Oncological Adequacy of Laparoscopic Surgery for Bulky Gastric Cancer: Results of a Western Single-Center Series.

BACKGROUND: Gastric cancer is increasing worldwide and one million new cases were estimated globally in 2020. Use of the laparoscopic approach is increasing especially for subtotal gastrectomy. However, to date, solid data on locally advanced bulky tumors are lacking. The aim of this study is to assess the role of laparoscopic surgery in bulky gastric tumors. METHODS: We performed an observational retrospective single-center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, intra-operative data, peri-operative data, and pathological data. Statistical analysis was conducted, including descriptive statistics and chi-squared test, to analyze the differences between categorical variables. RESULTS: O the 116 patients who underwent gastric surgery, 49 patients were included in the study protocol. All patients had bulky gastric tumors. Eighteen patients underwent laparoscopic gastrectomy and 31 open gastrectomy. The median number of lymph nodes removed was 28.5 (15-46) in the laparoscopic group and 23.05 (6-62) in the open group (p = 0.04). In total, 5.6% of patients of the laparoscopic group had <16 lymph nodes harvested and 35.5% in the open group (p = 0.035). No statistical differences were found between the open and laparoscopic groups in terms of surgical margins (p = 0.69). CONCLUSIONS: Laparoscopic surgery is still a subject of debate in locally advanced bulky gastric cancer. Limited data are available concerning Western patients. This study showed superiority in terms of the quality of lymphadenectomy and non-inferiority in terms of radical resection margins.

Low Anterior Resection Syndrome (LARS) after Surgery for Rectal Cancer: An Inevitable Price to Pay for Survival, or a Preventable Complication?

BACKGROUND: Rectal cancer is frequent and often treated with sphincter-saving procedures that may cause LARS, a syndrome characterized by symptoms of bowel disfunction that may severely affect quality of life. LARS is common, but its pathogenesis is mostly unknown. The aim of this study is to assess the incidence of LARS and to identify potential risk factors. METHODS: We performed an observational retrospective single center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, and intra- and peri-operative data. Statistical analysis was conducted, including descriptive statistics and multivariate logistic regression to identify independent risk factors. RESULTS: Total LARS incidence was 31%. Statistically significant differences were found in tumor distance from anal verge, tumor extension (pT and diameter) and tumor grading (G). Multivariate analysis identified tumor distance from anal verge and tumor extension as an independent predictive factor for both major and total LARS. Adjuvant therapy, although not significant at univariate analysis, was identified as an independent predictive factor. Time to stoma closure within 10 weeks seems to reduce incidence of major LARS. CONCLUSIONS: bold LARS affects a considerable portion of patients. This study identified potential predictive factors that could be useful to identify high risk patients for LARS.

Laparoscopic versus open distal gastrectomy for locally advanced gastric cancer in middle-low-volume centers in Western countries: a propensity score matching analysis.

BACKGROUND: Gastrectomy with D2 lymphadenectomy is the standard treatment for patients with resectable gastric cancer. Laparoscopic distal gastrectomy (LDG) is routinely performed for early gastric cancer, and its indications are increasing even for locally advanced gastric cancer. The aim of this study is to compare two middle-low-volume centers in Western countries experience on LDG versus open distal gastrectomy (ODG) for locally advanced gastric cancer in terms of surgical and oncological outcomes. METHODS: We reviewed the data of 123 consecutive patients that underwent LDG and ODG with D2 lymphadenectomy between 2009 and 2014. Among them, 91 were eligible for inclusion (46 LDG and 45 ODG). After propensity score matching analysis, using a 1:1 case-control match, 34 patients were stratified for each group. RESULTS: The mean operative time was significantly longer in the LDG group (257.2 vs. 197.2, p < 0.001). No differences were observed in terms of intraoperative blood loss, average number of lymph nodes removed, and lymph node metastases. The postoperative morbidity was comparable in the two groups. LDG group had a significant faster bowel canalization and soft oral intake (p < 0.001). The 5-year overall and disease-free survival were higher for patients treated by laparoscopy, but the post-hoc subgroups analysis revealed that the advantage of LDG was significant just in N0 and stage IB-II patients, whereas N+ and stage III patient's survival curves were perfectly superimposable. CONCLUSIONS: LDG for locally advanced gastric cancer seems to be feasible and safe with surgical and long-term oncological outcomes comparable with open surgery, even in medium-low-volume centers.

Utility of intraoperative neuromonitoring in detecting recurrent nerve's anatomical anomalies during thyroidectomy.

Anatomical variations such as a non-recurrent laryngeal nerve (NRLN) are very rare (reported rates within 0.6-1% to the right side and only four cases to the left side) but they can lead to serious risk of nerve lesion during thyroidectomy. It is known that to prevent inferior laryngeal nerve lesions, it is mandatory to obtain a correct and wide exposure of the nerve during all kind of thyroid surgeries but in case of laryngeal nerve position anomalies, it is hard to achieve a safe nerve identification. Continuous intraoperative neuromonitoring (C-IONM) technology can detect the presence of NRLN. In this study we present seven cases of NRLN incidentally found during our last 10-year experience, in a total of 1074 procedures, including total thyroidectomy and lobectomy. Three out of seven cases were identified with the help of C-IONM. On the other hand, the other four cases of non-recurrent laryngeal nerve were identified during an extensive dissection of the thyroid lodge. We registered no nerve palsy in the group of patients who underwent surgery with the help of C-IONM, while we had two nerve palsies (out of four cases) in the group of patients without the help of C-IONM. In our experience we also registered a reduction of surgery time when we used the C-IONM. In our opinion C-IONM is a safe method to discover anatomical anomalies such as a non-recurrent laryngeal nerve and may help to reduce nerve palsy rate.