Characteristics of gastrointestinal stromal tumors associated to other tumors: Características de los tumores del estroma gastrointestinal asociados a otras neoplasias.

INTRODUCTION: Our aim is to analyze the differences between sporadic gastrointestinal stromal tumors and those associated with other tumors. METHODS: Retrospective cohort study including patients with diagnosis of gastrointestinal stromal tumors operated at our center. Patients were divided into two groups, according to whether or not they had associated other tumors, both synchronously and metachronously. Disease free survival and overall survival were calculated for both groups. RESULTS: 96 patients were included, 60 (62.5%) were male, with a median age of 66.8 (35-84). An association with other tumors was found in 33 cases (34.3%); 12 were synchronous (36.3%) and 21 metachronous (63.7%). The presence of mutations in associated tumors was 70% and in non-associated tumors 75%. Associated tumors were classified as low risk tumors based on Fletcher's stratification scale (p = 0.001) as they usually were smaller in size and had less than ≤5 mitosis per 50 HPF compared to non-associated tumors. When analyzing overall survival, there were statistically significant differences (p = 0,035) between both groups. CONCLUSION: The relatively high proportion of gastrointestinal stromal tumors cases with associated tumors suggests the need to carry out a study to rule out presence of a second neoplasm and a long-term follow-up should be carried out in order to diagnose a possible second neoplasm. Gastrointestinal stromal tumors associated with other tumors have usually low risk of recurrence with a good long-term prognosis.

Short-term postoperative outcomes of gastric adenocarcinoma patients treated with curative intent in low-volume centers.

BACKGROUND: Quality standards in postoperative outcomes have not yet been defined for gastric cancer surgery. Also, the effect of centralization of gastric cancer surgery on the improvement of postoperative outcomes continues to be debated. Short-term postoperative outcomes in gastric carcinoma patients in centers with low-volume of annual gastrectomies were assessed. The effect of age on major postoperative morbidity and mortality was also analyzed. METHODS: Patients with gastric or gastroesophageal junction Siewert III type carcinomas who underwent surgical treatment with curative intent between January 2013 and December 2016 were included. Data were obtained from the population-based surgical registry Esophagogastric Carcinoma Registry of the Comunitat Valenciana (RECEG-CV). The RECEG-CV gathers information on demographic characteristics and comorbidity, preoperative study and neoadjuvant treatment, surgical procedure, pathological study, postoperative outcomes, and follow-up. Seventeen hospitals belonging to the public network participated in this registry. RESULTS: Data from 591 patients were analyzed. Postoperative major morbidity occurred in 154 (26.1%) patients. Overall 30-day or in-hospital mortality, and 90-day postoperative mortality rates were 8.6% and 10.1% respectively. Failure-to-rescue was 39% and it was significantly higher in patients aged 75 years or older in comparison with younger patients (55.3% vs 23.1% p < 0.001). In the multivariable analysis, age ≥ 75 years (p = 0.029), laparoscopic approach (p = 0.005), and total gastrectomy (p = 0.005) were associated with major postoperative morbidity. Age ≥ 75 years (p = 0.027), pulmonary complications (p = 0.001), cardiac complications (p = 0.001), leakage (p = 0.003), and hemorrhage (p = 0.013) were associated with postoperative mortality. CONCLUSIONS: Centralization of gastric adenocarcinoma treatment in centers with higher annual caseload should be considered to improve the short-term postoperative outcomes in low-volume centers. Patients aged 75 or older had a significantly increased risk of major postoperative morbidity and mortality, and higher failure-to-rescue.

When laparoscopic repair is feasible for diaphragmatic hernia in adults? A retrospective study and literature review.

