Recurrence Patterns and Long-term Results After Induction Chemotherapy, Chemoradiotherapy, and Curative Surgery in Patients With Locally Advanced Esophageal Cancer.

OBJECTIVE: The long-term follow up data of 2 prospective phase II trials is reported (NCT00072033, NCT00445861), which investigated neoadjuvant chemoradiation followed by surgery in patients with esophageal carcinoma. Postoperative complications as well as prognostic factors and patterns of relapse during long-term observation are shown. SUMMARY OF BACKGROUND DATA: Long-term follow-up is often missing in the complex setting of multimodal treatments of esophageal carcinoma; this leads to rather undifferentiated follow-up guidelines for this tumor entity. METHODS: In the first trial, patients received induction chemotherapy followed by chemoradiation and surgery. In the second trial, cetuximab was added to the same neoadjuvant treatment concomitant with induction chemotherapy and chemoradiation. RESULTS: Eighty-two patients underwent surgery; the median follow-up time was 6.8 and 6.4 years, respectively. Fifty-five percent were diagnosed with adenocarcinoma, 80% clinically node-positive, 68% received transthoracic esophagectomy, and 32% transhiatal or transmediastinal resection. Five patients died postoperatively in-hospital due to complications (6%). The median overall survival was 4.3 years, and the median event-free survival was 2.7 years. Patients with adenocarcinoma rarely relapsed after a 3-year event-free survival. Whereas patients with residual tumor cells after neoadjuvant therapy primarily experienced relapse within the first 2 postoperative years, this in contrast to several patients with complete remission who also experienced late relapses 4 years after surgery. CONCLUSION: After curative surgery in a multimodal setting, the histological type and the response to neoadjuvant therapy predicted the time frame of relapse; this knowledge may influence further follow-up guidelines for esophageal carcinoma.

Endoscopic resection with adjuvant chemo-radiotherapy for superficial esophageal squamous cell carcinoma: A critical review.

Radical esophagectomy with extended lymph node dissection is considered the standard of care in treatment of squamous cell carcinoma of esophagus with deep mucosal invasion (pT1a m3) or submucosal involvement (pT1b). However, despite the increasing use of minimally invasive approaches, it remains a major surgery associated with significant morbidities and even mortality risk. Endoscopic resection (ER) results in excellent local control in early superficial mucosal (pT1a) disease yet there is substantial risk of lymph node metastases in T1b disease. Therefore, ER followed by combined with chemo-radiotherapy (CRT) would potentially improve the outcome in pT1a m3 or pT1b disease and would be an attractive conservative alternative to esophagectomy. Retrospective series published so far have shown promising results for this combined treatment. Herein the current literature of the indications, treatment outcome and toxicities of this treatment strategy are discussed and critically reviewed.

Exclusive neoadjuvant chemotherapy in locally advanced resectable gastric and gastro-esophageal junction adenocarcinoma.

BACKGROUND: Perioperative chemotherapy improves the prognosis of patients with locoregionally advanced resectable gastric and gastro-esophageal junction adenocarcinoma. Nevertheless, only 50% of operated patients could receive the postoperative component chemotherapy. An exclusive preoperative chemotherapy is therefore an interesting strategy. We report the clinical course of patients with operable gastric and gastroesophageal junction adenocarcinoma treated with an intention of exclusive preoperative chemotherapy. METHODS: The medical records of all consecutive patients with an operable gastric or gastroesophageal junction adenocarcinoma and treated with an intention of exclusive preoperative chemotherapy were analysed. RESULTS: Between 1999 and 2014, 90 eligible patients were identified. Fifty-eight patients (64%) presented with clinical T3-T4 tumour and 63 (70%) had a lymph node involvement. Eighty (90%) patients were treated with 4 cycles of preoperative chemotherapy containing docetaxel, 5-fluorouracil (5FU) and a platinum salt. All patients had surgery with a D2 lymphatic dissection and R0 resection rates in 91% and 88% respectively. Median progression-free survival was 6.1 years (95% confidence intervals (CI): 1.6, NC) with median overall survival of 8.1 years (95% CI: 4.1, NC). CONCLUSION: Our study suggests that an exclusive neoadjuvant approach when associated with a D2 lymph node dissection in resectable gastric and gastro-esophageal junction adenocarcinoma appears a feasible strategy with encouraging survival.

