BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 2): UPDATE ON TREATMENT.

BACKGROUND: : The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented. AIM: : To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment. METHODS: To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation. RESULTS: : Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3. CONCLUSION: : The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

Brazilian gastric cancer association guidelines (part 2): update on treatment / Diretrizes da associação brasileira de câncer gástrico (parte 2): atualização sobre o tratamento

ABSTRACT Background : The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented. Aim : To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment. Methods: To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation. Results : Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3. Conclusion : The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

RESUMO Racional: O II Consenso Brasileiro de Câncer Gástrico da Associação Brasileira de Câncer Gástrico ABCG (Parte 1) foi recentemente publicado. Nesta ocasião inúmeros especialistas que atuam no tratamento desta doença expressaram suas opiniões diante declarações apresentadas. Objetivo: Apresentar as Diretrizes da ABCG (Parte 2) quanto às indicações de tratamento cirúrgico, técnicas operatórias, extensão de ressecção e terapia combinada. Métodos: Para formulação destas diretrizes os autores realizaram extensa e atual revisão referente a cada declaração presente no II Consenso, utilizando as bases Medline/PubMed, Cochrane Library e SciELO, inicialmente com os seguintes descritores: câncer gástrico, gastrectomia, linfadenectomia, terapia combinada. Ainda, cada declaração foi classificada de acordo com o nível de evidência e grau de recomendação. Resultados: Das 43 declarações presentes neste estudo, 11 (25,6%) foram classificadas com nível de evidência A, 20 (46,5%) B e 12 (27,9%) C. Quanto ao grau de recomendação, 18 (41,9%) declarações obtiveram grau de recomendação 1, 14 (32,6%) 2a, 10 (23,3%) 2b e um (2,3%) 3. Conclusão: O complemento das diretrizes aqui presentes possibilita que cirurgiões e oncologistas que atuam no combate ao câncer gástrico possam oferecer o melhor tratamento possível, de acordo com as condições locais disponíveis.

BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 1): AN UPDATE ON DIAGNOSIS, STAGING, ENDOSCOPIC TREATMENT AND FOLLOW-UP.

BACKGROUND: The II Brazilian Consensus on Gastric Cancer by the Brazilian Gastric Cancer Association (ABCG) was recently published. On this occasion, several experts in gastric cancer expressed their opinion before the statements presented. AIM: To present the ABCG Guidelines (part 1) regarding the diagnosis, staging, endoscopic treatment and follow-up of gastric cancer patients. METHODS: To forge these Guidelines, the authors carried out an extensive and current review regarding each statement present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases with the following descriptors: gastric cancer, staging, endoscopic treatment and follow-up. In addition, each statement was classified according to the level of evidence and degree of recommendation. RESULTS: Of the 24 statements, two (8.3%) were classified with level of evidence A, 11 (45.8%) with B and 11 (45.8%) with C. As for the degree of recommendation, six (25%) statements obtained grade of recommendation 1, nine (37.5%) recommendation 2a, six (25%) 2b and three (12.5%) grade 3. CONCLUSION: The guidelines presented here are intended to assist professionals working in the fight against gastric cancer with relevant and current information, granting them to be applied in the daily medical practice.

II BRAZILIAN CONSENSUS ON GASTRIC CANCER BY THE BRAZILIAN GASTRIC CANCER ASSOCIATION.

BACKGROUND: Since the publication of the first Brazilian Consensus on Gastric Cancer (GC) in 2012 carried out by the Brazilian Gastric Cancer Association, new concepts on diagnosis, staging, treatment and follow-up have been incorporated. AIM: This new consensus is to promote an update to professionals working in the fight against GC and to provide guidelines for the management of patients with this condition. METHODS: Fifty-nine experts answered 67 statements regarding the diagnosis, staging, treatment and prognosis of GC with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications. RESULTS: Of the 67 statements, there was consensus in 50 (74%). In 10 declarations, there was 100% agreement. CONCLUSION: The gastric cancer treatment has evolved considerably in recent years. This consensus gathers consolidated principles in the last decades, new knowledge acquired recently, as well as promising perspectives on the management of this disease.

