Comparison of the 6th and 7th editions of the AJCC/UICC TNM staging system for gastric cancer focusing on the "N" parameter-related survival: the monoinstitutional NodUs Italian study.

BACKGROUND: A large number of Asian population studies examined the difference between the 6th and the 7th tumor, node, metastasis (TNM) while it is still poorly validated among Caucasian populations. This is a retrospective study aimed at investigating the efficacy of the 7th edition American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) staging system for gastric cancer focusing on the "N" parameter-related survival for prognostic assessment in gastric cancer patients of a single Western high-volume institution. METHODS: From January 2002 to December 2009, the data of 274 patients with gastric cancer who underwent gastric surgery at the 8th General and Gastrointestinal Surgical Centre of the Second University of Naples were analyzed retrospectively. We collected data for patient demographics, tumor characteristics, surgical characteristics, and TNM stage. Particularly, the nodal status, with the number of dissected nodes and metastatic nodes, was reviewed from the pathology records. The same patient dataset was used to stage patients according to both the 6th and 7th edition criteria. RESULTS: Age at surgery, tumor location, histological grade, Lauren's classification subtypes, and 6th and 7th AJCC/UICC N categories were found to have statistically significant associations with overall survival on univariate analysis. In the 6th edition staging system, the Kaplan-Meier plot did not show significant overlapped survival curves: significant differences were found between N0 and N1, P<.001; N1 and N2, P=.04; and N2 and N3, P<.001. On the contrary, in the 7th edition, among all five substages, there were similar survival curves between N categories 2 and 3a (P=.98) with a statistically significant discriminatory ability only between N1 versus N3b and N2 versus N3b (P=.02 and .04, respectively). CONCLUSIONS: Based on analysis, we found that several clinicopathological variables, especially histological grade and Lauren's classification, were significant prognostic factors in our database. The 6th and 7th AJCC/UICC N classifications represent significantly independent prognostic factors, and the 6th AJCC/UICC N classification seems to be superior to the 7th AJCC/UICC N classification in terms of uniformity, differentiation, and monotonicity of gradients.

Peripherally inserted central catheter tip position: a novel empirical-ultrasonographical index in a modern surgical oncology department.

BACKGROUND: The correct positioning of ultrasound-guided, peripherally inserted central catheters (UGPICCs) is essential to avoid multiple complications. We describe for the first time a retrospective study to evaluate a novel and easy transabdominal ultrasound-guided approach, so-called "Marano index," to place the UGPICCs tip correctly, making oncological surgeons able to obtain a high successful initial placement rate without postinsertion chest radiography. METHODS: We examined the placement of UGPICCs applying, in 53 patients, the "Marano index." The tip catheter location was controlled by postprocedural chest radiography. Sensitivity, positive predictive value, and accuracy of index application also were calculated and compared with radiographic findings. RESULTS: The ultrasonographic-guided insertion was successful in all patients (100%). The identification of catheter inside the inferior vena cava was registered in 50 patients (94.3%), and in all cases it was clear the precise catheter placement, after Marano index application, with the real tip position and the concordance between postprocedural radiography in 100% of cases. The overall accuracy of this novel empirical-ultrasonographical index was 94%, with positive predictive value of 94% and sensitivity of 100%. CONCLUSIONS: This technique, once validated in a larger cohort, would allow the insertion of UGPICC without radiologic confirmation in selected patients with an adequate ultrasound body habitus. This would avoid unneeded radiation exposure from chest X-rays and would potentially save cost and time. This strategy provides only minimal deviation from the current practice and it is hence technically easy to learn and perform accurately with basic training by digestive oncological surgeons.

The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia.

BACKGROUND: Although minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia. METHODS: A total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge. RESULTS: There were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux. CONCLUSION: All patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.

Clinical and immunological impact of early postoperative enteral immunonutrition after total gastrectomy in gastric cancer patients: a prospective randomized study.

BACKGROUND: Enteral immunodiet has been gaining increasing attention, but experimental data of its clinical effects in patients with gastric cancer are inconsistent, contradictory, and poorly investigated. The aim of this study was to assess the impact of early postoperative enteral immunonutrition on clinical and immunological outcomes in a homogeneous group of gastric cancer patients submitted to total gastrectomy. METHODS: A total of 109 patients with gastric cancer were randomized to receive early postoperative enteral immunonutrition (formula supplemented with arginine, omega-3 fatty acids and ribonucleic acid [RNA]), or an isocaloric-isonitrogenous control. The postoperative outcome was evaluated based on clinical variables, including postoperative infectious complications, anastomotic leak rate, and length of hospitalization. In addition, state of cellular immunity was evaluated and compared between the 2 groups. RESULTS: The incidence of postoperative infectious complications in the immunodiet group (7.4%) was significantly (p < .05) lower than that of the control group (20%), as well as the anastomotic leak rate (3.7% in immunodiet group vs 7.3% in standard nutrition group, p < .05). Mortality rate did not show any significant differences; patients of the immunodiet group were found to have a significantly reduced length of hospitalization (12.7 ± 2.3 days) when compared with standard diet group (15.9 ± 3.4 days, p = .029). The data on cellular immunity showed that the postoperative CD4(+) T-cell counts decreased in both groups, but the reduction in the IED group was significantly higher (p = .032) compared with the SND group. CONCLUSIONS: Early postoperative enteral immunonutrition significantly improves clinical and immunological outcomes in patients undergoing gastrectomy for gastric cancer.

