Resection for Hilar Cholangiocarcinoma: Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Long-term Outcome

Introduction

Resection for hilar cholangiocarcinoma is the single hope for long-term survival.

Methods

Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan–Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model).

Results

The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR?=?0.03, 95 % CI 0–0.19, p?<?0.001), caudate lobe invasion (HR?=?6.33, 95 % CI 1.31–30.46, p?=?0.021), adjuvant gemcitabine-based chemotherapy (HR?=?0.38, 95 % CI 0.15–0.94, p?=?0.037), and the neutrophil-to-lymphocyte ratio (HR?=?0.78, 95 % CI 0.62–0.98, p?=?0.036) as independent prognostic factors for disease-free survival. The independent prognostic factors for overall survival were R0 resection (HR?=?0.03, 95 % CI 0–0.22, p?<?0.001), caudate lobe invasion (HR?=?11.75, 95 % CI 1.65–83.33, p?=?0.014), and adjuvant gemcitabine-based chemotherapy (HR?=?0.19, 95 % CI 0.06–0.56, p?=?0.003).

Conclusions

The negative resection margin represents the most important prognostic factor. Adjuvant gemcitabine-based chemotherapy appears to benefit survival. The neutrophil-to-lymphocyte ratio may potentially be used to stratify patients for future clinical trials.     

Liver Resection in the Elderly: Significance of Comorbidities and Blood Loss

Objective

Liver resection is increasingly performed in elderly patients who are suspected of increased postoperative morbidity (PM) and reduced overall survival (OS). Patient selection based on the identification of age-adjusted risk factors may help to decrease PM and OS.

Design and Participants

Prospectively collected data of 879 patients undergoing elective hepatic resection were analyzed. This population was stratified into three age cohorts: >70 years (n?=?228; 26 %), 60–69 years (n?=?309; 35 %), and <60 years (n?=?342; 39 %). Multivariate survival analysis was performed.

Results

The incidence of severe (p?<?0.01) and non-surgical (p?<?0.001) postoperative complications was higher in older compared to younger patients. Major estimated blood loss (EBL; p?=?0.039) and comorbidities (p?=?0.002) independently increased PM. EBL was comparable between all age cohorts. However, preexisting comorbidities, major EBL, and postoperative complications markedly decreased OS in contrast to younger patients. Adjusted for age, independent predictors of OS were comorbidities (HR?=?1.51; p?=?0.001), major hepatectomy (HR?=?1.33; p?=?0.025), increased EBL (HR?=?1.32; p?=?0.031), and postoperative complications (HR?=?1.64; p?<?0.001).

Conclusion

Although increased age should not be a contraindication for liver resection, this study accents the avoidance of major blood loss in elderly patients and a stringent patient selection based on preexisting comorbidities.     

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N?=?2,799, 76.1 %) and had resection for malignancy (N?=?2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR?=?1.01, 95 % CI?=?1.01–1.02, p?=?0.001), preoperative malnutrition (OR?=?1.65, 95 % CI?=?1.35–2.02, p?<?0.001), total gastrectomy (OR?=?1.63, 95 % CI?=?1.31–2.03, p?<?0.001), benign indication for resection (OR?=?1.60, 95 % CI?=?1.29–1.97, p?<?0.001), blood transfusion (OR?=?2.57, 95 % CI?=?2.10–3.13, p?<?0.001), and intraoperative placement of a feeding tubes (OR?=?1.28, 95 % CI?=?1.00–1.62, p?=?0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR?=?1.23, 95 % CI?=?0.99–1.53, p?=?0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p?<?0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

     

Preoperative therapy of esophagogastric cancer: the problem of nonresponding patients

Introduction

Preoperative treatment is nowadays standard for locally advanced esophagogastric cancer in Europe. Surprisingly, little attention has been paid to nonresponders so far. The aim of our retrospective exploratory study was the comparison of responder, nonresponder, and primary resected patients in respect of outcome considering the tumor entity.

