Current trends in the management of Gastro-oEsophageal cancers: Updates to the ESSO core curriculum (ESSO-ETC-UGI-WG initiative).

Gastro-oEsophageal Cancers (GECs) are severe diseases whose management is rapidly evolving. The European Society of Surgical Oncology (ESSO) is committed to the generation and spread of knowledge, and promotes the multidisciplinary management of cancer patients through its core curriculum. The present work discusses the approach to GECs, including the management of oligometastatic oesophagogastric cancers (OMEC), the diagnosis and management of peritoneal metastases from gastric cancer (GC), the management of Siewert Type II tumors, the importance of mesogastric excision, the role of robotic surgery, textbook outcomes, organ preserving options, the use of molecular markers and immune check-point inhibitors in the management of patients with GECs, as well as the improvement of current clinical practice guidelines for the management of patients with GECs. The aim of the present review is to provide a concise overview of the state-of-the-art on the management of patients with GECs and, at the same time, to share the latest advancements in the field and to foster the debate between surgical oncologists treating GECs worldwide. We are sure that our work will, at the same time, give an update to the advanced surgical oncologists and help the training surgical oncologists to settle down the foundations for their future practice.

[Esophageal cancer: standards and innovations in multidisciplinary treatment]. / Cancer de l'œsophage : standards et innovations du traitement multidisciplinaire.

Esophageal cancer is a severe disease that requires a combined therapeutic approach to improve the prognosis. Once the initial assessment is completed, the patient's case should be discussed in a multidisciplinary conference in a specialized center to decide on an appropriate therapeutic strategy taking into account the stage of the disease and the patient's general condition. Several advances in treatment, both from a surgical technique standpoint, with the advent of minimally invasive and robotic surgery, and from a medical perspective, with the use of immunotherapy under certain conditions, have dramatically improved mortality rates. In this article, we explore the standards and latest innovations in the multimodal treatment of esophageal cancer.

Le cancer de l'œsophage est une pathologie sévère nécessitant une approche thérapeutique combinée afin d'en améliorer le pronostic. Une fois le bilan initial réalisé, le cas du patient doit être discuté lors d'un colloque multidisciplinaire dans un centre spécialisé, afin de décider d'une stratégie thérapeutique adaptée tenant compte du stade de la maladie et de l'état général du patient. Plusieurs avancées en matière de traitement, tant du point de vue technique chirurgical, par l'avènement de la chirurgie minimalement invasive et robotique, que du point de vue médical, par le recours à l'immunothérapie sous certaines conditions, ont permis d'améliorer drastiquement le taux de mortalité. Dans cet article, nous explorons les standards ainsi que les dernières innovations dans le traitement multimodal du cancer de l'œsophage.

A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study.

BACKGROUND: Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. PATIENTS AND METHODS: All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. RESULTS: Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500 ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). CONCLUSION: The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

Assessment of predictors of early postoperative complications after primary robotically assisted Roux-en-Y gastric bypass: a multicenter, retrospective cohort study.

BACKGROUND: Robotic Roux-en-Y gastric bypass (RRYGB) is performed in an increasing number of bariatric centers worldwide. Previous studies have identified a number of demographic and clinical variables as predictors of postoperative complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Some authors have suggested better early postoperative outcomes after RRYGB compared to LRYGB. The objective of the present study was to assess potential predictors of early postoperative complications after RRYGB. METHODS: A retrospective analysis of two prospective databases containing patients who underwent RRYGB between 2006 and 2019 at two high volumes, accredited bariatric centers was performed. Primary outcome was rate of 30 day postoperative complications. Relevant demographic, clinical and biological variables were entered in a multivariate, logistic regression analysis to identify potential predictors. RESULTS: Data of 1276 patients were analyzed, including 958 female and 318 male patients. Rates of overall and severe 30 day complications were 12.5% (160/1276) and 3.9% (50/1276), respectively. Rate of 30 day reoperations was 1.6% (21/1276). The overall gastrointestinal leak rate was 0.2% (3/1276). Among various demographic, clinical and biological variables, male sex and ASA score >2 were significantly correlated with an increased risk of 30 day complication rates on multivariate analysis (OR 1.68 and 1.67, p=0.005 and 0.005, respectively). CONCLUSION: This study identified male sex and ASA score >2 as independent predictors of early postoperative complications after RRYGB. These data suggest a potentially different risk profile in terms of early postoperative complications after RRYGB compared to LYRGB. The robotic approach might have a benefit for patients traditionally considered to be at higher risk of complications after LRYGB, such as those with BMI >50. The present study was however not designed to assess this hypothesis and larger, prospective studies are necessary to confirm these results.

