Impact of perioperative chemotherapy on postoperative morbidity after gastrectomy for gastric cancer.

INTRODUCTION: The use of perioperative chemotherapy (CT) in patients with advanced gastric carcinoma increases their overall survival. This therapy may also increase the number of patients with R0 resection. Potential drawbacks of this therapy, besides its toxicity, include increased surgical morbidity. METHODS: We retrospectively evaluated the records of patients undergoing gastrectomy with curative intent, for carcinoma, at our institution between January 2009 and August 2018. They were divided into two groups: direct surgery (SURG) and perioperative CT (CHEMO). Patients with other neoadjuvant therapies and cardia Siewert I and II carcinomas were excluded. The primary objective was to evaluate the impact of perioperative CT on surgical morbidity. As secondary objectives, resection radicality and total lymph node count were compared between the two groups. RESULTS: A total of 307 patients (97 direct surgery and 210 perioperative CT) were evaluated. Median age was 67 years old. The overall major surgical morbidity (Clavien-Dindo 3-5) was 10.6% in the CHEMO group and 12.4 in the SURG group (p=0.643). There was no statistically significant difference between the surgical radicality (R0 98% in the SURG group vs 97.5% CHEMO group (p=0.865). There was an increase in the total number of lymph nodes retrieved in the specimen in the CHEMO group (25 vs 22, p=0.001), a difference that was not maintained in the subgroup analysis as a function of the surgery performed. CONCLUSIONS: Perioperative CT in gastric carcinoma does not increase surgical morbidity, surgical radicality and total lymph node count.

Oesophageal GIST.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. Oesophageal GISTs are extremely uncommon, accounting for 0.7% of all GISTs, and their management is surrounded by some debate. We report a case of a 70-year-old man who was incidentally diagnosed with an oesophageal lesion on a 18F-fluorodeoxyglucose positron emission tomography. An endoscopic study revealed a non-obstructing 40 mm oesophageal lesion. Endoscopic ultrasound showed a well-circumscribed submucosal tumour on the middle oesophagus. Fine-needle aspiration was positive for CD117 and the overall features were of a GIST. After an initial thoracoscopic approach, the tumour was completely enucleated through a thoracotomy incision. The patient experienced no surgical complications and was discharged on day 4. Histopathology and immunohistochemical staining confirmed a low-risk GIST.

Transitioning from anatomic landmarks to ultrasound guided central venous catheterizations: guidelines applied to clinical practice.

INTRODUCTION: Centrally inserted central catheter (CICC) insertion is a commonly performed procedure that may give rise to different complications. Despite the suggestion of guidelines to use ultrasound guidance (USG) for vascular access, not all centers use it systematically. The aim of this study is to illustrate the experience with ultrasound in CICC placement at a high-volume oncological center, in a country where the landmark technique is standard. METHODS: Retrospective analysis of a prospective database was performed on CICC placement under USG in the Central Venous Catheter Unit of Instituto Português de Oncologia de Lisboa Francisco Gentil, from 2012 to 2015. RESULTS: Three thousand five hundred and seventy-two procedures were recorded. From 2728 CICC placements, 1187 (43.5%) were done using USG. The majority of CICC placements were successful without immediate complications (96.1%). In 55 cases (4.6%), more than three attempts were necessary to puncture the vein. Pneumothorax occurred in 5 cases (0.4%) and arterial puncture was registered in 41 cases (3.5%). An increasing use of USG for placing CICCs was planned and observed over the years and, in the last year of the study, 67.3% of the CICC placements were with USG. CONCLUSIONS: CICC placement with USG is a safe and effective technique. Despite some resistance that is observed, these results support that it is worth following the guidelines that advocate the use of the USG in the placement of CICC.

Enteric repair in aortoduodenal fistulas: a forgotten but often lethal player.

BACKGROUND: An aortoenteric fistula is an abnormal communication between the aorta and the bowel lumen. It is usually caused by previous aortic surgery and involves the duodenum (ADF) in most cases. The treatment of this high-mortality condition is based on the correction of enteric and vascular defects. However, enteric repair indications and impact are unknown. OBJECTIVE: We sought to characterize the surgical procedures available for duodenal repair in ADF and estimate their impact in mortality. METHODS: A literature search was conducted, between the years 1951-2010. Cases (791 from 614 references) were individually registered and analyzed to demography, enteric location, type and cause of fistula, type of surgical procedure, mortality, and cause of death. Risk factors to outcome were estimated by univariate and multivariate analysis. RESULTS: The enteric procedure was described in 331 cases: duodenorrhaphy (with or without omentum interposition; with or without enterostomy) in 266 cases, duodenal resection/reconstruction in 54 cases, antibiotic or abdominal drainage alone in 4 cases, and nothing was done in 7 cases. Vascular treatment was described in 515 cases: extra-anatomic bypass in 207 cases, in situ graft in 197 cases, direct closure of the aortic defect in 52 cases, endovascular procedures in 32 cases, and others arterial reconstructions in 27 cases. Univariate analysis revealed that mortality caused by ADF is directly associated with primary ADF type, direct closure of the aortic defect, and is inversely associated with recent publications, omentum interposition, use of an in situ graft, and endovascular prosthesis. Multivariate analysis revealed that omentum interposition and the use of an in situ graft were independent factors to the outcome, and that omentum use was the strongest factor related to survival. The most common cause of death was ADF recurrence (41.8%), which was significantly high (P = 0.036) in the patients who underwent simple duodenorrhaphy. CONCLUSIONS: The literature supports the use of omentum interposition and suggests that duodenal derivation is preferable to the simple closure of fistula. Delayed or avoided enteric repair after endovascular treatment emerged as an option, but needs additional supporting research.