Rationale for gastrectomy with D2 lymphadenectomy in the treatment of gastric cancer.

BACKGROUND: In the surgical management of gastric cancer, D2 lymphadenectomy aims to reduce the incidence of locoregional relapse, and to increase patient survival. METHODS: A prospective study was made of 126 consecutive patients operated upon for gastric cancer, with gastrectomy and D2 lymphadenectomy. Hospital morbidity and mortality, relapses, and patient survival after 5 years were studied. RESULTS: The overall hospital mortality rate was 1.6%, with a mortality of 2.1% in the patients submitted to total gastrectomy. The overall morbidity rate was 29.4%. Dehiscence of the esophagojejunal anastomosis was recorded in 1.6%. The median follow-up was 73.6 months. Relapses were observed in 37% of the patients (76% in the first 2 years). Overall actuarial survival after 5 years was 52.3%, and 5-year survival in the patients with R0 resection with positive N2 lymph nodes according to the Japanese classification was 26.5%. CONCLUSION: Our results show that D2 lymphadenectomy can be performed with low morbidity-mortality, and a 5-year survival of more than 50%. The procedure offers benefit in terms of survival for a certain percentage of patients with positive level N2 lymph nodes.

Surgical treatment of recurrent gastric cancer.

BACKGROUND: The value of programs to detect recurrence of a previously operated gastric cancer is a controversial subject. D2 lymphadenectomy achieves better local control and a lower local recurrence rate than D1 lymphadenectomy. METHODS: The results achieved with surgical treatment of recurrent gastric cancer in a series of 126 consecutive patients who had been treated with gastrectomy with D2 lymphadenectomy are reported. In-hospital mortality was 1.6%. RESULTS: Follow-up of the remaining 124 patients for a median period of 73.6 months detected recurrence in 46 patients (37%). There were 14 local, 12 peritoneal, and 15 distant recurrences. Recurrent gastric cancer was detected within 2 years in 76% of the patients. Of the 46 patients with recurrence, 5 patients (11%) were selected for surgery (4 local and 1 peritoneal recurrence). The median disease-free time after surgery for recurrence was 26 months (range, 14-58 months). There was no in-hospital mortality. The median survival time after surgery for recurrence was 26 months (range, 9-87 months). One patient died during follow-up, while none of the other patients have any evidence of new recurrence. CONCLUSION: Surgery for recurrent gastric cancer is a valid alternative in selected patients, provided it is performed by specialized work teams.

[Morbidity and mortality in gastrectomy with D2 lymphadenectomy in a specialised unit]. / Morbilidad y mortalidad de la gastrectomía con linfadenectomía D2 en una unidad especializada.

INTRODUCTION: The combination of gastrectomy and D2 lymphadenectomy is still not a widely accepted therapeutic option by Western surgeons, due to its high post-operative morbidity and mortality. OBJECTIVE: To evaluate the morbidity and mortality in a series of patients with gastric cancer treated by gastrectomy and D2 lymphadenectomy, and compare these results with those published by centres with notable experience. PATIENTS AND METHOD: A descriptive and prospective study on a series of 126 consecutive patients with gastric cancer treated by gastrectomy and D2 lymphadenectomy. All complications were recorded, grouped into abdominal and non-abdominal, as well as surgical re-interventions. RESULTS: Total gastrectomy was performed on 95 (75.4%) of the 126 patients. It was combined with splenectomy in 22 cases (17.5%) and left pancreatectomy in 9 (7.1%). The stages, according to the AJCC, were: stage 0: 4.8%, IA: 17.5%, IB: 22.2%, II: 10.3%, IIIA: 16.7%, IIIB: 9.5%, and stage IV: 19%. Of these patients 52.4% were overweight and more than 60% had an ASA risk assessment of III or IV. Fifty complications arose in 37 (29%) of the 26 patients, which required 12 surgical re-interventions (all in total gastrectomy cases). Four anastomosis dehiscence were diagnosed and 4 intra-abdominal abscesses with no evidence of anastomosis dehiscence which were resolved with drainage. Two (1.6%) of the 126 patients died, both after total gastrectomy and with no evidence of intra-abdominal complications. CONCLUSIONS: Patients with gastric cancer, even with associated risk factors, can be treated by gastrectomy and D2 lymphadenectomy with similar morbidity and mortality rates to those centres with more experience, due to a great extent to sub-specialising in this surgery.

