Management of Patients with Gastric or Gastroesophageal Junction Cancer: From Theory to Integrated Clinical Path- ways Implementation in the Real World.

Introduction: Best care of esophagogastric junction and gastric cancer (EGC) requires a complex, timely interaction between members of a multi-disciplinary team (MDT). An integrated clinical pathway (ICP) is necessary to achieve this goal as well as the implementation of its use in daily practice. The objective of this study was to elaborate on an integrated clinical pathway for the multi-disciplinary management of ECG. Authors also put in act an implementation program to improve adherence to guidelines thought an ICP. Method: This prospective work carried out by a multi-institutional MDT in Italy identified expert panel extracted relevant recommendations and/or statements from published papers and guidelines obtaining a set of crucial interventions employed the Estimate-Talk-Estimate method. A flow-chart diagram was elaborated to elicit the process at a glance. The primary outcome measure was the elaboration of an ICP with a high consensus rate also reported as a snapshot diagram and its implementation in daily clinical practice. An accredited certification body agency validated results, and an implementation process was started in several hospitals known to treat ECG. Results: A methodologist aggregated a multi-disciplinary panel of experts from different institutions. The panel elaborated a flow-chart diagram with crucial intervention highlight and connecting lines, as well as outcome measures. An accredited certification body agency validated the entire process, representing the basis for empowerment and implementation among patients and oncological professionals in various hospitals. Conclusion: The multi-disciplinary and multi-institutional expert panel successfully elaborated on a validated ICP for all stages ECG. An in-hospital implementation program has been programmed.

Effects of biliopancreatic diversion on diurnal leptin, insulin and free fatty acid levels.

BACKGROUND: Free fatty acid (FFA) levels are raised in obesity as a consequence of increased production and reduced clearance. They may link obesity with insulin resistance. Bariatric surgery can result in considerable weight loss and reduced insulin resistance, but the mechanism of action is not well understood. Although drugs such as metformin that lower insulin resistance can contribute to weight loss, a better understanding of the links between obesity, weight loss and changes in insulin resistance might lead to new approaches to patient management. METHODS: Variations in circulating levels of leptin, insulin and FFAs over 24 h were studied in severely obese (body mass index over 40 kg/m(2) ) women before and 6 months after biliopancreatic diversion (BPD). Body composition was measured by dual-energy X-ray absorptiometry. A euglycaemic-hyperinsulinaemic clamp was used to assess insulin sensitivity. Levels of insulin, leptin and FFAs were measured every 20 min for 24 h. Pulsatile hormone and FFA analyses were performed. RESULTS: Among eight patients studied, insulin sensitivity more than doubled after BPD, from mean(s.d.) 39·78(7·74) to 96·66(27·01) mmol per kg fat-free mass per min, under plasma insulin concentrations of 102·29(9·60) and 93·61(9·95) µunits/ml respectively. The secretory patterns of leptin were significantly different from random but not statistically different before and after BPD, with the exception of the pulse height which was reduced after surgery. Both plasma insulin and FFA levels were significantly higher throughout the study day before BPD. Based on Granger statistical modelling, lowering of daily FFA levels was linked to decreased circulating leptin concentrations, which in turn were related to the lowering of daily insulin excursions. Multiple regression analysis indicated that FFA level was the only predictor of leptin level. CONCLUSION: Lowering of circulating levels of FFAs after BPD may be responsible for the reduction in leptin secretion, which in turn can decrease circulating insulin levels. Surgical relevance Insulin resistance is a common feature of obesity and type II diabetes. These patients are also relatively insensitive to the biological effects of leptin, a satiety hormone produced mainly in subcutaneous fat. Biliopancreatic diversion, a malabsorptive bariatric operation that drastically reduces circulating lipid levels, improves insulin resistance independently of weight loss. The mechanism of action, however, has still to be elucidated. This study demonstrated that normalization of insulin sensitivity after bariatric surgery was associated with a reduction in 24-h free fatty acid concentrations and changes in the pattern of leptin peaks in plasma. Bariatric surgery improves the metabolic dysfunction of obesity, and this may be through a reduction in circulating free fatty acids and modification of leptin metabolism.

Vacuum Assisted Closure (VAC) therapyTM as a swiss knife multi-tool for enteric fistula closure: tips and tricks: a pilot study.

OBJECTIVE: Enterocutaneous fistulas (ECFs) are an uncommon surgical problem, but they are characterized by a difficult management. Vacuum-assisted closure (VAC) therapy is a method utilized for chronic and traumatic wound healing. At first, VAC therapy had been contraindicated in the treatment of intestinal fistulas, but as time went by, VAC therapy revealed itself to be a "Swiss knife multi-tool". This paper presents some clinical cases of enterocutaneous (ECF) and enteroatmospheric fistulas (EAF) treated with VAC therapy™. MATERIALS AND METHODS: The history of 8 patients treated for complex fistulas was revised. Four of them presented with enterocutaneous and four with enteroatmospheric fistulas. All were treated with VAC therapy with variations elaborated to help in accelerated closure of intestinal wall lesions. RESULTS: Four out of four ECFs closed spontaneously. In the EAF group, in three cases the fistula turned slowly into an entero-cutaneous fistula, and in one out of four it closed spontaneously. The mean length of VAC therapy™ was 35.5 days and that of spontaneous closure was 36.4 days. CONCLUSIONS: The results of our study encourage the use of VAC therapy™ for the treatment of enterocutaneous fistulas. VAC therapy™ use has a double therapeutic value: (1) it promotes the healing of the skin and allows also the management of EAFs; (2) in selected cases, those in which it is possible to create a deep fistula tract ("well") it is possible to assist to a complete healing with closure of the ECFs.

