Preoperative and Postoperative Approaches to Gastroesophageal Cancer: What is All the Fuss About.

Gastroesophageal cancers carry poor prognoses, and are a leading cause of cancer-related morbidity and mortality worldwide. Even in those with resectable disease, more than half of patients treated with surgery alone experience disease recurrence. Multimodality approaches using preoperative and postoperative chemotherapy and/or radiotherapy have been established, resulting in incremental improvements in outcomes. Globally, there is no standardized approach, and treatment varies with geographic location. The question remains of how to select the optimal perioperative treatment that will maximize benefit for patients while avoiding toxicities from unnecessary therapies. This article reviews currently available evidence supporting preoperative and postoperative therapy in gastroesophageal cancers, with an emphasis on recent practice-changing trials and ongoing areas of investigation, including the role of immune checkpoint inhibition and biomarker-guided treatment.

Impact of adjuvant therapy in patients with a microscopically positive margin after resection for gastric and esophageal cancers.

BACKGROUND: A microscopically positive (R1) resection margin following resection for gastric and esophageal cancers has been documented to be a poor prognostic factor. The optimal strategy and impact of different modalities of adjuvant treatment for an R1 resection margin remain unclear. METHODS: A retrospective analysis was performed for patients with gastric and esophageal adenocarcinoma treated at the Princess Margaret Cancer Centre (PMCC) from 2006-2016. Electronic medical records of all patients with an R1 resection margin were reviewed. Kaplan-Meier and Cox proportional hazards methods were used to analyze recurrence free survival (RFS) and overall survival (OS) with stage and neoadjuvant treatment as covariates in the multivariate analysis. RESULTS: We identified 69 gastric and esophageal adenocarcinoma patients with a R1 resection. Neoadjuvant chemoradiation was used in 13% of patients, neoadjuvant chemotherapy in 12%, surgery alone in 75%. Margins involved included proximal in 30%, distal in 14%, radial in 52% and multiple margins in 3% of patients. Pathological staging showed 3% with stage I disease, 20% stage II and 74% stage III. Adjuvant therapy was given in 52% of R1 pts (28% CRT, 20% chemotherapy alone, 3% radiation alone, 1% reoperation). Median RFS was 14.1 months [95% confidence interval (CI), 11.1-17.2]. The site of first recurrence was 72% distant, 12% mixed, 16% locoregional alone. Median OS was 34.5 months (95% CI, 23.3-57.9) for all patients. There was no significant difference in RFS (adjusted P=0.26) or OS (adjusted P=0.83) comparing modality of adjuvant therapy. CONCLUSIONS: Most patients with positive margins after resection for gastric and esophageal cancer had advanced pathologic stage and prognosis was poor. Our study did not find improved RFS or OS with adjuvant treatment and only one patient had reresection. The main failure pattern was distant recurrence, suggesting that patients being considered for adjuvant radiotherapy (RT) should be carefully selected. Further studies are required to determine factors to select patients with good prognosis despite a positive margin, or those who may benefit from adjuvant treatment.

Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery.

This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.

Cette déclaration de consensus fait des recommandations pour la prescription d'analgésiques à la sortie de l'hôpital pour les patients adultes n'ayant jamais pris d'opiacés et qui subissent une intervention chirurgicale non urgente. Elle encourage les prestataires de soins de santé (chirurgiens, anesthésiologistes, infirmières et infirmiers, infirmières et infirmiers praticiens, équipes antidouleur, pharmaciens, professionnels de la santé et stagiaires) à (1) utiliser des traitements non opiacés et à réduire la prescription d'opiacés afin de réduire le nombre de pilules opiacées pouvant être détournées; et (2) à éduquer les patients, ainsi que leurs familles et soignants, sur les options de prise en charge de la douleur après l'opération afin d'optimiser la qualité des soins pour la douleur postopératoire.Ces recommandations s'appliquent aux patients adultes n'ayant jamais pris d'opioïdes et qui subissent une intervention chirurgicale non urgente. Cette déclaration de consensus est destinée à être utilisée par les prestataires de soins de santé impliqués dans la prise en charge des patients opérés et les soins qui leur sont apportés.Un processus Delphi modifié a été utilisé pour parvenir à un consensus sur les recommandations. Tout d'abord, les auteurs ont procédé à une de la portée de la littérature afin de déterminer les pratiques exemplaires actuelles et les lignes directrices existantes. À partir de la littérature disponible et de l'expertise des auteurs, une liste provisoire de recommandations a été créée. Ensuite, les auteurs ont demandé aux principales parties prenantes d'examiner et de commenter plusieurs versions préliminaires du document et d'assister à une réunion de consensus en personne. Le groupe des parties prenantes du processus Delphi modifié comprenait des chirurgiens, des anesthésiologistes, des résidents, des fellows, des infirmières et infirmiers, des pharmaciens et des patients. Après de multiples itérations, le document a été jugé complet. Les recommandations n'ont pas été notées car elles étaient fondées sur un consensus plutôt que sur des données probantes.