Sutureless jejuno-jejunal anastomosis in gastric cancer patients: a comparison with handsewn procedure in a single institute.

BACKGROUND: The biofragmentable anastomotic ring has been used to this day for various types of anastomosis in the gastrointestinal tract, but it has not yet achieved widespread acceptance among surgeons. The purpose of this retrospective study is to compare surgical outcomes of sutureless with suture method of Roux-and-Y jejunojejunostomy in patients with gastric cancer. METHODS: Two groups of patients were obtained based on anastomosis technique (sutureless group versus hand sewn group): perioperative outcomes were recorded for every patient. RESULTS: The mean time spent to complete a sutureless anastomosis was 11 ± 4 min, whereas the time spent to perform hand sewn anastomosis was 23 ± 7 min. Estimated intraoperative blood loss was 178 ± 32 ml in the sutureless group and 182 ± 23 ml in the suture-method group with no significant differences. No complications were registered related to enteroanastomosis. Intraoperative mortality was none for both groups. CONCLUSIONS: The Biofragmentable Anastomotic Ring offers a safe and time-saving method for the jejuno-jejunal anastomosis in gastric cancer surgery, and for this purpose the ring has been approved as a standard method in our clinic. Nevertheless currently there are few studies on upper gastrointestinal sutureless anastomoses and this could be the reason for the low uptake of this device.

Characteristics and outcomes of laparoscopic surgery in patients with large hiatal hernia. A single center study.

INTRODUCTION: Giant hiatal hernia is characterized by the presence of more than 1/3 of the stomach in the chest, through the diaphragmatic hiatus, with or without other intra-abdominal organs. It is a rare pathology, representing the 5-10% of all hiatal hernias. The advent of laparoscopic surgery led to new surgical techniques, which include the simple reduction with the excision of the hernial sac and the execution of a posterior hiatoplasty, with or without mesh, and the execution of a Collis-Nissen gatroplasty in case of short esophagus. PRESENTATION OF CASES: We followed 24 cases of giant hiatal hernia with more than 1/3 stomach located in the chest, analyzing the results reached by the miniinvasive procedure, and the long-term pathophysiologic results of the disease. DISCUSSION: Laparoscopic hiatal hernia repair results in less postoperative pain compared with the open approach. The smaller incisions of minimally-invasive surgery are less likely to be complicated by incisional hernias and wound infection. Postoperative respiratory complications are reduced. CONCLUSION: Results from multiple studies are similar, with shorter hospital stay and less morbidity resulting from the minimally invasive approach.

An unusual case of left hepatectomy for Focal Nodular Hyperplasia (FNH) linked to the use of Anabolic Androgenic Steroids (AASs).

INTRODUCTION: Focal Nodular Hyperplasia (FNH) is the second most common benign tumor of the liver. Clinically FNH is asymptomatic and discovered incidentally . The pathogenesis is unclear; FNH is usually asymptomatic. When the tumor is large, it may be painful. Surgery is recommended only in the case of complications such as compression of adjacent organs, lesion progression with tumor size >5cm and presence of symptoms. PRESENTATION OF CASE: A 30 years old man, was evaluated during a routine visit, for diffuse abdominal pain and weight loss; Abdominal ultrasound showed no evidence of biliary obstruction but the US shows a hypoechoic, well defined focal lesion in the left liver. For a more accurate diagnosis a Magnetic Resonance detected a focal area about 14×9 cm in diameter, hypointense. Liver biopsy was not done.We could not diagnose it definitively as FNH from the results of imaging studies; so for the size of symptomatic lesion, the undefined diagnosis of FNH ,and due to the great increase in the size of the mass located in the left lobe, during such a short period , the surgery was been recommended. DISCUSSION: FNH is the second most common hepatic lesion, but clinically relevant cases of FNH are rare with a reported prevalence in US studies of 0,03%. In our case the young patient was taking dietary supplements including anabolic androgenic steroids (AASs), carnitine and l-arginine. CONCLUSION: The particularity of our case is the increasing of the lesion in two years in which the patient made use of anabolic steroids. under use of . This could be the explanation for increasing of nodule.