[Management of peritoneal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy]. / Prise en charge de la carcinose péritonéale par chirurgie cytoréductive et chimiothérapie hyperthermique intrapéritonéale.

In 2016, peritoneal carcinomatosis can be considered as a chronic disease that can be treated and sometimes cured. Hyperthermic Intra PEritoneal Chemotherapy (HIPEC) is a procedure developed in the eighties. Combined with CytoReductive (CR) surgery, this protocol underwent a considerable expansion in Washington Cancer Institute. CR combined with HIPEC was demonstrated to be the only curative treatment for PseudoMyxoma Peritonei syndrome (PMP). It is actually approved in the management of peritoneal carcinomatosis of ovarian, colorectal, or peritoneal primitive (mesothelioma) origin but is still studied for gastric cancer. CR/HIPEC is associated with an important mortality and morbidity. This article takes stock of indications to CR/HIPEC.

Roux-en-Y gastric bypass for super obese patients: what approach?

BACKGROUND: Super obese (SO) patients with a Body Mass Index (BMI) ≥ 50 kg/m(2) still represent a real anesthesiological and surgical challenge. While the best procedure to perform in this population remains unclear, robotic technology has been proposed to accomplish Roux-en-Y gastric bypass (RYGB). The study aim is to report our experience of robotic RYGB for SO patients and to compare it with open and laparoscopic surgery. METHODS: From July 1997 to March 2014, all consecutive RYGB cases for SO patients were collected in a dedicated database and reviewed retrospectively. Two hundred and fourteen SO patients were operated on: 65 by a robotic approach (30.4%), 54 by a laparoscopic approach (25.2%), and 95 using an open approach (44.4%). Peri- and post-operative data were compared between the three approaches. RESULTS: There were more male patients in the robotic group, but with a slightly lower BMI. The operative time was longer for the robotic (+27 min) and laparoscopic (+21 min) groups in comparison with the open group (P < 0.05). Overall, there were less reoperations (P < 0.05) and a shorter hospital stay (P < 0.05) in the robotic group in comparison with other groups. Of note there was also a trend in favor of robotics with less conversions (P = 0.08) and less postoperative complications (P ≥ 0.05). CONCLUSIONS: Robotic RYGB can be performed safely in super obese patients with results that compare favorably with laparoscopic and open surgery. However, the robotic approach has a longer operative time. The exact role of robotics for super obese population needs to be clarified in larger and randomized trials before drawing definitive conclusions. Copyright © 2015 John Wiley & Sons, Ltd.

Twelve key nutritional issues in bariatric surgery.

In morbidly obese patients, i.e. body mass index ≥35, bariatric surgery is considered the only effective durable weight-loss therapy. Laparoscopic Roux-en-Y gastric bypass (LRYGBP), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS) are associated with risks of nutritional deficiencies and malnutrition. Therefore, preoperative nutritional assessment and correction of vitamin and micronutrient deficiencies, as well as long-term postoperative nutritional follow-up, are advised. Dietetic counseling is mandatory during the first year, optional later. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health. In this review, twelve key perioperative nutritional issues are raised with focus on LRYGBP and LSG procedures, the most common current bariatric procedures.

Laparoscopic versus robotic Roux-en-Y gastric bypass: lessons and long-term follow-up learned from a large prospective monocentric study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) has become the procedure of choice for the treatment of morbid obesity. Recently, several reports have shown the potential advantages of the robotic approach, notably by reducing complications. The aim of this study is to report our long-term experience with robotic Roux-en-Y gastric bypass (RYGB) and to compare outcomes with the laparoscopic approach. METHODS: From January 2003 to September 2013, 777 consecutive minimally invasive RYGB have been performed in our institution: 389 laparoscopically (50.1 %) and 388 robotically (49.9 %). During the study period, all the data regarding these consecutive RYGB has been prospectively collected in a dedicated database. RESULTS: While longer in duration compared to laparoscopy (+30 min; p=0.0001), the robotic approach had a lower conversion rate (0.8 vs. 4.9 %; p=0.0007), and less complications (11.6 % vs. 16.7 %; p=0.05), in particular, less gastrointestinal leaks (0.3 vs. 3.6 %; p=0.0009). There were also less early reoperations (1 vs. 3.3 %; p=0.05) and a shorter hospital stay in the robotic group (6.2 vs. 10.4 days; p=0.0001). There were no statistical differences between the early and the current robotic experience, except in operative time and hospital stay, which were shorter for the last 100 cases. Finally, the BMI loss was significantly higher in the laparoscopic group starting at the first post-operative year. CONCLUSIONS: Robotic RYGB is not only safe and feasible, but also a valid option in comparison to laparoscopy. At the cost of a longer operative time, we observed better short-term outcomes with the robotic approach.