Brazilian gastric cancer association guidelines (part 1): an update on diagnosis, staging, endoscopic treatment and follow-up / Diretrizes da associação brasileira de câncer gástrico (parte 1): atualização sobre o diagnóstico, estadiamento, tratamento endoscópico e seguimento

The II Brazilian Consensus on Gastric Cancer by the Brazilian Gastric Cancer Association (ABCG) was recently published. On this occasion, several experts in gastric cancer expressed their opinion before the statements presented. Aim: To present the ABCG Guidelines (part 1) regarding the diagnosis, staging, endoscopic treatment and follow-up of gastric cancer patients. Methods: To forge these Guidelines, the authors carried out an extensive and current review regarding each statement present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases with the following descriptors: gastric cancer, staging, endoscopic treatment and follow-up. In addition, each statement was classified according to the level of evidence and degree of recommendation. Results: Of the 24 statements, two (8.3%) were classified with level of evidence A, 11 (45.8%) with B and 11 (45.8%) with C. As for the degree of recommendation, six (25%) statements obtained grade of recommendation 1, nine (37.5%) recommendation 2a, six (25%) 2b and three (12.5%) grade 3. Conclusion: The guidelines presented here are intended to assist professionals working in the fight against gastric cancer with relevant and current information, granting them to be applied in the daily medical practice.

O II Consenso Brasileiro de Câncer Gástrico da Associação Brasileira de Câncer Gástrico (ABCG) foi recentemente publicado. Nesta ocasião, inúmeros especialistas que atuam no tratamento desta doença expressaram sua opinião diante declarações apresentadas. Objetivo: Apresentar as Diretrizes da ABCG (Parte 1) quanto ao diagnóstico, estadiamento, tratamento endoscópico e seguimento dos pacientes com câncer gástrico. Métodos: Para formulação destas Diretrizes os autores realizaram extensa e atual revisão referente a cada declaração presente no II Consenso, utilizando as bases Medline/PubMed, Cochrane Library e SciELO com os seguintes descritores: câncer gástrico, estadiamento, tratamento endoscópico e seguimento. Ainda, cada declaração foi classificada de acordo com o nível de evidência e grau de recomendação. Resultados: Das 24 declarações, duas (8,3%) foram classificadas com nível de evidência A, 11 (45,8%) B e 11 (45,8%) C. Quanto ao grau de recomendação, seis (25%) declarações obtiveram grau de recomendação 1, nove (37,5%) grau 2a, seis (25%) 2b e três (12,5%) 3. Conclusão: As diretrizes aqui presentes têm a finalidade de auxiliar os profissionais que atuam no combate ao câncer gástrico com informações relevantes e atuais, permitindo que sejam aplicadas na prática médica diária.

Ii brazilian consensus on gastric cancer by the brazilian gastric cancer association / Ii consenso brasileiro de câncer gástrico realizado pela associação brasileira de câncer gástrico

ABSTRACT Background: Since the publication of the first Brazilian Consensus on Gastric Cancer (GC) in 2012 carried out by the Brazilian Gastric Cancer Association, new concepts on diagnosis, staging, treatment and follow-up have been incorporated. Aim: This new consensus is to promote an update to professionals working in the fight against GC and to provide guidelines for the management of patients with this condition. Methods: Fifty-nine experts answered 67 statements regarding the diagnosis, staging, treatment and prognosis of GC with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications. Results: Of the 67 statements, there was consensus in 50 (74%). In 10 declarations, there was 100% agreement. Conclusion: The gastric cancer treatment has evolved considerably in recent years. This consensus gathers consolidated principles in the last decades, new knowledge acquired recently, as well as promising perspectives on the management of this disease.

RESUMO Racional: Desde a publicação do primeiro Consenso Brasileiro sobre Câncer Gástrico em 2012 realizado pela Associação Brasileira de Câncer Gástrico (ABCG), novos conceitos sobre o diagnóstico, estadiamento, tratamento e seguimento foram incorporados. Objetivo: Promover uma atualização aos profissionais que atuam no combate ao câncer gástrico (CG) e fornecer diretrizes quanto ao manejo dos pacientes portadores desta afecção. Métodos: Cinquenta e nove especialistas responderam 67 declarações sobre o diagnóstico, estadiamento, tratamento e prognóstico do CG com cinco alternativas possíveis: 1) concordo plenamente; 2) concordo parcialmente; 3) indeciso; 4) discordo e 5) discordo fortemente. Foi considerado consenso a concordância de pelo menos 80% da soma das respostas "concordo plenamente" e "concordo parcialmente". Este artigo apresenta apenas as respostas dos especialistas participantes. Os comentários sobre cada declaração, assim como uma revisão da literatura serão apresentados em publicações futuras. Resultados: Das 67 declarações, houve consenso em 50 (74%). Em 10 declarações, houve concordância de 100%. Conclusão: O tratamento do câncer gástrico evoluiu consideravelmente nos últimos anos. Este consenso reúne princípios consolidados nas últimas décadas, novos conhecimentos adquiridos recentemente, assim como perspectivas promissoras sobre o manejo desta doença.

