Complex Vascular Resections for Retroperitoneal Soft Tissue Sarcoma.

Retroperitoneal sarcomas (RPSs) are locally aggressive tumors that can compromise major vessels of the retroperitoneum including the inferior vena cava, aorta, or main tributary vessels. Vascular involvement can be secondary to the tumor's infiltrating growth pattern or primary vascular origin. Surgery is still the mainstay for curing this disease, and resection of RPSs may include major vascular resections to secure adequate oncologic results. Our improved knowledge in the tumor biology of RPSs, in conjunction with the growing surgical expertise in both sarcoma and vascular surgical techniques, has allowed for major vascular reconstructions within multi-visceral resections for RPSs with good perioperative results. This complex surgical approach may include the combined work of various surgical subspecialties.

Ongoing Controversies in Esophageal Cancer II: Gastrectomy versus Esophagectomy for Siewert Type II Esophageal Adenocarcinoma.

The optimal management of Siewert Type II or Junction AEG II adenocarcinoma remains a point of debate. Surgical options include an extended total gastrectomy or esophagectomy. Accurately identifying the location of the esophagogastric junction (GEJ) is important as the epicenter of the lesion is defined in reference to the GEJ. Type II tumors, in the most recent iteration of the AJCC, describe these lesions as being within 1 cm cephalad and 2 cm caudal to GEJ. Accurate staging of the location and identification of nodal metastasis is vital to guide the optimal surgical approach. Endoscopy, endosonography, CT, and PET help guide decision-making as to what junctional subtype is present. The extent of resection and lymphadenectomy remains contestable. Both surgical approaches remain viable, as each has its own advantages and issues. The key to the management of these cancers is that the surgeon has the capability to operate on both sides of the diaphragm to manage these oftentimes challenging malignancies.

Leiomyosarcoma: Current Clinical Management and Future Horizons.

Leiomyosarcomas are soft tissue tumors that are derived from smooth muscle mainly in the pelvis and retroperitoneum. Percutaneous biopsy is paramount to confirm diagnosis. Imaging is necessary to complete clinical staging. Multimodal treatment should be directed by expert sarcoma multidisciplinary teams that see a critical volume of these rare tumors. Surgery is the mainstay of curative intent treatment; however due to its high metastatic progression, there may be a benefit for neoadjuvant systemic treatment. Adjuvant systemic treatment has no proven disease-free survival, and its main role is in the palliative setting to potentially prolong overall survival.

Starting a peritoneal carcinomatosis treatment program in a developing country: A prospective analysis.

BACKGROUND: Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) has become a valuable treatment strategy for selected patients with peritoneal carcinomatosis (PC). In Chile, it is an emerging technique. The aim of this study is to describe our protocol and report our perioperative results. METHODS: A prospectively maintained database for patients undergoing exploratory surgery for PC was reviewed. Eligible patients were selected using the peritoneal cancer index in correlation with the primary tumor. Patients underwent HIPEC using mitomycin C. Clinical data and postoperative results were analyzed. RESULTS: Seventy-six patients underwent exploratory surgery. Most patients were female (55%) with a median age of 62 years (range, 25-83). Complete CRS and HIPEC were achieved in 53 patients. The most frequent primary tumor site was colon-rectum (49%). The median number of resected organs was 4 (range, 1-13). Overall 90-day incidence of major complications was 26%. After a median follow-up of 26 months, 44 patients (83%) in the resected group were alive with no evidence of disease. CONCLUSIONS: The PC treatment program at our institution has been established in a safe manner, with acceptable morbidity comparable to high-volume centers. A comprehensive preoperative evaluation, careful patient selection, and a cohesive team are necessary for successful results.

Simultaneous resection of colorectal cancer with synchronous liver metastases (RESECT), a pilot study.

