.

Methods:

Patients of a single institute were evaluated after completion of trimodal therapy. Univariate and multivariate analyses were performed to evaluate variables that can influence in the number of retrieved lymph nodes and retrieved metastatic lymph nodes.

Results:

One hundred and forty-nine patients were included. Thoracoscopy access was considered an independent factor for the number of lymph nodes retrieved, but was neither related to the number of positive lymph nodes retrieved nor to lymphnodal recurrence. Pathological complete response on the primary tumor and male were independent variables associated with the number of positive lymph node retrieved. Pathological complete response on the primary tumor site did not statistically influence the likelihood of a lower number of lymph nodes retrieved.

Conclusion:

Patients submitted to esophagectomy after neoadjuvant chemoradiotherapy, thoracoscopic access is more accurate for pathological staging, even in a complete pathological response. With a proper patient selection, transhiatal surgery may preserve the quality of lymphadenectomy of the positive lymph nodes.

Abstract A21: Association between polymorphisms in inflammatory response related-genes and the susceptibility, progression, and prognosis of gastric cancer

Introduction: The chronic inflammatory microenvironment in the stomach has been described as a critical component for both tumor initiation and progression. Furthermore, genetic variants have been shown to influence the inter-individual variations in the inflammatory response. Therefore, we aimed to investigate whether polymorphisms in inflammatory response related-genes were associated with risk for gastric tumor development, clinical outcomes, and overall and disease-free survival of this disease in a Brazilian population sample.

Methods: Sixteen selected genetic variants in eleven genes (COX-2, OGG1, TNFB, TNFA, HSPA1L, HSPA1B, VEGFA, IL17F, LGALS3, PHB, and TP53) were genotyped in 262 control individuals and 178 gastric cancer patients. Genetic association analyses were investigated in different models (Genotype, Allele, Dominant, and Recessive) in both total sample (N=178) and stratified for the diffuse histologic subtype based on Lauren´s classification (N=112). We also calculated the linkage disequilibrium among the polymorphisms and the haplotype associations were carried out using Haploview and PLINK softwares.

Results: Regarding the susceptibility genetic markers, we found that rs1042522 (TP53) Pro allele carriers presented about 2-fold higher risk for developing gastric cancer in a multivariate analysis and this association was even stronger when analyzing only cases with the diffuse subtype. We also found that CTC haplotype (composed by rs699947, rs833061, and rs2010963 of VEGFA) was associated with gastric malignancy. On the other hand, the presence of A allele of rs699947 (VEGFA) was associated with a protection against developing this disease.

Regarding the disease progression, the following polymorphisms/haplotypes were able to predict outcomes associated with a worse aggressiveness: rs689466 (COX-2); rs1052133 (OGG1); rs699947, rs833061, and rs2010963 (VEGFA); rs4644 (LGALS3); rs1042522 (TP53); GG haplotype (TNFB/TNFA); ACG and CTC haplotype (VEGFA) and GT haplotype (rs689466 and rs5275 of COX-2 gene). On the other hand, other variants were associated with better outcomes: rs5275 (COX-2); rs2227956 (HSPA1L), and rs3025039 (VEGFA). We also observed that the rs909253 (TNFB) polymorphism was able to predict a better outcome only when stratifying for the individuals diagnosed with the diffuse subtype.

Finally, regarding the impact on prognosis, rs909253 (TNFB) was associated with a favorable prognosis when analyzing both the overall and disease-free survivals while rs4644 (LGALS3) His allele carriers presented a worse prognosis with shorter disease-free survival time.

Conclusions: These results helped us to clarify the potential role of these polymorphisms in genes involved in the modulation of the inflammatory response in the pathogenesis of gastric malignancy, highlighting that the host genetic variants might act together with other factors to influence the susceptibility, progression, and prognosis of gastric cancer.

Citation Format: Tatiane K. Furuya, Carlos E. Jacob, Michele T. Tomitão, Lizeth C. Cordoba-Camacho, Marcus K. Ramos, José Eluf-Neto, Venâncio A. Alves, Bruno Zilberstein, Ivan Cecconello, Ulysses Ribeiro-Junior, Roger Chammas. Association between polymorphisms in inflammatory response related-genes and the susceptibility, progression, and prognosis of gastric cancer [abstract]. In: Proceedings of the AACR International Conference held in cooperation with the Latin American Cooperative Oncology Group (LACOG) on Translational Cancer Medicine; May 4-6, 2017; São Paulo, Brazil. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(1_Suppl):Abstract nr A21.

Hand-assisted Approach as a Model to Teach Complex Laparoscopic Hepatectomies: Preliminary Results

BACKGROUND

Currently, there are limited and scarce models to teach complex liver resections by laparoscopy. The aim of this study is to present a hand-assisted technique to teach complex laparoscopic hepatectomies for fellows in liver surgery.

