RESUMO
BACKGROUND: The literature on the prognostic relevance of signet-ring cell (SRC) histology in gastric cancer (GC) is controversial which is most likely related to inconsistent SRC classification based on haematoxylin-eosin staining. We hypothesised that mucin stains can consistently identify SRC-GC and predict GC patient outcome. METHODS: We performed a comprehensive literature review on mucin stains in SRC-GC and characterised the mucin expression in 851 Caucasian GC and 410 Asian GC using Alcian Blue (AB)-Periodic Acid-Schiff (PAS), MUC2 (intestinal-type mucin), and MUC5AC (gastric-type mucin). The relationship between mucin expression and histological phenotype [poorly cohesive (PC) including proportion of SRCs, non-poorly cohesive (non-PC), or mucinous (MC)], clinicopathological variables, and patient outcome was analysed. RESULTS: Depending on mucin expression and cut-offs, the positivity rates of SRC-GC reported in the literature varied from 6 to 100%. Patients with MUC2 positive SRC-GC or SRC-GC with (gastro)intestinal phenotype had poorest outcome. In our cohort study, PC with ≥ 10% SRCs expressed more frequently MUC2, MUC5AC, and ABPAS (p < 0.001, p = 0.004 and p < 0.001, respectively). Caucasians with AB positive GC or combined ABPAS-MUC2 positive and MUC5AC negative had poorest outcome (all p = 0.002). This association was not seen in Asian patients. CONCLUSIONS: This is the first study to suggest that mucin stains do not help to differentiate between SRC-GC and non-SRC-GC. However, mucin stains appear to be able to identify GC patients with different outcome. To our surprise, the relationship between outcome and mucin expression seems to differ between Caucasian and Asian GC patients which warrants further investigations.
Assuntos
Povo Asiático/estatística & dados numéricos , Carcinoma de Células em Anel de Sinete/patologia , Neoplasias Esofágicas/patologia , Mucina-1/metabolismo , Neoplasias Gástricas/patologia , População Branca/estatística & dados numéricos , Idoso , Carcinoma de Células em Anel de Sinete/etnologia , Carcinoma de Células em Anel de Sinete/metabolismo , Carcinoma de Células em Anel de Sinete/terapia , Estudos de Coortes , Terapia Combinada , Neoplasias Esofágicas/etnologia , Neoplasias Esofágicas/metabolismo , Neoplasias Esofágicas/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Neoplasias Gástricas/etnologia , Neoplasias Gástricas/metabolismo , Neoplasias Gástricas/terapia , Taxa de SobrevidaRESUMO
Application of enhanced recovery protocols (ERP) in esophageal surgery seems to lead an advantage in terms of length of hospital staying and outcomes, but only few data exist on its cost effectiveness. Previous literature analyzed pre- and post-ERP groups, finding a cost reduction with the introduction of the pathway. We aimed to study the influence on costs of accumulating experience and compliance in an ERP group. Seventy-one patients have been treated at our institution from January 2014 to June 2017 with our ERP for Ivor-Lewis esophagectomy. Direct costs were divided into subcategories and were analyzed as a function of calendar year and compliance. Factor affecting costs were searched. Univariable analysis highlighted a significant reduction in costs over time. Increase in compliance led to a progressive cost reduction for each ERP item completed (14 852-11 045). While age was not found to significantly influence the cost (p = 0.341), complications seemed to nullify the effect of experience: the median was 11 507 in uncomplicated patients, and increased to 13 791 in Clavien-Dindo 3-4 (CD3-4) patients. Compliance and CD3-4 remained significant also in multivariable analysis, accomplished by quantile regression, while year of surgery lost its significance. Our results evidence how accumulating experience in ERP led to a cost reduction over time, which was mainly mediated by an increase in compliance. Indeed, compliance was the main factor in reducing ERP cost while CD3-4 complications were the most important factor in cost increasing, nullifying the benefit of compliance.
