Surgeon proficiency gain and survival after gastrectomy for gastric adenocarcinoma: A population-based cohort study

OBJECTIVE

Quality of surgery is essential for survival in gastric adenocarcinoma, but studies examining surgeons' proficiency gain of gastrectomies are scarce. This study aimed to reveal potential proficiency gain curves for surgeons operating patients with gastric cancer.

METHODS

Population-based cohort study of patients who underwent gastrectomy for gastric adenocarcinoma in Sweden between 2006 and 2015 with follow-up throughout 2020. Data were retrieved from national registries and medical records. Risk prediction models were used to calculate outcome probabilities, and risk-adjusted cumulative sum curves were plotted to assess differences (change points) between observed and expected outcomes. The main outcome was long-term (>3-5 years) all-cause mortality after surgery. Secondary outcomes were all-cause mortality within 30 days, 31-90 days, 91 days to 1 year and>1-3 years of surgery, resection margin status, and lymph node yield.

RESULTS

The study included 261 surgeons and 1636 patients. The>3- to 5-year mortality was improved after 20 cases, and decreased from 12.4% before to 8.6% after this change point (p = 0.027). Change points were suggested, but not statistically significant, after 22 cases for 30-day mortality, 28 cases for 31- to 90-day mortality, 9 cases for 91-day to 1-year mortality, and 10 cases for>1- to 3-year all-cause mortality. There were statistically significant improvements in tumour-free resection margins after 28 cases (p < 0.005) and greater lymph node yield after 13 cases (p < 0.001).

CONCLUSIONS

This study reveals proficiency gain curves regarding long-term survival, resection margin status, and lymph node yield in gastrectomy for gastric adenocarcinoma, and that at least 20 gastrectomies should be conducted with experienced support before doing these operations independently.

Learning Curves of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Bariatric Surgery: a Systematic Review and Introduction of a Standardization

BACKGROUND

The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG.

METHODS

A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected.

RESULTS

A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery.

CONCLUSIONS

Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.

Minimal Access Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumours - A Single Centre Experience

Introduction: Laparoscopic techniques have been increasingly adopted in the field of General Surgery in the last decades. The main disadvantages of laparoscopy are related to limited degrees of freedom of instruments and poor ergonomics, which are associated with a steep learning curve. Robotic surgery overcomes most of the technical limitations of laparoscopic surgery and has the potential to expand the indications of minimal access surgery (MAS) in procedures that are difficult to perform using laparoscopy. Methods: Patients who underwent MAS resections of gastric gastrointestinal stromal tumours (GIST) between January 2002 and October 2018 in a single Surgical Department were retrospectively analysed. Demographic data as well as the following characteristics were recorded for each patient: age, sex, symptoms, tumour location and size, type of surgical procedure, intraoperative blood loss, operative time, length of hospital stay, histopathological assessment of resection margins, and incidence of perioperative complications. Results: The mean patient age was 58 (range, 27-81 years). Most lesions were found on the great curvature (7) and in the distal stomach or antrum (7), respectively. Twenty patients underwent laparoscopic resection, while five patients had robotic resection of gastric GISTs. Surgical laparoscopic treatment consisted of antrectomy (n=4) and wedge gastrectomy (n=16). In all robotic cases a wedge gastrectomy was performed. One patient was converted to open surgery due to adhesions from previous operation. The mean operative time was 130 minutes (range, 70-210 minutes).The mean tumour size was 3.8 cm (range, 2-7 cm). There were no complications except one case that required reoperation for postoperative bleeding. There were no mortalities. Conclusion: The MAS approach of gastric GISTs is safe and effective and it is associated with low morbidity. Therefore, it should constitute the first option in patients with small tumours and favourable locations. The only limiting factor for the widespread use of MAS resections for gastric GISTs is surgeon expertise in this challenging technique.

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.

Recurrence pattern and its predictors for advanced gastric cancer after total gastrectomy

This study aimed to investigate the recurrence patterns of advanced gastric cancer (AGC) after curative total gastrectomy and further explore predictors for each pattern of recurrence.Data of 299 AGC patients between 2010 and 2014 were retrospectively analyzed to investigate the clinicopathologic factors affecting the recurrence pattern of AGC patients underwent curative total gastrectomy.Sixty-eight (22.7%) AGC patients had recurrence after total gastrectomy. Distant metastasis (DM) was the most prevalent pattern with 29 (42.6%) cases, followed by peritoneal recurrence (PR) with 25 (36.8%) patients, and locoregional recurrence (LR) occurred in 23 (33.8%) patients. The recurrence rates within 2 and 5 years were 77.9% and 97.1%. Extent of lymphadenectomy (P < .001, χ2 = 17.366), depth of tumor invasion (P < .001, χ2 = 21.638), lymph node metastasis (P = .046, χ2 = 9.707), and number of negative lymph nodes (P = .017, χ2 = 2.406) were associated with tumor recurrence by univariate analysis. Multivariate analyses revealed that the extent of lymphadenectomy (P = .034, 95% CI: 1.074-6.414) and T4b status (P = .015, 95% CI: 0.108-0.785) were independent predictors for LR; histological type (P = .041, 95% CI: 0.016-0.920) and T4b status (P = .007, 95% CI: 0.102-0.690) for PR; and pN status (P = .032) for DM.In AGC patients following total gastrectomy, recurrent predictors various among locoregional, peritoneal, and distant recurrence. Recurrent predictors of tumor invasion, lymph node metastasis, and histological type could guide follow-up and risk-oriented adjuvant treatment, extended lymphadenectomy was considered to reduce LR of AGC patients after curative total gastrectomy.

Biliary Cannulation in Patients with Roux-en-Y Gastrectomy: An Analysis of the Factors Associated with Successful Cannulation

Objective We investigated the results of biliary cannulation using a short-type single-balloon enteroscope in patients with a native papilla who had previously undergone Roux-en-Y gastrectomy and analyzed the factors associated with successful cannulation. Methods The study subjects consisted of patients with a native papilla who had previously undergone Roux-en-Y gastrectomy and endoscopic retrograde cholangiopancreatography using a short-type single-balloon enteroscope at our institution between September 2011 and July 2019. We carried out a retrospective investigation of the outcomes, including assessing the success rate of biliary cannulation, and analyzed the factors associated with successful cannulation. Results In total, 78 patients underwent biliary cannulation of a native papilla. The success rate of biliary cannulation was 80.8% (88.5% when including success on repeated attempts). The success rate of the standard cannulation technique was 60.3%, with the use of advanced cannulation techniques to secure the pancreatic duct providing the same additional effect as a normal anatomy. Adverse events occurred in 9.0% of cases. A multivariate analysis of the Roux-en-Y gastrectomy patients found that cannulation was more likely to be successful in patients in whom the scope could be placed in the retroflex position (odds ratio: 7.88, 95% confidence interval: 2.19-37.77, p<0.001). Conclusion Selective biliary cannulation using a short-type single-balloon enteroscope in patients with a native papilla who had undergone Roux-en-Y gastrectomy was effective and safe. The retroflex position provided a good papilla field of view and improved the success rate of biliary cannulation.

Optimal proximal resection margin distance for gastrectomy in advanced gastric cancer

BACKGROUND

The conventional guidelines to obtain a safe proximal resection margin (PRM) of 5-6 cm during advanced gastric cancer (AGC) surgery are still applied by many surgeons across the world. Several recent studies have raised questions regarding the need for such extensive resection, but without reaching consensus. This study was designed to prove that the PRM distance does not affect the prognosis of patients who undergo gastrectomy for AGC.

AIM

To investigate the influence of the PRM distance on the prognosis of patients who underwent gastrectomy for AGC.

METHODS

Electronic medical records of 1518 patients who underwent curative gastrectomy for AGC between June 2004 and December 2007 at Asan Medical Center, a tertiary care center in Korea, were reviewed retrospectively for the study. The demographics and clinicopathologic outcomes were compared between patients who underwent surgery with different PRM distances using one-way ANOVA and Fisher’s exact test for continuous and categorical variables, respectively. The influence of PRM on recurrence-free survival and overall survival were analyzed using Kaplan-Meier survival analysis and Cox proportional hazard analysis.