INTRODUCTION: The "traditional approach" to resect synchronous colorectal cancer with liver metastases (CRLM) is to perform staged resections. Many institutions perform simultaneous resection. Disadvantages to the simultaneous approach include longer operating room times, which may increase major postoperative complication rates. Data supporting simultaneous resection are limited to retrospective studies that are subject to selection bias. Therefore, we have proposed a single-arm prospective cohort pilot study to evaluate the postoperative complications following simultaneous resection of synchronous CRLM. METHODS AND ANALYSIS: This single-arm study will be performed in five high-volume hepatobiliary centres to prospectively evaluate the following objectives: (1) To determine the 90-day postoperative complication rate of patients diagnosed with synchronous CRLM undergoing a simultaneous colorectal and liver resection, including major liver resections; (2) To determine the postoperative mortality rate at 90 days following index surgery; (3) To determine change in global health-related Quality of Life (QoL) following simultaneous resection at three months compared to baseline; and (4) To build a costing model for simultaneous resection, We will also evaluate the feasibility of performing combined resection in these patients by evaluating the number of eligible patients enrolled in the study and determining the reasons eligible patients were not enrolled. This protocol has been registered with ClinicalTrials.gov (NCT02954913). ETHICS AND DISSEMINATION: This study has been provincially approved by the central research ethics board. Study results will inform the design a randomized controlled trial by providing information about the comprehensive complication index in this patient population used to calculate the sample size for the trial.

Liver resection after chemotherapy and tumour downsizing in patients with initially unresectable colorectal cancer liver metastases.

OBJECTIVES: Among patients with initially unresectable colorectal cancer liver metastases (CLM), a subset are rendered resectable following the administration of systemic chemotherapy. This study reports the results achieved in liver resections performed at a single hepatobiliary referral centre after downsizing chemotherapy in patients with initially unresectable CLM. METHODS: All liver resections for CLM performed over a 10-year period at the Toronto General Hospital were considered. Data on initially non-resectable patients who received systemic therapy and later underwent surgery were included for analysis. RESULTS: Between January 2002 and July 2012, 754 liver resections for CLM were performed. A total of 24 patients were found to meet the study inclusion criteria. Bilobar CLM were present in 23 of these 24 patients. The median number of tumours was seven (range: 2-15) and median tumour size was 7.0 cm (range: 1.0-12.8 cm) before systemic therapy. All patients received oxaliplatin- or irinotecan-based chemotherapy. Fourteen patients received combined treatment with bevacizumab. Negative margin (R0) resection was accomplished in 21 of 24 patients. There was no perioperative mortality. Ten patients suffered perioperative morbidity. Eighteen patients suffered recurrence of disease within 9 months. Rates of disease-free survival at 1, 2 and 3 years were 47.6% [95% confidence interval (CI) 30.4-74.6%], 23.8% (95% CI 11.1-51.2%) and 19.0% (95% CI 7.9-46.0%), respectively. Overall survival at 1, 2 and 3 years was 91.5% (95% CI 80.8-100%), 65.3% (95% CI 48.5-88.0%) and 55.2% (95% CI 37.7-80.7%), respectively. CONCLUSIONS: Liver resection in initially unresectable CLM can be performed with low rates of morbidity and mortality in patients who respond to systemic chemotherapy, although these patients do experience a high frequency of disease recurrence.

A cadaveric porcine model for assessment in laparoscopic bariatric surgery--a validation study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most effective surgical therapy for morbid obesity. It is an advanced laparoscopic surgical procedure and has a protracted learning curve. Therefore, it is important to develop innovative ways of training and assessing surgeons. The aim of this study is to determine if a cadaveric porcine jejuno-jejunostomy model is an accurate way of assessing a surgeon's technical skills by determining if a correlation exists with how he performs in the operating room. METHODS: Eight surgeons of varying experience performed a side-to-side stapled jejuno-jejunostomy on a cadaveric bench model before proceeding to perform the procedure on a real patient scheduled for LRYGBP. Performance was assessed using a motion tracking device, the Imperial College Surgical Assessment Device. Each procedure was recorded in video and scored by two blinded expert surgeons using procedure-specific rating scales. RESULTS: The cadaveric bench model demonstrated concurrent validity with significant correlations between performance on the cadaveric model and patient for dexterity measures. Left-hand path length, r = 0.857 (median, 27, 41.3; P = 0.007), right-hand path length, r = 0.810 (median, 31.5, 60; P = 0.015) and total number of movements, r = 0.743 (median, 422, 637; P = 0.035). This correlation in performance was also demonstrated in the video rating scales, r = 0.727 (median, 13.2, 14.8; P = 0.041). No correlation was found in operative time (median, 541, 742; P = 0.071). CONCLUSIONS: This study demonstrates the concurrent validity of the cadaveric porcine model, showing similar performances in surgeons completing a jejuno-jejunostomy on the cadaveric model and the patient.