Morbilidad y mortalidad de la gastrectomía con linfadenectomía D2 en una unidad especializada / Morbidity and mortality in gastrectomy with D2 lymphadenectomy in a specialised unit

Introducción. La asociación de gastrectomía y linfadenectomía D2 no es todavía una opción terapéutica ampliamente aceptada por los cirujanos occidentales debido a que la morbilidad y la mortalidad postoperatorias son elevadas. Objetivo. Evaluar la morbilidad y la mortalidad en una serie de pacientes con cáncer gástrico tratados con gastrectomía y linfadenectomía D2, y comparar estos resultados con los publicados por centros con experiencia relevante. Pacientes y método. Estudio descriptivo y prospectivo de una serie de 126 pacientes consecutivos con cáncer gástrico tratados con gastrectomía y linfadenectomía D2. Se registraron todas las complicaciones, agrupadas en abdominales y no abdominales, así como las reintervenciones quirúrgicas. Resultados. Se realizó gastrectomía total en 95 (75,4%) de los 126 pacientes. Se asoció esplenectomía en 22 (17,5%) casos y pancreatectomía izquierda en 9 (7,1%). Los estadios, según la AJCC, fueron: estadio 0, el 4,8%; IA, el 17,5%; IB, el 22,2%; II, el 10,3%; IIIA, el 16,7%; IIIB, el 9,5%, y IV, el 19%. El 52,4% de los pacientes tenían sobrepeso y más del 60%, una valoración del riesgo ASA III o IV. Se produjeron 50 complicaciones en 37 (29%) de los 126 pacientes, que precisaron 12 reintervenciones quirúrgicas (todas en casos de gastrectomía total). Se diagnosticaron 4 dehiscencias de anastomosis y 4 abscesos intraabdominales sin evidencia de dehiscencia anastomótica que se solucionaron con drenaje. De los 126 pacientes, 2 (1,6%) fallecieron, ambos tras una gastrectomía total y sin evidencia de complicaciones intraabdominales. Conclusiones. A los pacientes con cáncer gástrico, incluso con factores de riesgo asociados, se puede tratarlos con gastrectomía y linfadenectomía D2, con cifras de morbilidad y mortalidad semejantes a las de los centros de mayor experiencia, en gran parte debido a la subespecialización en esta cirugía (AU)

Introduction. The combination of gastrectomy and D2 lymphadenectomy is still not a widely accepted therapeutic option by Western surgeons, due to its high post-operative morbidity and mortality. Objective. To evaluate the morbidity and mortality in a series of patients with gastric cancer treated by gastrectomy and D2 lymphadenectomy, and compare these results with those published by centres with notable experience. Patients and method. A descriptive and prospective study on a series of 126 consecutive patients with gastric cancer treated by gastrectomy and D2 lymphadenectomy. All complications were recorded, grouped into abdominal and non-abdominal, as well as surgical re-interventions. Results. Total gastrectomy was performed on 95 (75.4%) of the 126 patients. It was combined with splenectomy in 22 cases (17.5%) and left pancreatectomy in 9 (7.1%). The stages, according to the AJCC, were: stage 0: 4.8%, IA: 17.5%, IB: 22.2%, II: 10.3%, IIIA: 16.7%, IIIB: 9.5%, and stage IV: 19%. Of these patients 52.4% were overweight and more than 60% had an ASA risk assessment of III or IV. Fifty complications arose in 37 (29%) of the 26 patients, which required 12 surgical re-interventions (all in total gastrectomy cases). Four anastomosis dehiscence were diagnosed and 4 intra-abdominal abscesses with no evidence of anastomosis dehiscence which were resolved with drainage. Two (1.6%) of the 126 patients died, both after total gastrectomy and with no evidence of intra-abdominal complications. Conclusions. Patients with gastric cancer, even with associated risk factors, can be treated by gastrectomy and D2 lymphadenectomy with similar morbidity and mortality rates to those centres with more experience, due to a great extent to sub-specialising in this surgery (AU)

[Results of laparoscopic fundoplication in gastroesophageal reflux disease with atypical manifestations]. / Resultados de la fundoplicatura laparoscópica en la enfermedad por reflujo gastroesofágico con síntomas atípicos.