Robotic revisional bariatric surgery: a comparative study with laparoscopic and open surgery.

BACKGROUND: Revisional bariatric procedures (RBP) can be technically challenging. While robotics might provide help for complex procedures, the study aim was to report our experience with robotic RBP. METHODS: From March 2000 to June 2013, 60 consecutive RBP (11 robotic, 21 laparoscopic, 28 open) have been prospectively entered into a dedicated database and reviewed retrospectively. Outcomes have been compared between the three approaches. RESULTS: The robotic group had fewer complications (0 vs. 14.3% for laparoscopy, vs. 10.7% for open; P > 0.05), but took longer than the other approaches (352 vs. 270 vs. 250 minutes respectively; P < 0.05). There were fewer conversions in the robotic group (0 vs. 14.3% for laparoscopy; P > 0.05), and a significantly shorter hospital stay (6 vs. 8 vs. 9 days, respectively). CONCLUSIONS: Robotic RBP is feasible and safe, but at the price of a longer operative time. The exact role of robotics remains yet to be defined for this indication in larger studies.

Plastic surgery improves long-term weight control after bariatric surgery.

BACKGROUND: The positive impact of Roux-en-Y gastric bypass on weight, comorbidities, and health-related quality of life is well documented. However, 50 percent of patients regain some of the lost weight after 2 years with Roux-en-Y gastric bypass and present a mean weight regain of 10 to 15 percent after several years, partially losing the previously obtained benefits. The authors hypothesize that body contouring could decrease weight regain, leading to better long-term weight control after Roux-en-Y gastric bypass. METHODS: In a matched control study, variations in weight for 98 patients with body contouring after Roux-en-Y gastric bypass were compared with those of 102 matched control patients with Roux-en-Y gastric bypass alone. Data were collected prospectively at 1, 3, 6, 9, 12, and 18 months after Roux-en-Y gastric bypass and then yearly until 7 years. RESULTS: After a massive mean weight loss of 45.2 kg during the first 2 years after Roux-en-Y gastric bypass, patients with Roux-en-Y gastric bypass alone presented a higher continuous mean weight regain than those with Roux-en-Y gastric bypass and body contouring (1.78 kg/year versus 0.51 kg/year of weight regain, respectively; p = 0.001). After 7 years, patients with Roux-en-Y gastric bypass presented significantly higher mean weight regain than patients with Roux-en-Y gastric bypass and body contouring (i.e., 10.8 percent versus 3.6 percent mean weight gain, respectively; p < 0.001). Netting out mean skin excision weight of 2.04 kg by body contouring, the weight regain was 22.9 kg for patients with Roux-en-Y gastric bypass alone and only 6.2 kg for those with Roux-en-Y gastric bypass and body contouring. CONCLUSIONS: The authors demonstrated that patients with body contouring present better long-term weight control after Roux-en-Y gastric bypass. Therefore, body contouring must be considered as a reconstructive operation in the treatment of morbid obesity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass.

BACKGROUND: Robotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy. METHODS: We collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases. RESULTS: Nine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000). CONCLUSIONS: Robotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complications.

[Tracheal replacement grafts: current options]. / Greffes trachéales: options actuelles.

A critical review of publications on tracheal reconstruction is presented. The extent of the resection defect in terms of horizontal circumference or longitudinal extension determines the difficulty of the reconstruction. To allow a valid comparison, a classification of tracheal defects is proposed. The reconstruction materials can be subdivided into synthetic grafts, autografts, allografts, and bioengineering constructs. Reconstruction of tracheal defects greater than half of the tracheal length was not possible until recently. Numerous publications on animal experimental techniques, and rare human case reports show few successful outcomes. During the last five years, new reconstructive options have emerged: autograft of composite flaps mimicking tracheal architecture and bioengineered tracheal constructs.