Patients and methods

From 2001–2011, 607 patients with locally advanced esophagogastric carcinoma (adenocarcinoma of the esophagogastric junction (AEG), n?=?293; squamous cell cancer (SCC), n?=?111; gastric cancer, n?=?203) after preoperative treatment (n?=?281) or primary resection (n?=?326) were included. Histopathological response evaluation (Becker criteria) was available for 263.

Results

A total of 76/263 (28.9 %) were responders (<10 % residual tumor). There was an association of response with increased R0 resections (p?<?0.001) but also with a higher complication rate (p?=?0.008) compared to nonresponse and primary surgery. Mortality was not influenced. Increased R0 resections after response were confirmed in every tumor entity (AEG, p?=?0.010; SCC, p?=?0.023; gastric cancer, p?=?0.006). Median survival was best for responders with 43.5 months [95 % confidence interval (CI), 27.9–59.1], followed by nonresponders with 24.3 months (95 % CI, 21.6–27.0) and primary resected patients with 20.8 months (95 % CI, 17.7–23.9; p?=?0.002). AEG (p?=?0.012) and gastric cancer (p?=?0.017) revealed identical results, but in the subgroup of SCC, the survival of nonresponders (median, 11.6 months; 95 % CI, 6.9–16.3) was even worse than for primary resected patients (median, 23.8 months; 95 % CI, 1.7–46.0; p?=?0.012).

Conclusion

The histopathological response rate was low. Generally, nonresponding patients with AEG or gastric cancer seem not to have a disadvantage compared to primary resected patients, but nonresponders with SCC have a worse prognosis, which strengthens the demand for a critical patient selection in surgery for this tumor entity.     

Postoperative morbidity is an additional prognostic factor after potentially curative pancreaticoduodenectomy for primary duodenal adenocarcinoma

Purpose

The aims of this paper were to evaluate the clinical features of patients with primary duodenal adenocarcinoma and to address the prognostic relevance of different surgical and pathological variables after potentially curative pancreaticoduodenectomy.

Methods

Patients with primary duodenal adenocarcinoma observed from 2000 through 2009 were identified from a single-institution electronic database. Univariate and multivariate analyses were performed to identify factors associated with survival.

Results

The study population consisted of 37 patients. Of these, 25 underwent pancreaticoduodenectomy, while the remaining 12 were not amenable to resection and underwent bypass operations or were given best supportive care. Overall survival after radical resection (R0) was significantly longer than after palliative surgery (180 versus 35 months, p?=?0.013). On multivariate analysis, tumor grade (hazard ratio (HR)?=?1.345, 95% CI?=?1.28–1.91, p?=?0.03) and the occurrence of postoperative or abdominal complications (HR?=?1.781, 95% CI?=?1.10–2.89, p?=?0.037; HR?=?1.878, 95% CI?=?1.21–3.08, p?=?0.029) were found to be significant prognostic factors for survival in patients undergoing potentially curative resection. In particular, median survival was 180 months in patients with an uneventful postoperative course and 52 months in those with abdominal complications. The 5-year overall survival rates were 100 and 60 %, respectively.

Conclusions

According to the present findings, the development of postoperative complications may be an additional prognostic factor after potentially curative pancreaticoduodenectomy for primary duodenal adenocarcinoma. This emphasizes the need for centralization to high-volume centers where an appropriate postoperative care can be delivered.     

Surgery Is an Essential Component of Multimodality Therapy for Patients with Locally Advanced Esophageal Adenocarcinoma

Background

Experience with neoadjuvant chemoradiation (CXRT) has raised questions regarding the additional benefit of surgery after locally advanced esophageal adenocarcinoma patients achieve a clinical response to CXRT. We sought to quantify the value of surgery by comparing the overall (OS) and disease-free survival (DFS) of trimodality-eligible patients treated with definitive CXRT vs. CXRT followed by esophagectomy.