MATERIALS AND METHODS

Laparoscopic hand-assisted approach for resections of liver lesions located in posterosuperior segments (7, 6/7, 7/8, 8) was performed by the trainees with guidance and intermittent intervention of a senior surgeon. Data as: (1) percentage of time that the senior surgeon takes the surgery as main surgeon, (2) need for the senior surgeon to finish the procedure, (3) necessity of conversion, (4) bleeding with hemodynamic instability, (5) need for transfusion, (6) oncological surgical margins, were evaluated.

RESULTS

In total, 12 cases of complex laparoscopic liver resections were performed by the trainee. All cases included deep lesions situated on liver segments 7 or 8. The senior surgeon intervention occurred in a mean of 20% of the total surgical time (range, 0% to 50%). A senior intervention >20% was necessary in 2 cases. There was no need for conversion or reoperation. Neither major bleeding nor complications resulted from the teaching program. All surgical margins were clear.

CONCLUSIONS

This preliminary report shows that hand-assistance is a safe way to teach complex liver resections without compromising patient safety or oncological results. More cases are still necessary to draw definitive conclusions about this teaching method.

Adverse events of self-expandable esophageal metallic stents in patients with long-term survival from advanced malignant disease

BACKGROUND AND AIMS

Self-expandable metallic stents are considered the best palliative treatment of dysphagia for patients with advanced esophageal cancer. Adverse events (AEs) are a major concern, especially in patients with better prognosis and longer survival. The present study aimed to evaluate the AEs of patients who survived longer than 6 months with esophageal stents in place.

METHODS

This is a retrospective analysis of a prospectively collected database including all patients submitted to esophageal stent placement for the palliation of malignant diseases during the period from February 2009 to February 2014 at a tertiary care academic center who had stents longer than 6 months.

RESULTS

Sixty-three patients were included. Mean follow-up was 10.7 months. Clinical success was achieved in all patients, and the median stent patency was 7.1 months. AEs occurred in 40 patients (63.5%), totaling 62 AEs (mean, 1.5 AEs per patient). Endoscopic management of AEs was successful in 84.5% of cases, with a mean of 1.6 reinterventions per patient. The univariate analysis revealed that performance status, age, and post-stent radiotherapy presented a trend to higher risk of AEs. The multivariate analysis revealed that only performance status was associated with AEs (P = .025; hazard ratio, 4.1).

CONCLUSIONS

AEs are common in patients with long-term esophageal stenting for malignancy. However, AEs were not related to higher mortality rate, and most AEs could be successfully managed by endoscopy. Only performance status was a risk factor for AEs. Our data suggest that metallic stenting is a valid option for the treatment of malignant esophageal conditions, even when survival longer than 6 months is expected.

Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer

OBJECTIVES:

This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer.

METHODS:

Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155.

RESULTS:

The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement.

CONCLUSIONS:

Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.

PROGNOSTIC FACTORS AND SURVIVAL ANALYSIS IN ESOPHAGEAL CARCINOMA

Background:

Despite recent advances in diagnosis and treatment, esophageal cancer still has high mortality. Prognostic factors associated with patient and with disease itself are multiple and poorly explored.

Aim:

Assess prognostic variables in esophageal cancer patients.

Methods:

Retrospective review of all patients with esophageal cancer in an oncology referral center. They were divided according to histological diagnosis (444 squamous cell carcinoma patients and 105 adenocarcinoma), and their demographic, pathological and clinical characteristics were analyzed and compared to clinical stage and overall survival.

Results:

No difference was noted between squamous cell carcinoma and esophageal adenocarcinoma overall survival curves. Squamous cell carcinoma presented 22.8% survival after five years against 20.2% for adenocarcinoma. When considering only patients treated with curative intent resection, after five years squamous cell carcinoma survival rate was 56.6 and adenocarcinoma, 58%. In patients with squamous cell carcinoma, poor differentiation histology and tumor size were associated with worse oncology stage, but this was not evidenced in adenocarcinoma.

Conclusion:

Weight loss (kg), BMI variation (kg/m²) and percentage of weight loss are factors that predict worse stage at diagnosis in the squamous cell carcinoma. In adenocarcinoma, these findings were not statistically significant.

EVALUATION OF LYMPHATIC SPREAD, VISCERAL METASTASIS AND TUMORAL LOCAL INVASION IN ESOPHAGEAL CARCINOMAS

Background:

Knowing esophageal tumors behavior in relationship to lymph node involvement, distant metastases and local tumor invasion is of paramount importance for the best esophageal tumors management.

Aim:

To describe lymph node involvement, distant metastases, and local tumor invasion in esophageal carcinoma, according to tumor topography and histology.

