Estudio comparativo entre la gastrectomía total y subtotal en el cáncer distal de estómago: metaanálisis de estudios prospectivos y retrospectivos / Comparative study between total and subtotal gastrectomy for distal gastric cancer: Meta-analysis of prospective and retrospective studies

El tipo de gastrectomía, total (GT) o distal (GD), en el cáncer gástrico medio o distal no está claramente consensuada, sobre todo cuando es indiferenciado o difuso de Lauren. Pretendemos en este metaanálisis definir en términos de supervivencia y morbimortalidad cuál de las 2 técnicas debiera ser recomendada. Se han incluido trabajos prospectivos y retrospectivos que comparen ambas técnicas hasta un total de 6.303 pacientes (3.641 GD y 2.662 GT). La GD se asoció de forma significativa con menos complicaciones, menos fístulas anastomóticas y menos mortalidad peroperatoria. El número de ganglios en la GD fue significativamente menor, pero siempre por encima de 15. Por último, la supervivencia a 5 años de la GD fue también superior. Por tanto, la GD, siempre que se obtenga un margen de seguridad e independientemente del tipo histológico, debe efectuarse en la cirugía de cáncer distal de estómago

There is no clear agreement on the type of gastrectomy to be used (either total [TG] or distal [DG]) in middle or distal gastric cancer, especially when it is undifferentiated or Lauren diffuse type. In this meta-analysis, we intend to define which of the 2 techniques should be recommended, based on survival, morbidity and mortality rates. Prospective and retrospective studies comparing both techniques have been included for a total of 6303 patients (3,641 DG and 2,662 TG). DG was significantly associated with fewer complications, fewer anastomotic fistulae, and less perioperative mortality. The number of lymph nodes in DG was significantly lower, but always above 15. Finally, even the 5-year survival of DG was also higher. Therefore, DG, as long as a safety margin is obtained and regardless of the histological type, should be performed in surgery for distal stomach cancer

Comparative study between total and subtotal gastrectomy for distal gastric cancer: Meta-analysis of prospective and retrospective studies. / Estudio comparativo entre la gastrectomía total y subtotal en el cáncer distal de estómago: metaanálisis de estudios prospectivos y retrospectivos.

There is no clear agreement on the type of gastrectomy to be used (either total [TG] or distal [DG]) in middle or distal gastric cancer, especially when it is undifferentiated or Lauren diffuse type. In this meta-analysis, we intend to define which of the 2techniques should be recommended, based on survival, morbidity and mortality rates. Prospective and retrospective studies comparing both techniques have been included for a total of 6303 patients (3,641 DG and 2,662 TG). DG was significantly associated with fewer complications, fewer anastomotic fistulae, and less perioperative mortality. The number of lymph nodes in DG was significantly lower, but always above 15. Finally, even the 5-year survival of DG was also higher. Therefore, DG, as long as a safety margin is obtained and regardless of the histological type, should be performed in surgery for distal stomach cancer.

Hartmann's procedure for obstructive carcinoma of the left colon and rectum: a comparative study with one-stage surgery.

INTRODUCTION AND OBJECTIVES: Despite the criticisms from prestigious expert committees, a high percentage of surgeons continue to use, as the technique-of-choice, Hartmann's procedure for acute malignant intestinal obstruction of the distal colon and rectum, without faecal peritonitis. We have reviewed our results with this technique and compared them with other series of patients in the literature undergoing one-stage surgery (resection with primary anastomosis or sub-total colectomy). MATERIAL AND METHODS: A retrospective and descriptive study using clinical histories and, from which, the variables studied were: median hospitalisation stay, morbido-mortality and reconstruction index. RESULTS: Included in the analysis were 44 patients (24 male; 20 female) with an age range between 37 and 87 years (median age: 67.04 years). The median hospitalisation stay was 15.59 days (range: 8-39). In the 10 patients undergoing reconstruction this was 12.8 days (range: 10-17). The overall stay, therefore, was 28.39 days. The median stay in the series of patients having one-stage surgery was 13.9 days. The morbidity using Hartmann's procedure was 43.18% (19/44) and, in the patients with reconstruction, 40% (4/10). The morbidity in the literature series with one-stage surgery was 22.53%. Mortality in our study was 0%. The mortality in the 16 cases from the literature was close to 5%, although in 3 of the studies this was also 0%. The percentage undergoing reconstruction was 22.72% (10 cases). The median age in the non-reconstructed patients was 71.42 years (range: 46-87) compared to a median age of 52.6 (range 37-67) in the group with reconstruction (p < 0.001). The percentages undergoing reconstruction, according to tumour stage, were Dukes B: 36.84%; Dukes C: 23.07%; Dukes D: 0% (p < 0.001). The median waiting-time for a reconstruction was 15.73 months (range: 8-33). CONCLUSIONS: Comparisons of our results with the outcomes in the series of patients in the literature with one-stage surgery indicate that "one-stage surgery" is the more suitable but, however, with two conditions: a sufficient command of the technique so as to minimise complications and a strict patient selection, with the Hartmann's procedure being retained for patients with high anaesthesia risk.