Assuntos
Protocolos Clínicos/normas , Recuperação Pós-Cirúrgica Melhorada/normas , Esofagectomia/reabilitação , Fidelidade a Diretrizes/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Adulto , Custos e Análise de Custo , Esofagectomia/efeitos adversos , Esofagectomia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Análise de RegressãoRESUMO
Candidate genes involved in DNA repair, 5-fluorouracil metabolism and drug detoxification were genotyped in 124 patients receiving neoadjuvant chemoradiation treatment for locally advanced esophageal cancer and their predictive role for long-term relapse-free survival (RFS) and cancer-specific survival (CSS) were evaluated. A panel including MTHFR 677TT, MDR1 2677GT, GSTP1 114CC, XPC 499CC and XPC 939AC+CC, defined as high-risk genotypes, discriminated subgroups with significantly different outcomes. When the panel was combined with histology, patients split into two subsets with 5-year RFS and CSS rates of 65% vs 27% (hazard ratio (HR) 3.0, P<0.0001) and 69% vs 31% (HR 2.9, P<0.0001), respectively. Combining the 5-single-nucleotide polymorphism (5-SNP) panel with pathological response defined two major informative risk classes with 5-year PFS and CSS rates of 79.4% vs 17.7% (HR 6.71, P<0.0001) and 79.3% vs 26.3% (HR 6.25, P<0.0001), respectively. This classification achieved a sensitivity of 79%, a specificity of 85.4% and an accuracy of 81.8%.
Assuntos
Adenocarcinoma/terapia , Biomarcadores Tumorais/genética , Carcinoma de Células Escamosas/terapia , Quimiorradioterapia Adjuvante , Neoplasias Esofágicas/terapia , Perfilação da Expressão Gênica/métodos , Terapia Neoadjuvante , Polimorfismo de Nucleotídeo Único , Adenocarcinoma/genética , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Carcinoma de Células Escamosas/genética , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Intervalo Livre de Doença , Neoplasias Esofágicas/genética , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Carcinoma de Células Escamosas do Esôfago , Feminino , Regulação Neoplásica da Expressão Gênica , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Farmacogenética , Medicina de Precisão , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Prognostic models from Korea and Italy have been developed that predict overall survival and cancer recurrence respectively after radical gastrectomy for gastric cancer. The aim of this study was to validate the two models in independent patient cohorts, and to evaluate which factors may explain differences in prognosis between Korean and Italian patients with gastric cancer. METHODS: Patients who underwent radical gastrectomy for gastric cancer between January 2000 and December 2004 at Seoul National University Hospital and at eight centres in Italy were included. Discrimination of the models was tested with receiver operating characteristic (ROC) curves and calculation of area under the curve (AUC). Calibration was evaluated by plotting actual survival probability against predicted survival probability for the Korean nomogram, and actual against predicted risk of recurrence for the Italian score. RESULTS: Some 2867 and 940 patients from Korea and Italy respectively were included. The Korean nomogram achieved good discrimination in the Italian cohort (AUC 0·80, 95 per cent c.i. 0·77 to 0·83), and the Italian model performed well in the Korean cohort (AUC 0·87, 0·85 to 0·89). The Korean nomogram also achieved good calibration, but this was not seen for the Italian model. Multivariable analyses confirmed that Italian ethnicity was an independent risk factor for cancer recurrence (odds ratio (OR) 1·72, 1·31 to 2·25; P < 0·001), but not for overall survival (OR 1·20, 0·95 to 1·53; P = 0·130). CONCLUSION: Both prognostic models performed fairly well in independent patient cohorts. Differences in recurrence rates of gastric cancer may be partially explained by ethnicity.
Assuntos
Gastrectomia/métodos , Recidiva Local de Neoplasia/mortalidade , Neoplasias Gástricas/cirurgia , Métodos Epidemiológicos , Feminino , Gastrectomia/mortalidade , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , República da Coreia/epidemiologia , Neoplasias Gástricas/mortalidadeRESUMO
This article is about an emerging issue in esophageal surgery: enhanced recovery after surgery (ERAS) Few data are published in literature and its safety and feasibility is still debated. The focus of our paper is on the feasibility of an ERAS protocol for esophagectomy (including both the Ivor-Lewis and McKeown procedure) in a high volume center comparing to a standard perioperative protocol. We introduced a novelty item on this type of surgery: resume of oral feeding in the first postoperative day. We analyzed the dropout rate for each item and the postoperative morbidity. We studied 39 patients operated in the Upper GI division of Verona University Hospital between January 2013 and August 2014; 22 patients (ERAS group) were studied in a perspective way while 17 patients (standard group) were studied retrospectively. The enhanced recovery protocol included intraoperative fluid management, time of extubation after surgery, intensive care unit discharge, drains and nasogastric tube management, mobilization of the patient, oral food intake. We compared the results between the two groups in term of hospital stay, postoperative morbidity and mortality. We also calculated the percentage completion of the protocol, evaluating patient drop-out rates for each of the items. Patients showed an improvement in the ERAS group in terms of earlier extubation, earlier intensive care unit discharge (p < 0.01), earlier thoracic drain, urinary catheter (p < 0.01) and nasogastric tube removal (p = 0.02), earlier mobilization (p < 0.01), and resume of oral feeding (p < 0.01). Median length of hospital stays in the ERAS group was 9 days while in the standard group was 10 days (p = 0.23). Postoperative morbidity and mortality were comparable between the two groups. This study shows the feasibility and safety of an ERAS protocol for esophageal surgery in a high-volume center. These data strengthen the literature results on this argument calling for larger sample size studies.
Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/reabilitação , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Extubação/métodos , Protocolos Clínicos , Deambulação Precoce , Ingestão de Alimentos , Esofagectomia/métodos , Estudos de Viabilidade , Métodos de Alimentação , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados Intraoperatórios/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: About 20% of resectable oesophageal carcinoma is resistant to preoperative chemoradiotherapy. Here we hypothesised that the expression of the antiapoptotic gene Baculoviral inhibitor of apoptosis repeat containing (BIRC)3 induced by the transforming growth factor ß activated kinase 1 (TAK1) might be responsible for the resistance to the proapoptotic effect of chemoradiotherapy in oesophageal carcinoma. METHODS: TAK1 kinase activity was inhibited in FLO-1 and KYAE-1 oesophageal adenocarcinoma cells using (5Z)-7-oxozeaenol. The BIRC3 mRNA expression was measured by qRT-PCR in 65 pretreatment frozen biopsies from patients receiving preoperatively docetaxel, cisplatin, 5-fluorouracil, and concurrent radiotherapy. Receiver operator characteristic (ROC) analyses were performed to determine the performance of BIRC3 expression levels in distinguishing patients with sensitive or resistant carcinoma. RESULTS: In vitro, (5Z)-7-oxozeaenol significantly reduced BIRC3 expression in FLO-1 and KYAE-1 cells. Exposure to chemotherapeutic agents or radiotherapy plus (5Z)-7-oxozeaenol resulted in a strong synergistic antiapoptotic effect. In patients, median expression of BIRC3 was significantly (P<0.0001) higher in adenocarcinoma than in the more sensitive squamous cell carcinoma subtype. The BIRC3 expression significantly discriminated patients with sensitive or resistant adenocarcinoma (AUC-ROC=0.7773 and 0.8074 by size-based pathological response or Mandard's tumour regression grade classifications, respectively). CONCLUSIONS: The BIRC3 expression might be a valid biomarker for predicting patients with oesophageal adenocarcinoma that could most likely benefit from preoperative chemoradiotherapy.
Assuntos
Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Quimiorradioterapia/métodos , Neoplasias Esofágicas/terapia , Proteínas Inibidoras de Apoptose/metabolismo , MAP Quinase Quinase Quinases/fisiologia , Proteínas de Neoplasias/metabolismo , Ubiquitina-Proteína Ligases/metabolismo , Zearalenona/análogos & derivados , Adenocarcinoma/metabolismo , Adenocarcinoma/patologia , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Apoptose/efeitos dos fármacos , Apoptose/efeitos da radiação , Proteína 3 com Repetições IAP de Baculovírus , Carcinoma de Células Escamosas/metabolismo , Carcinoma de Células Escamosas/patologia , Linhagem Celular Tumoral , Cisplatino/administração & dosagem , Docetaxel , Regulação para Baixo , Resistencia a Medicamentos Antineoplásicos , Neoplasias Esofágicas/metabolismo , Neoplasias Esofágicas/patologia , Junção Esofagogástrica , Feminino , Fluoruracila/administração & dosagem , Humanos , Técnicas In Vitro , Proteínas Inibidoras de Apoptose/genética , MAP Quinase Quinase Quinases/antagonistas & inibidores , Masculino , Pessoa de Meia-Idade , Proteínas de Neoplasias/genética , RNA Mensageiro/metabolismo , Curva ROC , Tolerância a Radiação , Taxoides/administração & dosagem , Ubiquitina-Proteína Ligases/genética , Zearalenona/farmacologiaRESUMO
BACKGROUND: To obtain a prognostic stratification model for resected gastric cancer patients. PATIENTS AND METHODS: Clinicopathological and molecular data (expression of Cdx2, Apc, ß-catenin, E-cadherin, Fhit, p53, and human epidermal growth factor receptor-2 (Her2); HER2 and TOPO2A gene copy number; PIK3CA mutations; microsatellite instability) were correlated to cancer-specific/overall survival (CSS/OS) using a Cox model. Individual patient probability (IPP) was estimated by logistic equation. A continuous score to identify risk-classes was derived according to the model ratios. RESULTS: Two-hundred eight patients were studied (median follow-up 20 months). At multivariate analysis, sex, stage, margins, location, nodes, Apc, and Fhit were independent predictors for CSS; the same factors (and age and Her2, except Fhit) predicted OS. Multivariate model predicted IPP with high prognostic accuracy (0.90 for CSS; 0.91 for OS). A two-class model significantly separated low- and high-risk patients for CSS (23.4% and 85.6%, P < 0.0001) and OS (21.4% and 82.0%, P < 0.0001). A three-class model differentiated low-, intermediate-, and high-risk patients for CSS (6.3%, 35.3%, and 88.0%, P < 0.0001) and OS (6.1%, 34.6%, and 86.5%, P < 0.0001). CONCLUSIONS: A risk classification system comprising the immunohistochemical expression of three proteins (Apc, Fhit, and Her2) and five clinicopathological parameters (stage, resected nodes, margins, location, and sex) accurately separates the resected gastric cancer patients into three classes of risk.