RESULTS

The median PRM distance was 4.8 cm and 3.5 cm in the distal gastrectomy (DG) and total gastrectomy (TG) groups, respectively. Patient cohorts in the DG and TG groups were subdivided into different groups according to the PRM distance; ≤ 1.0 cm, 1.1-3.0 cm, 3.1-5.0 cm and > 5.0 cm. The DG and TG groups showed no statistical difference in recurrence rate (23.5% vs 30.6% vs 24.0% vs 24.7%, P = 0.765) or local recurrence rate (5.9% vs 6.5% vs 8.4% vs 6.2%, P = 0.727) according to the distance of PRM. In both groups, Kalpan-Meier analysis showed no statistical difference in recurrence-free survival (P = 0.467 in DG group; P = 0.155 in TG group) or overall survival (P = 0.503 in DG group; P = 0.155 in TG group) according to the PRM distance. Multivariate analysis using Cox proportional hazard model revealed that in both groups, there was no significant difference in recurrence-free survival according to the PRM distance.

CONCLUSION

The distance of PRM is not a prognostic factor for patients who undergo curative gastrectomy for AGC.

Surgical management of gastric adenocarcinoma. Official expert recommendations delivered under the aegis of the French Association of Surgery (AFC)

Gastric adenocarcinoma (GA) is the 5^th most common cancer in the world; in France, however, its incidence has been steadily decreasing. Twenty-five experts brought together under the aegis of the French Association of Surgery collaborated in the drafting of a series of recommendations for surgical management of GA. As concerns preoperative evaluation and work-up, echo-endoscopy aimed at clarifying lymph node status should be performed in all candidates for surgical resection and exploratory laparoscopy in cases of GA cT3/T4 and/or N+ for peritoneal carcinomatosis. On the other hand, PET-scan should not be performed systematically, but only when the other modalities for diagnosis prove insufficient. Laparotomy remains the route of choice to achieve total or partial gastrectomy with D2 lymph node lymphadenectomy for advanced lesions (>T2N0). To limit the risk of dumping syndrome and esophageal reflux and as a way of reestablishing continuity, construction of a jejunal pouch on Roux-en-Y following total gastrectomy is recommended. In cases of peritoneal carcinosis in GA with a low peritoneal cancer index (PCI) (<7) in a patient in good general condition whose disease is controlled by chemotherapy, macroscopically complete cytoreduction with intraperitoneal hyperthermal chemotherapy will probably be required, and it will have to take place in an expert center. Only in the event of Child A cirrhosis may gastrectomy with D2 lymphadenectomy be considered. Palliative gastrectomy or surgical bypass for distal stomach obstruction in a patient in good general condition may also be envisioned.

[Practical membrane anatomy of en bloc mesogastrium excision in lymph node dissection of gastric cancer]

Gastric cancer is a common malignant tumor of digestive system. D2 procedure is recognized as the standard operation for advanced gastric cancer at present. However, controversies still exist in the standardization and quality control of surgical procedures. Total mesorectal excision (TME) and complete mesocolic excision (CME) based on the membrane anatomy perfectly solve these problems in the treatment for colorectal cancer. However, the complexity of mesogastrium determines that TME and CME cannot be easily transplanted to the treatment of gastric cancer. The practical membrane anatomy in gastric cancer surgery is just emerging and its impact on the treatment of gastric cancer is immeasurable. By reviewing the evolution and embryonic development of digestive system, and combining with actual operation, this paper analyzes and redefines several key issues such as traditional Toldt space, Gerota fascia and complete mesenteric excision. On this basis, we propose a novel and feasible surgical procedure named regional en bloc mesogastrium excision (rEME) for distal gastric cancer. The concept of en bloc mesogastrium excision (EME) based on membrane anatomy may have some influences on the lymph node grouping from the 'Japanese Classification of Gastric Carcinoma'. Performance of EME may reduce the controversies about the group of lymph nodes and their borders. EME in the infra-pyloric region weakens the significance of subdivision of No.6 lymph nodes into No.6a, No.6v and No.6i. More studies are needed in the construction of a mature theoretical system for practical membrane anatomy in gastric surgery.

Quality assurance of surgery in the randomized ST03 trial of perioperative chemotherapy in carcinoma of the stomach and gastro-oesophageal junction

BACKGROUND

The UK Medical Research Council ST03 trial compared perioperative epirubicin, cisplatin and capecitabine (ECX) chemotherapy with or without bevacizumab (B) in gastric and oesophagogastric junctional cancer. No difference in survival was noted between the arms of the trial. The present study reviewed the standards and performance of surgery in the context of the protocol-specified surgical criteria.

METHODS

Surgical and pathological clinical report forms were reviewed to determine adherence to the surgical protocols, perioperative morbidity and mortality, and final histopathological stage for all patients treated in the study.

RESULTS

Of 1063 patients randomized, 895 (84·2 per cent) underwent resection; surgical details were available for 880 (98·3 per cent). Postoperative assessment data were available for 873 patients; complications occurred in 458 (52·5 per cent) overall, of whom 71 (8·1 per cent) developed complications deemed to be life-threatening by the responsible clinician. The most common complications were respiratory (211 patients, 24·2 per cent). The anastomotic leak rate was 118 of 873 (13·5 per cent) overall; among those who underwent oesophagogastrectomy, the rate was higher in the group receiving ECX-B (23·6 per cent versus 9·9 per cent in the ECX group). Pathological assessment data were available for 845 patients. At least 15 nodes were removed in 82·5 per cent of resections and the median lymph node harvest was 24 (i.q.r. 17-34). Twenty-five or more nodes were removed in 49·0 per cent of patients. Histopathologically, the R1 rate was 24·9 per cent (208 of 834 patients). An R1 resection was more common for proximal tumours.

CONCLUSION

In the ST03 trial, the performance of surgery met the protocol-stipulated criteria. Registration number: NCT00450203 ( http://www.clinicaltrials.gov).

The role of endoscopy in the management of hereditary diffuse gastric cancer syndrome

Hereditary diffuse gastric cancer (HDGC) syndrome is an inherited cancer risk syndrome associated with pathogenic germline CDH1 variants. Given the high risk for developing diffuse gastric cancer, CDH1 carriers are recommended to undergo prophylactic total gastrectomy for cancer risk reduction. Current guidelines recommend upper endoscopy in CDH1 carriers prior to surgery and then annually for individuals deferring prophylactic total gastrectomy. Management of individuals from HDGC families without CDH1 pathogenic variants remains less clear, and management of families with CDH1 pathogenic variants in the absence of a family history of gastric cancer is particularly problematic at present. Despite adherence to surveillance protocols, endoscopic detection of cancer foci in HDGC is suboptimal and imperfect for facilitating decision-making. Alternative endoscopic modalities, such as chromoendoscopy, endoscopic ultrasound, and other non-white light methods have been utilized, but are of limited utility to further improve cancer detection and risk stratification in HDGC. Herein, we review what is known and what remains unclear about endoscopic surveillance for HDGC, among individuals with and without germline CDH1 pathogenic variants. Ultimately, the use of endoscopy in the management of HDGC remains a challenging arena, but one in which further research to improve surveillance is crucial.