Multivisceral resections for gastrointestinal stromal tumors: are the risks justifiable?

BACKGROUND: Surgical resection is the cornerstone of treatment for non-metastatic gastrointestinal stromal tumors (GISTs). Multivisceral resection (MVR) for locally advanced tumors is often required to achieve negative margins. The purpose of this study was to review the peri-operative and long-term oncologic outcomes for patients who required MVR versus single-organ resection (SOR) for GISTs. METHODS: All patients who underwent treatment for GISTs at a tertiary cancer center between 2001 and 2011 were identified. Patient characteristics and clinical outcomes were compared using the chi-squared/Fisher's exact test and Student's t-test. Disease-free (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier product-limit method. RESULTS: 33 patients underwent MVR and 77 underwent SOR. Tumors in the MVR group were larger and had a higher mitotic index. MVR patients had longer operative times, greater operative blood loss and more peri-operative complications. There was no significant difference in the final margin status between the two groups (R0 resection: SOR 92.2%, MVR 81.8%, p = 0.1303). 5-year DFS was significantly lower in the MVR cohort (44.4% vs. 78.9%, p = 0.0090), but there was no difference in 5-year OS (80.2% vs. 90.5%, p = 0.2547). CONCLUSIONS: MVR patients had more aggressive tumors and more complications; however, there was no difference in 5-year OS between the MVR and SOR cohorts. These findings support the use of MVR in the appropriately selected patient. Further studies are necessary to fully define its clinical application.

The accuracy of three predictive models in the evaluation of recurrence rates for gastrointestinal stromal tumors.

BACKGROUND: Treatment decisions for gastrointestinal stromal tumors (GIST) are frequently guided by tumor characteristics. An accurate prediction of recurrence is important to determine the benefit from targeted therapy. Our goal was to compare the concordance of three validated risk stratification schemes with observed outcomes in patients undergoing resection for GISTs. METHODS: Patients who underwent surgery for GISTs from 2001 to 2011 at a tertiary centre were identified. Survival was evaluated using the Kaplan-Meier product-limit method. Cox proportional hazard models were used to obtain predicted recurrence for each system and concordance indices were calculated. RESULTS: Of 110 patients identified, 77 (70.0%) had surgery and 29 (26.4%) also received adjuvant therapy. The majority of patients had tumors that were very low (4.5%), low (32.7%), or intermediate (22.7%) in terms of malignant potential. R0 resection was achieved in 89.1% of cases. Observed 2-year and 5-year recurrence rates were significantly lower than those predicted by the Memorial Sloan Kettering Cancer Center nomogram (7.6% vs. 19.3% and 18.4% vs. 27.0%); however, it was the most favorable tool compared to the US National Institutes of Health (NIH)-consensus (P = 0.0017) and modified NIH-consensus (P < 0.001), with a concordance index of 0.811. CONCLUSION: Development of a novel predictive tool that includes additional prognostic factors may better stratify recurrence following resection for GIST.

Multidisciplinary cancer care: does it improve outcomes?

Multidisciplinary care has been advocated as a solution for increasingly complex treatment decisions in cancer patients. The impact of multidisciplinary care on patient survival has been studied, but evidence is limited by poor methodological quality. Lack of conclusive evidence for increased survival is balanced against improvements in quality of care, guideline adherence, reduction in wait times, and greater satisfaction for patients and care providers.

Current role of minimally invasive approaches in the treatment of early gastric cancer.

Despite declining incidence, gastric cancer remains one of the most common cancers worldwide. Early detection in population-based screening programs has increased the number of cases of early gastric cancer, representing approximately 50% of newly detected gastric cancer cases in Asian countries. Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis. Laparoscopic and robotic resections for early gastric cancer, including function-preserving resections, have propagated through advances in technology and surgeon experience. The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer.

Improving multidisciplinary cancer conferences: a population-based intervention.

