Laparoscopic versus open surgery for locally advanced and metastatic gastric cancer complicated with bleeding and/or stenosis: short- and long-term outcomes.

BACKGROUND: Laparoscopic surgery has justified its efficacy in the treatment of early gastric cancer. There are limited data indicating the eligibility of laparoscopic interventions in locally advanced gastric cancer. Publications describing the safety of laparoscopic techniques in the treatment of local and metastatic gastric cancer complicated by bleeding and stenosis are scarce. METHODS: The study included patients with histologically confirmed locally advanced and disseminated gastric cancer and complicated with bleeding and/or stenosis who underwent gastrectomy with vital indications between February 2012 and August 2018. Surgical and oncologic outcomes after laparoscopic surgery (laparoscopic surgery) and open surgery (OS) were compared. RESULTS: In total, 127 patients (LS, n = 52; OS, n = 75) were analyzed. Baseline characteristics were similar between the groups. Forty-four total gastrectomies with resection of the abdominal part of the esophagus, 63 distal subtotal (43 Billroth-I and 20 Billroth-II), and 19 proximal gastrectomies were performed. The median duration of surgery was significantly longer in the LS group, 253 min (interquartile range [IQR], 200-295) versus 210 min (IQR, 165-220) (p < 0.001), while median intraoperative blood loss in the LS group was significantly less, 180 ml (IQR, 146-214) versus 320 ml (IQR, 290-350), (p < 0.001). Early postoperative complications occurred in 35% in the LS group and in 45 % of patients in the OS group (p = 0.227). There was no difference in postoperative mortality rates between the groups (3 [6 %] versus 5 (7 %), p = 1.00). Median intensive care unit stay and median postoperative hospital stay were significantly shorter after laparoscopy, 2 (IQR, 1-2) versus 4 (IQR, 3-4) days, and 8 (IQR, 7-9) versus 10 (IQR, 8-12) days, both p < 0.001. After laparoscopy, patients started adjuvant chemotherapy significantly earlier than those after open surgery, 20 vs. 28 days (p < 0.001). However, overall survival rates were similar between the group. Three-year overall survival was 24% in the LS group and 27% in the OS groups. CONCLUSIONS: Despite the technical complexity, in patients with complicated locally advanced and metastatic gastric cancer, laparoscopic gastrectomies were associated with longer operation time, reduced intraoperative blood loss, shorter reconvalescence, and similar morbidity, mortality rates and long-term oncologic outcomes compared to conventional open surgery.

Mediastinal anatomical landmarks, their variants and tips for video-assisted thoracoscopic navigation during oesophageal extirpation.

PURPOSE: There is no systematic description of primary anatomical landmarks that allow a surgeon to reliably and safely navigate the superior and posterior mediastinum's fat tissue spaces near large vessels and nerves during video-assisted endothoracoscopic interventions in the prone position of a patient. Our aim was to develop an algorithm of sequential visual navigation during thoracoscopic extirpation of the esophagus and determine the most permanent topographic and anatomical landmarks allowing safe thoracoscopic dissection of the esophagus in the prone position. METHODS: The anatomical study of the mediastinal structural features was carried out on 30 human cadavers before and after opening the right pleural cavity. RESULTS: For thoracoscopic extirpation of the esophagus in the prone position, anatomical landmarks are defined, their variants are assessed, and an algorithm for their selection is developed, allowing their direct visualization before and after opening the mediastinal pleura. CONCLUSION: The proposed algorithm for topographic and anatomical navigation based on the key anatomical landmarks in the posterior mediastinum provides safe performance of the video-assisted thoracoscopic extirpation of the esophagus in the prone position.

The patient with megaesophagus due to long-term achalasia combined with squamous cell carcinoma: A case report.

INTRODUCTION: Achalasia is a rare disease of the esophagus accompanied by progressive development of symptoms such as dysphagia, vomiting, and chest pain, which in case of ineffective treatment leads to the formation of megaesophagus and requires radical surgical treatment. The relationship between the lengthy course of esophageal achalasia and the chance of developing esophageal cancer has been evidenced in the international literature. PRESENTATION OF CASE: This paper presents a case of a patient with long-term (30 years) achalasia, grade 4 dysphagia, and severe concomitant cardiovascular pathology who was diagnosed with megaesophagus and carcinoma of the lower thoracic esophagus after receiving solely symptomatic treatment. The patient underwent a video-assisted thoracoscopic K.C. McKeown esophagectomy, two-field lymphadenectomy, and esophageal gastroplasty. The postoperative period proceeded without complications. Ten months post-surgery there were no signs of recurrence or progression of the disease. The patient also noted a decrease in cardiac symptoms. DISCUSSION: Clinical manifestations of achalasia are characterized by progressive dysphagia, predominant nocturnal regurgitation, aspiration of undigested food, and weight loss. The role of cancer surveillance in achalasia remains controversial. Medical therapy and minimally invasive interventions can be used for both early and late stages of the disease. The use of minimally invasive techniques for the megaesophagus is recognized as ineffective and increases the risk of post-manipulation complications. CONCLUSION: Since minimally invasive techniques are ineffective, radical surgical treatment, or esophagectomy, appears to be the best choice in case of the development of megaesophagus and the detection of esophageal cancer.

Minilaparotomy removal of giant gastric trichobezoar in a female teenager.

While small gastric trichobezoars may be removed via gastroscopy, large trichobezoars require surgical removal by gastrotomy through abdominal incision. We present a case of a successful minilaparotomy removal of a giant (2500-g) gastric trichobezoar in a 15-year-old girl with marginal psychological disturbances.

Mini-laparotomy cholecystectomy: technique, outcomes: a prospective study.

BACKGROUND: The last decades have been characterized by a rapid growth in minimally invasive techniques for acute and chronic cholecystitis. The aim of our study was to analyze 10 years of experience with the mini-laparotomy cholecystectomy. METHODS: From 1994 to 2004, we performed 2295 mini-laparotomy cholecystectomies, including 1028 patients with acute and 1267 patients with chronic cholecystitis. There were 1780 women and 515 men. We utilized a special surgical tool kit with a system of circular and small hook-retractors incorporating an illuminator and long surgical instruments. Our surgical approach was carried out using a 3-5 cm longitudinal incision located immediately above the gallbladder with a muscle splitting technique. RESULTS: The mean time of operation was 64.5+/-24.5 min and the conversion rate was 3.7%. Intraoperative complications occurred in 25 cases (1.1%), including 4 cases (0.17%) of biliary tract injury. Cholecystectomy was combined with intervention on the choledochus and the papilla of Vater in 133 patients with choledocholithiasis. Postoperative complications developed in 4.1%. Five hundred and five patients (22%) required opioid analgesics on the first postoperative day. The mortality rate was 0.17%. The mortalities involved patients who had severe concomitant diseases and required urgent surgery for acute cholecystitis. Patients operated for acute cholecystitis had significantly higher rates of postoperative complications (5.8% vs. 2.8%), need for opioids (25.5% vs. 19.2%) and mortality (0.39% vs. 0%). CONCLUSIONS: Mini-laparotomy cholecystectomy is an alternative to laparoscopic approach in the surgical treatment of acute and chronic cholecystitis.