Outcome of endoscopic vacuum therapy for duodenal perforation.

BACKGROUND: Duodenal defects are complex clinical situations, and their management is challenging and associated with high mortality. Besides surgery, endoscopic treatment options exist, but the size and location of the perforation can limit their application. We present a retrospective study, demonstrating a successful application of endoscopic vacuum therapy (EVT) for duodenal leaks. METHODS: We performed a retrospective study of all patients who underwent EVT for duodenal perforations between 2016 and 2021 at two tertiary centers. We analyzed demographic and clinical patient characteristics, surgical outcomes, leak characteristics, sponge-related complications, and success rate. RESULTS: Indications for treatment with EVT in the duodenum consisted of leak after duodenal suture of a perforated ulcer (n = 4), iatrogenic perforation after endoscopic resection (n = 2), iatrogenic perforation during surgery (n = 2), and anastomotic leak after upper gastrointestinal surgery (n = 2). EVT was used as a first-line treatment in seven patients and as a second-line treatment in three patients. EVT was successfully applied in all interventions (n = 10, 100%). Overall, EVT lead to definitive closure of the defects in eight out of ten patients (80%). No severe EVT-related adverse events occurred. CONCLUSION: EVT is safe and technically feasible, so it emerges as a promising endoscopic treatment option for duodenal leaks. However, multidisciplinary collaboration and management are important to reduce the occurrence of postoperative complications, and to improve recovery rates.

A 56-Year-Old Woman with Acute Cholecystitis and a Moynihan's Hump, or Caterpillar Configuration, of the Right Hepatic Artery Identified During Laparoscopic Cholecystectomy.

BACKGROUND When performing a cholecystectomy, several variations can be encountered by the surgeon. The "Moynihan's hump" or "caterpillar configuration" of the right hepatic artery are the terms used to describe a tortuous right hepatic artery running proximal or parallel to the cystic duct, resulting in a small or short cystic artery and occupying most of Calot's triangle. This report is of a 56-year-old woman with acute cholecystitis and a Moynihan's hump or caterpillar configuration identified at laparoscopic cholecystectomy. CASE REPORT A 56-year-old woman presented herself to the Emergency Department with abdominal pain in the right upper quadrant for a week, associated with nausea, vomiting, and abnormal warm and cold sensation. Acute cholecystitis was diagnosed with ultrasound, and a laparoscopic cholecystectomy using a 4-port technique was performed. During the dissection of Calot's triangle, a large pulsatile vessel forming a loop was found, which turned out to be the right hepatic artery. The anatomic variation that was observed during the procedure is called Moynihan's hump or caterpillar configuration of the right hepatic artery. The surgery was uneventful, and the patient was discharged the next day. CONCLUSIONS The Moynihan's hump or caterpillar configuration of the right hepatic artery is a rare anomaly, with an incidence reported to be between 1.3% and 13.3%. This report has shown that although a Moynihan's hump or caterpillar configuration of the right hepatic artery is rare, the surgeon should be aware of this anatomic anomaly when performing gallbladder surgery to prevent arterial damage and operative complications.

Is an Early Resumption of a Regular Diet After Laparoscopic Roux-en-Y Gastric Bypass Safe?

BACKGROUND: Return to a normal diet is a crucial step after bariatric surgery. Proximal anastomosis is a source of concern for early feeding as the passage of solid food through a recent anastomosis could well increase pressure and the risk of leakage. This study aims to assess the safety of an early normal diet after a laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIALS AND METHODS: All consecutive patients undergoing primary LRYGB between January 2015 and December 2020 were included prospectively. Three postoperative pureed diets were compared at 4 weeks, 2 weeks, and 1 week. All-cause morbidity at 90 days was the main outcome. Overall complications, severe complications (Clavien-Dindo ≥ grade 3a), length of hospital stay, number of emergency, and unplanned consultations during the 3 postoperative months were recorded for each group. RESULTS: Three hundred and sixty-seven patients with a mean BMI of 42.10 kg/m2 (± SD: 4.78) were included. All-cause morbidity at 90 days was 11.7% (43/367) and no significant difference was observed between the 3 groups. Adjustment for patients and operative cofounders did not demonstrate any increased risk of postoperative complications between the 3 groups, with an odds ratio of 1, 1.23(95% CI [0. 55-2.75]), and 1.14 (95% CI [0.49, 2.67]) for groups 1, 2, and 3 respectively. Severe complications (Clavien-Dindo ≥ grade 3a) and emergency or unplanned consultations were also similar in the 3 groups. CONCLUSION: Return to a normal diet 1 week after LRYGB did not increase short-term morbidity and unplanned consultations. It may be safe and contribute to patient comfort.

