Current management of gastric cancer.

Gastric cancer is a disease with high incidence and mortality in our population. The prognosis of patients with this disease is closely related to the neoplasm stage at diagnosis, including the following characteristics of the tumor: extension into the gastric wall thickness, spread to locoregional lymph nodes and the ability to generate distant metastases, as described by the TNM classification. For localized tumors characterized only by invasion of mucosa or submucosa at diagnosis, survival at 5 years is between 70 and 95% with exclusive surgical management; however, when extension into the gastric wall is higher and/or there is locoregional nodal involvement, survival decreases to 20-30% at 5 years. Currently, at high-volume centers, the extent of gastrectomy is individualized based on several parameters, which in an increasing number of cases allows a total gastrectomy with D2 lymphadenectomy and preservation of the spleen and pancreas. This improved procedure increases the chance of R0 surgery and improves the relationship between resected and affected lymph nodes, resulting in a decreased risk of the long-term locoregional recurrence. To improve these results, different therapeutic strategies combining chemotherapy or chemoradiotherapy with surgery have been tested. Previously, the Intergroup 0116 clinical trial, published in 2001, which changed clinical practice in the United States, showed that adjuvant chemoradiotherapy improved survival (from 26 to 37 months overall survival) of these patients. In Europe, perioperative chemotherapy has been considered the standard treatment, since the publication of two randomized phase III trials showed an increase at 5 years survival in the group treated with chemotherapy.

Situación actual en el tratamiento del cáncer gástrico / Current management of gastric cancer

El cáncer gástrico es un tumor de alta incidencia y mortalidad en nuestro medio, y su pronóstico está íntimamente relacionado con la situación neoplásica al diagnóstico, que incluye su extensión en el grosor de la pared gástrica, sobre los ganglios linfáticos locorregionales y su capacidad de generar metástasis a distancia, extensión basada en la clasificación TNM. En aquellos tumores localizados al diagnóstico, caracterizados por la invasión únicamente de mucosa-submucosa, la supervivencia a 5 años se establece entre el 70 y el 95% con manejo quirúrgico exclusivo, sin embargo, cuando la extensión en la pared es mayor y/o existe afectación ganglionar locorregional, la supervivencia disminuye al 20-30% a 5 años. Actualmente en centros con alto volumen de pacientes, la extensión de la gastrectomía se individualiza en función de varios parámetros, optándose, en cada vez más casos, por la realización de una gastrectomía total con linfadenectomía D2 y preservación esplenopancreática, pues esta aumenta las posibilidades de conseguir una cirugía R0 y mejora la relación entre ganglios resecados y ganglios afectados, lo que se traduce en una disminución del riesgo de recidiva locorregional a largo plazo. Con el objetivo de mejorar estos resultados, se han ensayado distintas estrategias terapéuticas de quimioterapia o quimiorradioterapia asociadas a la cirugía. Entre todas ellas destaca el ensayo 0116 del intergroup, publicado en el 2001, que cambió la práctica clínica asistencial en Estados Unidos, ya que demostró que un tratamiento de quimiorradioterapia tras la cirugía mejoraba la supervivencia (de 26 a 37 meses de mediana) de estos pacientes. En Europa es la quimioterapia perioperatoria el tratamiento estándar habitual, desde que se publicaron dos estudios aleatorizados fase III que demostraron un aumento en la supervivencia a 5 años en el grupo tratado con quimioterapia(AU)

Gastric cancer is a disease with high incidence and mortality in our population. The prognosis of patients with this disease is closely related to the neoplasm stage at diagnosis, including the following characteristics of the tumor: extension into the gastric wall thickness, spread to locoregional lymph nodes and the ability to generate distant metastases, as described by the TNM classification. For localized tumors characterized only by invasion of mucosa or submucosa at diagnosis, survival at 5 years is between 70 and 95% with exclusive surgical management; however, when extension into the gastric wall is higher and/or there is locoregional nodal involvement, survival decreases to 20-30% at 5 years. Currently, at high-volume centers, the extent of gastrectomy is individualized based on several parameters, which in an increasing number of cases allows a total gastrectomy with D2 lymphadenectomy and preservation of the spleen and pancreas. This improved procedure increases the chance of R0 surgery and improves the relationship between resected and affected lymph nodes, resulting in a decreased risk of the long- term locoregional recurrence. To improve these results, different therapeutic strategies combining chemotherapy or chemoradiotherapy with surgery have been tested. Previously, the Intergroup 0116 clinical trial, published in 2001, which changed clinical practice in the United States, showed that adjuvant chemoradiotherapy improved survival (from 26 to 37 months overall survival) of these patients. In Europe, perioperative chemotherapy has been considered the standard treatment, since the publication of two randomized phase III trials showed an increase at 5 years survival in the group treated with chemotherapy(AU)

