Optimal lymph node dissection for gastric cancer: a narrative review.

The management of gastric cancer has long been debated, particularly the extent of lymph node (LN) dissection required during curative surgery. LN invasion stands out as the most critical prognostic factor in gastric cancer. Historically, Japanese academic societies were the pioneers in defining a classification system for regional gastric LN stations, numbering them from 1 to 16. This classification was later used to differentiate between different types of LN dissection, such as D1, D2 and D3. However, these definitions were often considered too complex to be universally adopted, resulting in wide variations in recommendations from one country to another and making it difficult to compare published studies. In addition, the optimal extent of LN dissection remains uncertain, with initially recommended dissections being extensive but associated with significant morbidity without a clear survival benefit. The aim of this review is to make a case for extending LN dissection based on the existing literature, which includes a comprehensive examination of the current definitions of lymphadenectomy and an analysis of the results of all randomised controlled trials evaluating morbidity, mortality and long-term survival associated with different types of LN dissection. Finally, we provide a summary of the various recommendations issued by organizations such as the Japanese Gastric Research Association, the National Comprehensive Cancer Network, the European Society for Medical Oncology, and the French National Thesaurus of Digestive Oncology.

Iatrogenic ureteral injury during colorectal surgery has a significant impact on patient outcomes: a French multicentric retrospective cohort study.

AIM: The long-term urological sequelae after iatrogenic ureteral injury (IUI) during colorectal surgery are not clearly known. The aims of this work were to report the incidence of IUI and to analyse the long-term consequences of urological late complications and their impact on oncological results of IUI occurring during colorectal surgery through a French multicentric experience (GRECCAR group). METHOD: All the patients who presented with IUI during colorectal surgery between 2010 and 2019 were retrospectively included. Patients with ureteral involvement needing en bloc resection, delayed ureteral stricture or noncolorectal surgery were not considered. RESULTS: A total of 202 patients (93 men, mean age 63 ± 14 years) were identified in 29 centres, corresponding to 0.32% of colorectal surgeries (n = 63 562). Index colorectal surgery was mainly oncological (n = 130, 64%). IUI was diagnosed postoperatively in 112 patients (55%) after a mean delay of 11 ± 9 days. Intraoperative diagnosis of IUI was significantly associated with shorter length of stay (21 ± 22 days vs. 34 ± 22 days, p < 0.0001), lower rates of postoperative hydronephrosis (2% vs. 10%, p = 0.04), anastomotic complication (7% vs. 22.5%, p = 0.002) and thromboembolic event (0% vs. 6%, p = 0.02) than postoperative diagnosis of IUI. Delayed chemotherapy because of IUI was reported in 27% of patients. At the end of the follow-up [3 ± 2.6 years (1 month-13 years)], 72 patients presented with urological sequalae (36%). Six patients (3%) required a nephrectomy. CONCLUSION: IUI during colorectal surgery has few consequences for the patients if recognized early. Long-term urological sequelae can occur in a third of patients. IUI may affect oncological outcomes in colorectal surgery by delaying adjuvant chemotherapy, especially when the ureteral injury is not diagnosed peroperatively.

Are colorectal cancer patients at risk for COVID-19 infection during the postoperative period? The Covid-GRECCAR study.

INTRODUCTION: During the COVID-19 pandemic, cancer patients have been regarded as having a high risk of severe events if they are infected with SARS-CoV-2, particularly those under medical or surgical treatment. The aim of this study was to assess the posttreatment risk of infection by SARS-CoV-2 in a population of patients operated on for colorectal cancer 3 months before the COVID-19 outbreak and who after hospitalization returned to an environment where the virus was circulating. MATERIALS AND METHODS: This French, multicenter cohort study included consecutive patients undergoing elective surgery for colorectal cancer between January 1 and March 31, 2020, at 19 GRECCAR hospitals. The outcome was the rate of COVID-19 infection in this group of patients who were followed until June 15, 2020. RESULTS: This study included 448 patients, 262 male (58.5%) and 186 female (41.5%), who underwent surgery for colon cancer (n = 290, 64.7%), rectal cancer (n = 155, 34.6%), or anal cancer (n = 3, 0.7%). The median age was 68 years (19-95). Comorbidities were present in nearly half of the patients, 52% were at least overweight, and the median BMI was 25 (12-42). At the end of the study, 448 were alive. Six patients (1.3%) developed COVID-19 infection; among them, 3 were hospitalized in the conventional ward, and none of them died. CONCLUSION: The results are reassuring, with only a 1.3% infection rate and no deaths related to COVID-19. We believe that we can operate on colorectal cancer patients without additional mortality from COVID-19, applying all measures aimed at reducing the risk of infection.

Lymphoid Aggregates Remodel Lymphatic Collecting Vessels that Serve Mesenteric Lymph Nodes in Crohn Disease.