Efficacy and safety of endoscopic submucosal dissection for papillary adenocarcinoma-type early gastric cancer

Endoscopic submucosal dissection (ESD) has increasingly been used to treat early gastric cancer (EGC); however, its efficacy in treating papillary adenocarcinoma-type EGC remains unknown.We sought to identify risk factors for lymph node (LN) metastasis in papillary adenocarcinoma-type EGC and evaluate the clinical outcome after ESD.This study retrospectively reviewed the medical records of patients who were diagnosed with EGC in our hospital from January 2009 to December 2016. In total, 85 patients had papillary adenocarcinoma-type EGC, of whom 52 and 33 underwent surgical treatment and ESD, respectively. This study analyzed the LN metastasis risk factors and clinical outcomes between these 2 groups and with those of an existing ESD indication group.LN metastasis occurred in 13 (25.0%) of 52 patients who underwent surgery. Multivariate analysis indicated that lymphovascular invasion was an independent risk factor (odds ratio: 20.624; 95% confidence interval: 19.628-21.497; P = .001). Of 33 patients who underwent ESD, 21 (63.6%) had an absolute indication and 12 (36.4%) had an expanded indication. All 3 (9.1%) patients with non-curative resection underwent additional surgery. The clinical outcomes were compared to those of 926 patients who underwent ESD of non-papillary adenocarcinoma-type EGC. There were no significant differences in curative resection rate (P = .327), procedure-related complication (P = .853), local recurrence (P = 1.000), or overall survival (P = 1.000).ESD of papillary adenocarcinoma-type EGC showed an acceptable outcome in comparison to an existing ESD indication group. However, these patients exhibit a relatively higher risk of LN metastasis.

Learning curve and short-term outcomes of modularized LADG for advanced gastric cancer: A retrospective study

Laparoscopy-assisted distal gastrectomy (LADG) is a complicated procedure. To reduce the difficulty of the operation and standardize the surgical procedure, we explored a new operation mode, which we termed modularized LADG (MLADG). To further extend the new operation mode, we conducted this study to evaluate the short-term outcomes of MLADG for advanced gastric cancer, and determine the learning curve.Data from 100 consecutive patients who received LADG between October 2016 and October 2017 were retrospectively analyzed. Short-term outcomes, such as operation time and intraoperative blood loss, were evaluated, and the learning curve was calculated.For MLADG, the mean operation time was 168.2 ± 13.0 minutes, the mean intraoperative blood loss was 93.6 ± 29.1 ml, the mean number of harvested lymph nodes was 28.6 ± 4.2, and conversion to open surgery occurred in only 1 case. In addition, MLADG had an acceptable postoperative complication incidence and fast postoperative recovery. After the first 20 cases, the operation skill reached a mature and stable level.Our results indicate that MLADG is an oncologically feasible and technically safe surgical procedure. For the trainees with rich experience in open distal gastrectomy, the learning curve is considered to be completed after 20 MLADG cases.

[Clinical significance and principles of the specification procedures for lymph node examination after curative surgery for gastric cancer]

So far, the category based on the number of metastatic lymph nodes (eg. pN stage) has been demonstrated to be the optimal staging of lymph node metastasis after curative surgery for gastric cancer. Although pN stage has been updating since 1992, it has been still controversial to guarantee the acquisition for the accurate information of lymph node metastasis from gastric cancer. Generally, stage migration of lymph node metastasis means that number of metastatic lymph node is positively correlated with the extent of lymphadenectomy, and with the expansion of lymphadenectomy extent, occurrence of stage migration of lymph node metastasis may decrease gradually or be avoided (Will-Roger phenomena). Stage migration of lymph node metastasis is considered to have a significant impact on the pathologic stage, prognostic evaluation and strategy formulation of adjuvant therapy. Actually, stage migration of lymph node metastasis may be induced by individual difference in patients, disease stage, special biological behaviors of tumor, extent of lymphadenectomy, procedures of lymph node examination and so on, which may undermine the accurate staging of lymph node metastasis from gastric cancer in clinic. The specification procedures for lymph node examination following the radical lymphadenectomy for gastric cancer are not only the necessary method to figure out the comprehensive information of lymph node metastasis from patients but also the essential evidence to embody the high quality of curative gastrectomy for patients, which may provide the optima database for the further precise diagnosis and treatment of gastric cancer.

[Clinical value of superior mesenteric vein (No.14v) lymph node dissection in D2 gastrectomy for locally advanced distal gastric cancer]

OBJECTIVE

To explore the value of superior mesenteric vein (No.14v) lymph node dissection in D2 gastrectomy for locally advanced distal gastric cancer.

METHODS

A retrospective cohort study was carried out. A total of 796 patients with locally advanced distal gastric cancer undergoing D2 gastrectomy at the Cancer Center of Guangzhou Medical University between 2002 and 2016 were enrolled.

INCLUSION CRITERIA

locally advanced distal gastric adenocarcinoma confirmed by postoperative pathology; adenocarcinoma located at or invaded into lower 1/3 stomach; lymphadenectomy was D2 or D2+; negative resection margin confirmed by pathology; no distal metastasis was found; preoperative neoadjuvant chemotherapy was not administrated. Patients with undefined group of lymph nodes by postoperative pathology and those who were died perioperatively were excluded. Among 796 patients, 293 underwent No.14v dissection (No.14vD+ group) and the other 503 patients did not undergo No.14v dissection (No.14vD- group). The 5-year overall survival was compared between the two groups. Therapeutic index of No.14v lymph nodes was calculated according to the following formula: therapeutic index=metastatic rate of No.14 lymph nodes (%) × 5-year survival rate of patients with No.14 lymph node metastasis(%) × 100. Meanwhile, stratified analyses based on pathological TNM staging were performed.

RESULTS

There were no significant differences in age, gender, tumor size, Borrmann type, Lauren classification, histological type, surgical procedure, and number of harvested lymph node between two groups (all P>0.05). However, compared to No.14vD- group, No.14vD+ group had more advanced T staging (χ² =14.771, P=0.005) and TNM staging (χ² =18.339, P=0.003), and higher ratio of receiving adjuvant chemotherapy (χ² =4.205, P=0.040). The median follow-up period was 47 months. The 5-year survival rate in No.14vD+ and No.14vD- groups was 57.4% and 46.8% respectively without statistically significant difference (P=0.313). After adjusting for confounding factors, Cox proportional hazards model showed that No.14v lymphadenectomy was not an independent prognostic factor(HR=0.802, 95%CI: 0.545-1.186, P=0.124). Stratified analyses revealed that in all TNM stages, 5-year survival rates were not significantly different between two groups (all P>0.05). However, No.14v lymphadenectomy showed a tendency of survival benefit when the tumor staging after advancing to III A stage(III A: P=0.103; III B: P=0.085; III C: P=0.060). Five-year survival rates of No.14vD+ and No.14vD- groups in stage III A were 54.9% and 45.2%, in III B stage were 39.8% and 29.5%, in III C stage were 27.5% and 16.2%, respectively. After combining III A, III B and III C, the No.14vD+ group had a higher 5-year survival rate than No.14vD- group (39.2% vs. 27.7%, P=0.006). The No.14v metastasis rate in No14v+ group was 12.6%(37/293), including 0%(0/46), 2.5%(1/40), 4.9%(2/41), 15.7%(8/51), 20.8%(11/53) and 24.2%(15/62) in stages I B, II A, II B, III A, III B and III C respectively. The metastasis rate of No.14v lymph node in stage III patients was 20.5%(34/166). The 5-year survival rate of these 34 stage III patients with No.14v metastasis was 21.1%. The therapeutic index of No.14v lymph node in stage III patients was 4.3, which was comparable with 3.9 of No.9 and 4.9 of No.11p, even higher than 2.6 of No.1.

CONCLUSIONS

Although No.14v lymphadenectomy can not improve the overall survival of patients with locally advanced distal gastric cancer, but it may significantly improve survival in those with stage III cancer. The therapeutic index of No.14v lymph node is similar to No.2 station lymph node in patients with stage III distal gastric cancer. Therefore No.14v lymph node should be included in D2 dissection.