INTRODUCTION: Gastroesophageal reflux disease (GERD) may present with typical (heartburn and regurgitation) and atypical symptoms (cough, asthma, non-cardiac chest pain). Laparoscopic fundoplication has been performed for approximately 10 years, with results similar to or better than those obtained with open antireflux procedures. The aim of this study was to evaluate the clinical and functional results of laparoscopic fundoplication in patients with GERD and atypical symptoms. PATIENTS AND METHOD: There were 158 consecutive patients with GERD who underwent a 360 degrees laparoscopic fundoplication (January 1999 to March 2006) and 27 patients had atypical symptoms. All patients underwent preoperative manometry and 24 hour pH-metry and 78% underwent the same tests postoperatively (at 6 months). Data from hospital records were analyzed and a clinical telephone survey was conducted. RESULTS: There was no mortality and no conversions were required. The median length of follow-up was 21 months. All atypical symptoms (cough, chest pain, asthma, dysphonia and hoarseness) were significantly reduced (p < 0.05). There was no relationship between symptom persistence in five patients and pathologic acid reflux, except in one patient. Eighty-nine percent of the patients responded to the telephone survey; of these, 79% had no symptoms. The median satisfaction score was 9 (from 0 to 10). CONCLUSIONS: Laparoscopic fundoplication for GERD with atypical symptoms is a safe procedure with good results (clinical and functional) in trained groups patients. Moreover a high satisfaction rate is obtained.

Resultados de la fundoplicatura laparoscópica en la enfermedad por reflujo gastroesofágico con síntomas atípicos / Results of laparoscopic fundoplication in gastroesophageal reflux disease with atypical manifestations

Introducción. La enfermedad por reflujo gastroesofágico (ERGE) se presenta clínicamente con síntomas típicos (pirosis y regurgitaciones) y atípicos (tos, asma, dolor torácico no cardíaco). La fundoplicatura laparoscópica (FPL) se realiza desde hace más de 10 años para el tratamiento de esta enfermedad con resultados similares o mejores que con cirugía abierta. El objetivo de este trabajo es evaluar los resultados clínicos y funcionales de la FPL en la ERGE con síntomas atípicos. Pacientes y método. De 158 pacientes consecutivos con ERGE que fueron sometidos a FPL tipo Nissen (enero de 1999 a marzo de 2006), se identificó a 27 pacientes con síntomas atípicos. A todos se les realizó manometría y pH-metría preoperatoria y al 78% de ellos, en el postoperatorio (sexto mes). Se analizaron los datos de la historia clínica y se realizó una encuesta clínica telefónica. Resultados. No hubo mortalidad ni conversiones. La mediana del seguimiento fue de 21 meses. Todos los síntomas atípicos (tos, dolor torácico, asma, afonía y carraspera) disminuyeron significativamente (p < 0,05). La persistencia de síntomas en 5 pacientes no se relacionó, salvo en 1 de ellos, con reflujo ácido patológico. Respondieron a la encuesta telefónica un 89% de los pacientes, y el 79% no tenía síntomas. La mediana de satisfacción de los pacientes por la cirugía fue de 9 en una escala del 0 al 10. Conclusiones. La FPL en la ERGE con síntomas atípicos es un procedimiento seguro y tiene buenos resultados (clínica y funcionalmente) en grupos especializados; se obtiene, además, una alta aceptación por parte de los pacientes (AU)

Introduction. Gastroesophageal reflux disease (GERD) may present with typical (heartburn and regurgitation) and atypical symptoms (cough, asthma, non-cardiac chest pain). Laparoscopic fundoplication has been performed for approximately 10 years, with results similar to or better than those obtained with open antireflux procedures. The aim of this study was to evaluate the clinical and functional results of laparoscopic fundoplication in patients with GERD and atypical symptoms. Patients and method. There were 158 consecutive patients with GERD who underwent a 360° laparoscopic fundoplication (January 1999 to March 2006) and 27 patients had atypical symptoms. All patients underwent preoperative manometry and 24 hour pH-metry and 78% underwent the same tests postoperatively (at 6 months). Data from hospital records were analyzed and a clinical telephone survey was conducted. Results. There was no mortality and no conversions were required. The median length of follow-up was 21 months. All atypical symptoms (cough, chest pain, asthma, dysphonia and hoarseness) were significantly reduced (p < 0.05). There was no relationship between symptom persistence in five patients and pathologic acid reflux, except in one patient. Eighty-nine percent of the patients responded to the telephone survey; of these, 79% had no symptoms. The median satisfaction score was 9 (from 0 to 10). Conclusions. Laparoscopic fundoplication for GERD with atypical symptoms is a safe procedure with good results (clinical and functional) in trained groups patients. Moreover a high satisfaction rate is obtained (AU)

Intra-abdominal follicular dendritic cell sarcoma.