BACKGROUND: Multidisciplinary cancer conferences (MCCs) facilitate the discussion of appropriate diagnostic and treatment options for an individual cancer patient. In 2007, a study conducted in Ontario found that 52 % of hospitals were able to provide access to MCCs. In 2006, Cancer Care Ontario published minimum standards for MCCs. A framework for measurement was developed to monitor MCCs at the hospital, regional, and provincial level. The objective of this study was to review the results from initial efforts to improve quality and access through a population-based intervention. METHODS: Data collection was completed prospectively between October to December in 2009, 2010, and 2011. A criterion satisfaction score (CSS) was developed on the basis of indicators including MCC frequency, type of patient case review, the presence of a chair and coordinator, and the attendance of appropriate medical staff members. For each hospital and region, the overall number of MCCs, patients discussed, and CSSs was calculated. RESULTS: Data were available from 13 of 14 regions in 2009 and all 14 regions in 2010 and 2011. The number of MCCs increased from 660 in 2009 to 798 in 2011 (p = 0.06). The number of patients discussed at MCCs increased from 4,695 in 2009 to 5,702 in 2011 (p = 0.22). The CSS scores across the regions improved significantly across 2009-2011 (p < 0.001). CONCLUSIONS: A population-based intervention has been associated with an improvement in access and quality of MCCs.

Processes of care in the multidisciplinary treatment of gastric cancer: results of a RAND/UCLA expert panel.

IMPORTANCE: There is growing interest in reducing the variations and deficiencies in the multidisciplinary management of gastric cancer. OBJECTIVE: To define optimal treatment strategies for gastric adenocarcinoma (GC). DESIGN, SETTING, AND PARTICIPANTS: RAND/UCLA Appropriateness Method involving a multidisciplinary expert panel of 16 physicians from 6 countries. INTERVENTIONS: Gastrectomy, perioperative chemotherapy, adjuvant chemoradiation, surveillance endoscopy, and best supportive care. MAIN OUTCOMES AND MEASURES: Panelists scored 416 scenarios regarding treatment scenarios for appropriateness from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate; 4 to 6, uncertain; and 7 to 9, appropriate. Agreement was reached when 12 of 16 panelists scored the scenario similarly. Appropriate scenarios agreed on were subsequently scored for necessity. RESULTS: For patients with T1N0 disease, surgery alone was considered appropriate, while there was no agreement over surgery alone for patients T2N0 disease. Perioperative chemotherapy was appropriate for patients who had T1-2N2-3 or T3-4 GC without major symptoms. Adjuvant chemoradiotherapy was classified as appropriate for T1-2N1-3 or T3-4 proximal GC and necessary for T1-2N2-3 or T3-4 distal GC. There was no agreement regarding surveillance imaging and endoscopy following gastrectomy. Surveillance endoscopy was deemed to be appropriate after endoscopic resection. For patients with metastatic GC, surgical resection was considered inappropriate for those with no major symptoms, unless the disease was limited to positive cytology alone, in which case there was disagreement. CONCLUSIONS AND RELEVANCE: Patients with GC being treated with curative intent should be considered for multimodal treatment. For patients with incurable disease, surgical interventions should be considered only for the management of major bleeding or obstruction.

Surgical management of gastric perforation in the setting of gastric cancer.

BACKGROUND: Gastric perforation is a rare presentation of gastric cancer and is thought to be a predictor of advanced disease and, thus, poor prognosis. Guidelines do not exist for the optimal management strategy. We aimed to identify, review, and summarize the literature pertaining to perforation in the setting of gastric cancer. METHODS: A qualitative, systematic review of the literature was performed from January 1, 1985, to January 1, 2010. Searches of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were performed using search terms related to gastric cancer surgery. Abstracts were examined by two independent reviewers and a standardized data collection tool was used to extract relevant data points. Summary tables were created. RESULTS: Nine articles were included. Perforation was reported to occur in fewer than 5% of gastric cancer patients. Preoperative diagnosis of a gastric cancer was rated and occurred in 14-57% of patients in the papers reviewed. Mortality rates for emergency gastrectomy ranged from 0 to 50% and for simple closure procedures the rates ranged from 8 to 100%. Patients able to receive an R0 gastrectomy demonstrated better long-term survival (median 75 months, 50% 5-year) compared with patients who had simple closure procedures. CONCLUSIONS: Gastric cancer patients presenting with a gastric perforation demonstrate improved overall survival with an R0 resection; however, implementation of this management technique is complicated by infrequent preoperative gastric cancer diagnosis, and inability to perform an oncologic resection due to patient instability and intra-abdominal contamination.

A systematic review of spleen and pancreas preservation in extended lymphadenectomy for gastric cancer.