Assuntos
Hidrolases Anidrido Ácido/metabolismo , Proteína da Polipose Adenomatosa do Colo/metabolismo , Carcinoma/metabolismo , Proteínas de Neoplasias/metabolismo , Receptor ErbB-2/metabolismo , Neoplasias Gástricas/metabolismo , Proteína da Polipose Adenomatosa do Colo/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Carcinoma/mortalidade , Carcinoma/secundário , Carcinoma/cirurgia , Análise Mutacional de DNA , Feminino , Expressão Gênica , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Modelos de Riscos Proporcionais , Curva ROC , Receptor ErbB-2/genética , Estudos Retrospectivos , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgiaRESUMO
BACKGROUND: Neoadjuvant chemoradiotherapy (CRT) is now considered the standard of care by many centers in the treatment of both squamous cell carcinoma (SCC) and adenocarcinoma of the esophagus. This study evaluates the effectiveness of a neoadjuvant CRT protocol, as regards pathological complete response (pCR) rate and long-term survival. METHODS: From 2003 to 2011, at Upper G.I. Surgery Division of Verona University, 155 consecutive patients with locally advanced esophageal cancers (90 SCC, 65 adenocarcinoma) were treated with a single protocol of neoadjuvant CRT (docetaxel, cisplatin, and 5-fluorouracil with 50.4 Gy of concurrent radiotherapy). Response to CRT was evaluated through percentage of pathological complete response (pCR or ypT0N0), overall (OS) and disease-related survival (DRS), and pattern of relapse. RESULTS: One hundred thirty-one patients (84.5 %) underwent surgery. Radical resection (R0) was achieved in 123 patients (79.3 %), and pCR in 65 (41.9 %). Postoperative mortality was 0.7 % (one case). Five-year OS and DRS were respectively 43 and 49 % in the entire cohort, 52 and 59 % in R0 cases, and 72 and 81 % in pCR cases. Survival did not significantly differ between SCC and adenocarcinoma, except for pCR cases. Forty-nine patients suffered from relapse, which was mainly systemic in adenocarcinoma. Only three out of 26 pCR patients with previous adenocarcinoma developed relapse, always systemic. CONCLUSIONS: This study suggests that patients treated with the present protocol achieve good survival and high pCR rate. Further research is necessary to evaluate whether surgery on demand is feasible in selected patients, such as pCR patients with adenocarcinoma.
Assuntos
Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/terapia , Terapia Neoadjuvante , Adenocarcinoma/secundário , Adulto , Idoso , Carcinoma de Células Escamosas/secundário , Quimiorradioterapia Adjuvante , Cisplatino/administração & dosagem , Docetaxel , Neoplasias Esofágicas/patologia , Esofagectomia , Feminino , Fluoruracila/administração & dosagem , Hospitais com Alto Volume de Atendimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Neoplasia Residual , Dosagem Radioterapêutica , Taxa de Sobrevida , Taxoides/administração & dosagem , Resultado do TratamentoRESUMO
Severe acute pancreatitis (SAP) management has changed over the last fifteen years, and from too aggressive behaviour, we moved to a cautious one. In every case, we can appreciate defect of extremist conceptual position. We reviewed our strategy on disease treatment, and we analyzed treatment of single cases. We collected 4 SAP cases from January 2009 to January 2010. All patients were septic, and we adopted the same approach for all of them, avoiding surgery without peritoneal infection. In all patients we placed jejumostomy and, after cleaning of septic site, we started immediate enteral nutrition (EN). Antibiotic therapy against Gram+, Gram- and antifugal drug had been started. No one died and all patients were back to an active life even if social costs are considerably high especially due to very long hospital stay.