Methods

We identified 143 clinical stage III esophageal adenocarcinoma patients that were eligible for trimodality therapy. All patients successfully completed neoadjuvant CXRT and were considered appropriate candidates for resection. Patients that were medically inoperable were excluded. Cox regression models were used to identify significant predictors of survival.

Results

Among the 143 patients eligible for surgery after completing CXRT, 114 underwent resection and 29 did not. Poorly differentiated tumors (HR?=?2.041, 95% CI?=?1.235–3.373) and surgical resection (HR?=?0.504, 95% CI?=?0.283–0.899) were the only independent predictors of OS. Patients treated with surgery had a 50 and 54 % risk reduction in overall and cancer-specific mortality, respectively. Median OS (41.2 vs. 20.3 months, p?=?0.012) and DFS (21.5 vs. 11.4 months, p?=?0.007) were significantly improved with the addition of surgery compared to definitive CXRT.

Conclusions

Surgery provides a significant survival benefit to trimodality-eligible esophageal adenocarcinoma patients with locally advanced disease.     

Readmission Following Gastric Cancer Resection: Risk Factors and Survival

Background

This study utilized a multi-institutional database to evaluate risk factors for readmission in patients undergoing curative gastrectomy for gastric adenocarcinoma with the intent of describing both perioperative risk factors and the relationship of readmission to survival.

Methods

Patients who underwent curative resection of gastric adenocarcinoma from 2000 to 2012 from seven academic institutions of the US Gastric Cancer Collaborative were analyzed. In-hospital deaths and palliative surgeries were excluded, and readmission was defined as within 30 days of discharge. Univariate and multivariable logistic regression analyses were employed and survival analysis conducted.

Results

Of the 855 patients, 121 patients (14.2 %) were readmitted. Univariate analysis identified advanced age (p?<?0.0128), American Society of Anesthesiology status ≥3 (p?=?0.0045), preexisting cardiac disease (p?<?0.0001), hypertension (p?=?0.0142), history of smoking (p?=?0.0254), increased preoperative blood urea nitrogen (BUN; p?=?0.0426), concomitant pancreatectomy (p?=?0.0056), increased operation time (p?=?0.0384), estimated blood loss (p?=?0.0196), 25th percentile length of stay (<7 days, p?=?0.0166), 75th percentile length of stay (>12 days, p?=?0.0256), postoperative complication (p?<?0.0001), and total gastrectomy (p?=?0.0167) as risk factors for readmission. Multivariable analysis identified cardiac disease (odds ratio (OR) 2.4, 95 % confidence interval (CI) 1.6–3.3, p?<?0.0001), postoperative complication (OR 2.3, 95 % CI 1.6–5.4, p?<?0.0001), and pancreatectomy (OR 2.2, 95 % CI 1.1–4.1, p?=?0.0202) as independent risk factors for readmission. There was an association of decreased overall median survival in readmitted patients (39 months for readmitted vs. 103 months for non-readmitted). This was due to decreased survival in readmitted stage 1 (p?=?0.0039), while there was no difference in survival for other stages. Stage I readmitted patients had a higher incidence of cardiac disease than stage I non-readmitted patients (58 vs. 24 %, respectively, p?=?0.0002).

Conclusions

Within this multi-institutional study investigating readmission in patients undergoing curative resection for gastric cancer, cardiac disease, postoperative complication, and concomitant pancreatectomy were identified as significant risk factors for readmission. Readmission was associated with decreased overall median survival, but on further analysis, this was driven by differences in survival for stage I disease only.

     

Prognostic Significance of Non-curative Gastrectomy for Incurable Gastric Carcinoma

Background

To date, there is no convincing evidence regarding the benefits of non-curative gastrectomy for gastric carcinoma. In the present study, we reviewed the outcomes of patients who underwent surgery for incurable gastric carcinoma and evaluated the prognostic significance of non-curative gastrectomy.

