Utility of Molecular Analysis of Peritoneal Fluid in Staging Laparoscopy of Advanced Esophagogastric Junction and Gastric Cancer Prior to Neoadjuvant Treatment.

PURPOSE: Molecular analysis of peritoneal fluid in staging laparoscopy of gastric cancer is performed to improve the detection of free intraperitoneal tumor cells. Nevertheless, its significance is controversial, especially in patients with negative cytology but positive molecular analysis. The aim of this study was to analyze the sensitivity of molecular analysis and its prognostic value. METHODS: A retrospective analysis from April 2011 to October 2019 was performed. Cytology (Cyt) and molecular analysis were analyzed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) of the carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) tumor makers. RESULTS: During the study period, 138 staging laparoscopies were performed. Macroscopic carcinomatosis was found in 12.3%. Of the remaining 87.7%, 9.9% were Cyt + and 11.6% were Cyt- RT-PCR + . Of the latter, 9 responded to chemotherapy and underwent radical surgery. The sensitivity of cytology and molecular analysis was 0.70 and 0.76, respectively (p = 0.67). The 2-year overall survival (OS) of Cyt- RT-PCR + vs. Cyt + was similar (p = 0.1). The 2-year OS of Cyt-RT-PCR + subgroup who underwent radical surgery vs. Cyt-RT-PCR- patients was similar (p = 0.69), but disease-free survival was shorter in the first group (p = 0.005). CONCLUSION: Our results show that the sensitivity of molecular analysis is similar to that of cytology. The prognostic value of positive molecular analysis was similar to positive cytology in terms of 2-year overall survival, except in the subgroup of operated patients in whom the overall survival was similar to that of those with a negative molecular analysis, albeit with a shorter disease-free survival.

Gastric and Small Intestine Gist: Results of 156 Cases in 20 Years.

PURPOSE: Gastric and small intestine are the most common gastrointestinal stromal tumors (GISTs). There are few studies of patients who underwent surgical treatment with disparate findings. We aimed to evaluate the differences between groups and the risk factors for recurrence and mortality. METHODS: A retrospective study of 96 gastric and 60 small intestine GIST was performed between 1995 and 2015. Both groups were compared in terms of clinicopathologic features, morbidity, recurrence, and mortality. Statistical analysis was performed with SPSS®. RESULTS: Eighty-one gastric GISTs and 56 small intestine GISTs underwent surgical treatment. Gastrointestinal bleeding was the most common cause of emergency surgery being more frequent in gastric GIST (P = 0.009); however, emergency surgery was indicated more frequently in the small intestinal GIST (P = 0.004) and was mostly due to perforation (P = 0.009). With a median follow-up of 66.9 (39.7-94.8) months, 28 (20.4%) patients had recurrence. A mitotic index > 5 (P ≤ 0.001) and the intestinal location (P = 0.012) were significantly associated to recurrence. Tumor size > 15 cm (P = 0.001) and an age of ≥ 75 years (P = 0.014) were associated to mortality. On univariate analysis, higher mean values of Ki-67 were associated to higher mortality (P = 0.0032). Small intestine GIST presented lower disease-free survival (DFS) than that of gastric GIST (65.7% vs 90.8%) with P = 0.003. The overall survival (OS) of gastric and small intestine GIST was 74.7% and 71.6%, respectively (P = 0.68). CONCLUSION: Small intestine GIST received emergency surgery more frequently showing lower DFS and same OS than that of gastric GIST. We found that Ki-67 could be a prognostic factor. Further studies are necessary to assess whether Ki-67 is a prognostic risk factor for GISTs.