[Feasibility and efficacy of laparoscopic treatment for advanced gastric cancer from LOC-A study]

With the progression of surgical techniques, laparoscopic equipment and treatment concepts, laparoscopic radical gastrectomy has been widely used in clinical practice. However, whether laparoscopic surgery can be used for the treatment of locally advanced gastric cancer is still controversial. Recent results from the Korean KLASS-02 study, the Japanese JCOG-0901 study, and the Chinese CLASS-01 study suggest that there is no significant difference in the short-term efficacy between laparoscopic surgery and open surgery in the treatment of locally advanced gastric cancer. The long-term results have not been published. The LOC-A study was a multicenter, large sample size retrospective analysis that enrolled 1948 laparoscopic and open surgery cases with stage II to III locally advanced gastric cancer in 8 Japanese hospitals between 2008 and 2014. As a result, after removal of confounding factors by propensity score matching (PSM), the analysis showed no significant difference in long-term efficacy between laparoscopic surgery and open surgery for locally advanced gastric cancer. However, some bias still remain after the bias-control. Therefore, due to insufficiency of the high-level evidence-based medical evidence, we believe that the all-round promotion of laparoscopic surgery of locally advanced gastric cancer is too early, nevertheless, we should also recognize that the minimally invasive treatment of gastric cancer is the current development trend, and we should be confident in laparoscopic treatment of locally advanced gastric cancer.

A Delphi Consensus of the Crucial Steps in Gastric Bypass and Sleeve Gastrectomy Procedures in the Netherlands

PURPOSE

Bariatric procedures are technically complex and skill demanding. In order to standardize the procedures for research and training, a Delphi analysis was performed to reach consensus on the practice of the laparoscopic gastric bypass and sleeve gastrectomy in the Netherlands.

METHODS

After a pre-round identifying all possible steps from literature and expert opinion within our study group, questionnaires were send to 68 registered Dutch bariatric surgeons, with 73 steps for bypass surgery and 51 steps for sleeve gastrectomy. Statistical analysis was performed to identify steps with and without consensus. This process was repeated to reach consensus of all necessary steps.

RESULTS

Thirty-eight participants (56%) responded in the first round and 32 participants (47%) in the second round. After the first Delphi round, 19 steps for gastric bypass (26%) and 14 for sleeve gastrectomy (27%) gained full consensus. After the second round, an additional amount of 10 and 12 sub-steps was confirmed as key steps, respectively. Thirteen steps in the gastric bypass and seven in the gastric sleeve were deemed advisable. Our expert panel showed a high level of consensus expressed in a Cronbach's alpha of 0.82 for the gastric bypass and 0.87 for the sleeve gastrectomy.

CONCLUSIONS

The Delphi consensus defined 29 steps for gastric bypass and 26 for sleeve gastrectomy as being crucial for correct performance of these procedures to the standards of our expert panel. These results offer a clear framework for the technical execution of these procedures.

Removal of Nasogastric Tube Accidentally Stitched to Roux-en-Y Oesophagojejunostomy Following a Radical Gastrectomy for Stomach Cancer: Case report and review of the literature

Nasogastric tubes (NGTs) are important for feeding, stenting and decompression after gastrointestinal surgeries, particularly in the upper gastrointestinal tract. Resistance in the removal of a NGT is a rare surgical complication and may be due to a knot in the tube or a stitch anchoring the tube to an anastomosis. We report a 41-year-old male patient who was admitted to the King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in 2015 with stomach cancer. He underwent a radical total gastrectomy with a Roux-en-Y oesophagojejunostomy. One week after the surgery, removal of the NGT was attempted; however, this was very difficult and the proximal end of the tube was cut off as a temporary measure. Six weeks later, an upper gastrointestinal tract endoscopy revealed that the distal end of the NGT had been accidentally stitched to the Roux-en-Y oesophagojejunostomy. The stitch was removed and the rest of the NGT was successfully extracted using a snare.

[Gastric bypass versus sleeve, pros and cons]

Gastric bypass versus sleeve, pros and cons  The most commonly performed bariatric procedure today is gastric bypass, while sleeve gastrectomy has become more common in recent years. Little is known about the long-term effects of sleeve gastrectomy and despite several randomized trials it is still unknown which procedure is the most favourable. Two recently published randomized trials show that the two procedures result in comparable weight loss in the short term while gastric bypass could possibly result in better weight loss in the long term. However, gastric bypass tends to lead to a higher incidence of post-operative complications compared to sleeve gastrectomy.

Biliopancreatic diversion with duodenal switch leads to better postprandial glucose level and beta cell function than sleeve gastrectomy in individuals with type 2 diabetes very early after surgery

OBJECTIVE

The aim of this study was to compare the short-term effect of sleeve gastrectomy (SG) and biliopancreatic diversion with duodenal switch (DS) in order to determine if exclusion of the upper gastrointestinal tract confers greater metabolic improvement, independent of weight loss.

METHODS

Standard meals were administered before and on day 3 and 4 after SG to assess insulin sensitivity, β-cell function and gastrointestinal hormone responses in matched normoglycemic (NG) and type 2 diabetes (T2D) participants. A third group of matched T2D participants who underwent DS with the same meal test administered prior to and 3days after surgery was also recruited.

RESULTS

Despite significant metabolic improvement, T2D participants failed to fully normalize insulin resistance and β-cell dysfunction 3 and 4days after SG. Our results demonstrate the superiority of DS over SG in terms of short-term improvement in postprandial glucose excursion and β-cell function 3days after the surgery, with similar improvement in hepatic insulin sensitivity.

CONCLUSION

Our findings support the notion that caloric restriction represents an important mechanism to explain the very early anti-diabetic effects observed after bariatric surgery. However, exclusion of the upper gastrointestinal tract also provides further metabolic improvements, possibly mediated by gastrointestinal hormonal responses and altered postprandial glucose absorption.

[Discussion on standardized implementation of laparoscopic radical lymphadenectomy for distal gastric cancer]

Laparoscopic radical gastrectomy for gastric cancer has been widely applied in clinical practice, and its indications have been extended from early gastric cancer to advanced gastric cancer. It is acknowledged that laparoscopic radical gastrectomy is technically challenging because of the complexity of anatomy, rich blood supply, and extensive lymph node dissection. This paper primarily intends to share the experience of laparoscopic radical D2 gastrectomy for distal gastric cancer with details of choosing the location of Trocar, surgical approaches and the sequence of lymph node dissection. All the surgeries were performed at Department of General Surgery and Gastrointestinal Surgery, Guangdong General Hospital. The finding suggests that a correct laparoscopic Trocar placement is the foundation of adequate surgical field visualization. Under most circumstances, the observation hole should be around 2 cm below the umbilicus and the operating hole should be close to the bilateral clavicle midline. Furthermore, proper surgical approach and sequence of lymph node dissection are the prerequisites for successful laparoscopic radical D2 gastrectomy, as well as the reassurance of dissecting lymph node safely and comprehensively. The position of surgical team adopted in our center is that the surgeon stands to the left of the patient, with laparoscope operator stands in between patient's legs while the first assistant positions himself opposite the surgeon on the right side of the patient. This position correlates to the rules of sequential lymph node dissection, which is "from left to right", "from proximal to distal" and "from inferior to superior". Therefore, it is conductive to inferior and superior pylorus region dissection and it can effectively prevent subsidiary-injury. In our center, the procedure of lymph node dissection has been standardized: the initial step is to undergo station 4sb dissection and greater gastric curvature clearance; then change the patient's position to clean the sub-pyloric lymph node region and cut off the duodenum by linear stapler; followed by the clearance of inferior region of the pylorus and the upper margin of the pancreas; in the final step, the first and the third groups of lymph node dissection is performed. Although varied surgical approaches and sequences of lymph node dissection are applied in different hospitals, the techniques required for laparoscopic D2 radical gastrectomy for gastric cancer are sophisticated and advanced in general. Radical lymph node dissection is complicated, urging surgeons to familiarize themselves with the anatomy of gastric peripheral vascular system and characteristics of lymph node drainage. By designing and implementing effective strategies, such as formulating a regular team, positioning surgical team reasonably, changing a patient's posture during operation, choosing an appropriate surgical approach and following a logically sequence of lymph node dissection, surgeons can standardize the complete surgical procedure, which ultimately reduces bleeding during surgery and shortens the operative time.