Assuntos
Pancreatite Necrosante Aguda/terapia , Adulto , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Efeitos Psicossociais da Doença , Drenagem , Endoscopia Gastrointestinal , Nutrição Enteral , Seguimentos , Humanos , Itália , Jejunostomia , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Pancreatite Necrosante Aguda/diagnóstico , Pancreatite Necrosante Aguda/economia , Pancreatite Necrosante Aguda/cirurgia , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: The aim of the present multicentre observational study was to evaluate potential changes in clinical and pathological features of patients with gastric cancer (GC) treated in a 15-year interval. METHODS: A centralized prospective database including clinical, surgical, pathological and follow-up data from 2822 patients who had resection of a primary GC was analysed. The analysis focused on three periods: 1991-1995 (period 1), 1996-2000 (period 2) and 2001-2005 (period 3). Surgical procedure, pathological classification and follow-up were standardized among centres. RESULTS: The number of resections decreased from 1024 in period 1 to 955 and 843 in periods 2 and 3 respectively. More advanced stages and a smaller number of intestinal-type tumours of the distal third were observed over time. Five-year survival rates after R0 resection (2320 patients) did not change over time (overall: 56·6 and 51·2 per cent in periods 1 and 3; disease-free: 66·8 and 61·1 per cent respectively). Decreases in survival in more recent years were related particularly to more advanced stage, distal tumours and tumours in women. Multivariable analysis showed a lower probability of overall and disease-free survival in the most recent interval: hazard ratio 1·22 (95 per cent confidence interval 1·06 to 1·40) and 1·29 (1·06 to 1·58) respectively compared with period 1. Recurrent tumours were more frequently peritoneal rather than locoregional. CONCLUSION: Overall and disease-free survival rates after R0 resection of GC were unchanged over time.
Assuntos
Neoplasias Gástricas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Métodos Epidemiológicos , Feminino , Gastrectomia/métodos , Gastrectomia/mortalidade , Humanos , Itália/epidemiologia , Excisão de Linfonodo/métodos , Excisão de Linfonodo/mortalidade , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Distribuição por Sexo , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Prophylactic use of abdominal drain in gastrectomy has been questioned in the last 15 years, and a 2015 Cochrane meta-analysis on four RCTs concluded that there was no convincing evidence to the routine drain placement in gastrectomy. Nevertheless, the authors evidenced the moderate/low quality of the included studies and highlighted how 3 out of 4 came from Eastern countries. After 2015, only retrospective studies have been published, all with inconsistent results. METHODS: ADiGe (Abdominal Drain in Gastrectomy) Trial is a multicenter prospective randomized non-inferiority trial with a parallel design. It aimed to verify whether avoiding routine use of abdominal drain is burdened with complications, particularly an increase in postoperative invasive procedures. Patients with gastric cancer, scheduled for subtotal or total gastrectomy with curative intent, are eligible for inclusion, irrespective of previous oncological treatment. The primary composite endpoint is reoperation or percutaneous drainage procedures within 30 postoperative days. The primary analysis will verify whether the incidence of the primary composite endpoint is higher in the experimental arm, avoiding routine drain placement, than control arm, undergoing prophylactic drain placement, in order to falsify or support the null hypothesis of inferiority. Secondary endpoints assessed for superiority are overall morbidity and mortality, Comprehensive Complications Index, incidence and time for diagnosis of anastomotic and duodenal leaks, length of hospital stay, and readmission rate. Assuming one-sided alpha of 5%, and cumulative incidence of the primary composite endpoint of 6.4% in the control arm and 4.2% in the experimental one, 364 patients allow to achieve 80% power to detect a non-inferiority margin difference between the arm proportions of 3.6%. Considering a 10% drop-out rate, 404 patients are needed. In order to have a balanced percentage between total and subtotal gastrectomy, recruitment will end at 202 patients for each type of gastrectomy. The surgeon and the patient are blinded until the end of the operation, while postoperative course is not blinded to the patient and caregivers. DISCUSSION: ADiGe Trial could contribute to critically re-evaluate the role of prophylactic drain in gastrectomy, a still widely used procedure. TRIAL REGISTRATION: Prospectively registered (last updated on 29 October 2020) at ClinicalTrials.gov with the identifier NCT04227951 .