Multidisciplinary cancer care may impact on the postoperative mortality and survival of patients with oesophageal and oesophagogastric junction cancer: a retrospective cohort study

Background. Modern management of Oesophageal and oesophagogastric junction (OGJ) cancers requires a multidisciplinary approach, which was implemented at our health centre in 2005. This study aimed to assess the impact of this change on clinical outcomes. Methods. A retrospective cohort study was conducted, covering all patients treated for oesophageal and OGJ cancer at the cancer centre established by the Bellvitge University Hospital and Catalonian Institute of Oncology, over two time periods, i.e. 2000–2004 and 2005–2008. Descriptive and multivariate analyses were performed using survival at 1 and 3 years as dependent variables. Results. Between 1 January 2000 and 31 December 2008, 586 patients were included. Number of patients with unknown stage at diagnosis was significantly reduced. Preoperative strategies at the oesophageal location clearly increased in the recent period. A multidisciplinary approach resulted in a significant reduction in surgical mortality (11.8 vs. 2 %) in the period 2005–2008. Analysis restricted to patients undergoing surgery with curative intent indicated a significant increase in 1- and 3-year survival in the latter period (68.4 vs. 89.8 and 38.2 vs. 57.1 %, respectively). Multivariate analysis showed that variables associated with improved survival were: age; tumour stage; radical intent of treatment (surgery and radical combined chemoradiotherapy); and therapeutic strategy. Conclusion. Better selection of patients for therapy together with improved staging resulted in a significant improvement in 1- and 3-year survival in cases undergoing surgery with curative intent. These changes would support the adoption of a multidisciplinary approach to clinical decision-making in cases of oesophageal and OGJ cancer (AU)

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Multidisciplinary cancer care may impact on the postoperative mortality and survival of patients with oesophageal and oesophagogastric junction cancer: a retrospective cohort study.

BACKGROUND: Modern management of Oesophageal and oesophagogastric junction (OGJ) cancers requires a multidisciplinary approach, which was implemented at our health centre in 2005. This study aimed to assess the impact of this change on clinical outcomes. METHODS: A retrospective cohort study was conducted, covering all patients treated for oesophageal and OGJ cancer at the cancer centre established by the Bellvitge University Hospital and Catalonian Institute of Oncology, over two time periods, i.e. 2000-2004 and 2005-2008. Descriptive and multivariate analyses were performed using survival at 1 and 3 years as dependent variables. RESULTS: Between 1 January 2000 and 31 December 2008, 586 patients were included. Number of patients with unknown stage at diagnosis was significantly reduced. Preoperative strategies at the oesophageal location clearly increased in the recent period. A multidisciplinary approach resulted in a significant reduction in surgical mortality (11.8 vs. 2 %) in the period 2005-2008. Analysis restricted to patients undergoing surgery with curative intent indicated a significant increase in 1- and 3-year survival in the latter period (68.4 vs. 89.8 and 38.2 vs. 57.1 %, respectively). Multivariate analysis showed that variables associated with improved survival were: age; tumour stage; radical intent of treatment (surgery and radical combined chemoradiotherapy); and therapeutic strategy. CONCLUSION: Better selection of patients for therapy together with improved staging resulted in a significant improvement in 1- and 3-year survival in cases undergoing surgery with curative intent. These changes would support the adoption of a multidisciplinary approach to clinical decision-making in cases of oesophageal and OGJ cancer.

Preoperative gastric conditioning in cervical gastroplasty.

To determine if ischemic conditioning of the stomach improves the morbidity, mortality, and the anastomotic failure in gastroplasties with cervical anastomosis. Analysis of all patients with indication for cervical gastroplasty during the period of study. In all cases, ischemic conditioning was performed by selective embolization. Anastomotic failure, morbidity, and mortality rates were studied. Thirty-nine consecutive patients were included. Angiography and selective embolization of the left gastric, right gastric, and splenic arteries were performed. Surgery was performed 2 weeks later. Four patients did not have a complete embolization; median hospital stay after conditioning was 1.24 ± 0.6 days. In two patients, surgery could not be completed. Of the 33 remaining, 29 had a posterior mediastinic gastroplasty and four through the anterior mediastinum. The most common morbidity was respiratory. Five patients had a reoperation and the mortality was 6%. One case of anastomotic leak was found (3%). The mean hospital stay was 17.5 days. Preoperative embolization is a technique with acceptable morbidity and a short hospital stay. In our experience it can reduce the incidence of the morbidity, mortality, and anastomotic leak in gastroplasties with cervical anastomosis. Prospective studies will be necessary to demonstrate the validity of this approach.

Effect of weight loss induced by gastric bypass on proinflammatory interleukin-18, soluble tumour necrosis factor-alpha receptors, C-reactive protein and adiponectin in morbidly obese patients.