Survival predictors for second-line chemotherapy in Caucasian patients with metastatic gastric cancer.

PRINCIPLES: There are very limited data suggesting a benefit for second-line chemotherapy in advanced gastric cancer. Therefore, the number of patients who receive further treatment after failure of first-line chemotherapy varies considerably, ranging from 14% to 75%. In the absence of a demonstrated survival benefit of second-line chemotherapy, appropriate selection of patients based on survival predictors is essential. However, no clinico-pathologic parameters are currently widely adopted in clinical practice. We looked exclusively at Caucasian patients with metastatic gastric cancer treated with second-line chemotherapy to see if we could establish prognostic factors for survival. METHODS: This study retrospectively evaluated 43 Caucasian patients with metastatic gastric cancer treated with second-line chemotherapy at the Geneva University Hospital. Prognostic values of clinico-pathologic parameters were analysed by Cox regression for overall survival (OS). RESULTS: Univariate analysis found three variables to be associated with survival: progression-free survival (PFS) at first-line chemotherapy of more than 26 weeks (hazard ratio (HR) = 0.33, confidence interval (CI) 95% 0.16-0.65, p = 0.002), previous curative surgery (HR = 0.51, CI 95% 0.27-0.96, p = 0.04) and carcinoma embryonic antigen (CEA) >6.5 µg/l (HR = 1.97, CI 95% 1.06-3.65, p = 0.03). CONCLUSIONS: In line with published data, sensitivity to previous chemotherapy identifies Caucasian patients who will survive the longest following second-line chemotherapy. A low tumour burden and previous curative gastrectomy also seem to have a positive prognostic value.

Laparoscopic versus open sigmoid resection for diverticulitis: long-term results of a prospective, randomized trial.

BACKGROUND: Elective laparoscopic sigmoid resection for diverticulitis has proven short-term benefits, but little data are available from prospective randomized trials regarding long-term outcome, quality of life, and functional results. METHODS: Of 113 patients randomized to undergo laparoscopic (LAP) versus open (OP) sigmoid resection for diverticulitis, 105 (93%, LAP = 54, OP = 51) patients were examined and answered the Gastrointestinal Quality of Life Index (GIQLI) questionnaire, with a median follow-up of 30 (range, 9-63) months after surgery. RESULTS: Incisional hernias were detected in five (9.8%) patients in the OP group versus seven (12.9%) in the LAP group, P = 0.84). Overall satisfaction with the operation on a scale of 0 (very poor) to 10 (excellent) was 9 (range, 2-10) in the OP group versus 9 (range, 2-10) in the LAP group (P = 0.78). Median GIQLI score was 115 (range, 57-144) in the OP group versus 110 (range, 61-134) in the LAP group (P = 0.17). Overall satisfaction with the cosmetic aspect of the scar on a scale of 0 (very poor) to 10 (excellent) was 8 (range, 1-10) in the OP group versus 9 (range, 0-10) in the LAP group (P = 0.01). Finally, median hospital cost (including reoperations for hernias) was 11,606 (5,230-147,982) CHF in the LAP group versus 12,138 (6,098-39,786) CHF in the OP group (P = 0.47). CONCLUSIONS: Both open and laparoscopic approaches for sigmoid resection achieve good long-term results in terms of gastrointestinal function, quality of life, and patients' satisfaction. Significant long-term benefits of laparoscopic surgery are restricted to cosmetic (ClinicalTrials.gov protocol #NCT00453830).

Short versus long Roux-limb length in Roux-en-Y gastric bypass surgery for the treatment of morbid and super obesity: a systematic review of the literature.

Because of an important burden of disease, obesity is a major public health challenge in the twenty-first century. Where medico-psychological management has shown its limitations, bariatric surgery is now acknowledged as the most efficient therapy potentially offered to severely obese patients. Among other options, Roux-en-Y gastric bypass (RYGBP) is the most frequently performed procedure. The objective of this review is to systematically evaluate the effect of the Roux- (alimentary) limb length on postoperative weight loss after RYGBP in severely obese patients. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched using terms related to Roux-limb, gastric bypass and obesity. To be included, studies had to be either randomized controlled trials, quasi-randomized controlled trials or prospective cohort studies comparing a shorter to a longer Roux-limb. Studies were critically appraised with regard to methodological components. Eight studies were reviewed. Variations in methodology, operation design and outcome assessment among studies caused considerable clinical heterogeneity, preventing us from performing a meta-analysis. The overall quality was questionable, owing to lack of rigor in methodological components reporting. Results were heterogeneous, but we identified a trend supporting that the construction of a longer Roux-limb is more efficient in super obese patients. This review suggests that the tailoring of a longer Roux-limb might only be efficient in super obese patients. The overall limited quality of the included studies prompts to call for improvement in trial design in surgery.