Characterization of oncogene suppressor marker expression in patients with submucosal gastric carcinoma.

The aim of the present study was to determine the clinical significance of p53 and p21ras p21wafl, p27kip1 and p16ink4a expression in cases of early gastric cancer. A total of 81 patients who had undergone gastrectomy with D2 lymphadenectomy between 1971 and 2004 were retrospectively investigated. The immunohistochemical expression of p21ras, p53, p21waf1/cip1, p27kip1 and p16ink4a in the tissues was evaluated. In normal, metaplastic and tumoral mucosa, p53 was positive in 53, 87.3, and 87.1% of the cases, respectively. In the same tissues, p21ras was positivE in 85.3, 86 and 96.8%, respectively. Positivity FOR p16ink4a was DETECTED IN 46.3, 91.1 and 86% OF THE CASES, respectively, WHEREAS p27kip1 WAS positiVE IN 60, 94.7 and 95.3%, and p21wafl/cip1 WAS positivE IN 32.4, 72.7 and 71.4% OF THE CASES, respectively. All THE tumors WERE positive for p53. Tumors with lymph node invasion presented WITH OVERexpression (+4) of p53 in 47% of the cases VS. 17% OF patients who DID not HAVE lymph node involvement. THEREFORE, higher expression of p53, p21ras and p21wafl/cip1 IN the tumor exhibited a statistically significant association with lymph node involvement.

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.

INTRODUÇÃO: A cirurgia minimamente invasiva amplamente usada para tratar doenças benignas do aparelho digestivo, tornou-se o foco de intenso estudo nos últimos anos no campo da oncologia cirúrgica. Desde então, a experiência com este tipo de abordagem tem crescido, com o objetivo de fornecer os mesmos resultados oncológicos e sobrevivência à cirurgia convencional. Em relação ao câncer gástrico, o tratamento cirúrgico ainda é considerado o único tratamento curativo, considerando a extensão da ressecção e linfadenectomia realizada. A gastrectomia convencional continua a ser a principal modalidade realizada em todo o mundo. Não obstante, o papel do acesso minimamente invasivo tem ainda de ser esclarecido. OBJETIVO: Avaliar e resumir o estado atual da ressecção minimamente invasiva do câncer gástrico. MÉTODO: Foi realizada revisão da literatura utilizando as bases Medline/PubMed, Cochrane Library e SciELO com os seguintes descritores: câncer gástrico, cirurgia minimamente invasiva, gastrectomia robótica, gastrectomia laparoscópica, neoplasia de estômago. A língua usada para a pesquisa foi o inglês. RESULTADOS: Foram considerados para elaboração desta revisão 28 artigos, entre eles ensaios clínicos randomizados, metanálises, estudos coorte prospectivos e retrospectivos. CONCLUSÃO: A gastrectomia minimamente invasiva é opção técnica no tratamento do câncer gástrico precoce. Quanto ao câncer avançado, estudos recentes têm demonstrado a segurança e a viabilidade do acesso videolaparoscópico. A gastrectomia robótica provavelmente melhorará os resultados obtidos com a laparoscopia. Porém, o alto custo ainda é impedimento para sua utilização em larga escala.

Minimally invasive surgery for gastric cancer: time to change the paradigm / Cirurgia minimamente invasiva no câncer gástrico: tempo de mudar o paradigma

ABSTRACT 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.