BACKGROUND: Diaphragmatic hernia (DH), congenital or traumatic, is uncommon but sometimes can lead to a serious surgical emergency. There are no clinical guidelines or approved recommendations for the management of this condition, and most data are from retrospective, single-institution series. The aim is to analyze the management of the DH at our institution and review the indications for laparoscopic repair. METHODS: A retrospective serie of patients diagnosed of DH with surgical treatment at our institution between 2009 and 2019. Literature review was carried out to establish the current indications of laparoscopic repair in each type of DH. RESULTS: Surgery was carried out in 15 patients with DH, 5 congenital and 10 traumatic hernias. Traumatic hernias were classified as acute (n = 2) and chronic (n = 8). 53.4% of all cases (8 patients) required urgent surgery using an abdominal approach (5 open and 3 laparoscopic) and elective surgery was performed in 46.6% of all cases (7 patients) with an abdominal approach (3 open and 4 laparoscopic) and 2 patients with a combined approach. Primary repair was performed in 4 patients (26.6%), closure and mesh reinforcement in 9 cases (60%) and only mesh placement in 2 patients (13.4%). Postoperative morbidity and mortality were 20% and 0%, respectively. No recurrences were detected. CONCLUSIONS: DH may pose different scenarios which require urgent or elective surgical treatment. Laparoscopic approach may be a first option in elective surgery; and in emergency setting taking into account hemodynamic stability and associated injuries.

Modified Devine Exclusion for Unresectable Distal Gastric Cancer in Symptomatic Patients.

BACKGROUND: In patients with outlet obstruction syndrome and/or severe anemia secondary to unresectable gastric cancer (GC), partial stomach-partitioning gastrojejunostomy, or modified Devine exclusion, is a surgical alternative. METHODS: A retrospective study was conducted on patients with unresectable distal GC treated with modified Devine exclusion as palliative surgery between February 2005 and December 2015. It consisted of a series of 10 patients with outlet obstruction syndrome and/or severe anemia. The outcomes of this technique were based on oral tolerance, blood transfusions, postoperative complications, and survival. RESULTS: Early oral tolerance and a low rate of blood transfusions were observed postoperatively. There was no postoperative mortality and a very low complication rate without anastomotic leakage. Median survival was 9 months. CONCLUSIONS: Partial stomach-partitioning gastrojejunostomy is a safe procedure for unresectable GC which can improve the quality of life of these patients.

"Magic" of our gastric cancer results on perioperative chemotherapy.

AIM: To determine reproducibility of perioperative chemotherapy for gastric cancer (GC) on our settings by identifying patient's overall survival and comparing them to larger studies. METHODS: Retrospective analysis of our series, where we present our eleven-year's experience on GC managed according to perioperative approach of three preoperative chemotherapy cycles followed by surgery and finally three postoperative chemotherapy cycles. Chemotherapic scheme used was Xelox (Oxaliplatin and Capecitabine). Epidemiologic parameters as well as surgical variables were analysed, presented, and compared to other series with similar approaches. Survival was estimated by Kaplan Meier/log rank method and also compared to these studies. RESULTS: Mean age was 65 years old. Overall survival in our series was 37.7%, similar to other groups using perioperative schemes. Mortality was 4% and morbidity 30%, which are also similar to those groups. Survival curves were compared to larger studies, finding similarities on them. Subgroup survival analysis between chemotherapy responders and non-responders didn't reach statically significant differences. CONCLUSION: Perioperative chemotherapic scheme can be reproduced on our setting with good results and without increasing morbidity or mortality.

Cardiac complications after laparoscopic large hiatal hernia repair. Is it related with staple fixation of the mesh? -Report of three cases.

INTRODUCTION: Laparoscopic Nissen operation with mesh reinforcement remains being the most popular operation for large hiatal hernia repair. Complications related to mesh placement have been widely described. Cardiac complications are rare, but have a fatal outcome if they are misdiagnosed. PRESENTATION OF CASES: We sought to outline our institutional experience of three patients who developed cardiac complications following a laparoscopic Nissen operation for large hiatal hernia repair. DISCUSSION: Laparoscopic hiatoplasty and Nissen fundoplication are safe and effective procedures for the hiatal hernia repair, but they are not exempt from complications. Fixation technique and material used must be taken into account. We have conducted a review of the literature on complications related to these procedures. CONCLUSION: In the differential diagnosis of hemodynamic instability after laparoscopic hiatal hernia repair, cardiac tamponade and other cardiac complications should be considered.