OBJECTIVE: Interleukin-18 (IL-18) is a potent proinflammatory cytokine whose role in human obesity has recently been suggested. The aim of our study was to analyse in morbidly obese patients undergoing gastric bypass, the relationship of IL-18 with insulin resistance and with proinflammatory cytokines (tumour necrosis factor-alpha receptors, sTNFR), C-reactive protein (CRP) and with adiponectin. DESIGN: Observational and prospective study. PATIENTS: Sixty-five morbidly obese patients, aged 45 +/- 8.9 years, were studied before and 12 months after gastric bypass. MEASUREMENTS: We analysed plasma concentrations of IL-18, sTNFR, CRP and adiponectin. RESULTS: Plasma concentrations of sTNFR2, IL-18 and CRP were decreased and adiponectin significantly increased after bypass surgery. In the multiple regression analysis, preoperative values of IL-18 remained significantly associated with preoperative triglycerides (beta = 0.47, P = 0.005) and TNFR2 (beta = 0.47, P = 0.004). R(2) for the model = 0.38. Postoperative IL-18 concentrations in the multiple regression analysis were significantly associated with postoperative homeostasis model assessment of insulin resistance (HOMA-IR) (beta = 0.092, P = 0.019) and triglycerides (beta = 0.40, P = 0.036). R(2) for the model = 0.46. IL-18 did not correlate with body mass index, fat mass, fat-free mass or body fat. No relationship was either found between adiponectin and IL-18, TNFR1 and -2 and CRP. CONCLUSIONS: Massive weight loss induced by gastric bypass reduces IL-18, TNFR2 and CRP. IL-18 might be a marker of the chronic inflammatory process underlying insulin resistance but its lack of association with anthropometric and body composition parameters does not support a major secretion by human adipocytes. IL-18 and sTNFR1 and -2 do not play a main role in the inhibition of the secretion of adiponectin.

Laparoscopic procedures in patients who have previously undergone laparotomic operations.

BACKGROUND: Patients who have undergone laparotomy can undergo laparoscopic procedures and thus benefit from the advantages that the technique offers without significantly increasing the risk of the operation. METHODS: We present the results of 240 patients, chosen at random who underwent laparoscopic procedures and who had already had 1 or more laparotomic abdominal operations. We carried out 180 cholecystectomies, 12 of which for acute inflammation of the gall bladder, 10 for acute biliary pancreatitis, 3 with exploration of the common bile duct, 45 Nissen fundoplication procedures, of which 16 with removal of the gall bladder, 4 subtotal gastrectomies, 2 GEAs, 2 left colectomies, 4 adhesiolyses. RESULTS: The duration of the procedure varied from 40 to 300 minutes, and hospitalization time after the operation from 1 to 15 days, depending on the previous operation and on the laparoscopic procedure used. A traditional operation (conversion) became necessary in 1.35% of patients. Complica-tions arose in 4% of cases: 4 hematomas, 1 infected wound, 2 bile leaks and 2 bowel fistulas at low flow. CONCLUSIONS: Laparoscopic surgery in pa-tients who have previously undergone abdominal operations is difficult. The extent of conversions and complications can be contained within acceptable limits by choosing carefully the insertion point of the first trocar and dissecting the bowel with great precision.

Emergency laparoscopic treatment for acute massive bleeding of an esophageal ulcer.

Laparoscopic fundoplication is now considered the treatment of choice for the management of severe gastroesophageal reflux disease (GERD) and its complications. The laparoscopic approach achieves the same good results as open surgery in elective surgery for GERD; it also has all the advantages of minimally invasive surgery. Today, laparoscopy plays also a significant role in a great variety of emergency abdominal situations and acute abdominal pain. A 30-year-old man was admitted to our center due to an upper gastrointestinal bleed caused by a esophageal ulcer over a Barrett's esophagus located in lower third of the esophagus. Two therapeutic esophagogastroscopies were done in 24 h, but urgent surgical intervention was indicated because of recurrent transfusion-demanding bleeding. A combined laparoscopic-endoscopic approach was followed. Surgery began with a complete hiatal dissection, including the distal third of the esophagus, diaphragmatic crus, and wide retrogastric window. Intraoperative flexible esophagoscopy revealed an active ulcer bleeding on the right anterior quadrant in the lower esophagus. Two transfixive stitches were applied through the wall of the esophagus at the site indicated by the light of the flexible endoscope, and complete hemostasis was achieved. Finally, employing the anterior wall of the fundus, a short Nissen-Rossetti fundoplication was performed. The operating time was 140 min. There were no complications and there has been no recurrence of the bleeding.