RESUMO Introdução: A cirurgia minimamente invasiva amplamente usada para tratar doenças benignas do aparelho digestivo, tornou-se o foco de intenso estudo nos últimos anos no campo da oncologia cirúrgica. Desde então, a experiência com este tipo de abordagem tem crescido, com o objetivo de fornecer os mesmos resultados oncológicos e sobrevivência à cirurgia convencional. Em relação ao câncer gástrico, o tratamento cirúrgico ainda é considerado o único tratamento curativo, considerando a extensão da ressecção e linfadenectomia realizada. A gastrectomia convencional continua a ser a principal modalidade realizada em todo o mundo. Não obstante, o papel do acesso minimamente invasivo tem ainda de ser esclarecido. Objetivo: Avaliar e resumir o estado atual da ressecção minimamente invasiva do câncer gástrico. Método: Foi realizada revisão da literatura utilizando as bases Medline/PubMed, Cochrane Library e SciELO com os seguintes descritores: câncer gástrico, cirurgia minimamente invasiva, gastrectomia robótica, gastrectomia laparoscópica, neoplasia de estômago. A língua usada para a pesquisa foi o inglês. Resultados: Foram considerados para elaboração desta revisão 28 artigos, entre eles ensaios clínicos randomizados, metanálises, estudos coorte prospectivos e retrospectivos. Conclusão: A gastrectomia minimamente invasiva é opção técnica no tratamento do câncer gástrico precoce. Quanto ao câncer avançado, estudos recentes têm demonstrado a segurança e a viabilidade do acesso videolaparoscópico. A gastrectomia robótica provavelmente melhorará os resultados obtidos com a laparoscopia. Porém, o alto custo ainda é impedimento para sua utilização em larga escala.

Brazilian consensus in gastric cancer: guidelines for gastric cancer in Brazil.

BACKGROUND: In Brazil, gastric cancer is the fourth most common malignancy among men and sixth among women. The cause is multivariate and the risks are well known. It has prognosis and treatment defined by the location and staging of the tumor and number of lymph nodes resected and involved. AIM: The Brazilian Consensus on Gastric Cancer promoted by ABCG was designed with the intention to issue guidelines that can guide medical professionals to care for patients with this disease. METHODS: Were summarized and answered 43 questions reflecting consensus or not on diagnosis and treatment that may be used as guidance for its multidisciplinary approach. The method involved three steps. Initially, 56 digestive surgeons and related medical specialties met to formulate the questions that were sent to participants for answers on scientific evidence and personal experience. Summaries were presented, discussed and voted in plenary in two other meetings. They covered 53 questions involving: diagnosis and staging (six questions); surgical treatment (35 questions); chemotherapy and radiotherapy (seven questions) and anatomopathology, immunohistochemistry and perspective (five questions). It was considered consensus agreement on more than 70% of the votes in each item. RESULTS: All the answers were presented and voted upon, and in 42 there was consensus. CONCLUSION: It could be developed consensus on most issues that come with the care of patients with gastric cancer and they can be transformed in guidelines.

Prevenção do tromboembolismo na cirurgia do câncer do aparelho digestivo / Thromboembolism prevention in surgery of digestive cancer

RACIONAL: Tromboembolismo venoso é complicação frequente após tratamento cirúrgico em geral e, de um modo especial, na condução terapêutica do câncer. A cirurgia do aparelho digestivo tem sido referida como potencialmente indutora desta complicação. Os pacientes com câncer digestivo, têm risco substancialmente aumentado de iniciarem ou de terem recorrência de processo tromboembólico. OBJETIVO: Oferecer aos cirurgiões que atuam na cirurgia digestiva e geral orientação segura sobre como efetuar a tromboprofilaxia dos pacientes que necessitam de operações no tratamento de doenças malignas digestivas. MÉTODOS: A Diretriz foi baseada a partir da elaboração de 15 questões clínicas relevantes e relacionadas ao risco, tratamento e prognóstico do paciente submetido ao tratamento cirúrgico do câncer do aparelho digestivo. Elas focaram tanto os eventos tromboembólicos associados às operações quanto os aspectos relacionados à sua profilaxia. As questões foram estruturadas por meio do P.I.C.O. (Paciente, Intervenção ou Indicador, Comparação e Outcome), permitindo gerar estratégias de busca da evidência nas principais bases primárias de informação científica (Medline/Pubmed, Embase, Lilacs/Scielo, Cochrane Library, Premedline via OVID). Também foi realizada busca manual da evidência e de teses (BDTD e IBICT). A evidência recuperada foi selecionada a partir da avaliação crítica utilizando instrumentos (escores) discriminatórios de acordo com a categoria da questão: risco, terapêutica e prognóstico (JADAD para Ensaios Clínicos Randomizados e New Castle Otawa Scale para estudos não randômicos). Após definir os estudos potenciais para sustento das recomendações, eles foram selecionados pela força da evidência e grau de recomendação segundo a classificação de Oxford, incluindo a evidência disponível de maior força. RESULTADOS: Foram avaliados 53.555 trabalhos pelo título e/ou resumo. Deste total foram selecionados (1ª seleção) 478 trabalhos avaliados pelo texto completo. A partir deles, para sustentar as recomendações, foram incluídos neste consenso 132 trabalhos. As 15 perguntas formuladas puderam ser respondidas com artigos com grau de evidência correspondentes à 31 A, 130 B, 1 C e 0 D. CONCLUSÃO: Esta revisão possibilitou elaborar orientação segura para a profilaxia do tromboembolismo nas operações sobre o câncer do aparelho digestivo, abordando os tópicos mais frequentes do quotidiano do trabalho dos cirurgiões gerais e do aparelho digestivo.