BACKGROUND: The overall prognosis and survival of patients with advanced gastric cancer are generally poor. Extended lymphadenectomy is recommended for patients with advanced gastric cancer; however, splenectomy and distal pancreatectomy performed with an extended lymph node dissection may be associated with increased morbidity and mortality. METHOD: Electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1 January 1998 to 31 December 2009. Studies on gastric carcinoma investigating extended lymphadenectomy with splenectomy and/or pancreaticosplenectomy that reported data on surgical outcomes or survival were selected. RESULTS: Forty studies were included in this review. Decreased complication rates were demonstrated with spleen preservation in two prospective studies and three retrospective studies, and with pancreas preservation in five retrospective studies. No randomized controlled trial showed survival benefit or detriment for preservation of spleen or pancreas in extended lymphadenectomy. Improved survival was demonstrated with spleen preservation in two prospective and eight retrospective studies, and with pancreas preservation in one prospective and four retrospective studies. CONCLUSIONS: Preservation of the spleen and pancreas during extended lymphadenectomy for gastric cancer decreases complications with no clear evidence of improvement or detriment to overall survival.

Multivisceral resection for gastric cancer: a systematic review.

BACKGROUND: The overall prognosis and survival of patients with advanced gastric cancer is generally poor. One of the most powerful predictors of outcomes in gastric cancer surgery is an R0 resection. However, the extent of the required surgical resection and the additional benefit of multivisceral resection (MVR) are controversial. METHODS: Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. All search titles and abstracts were independently rated for relevance by a minimum of two reviewers. RESULTS: Seventeen studies were included in this review. Among the 1343 patients who underwent MVR, overall complication rates ranged from 11.8 to 90.5%. Perioperative mortality was found to be 0-15%. Pathological T4 disease was confirmed in 28.8-89% of patients. R0 resection and extent of nodal involvement were important predictors of survival in patients undergoing MVR. Patient outcomes may also be affected by the number of organs resected. CONCLUSIONS: Gastrectomy with MVR can be safely pursued in patients with locally advanced gastric cancer to achieve an R0 resection. MVR may not be beneficial in patients with extensive nodal disease.

Perioperative supplemental oxygen in colorectal patients: a meta-analysis.

BACKGROUND: Perioperative supplemental oxygen has been proposed to decrease the incidence of surgical site infection (SSI) in colorectal surgery. A number of randomized controlled trials (RCTs) have been reported with inconsistent results. In addition, relevant clinical outcomes other than SSIs have been collected in these studies and have been equivocal. A meta-analysis of RCTs was performed to elucidate the effects of perioperative supplemental oxygen in colorectal surgery on SSI incidence, mortality, ICU admission, and length of stay. MATERIALS AND METHODS: A literature search of MEDLINE, PubMed, EMBASE, the Cochrane Library, and the Cochrane Clinical Trials Registry was performed in duplicate. In addition, bibliographic searches were performed, and experts were contacted for unpublished data. RCTs involving colorectal patients that included perioperative supplemental oxygen as a treatment arm and defined SSI as an outcome were included. RESULTS: Five studies met inclusion criteria. Using a random-effects model, perioperative supplemental oxygen did not significantly reduce SSIs (OR = 0.69, 95% CI [0.43, 1.10], P = 0.12). However, a significant mortality benefit was observed (OR = 0.18, 95% CI [0.05, 0.69], P = 0.01). There was no significant difference in the rate of ICU admission or length of stay. Tests of heterogeneity were performed, and significant heterogeneity was only present with respect to length of stay. CONCLUSIONS: Perioperative supplemental oxygen in colorectal surgery does not significantly reduce SSI. However, supplemental oxygen appears to confer a mortality benefit, a previously unreported finding. Further RCTs are required to confirm these conclusions.

Microscopic colitis: a review for the surgical endoscopist.

Microscopic colitis (MC) is an inflammatory condition of the colon distinct from Crohn disease or ulcerative colitis that can cause chronic diarrhea as well as cramping and bloating. Although it was first described 30 years ago, awareness of this entity as a cause of diarrhea has only become more widespread recently. Up to 20% of adults with chronic diarrhea who have an endoscopically normal colonoscopy may have MC. Endoscopic and radiological examinations are usually normal, but histology reveals increased lymphocytes in the colonic mucosa, which typically cause watery nonbloody diarrhea. Treatment is initially supportive but can include corticosteroids and immunomodulatory therapy for resistant cases. Since surgeons perform a large number of colonoscopies and sigmoidoscopies to assess diarrhea, it is important to be aware of this disease and to look for it with mucosal biopsy in appropriate patients.