Methods:

A total of 444 patients with esophageal squamous cell carcinoma and 105 adenocarcinoma were retrospectively analyzed. They were divided into four groups: adenocarcinoma and squamous cell carcinoma in the three esophageal segments: cervical, middle, and distal. They were compared based on their CT scans at the time of the diagnosis.

Results:

Nodal metastasis showed great relationship with of primary tumor site. Lymph nodes of hepatogastric, perigastric and peripancreatic ligaments were mainly affected in distal tumors. Periaortic, interaortocaval and portocaval nodes were more commonly found in distal squamous carcinoma; subcarinal, paratracheal and subaortic nodes in middle; neck chains were more affected in cervical squamous carcinoma. Adenocarcinoma had a higher frequency of peritoneal involvement (11.8%) and liver (24.5%) than squamous cell carcinoma. Considering the local tumor invasion, the more cranial neoplasia, more common squamous invasion of airways, reaching 64.7% in the incidence of cervical tumors. Middle esophageal tumors invade more often aorta (27.6%) and distal esophageal tumors, the pericardium and the right atrium (10.4%).

Conclusion:

Esophageal adenocarcinoma and squamous cell carcinoma in different topographies present peculiarities in lymph node involvement, distant metastasis and local tumor invasion. These differences must be taken into account in esophageal cancer patients' care.

Robotic abdominal surgery: a Brazilian initial experience

BACKGROUND

Robotic brought to laparoscopy the enrichment of movements, the easy to perform maneuvers and procedures, visualization in three dimensions, and ergonomics for the surgeon.

AIM

To describe Brazilian experience with robotically-assisted abdominal surgery.

METHODS

From July 2008 to April 2010, patients were admitted for abdominal surgery and agreed to being operated with the help of the robot by a trained medical staff. All patients were operated by the same surgical robotic approach. Time required for complete surgery, and console time, were recorded.

RESULTS

Forty-four patients were operated, most for hernial hiatal correction or bariatric surgery. All patients, except one, were discharged in the day after surgery. The only complication was a fistula due to a videolaparoscopic clamping procedure during bariatric surgery. There was no hemorrhage. No re-operation was necessary, neither conversion to laparoscopic or open surgery. Mean surgery time for the whole sample was 249.7 minutes (4.1 hours) and console time was 153.4 minutes (2.5 hours). Patients' blood lost was minimal.

CONCLUSIONS

Robotically assisted abdominal surgery is safe for the patients, with reduced bleeding and acceptable surgical time, and also ergonomic for the surgeons.

Results of D2 gastrectomy for gastric cancer: lymph node chain dissection or multiple node resection?

BACKGROUND

Eastern literature is remarkable for presenting survival rates for surgical treatment of gastric adenocarcinoma superior to those presented in western countries.

AIM

To analyze the long-term result after D2 gastrectomy for gastric cancer.

METHODS

Two hundred seventy four underwent gastrectomy with D2 lymph node dissection as exclusive treatment. The inclusion criteria were: 1) lymph node removal according to Japanese standardized lymphatic chain dissection; 2) potentially curative surgery described in medical records as D2 or more lymph node dissection; 3) tumoral invasiveness of gastric wall restricted to the organ (T1-T3); 4) absence of distant metastasis (N0-N2/M0); 5) a minimum of five years follow-up. Clinical pathological data included sex, age, tumor location, Borrmann's macroscopic tumor classification, type of gastrectomy, mortality rates, hystological type, TNM classification and staging according to UICC TNM 1997.

RESULTS

Total gastrectomy was performed in 77 cases (28.1%) and subtotal gastrectomy in 197 (71.9%). The tumor was located in the upper third in 28 cases (10.2%), in the middle third in 53 (19.3%), and in the lower third in 182 (66.5%). Among patients that had their Borrmann's classification assigned, five cases (1.8%) were BI, 34 (12.4%) BII, 230 (84.0%) BIII and 16 (5.9%) BIV. Tumors were histologically classified as Laurén intestinal type in 119 cases (43.4%) and as diffuse type in 155 (56.6%). According to UICC TNM 1997 classification, early gastric cancer (T1) was diagnosed in 68 cases (24.8 %); 51 (18.6%) were T2, and 155 (56.6%) were T3. No lymph node involvement (N0) was observed in 129 cases (47.1%), whereas 100 (36.5%) were N1 (1-6 lymph nodes), and 45 (16.4%) were N2 (7-15 lymph nodes).The median number of lymph nodes dissected was 35. The overall long-term (five-year) survival rate, for stages I to IIIb was 70.4%.

CONCLUSION

Digestive surgeons must be stimulated in performing D2 gastrectomies to avoid wasting the only treatment to gastric adenocarcinoma that has proven to be efficient up to this days. It must be emphasized that standardized lymph nodes dissection according to tumor location is more important that only the number of removed nodes.