BACKGROUND: The venous thromboembolism is a common complication after surgical treatment in general and, in particular, on the therapeutic management on cancer. Surgery of the digestive tract has been reported to induce this complication. Patients with digestive cancer have substantial increased risk of initial or recurrent thromboembolism. AIM: To provide to surgeons working in digestive surgery and general surgery guidance on how to make safe thromboprophylaxis for patients requiring operations in the treatment of their gastrointestinal malignancies. METHODS: The guideline was based on 15 relevant clinical issues and related to the risk factors, treatment and prognosis of the patient undergoing surgical treatment of cancer on digestive tract. They focused thromboembolic events associated with operations and thromboprophylaxis. The questions were structured using the PICO (Patient, Intervention or Indicator, Comparison and Outcome), allowing strategies to generate evidence on the main primary bases of scientific information (Medline / Pubmed, Embase, Lilacs / Scielo, Cochrane Library, PreMedline via OVID). Evidence manual search was also conducted (BDTD and IBICT). The evidence was recovered from the selected critical evaluation using discriminatory instruments (scores) according to the category of the question: risk, prognosis and therapy (JADAD Randomized Clinical Trials and New Castle Ottawa Scale for studies not randomized). After defining potential studies to support the recommendations, they were selected by the strength of evidence and grade of recommendation according to the classification of Oxford, including the available evidence of greater strength. RESULTS: A total of 53,555 papers by title and / or abstract related to issue were found. Of this total were selected (1st selection) 478 studies that were evaluated as full-text. From them to support the recommendations were included in the consensus 132 papers. The 15 questions could be answered with evidence grade of articles with 31 A, 130 B, 1 C and 0 D. CONCLUSION: It was possible to prepare safe recommendations as guidance for thromboembolism prophylaxis in operations on the digestive tract malignancies, addressing the most frequent topics of everyday work of digestive and general surgeons.

Thromboembolism prevention in surgery of digestive cancer.

BACKGROUND: The venous thromboembolism is a common complication after surgical treatment in general and, in particular, on the therapeutic management on cancer. Surgery of the digestive tract has been reported to induce this complication. Patients with digestive cancer have substantial increased risk of initial or recurrent thromboembolism. AIM: To provide to surgeons working in digestive surgery and general surgery guidance on how to make safe thromboprophylaxis for patients requiring operations in the treatment of their gastrointestinal malignancies. METHODS: The guideline was based on 15 relevant clinical issues and related to the risk factors, treatment and prognosis of the patient undergoing surgical treatment of cancer on digestive tract. They focused thromboembolic events associated with operations and thromboprophylaxis. The questions were structured using the PICO (Patient, Intervention or Indicator, Comparison and Outcome), allowing strategies to generate evidence on the main primary bases of scientific information (Medline / Pubmed, Embase, Lilacs / Scielo, Cochrane Library, PreMedline via OVID). Evidence manual search was also conducted (BDTD and IBICT). The evidence was recovered from the selected critical evaluation using discriminatory instruments (scores) according to the category of the question: risk, prognosis and therapy (JADAD Randomized Clinical Trials and New Castle Ottawa Scale for studies not randomized). After defining potential studies to support the recommendations, they were selected by the strength of evidence and grade of recommendation according to the classification of Oxford, including the available evidence of greater strength. RESULTS: A total of 53,555 papers by title and / or abstract related to issue were found. Of this total were selected (1st selection) 478 studies that were evaluated as full-text. From them to support the recommendations were included in the consensus 132 papers. The 15 questions could be answered with evidence grade of articles with 31 A, 130 B, 1 C and 0 D. CONCLUSION: It was possible to prepare safe recommendations as guidance for thromboembolism prophylaxis in operations on the digestive tract malignancies, addressing the most frequent topics of everyday work of digestive and general surgeons.