Combined Treatment of an Aortoesophageal Fistula After Aortoplasty for Aortic Stenosis.

The aortoesophageal fistula secondary to the rupture of an aneurysm is a rare entity that usually has a fatal outcome. We present the case of a young patient with an aortoesophageal fistula secondary to a thoracic aortic aneurysm successfully treated with a combination of endoscopic and surgical techniques.

Recurrence of esophageal cancer after R0 surgery. Risk factors and evolution.

INTRODUCTION: despite advances in surgical and adjuvant therapy, recurrence in esophageal cancer submitted to R0 surgery remains high. The aim is to define risk factors and recurrence patterns. Additionally, to show the management carried out and the outcome of patients showing recurrence. MATERIAL AND METHODS: observational and prospective study that included 61 patients. Neoadjuvancy therapy was indicated on T3, T4 and N+ tumors and every lymph node dissection was performed in two fields. Recurrence is defined at distance, regional or local, when, recurrence is detected after six months. According to clinical features and the recurrences, a palliative, chemotherapeutic or surgical management was indicated. RESULTS: there were 54 men and the mean age was 59.7 years. The most frequent stage was the IIA and 17 (27.9%) had positive lymph nodes. Thirty (49.2%) had showed recurrence with a median disease-free interval of 10.5 months. The pTNM, the absence of response to the neoadjuvancy and the presence of compromised lymph nodes were found to be risk factors for recurrence. Only the presence of compromised lymph nodes was significant in the multivariate analysis. After diagnosis of the recurrence, median survival was 7 months and 6 subjects survived beyond 1 year. CONCLUSIONS: we confirmed the high incidence of recurrence in esophageal cancer, where the presence of compromised lymph nodes is probably the main risk factor. After the diagnosis of a relapse the prognosis would be bad, however there would be a small subsidiary group for treatment where outcomes would be better.

The influence of advanced age on the morbi-mortality of gastric cancer after curative surgery.

INTRODUCTION: gastric cancer (GC) is the fourth leading cause of cancer death in Spain after lung, colorectal, breast and prostate tumours. Surgery remains the only potentially curative treatment in localized gastric cancer. OBJECTIVE: the aim of our study is to evaluate and compare the clinical and surgical aspects, development of postoperative complications and outcomes of patients over 75 years old compared with younger patients in our centre. MATERIAL AND METHODS: comparative retrospective study, from March 2003 to June 2011. We diagnosed 166 cases of GC, 109 (65 %) underwent curative surgery. Two groups were settled: group M: < or = 75 years (41 patients) and group m: < 75 years (68 patients). We analyzed age, sex, comorbidities, tumour location, clinical stage, perioperative chemotherapy, surgical technique, postoperative complications, recurrence and mortality from cancer. RESULTS: a more frequent presence of cardiovascular comorbidities and a greater postoperative mortality by medical causes were the only significant differences between both groups. Also, a lower proportion of patients in group M received preoperative chemotherapy and underwent D1 lymphadenectomy. However, the rate of local and systemic recurrence and overall survival were similar in both groups. CONCLUSIONS: age should not be considered a contraindication for curative surgery on GC. The general condition and comorbidities are more important to contraindicate surgical treatment.

[Surgical treatment of gastrointestinal stromal tumours. Analysis of our experience]. / Tratamiento quirúrgico de los tumores del estroma gastrointenstinal. Análisis de nuestra experiencia.