Follicular dendritic cell (FDC) sarcoma is a very rare condition. We report here an intra-abdominal FDC sarcoma occurring as a mass, dependent on the celiac and left gastric lymph chains, that was completely excised. Eighteen months after surgery a recurrence at the liver pedicle was detected by a CT-scan and fully resected; in order to prevent another disease relapse postoperative radiotherapy was given.

Esophageal squamous cell carcinoma after liver transplantation.

The occurrence of an oesophageal squamous cell carcinoma following liver transplantation is very infrequent. Such an event has been related to a history of alcohol-induced cirrhosis, as in other squamous cell tumours of the oropharynx. We report the case of a 64-year-old male patient diagnosed as having oesophageal squamous cell carcinoma six years after having had a liver transplant due to alcohol-induced cirrhosis. The tumour was treated surgically and consisted of an Ivor-Lewis oesophagectomy. The patient is disease-free 17 months after surgery. A review of the cases reported in the literature indicated treatment with chemotherapy and radiation therapy, and with excision in some cases. Generally, despite aggressive treatment the prognosis is poor.

Esophageal squamous cell carcinoma after liver transplantation

The occurrence of an oesophageal squamous cell carcinoma following liver transplantation is very infrequent. Such an event has been related to a history of alcohol-induced cirrhosis, as in other squamous cell tumours of the oropharynx. We report the case of a 64-year-old male patient diagnosed as having oesophageal squamous cell carcinoma six years after having had a liver transplant due to alcohol-induced cirrhosis. The tumour was treated surgically and consisted of an Ivor-Lewis oesophagectomy. The patient is disease-free 17 months after surgery. A review of the cases reported in the literature indicated treatment with chemotherapy and radiation therapy, and with excision in some cases. Generally, despite aggressive treatment the prognosis is poor

Nutrición enteral con yeyunostomía con catéter de aguja en la anastomosis esofágica. Complicaciones de la técnica / Enteral nutrition with needle catheter jejunostomy in esophageal anastomosis. Complications of the technique

Objetivo. El objetivo de este trabajo ha sido evaluar la presencia de complicaciones asociadas al empleo de la yeyunostomía quirúrgica con catéter y la tolerancia de la nutrición enteral. Pacientes y método. Estudio retrospectivo de 58 pacientes consecutivos a los que se les practicó cirugía resectiva esofágica o gástrica con anastomosis esofágica y se les realizó una yeyunostomía con catéter de aguja. Las variables estudiadas han sido: el inicio de la nutrición enteral, la duración de la perfusión, las complicaciones asociadas con el uso de la yeyunostomía y la tolerancia de la nutrición enteral. Resultados. La mortalidad de la serie ha sido del 1,7%. La infusión de nutrición enteral se inició en una media de 4,84 ± 5,01 días y duró una media de 7,9 ± 7,5 días. En 1 paciente no pudo utilizarse la yeyunostomía por obstrucción del catéter; en otros 2 pacientes se objetivó cierta resistencia a la perfusión de la nutrición pero pudieron ser alimentados a través de la sonda. Un paciente tuvo que ser reintervenido por presentar una peritonitis por extravasación de la nutrición enteral dentro de la cavidad peritoneal. Dos pacientes presentaron dificultad para la retirada del catéter, y 1 de ellos precisó la exploración de la herida cutánea bajo anestesia local. La tasa global de complicaciones en relación con la yeyunostomía fue del 10,3%. La tolerancia de la nutrición enteral fue correcta en 41 casos, se disminuyó el ritmo de la infusión en 6 casos y se suspendió por intolerancia en 10. Conclusiones. La yeyunostomía con catéter de aguja es una buena opción en los pacientes con anastomosis esofágicas debido a la baja morbilidad asociada con su empleo y la buena tolerancia de la nutrición enteral (AU)