Are histological alterations observed in the gallbladder precancerous lesions?

INTRODUCTION: Gallbladder cancer, which is characterized by rapid progression and a poor prognosis, is a complex disease to treat. Unfortunately, little is known currently about its etiology or pathogenesis. A better understanding of its carcinogenesis and determining risk factors that lead to its development could help improve the available treatment options. METHOD: Based on this better understanding, the histological alterations (such as acute cholecystitis, adenomyomatosis, xanthogranulomatous cholecystitis, polyps, pyloric metaplasia, intestinal metaplasia, dysplasia, cancer and others) in gallbladders from 1,689 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis were analyzed. The association of these gallbladder histological alterations with clinical data was studied. RESULTS: Gender analysis revealed a greater incidence of inflammatory changes in males, while dysplasia and cancer were only found in women. The incidence of cholesterolosis was greater in the patients 60 years of age and under, and the incidence of adenomyomatosis and gangrene was greater in the elderly patients. A progressive increase in the average age was observed as alterations progressed through pyloric metaplasia, intestinal metaplasia, dysplasia and then cancer, suggesting that the metaplasia-dysplasia-carcinoma sequence may occur in gallbladder cancer. Gallbladder histological alterations were also observed in asymptomatic patients. CONCLUSION: The results of this study suggest that there could be an association between some histological alterations of gallbladder and cancer, and they also suggest that the metaplasia-dysplasia-carcinoma sequence could in fact be true in the case of gallbladder cancer. Nevertheless, further studies directed towards a perfect understanding of gallbladder carcinogenesis are required.

Are histological alterations observed in the gallbladder precancerous lesions?

INTRODUCTION: Gallbladder cancer, which is characterized by rapid progression and a poor prognosis, is a complex disease to treat. Unfortunately, little is known currently about its etiology or pathogenesis. A better understanding of its carcinogenesis and determining risk factors that lead to its development could help improve the available treatment options. METHOD: Based on this better understanding, the histological alterations (such as acute cholecystitis, adenomyomatosis, xanthogranulomatous cholecystitis, polyps, pyloric metaplasia, intestinal metaplasia, dysplasia, cancer and others) in gallbladders from 1,689 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis were analyzed. The association of these gallbladder histological alterations with clinical data was studied. RESULTS: Gender analysis revealed a greater incidence of inflammatory changes in males, while dysplasia and cancer were only found in women. The incidence of cholesterolosis was greater in the patients 60 years of age and under, and the incidence of adenomyomatosis and gangrene was greater in the elderly patients. A progressive increase in the average age was observed as alterations progressed through pyloric metaplasia, intestinal metaplasia, dysplasia and then cancer, suggesting that the metaplasia-dysplasia-carcinoma sequence may occur in gallbladder cancer. Gallbladder histological alterations were also observed in asymptomatic patients. CONCLUSION: The results of this study suggest that there could be an association between some histological alterations of gallbladder and cancer, and they also suggest that the metaplasia-dysplasia-carcinoma sequence could in fact be true in the case of gallbladder cancer. Nevertheless, further studies directed towards a perfect understanding of gallbladder carcinogenesis are required.

The prognostic value of CD147/EMMPRIN is associated with monocarboxylate transporter 1 co-expression in gastric cancer.