Applicability of the Proposed Japanese Model for the Classification of Gastric Cancer Location: The "PROTRADIST" Retrospective Study.

BACKGROUND: The extension of lymphadenectomy for surgical treatment of gastric cancer remains discordant among European and Japanese surgeons. Kinami et al. (Kinami S, Fujimura T, Ojima E, et al. PTD classification: proposal for a new classification of gastric cancer location based on physiological lymphatic flow. Int. J. Clin. Oncol. 2008;13:320-329) proposed a new experimental classification, the "Proximal zone, Transitional zone, Distal zone" (PTD) classification, based on the physiological lymphatic flow of gastric cancer site. The aim of the present retrospective study is to assess the applicability of PTD Japanese model in gastric cancer patients of our Western surgical department. METHODS: Two groups of patients with histologically documented adenocarcinoma of the stomach were retrospectively obtained: In the first group were categorized 89 patients with T1a-T1b tumor invasion; and in the second group were 157 patients with T2-T3 category. The data collected were then categorized according to the PTD classification. RESULTS: In the T1a-T1b group there were no lymph node metastases within the r-GA or r-GEA compartments for tumors located in the P portion, and similarly there were no lymphatic metastases within the l-GEA or p-GA compartments for tumors located in the D portion. On the contrary, in the T2-T3 group the lymph node metastases presented a diffused spreading with no statistical significance between the two classification models. CONCLUSIONS: Our results show that the PTD classification based on physiological lymphatic flow of the gastric cancer site is a more physiological and clinical version than the Upper, Medium And Lower classification. It represents a valuable and applicable model of cancer location that could be a guide to a tailored surgical approach in Italian patients with neoplasm confined to submucosa. Nevertheless, in order to confirm our findings, larger and prospective studies are needed.

Large symptomatic gastric diverticula: two case reports and a brief review of literature.

Gastric diverticula are rare and uncommon conditions. Most gastric diverticula are asymptomatic. When symptoms arise, they are most commonly upper abdominal pain, nausea and emesis, while dyspepsia and vomiting are less common. Occasionally, patients with gastric diverticula can have dramatic presentations related to massive bleeding or perforation. The diagnosis may be difficult, as symptoms can be caused by more common gastrointestinal pathologies and only aggravated by diverticula. The appropriate management of diverticula depends mainly on the symptom pattern and as well as diverticulum size. There is no specific therapeutic strategy for an asymptomatic diverticulum. Although some authors support conservative therapy with antacids, this provides only temporary symptom relief since it is not able to resolve the underlying pathology. Surgical resection is the mainstay of treatment when the diverticulum is large, symptomatic or complicated by bleeding, perforation or malignancy, with over two-thirds of patients remaining symptom-free after surgery, while laparoscopic resection, combined with intraoperative endoscopy, is a safe and feasible approach with excellent outcomes. Here, we present two cases of uncommon large symptomatic gastric diverticula with a discussion of the cornerstones in management and report a minimally invasive solution, with a brief review of the literature.

The calibrated laparoscopic Heller myotomy with fundoplication.

BACKGROUND: Esophageal achalasia is the most common primary esophageal motor disorder. Laparoscopic Heller's myotomy combined with fundoplication represents the treatment of choice for this disease, achieving good results in about 90% of patients. However, about 10% of treated patients refer persistent or recurrent dysphagia. Many Authors showed that this failure rate is related to inadequate myotomy. OBJECTIVE: To verify, from experimental to clinical study, the modifications induced by Heller's myotomy of the esophago- gastric junction on LES pressure (LES-P profile, using a computerized manometric system. METHODS: From 2002 to 2010 105 patients with achalasia underwent laparoscopic calibrated Heller myotomy followed by antireflux surgery. The calibrated Heller myotomy was extended for at least 2.5 cm on the esophagus and for 3 cm on the gastric side. Each step was evaluated by intraoperative manometry. Moreover, intraoperative manometry and endoscopy were used to calibrate the fundoplication. RESULTS: The preoperative mean LES-P was 37.73 ± 12.21. After esophageal and gastric myotomy the mean pressure drop was 21.3% and 91.9%, respectively. No mortality was reported. CONCLUSION: Laparoscopic calibrated Heller myotomy with fundoplication achieves a good outcome in the surgical treatment of achalasia. The use of intraoperative manometry enables an adequate calibration of myotomy, being effective in the evaluation of the complete pressure drop, avoiding too long esophageal myotomy and, especially, too short gastric myotomy, that may be the cause of surgical failure.