Laparoscopic surgery in the elderly patient.

BACKGROUND: Elderly patients represent a unique surgical challenge because of the associated complex comorbidity and diminished cardiopulmonary reserve. Therefore, minimally invasive surgery in the elderly may have a larger impact compared to the younger population. The aim of this study was to prospectively evaluate the experience of laparoscopic surgery in patients >or=70 years of age in our unit. METHODS: Two hundred and thirty-two patients (34 females and 98 males) older than 70 years who underwent various elective and emergency laparoscopic procedures between 1992 and 1997 were assessed prospectively. Preoperative comorbidity, operative results, and postoperative outcomes were analyzed. RESULTS: The median age of the patients was 76 years. The majority of patients were ASA class II. The mean hospital stay was 3.4 days. The overall morbidity and mortality rates were 10.8% and 3.4% respectively, and the conversion rate was 4.3%. CONCLUSIONS: Our experience suggests that laparoscopic surgery in the elderly is safe, is associated with short hospital stay, and produces less morbidity and mortality. Therefore, it should be adopted widely if the expertise in the area of laparoscopic surgery is available for this group of patients.

The contribution of laparoscopy to the treatment of gastric cancer.

BACKGROUND: Laparoscopy plays a role in the preoperative diagnosis of gastric cancer, particularly in determining the location and extent of the neoplasia. In addition to its use in staging, laparoscopy is indicated for the gastric resection of T1-T2, and its middle- and long-term results are comparable to those obtainable with open surgery. Herein we describe our experience with the laparoscopic resection of gastric carcinomas, including the dissection of lymph nodes and the Billroth II reconstruction of digestive continuity with gastrojejunostomia. METHODS: We carried out laparoscopic gastric resections in 25 patients with adenocarcinomas. Our method involved installing five trocars, tying the left and right gastric vessels and the right gastro-epiploic vessels, sectioning the duodenum 3 cm from the pylorus, sectioning the remaining portion of the stomach obliquely 3 cm from the cardias, and performing Billroth II reconstruction. RESULTS: The average duration of the operation was 4 h 45 min. The average number of removed lymph nodes was 30.5 (range, 22-41). Five patients were converted to laparotomy. Significant complications were observed in four cases (16%). Hospitalization ranged from 5 to 16 days. The average follow-up was 38 months (range, 7-63), without evidence of relapse. CONCLUSION: In terms of morbidity, our results were similar to those obtained with open surgery. Lymphectomy according to the extent and number of lymph nodes is acceptable in the treatment of tumors of the lower third of the stomach. More case studies are needed to provide further indications of the applicability of the technique (which is currently used only in a few centers) and long-term results.

Results of the management of upper gastrointestinal bleeding from gastroesophageal varices.

INTRODUCTION: The management of upper gastrointestinal bleeding caused by rupture of gastric and/or esophageal varices in patients with liver cirrhosis must focus on the initial control of the haemorrhage avoiding further worsening of an already poor liver function and the prevention of early relapsing bleeding. Therapeutic options include endoscopic, pharmacological and surgical methods. MATERIAL AND METHODS: Prospective study of the results obtained after the follow-up of 90 bleeding episodes in a total of 54 patients, 35 men and 19 women, with a mean age of 58 years (range 32-77), to which a therapeutic protocol for acute bleeding secondary to portal hypertension was applied over a 22-months period. Patient classification according to Child-Pugh upon admission was 57% Child A, 34% Child B and 9% Child C. RESULTS: Mean hospital length of stay was 9 days (2-50). Of the 90 bleeding episodes, 15 were early relapsing bleeding episodes (16.7%). Twelve patients died (mortality rate of 22.2% by patients and 13.4% by bleeding episodes). Twelve emergency surgical procedures were performed because of the persistence of haemorrhage. Forty one per cent of patients were readmitted because of relapsing bleeding at least once during the follow-up period. CONCLUSIONS: Management of upper gastrointestinal bleeding due to gastroesophageal varices in patients with liver cirrhosis requires a combined therapy in order to attain maximum effectiveness in acute haemorrhagic episodes and to address all potential later consequences. Such therapy should be provided in a hospital fully equipped and with specialists in this pathology. Based on our experience, emergency surgery as rescue treatment for persistent or short-term relapsing bleeding should be restricted to patients with good hepatic function because of its high morbidity and mortality.