Multimodal treatment in oligometastatic gastric cancer.

Gastric cancer is generally diagnosed at an advanced stage, especially in countries without screening programs. Previously, the metastatic stage was synonymous with palliative management, and surgical indications were only for symptomatic relief. However, this therapeutic option is associated with poor prognosis. A subgroup of patients with limited metastatic disease could benefit from intensive treatment. A combination of chemotherapy, immunotherapy, and targeted therapy could help either maintain a resectable state for oligometastatic disease or diminish the metastasis size to obtain a complete resection configuration. This latter strategy is known as conversion therapy and has growing evidence with favorable outcomes. Oncosurgical approach of metastatic disease could prolong survival in selected patients. The challenge for the surgeon and oncologist is to identify these specific patients to offer the best multimodal management. We review in this article the actual evidence for the treatment of oligometastatic gastric cancer with curative intent.

[Treatment options for oligometastatic gastric cancer]. / Therapieoptionen beim oligometastasierten Magenkarzinom.

BACKGROUND: At the time of diagnosis of gastric cancer approximately one third of patients already have metastases. It is important to differentiate between oligometastasis and the diffuse metastatic situation. For the first time the definition of oligometastasis has been integrated into the German S3 guidelines. OBJECTIVE: Can multimodal treatment with tumor resection and metastasectomy combined with perioperative chemotherapy, increase the chances of survival in oligometastatic patients? MATERIAL AND METHODS: In this review article the data situation of the current literature is discussed. RESULTS: The Dutch D1/D2 trial reported an increased median survival for a subgroup of patients with single metastasis who underwent resection. Multimodal treatment with resection doubled the median survival of oligometastatic patients in the German AIO-FLOT 3 study and as a consequence, the AIO-FLOT 5 (RENAISSANCE) trial was designed. Patients with oligometastatic gastric and esophagogastric junction cancer are randomized after chemotherapy to either undergo resection followed by adjuvant chemotherapy or to undergo definitive chemotherapy. Further randomized trials investigate the benefit of antibodies and immune checkpoint inhibitors in locoregional and advanced metastatic gastric cancer with promising results. CONCLUSION: The results of the ongoing randomized trials will show if oligometastatic patients benefit from a multimodal treatment with resection. The clear definition of the oligometastatic state, assessment of the response to neoadjuvant chemotherapy and realistic estimation of the R0 resectability will be useful for patient selection.

Global Benchmark Values for Laparoscopic Roux-en-Y-Gastric Bypass: a Potential New Indicator of the Surgical Learning Curve.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a technically demanding procedure. The learning curve of LRYGB is challenging and potentially associated with increased morbidity. This study evaluates whether a general laparoscopic surgeon can be safely trained in performing LRYGB in a peripheral setting, by comparing perioperative outcomes to global benchmarks and to those of a senior surgeon. METHODS: All consecutive patients undergoing primary LRYGB between January 2014 and December 2017 were operated on by a senior (A) or a trainee (B) bariatric surgeon and were prospectively included. The main outcome of interest was all-cause morbidity at 90 days. Perioperative outcomes were compared with global benchmarks pooled from 19 international high-volume centers and between surgeons A and B for their first and last 30 procedures. RESULTS: The 213 included patients had a mean all-cause morbidity rate at 90 days of 8% (17/213). 95.3% (203/213) of the patients were uneventfully discharged after surgery. Perioperative outcomes of surgeon B were all within the global benchmark cutoffs. Mean operative time for the first 30 procedures was significantly shorter for surgeon A compared with surgeon B, with 108.6 min (± 21.7) and 135.1 min (± 28.1) respectively and decreased significantly for the last 30 procedures to 95 min (± 33.7) and 88.8 min (± 26.9) for surgeons A and B respectively. CONCLUSION: Training of a new bariatric surgeon did not increase morbidity and operative time improved for both surgeons. Perioperative outcomes within global benchmarks suggest that it may be safe to teach bariatric surgery in peripheral setting.