Complicaciones de la anastomosis esofagogástrica en la operación de Ivor Lewis / Oesophagogastric anastomosis complications in the Ivor Lewis operation

Introducción La esofaguectomía es el principal tratamiento del cáncer de esófago. La dehiscencia de la anastomosis esofagogástrica es una complicación grave de la operación de Ivor Lewis que se asocia a una elevada mortalidad. El objetivo de este estudio es analizar su incidencia, su diagnóstico y los resultados del tratamiento. Material y métodos Análisis descriptivo de una serie consecutiva de esofaguectomías según la técnica de Ivor Lewis realizadas durante 5 años. Todas las anastomosis se realizaron de forma manual. Se registró la morbilidad general, dehiscencia de anastomosis, mortalidad intrahospitalaria, supervivencia y estenosis de la anastomosis. Resultados Se realizaron 41 anastomosis intratorácicas. Se presentaron complicaciones, de cualquier índole, en el 49% de los casos y se diagnosticaron 3 dehiscencias de la anastomosis (7,3%), una de ellas asintomática. Se reintervino de urgencia a un paciente, y los otros dos fueron tratados con drenajes y tratamiento conservador. La mortalidad de la serie fue del 7,3%, ninguna relacionada con la dehiscencia. La supervivencia a los 5 años fue del 27%. Un 34% de los pacientes desarrollaron estenosis de la anastomosis. Conclusiones La anastomosis intratorácica tras esofaguectomía puede realizarse, en nuestra experiencia, con una baja incidencia de dehiscencias y sin mortalidad por esta causa. El tratamiento de las mismas debe individualizarse y una parte considerable no precisa reintervención quirúrgica (AU)

Introduction: Oesophagectomy is the principal treatment for cancer of the oesophagus. The oesophagogastric anastomotic leak is a serious complication of the Ivor Lewis operation, and is associated with increased mortality. The objective of this study is to analyse its incidence, its diagnosis and treatment results. Material and methods: A descriptive analysis of a consecutive series of oesophagectomies, carried out during a 5 year period, using the Ivor Lewis technique. All patients had hand sewn anastomosis. Data were collected on general morbidity, anastomosis leak, hospitalmortality, survival, and stenosis of the anastomosis. Results: A total of 41 intrathoracic anastomoses were performed. Complications, of any type, were observed in 49% of cases, of which 3 (7.3%) were anastomotic leaks, one of the masymptomatic. One patient was urgently reoperated, and two others were treated with drains and conservative treatment. The mortality of the series was 7.3%, none associated with the anastomotic leak. The survival at 5 years was 27%, and 34% of the patients developed stenos is of the anastomosis. Conclusions: Intrathoracic anastomosis after oesophagectomy, in our experience, can be performed with a low incidence of anastomotic leaks and without mortality due to this cause. Their treatment must be individualised and a considerable proportion do not require surgical intervention (AU)

[Oesophagogastric anastomosis complications in the Ivor Lewis operation]. / Complicaciones de la anastomosis esofagogástrica en la operación de Ivor Lewis.

INTRODUCTION: Oesophagectomy is the principal treatment for cancer of the oesophagus. The oesophagogastric anastomotic leak is a serious complication of the Ivor Lewis operation, and is associated with increased mortality. The objective of this study is to analyse its incidence, its diagnosis and treatment results. MATERIAL AND METHODS: A descriptive analysis of a consecutive series of oesophagectomies, carried out during a 5 year period, using the Ivor Lewis technique. All patients had hand sewn anastomosis. Data were collected on general morbidity, anastomosis leak, hospital mortality, survival, and stenosis of the anastomosis. RESULTS: A total of 41 intrathoracic anastomoses were performed. Complications, of any type, were observed in 49% of cases, of which 3 (7.3%) were anastomotic leaks, one of them asymptomatic. One patient was urgently reoperated, and two others were treated with drains and conservative treatment. The mortality of the series was 7.3%, none associated with the anastomotic leak. The survival at 5 years was 27%, and 34% of the patients developed stenosis of the anastomosis. CONCLUSIONS: Intrathoracic anastomosis after oesophagectomy, in our experience, can be performed with a low incidence of anastomotic leaks and without mortality due to this cause. Their treatment must be individualised and a considerable proportion do not require surgical intervention.