Assuntos
Gastrectomia , Complicações Pós-Operatórias , Drenagem , Gastrectomia/efeitos adversos , Humanos , Metanálise como Assunto , Estudos Multicêntricos como Assunto , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos RetrospectivosRESUMO
BACKGROUND AND AIMS: The aim of this project was to evaluate the current practice of D2 in Europe. MATERIALS AND METHODS: In the first part of the study, 18 European high volume gastric cancer centres completed a questionnaire, designed to evaluate their preferred lymphadenectomy in a series of clinical scenarios. Surgeon compliance with international guidelines for lymphadenectomy was evaluated. In the second part, information on 381 gastrectomies performed for primary gastric cancer by participating surgeons from January to December 2015, was retrospectively collected. RESULTS: Surgical choice in clinical scenarios was affected by tumour stage and to a lesser extent, site and histotype. In particular, in early gastric cancer with diffuse histology D2 was recommended by >70% of surgeons, while this percentage dropped to 44% in intestinal histotypes. When surgeons selected a D2 dissection, the procedure was rarely fully compliant with the Japanese guidelines. In the review of gastrectomy experience an adequate number of nodes (≥15 nodes) was retrieved in 97% after D2. The number of retrieved nodes varied with median values ranging from 17 to 35 (p < 0.001) after D2. D2/D2+ was more frequently performed in mixed (80%) and diffuse (78%) cases than in intestinal cases (69%) (p = 0.016). CONCLUSIONS: Although an adequate lymphadenectomy was achieved in almost all cases in dedicated centres, there is still variation in the number of retrieved nodes. Tumor histology largely affects surgeon's choice as regards the extent of lymphadenectomy; however, the role of histology in planning surgical procedures needs to be verified in prospective trials.
Assuntos
Excisão de Linfonodo/métodos , Neoplasias Gástricas/cirurgia , Europa (Continente) , Gastrectomia , Humanos , Especialização , Neoplasias Gástricas/patologiaRESUMO
BACKGROUND: Tumour regression grade (TRG) is used to evaluate responses to induction therapy in cancer of the oesophagus or cardia. This study aimed to determine whether inclusion of node category could improve the prognostic accuracy provided by TRG, and explore the prognostic value of an alternative classification based on size of residual foci and node category. METHODS: Patients with oesophageal or cardia cancer treated with neoadjuvant chemoradiotherapy followed by resection were studied. Treatment-induced response at the primary site was evaluated by TRG and by a method whereby patients were classified as having no residual cancer, minimal residual disease (MRD) or as non-responders. RESULTS: Between 2000 and 2007, 108 patients underwent resection. Disease-related survival decreased with increasing TRG in node-negative (N0) patients (P < 0.001), whereas in node-positive (N+) patients it was poor irrespective of TRG (P = 0.241). For N0 disease, 3-year survival in patients with MRD (58 (95 per cent confidence interval 26 to 80) per cent) was intermediate between that in patients with no residual cancer (85 (70 to 93) per cent) and non-responders (28 (4 to 59) per cent). Worst prognosis was for N+ disease (21 (9 to 36) per cent). CONCLUSION: Node category should be considered when evaluating response to induction therapy in oesophageal or cardia cancer. A new classification based on size of residual foci and node category seems promising.
Assuntos
Neoplasias Esofágicas/terapia , Neoplasias Gástricas/terapia , Adulto , Idoso , Cárdia , Quimioterapia Adjuvante , Intervalo Livre de Doença , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/etiologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Neoplasia Residual/patologia , Radioterapia Adjuvante , Indução de Remissão , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Resultado do TratamentoRESUMO
AIM: To evaluate the short-term clinical outcome of the patients with Zenker 's diverticulum undergone to endoscopic esophago-diverticulostomy according to Collard. PATIENTS AND METHODS: A retrospective analysis evaluated 123 patients. The most common symptom was dysphagia, severe in 50 patients (40.6%) and moderate in 73 (59.4%), with a mean dysphagia score of 2.3 (range 0-4). Regurgitation was present in 70 cases (56.9%), with a mean score of 0.8 (range 0-2). The mean diameter of diverticula was 4.1 cm (range 2.5-10). The procedure was undertaken in 87 male and 36 female with a mean follow-up of 69.1 months (range 1-168). RESULTS: Good results were obtained in 82 patients (66.7%), and the improvement of symptoms in 24 (19.5%), data confirmed by pre versus postoperative dysphagia mean score (2.3 vs 0.4) and by regurgitation score (0.8 vs 0.2). The failures have been seen in 17 patients (13.8%). The mean time of the intervention was 18 minutes (range 15-40), while the mean length of postoperative hospital stay was 2.5 days (range 1-5), with a oral intake in first postoperative day (mean). Major complications were documented in 2 patients (1.6%), minor ones in 10 patients (6.1%), without mortality. CONCLUSION: Nowadays esophago-diverticulostomy according to Collard, based on our results and on the literature data, represent the most effective and safe technique for the patients with Zenker's diverticulum, with low rate of morbidity and mortality compared to the others surgical on endoscopic procedures.