Surgical outcome after docetaxel-based neoadjuvant chemotherapy in locally-advanced gastric cancer.

AIM: To investigate feasibility, morbidity and surgical mortality of a docetaxel-based chemotherapy regimen randomly administered before or after gastrectomy in patients suffering from locally-advanced resectable gastric cancer. METHODS: Patients suffering from locally-advanced (T3-4 any N M0 or any T N1-3 M0) gastric carcinoma, staged with endoscopic ultrasound, bone scan, computed tomography, and laparoscopy, were assigned to receive four 21 d/cycles of TCF (docetaxel 75 mg/m(2) day 1, cisplatin 75 mg/m(2) day 1, and fluorouracil 300 mg/m(2) per day for days 1-14), either before (Arm A) or after (Arm B) gastrectomy. Operative morbidity, overall mortality, and severe adverse events were compared by intention-to-treat analysis. RESULTS: From November 1999 to November 2005, 70 patients were treated. After preoperative TCF (Arm A), thirty-two (94%) resections were performed, 85% of which were R0. Pathological response was complete in 4 patients (11.7%), and partial in 18 (55%). No surgical mortality and 28.5% morbidity rate were observed, similar to those of immediate surgery arm (P = 0.86). Serious chemotherapy adverse events tended to be more frequent in arm B (23% vs 11%, P = 0.07), with a single death per arm. CONCLUSION: Surgery following docetaxel-based chemotherapy was safe and with similar morbidity to immediate surgery in patients with locally-advanced resectable gastric carcinoma.

Parenteral nutrition independence in a patient left with 25 cm of ileum and jejunum: a case report.

A 44-year-old woman with a history of Roux-en-Y gastric bypass (RYGBP) suffered small bowel volvulus. She was left post-operatively with an intact duodenum, 25 cm of jejunum and ileum, and a colon in continuity, a situation synonymous to short bowel syndrome. This report describes her surgical, medical and nutritional follow-up until complete weaning of parenteral nutrition despite of her very short remnant small bowel and persistently low citrullinemia. The discussion aims at demonstrating the rarity of these complications after RYGBP according to the literature. Furthermore, it challenges the validity of the present markers of parenteral nutrition independence (remnant small bowel length, citrullinemia) in case of short bowel syndrome.

Water-immersion sigmoidoscopy to treat acute GI bleeding in the perioperative period after surgical colorectal anastomosis.

BACKGROUND: The occurrence of lower acute GI bleeding in the early perioperative period after colorectal anastomosis represents a life-threatening condition. The early treatment includes surgery or endoscopy, the latter being subject to complications associated with air insufflation and associated perforation. OBJECTIVE: To study the feasibility, efficacy, and safety of early perioperative water-immersion endoscopy to treat the source of bleeding in patients having undergone colorectal anastomosis. DESIGN: To prospectively study patients with active lower GI bleeding early after colorectal anastomosis and subject them to therapeutic water-immersion endoscopy instead of surgery. SETTING: University referral center for digestive surgery and endoscopy. PATIENTS: This study involved 2 patients presenting with active lower GI bleeding within 4 days after colorectal surgery. INTERVENTION: Instead of air insufflation during endoscopy, an underwater investigation was performed in each patient after colonic water immersion. MAIN OUTCOME MEASUREMENTS: Efficacy of therapeutic endoscopy. RESULTS: Water-immersion endoscopy in each case allowed us to identify the location of the anastomosis and the source of active bleeding. It allowed us to safely place clips on the active vessels and stop the bleeding. LIMITATIONS: Number of patients included, no comparison between conventional endoscopy and water-immersion endoscopy. CONCLUSION: Diagnostic as well as therapeutic water-immersion colonoscopy is safe in patients presenting with active lower GI bleeding in the early perioperative period after colorectal anastomosis.