The role of laparoscopy for gastric surgery in the West.

The only potentially curative treatment available for gastric adenocarcinoma is surgical resection. However, many controversies exist regarding treatment strategy, including whether the laparoscopic approach is appropriate. Many reports of laparoscopic techniques for cancer resection have shown oncologic equivalency to the open technique, with the known benefits of the minimally invasive approach, such as decreased pain, length of hospital stay, blood loss, and complications. The Eastern experience with laparoscopic gastrectomy has been extensive, associated with the increased incidence of early gastric cancers. However, in the West, laparoscopic approaches for gastric cancer have been more slowly accepted, largely due to the lower incidence of gastric cancer in this part of the world. Therefore, we aimed to review the technical feasibility and oncologic efficacy of the laparoscopic versus open approach to resection for gastric adenocarcinoma in the West. Review of the literature demonstrates that laparoscopic gastrectomy is a safe technique with short-term oncologic results that are equivalent in terms of margin status and lymph node retrieval and are associated with additional benefits of the minimally invasive approach, although long-term follow up is necessary. Laparoscopic gastrectomy for adenocarcinoma, similar to findings in the East, resulted in a decreased length of hospital stay, decreased narcotic use, fewer complications, and equivalent short-term oncologic outcomes. It appears that the minimally invasive approach for gastric resection of adenocarcinoma is safe and satisfies oncologic requirements, and is justified for use in selected patients.

Laparoscopic versus open subtotal gastrectomy for adenocarcinoma: a case-control study.

OBJECTIVE: The aim of this study is to compare technical feasibility and oncologic efficacy of totally laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma. BACKGROUND: Laparoscopic gastrectomy for adenocarcinoma is emerging in the West as a technique that may offer benefits for patients, although large-scale studies are lacking. METHODS: This study was designed as a case-controlled study from a prospective gastric cancer database. Thirty consecutive patients undergoing laparoscopic subtotal gastrectomy for adenocarcinoma were compared with 30 patients undergoing open subtotal gastrectomy. Controls were matched for stage, age, and gender via a statistically generated selection of all gastrectomies performed during the same period of time. Patient demographics, tumor-node-metastasis (TNM) stage, histologic features, location of tumor, lymph node retrieval, recurrence, margins, and early and late postoperative complications were compared. RESULTS: Tumor location and histology were similar between the two groups. Median operative time for the laparoscopic approach was 270 min (range 150-485 min) compared with median of 126 min (range 85-205 min) in the open group (p < 0.01). Hospital length of stay after laparoscopic gastrectomy was 5 days (range 2-26 days), compared with 7 days (range 5-30 days) in the open group (p = 0.01). Postoperative pain, as measured by number of days of IV narcotic use, was significantly lower for laparoscopic patients, with a median of 3 days (range 0-11 days) compared with 4 days (range 1-13 days) in the open group (p < 0.01). Postoperative early complications trended towards a decrease for laparoscopic versus open surgery patients (p = 0.07); however, there were significantly more late complications for the open group (p = 0.03). Short-term recurrence-free survival and margin status was similar between the two groups (p = not significant) with adequate lymph node retrieval in both groups. CONCLUSIONS: Laparoscopic subtotal gastrectomy for adenocarcinoma is comparable to the open approach with regard to oncologic principles of resection, with equivalent margin status and adequate lymph node retrieval, demonstrating technically feasibility and equivalent short-term recurrence-free survival. Additional benefits of decreased postoperative complications, decreased length of hospital stay, and decreased narcotic use make this a preferable approach for selected patients.

Laparoscopic sleeve gastrectomy with ileal transposition (SGIT): A new surgical procedure as effective as gastric bypass for weight control in a porcine model.

