Gastrectomy for Distal Gastric Cancer: Transitioning from an Open to a Minimally Invasive Surgical Practice. A Single Surgeon Experience.

BACKGROUND: Surgical resection is the only curative option for gastric carcinoma (GC). Minimally invasive techniques are gaining popularity. OBJECTIVES: To present a single-surgeon's experience in transitioning from an open to a minimally invasive approach, focusing on surgical and oncological outcomes. METHODS: We conducted a retrospective analysis including distal gastrectomy patients 2012-2020 operated by a single surgeon. Two cohorts were compared: open (ODG) and laparoscopic distal gastrectomy (LDG). RESULTS: Overall, 173 patients were referred for gastrectomy during the study years. We excluded 80 patients because they presented with non-GC tumors, underwent proximal or total gastrectomy, or underwent palliative surgery. Neoadjuvant treatment was administered to 62 patients (33.3%). Billroth 1 was the preferred method of reconstruction (n=77, 82.8%), followed by Roux-en-Y (n=12, 13%). Fifty-one patients (54.8%) underwent LDG, 42 (45.2%) underwent ODG. The LDG group had significantly shorter lengths of stay (6 days, interquartile range [IQR] 1-3 5-8 vs. 5 days, IQR 1-3 4-6, P = 0.001, respectively), earlier return to oral feeding (1 day, IQR 1-3 1-3 vs. 2 days, IQR 1-3 1-3.2, P < 0.001), and earlier removal of drains (4 days, IQR 1-3 3-5.2 vs. 5 days, IQR 1-3 3.5-6.7, P < 0.001). Overall lymph node yield was 30 (IQR 1-3 24-39) and was similar among groups (P = 0.647). CONCLUSIONS: Laparoscopic techniques for resection of distal GC are feasible and safe, leading to good perioperative outcomes and adequate lymph node yield.

Evaluation of peritoneal CEA levels following colorectal cancer surgery.

BACKGROUND: Peritoneal carcinoembryonic antigen (pCEA) levels in the early postoperative period following a curative resection of colorectal cancer (CRC) have not been previously studied. METHODS: Postoperative peritoneal fluids of 36 CRC patients followed by 24 benign colonic disease patients were evaluated for CEA levels and tumor cell presence. Serum CEA levels were also evaluated prior and after surgery. RESULTS: Although high postoperative pCEA levels were observed in some benign patients, more CRC patients exhibited significant elevation of postoperative pCEA (>5 ng/ml) compared to benign patients (50% vs. 23%, P = 0.039). Postoperative median pCEA levels of CRC patients were significantly higher compared to benign patients (5.4 vs. 2 ng/ml, P = 0.011). Specifically, pCEA levels in CRC patients were significantly elevated when measured during the first 24 hr after surgery. Postoperative pCEA levels were associated with colon tumor location compared to rectal location. However, no correlation was found with known risk factors for cancer recurrence or with serum CEA levels. CONCLUSIONS: Postoperative pCEA levels may be significantly elevated following a curative resection for CRC. Its significance within patient's prognostic evaluation remains to be studied. Inclusion of patient's follow-up data may reveal the significance of elevated pCEA levels following CRC resection.

High Rates of Incisional Hernia After Laparoscopic Right Colectomy With Midline Extraction Site.

BACKGROUND: Laparoscopic surgery aims at reducing wound complications and improving cosmetics, among other advantages. High rates of postoperative ventral hernia (POVH) are observed after laparoscopic-assisted colectomies. MATERIALS AND METHODS: In a 2011 to 2016 retrospective study of all patients at Rabin Medical Center, we examined POVH prevalence after right hemicolectomy for neoplasia and correlation to specimen extraction site. We also compared laparoscopic-assisted colectomy to hand-assisted laparoscopic colectomy. Included were patients who had postoperative abdominal computed tomography or magnetic resonance imaging scan as part of their routine oncological follow-up to 6 months postsurgery. Patients were excluded for conversion to laparotomy, and prior abdominal surgeries after right colectomy and before follow-up computed tomography/magnetic resonance imaging scan. Demographic and surgical data were collected from patient electronic records, and scans reviewed for POVH by a designated radiologist. RESULTS: Of 370 patients, 138 (mean age 70.09 y, 58 males) were included: 54 (39.1%) were diagnosed with POVH, 42/72 (58.3%) at midline extraction site, and 12/66 (18.8%) at off-midline extraction sites (P<0.0001). Surgical site infections and patients positive for tumor metastasis were associated with higher POVH rates. Most (74%) POVHs were identified within 18 months postsurgery (P<0.0001). Body mass index, age, sex, diabetes mellitus, smoking, tumor size, lymph nodes positive for metastasis, and hand-assisted laparoscopic colectomy were not associated with POVH prevalence. CONCLUSION: High rates of radiologically diagnosed POVH were found after laparoscopic-assisted colectomy, with association to midline extraction site, surgical site infections, and positive tumor distant metastasis.

Inhibition of TNFα in peritoneal fluids of patients following colorectal resection attenuates the postoperative stress-related increase in colon cancer cell migration: A prospective, in vitro study.

BACKGROUND AND OBJECTIVES: Surgical trauma in patients undergoing colorectal cancer resection generates local and systemic inflammatory responses that can affect oncological outcomes. Post-operative peritoneal fluids of patients undergoing colorectal surgery increase the pro-malignant effect of cancer cells in vitro with correlation to elevated TNFα in these fluids. This study evaluated whether inhibiting TNFα in patients' postoperative fluid biopsies would attenuate this effect. METHODS: Peritoneal fluids from 53 patients undergoing colorectal surgery were sampled before and daily after surgery via intra-abdominal drains. Fluid biopsies were evaluated for their impact on the migration capacity of colon cancer cells and for cytokine levels. TNFα was inhibited using infliximab and cell migration was reevaluated. RESULTS: Colon cancer migration capacity was increased in postoperative fluid biopsies from all patients (P < 0.005) and was elevated compared to pre-resection levels. Infliximab attenuated this effect in >90%, decreasing migration capacity by 30% (p < 0.001). CONCLUSIONS: Inhibition of TNFα in postoperative peritoneal fluids attenuates the increase in cancer cell migration capacity generated following colorectal resection. These findings correlate with other studies suggesting that attenuation of the post-operative inflammatory response may have oncological benefit. Clinical studies are needed to evaluate the effect of peri-operative TNFα inhibition in clinical settings.