MINIMALLY INVASIVE SURGERY FOR GASTRIC CANCER: TIME TO CHANGE THE PARADIGM

INTRODUCTION

Minimally invasive surgery widely used to treat benign disorders of the digestive system, has become the focus of intense study in recent years in the field of surgical oncology. Since then, the experience with this kind of approach has grown, aiming to provide the same oncological outcomes and survival to conventional surgery. Regarding gastric cancer, surgery is still considered the only curative treatment, considering the extent of resection and lymphadenectomy performed. Conventional surgery remains the main modality performed worldwide. Notwithstanding, the role of the minimally invasive access is yet to be clarified.

OBJECTIVE

To evaluate and summarize the current status of minimally invasive resection of gastric cancer.

METHODS

A literature review was performed using Medline/PubMed, Cochrane Library and SciELO with the following headings: gastric cancer, minimally invasive surgery, robotic gastrectomy, laparoscopic gastrectomy, stomach cancer. The language used for the research was English.

RESULTS

28 articles were considered, including randomized controlled trials, meta-analyzes, prospective and retrospective cohort studies.

CONCLUSION

Minimally invasive gastrectomy may be considered as a technical option in the treatment of early gastric cancer. As for advanced cancer, recent studies have demonstrated the safety and feasibility of the laparoscopic approach. Robotic gastrectomy will probably improve outcomes obtained with laparoscopy. However, high cost is still a barrier to its use on a large scale.

Surgical care quality and oncologic outcome after D2 gastrectomy for gastric cancer

AIM: To examine the quality of surgical care and long-term oncologic outcome after D2 gastrectomy for gastric cancer.

METHODS: From 1999 to 2008, a total of 109 consecutive patients underwent D2 gastrectomy without routine pancreaticosplenectomy in a multimodal setting at our institution. Oncologic outcomes together with clinical and histopathologic data were analyzed in relation to the type of surgery performed. Staging was carried out according to the Union for International Cancer Control criteria of 2002. Patients were followed-up for five years at the outpatient clinic. The primary measure of outcome was long-term survival with the quality of surgery as a secondary outcome measure. Clinical data were retrospectively collected from the patient records, and causes of death were obtained from national registries.

RESULTS: A total of 109 patients (58 men) with a mean age of 67.4 ± 11.2 years underwent total gastrectomy or gastric resection with D2 lymph node dissection. The tumor stage distribution was as follows: stage I, (27/109) 24.8%; stage II, (31/109) 28.4%; stage III, (41/109) 37.6%; and stage IV, (10/109) 9.2%. Forty patients (36.7%) received chemotherapy or chemoradiotherapy. The five-year overall survival rate for all 109 patients was 45.0%, and was 47.1% for the 104 patients treated with curative R0 resection. The five-year disease-specific survival rates were 53.0% and 55.8%, respectively. In a multivariate analysis, body mass index and tumor stage were independent prognostic factors for overall survival (both P < 0.01), whereas body mass index, tumor stage, tumor site, Lauren classification, and lymph node invasion were prognostic factors for cancer-specific survival (all P < 0.05). Postoperative 30-d mortality was 1.8% and 30-d, surgical (including three anastomotic leaks, two of which were treated conservatively), and general morbidities were 26.6%, 12.8%, and 14.7%, respectively.

CONCLUSION: D2 dissection is a safe surgical option for gastric cancer, providing quality surgical care and long-term oncologic outcomes that are in line with current Western standards.

Learning curve for hand-assisted laparoscopic D2 radical gastrectomy

AIM: To describe the learning curves of hand-assisted laparoscopic D2 radical gastrectomy (HALG) for the treatment of gastric cancer.

METHODS: The HALG surgical procedure consists of three stages: surgery under direct vision via the port for hand assistance, hand-assisted laparoscopic surgery, and gastrointestinal tract reconstruction. According to the order of the date of surgery, patients were divided into 6 groups (A-F) with 20 cases in each group. All surgeries were performed by the same group of surgeons. We performed a comprehensive and in-depth retrospective comparative analysis of the clinical data of all patients, with the clinical data including general patient information and intraoperative and postoperative observation indicators.

RESULTS: There were no differences in the basic information among the patient groups (P > 0.05). The operative time of the hand-assisted surgery stage in group A was 8-10 min longer than the other groups, with the difference being statistically significant (P = 0.01). There were no differences in total operative time between the groups (P = 0.30). Postoperative intestinal function recovery time in group A was longer than that of other groups (P = 0.02). Lengths of hospital stay and surgical quality indicators (such as intraoperative blood loss, numbers of detected lymph nodes, intraoperative side injury, postoperative complications, reoperation rate, and readmission rate 30 d after surgery) were not significantly different among the groups.

CONCLUSION: HALG is a surgical procedure that can be easily mastered, with a learning curve closely related to the operative time of the hand-assisted laparoscopic surgery stage.

[OPTIMIZATION OF THE METHOD OF SUPRAPANCREATIC LYMPH NODE DISSECTION IN LAPAROSCOPY-ASSISTED GASTRECTOMY (IN THE FINAL ANALYSIS OF INTERNATIONAL CONFERENCES <<SCHOOL OF STOMACH SURGERY>>)]

The article analyzed the methods of suprapancretic lymph node dissection in laparoscopic gastrectomy which were devel- oped and applied in Japan. The authors described the details of operation technique. There were noted the advantages of medial approach for suprapancreatic lymph node dissection.

Laparoscopic gastric surgery for cancer: Where do we stand?

Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays this debate is apparently coming to an end. Laparoscopic surgery has been employed in the surgical treatment of gastric cancer for two decades now, but with controversies about the extent of resection and lymphadenectomy. Despite these difficulties, the apparent advantages of the laparoscopic approach helped its implementation in early stage and distal gastric cancer, with an increase on the uptake for distal gastrectomy for more advanced disease and total gastrectomy. Nevertheless, there is no conclusive evidence about the laparoscopic approach yet. In this review article we present and analyse the current status of laparoscopic surgery in the treatment of gastric cancer.

Multimodality treatment of potentially curative gastric cancer: geographical variations and future prospects

After much controversy, multimodality therapy is now accepted worldwide as the gold standard for treatment of resectable bulky localized gastric cancer. There is significant regional variation in the style of multimodality treatment with adjuvant chemoradiation the North American standard, neoadjuvant chemotherapy preferred in Europe and Australasia, whilst adjuvant chemotherapy is preferred in Asia. With further standardization of surgery and D1+/D2 resections increasingly accepted world wide, and in particular in the West, as the surgical standard of care for potentially curable disease, it is timely to reassess the multimodality regimes being used. The challenge in the use of multimodality therapy is how current outcomes can be standardized and improved further. Recent studies indicate that mere intensification of the regime in time, dosage or addition of further agents does not improve localized gastric cancer outcomes. More novel strategies including early commencement of adjuvant therapies, intra-peritoneal chemotherapy or assessing neoadjuvant response with positron emission tomography scanning may give improvements in outcomes. The introduction of targeted therapies means that the adjuvant use of biological agents needs to be explored. By proper assessment of the patient's co-morbidities, full tumour staging, and a better understanding of the tumour's molecular pathology, multimodality therapy for gastric adenocarcinoma may be individualized to optimize the likelihood of cure.

Validity of the MAGIC study: sufficient for recommendations?

According to the recommendations of the German S3 guideline, perioperative chemotherapy is an integral part of the treatment concept for advanced gastric cancer. The leading trial which examined the effects of perioperative chemotherapy is the MAGIC study. An examination of the validity of this study with a standardized method revealed shortcomings in the six areas: design, protocol, selection of patients, randomization / homogeneity of patient groups, quality of the surgical care and the statistical evaluation. These shortcomings and their influence on the study results are described in this paper to reveal the importance of these effects for discussion in guidelines committees.

The high volume debate in a low volume country: centralisation of oesophageal resection in New Zealand

AIM

Centralisation of oesophageal resection for cancer remains an area of debate. However, no consensus for the requirements of high volume centres yet exists and some low volume centres have been able to produce a comparable outcome. With the small population of New Zealand more than one high volume centre might not be achievable. We reviewed our series of oesophageal resections and compared them to outcomes in the literature to challenge the need for only high volume centres within New Zealand

METHODS

A retrospective analysis of all consecutive oesophagogastrectomies performed in Christchurch Public Hospital (Christchurch City, New Zealand) from January 1998 until June 2009 was undertaken.