INTRODUCTION: Bariatric surgery has evolved into multiple forms in the last decades, combining food restriction and malabsorption. The aim of this study was to develop a new technique based on food restriction and early stimulation of the distal gut, thus maintaining the alimentary tract continuity. METHODS: Thirty-two Yorkshire pigs, weight 22.2 +/- 5.4 kg (mean +/- SD) were randomly assigned to four laparoscopic procedures: ileal transposition (IT, n = 8); sleeve gastrectomy with ileal transposition (SGIT, n = 8); Roux-en-Y gastric bypass (GBP, n = 8); sham operation (SHAM, n = 8). Firing 45-mm linear staplers over a 60-F bougie, resecting the greater curvature and fundus, constituted a sleeve gastrectomy. Ileal transposition was performed by isolating a 100-cm ileal segment proximal to the ileocecal valve and by dividing the proximal jejunum 15 cm distal to the ligament of Treitz and performing re-anastomosis. Gastric bypass consisted of creating a proximal gastric pouch and a 300 cm alimentary limb. Sham operation was performed by bowel transections and re-anastomosis in the ileum and proximal jejunum together with gastrotomy and closure. Animals were evaluated weekly for weight increase and food intake. We performed a logistic regression analysis to compare weight progression curves, and analysis of variance (ANOVA) and Bonferroni (Dunn) tests to detect differences in weight and food intake. RESULTS: We observed significant differences in mean weight after 18 weeks between SGIT (30.9 +/- 13.4 kg) and SHAM (72.5 +/- 10.7 kg) (p = 0.0002), and GBP (28.6 +/- 2.5 kg) and SHAM (p = 0.0001), and IT (56.1 +/- 13.4 kg) and SHAM (p = 0.0081). No differences were observed between RYGB and SGIT. We also observed significant differences in food intake (grams per day) in the third month between SGIT (1668 +/- 677 g) versus SHAM (3252 +/- 476 g) (p = 0.0006), and GBP (2011 +/- 565 g) versus SHAM (p = 0.039). No differences were observed in food intake between SGIT and GBP. CONCLUSION: SGIT proved to be as effective in the short term as GBP on weight progression with no bypass of the proximal gut.

Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the most common surgical treatment for morbid obesity. Intestinal obstruction and internal hernias are complications more commonly observed after LRYGB than after open RYGB. The aim of this study was to evaluate the incidence of these complications in patients who had undergone LRYGB using an antecolic versus a retrocolic technique. METHODS: From August 2001 to August 2005, LRYGB was performed in 754 patients. The retrocolic and antecolic technique was used in 300 and 454 consecutive patients, respectively. The mean patient age was 37 +/- 10 years, and 552 of the patients (73%) were women. The mean preoperative body mass index was 41.3 +/- 5 kg/m2. The median follow-up was 16 months. RESULTS: During follow-up, 36 patients (4.7%) underwent surgical exploration secondary to intestinal obstruction. This complication was observed in 28 (9.3%) and 8 (1.8%) patients in the retrocolic and antecolic technique groups, respectively (P <.001). In the retrocolic technique group, an internal hernia developed in 24 patients compared with 3 patients in the antecolic technique group. On multivariate analysis, the retrocolic technique was identified as a risk factor (P <.001). CONCLUSION: A greater incidence of intestinal obstruction and internal hernia was observed in the retrocolic technique group than in the antecolic technique group undergoing LRYGB. The results of our study have shown that the use of the retrocolic technique is a risk factor for intestinal obstruction after LRYGB.

[Laparoscopic gastrectomy in gastric cancer: experience in four patients]. / Gastrectomía laparoscópica en cáncer gástrico: Experiencia preliminar.

BACKGROUND: The development of the laparoscopic surgery has allowed its incorporation to the surgical treatment of gastric cancer. AIM: To evaluate the feasibility and safety of laparoscopic gastrectomy in gastric cancer in our institution. PATIENTS AND METHODS: Prospective data in four patients who underwent laparoscopic gastrectomy for gastric cancer from May to August of 2005 was reviewed. Demographic data, clinical characteristics and postoperative results were registered. Patients were staged according to TNM-AJJC staging system. RESULTS: Four patients aged 48 to 80 years (three males), underwent a completely laparoscopic R0 gastrectomy with lymph node dissection. Two patients underwent total gastrectomy. A subtotal Billroth II gastrectomy was performed in the other two patients. The mean operative time was 260 minutes (Range 180-330). There were no conversions to open surgery. The mean postoperative hospital stay was 6.5 days (Range 6-7 days). There were no complications. According to pathology, one patient presented carcinoma in stage IA, two patients in stage IB and one patient in stage IIIB. The mean number of lymph nodes dissected was 40 (Range 35-54). CONCLUSIONS: Laparoscopic gastrectomy is a feasible procedure with good postoperative results in this preliminary experience.