Metástasis hepáticas de origen colorrectal: ¿es posible la cirugía basada en la mejor evidencia clínica? / Liver metastases from colorectal cancer. Is the practice of surgery based on the best clinical evidence possible?

El único tratamiento curativo para las metástasis hepáticas de origen colorrectal es la cirugía. Los estudios que así lo avalan, sin embargo, son retrospectivos. Esta ausencia de evidencia clínica de grado I ha impulsado un fuerte deseo por identificar aquellos factores asociados a un índice mayor de recurrencia, e incluso agruparlos en forma de escalas clínicas (asignando a cada factor de mal pronóstico un punto), en las que una mayor puntuación se asocia con una peor supervivencia. En esta revisión discutimos todos ellos, sin olvidar otras alternativas terapéuticas que mejoran el índice de resecabilidad. A continuación, repasamos todos los estudios prospectivos aleatorizados publicados sobre este tema, los cuales, mayoritariamente, se centran en la quimioterapia adyuvante a la cirugía curativa con márgenes negativos, con el fin de validarla o rechazarla. Finalmente, incluimos el algoritmo de actuación de la Universidad de California, San Francisco, en la cirugía de las metástasis hepáticas de origen colorrectal (AU)

To date, surgical resection remains the only curative treatment for liver metastases from colorectal cancer. However, the evidence supporting this treatment is based on retrospective studies. The lack of level I clinical evidence has stimulated strong interest in identifying the factors predictive of recurrence, and even to use them to create clinical risk scores (assigning one point to each factor for poor prognosis), in which a higher score indicates a poorer prognosis. In the present review, we discuss all these factors, as well as the therapeutic alternatives that improve local disease control. Next, we review all the prospective randomized studies published on this topic, which mainly focus on adjuvant chemotherapy associated with curative surgery with negative margins, with the aim of validating or rejecting this treatment. Lastly, we include the algorithm of the University of California at San Francisco for surgery in liver metastases from colorectal cancer (AU)

Hartmann's procedure for obstructive carcinoma of the left colon and rectum: a comparative study with one-stage surgery