RESULTS

Within this period 128 oesophagogastrectomies were performed. Median admission duration was 12 days. The overall complication rate was 53.9% of which 5.5% was an anastomotic leak. Combined in-hospital and 30-day-mortality was 1.6% (2/128). The 5-year-survival was 32.4% for adenocarcinoma and 47.7% for squamous cell carcinoma. Conclusion This series has shown that a low volume centre within New Zealand is able to deliver a satisfactory level of care for oesophagectomy. Given New Zealand's low population density it is debatable to what extent care should be centralised for treatment of oesophageal carcinoma.

Advanced gastric cancer: is there enough evidence to call second-line therapy standard?

Gastric cancer and cancer of the gastro-oesophageal junction (GOJ) are the 4th most common cancer diagnoses worldwide with regional differences in incidence rates. The treatment of gastric and GOJ cancers is complex and requires multimodality treatment including chemotherapy treatment, surgery, and radiotherapy. During the past decade considerable improvements were achieved by advanced surgical techniques, tailored chemotherapies/radiotherapy and technical innovations in clinical diagnostics. In patients with advanced or metastatic gastric/GOJ cancer systemic chemotherapy with fluoropyrimidine/platinum-based regimens (+/-human epidermal growth factor receptor-2 antibody) is the mainstay of treatment. Despite these improvements, the clinical outcome for patients with advanced or metastatic disease is generally poor with 5-year survival rates ranging between 5%-15%. These poor survival rates may to some extent be related that standard therapies beyond first-line therapies have never been defined. Considering that this patient population is often not fit enough to receive further treatments there is an increasing body of evidence from phase-2 studies that in fact second-line therapies may have a positive impact in terms of overall survival. Moreover two recently published phase-3 studies support the use of second-line chemotherapy. A South Korean study compared either, irinotecan or docetaxel with best supportive care and a German study compared irinotecan with best supportive care-both studies met their primary endpoint overall survival. In this "Field of Vision" article, we review these recently published phase-3 studies and put them into the context of clinical prognostic factors helping to guide treatment decisions in patients who most likely benefit.

Standardized laparoscopy-assisted distal gastrectomy with a novel surgical technique for lifting the liver

BACKGROUND/AIMS

It is very important to achieve a sufficient field and space in laparoscopic assisted distal gastrectomy (LADG) for a less-experienced surgeon. In this study, the usefulness of a novel surgical technique to lift the liver was evaluated in LADG.

METHODOLOGY

Fifty-four patients who underwent standardized LADG for gastric cancer using the novel technique of lifting the liver were retrospectively evaluated based on video records. Patient characteristics, the time required to lift the liver and for gastrectomy, total operation time, blood loss and complications were analyzed.

RESULTS

The mean time necessary to lift the liver using this novel technique was 240.1±86.1 seconds and that for gastrectomy was 167.6±50.4 minutes. Blood loss was 72.5±59.6mL. The morbidity rate was 4/54 (7.4%).

CONCLUSIONS

Standardized LADG using this novel technique is feasible and possible in a period of time.

Control chart methods for monitoring surgical performance: a case study from gastro-oesophageal surgery

Graphical methods are becoming increasingly used to monitor adverse outcomes from surgical interventions. However, uptake of such methods has largely been in the area of cardiothoracic surgery or in transplants with relatively little impact made in surgical oncology. A number of the more commonly used graphical methods including the Cumulative Mortality plot, Variable Life-Adjusted Display, Cumulative Sum (CUSUM) and funnel plots will be described. Accounting for heterogeneity in case-mix will be discussed and how ignoring case-mix can have considerable consequences. All methods will be illustrated using data from the Scottish Audit of Gastro-Oesophageal Cancer services (SAGOCS) data set.

Usefulness of standardization in spreading of laparoscopy-assisted distal gastrectomy

BACKGROUND/AIMS

This study investigated outcomes of standardized laparoscopy-assisted distal gastrectomy (sLADG).

METHODOLOGY

Although laparoscopic surgery was performed in patients with early gastric cancers in our hospital, a number of staff surgeons performed individualized variations of the procedure. We introduced sLADG to our hospital, and the short-term outcomes of these patients were examined.

RESULTS

The mean surgical duration was significantly reduced (299 min. vs. 358 min, p < 0.01), and the amount of blood loss was also significantly decreased (98 ml vs. 207 ml, p < 0.05) in the standardized procedures in comparison with the previous procedures. However, there was no significant difference in the total number of retrieved lymph nodes among open procedure, conventional and standardized LADG series. Postoperative hospital stay and the occurrence of complications were significantly shorter and less frequent in the sLADG group.

CONCLUSIONS

Performance of sLADG by experienced surgeons is expected to promote a safe procedure without reducing surgical curability.

Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity

Laparoscopic sleeve gastrectomy (LSG) has been used as a first step of a two-stage approach in bariatric surgery for high-risk patients. Recently, LSG is being utilized as a primary and final procedure for morbid obesity with acceptable short-term results. The aim of this study is to investigate the effectiveness of LSG as a revisional procedure for patients with unsatisfactory outcomes after laparoscopic adjustable gastric band (LAGB). A retrospective review of a prospectively maintained database was performed. Data were reviewed for all patients undergoing revision from LAGB to LSG during the period May 2005 and May 2009. Data collected included demographics, indication for revision, operative time, length of stay, postoperative complications, and degree of weight reduction. Fifteen patients (three males and 12 females) had revisional surgery converting a LAGB to a LSG. The indication in four patients (26.66%) was weight regains and in five patients (33.33%) was poor weight loss; four patients (26.66%) had a band slippage and symptoms of gastroesophageal reflux, and one patient (6.66%) had poor weight loss, band slippage, and reflux. In one patient (6.66%), the indication was slippage and duodenal fistula. One-step revision procedure was done in 13 patients (86.66%), while two-step procedure was done in two patients (13.33%). Mean preoperative weight and BMI were 233.02 (181.4-300) lb and 38.66 (29.7-49.3) kg/m2, respectively. Mean weight loss at 2, 6, 12, 18, and 24 months postoperatively was 20.7, 48.3, 57.2, 60.1, and 13.5 lb, respectively. Mean % excess BMI loss was 28.9%, 64.2%, 65.3%, 65.7%, and 22.25% at 2, 6, 12, 18, and 24 months, respectively. There was one major complication (staple line leak) and one postoperative acute gastric outlet obstruction. We had no mortality. Thirteen patients were followed up postoperatively. The number decreased as follow-up time progressed. LSG could provide short-term weight loss after previously failed LABG, but prone to more complications compared to an initial LSG without a prior bariatric procedure.

Sleeve gastrectomy

Much has been published over the last few years about sleeve gastrectomy. It is a bariatric operation that has evolved from both established restrictive and malabsorptive procedures. Originally used as a bridge to definitive surgery in high-risk patients, it has recently been forwarded as a stand-alone procedure. Technical details of laparoscopic sleeve gastrectomy (LSG) vary, but the premise is removal of the vast majority of the stomach, especially the fundus, leaving only a thin gastric tube between the esophagus and the duodenum. This results in weight loss from restrictive as well as neurohormal mechanisms. Review of the literature reveals an average expected excess weight loss (EWL) of 61%. Morbidity and mortality seem to be on par with laparoscopic adjustable gastric banding (LAGB), but with superior weight loss results and an improved long-term complication profile. Unlike popular mixed malabsorptive procedures like Roux en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD-DS), there is no gastrointestinal segment exclusion, maintaining continuity for endoscopic interventions and surveillance. Comorbidity resolution with LSG is variable, though compares favorably with other bariatric procedures. While the early results seem promising, long-term data is still needed to define the place of LSG within the bariatric surgery armamentarium.

Gastroscopically controlled laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy is becoming increasingly established as a stand-alone procedure for weight reduction. The restrictive as well as humoral characteristics of this operation assure postoperative weight loss of up to 70-80% after 1 year. Complications also occur with this procedure.