Laparoscopy in acute biliary pancreatitis.

BACKGROUND: The high mortality rates (20-30%) still occurring in some forms of acute pancreatitis demands adequate clinical and instrumental protocols in order to establish the most suitable therapeutic option to employ. The use of laparoscopic surgery can reduce hospital stay and time for functional recovery. METHODS: The study enrolled 73 patients referring for acute biliary pancreatitis in whom staging with clinical, laboratory and instrumental criteria was performed. According to Ranson classification 63 patients (86.3%) had a mild-moderate acute biliary pancreatitis, 10 (13.6%) a severe one. In the first group laparoscopic cholecystectomy with retrograde cholangiography was performed within seven days of admission, in the second group surgical procedure followed medical treatment between eight and 30 days after the onset of the disease. No preoperative ERCP was performed. RESULTS: The rate of main biliary tract calculosis was 8.2% in group A: six cases all treated through laparoscopy. Two switches (2.7%) due to intolerance to the pneumoperitoneum, eight major postoperative complications (10.9%), and two deaths (2.7%) occurred and a mean hospital stay of 7.4 days was observed in group A versus 8.2 days in group B. CONCLUSIONS: The management suggested in this study for mild-moderate acute biliary pancreatitis showed consistent results with those of the recent literature, as far as morbidity (6.3%) and mortality (1.5%) are concerned. A higher number of severe biliary pancreatitis (10 cases) should be observed to assess the role of ERCP with endoscopic sphincterotomy rather than laparoscopic or combined treatment.

Resultados del tratamiento de la hemorragia digestiva alta por varices esofagogástricas / Results of the management of upper gastrointestinal bleeding from gastroesophageal varices

Introducción: el tratamiento de la hemorragia digestiva alta por rotura de varices esofágicas y/o gástricas en pacientes con cirrosis hepática debe estar dirigido al control inicial de la hemorragia --sin alterar más una función hepática ya deteriorada--, y a la prevención de la recidiva hemorrágica precoz. Métodos endoscópicos, farmacológicos y quirúrgicos forman el conjunto de alternativas terapéuticas. Material y métodos: estudio prospectivo de los resultados obtenidos tras el seguimiento de 90 episodios hemorrágicos de un total de 54 pacientes, 35 hombres y 19 mujeres, con una edad media de 58 años (32-77), sobre los que se aplicó un protocolo terapéutico de la hemorragia aguda secundaria a la hipertensión portal, durante un periodo de 22 meses. La clasificación según Child-Pugh al ingreso fue 57 por ciento Child A, 34 por ciento Child B y 9 por ciento Child C.Resultados: la estancia media hospitalaria fue de 9 días (250). De los 90 episodios hemorrágicos, se registraron 15 recidivas hemorrágicas precoces (16,7 por ciento). Murieron 12 pacientes (mortalidad del 22,2 por ciento por pacientes y del 13,4 por ciento por episodios hemorrágicos). Se realizaron 12 intervenciones de urgencias por persistencia de la hemorragia. El 41 por ciento de los pacientes reingresaron por recidiva de la hemorragia al menos una vez durante el periodo de seguimiento. Conclusiones: el tratamiento de la hemorragia digestiva alta por varices esófago-gástricas con cirrosis hepática, requiere un conjunto de diferentes tratamientos para obtener la máxima eficacia en el episodio hemorrágico agudo y poder abarcar todas las posibles repercusiones a posteriori; dicho tratamiento debería ser realizado en un centro hospitalario que disponga de material y personal especializado en esta patología. En nuestra experiencia, la cirugía de urgencias, como tratamiento de rescate de la hemorragia persistente o recidivante a corto plazo, sólo tendría lugar en algunos pacientes con una buena función hepática dada su alta morbi/mortalidad (AU)

Effect of oral supplementation of ornithine-alpha-ketoglutarate on the intestinal barrier after orthotopic small bowel transplantation.

