Extended lymph node dissection for gastric cancer: results of a prospective, multi-centre analysis of morbidity and mortality in 118 consecutive cases

This study reports interim data on post-operative morbidity, hospital mortality and duration of hospital stay of Italian patients undergoing extended lymph-node dissection combined with a pancreas-preserving technique for gastric cancer. Of the 218 patients admitted to one of eight general and/or university hospitals in North Italy, 118 were enrolled in the trial. Eligible patients presented with proven primary adenocarcinoma of the stomach without clinical evidence of distant, peritoneal and/or liver metastasis, or metastasis in para-aortic and retropancreatic nodes at intraoperative biopsy. Patients underwent the extended procedure as described by the Japanese Research Society for the Study of Gastric Cancer, following the Maruyama pancreas-preserving technique. A strict quality control system was used to ensure the performance of a standard surgical treatment. A surgeon of the reference centre (M.D.), who stayed at the National Cancer Center Hospital in Tokyo to learn the D2 technique from a specialist Japanese surgeon, became the trial supervisor and assisted each surgeon in all the Italian participating centres. The patients were staged according both to the TNM system and to the General Rules for the Gastric Cancer Study in Surgery and Pathology. Post-operative surgical complications developed in 21 patients (17.8%). The non-surgical complication rate was 2.5%. Reoperation was necessary in six patients (5%), all of whom survived. The 30-day mortality rate for the eligible group was 2.5%. The overall hospital mortality was the same. Total gastrectomy was associated with a slightly higher operative mortality (4.5% vs 1.3%). Only one patient died from an anastomotic leak. The rate of leakages was higher after total than after distal gastrectomy (15.9 vs 5.4%); the association of splenectomy and pancreatectomy worsened the morbidity rate. D2 lymphadenectomy with pancreas-preserving technique, when performed at experienced centres, seems a feasible and safe technique for the radical treatment of gastric cancer in selected Western patients.

[Postoperative fistulas after gastrectomy: risk factors in relation to incidence and mortality]

The relations between incidence and prognosis of postoperative fistulas after gastrectomy and some different variables were analysed in the present retrospective study. Thirteen digestive fistulas of 113 patients (11.9%) submitted to gastrectomy during the period 1989-1994 represent the study population. The incidence of postoperative fistulas was compared to the kind of gastric pathology, to the extension of gastrectomy, to different nutritional (serum haemoglobin, albumin and transferrin level, weight loss) and immunological factors (serum lymphocytes) and, for oncological patients, to the stage of the disease. Incidence was directly related to the extension of gastrectomy, to serum albumin and haemoglobin level, and to weight loss rate. The results were not statistically significant at Kruskal-Wallis and ANOVA tests. No relation was found between incidence of fistulas and serum transferrin level, number of lymphocytes and adoption of early postoperative enteral nutrition. Six patients had spontaneous closure of the fistula with conservative therapy. Seven patients required reoperation because of abdominal sepsis (53.8%). Three patients died (23%). Although spontaneous closure, reoperation and mortality were related to nutritional and immunological state, no examined variables showed a statistically significative relation. The adoption of early postoperative enteral nutrition was not related to the prognosis, unlike the stage of the disease: patients submitted to reoperation had a TNM III or IV stage; dead patients had a TNM IV stage. Treatment of metabolic-nutritional unbalance can prevent anastomotic failure and fistula after gastrectomy and improve the prognosis. The relation between early postoperative enteral nutrition and incidence and prognosis of postoperative fistulas remains unclear.

[Neoplastic adenopathies of the neck: role of tumors of the oral cavity and salivary glands]

The Authors report a series of 386 non-selected cases of cervical adenopathies with systemic (23.1%) and secondary (76.9%) tumors, treated using both simple biopsy and radical surgery. The predominant sites were right (29.0%) and left (23.6%) laterocervical. Histological tests revealed that in relation to metastatic adenopathies the predominant histotype in the series as a whole was squamous carcinoma (29.5%). Within the scope of metastatic adenopathies, tumors of the oral cavity or salivary glands, if taken together, account for the highest percentage of incidence: 14.2%. Three points emerge from an analysis of the data: 1) in the presence of lymph node tumors of the cervical district, taken as a whole, approximately 21.8% may be attributed to tumors of the oral cavity and salivary glands; 2) in the context of metastatic adenopathies, the predominant histotype is squamous carcinoma, 38.4%; 3) the presence of a high percentage of metastatic adenopathies of the neck due to cancer of the oral cavity and adjacent salivary glands always requires the greatest care to commence integrated chemo-radio-surgical treatment of prevent efficacy.

[The incidence of tumors of the oral cavity and salivary glands in cervical adenopathies. Case contributions]

The paper report 592 non-selected cases of cervical adenopathies treated using both simple biopsy and more radical surgery. The predominant sites were right (29.7%) and left (25.2%) laterocervical. Histological tests showed that in 206 cases (34.8%) the pathology was benign and/or aspecific, whereas in 386 cases (65.2%) the presence of metastatic or systemic cancer was identified. Within the scope of metastatic adenopathies, tumors of the oral cavity or salivary glands, if taken together, account for the highest percentage of incidence: 14.2%. For this reason, the presence of cervical adenopathies must be given priority in the search for possible primary lesions affecting all the anatomical structures forming the oral cavity and the adjacent salivary glands.

[Carcinoma of the tonsil. Case contributions]

The authors study a group of 25 patients treated for tonsillar carcinomas mainly in stage IV at the Istituto di Oncologia di Torino. The most part of the deaths are in the first 2 years after treatment, mainly due to distant metastases; a good stabilization of survival follows, obtained by radiation therapy alone or associated with surgery and/or chemotherapy.