METHODS

The technical details of the sleeve gastrectomy surgical procedure are described, while elaborating on potential complications and on calibration. In our case, we perform gastrectomy under intraoperative gastroscopic control for calibration as well as for suture control as a standard procedure. As a general practice, the staple line is reinforced with the bioabsorbable material Seamguard.

RESULTS

Since June 2006, 38 patients have undergone sleeve gastrectomy.Postsurgical bleeding occurred in 1 case (2.6%) and had to be treated surgically. 1 patient developed cicatricial stenosis and required dilatation (2.6%). After 1 year, 85% of patients had a weight loss of 70-80%.

CONCLUSION

Thanks to the standardisation of this procedure using staple line reinforcement and intraoperative gastroscopic control, the complication rate can be reduced and the successful outcome of this stand-alone,weight-reduction operation can be optimised.

Surgeons' knowledge of quality indicators for gastric cancer surgery

BACKGROUND

Gastric cancer survival in the West is inferior to that achieved in Asian centers. While differences in tumor biology may play a role, poor quality surgery likely contributes to understaging. We hypothesize that the majority of surgeons performing gastric cancer surgery in North America are unaware of the recommended standards.

METHODS

Using the Ontario College of Physicians and Surgeons registry, surgeons who potentially included gastric cancer surgery in their scope of practice were identified. A questionnaire was mailed to 559; of those, 206 surgeons reported managing gastric cancer. Results were evaluated by chi(2) and logistic regression; P < 0.05 was considered significant.

RESULTS

Eighty-six percent of respondents were male and 53% practiced in an urban nonacademic setting. Forty percent reported operating on two to five cases of gastric cancer per year, and 42% on fewer than two cases per year. One-third of surgeons identified 4 cm or less to be the desired gross proximal margin. Half used frozen section to evaluate margin status. Twenty percent of surgeons were unsure of the number of lymph nodes (LN) needed to accurately stage gastric cancer, and the median number reported by the remainder was 10 (range, 0-30). Only 16 of 206 identified both a proximal margin of 5 cm or less and 15 or more LN as desired targets. Those performing more than five gastric resections per year were more likely to report a D2 resection (P = 0.008).

CONCLUSION

The majority of surgeons operating on gastric cancer in Ontario did not identify recommended quality indicators of gastric cancer surgery. A continuing medical education program should be designed to address this knowledge gap to improve the quality of surgery and patient outcomes.

Secular Trends in the Use, Quality, and Outcomes of Gastrectomy for Noncardia Gastric Cancer in the United States

BACKGROUND

The overall survival with non-cardia gastric adenocarcinoma in the United States has remained poor and relatively unchanged over the past 2 decades. This brings into question the utilization and quality of gastrectomy and lymphadenectomy. We examined the trends, extent, and determinants of surgical treatment and the influence of gastrectomy and adequacy of lymphadenectomy (defined as collection of 15 or more lymph nodes) on non-cardia gastric cancer survival.

METHODS

Data from Surveillance, Epidemiology, and End Results (SEER) registries was used to identify patients with non-cardia adenocarcinoma diagnosed during 1983-2002. Logistic regression was used to examine determinants of gastric resection and adequacy of lymphadenectomy. Cox proportional hazard (PH) models were used to examine determinants of mortality risk for patients treated surgically. All models examined year of diagnosis, age, race, gender, geographic region, and cancer spread.

RESULTS

There were 16,846 patients with non-cardia gastric cancer of whom 10,534 (62.5%) underwent gastric resection. Approximately 77.9% with localized disease underwent resection. Resection for non-cardia gastric cancer declined 6% for all stages and 20% for local stages between 1983 and 2002. In multivariable models, gastrectomies were less likely to be performed between 1998-2002 (-37% compared to 1983-1987), for localized disease (-78% compared to regional disease), for patients older than 70 (-39% compared to patients younger than 40), and for patients from New Mexico (-45% compared to highest in Hawaii). Wide racial variability was also found (lowest for Whites [-54%] compared to Asians). Adequate LN sampling (15 or more LN) was recorded in only 25% overall and 20% of localized disease. Improvement in LN collection since 1997 has been modest, with only a 7% relative increase. The mortality risk of surgically treated non-cardia cancer patients has been unchanged for 15 years. Adequate lymphadenectomy was associated with a 19% decreased mortality risk in this group. Gender and racial differences in mortality risk were present (up to 13% higher in men compared to women and 22% higher in Whites compared Asians).

CONCLUSION

Gastrectomy for non-cardia gastric adenocarcinoma is underutilized, especially for localized disease. In the majority of operations for non-cardia gastric cancer, LN collection is inadequate. Racial and geographic variations with gastric resection and LN sampling are as significant as patient age and stage of the cancer. Disparities based on race and geographic region, as well as surgeon and facility factors need to be investigated and addressed to bring forth improvements in outcomes for non-cardia adenocarcinoma.

[Centralization on fewer surgeons--an example from gastric surgery]

INTRODUCTION

Previous studies have shown an association between surgical volume and a decreased mortality rate for departments as a whole as well as for individual surgeons. The background for this study was to investigate whether it would be beneficial to centralize gastric surgery, not only in fewer departments but also in fewer hands in the department.

MATERIALS AND METHODS

The study was based on the patient records of the 93 patients operated between 1 January 2000 and 1 September 2005. The surgeons were divided into two groups based on whether they had performed more than 15 or less than 5 operations during the period.

RESULTS

Of the 93 operations, 3 surgeons performed 80 and 7 surgeons performed the remaining 13 operations. The mortality was significantly increased in patients operated by surgeons with a low operation volume, p = 0.0004. The 12 acute operations were performed as often by a surgeon with low operation volume as by a surgeon with high operation volume. Again, mortality increased when the operation was performed by a surgeon with low operation volume, p = 0.015.

CONCLUSION

The results argue for a centralization of gastric resections on a few surgeons and for an organisation of acute surgery so that these procedures are performed by only a few experienced surgeons.

[Evaluation of the preserved function of the remnant stomach in pylorus preserving-gastrectomy by gastric emptying scintigraphy]

This study evaluated the preserved function of the remnant stomach by gastric emptying scintigraphy 1 year postoperatively in 49 patients who underwent pylorus-preserving gastrectomy (PPG), and it investigated whether this examination method is a useful tool for evaluation. The residual stomach function was classified as rapid, intermediate, and delayed emptying types according to gastric emptying curves. Then, the relationships were examined between the gastric emptying types and postprandial symptoms, food intake status, body weight changes, and endoscopic findings. Seventy-three percent of the PPG patients were classified as belonging to the intermediate emptying type, and the remainder (27%) to the delayed type. The frequencies of complaints such as epigastric fullness, nausea, and vomiting were high in the delayed emptying-type patients. The intermediate emptying-type patients consumed larger amounts of food and gained more weight than the delayed emptying-type patients. In conclusion, gastric function was evaluated by gastric emptying scintigraphy in PPG patients. This method might be useful not only for evaluating the motor function of the remnant stomach, but also for predicting postoperative status. Although PPG is a function-preserving operation, it should be considered that a quarter of the patients showed delayed emptying type which related to poor quality of life.

Total and subtotal laparoscopic gastrectomy for adenocarcinoma

BACKGROUND

Laparoscopic gastrectomies are currently performed in many centers, but compliance with oncologic requirements still represents a subject open to debate. The aim of this work was to compare the short-term and oncologic outcomes after laparoscopic and open surgery in gastric adenocarcinoma.

METHODS

From June 2000 through June 2005, 147 patients in our institution underwent gastrectomy by open or mininvasive approach for adenocarcinoma. The laparoscopy group included 48 patients, 29 with early gastric cancer (EGC) and 19 with antral advanced gastric cancer (AGC). The short-term results and oncologic data were compared to those obtained in 99 patients who underwent open surgery. Survival in the laparoscopy group was analyzed.