The aim of the present work was to assess the role of monocarboxylate transporters (MCTs), namely MCT1 and MCT4 as well as MCT/CD147 co-expression in gastric tissues and evaluate their clinico-pathological significance in gastric carcinoma. For that, we analysed the immunohistochemical expression of MCT1, MCT4 and CD147, in a large series of gastric samples, including non-neoplastic, tumour and metastatic tissues. A significant decrease in MCT4 plasma membrane expression was observed from non-neoplastic to gastric primary malignant tissues and to lymph-node metastasis and both MCT1 and MCT4 correlated with CD147. Importantly, both MCT4 and CD147 were more frequently expressed in Lauren's intestinal-type tumours and MCT1/CD147 co-expression was associated with advanced gastric carcinoma, Lauren's intestinal type, TNM staging and lymph-node metastasis. Our results showed that the prognostic value of CD147 was associated with MCT1 co-expression in gastric cancer cells, supporting the view that CD147 plasma membrane activity is dependent on MCT co-expression.

Gastric volvulus - A review of 38 cases / Volvo gástrico: revisão de 38 casos

BACKGROUND: Gastric volvulus is frequently an asymptomatic disease, and it is usually diagnosed during radiographic examination of the superior digestive tract. The acute form, however, can spawn serious and lethal clinical consequences. This disease is defined by the anomalous rotation of the stomach over itself, and it can be classified according to type, extension, direction, etiology, and clinical presentation. AIM: To review the records from 38 patients with gastric volvulus diagnosed in the Hospital das Clínicas of University of São Paulo between 1968 and 2001. METHODS: This is retrospective analysis of 38 patient records. It was collected from each patient: name, age of first symptom appearance, gender, main clinical findings and complementary exams, volvulus type, extension, direction, etiology, and clinical presentation, therapeutic procedures, type of surgery performed, eventual recurrence, and long-term evolution. RESULTS: It was observed that occurrences of gastric volvulus are mainly secondary (75.8%). For the majority of patients (n=33), surgery was chosen as the treatment option: chronic disease in 29 cases and acute in four. Conservative treatment was reserved only for patients with no clinical conditions to surgical treatment. Anterior gastropexy was associated to high recurrence rates. Suturing the low gastric curve to the hepatic capsule and the transverse colon to the left subphrenic space (Tanner´s operation) seemed to be the technical treatment of choice for primary gastric volvulus. CONCLUSION: Treatment of gastric volvolus must be tailored according the etiology of the disease.

RACIONAL: O volvo gástrico é frequentemente condição assintomática e diagnosticado em exame radiológico feito por outras causas. A forma aguda, no entanto, pode ter consequências graves e letais. Ele é definido como rotação anômala do estômago nele próprio e classificado de acordo com o tipo, extensão, direção, causa e apresentação clínica. OBJETIVO: Apresentar aspectos clínicos e morfológicos de volvos gástricos. em 38 pacientes. MÉTODOS: Análise retrospectiva onde foram coletadas informações registradas sobre 38 pacientes a cerda da idade, surgimento do primeiro sintoma, gênero, principais achados clínicos, de exames complementares, tipo do volvo, causa, procedimentos terapêuticos, recidivas e evolução tardia. RESULTADOS: Em 75,8% o volvo foi secundário Na maioria dos pacientes a opção de tratamento foi cirúrgica. Ele era crônico em 29 e agudo em quatro pacientes. O tratamento conservador foi indicado somente aos sem condições clínicas para operações. Gastropexia anterior foi associada à alta taxa de recidiva. A sutura da pequena curvatura gástrica à cápsula hepática e cólon transverso na fossa subfrência esquerda (operação de Tanner) parece ser o tratamento de escolha nos volvos primários. CONCLUSÃO: O tratamento do volvo gástrico deve ser feito sob medida caso a caso e de acordo com a causa da doença.

Colangiografia endoscópica retrograda com o endoscópio de duplo balão em paciente submetido à gastrectomia total em Y de Roux / Endoscopic retrograde cholangiography with double-balloon endoscope in patient with a Roux-en-y total gastrectomy

A endoscopia de duplo-balão tornou-se impor»tante procedimento na avaliação endoscópica das afecções do intestino delgado. Sua capacidade de intubação profunda ampliou suas indicações para o acesso de órgãos cirurgicamente deriva»dos e com a anatomia alterada. Os autores rela»tam caso de paciente de 56 anos, submetido àgastrectomia total com reconstrução em "Y" de Roux por câncer gástrico que evoluiu com cole»docolitíase, em que foi realizada colangiografia endoscópica retrógrada com papilotomia e re»moção dos cálculos com o uso do enteroscópio de duplo-balão.