Early pathological descriptions of Crohn disease (CD) argued for a potential defect in lymph transport; however, this concept has not been thoroughly investigated. In mice, poor healing in response to infection-induced tissue damage can cause hyperpermeable lymphatic collecting vessels in mesenteric adipose tissue that impair antigen and immune cell access to mesenteric lymph nodes (LNs), which normally sustain appropriate immunity. To investigate whether analogous changes might occur in human intestinal disease, we established a three-dimensional imaging approach to characterize the lymphatic vasculature in mesenteric tissue from controls or patients with CD. In CD specimens, B-cell-rich aggregates resembling tertiary lymphoid organs (TLOs) impinged on lymphatic collecting vessels that enter and exit LNs. In areas of creeping fat, which characterizes inflammation-affected areas of the bowel in CD, we observed B cells and apparent innate lymphoid cells that had invaded the lymphatic vessel wall, suggesting these cells may be mediators of lymphatic remodeling. Although TLOs have been described in many chronic inflammatory states, their anatomical relationship to preestablished LNs has never been revealed. Our data indicate that, at least in the CD-affected mesentery, TLOs are positioned along collecting lymphatic vessels in a manner expected to affect delivery of lymph to LNs.

Persistent perineal sinus after abdominoperineal resection.

BACKGROUND AND AIMS: Persistent perineal sinus (PPS) defined as a perineal wound remaining unhealed more than 6 months after abdominoperineal resection (APR) is a well-known complication. The aim of our study was (1) to evaluate the incidence of PPS after APR for Crohn's disease (CD) in the era of biotherapy, (2) to determine long-term outcome of PPS, (3) to study risk factors associated with delayed perineal healing, and (4) to compare the results in this CD patient group with patients without CD. METHODS: From 1997 to 2013, the records of patients who underwent APR for CD and for non-CD rectal cancer with or without radiochemotherapy at two French university hospitals were studied retrospectively. Perineal healing was evaluated by clinical examination at 1, 6, and 12 months after surgery. RESULTS: The cumulative probability of perineal wound unhealed at 6 and 12 months after surgery was 85 and 48%, respectively, for 81 patients who underwent APR for CD patients in contrast to 21 and 13%, respectively, for 25 non-CD patients with rectal cancer. Eight patients with CD (10%) remained with PPS after a median follow up of 4 years and spontaneous perineal healing occurred with time for all non-CD patients. Factors associated with delayed perineal healing in CD included age at surgery < 49 years (p = 0.001) and colonic-only Crohn's disease location (p = 0.045). Medical treatments had no significant impact on perineal healing. CONCLUSIONS: PPS beyond 6 months post-APR remains a frequent complication but mostly resolves over time. CD is a risk factor for developing PPS and factors associated with higher incidence of PPS were age at surgery < 49 years and colonic-only Crohn's disease location. Prevention of PPS in this population with muscle flap during APR deserves to be evaluated.

Perineal or Abdominal Approach First During Intersphincteric Resection for Low Rectal Cancer: Which Is the Best Strategy?

BACKGROUND: Intersphincteric resection during total mesorectal excision for low rectal cancer can be performed through a primary abdominal or a primary perineal approach. OBJECTIVE: The purpose of this study was to compare the results of a primary perineal approach with those of a primary abdominal approach in patients undergoing laparoscopic total mesorectal excision for low rectal cancer. DESIGN: This was a case-matched retrospective study from a prospectively maintained database. SETTING: The study was conducted at a tertiary colorectal surgery referral center. PATIENTS: From 2005 to 2013, among 138 patients with low rectal cancer who underwent total mesorectal excision with intersphincteric resection, 34 patients with a primary abdominal approach (abdominal group) were matched with 51 identical patients with a primary perineal approach (6-cm perineal dissection along the mesorectal plane; perineal group), according to TNM stage, sex, BMI, and age. MAIN OUTCOMES MEASURES: Postoperative morbidity, oncologic outcomes, and 3-year overall and disease-free survivals were measured. RESULTS: The operative time was significantly shorter in the perineal group (269 minutes in perineal vs 240 minutes in abdominal group; p = 0.01). Overall morbidity (47% vs 47%; p = 1.00), severe morbidity (16% vs 15%; p = 0.90), and clinical anastomotic leakage (24% vs 12%; p = 0.17) rates showed no differences when comparing the 2 groups. The overall R1 resection rate was similar in the 2 groups (16% vs 9%; p = 0.36), including a 10% vs 9% positive circumferential margin (p = 0.88) and a 8% vs 0% positive distal margin (p = 0.15). After a median follow-up of 39 months, 3-year overall (100% vs 93% (95% CI, 88%-98%); p = 0.26) and disease-free (63% (95% CI, 56%-71%) vs 62% (95% CI, 53%-71%); p = 0.58) survival rates showed no differences between the 2 groups. LIMITATIONS: The study was limited by its nonrandomized nature and limited sample size. CONCLUSIONS: In cases of laparoscopic total mesorectal excision with intersphincteric resection for low rectal cancer, the primary perineal approach appears to reduce operative time and is associated with similar short- and long-term outcomes as compared with the primary abdominal approach. The primary perineal approach should thus be considered as the standard strategy.