Assuntos
Esofagoscopia , Divertículo de Zenker/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Anastomotic leakage (AL) is a deadly complication after Ivor-Lewis esophagectomy. The use of an anastomotic drainage (AD), to diagnose and to potentially treat the leakage, is still a widespread practice. At present, scientific literature is lacking in this topic and its use is based on each center experience. We performed a retrospective analysis of 239 consecutive patients who underwent an Ivor-Lewis esophagectomy in our Department from 01/01/2006 to 31/12/2017. Until 28/02/2014, a transthoracic anastomotic drainage was routinely placed in 119 patients (anastomotic-drain group). Drainage removal was planned on POD 5 after the resume of oral intake. In the remaining 120 cases, no drainage was placed (no anastomotic-drain group). We compared the two groups to assess whether the anastomotic drainage had an impact on the timing of the anastomotic leakage diagnosis and treatment. In our series, we observed 9 anastomotic leaks in the first group (7.6%) and 3 in the second one (2.5%). In the anastomotic-drain group, median time for leak diagnosis was 10 days, and notably, in seven cases, the anastomotic drainage was already removed. Considering all the patients who experienced an AL, a re-operation was mandatory in one case, while endoscopic treatment was chosen for five cases and conservative treatment was adopted in three cases. The median hospital length of stay in these patients was 31 days. In the no anastomotic-drain group, one patient with anastomotic leakage was treated conservatively and discharged after 34 days. The other two cases were re-operated and an esophageal prosthesis was placed in both cases, and these patients were discharged, respectively, on POD 28 and POD 38. Concluding, the role of the anastomotic drain in Ivor-Lewis esophagectomy is still unclear. There is a shortage of the literature on this topic and our experience shows that the anastomotic drain has a limited sensibility in AL diagnosis and cannot replace the clinical signs and symptoms. Moreover, the drain it is often removed before the leakage becomes visible. In selected patients with a less severe leak, the anastomotic drain can be an effective treatment, but often a percutaneous drainage, it is an effective alternative choice. In severe dehiscence with sepsis, a reoperation remains the mainstay to control the mediastinal contamination and to eventually treat the leakage.
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Fístula Anastomótica/terapia , Drenagem/métodos , Esofagectomia/métodos , Anastomose Cirúrgica , Fístula Anastomótica/diagnóstico , Fístula Anastomótica/etiologia , Esofagectomia/efeitos adversos , Humanos , Fatores de TempoRESUMO
PURPOSE: The advantages of biological meshes for ventral hernia repair are still under debate. Given the high financial cost, the proper indications for biological meshes should be clarified to restrict their use to properly selected patients. METHODS: A retrospective database was instituted to register all cases of abdominal wall defect treated with biological meshes from 1/2010 to 3/2016. RESULTS: A total of 227 patients (mean age: 64 years) whose ventral abdominal defects were reconstructed with a biological mesh were included in the study. Patients were divided according to the 2010 four-level surgical-site complication risk grading system proposed by the Ventral Hernia Working Group (VHWG): Grade 1 (G1, 12 cases), Grade 2 (G2, 68 cases), Grade 3 (G3, 112 cases), and Grade 4 (G4, 35 cases). The surgical site complication rate was higher in patients with one or more risk factors (33.6% vs 19% in patients with no risk factors) (P = 0.68). Statistically significant risk factors associated with the onset of one or more postoperative surgical site complications included: diabetes, coronary artery disease, immunosuppression, and obesity. Recurrence was more common in patients with surgical site complications and mainly associated with infection (38.9%) and wound necrosis (44.4%), and in cases of inlay positioning of the mesh (36%). CONCLUSIONS: Due to their high costs, biological mesh should not be used in G1 patients. In infected fields (G4), they should only be used if no other surgical solution is feasible. There is a clear need to prospectively evaluate the performance of biological meshes.
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Bioprótese , Hérnia Ventral/cirurgia , Herniorrafia , Telas Cirúrgicas , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Recidiva , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.