Laparoscopic extraperitoneal colostomy in elective abdominoperineal resection for cancer: a single surgeon experience.

AIM: Parastomal herniation of end colostomies can be chronically debilitating for patients and a difficult problem to treat. To prevent parastomal hernia (PSH) formation an extraperitoneal colostomy (EPC) approach has been developed in open colorectal surgery and some studies have suggested a potential advantage to this approach. Here we describe our technique of laparoscopic extraperitoneal stoma formation and present our experience to date. METHODS: We performed a retrospective analysis of consecutive patients undergoing a laparoscopic abdominoperineal resection between March 1999 and March 2011. We performed the EPC technique as follows: under laparoscopic guidance, a smooth tip instrument was used to gently separate the peritoneum from the posterior aponeurotic plane to create an extraperitoneal tunnel running from the skin incision to the left flank of the abdominal cavity to join the previously dissected paracolic gutter. The colon was exteriorized and the position was checked to ensure the absence of torsion or kinking. RESULTS: Twenty-two patients underwent a standard laparoscopic abdominoperineal resection with total mesorectal excision. Colostomy was constructed extraperitoneally (EPC) or transperitoneally (TPC) in 12 and 10 patients respectively. There were five complications requiring operative intervention: two stomal necrosis and one surgical site infection in the TPC group and two small bowel occlusions in the EPC group. Four patients from the TPC group developed PSH at 24, 36, 48 and 72 months respectively while there were no cases of PSH in the EPC group. CONCLUSION: Extraperitoneal laparoscopic colostomy showed a potential reduction of PSH in our series of patients.

Multimedia manuscript. Thoracoscopic management of chylothorax after esophagectomy.

BACKGROUND: Chylothorax after esophagectomy is a potentially life-threatening complication, with a reported incidence rate of 1-4%. Two cases of postoperative chylothorax successfully managed thoracoscopically are reported. METHODS: In case 1, a 61-year-old man presenting with an adenocarcinoma of the lower esophagus underwent laparoscopic transhiatal esophagectomy after neoadjuvant chemotherapy. The thoracic duct was identified, and no obvious leaks were detected. The thoracic drain was removed on postoperative day (POD) 6, and chest X-rays were normal. The patient was discharged on POD 10. On POD 20, he was readmitted for acute cardiopulmonary distress. Computed tomography scan showed a massive right collection. After insertion of a chest tube, 8 l of chylous fluid were drained. Once hemodynamic stabilization had been established, the patient was scheduled for surgery. In case 2, a 54-year-old woman presenting with esophageal stenosis after caustic injury refractory to balloon dilation and stenting underwent esophagectomy. Mediastinal dissection was difficult due to fibrotic reaction. On POD 2, the patient presented with a massive chylothorax. In both cases, three trocars were inserted in the right pleural cavity. An incomplete lateral injury of the thoracic duct was found in case 1, and a complete transection proximal to the cervical anastomosis next to the left subclavian was found in case 2. Clips and sutures were used first to seal the duct. Fibrin glue was applied to reinforce the closure. A chest tube was left in place. RESULTS: The operative time was 60 min in case 1 and 55 min in case 2. The chylothorax did not recur, although the postoperative course was longer in case 2 due to associate comorbidities. CONCLUSIONS: The thoracic duct is exposed to injuries during esophagectomies, especially in cases of cancer and postcaustic injuries, leading to fibrotic reaction of the surrounding tissue. Early and delayed chylothorax can be managed efficiently by a thoracoscopic approach replicating the sealing techniques used in thoracotomy.

Single port laparoscopic cholecystectomy: which technique, which surgeon, for which patient? A study of the implementation in a teaching hospital.

BACKGROUND: Single port cholecystectomy is increasingly performed. This procedure can be challenging, and we lack factors predicting the operative difficulty. AIMS: To assess the role of surgeon experience and identify possible predictive factors of intraoperative difficulties. PATIENTS AND METHODS: Sixty-one selected patients were prospectively enrolled between January 2008 and August 2010. Six surgeons were involved (3 seniors, 3 juniors). Anthropometrics of the patients, types of ports, exposure methods and intraoperative data were recorded. Pain was assessed with the visual analogic scale at postoperative day 1 (POD 1 VAS). RESULTS: Fifty-eight patients with symptomatic gallstones and three with acute cholecystitis underwent single port cholecystectomy. The mean BMI, weight and height were 25.7 kg/m(2) (SD 4.45), 71.8 kg (SD 14.83) and 166 cm SD 0.07, respectively. Mean operative time was 68.4 min (SD 26.98). Anthropometrics had no influence on operative time. Senior surgeons performed more rapidly, but the difference was not significant. The overall mean POD 1 VAS was 2.26, (SD 1.81). The mean hospital stay was 2.22 days, (SD 0.9). No complications occurred. An additional exposure method was necessary in 19 procedures. This cluster presented a significantly higher operating time (81.5 min, SD 31.69 vs. 62.7, SD 22.74; p = 0.01) and POD 1 VAS (1.92 vs. 3; p = 0.031). CONCLUSION: Single trocar cholecystectomy can be implemented safely in teaching hospitals. Anthropometrics are not predictive of operative difficulties. The need for additional exposure systems affects the operative time and pain negatively, reflecting greater technical difficulties. Research to optimize instruments may help to solve these problems.