Risk factors for circumferential R1 resection after neoadjuvant radiochemotherapy and laparoscopic total mesorectal excision: a study in 233 consecutive patients with mid or low rectal cancer.

PURPOSE: This study aimed to identify risk factors for circumferential R1 resection (R1c) after neoadjuvant radiochemotherapy (RCT) and laparoscopic total mesorectal excision (TME) for mid or low rectal cancer. Better knowledge of pre- or intraoperative risk factors could possibly help for the management of these patients. METHODS: Between 2005 and 2013, 233 consecutive patients undergoing laparoscopic TME for low or mid rectal cancer after RCT were included. R1c resection was defined as a circumferential margin ≤ 1 mm. Univariate and multivariate analyses were performed to identify independent risk factors for R1c. RESULTS: Twenty-five patients had R1c resection (11%). In univariate analysis, low rectal cancer, anterior tumour, T4 on pretherapeutic magnetic resonance imaging (MRI), T4 and/or N+ on post-RCT MRI and operative time > 240 min were associated with a significantly increased risk of R1c resection. In multivariate analysis, only T4 on post-RCT MRI (odds ratio (OR) = 6.02 [1.06-33]; p = 0.043) and operative time >240 min. (OR = 5.4 [1.01-28.9]; p = 0.049) were identified as independent risk factors for R1c resection. The risk of R1c resection was 3% (n = 3/88), 10% (n = 5/51) or 38% (n = 3/8) when 0, 1 or 2 risk factors were present in the same patient, respectively. CONCLUSION: Patients with T4 on MRI after RCT and/or operative time >240 min. seems to be at higher risk for R1c resection. In a pragmatic approach, we consider that systematic second MRI after RCT could help the surgeon, especially in area where circumferential margin is too short, in order to reduce this risk of R1 resection.

Toward the end of abdominoperineal resection for rectal cancer? An 8-year experience in 189 consecutive patients with low rectal cancer.

OBJECTIVES: To assess whether recent advances, such as intersphincteric resection (ISR) or local excision (LE) if a suspicion of complete tumor response after radiochemotherapy (RCT), could have modified the rate of end stoma (ES) in low rectal cancer treatment. BACKGROUND: ES rate remains around 30% to 50% in patients with low rectal cancer. METHODS: From 2005 to 2013, all patients with low rectal cancer undergoing laparoscopic total mesorectal excision, with or without neoadjuvant RCT, and patients undergoing LE after RCT were included. RESULTS: A total of 189 patients presented a low rectal cancer; 162 (86%) underwent RCT; total mesorectal excision was performed in 172 (90%), followed by stapled colorectal anastomosis (n=26; 15%), manual coloanal anastomosis with partial (n=92; 53%) or total ISR (n=32; 19%), or ES that included abdominoperineal resection (n=21; 12%) and low Hartmann procedure (n=1; 1%). LE after RCT was performed in 19 of 189 (10%) patients with a suspicion of complete tumor response. Among them 2 of 19 (11%) underwent immediate secondary total mesorectal excision (1 abdominoperineal resection and 1 coloanal anastomosis with total ISR) because of poor pathological criteria. CONCLUSIONS: Management of rectal cancer with colorectal anastomosis and coloanal anastomosis with partial ISR allowed to obtain a 38% ES rate (71/189); the additional use of total ISR decreased this rate to 22% (39/189). Selective use of LE reduced this rate to only 12% (22/189). Nowadays, recent advances lead to a paradigm shift, with only 12% ES rate in low rectal cancer.

A randomized clinical trial of Saccharomyces cerevisiae versus placebo in the irritable bowel syndrome.

BACKGROUND: We aimed to evaluate clinical symptoms in subjects with irritable bowel syndrome receiving Saccharomyces cerevisiae in a randomized double-blind placebo-controlled clinical trial. METHODS: Overall, 179 adults with irritable bowel syndrome (Rome III criteria) were randomized to receive once daily 500 mg of Saccharomyces cerevisiae, delivered by one capsule (n = 86, F: 84%, age: 42.5 ± 12.5), or placebo (n = 93, F: 88%, age: 45.4 ± 14) for 8 weeks followed by a 3-week washout period. After a 2-week run-in period, cardinal symptoms (abdominal pain/discomfort, bloating/distension, bowel movement difficulty) and changes in stool frequency and consistency were recorded daily and assessed each week. A safety assessment was carried out throughout the study. RESULTS: The proportion of responders, defined by an improvement of abdominal pain/discomfort, was significantly higher (p = 0.04) in the treated group than the placebo group (63% vs 47%, OR = 1.88, 95%, CI: 0.99-3.57) in the last 4 weeks of treatment. A non-significant trend of improvement was observed with Saccharomyces cerevisiae for the other symptoms. Saccharomyces cerevisiae was well tolerated and did not affect stool frequency and consistency. CONCLUSION: Saccharomyces cerevisiae is well tolerated and reduces abdominal pain/discomfort scores without stool modification. Thus, Saccharomyces cerevisiae may be a new promising candidate for improving abdominal pain in subjects with irritable bowel syndrome.