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.

A rare case of Wunderlich syndrome five days after left hemicolectomy for colorectal cancer.

INTRODUCTION: Wunderlich syndrome (WS) is a surgical emergency characterized by spontaneous, non-traumatic retroperitoneal hemorrhage. Angiomyolipoma (AML), a benign mesenchymal tumor, is the most frequent cause of WS. We present a case of WS, appearance five days after a left hemicolectomy for cancer. PRESENTATION OF CASE: A 66 years-old man with a sigmoid adenocarcinoma and a small left AML (3.4cm) was undergone to left hemicolectomy. He was subjected to bridging therapy with high doses of low-molecular-weight heparin for prosthetic replacement of heart valve secondary to endocarditis and atrial fibrillation. Five days after surgery he presents retroperitoneal hemorrhage due to rupture of AML diagnosed by a CT scan and scintigraphy with labeled red blood cells. Total left nephrectomy was performed as the patient became unstable. DISCUSSION: Rupture of a renal AML is the main cause of WS. This risk increases with the size of the tumor (>4cm) and during pregnancy. CT scan is the best imaging modalities for diagnosis. The bridging therapy increases the perioperative bleeding risk. These patients are conservative treated with selective transarterial embolization. Nephrectomy is limited for the patients hemodynamically unstable or in case of failed embolization. CONCLUSION: This is a unusual case of WS after surgery in patients with small AML and treated with high dose of anticoagulant for cardiac disease. There are no other similar cases in literature.

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.

Sarcomatoid Carcinoma of the lung: A rare case of three small intestinal intussusceptions and literature review.

INTRODUCTION: Sarcomatoid carcinoma is an extremely rare, biphasic tumor characterized by a combination of malignant epithelial and mesenchymal cells. Limited data showed that most cases occurred with advanced local disease and metastasis. PRESENTATION OF CASE: We present a rare case of a 60-year-old man with three small intestinal intussusceptions due to metastatic pulmonary carcinosarcoma. He was explored for chest pain and hemoptysis in Emergency room. Due to his chest symptoms he had a computed tomography (CT) scan of the chest which showed a lesion about 60mm in diameter in the inferior lobe of the left lung. After 2 weeks physical examination demonstrated a distended abdomen and auscultation was indicated by hyperactive bowel sounds. Further imaging studies with abdominal computed tomography (CT) scan, showed multiple protruding small bowel tumors with entero enteric intussusceptions at three sites requiring a massive bowel resection at surgery. The pathology showed that it was positive for cytokeratin, vimentin, CD-34, and LIS; CK7 was focally positive; and CD117, CD20, and desmine were negative. The final diagnosis was metastatic small bowel carcinosarcoma with a lung primary. DISCUSSION: Lung carcinosarcoma is a high grade biphase neoplasm. The survival rate at 6 months is only around 27%. CONCLUSION: There are rare reports of small intestinal intussusceptions caused by metastatic lung carcinosarcoma, this presentation shows the third case in literature. Physicians should be more alert to symptoms or signs indicating GI metastais in patients with a history of lung cancer.

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.

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.

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.

Laparoscopic Nissen-Rossetti fundoplication is a safe and effective treatment for both Acid and bile gastroesophageal reflux in patients poorly responsive to proton pump inhibitor.

PURPOSE: The aim of this study was to evaluate the effectiveness of laparoscopic Nissen-Rossetti fundoplication in patients with gastroesophageal reflux disease (GERD) poorly responsive to standard dose proton pump inhibitor (PPI) therapy. METHODS: A total of 35 patients (19 women, 16 men, mean age 44.6 ± 14.01 years) were enrolled. All the patients underwent symptom questionnaires, upper gastrointestinal endoscopy, esophageal manometry, and combined 24-hour esophageal pH and bilirubin monitoring. Following this, the patients with persistent pathological esophageal acid and/or bilirubin exposure underwent laparoscopic antireflux surgery, followed by clinical and instrumental 12-month follow-up. RESULTS: One year after surgery, there was a significant improvement of symptom score, compared with standard PPI dose period (3.54 ± 1.67 vs 20.8 ± 10.9, P < .0001; paired t test) and mean percentage total time acid and bile exposure showed a significant decrease (4.9 ± 2.9 vs 2.03 ± 0.74 and 8.3 ± 3.03 vs 0.84 ± 0.56, P < .0001; paired t test). CONCLUSIONS: In patients with GERD poorly responsive to standard PPI dose, laparoscopic Nissen-Rossetti fundoplication appears to be a safe and effective treatment of symptoms, esophageal damage, as well as both acid and bile reflux.