Objective. The aim of this study was to evaluate the presence of complications associated with the use of surgical needle catheter jejunostomy and tolerance to enteral nutrition. Patients and method. We performed a retrospective study of 58 consecutive patients, who underwent esophageal or gastric resection with esophageal anastomosis and needle catheter jejunostomy. The variables studied were initiation of enteral nutrition, duration of perfusion, complications associated with the use of jejunostomy, and tolerance to enteral nutrition. Results. Mortality in the series was 1.7%. Infusion of enteral nutrition was started at mean of 4.84 ± 5.01 days and lasted for a mean of 7.9 ± 7.5 days. In one patient the jejunostomy could not be used due to catheter obstruction and in another 2 patients some resistance to perfusion of nutrition was observed but these patients could be fed through the tube. One patient had to undergo reintervention due to peritonitis caused by extravasation of the enteral nutrition within the peritoneal cavity. Catheter withdrawal was difficult in 2 patients; of these, 1 patient required investigation of the skin wound under local anesthetic. The overall rate of jejunostomy-related complications was 10.3%. Tolerance of enteral nutrition was acceptable in 41 patients, the infusion rate was reduced in 6 patients and infusion was discontinued due to intolerance in 10. Conclusions. Because needle catheter jejunostomy produces low morbidity and good tolerance to enteral nutrition, it is a valid alternative in patients with esophageal anastomosis (AU)

[Enteral nutrition with needle catheter jejunostomy in esophageal anastomosis. Complications of the technique]. / Nutrición enteral con yeyunostomía con catéter de aguja en la anastomosis esofágica. Complicaciones de la técnica.

OBJECTIVE: The aim of this study was to evaluate the presence of complications associated with the use of surgical needle catheter jejunostomy and tolerance to enteral nutrition. PATIENTS AND METHOD: We performed a retrospective study of 58 consecutive patients, who underwent esophageal or gastric resection with esophageal anastomosis and needle catheter jejunostomy. The variables studied were initiation of enteral nutrition, duration of perfusion, complications associated with the use of jejunostomy, and tolerance to enteral nutrition. RESULTS: Mortality in the series was 1.7%. Infusion of enteral nutrition was started at mean of 4.84+/-5.01 days and lasted for a mean of 7.9+/-7.5 days. In one patient the jejunostomy could not be used due to catheter obstruction and in another 2 patients some resistance to perfusion of nutrition was observed but these patients could be fed through the tube. One patient had to undergo reintervention due to peritonitis caused by extravasation of the enteral nutrition within the peritoneal cavity. Catheter withdrawal was difficult in 2 patients; of these, 1 patient required investigation of the skin wound under local anesthetic. The overall rate of jejunostomy-related complications was 10.3%. Tolerance of enteral nutrition was acceptable in 41 patients, the infusion rate was reduced in 6 patients and infusion was discontinued due to intolerance in 10. CONCLUSIONS: Because needle catheter jejunostomy produces low morbidity and good tolerance to enteral nutrition, it is a valid alternative in patients with esophageal anastomosis.

¿La esfinterotomía lateral interna con anestesia local en el tratamiento de la fisura anal crónica disminuye la tasa de incontinencia posquirúrgica? / Does lateral internal sphincterotomy under local anesthesia for chronic anal fissure reduce the rate of incontinence?

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Alteraciones de la continencia fecal en el tratamiento quirúrgico de la fisura anal crónica / Disturbance of fecal continence following surgery for chronic anal fissure

Objetivo. Determinar la tasa de incontinencia anal tras esfinterotomía lateral interna subcutánea en pacientes diagnosticados de fisura anal crónica. Pacientes y métodos. Cien pacientes consecutivos diagnosticados de fisura anal crónica y que presentaban una continencia fecal perfecta antes de la intervención fueron incluidos en el estudio. A todos los pacientes se les realizó una esfinterotomía lateral interna subcutánea. La continencia de los pacientes se valoró en consulta, antes de la operación y un año después mediante la escala de Miller et al. El análisis estadístico se realizó mediante los tests t de Student y de 2.Resultados. De los 100 pacientes incluidos en el estudio, 56 eran varones. La edad media fue de 45,2 años (intervalo, 24-88). Un año después de la operación, el 29 por ciento de los pacientes encuestados refirió alteraciones de la continencia fecal. De ellos, el 26 por ciento presentó alteraciones en la continencia de gases. Un 3 por ciento tuvo episodios de incontinencia para gases y para heces sólidas. Además, entre ambos grupos hubo 4 pacientes que presentaron incontinencia cuando padecían diarrea. No se observaron diferencias en la edad ni en el sexo entre los pacientes que presentaron alteraciones de la continencia y los que no la presentaron. Conclusiones. Nuestro estudio muestra que aunque esta técnica quirúrgica sea la mejor para tratar la fisura anal crónica, presenta una tasa grande de alteraciones de la continencia fecal, hecho que debería ser conocido por los pacientes a los que se les ofrezca esta intervención (AU)