The aim of this study was to analyze the possible protective effects of a glutamine and arginine precursor (ornithine-alpha-ketoglutarate [OKG]) on the mucosa of a transplanted intestine when administered with either a defined formula oral diet (DFD) or a standard chow. Isogenic male Lewis rats (250 g) were submitted to a laparotomy (groups 1 and 2) or to an orthotopic small bowel transplantation (SBT; groups 3-6). Groups 1, 3, and 5 received a DFD 14 days after surgery. Groups 2, 4, and 6 received standard chow. In addition, groups 5 and 6 received a daily oral supplementation of 1.4 g/kg of OKG. Weight changes and food intake were recorded daily. At the end of the study, bacterial translocation (BT) was measured in mesenteric lymph nodes, liver, and spleen. The protein/DNA index was also determined in intestinal mucosa. SBT induced BT in all transplanted groups, especially in those fed DFD. Addition of OKG (groups 5 and 6) significantly reduced BT in comparison with groups 3 and 4 and improved the protein/DNA index as well as weight gain. It is concluded that OKG supplementation protects the intestinal barrier after SBT, and that this effect is more marked when it is added to a standard chow.

Intraoperative colonic lavage and primary anastomosis in peritonitis and obstruction.

BACKGROUND: The surgical management of left colonic emergencies has evolved in the past few decades. Recently, there has been increasing interest in resection with primary anastomosis in selected cases. The aim of this study was to evaluate the differences in outcome in patients with peritonitis or obstruction treated by resection, on-table lavage and primary anastomosis of the left colon. METHODS: Between January 1992 and August 1995, 212 patients underwent emergency operation for a distal colonic lesion: 97 presented with peritonitis, 113 with obstruction and two with other indications. Intraoperative colonic lavage was performed in 37 patients with obstruction and in 24 with an acute intra-abdominal inflammatory process. RESULTS: The postoperative mortality rate was 5 per cent. The incidence of clinical anastomotic leakage was 5 per cent. Wound infection was observed in ten patients (16 per cent), more often in those with peritonitis (P = 0.03). The overall mean(s.d.) hospital stay was 15(9) days. CONCLUSION: Resection, on-table lavage and primary anastomosis constitute the operation of choice for selected patients with left colonic emergency.

[Surgical treatment of emergency pathology of the left colon]. / Tratamiento quirúrgico de la patología urgente del colon izquierdo.

The aim of this study was to evaluate the postoperative morbidity and mortality of patients with left colon disease that underwent emergency surgery. Intra-operative colonic irrigation (ICI) with primary anastomosis was used for unresectable lesions, faecal peritonitis, colon remnant associated lesions and poor performance status. The options included colostomy, Hartmann procedure or subtotal colectomy; 127 resections of left-sided large bowel were performed. In 56 cases the procedure was a Hartmann operation, in 38 cases subtotal colectomy and in 33 ICI. The most frequent complication was abdominal sepsis (29%). The overall mortality was 24%; 39% for the Hartmann procedure; 16% for subtotal colectomy and 6% for ICI. Our results suggest that ICI should be the first choice in patients with good performance status who undergo emergency surgery for left colon disease without faecal peritonitis or associated right colon lesions.

[Left hemicolectomy and intraoperative antegrade lavage in emergency surgery of the left colon]. / Hemicolectomía izquierda y lavado anterógrado peroperatorio en el tratamiento de la patología urgente del colon izquierdo.

We report our results with a left colonic resection and intraoperative antegrade colonic irrigation technique with primary anastomosis. Thirty five consecutive patients operated on in the Emergency Surgical Ward are presented. Twenty five with large bowel occlusion and 10 with sigma perforation. Anastomotic leakage (2 patients, 5.7%) and postoperative hospital stay (mean 15 days) were similar to cases of elective surgery. The intraoperative antegrade colonic irrigation technique has become the first choice in our Department to treat any patient with left colonic occlusion or perforation. Only patients with faecal peritonitis or ischemic colon were excluded.