RESULTS

In the laparoscopy group no intraoperative complications were observed, and conversion was needed in only one patient with a large advanced tumor. Overall, 32 lymph nodes were collected by D2 dissection, 30 for EGC, 34 for advanced cancers. The resection margin was 6.7 cm (range: 4-8 cm). The mean operating time was 240 min (range: 150-360 min), with a blood loss of 150 ml on average (range: 70-250 ml). Morbidity included two duodenal leaks that healed without reoperation; after enclosing or reinforcing the staple line, no further leaking was noted. There was one death from massive bleeding in a cirrhotic patient. Ambulation and oral feeding started significantly earlier than in open surgery. The mean hospital stay was 10 days (range: 7-24 days), significantly shorter than the stay of 18 days after open surgery (p < 0.05). All patients treated laparoscopically were alive without recurrence at the end of this study.

CONCLUSIONS

Short-term results with laparoscopic gastrectomy were better than with open surgery in this study. Oncologic radicality was a major concern, but in the authors' experience the extent of lymphadenectomy was the same as in open surgery. This study suggests that laparoscopic gastrectomy in malignancies is a reliable tool and oncologic requirements can be warranted.

Learning curve of laparoscopy-assisted distal gastrectomy with systemic lymphadenectomy for early gastric cancer

AIM

To evaluate the nature of the "learning curve" for laparoscopy-assisted distal gastrectomy (LADG) with systemic lymphadenectomy for early gastric cancer.

METHODS

The data of 90 consecutive patients with early gastric cancer who underwent LADG with systemic lymphadenectomy between April 2003 and November 2004 were reviewed. The 90 patients were divided into 9 sequential groups of 10 cases in each group and the average operative time of these 9 groups were determined. Other learning indicators, such as transfusion requirements, conversion rates to open surgery, postoperative complication, time to first flatus, and postoperative hospital stay, were evaluated.

RESULTS

After the first 10 LADGs, the operative time reached its first plateau (230-240 min/operation) and then reached a second plateau (<200 min/operation) for the final 30 cases. Although a significant improvement in the operative time was noted after the first 50 cases, there were no significant differences in transfusion requirements, conversion rates to open surgery, postoperative complications, time to first flatus, or postoperative hospital stay between the groups.

CONCLUSION

Based on operative time analysis, this study show that experience of 50 cases of LADG with systemic lymphadenectomy for early gastric cancer is required to achieve optimum proficiency.

Should Gastric Cancer Surgery be Performed in Community Hospitals?

Once the most common solid tumor malignancy in the United States, stomach cancer now ranks about 14th in incidence, with approximately 22,000 cases of adenocarcinoma of the stomach diagnosed annually. Gastrectomy for cancer is thus an infrequent operation, and indeed, the number of surgical residents completing 5-year training programs with an adequate number of gastrectomies is steadily shrinking. As time passes and experience with gastric surgery continues to diminish, questions concerning who and where gastric cancer surgery should be performed become increasingly relevant. For patients in major metropolitan areas, locating a high-volume hospital or surgeon is usually not an issue, but for a large portion of the country this may represent a major burden. Moreover, adding this additional volume of patients to an already overburdened system of a busy hospital may not be practical. A significant number of Americans continue to receive their care in low-volume hospitals. The majority of Americans receive their medical care locally and would much prefer a solution that would improve the medical care in their own back yard without altering their support system.

Clinical trials of surgical treatment of malignant diseases

The Dutch Gastric Cancer Study Group Trial was the first clinical phase III trial to be carried out in the field of cancer surgery. In spite of the excellent quality of the trial, it was heavily criticized for the poor quality of the treatment itself. Actually, the hospital mortality after the new surgical treatment (D2 lymph node dissection for gastric cancer) was unacceptably high. In surgical trials, special attention should be paid to quality issues specific to surgery. The first and the most important issue is the quality of treatment given. Reproducibility, homogeneity, and verifiability are the greatest problems in surgical trials. There are also some patient factors. If the patient is old, or fragile, or obese, the results of the surgical treatment can easily be affected by these factors. The surgeon can also be a prognostic factor, especially in complicated procedures or those requiring experience and training. Experience, including postoperative care, and dexterity affect the results. If surgeons do not know how to manage complications, mortality becomes very high. Because blinding is impossible in surgical trials, the treatment may easily be affected by personal preference or prejudice. To minimize the influence of these hampering factors, the procedures should be defined in as detailed a way as possible. If pretrial training or a feasibility study (phase II) is needed, it should be carried out properly for the patients' sake. An excellent design and excellent statistical analysis cannot lead to meaningful results if the quality of treatment is poor. Nonsense in, nonsense out.

The influence of case load and the extent of resection on the quality of treatment outcome in gastric cancer

AIMS

The background was to analyse the influence of hospital- and surgeon volume and of the extent of resective procedures on the quality of early and late treatment results in gastric cancer.

METHODS

The literature was reviewed by searching the databases of Medline, Cancerlit, Pubmed and the Cochran register.

RESULTS

The levels of evidence showed wide variations. The influence of hospital volume was more important for the outcome than the case load of the individual surgeon. The extent of surgical resection should be adapted to histology--or stage. The value of systematic lymph node dissection is still under discussion.

CONCLUSIONS

We have found that the best treatment results were seen in high volume hospitals with experienced surgeons, even taking into account extended surgical procedures. Further studies are needed to define the optimal number of operations necessary to be carried out each year.

[Gastric resection for cancer in Denmark, 1999-2004]

INTRODUCTION

We evaluated the organisation, management and outcome for patients operated on with gastric resection for cancer in Denmark in the period 1999-2003.

MATERIALS AND METHODS

Nationwide data based on the National Patient Registry and discharge information from hospital departments in the period 1 January 1999 to 31 December 2003 were analysed.

RESULTS

Thirty-seven departments performed 537 resections, with an average of 20 departments per year performing such operations. Five departments performed 57.2% of the operations, while 20 departments performed 10.2%. The average postoperative stay was 18 days and the hospital mortality rate was 8.2%, equally distributed with 7.8% for Billroth II resections and 8.5% for total gastrectomy.

DISCUSSION

The organization of gastric cancer surgery in Denmark in 1999-2003 was not optimal, with about 20 departments performing about 100 gastric resections annually, and with a mortality rate of slightly over 8% and an average hospital stay of 18 days. We propose that in future, gastric resections for cancer should be performed in a maximum of five departments nationwide.

Quality in the surgical treatment of cancer of the esophagus and gastroesophageal junction

Surgical treatment of cancer of the esophagus and gastroesophageal junction (GEJ) remains a complex and challenging task. Quality of care may be improved by concentrating these patients in high volume centres in order to decrease post-operative mortality. However, it appears that hospital mortality is a poor tool to measure the quality. More likely specialisation as well as appropriate hospital environment supporting a dedicated multidisciplinary team are key elements in improving both the short term and long term results. The dedicated specialist surgeon has a key role in improving these results through surgical quality. The most important goal in the surgical treatment of these cancers is to perform a complete resection (R0). Data from literature seem to indicate that R0 resection combined with extensive lymphadenectomy are resulting in improved disease free survival and possibly in improved 5 year survival, often reported to exceed 35% after such interventions. These results suggest that there is a great need for standardisation of surgery. Such a standardisation and the resulting improved quality most likely will result in a significant improvement of outcome of esophagectomy for cancer of the esophagus and GEJ. These improvements in outcome should become the gold standard to which all other therapeutic regimens should be compared. Poor surgical quality and related poor results should not be a justification for multimodality regimen.

[Clinical Practice Guidelines 2004. Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach: radiotherapy (therapeutic evaluation)]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients.

OBJECTIVES

To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors.

METHODS

The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement.

RESULTS

This guidelines presents the synthesis of the data concerning the evaluation of the therapeutic ones. The main questions concern the type of gastrectomy to realize (Total Gastrectomy or gastrectomy subtotal), the extent of the lymphadenectomy (D2, D3 versus D1, D3, D2 versus D4) and the role of postoperative chemotherapy and adjuvant concomitant chemoradiotherapy.