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Fístula Anastomótica/epidemiologia , Colectomia/métodos , Colo Transverso/cirurgia , Neoplasias do Colo/cirurgia , Tempo de Internação/estatística & dados numéricos , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Colo Transverso/patologia , Neoplasias do Colo/patologia , Intervalo Livre de Doença , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de TempoRESUMO
BACKGROUND: Short-term results of gastric cancer surgery vary remarkably worldwide, and international surgical quality criteria are urgently needed. To contribute to defining these criteria, we reviewed short-term results of gastrectomy for gastric cancer in three centers of the Italian Research Group for Gastric Cancer, with an average of 24.7, 29.5, and 18 gastrectomies per year. METHODS: Between 1988 and 2002, 1,032 patients underwent gastrectomy for gastric cancer in Verona, Siena, and Padua. D1, D2, and D3 lymphadenectomy were performed, respectively, in 228, 584, and 220 cases. RESULTS: The median number of retrieved lymph nodes was 14 (interquartile range 9-18.75) after D1, 29 (21-38) after D2, and 46.5 (37-57) after D3. Fewer than 15 nodes were retrieved in 54.5%, 6.2%, and 1.4% of cases undergoing, respectively, D1, D2, and D3. Adjacent organ removal was rare during D1 (splenectomy: 6.1%, splenopancreasectomy: 1.8%), and quite common during D3 (11.4%, 11.4%). Forty patients (3.9%) died postoperatively. Neither postoperative morbidity nor mortality was significantly associated with extension of lymphadenectomy. CONCLUSION: We conclude that at least D2 lymphadenectomy is necessary to achieve adequate disease staging (>or=15 nodes retrieved). Spleen and pancreas tail are more frequently removed during D3, but this removal is not associated with higher postoperative morbidity or mortality.
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Gastrectomia , Neoplasias Intestinais/cirurgia , Qualidade da Assistência à Saúde , Neoplasias Gástricas/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Neoplasias Intestinais/mortalidade , Neoplasias Intestinais/patologia , Itália/epidemiologia , Excisão de Linfonodo , Linfonodos/patologia , Linfonodos/cirurgia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Fatores de Risco , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Taxa de Sobrevida , Adulto JovemRESUMO
Endoscopic submucosal dissection (ESD) represents the standard of care for early gastric cancer in Eastern countries. Nevertheless, in the West, this procedure is not widespread. Aim of the study was to confirm the feasibility and the efficacy of ESD in the West. A total of 60 ESD were performed between January 2005 and December 2014 by two expert endoscopists. The analysis, based on a retrospective collected database, was conducted by dividing the study period in three subgroups. Clinical and technical outcomes have been compared. Rates of complete, curative and en bloc resection did not significantly change among the study periods. Three cases of perforation occurred (5%), one in each period. The operation time significantly decreased from the second to the third period (p < 0.001). When adjusting for gender, tumor size and site in multivariable analysis, operation time decreased by nearly 90 min from the first to the second period, and by more than 3 h from the first to the last period. The median follow-up was 33 months. No cases of local or lymphnodal recurrence were detected during the study period. One patient presented a synchronous lesion, whilst four metachronous lesions have been discovered after a median follow-up of 11 months. Our experience supports the feasibility and safety of ESD in the West, if an adequate learning curve is accomplished. Long-term outcomes are comparable to the Eastern series.
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Ressecção Endoscópica de Mucosa , Neoplasias Gástricas/cirurgia , Idoso , Idoso de 80 Anos ou mais , Medicamentos Biossimilares , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Segurança , Fatores de Tempo , Resultado do TratamentoRESUMO
AIM: Extramammary Paget's disease is a rare neoplastic condition, often associated with a synchronous or metachronous underlying skin or visceral malignancies. The aim of this study was to evaluate retrospectively the results we got in 5 cases of perianal Paget's disease and to revise what literature have reported about this issue. PATIENTS AND METHODS: Five patients with perianal EMPD were consecutively treated in our Division between March 1996 and December 2006. In 3 cases the disease was limited to the epidermidis, in one case with multiple recurrences there was dermal infiltration, and one patient had a low rectal adenocarcinoma with pagetoid phenomenon. The surgical treatment we performed in all patients was a wide perianal excision, followed by reconstruction with cutaneous grafts; the resection of rectal adenocarcinoma was carried out using the transanal approach. In two cases we performed a temporary stoma with the sigmoid colon to help the wound healing. RESULTS: We didn't record any complication neither postoperative nor at long time. Two patients developed a local recurrence, but none of our patients showed distant metastases. Four patients are alive and free from disease and one, who developed a multiple local recurrences, died for heart failure. DISCUSSION: The studies available in literature clearly distinguish between a primary EMPD (intraepidermal/intradermal) and secondary disease which is associated with anorectal adenocarcinomas and is thought to be a pagetoid phenomenon, while few informations can derive from those cases in which the disease is associated with an underlying cutaneous adnexal carcinoma. Disease tend to relapse even after a radical surgery and can have metastatic spread, also in intraepidermal form. CONCLUSIONS: Perianal EMPD is a complex disease, difficult to recognize and the association with synchronous or metachronous malignancies imposes long term clinical and instrumental follow up.