Introducción y objetivos. Un número elevado de cirujanos continúa empleando como técnica de elección la intervención de Hartmann en la obstrucción intestinal aguda maligna de colon distal al ángulo esplénico, sin peritonitis fecaloidea, a pesar de las críticas desde las unidades coloproctológicas de prestigio. Nos proponemos revisar nuestros resultados con esta técnica y compararlos con los de otras series con cirugía en un tiempo (resección y anastomosis primaria y colectomía subtotal). Material y métodos. Estudio retrospectivo y descriptivo sobre historias clínicas. Las variables estudiadas son: estancia media, morbimortalidad e índice de reconstrucción. Resultados. Cuarenta y cuatro pacientes (24 hombres y 20 mujeres) forman parte del estudio, con edades comprendidas entre 37 y 87 años (media 67,04). La estancia media hospitalaria fue de 15,59 días (rango: 8-39). En los 10 pacientes reconstruidos la estancia fue 12,8 (rango: 10-17). La estancia acumulada, por tanto, fue 28,39 días. La estancia media de las series consultadas con cirugía en un tiempo es de 13,9 días. El porcentaje de complicaciones en la operación de Hartmann fue del 43,18% (19/44) y en la reconstrucción siguiente del tránsito fue del 40% (4/10). La morbilidad media de las series consultadas en un tiempo es del 22,53% La mortalidad global de nuestra serie fue del 0%. La mortalidad media de las 16 series consultadas es ligeramente superior al 4%, aunque en 3 de ellas fue también del 0%. El porcentaje de reconstrucción fue del 22,72% (10 casos). La media de edad en los pacientes no reconstruidos fue 71,42 años (rango: 46-87), frente a 52,6 (rango: 37-67) en el grupo de los reconstruidos (p < 0,001). El porcentaje de reconstrucción según el estadio tumoral fue: estadio B el 36,84%, C el 23,07% y D el 0% (p < 0,001). El tiempo medio de espera antes de la reconstrucción fue 15,73 meses (rango: 8-33). Conclusiones. El análisis comparativo de nuestros resultados con los propios de las series de cirugía en un tiempo nos invita a aconsejar esta última como la más idónea, aunque siempre bajo dos condiciones: un dominio de su técnica, para minimizar complicaciones, y una rígida selección de los pacientes, procurando la técnica de Hartmann para los más deteriorados

Introduction and objectives. Despite the criticisms from prestigious expert committees, a high percentage of surgeons continue to use, as the technique-of-choice, Hartmann's procedure for acute malignant intestinal obstruction of the distal colon and rectum, without faecal peritonitis. We have reviewed our results with this technique and compared them with other series of patients in the literature undergoing one-stage surgery (resection with primary anastomosis or sub-total colectomy). Material and methods. A retrospective and descriptive study using clinical histories and, from which, the variables studied were: median hospitalisation stay, morbido-mortality and reconstruction index. Results. Included in the analysis were 44 patients (24 male; 20 female) with an age range between 37 and 87 years (median age: 67.04 years). The median hospitalisation stay was 15.59 days (range: 8-39). In the 10 patients undergoing reconstruction this was 12.8 days (range: 10-17). The overall stay, therefore, was 28.39 days. The median stay in the series of patients having one-stage surgery was 13.9 days. The morbidity using Hartmann's procedure was 43.18% (19/44) and, in the patients with reconstruction, 40% (4/10). The morbidity in the literature series with one-stage surgery was 22.53%. Mortality in our study was 0%. The mortality in the 16 cases from the literature was close to 5%, although in 3 of the studies this was also 0%. The percentage undergoing reconstruction was 22.72% (10 cases). The median age in the non-reconstructed patients was 71.42 years (range: 46-87) compared to a median age of 52.6 (range 37-67) in the group with reconstruction (p < 0.001). The percentages undergoing reconstruction, according to tumour stage, were Dukes B: 36.84%; Dukes C: 23.07%; Dukes D: 0% (p < 0.001). The median waiting-time for a reconstruction was 15.73 months (range: 8-33). Conclusions. Comparisons of our results with the outcomes in the series of patients in the literature with one-stage surgery indicate that "one-stage surgery" is the more suitable but, however, with two conditions: a sufficient command of the technique so as to minimise complications and a strict patient selection, with the Hartmann's procedure being retained for patients with high anaesthesia risk

[Liver metastases from colorectal cancer. Is the practice of surgery based on the best clinical evidence possible?]. / Metástasis hepáticas de origen colorrectal: es posible la cirugía basada en la mejor evidencia clínica?

To date, surgical resection remains the only curative treatment for liver metastases from colorectal cancer. However, the evidence supporting this treatment is based on retrospective studies. The lack of level I clinical evidence has stimulated strong interest in identifying the factors predictive of recurrence, and even to use them to create clinical risk scores (assigning one point to each factor for poor prognosis), in which a higher score indicates a poorer prognosis. In the present review, we discuss all these factors, as well as the therapeutic alternatives that improve local disease control. Next, we review all the prospective randomized studies published on this topic, which mainly focus on adjuvant chemotherapy associated with curative surgery with negative margins, with the aim of validating or rejecting this treatment. Lastly, we include the algorithm of the University of California at San Francisco for surgery in liver metastases from colorectal cancer.