Influência da invasão tumoral da linha de anastomose na sobrevivência de pacientes com câncer de coto gástrico / The influence of tumor invasion in anastomotic line on survival of patient with gastric stump cancer

RACIONAL: O câncer do coto gástrico desenvolve- se no remanescente gástrico de gastrectomia realizada há pelo menos 5 anos por doença benigna e os sítios mais comuns de acometimento são próximo à anastomose e na pequena curvatura. Considera-se que o coto gástrico é estado pré-canceroso. OBJETIVOS: Identificar o padrão de disseminação de linfonodos acometidos, quantificar a invasão tumoral da linha de anastomose e correlacionar: a invasão da linha de anastomose com o comprometimento linfonodal e mesenterial, o acometimento linfonodal com sobrevivência e o acometimento da linha de anastomose com sobrevivência. MÉTODOS: Estudo retrospectivo com revisão de prontuários, peças cirúrgicas e exames anátomo-patológicos de 113 pacientes com diagnóstico de câncer de coto gástrico definido como adenocarcinoma desenvolvido no remanescente gástrico de gastrectomia realizada há pelo menos cinco anos por doença benigna. RESULTADOS: A disseminação linfonodal não se mostrou específica; 75 por cento dos pacientes apresentaram invasão tumoral da linha de anastomose; em 66,7 por cento dos casos ocorreu invasão da linha anastomótica e linfonodal concomitantes; menos de 10 por cento dos casos exibiam invasão mesenterial; houve óbito em 86,5 por cento dos casos com invasão linfonodal e 64,7 por cento com invasão da linha de anastomose e em 100 por cento com invasão mesenterial. CONCLUSÕES: 1) O câncer de coto gástrico não tem padrão de disseminação linfonodal específico; 2) a linha de anastomose sofre freqüente invasão tumoral; 3) apesar de freqüente a invasão da linha anastomótica, não apresenta correlação estatística significante com o comprometimento linfonodal regional ou mesenterial; 4) a presença de invasão linfonodal implica em sobrevida menor, em especial a de linfonodos do mesentério; 5) a presença de acometimento neoplásico da linha anastomótica não se correlaciona com pior resultado de sobrevivência.

AIM: To identify the lymph node metastatic pattern for gastric stump cancer; to quantify the anastomotic site invasion by tumor growth; to correlate the invasion of anastomotic site with metastasis in lymph node in general and mesenterial lymph node involvement and the survival. METHODS: One hundred and thirteen patients with gastric stump cancer were retrospectively analyzed along with their medical records, surgical specimens and histopathologic exams. RESULTS: seventy five percent of patients had tumoral invasion in the anastomotic site. In 66.7 percent there was invasion of the anastomotic site with metastatic lymph nodes. Nine percent had mesenterial lymph node invasion. Fatal cases occurred in 86,5 percent with metastatic lymph node, 64,7 percent with invasion of the anastomotic site and 100 percent with mesenterial lymph node invasion. CONCLUSIONS: Metastatic lymph node dissemination is not specific to gastric stump cancer and does not present a pattern in the lymph node dissemination. Although frequent the tumor invasion in anastomotic line, there is no significant statistical correlation with the invasion of regional or mesenterial lymph nodes. Lymph node invasion reduces survival, mainly when mesenterial lymph node dissemination is present. Tumor invasion in anastomotic line does not reduce survival.

Trends in tumor location in gastric carcinoma over a 28-year period.

BACKGROUND/AIMS: Gastric cancer is still a leading cause of cancer death in the world and in Brazil. Historically a majority of gastric tumors were located in the distal third of the stomach. However, several studies have shown a shift in tumor location towards the proximal third. METHODOLOGY: Japanese rules for gastric cancer treatment were followed. All patients that were submitted to surgical resection for gastric cancer between 1971 and 1998 were included. These patients were divided into 3 time periods and classifled according to tumor location. RESULTS: 1021 patients underwent gastric resection for adenocarcinoma. The distal third of the stomach (53.7%) was the most common site. The proportion of tumors located in the proximal and middle thirds of the stomach increased significantly from 8.1% to 15% and 16.2 to 29.8% respectively at the last decade. CONCLUSIONS: The findings of this study suggest an increase in the incidence of tumors to the proximal third of the stomach. However the high incidence of these tumors reported in literature is not confirmed.