Esophageal cancer surgery: review of complications and their management.

Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.

Current surgical treatment standards for esophageal and esophagogastric junction cancer.

A number of different surgical techniques for the treatment of cancer of the esophagus and the esophagogastric junction have been proposed. Guidelines generally recommend a transthoracic approach for esophageal cancer, including Siewert type I tumors. In tumors of the proximal esophageal third, transthoracic esophagectomy may be extended to a three-field approach, including resection of cervical lymph nodes. However, the choice between transthoracic esophagectomy with intrathoracic anastomosis (Ivor Lewis esophagectomy) and the three-incision approach with cervical esophago-gastrostomy (McKeown esophagectomy) remains controversial, with guidelines varying among different countries. Furthermore, it is commonly accepted that Siewert type III tumors should be treated by extended total gastrectomy with transhiatal resection of the lower esophagus, whereas currently no consensus exists regarding the optimal surgical approach for the treatment of Siewert type II adenocarcinoma. Likewise, there is a major controversy regarding palliative and potentially curative treatment modalities in oligometastatic disease. This review deals with current surgical treatment standards for cancer of the esophagus and the eosphagogastric junction, including discussion of ongoing trials.

[Esophageal and esophago-gastric junction cancer†: management and multimodal treatment]. / Cancer de l'œsophage et de la jonction œsogastrique†: prise en charge et traitement multidisciplinaire.

Esophageal cancer remains an oncological burden with a low survival rate. Multidisciplinary management is essential to offer an adjusted treatment to the patient general condition and the tumor stage. New minimally invasive surgical treatments help to reduce the surgical trauma and improve post-operative patient recovery. Oncological treatments have also evolved and definitive treatment by radio-chemotherapy can be proposed in specific cases.

Le cancer de l'œsophage reste un fardeau oncologique avec un taux de survie bas. Une prise en charge multidisciplinaire est primordiale afin d'offrir un traitement adapté à l'état général du patient et au stade de la tumeur. De nouvelles prises en charge minimalement invasives chirurgicales permettent de diminuer le traumatisme d'une chirurgie majeure et améliorent la récupération des patients en postopératoire. Les traitements oncologiques ont également évolué et un traitement définitif par radiochimiothérapie peut être proposé dans des cas précis.

Laparoscopic Surgery for Gastric Cancer: The European Point of View.

OBJECTIVE: Multiple Asian studies have proved the feasibility of laparoscopic approach for surgical treatment of gastric cancer. The difference between Asian and European patients could limit their application in Europe. We reviewed the literature for European studies comparing open gastrectomy with laparoscopic approach in the treatment of gastric cancer. METHOD: We searched the keywords gastric cancer and laparoscopy in MEDLINE and EMBASE. We included all studies published between 1990 and 2016 and conducted in Europe. RESULT: We found 1 randomized and 13 cohort studies which compared laparoscopic with open gastrectomy. We found no mean difference in the number of lymph nodes harvested between laparoscopic and open group (mean difference: -0.49; 95% CI: -2.42; 1.44, p=0.62) and no difference of short-term or long-term mortality (short-term odds ratio: 0.74, p=0.47; long-term odds ratio: 0.65, p=0.11). We found a longer operative time in the laparoscopic group (mean difference: 35.75 minutes, p<0.01) but lesser reoperation rate than the open group (odds ratio: 1.55 p=0.01). CONCLUSION: European based population studies found results comparable with their Asian counterpart. In the current state of evidence, minimally invasive surgery for gastric cancer is safe and can achieve the same oncological results.

Minimal length of proximal resection margin in adenocarcinoma of the esophagogastric junction: a systematic review of the literature.