INTRODUCTION: Gastrointestinal stromal tumours (GIST) make up 2% of gastrointestinal tumours. Surgery is the only treatment method in localised cases. The laparoscopic approach has increased over the last few years. We present our experience in the treatment of GIST. MATERIAL AND METHODS: A total of 40 patients with 45 GIST had been subjected to surgical treatment between 1997 and 2010. Data was retrospectively collected on, demographic characteristics, location and tumour biology, diagnosis, type of surgery and the results of that surgery. RESULTS: A total of 24 males and 16 women, with a mean age of 66.7 years, were treated. The location was gastric in 24 cases (60%), small intestine in 13 (32.5%), colon in 2 (5%) and oesophagus in 1 case (2.5%). Laparotomy was performed in 27 cases, 12 by laparoscopy (1 thoracoscopy), and 1 endoscopic sigmoid tumour resection. Four cases (10%), all after laparotomy, had recurred after a median follow-up of 31 months (2-120), and 2 patients of the laparotomy group died due to their cancer. After a univariate analysis, the prognostic factors for a laparoscopic recurrence were: tumour size (P=.0001), mitosis number (P=.001), being a locally advanced tumour (P=.01) and a ruptured tumour (P=.002). Only size remained as a prognostic factor after the multivariate analysis (P=.029; RR 1.363; 95% CI; 1.033-1.799). The presence of a locally advanced tumour was shown to be significant in the univariate analysis, while there were no significant factors after the multivariate analysis. CONCLUSIONS: Correct preoperative staging is essential for deciding which surgical approach to employ.

Results on prognostic value of mutations in localized gastrointestinal stromal tumors (GIST) in one single center.

INTRODUCTION: to study the prognostic value of mutations in KIT or PDGFRA in gastrointestinal stromal tumors (GIST) managed in our department. MATERIALS AND METHODS: forty five patients with localized GIST underwent surgery between 1998 and 2010. Thirty six patients were enrolled in a retrospective study. DNA was isolated from 3 to 5 ìm sections of fixed and paraffin-embedded tissue. Exon 9, 11, 13 and 17 of c-kit gene and exon 12 and 18 of PDGFRA were amplified by PCR and sequenced. RESULTS: tumors with mutations were larger at the surgery and showed higher mitotic count (p < 0.05). The mutations were found in 22 patients (61.2%), 18 had mutations in exon 11 of c-kit gene. PDGFRA mutations were located in exon 12. The 5-years relapsefree survival rate for patients with tumors having mutations was 38% and 100% for patients without mutations (p < 0.01). The 5-year survival rate was significantly worse for patients with mutations (20 vs. 97%, p < 0.01), with tumors larger than 5 cm (28 vs. 97%, p < 0.01) and with > 50 mitosis/HPF (42 vs. 88%, p < 0.03). Multivariate analyses indicated that the mutations, mitotic counts, and tumor size were independent prognostic factors for survival in patients with localized GIST. CONCLUSIONS: in this series, having a detected mutation is a poor prognostic factor with significantly increased recurrence rate and shortens survival.

Achalasia and mycobacterium goodii pulmonary infection.

Achalasia is a common adult disorder that rarely manifests in children and infrequently can be associated with pulmonary nontuberculous mycobacteria infections. We describe here the first case of Mycobacterium goodii pulmonary infection associated with achalasia in a pediatric patient. Heller myotomy with Dor fundoplication and 12 months of treatment with ciprofloxacin and doxycycline resulted in complete clinical and radiologic improvement.

Computed tomographic diagnosis of obturator hernia and its surgical management: a case series.

The obturator hernia is a rare type of hernia which usually presents in thin, elderly women. The preoperative diagnosis is typically difficult, with non-specific signs and symptoms which result in a delay in the diagnosis. It can also be an incidental finding at exploratory laparotomy for a patient with intestinal obstruction. The treatment is surgical. A series of four females with obturator hernia is presented. All patients presented with a history of intestinal obstruction and the hernia was diagnosed preoperatively by computed tomography. All patients underwent a preperitoneal mesh repair with a favourable outcome. The diagnosis and the surgical approach are discussed.