Gastrectomía laparoscópica en cáncer gástrico: Experiencia preliminar / Laparoscopic gastrectomy in gastric cancer: Experience in four patients

Background: The development of the laparoscopic surgery has allowed its incorporation to the surgical treatment of gastric cancer. Aim: To evaluate the feasibility and safety of laparoscopic gastrectomy in gastric cancer in our institution. Patients and methods: Prospective data in four patients who underwent laparoscopic gastrectomy for gastric cancer from May to August of 2005 was reviewed. Demographic data, clinical characteristics and postoperative results were registered. Patients were staged according to TNM-AJJC staging system. Results: Four patients aged 48 to 80 years (three males), underwent a completely laparoscopic R0 gastrectomy with lymph node dissection. Two patients underwent total gastrectomy. A subtotal Billroth II gastrectomy was performed in the other two patients. The mean operative time was 260 minutes (Range 180-330). There were no conversions to open surgery. The mean postoperative hospital stay was 6.5 days (Range 6-7 days). There were no complications. According to pathology, one patient presented carcinoma in stage IA, two patients in stage IB and one patient in stage IIIB. The mean number of lymph nodes dissected was 40 (Range 35-54). Conclusions: Laparoscopic gastrectomy is a feasible procedure with good postoperative results in this preliminary experience.

Sleeve gastrectomy as treatment for severe obesity after orthotopic liver transplantation.

Obesity is highly prevalent in both liver transplant candidates and recipients, and can have a significant impact on perioperative morbidity and mortality and the overall cost of transplantation. Herein, we describe an obese patient who was managed sequentially with an intragastric balloon in the pre-transplant setting and a gastric sleeve following transplantation, with good long-term results. Sleeve gastrectomy is a non-malabsorptive bariatric procedure with potential benefit for liver transplant patients due to its lack of influence on the absorption of immunosuppressive agents.

Resolution of early stage diabetic nephropathy in an obese diabetic patient after gastric bypass.

Epidemiological studies have proven that obesity is a significant risk factor for type 2 diabetes. Long-term progression of diabetes leads to various microvascular complications, of which diabetic nephropathy has become of increasing importance, and is the main cause of end-stage renal failure in occidental countries. Microalbuminuria is the first marker of incipient diabetic nephropathy, an early stage glomerulopathy which can progress to renal failure and which historically has been treated with angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists. We report a severely obese diabetic patient on treatment for diabetic nephropathy with ACE-inhibitors and poor results, which resolved after Roux-en-Y gastric bypass.

Costos del tratamiento de erradicación del Helicobacter pylori en pacientes con úlcera péptica / Costs of treatment of Helicobacter pylori erradication in patients with peptic ulcer

Introducción: El tratamiento actual de la úlcera péptica en su etapa aguda es la erradicación del Helicobacter pylori (HP) junto con tratamiento de la úlcera con inhibidores de la bomba de protones (IBP). Objetivos Determinar el costo del tratamiento de erradicación con 2 antibióticos por 7 ó 14 días y el costo de diferentes inhibidores de la bomba de protones por 42 días. material y Método: Se revisó un documento farmacológico que contenía los precios de todos los medicamentos con un valor promedio de dólares de 670 pesos. Se analizó presentaciones, dosis y costo del tratamiento. Resultados: Hubo una importante variación de precios de los 2 antibióticos evaluados: Claritromicina y Amoxicilina, con costos que variaban entre 11.000 y 26.000 por 7 días. En cuanto a IBP hay 19 Omeprazoles en el merfcado nacional, con costos de tratamiento por 42 días que varían entre 2.922 pesos y 33800 pesos. Hay 5 Lanzoprazoles y 3 Pantoprazoles. El costo final de todo el tratamiento completo puede variar entre 14.229 pesos y 116.936 pesos. Conclusiones: Los costos de este tratamiento son muy variables y afectan fuertemente el presupuesto de los pacientes. por lo tanto, los médicos que prescriben estos tratamientos deben estar informados claramente de los costos.