The minimal length of proximal margin (PM) in esophagogastric junction cancer has not been established yet and its impact on patient survival remains unclear. Pubmed, Embase and Scopus databases were searched for "adenocarcinoma of the esophagogastric junction", "adenocarcinoma of the gastroesophageal junction" and "cardia cancer", each combined with "proximal margin". English written studies that specified PM length in AEG were included. Survival data in relation to PM were extracted. 13 studies, that were all retrospective case series, with a total number of 2648 patients met inclusion criteria and were analyzed. While 93% of 230 patients with Siewert type I had esophagectomy, 69% of 1270 patients with Siewert type II and 93% of 872 patients with Siewert type III had transhiatal extended gastrectomy. Minimal PM length was treated by five studies and ranged between 2 and 6 cm. While three studies defined minimal PM by the necessary length to obtain R0 resection, two studies found minimal PM length significantly associated with survival. Multivariate analyses revealed in two studies an independent impact of PM on survival, whereas one study did not found any significant relation between PM and survival. One study showed that PM length was significantly associated with survival in T2-4N0-2 tumors, but not in T1 or N3 tumors. In conclusion, available retrospective studies did not allow a conclusion for a minimal length of PM and showed no clear evidence for an impact of PM length on survival. Taking into consideration available data and the shrinkage phenomen, a PM > 2 cm might be necessary to obtain a sufficient PM.

The role of surgery in advanced disease for esophageal and junctional cancer.

The incidence of esophageal and junctional cancer has been increasing in western industrialized nations in the past 30 years. At the time of diagnosis, approximately 50% of patients with esophageal and junctional cancers have distant metastases and are considered incurable. In the recent ESMO guidelines and the German S3 guidelines, surgical therapy for metastatic disease is not recommended. In spite of these recommendations, the treatment of limited metastatic (oligo-metastastic) esophagogastric cancer is currently undergoing a shift towards a more aggressive therapy. Selected patients with oligo-metastatic disease may be considered for surgical resection of the primary tumor and the metastases after chemo(radio)therapy and careful evaluation in an interdisciplinary tumor board. We discuss in this review the literature and some guidelines for extended surgical approaches is laid out. In the future, randomized prospective studies like the German RENAISSANCE/FLOT5 trial and the French SURGIGAST trial will feed us with more evidence if multimodal therapy including surgery for limited metastatic disease is indicated.

[Gastric cancer : management and multidisciplinary treatment]. / Cancer de l'estomac : prise en charge et traitement multidisciplinaire.

Despite a decreasing incidence, gastric cancer remains a burden. Generally discovered at an advanced stage, survival improved with progress in perioperative treatment and surgical management. Preoperative staging is essential to accurately classify the tumor and introduce the appropriate treatment. Tumor location is particularly important because the treatment of tumors of the esophageal junction and the stomach is different. Minimally invasive techniques can probably reduce postoperative morbidity and help to put patients in the best possible conditions for adjuvant treatment.

Malgré une incidence en diminution, le cancer gastrique reste un fardeau. Généralement découvert à un stade avancé, la survie a pu être améliorée grâce aux progrès effectués dans le traitement périopératoire et la prise en charge chirurgicale. Le bilan complémentaire préopératoire est capital afin de classifier de manière précise la tumeur et d'introduire le traitement adéquat. La localisation de la tumeur est en particulier importante car le traitement des tumeurs de la jonction œsogastrique et de l'estomac est différent. Les techniques minimalement invasives permettent de diminuer la morbidité postopératoire et de mettre les patients dans les meilleures conditions possibles pour un éventuel traitement adjuvant.

Early esophageal cancer: the significance of surgery, endoscopy, and chemoradiation.

Early carcinomas of the esophagus are histologically classified as adenocarcinoma or squamous cell carcinoma and microscopically subdivided into mucosal and submucosal carcinomas depending on infiltration depth. The prevalence of lymph node metastasis in mucosal carcinoma remains low. However, lymph node metastases arise frequently from tumors with submucosal infiltration, with increasing prevalence in the deeper submucosal sublayers. According to current German guidelines, endoscopic resection is the recommended treatment in mucosal adenocarcinoma without histologic risk factors (lymphatic invasion 1, vascular invasion 1, >grade 2, R1-margin). In superficial submucosal infiltration without histologic risk factors, endoscopic resection can be considered. In squamous cell carcinoma, endoscopic resection is indicated up to middle layer mucosal carcinoma. Beyond these criteria, surgical resection should be considered. The gold standard is a subtotal transthoracic esophagectomy with two-field lymphadenectomy. Total esophagectomy is performed in cervical esophageal carcinoma and transhiatal extended gastrectomy in carcinoma of the cardia. Minimally invasive procedures show good oncologic results and reduce the morbidity of radical esophagectomy. Reduced morbidity might be an argument for surgical resection in borderline cases between endoscopic and surgical resection. In early squamous cell cancer, the combination of endoscopic resection and adjuvant chemoradiotherapy is a therapeutic option with promising results.