Methods

Between 2004 and 2011, a total of 197 patients undergoing elective surgery for incurable gastric carcinoma were divided into the gastric resection and non-resection groups. Patient survival was compared between the two groups, and the prognostic significance of non-curative gastrectomy was investigated using multivariate analysis.

Results

Overall, 162 (82.2 %) patients underwent non-curative gastrectomy with morbidity and mortality of 21.0 and 1.2 %, respectively. The median survival of patients undergoing non-curative gastrectomy was significantly longer than that of patients without gastrectomy (12.4 vs. 7.1 months, p = 0.003). Patients who received postoperative chemotherapy also showed significantly better survival than those without chemotherapy (13.2 vs. 4.3 months, p < 0.001). Multivariate analysis revealed that non-curative gastrectomy was an independent prognostic factor (hazard ratio 0.61, 95 % CI 0.40–0.93, p = 0.023) after adjusting for postoperative chemotherapy and other clinical factors. Median survival in patients receiving non-curative gastrectomy combined with postoperative chemotherapy was 13.9 months, which was significantly longer than gastrectomy alone (5.4 months), chemotherapy alone (9.6 months), and no treatment (3.2 months) (p < 0.001).

Conclusion

Primary tumor resection and postoperative chemotherapy are the most important prognostic factors for incurable gastric carcinoma. The survival benefits of non-curative gastrectomy need to be confirmed in a large-scale, randomized trial.     

Overweight Patients Achieve Ideal Body Weight Following Curative Gastrectomy Resulting in Better Long-Term Prognosis

Background

The relationship between body mass index (BMI) and long-term outcome in gastric cancer patients following radical gastrectomy continues to be debated. We investigated the association between BMI, clinicopathological features, and prognosis in Chinese gastric carcinoma patients.

Methods

A retrospective consecutive cohort study was performed on 1,296 patients who underwent gastrectomy with curative intent at the Tianjin Cancer Institute Hospital between 1999 and 2004. The clinicopathological characteristics, overall 5-year survival rate (OS), and preoperative and six-month postoperative BMIs of both overweight (BMI ≥25 kg/m²; H-BMI; n?=?364) and non-overweight (BMI <25 kg/m²; N-BMI; n?=?932) patients were compared.

Results

Among these patients, 364 (28.1 %) were overweight. The OS was significantly higher in the H-BMI than N-BMI group (33.2 vs. 24.1 %, respectively; p?<?0.001). Preoperative and six-month postoperative BMIs were 27.1?±?2.0 and 24.8?±?2.0 kg/m², respectively, in the H-BMI group (p?<?0.001), whereas they were 21.7?±?2.2 and 20.7?±?2.2 kg/m², respectively, in the N-BMI group (p?=?0.007). There was significantly better differentiation (p?=?0.034), less distant metastases (p?=?0.006), and a lower metastatic lymph node ratio (p?=?0.014) observed in the H-BMI groups. Multivariate analyses indicated age, BMI, pathological tumor depth, distant metastases, metastatic lymph node ratio, and tumor size as independent prognostic factors.

Conclusions

Our findings suggest that overweight patients were less likely to have tumors with aggressive features and can achieve ideal body weight following curative gastrectomy, possibly resulting in better long-term prognosis     

Prevalence of Nonalcoholic Steatohepatitis Among Patients with Resectable Intrahepatic Cholangiocarcinoma

Background and Aims

The objective of this report was to determine the prevalence of underlying nonalcoholic steatohepatitis in resectable intrahepatic cholangiocarcinoma.

Methods

Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent resection of intrahepatic cholangiocarcinoma at one of eight hepatobiliary centers between 1991 and 2011 were reviewed.

Results

Of 181 patients who underwent resection for intrahepatic cholangiocarcinoma, 31 (17.1 %) had underlying nonalcoholic steatohepatitis. Patients with nonalcoholic steatohepatitis were more likely obese (median body mass index, 30.0 vs. 26.0 kg/m², p?<?0.001) and had higher rates of diabetes mellitus (38.7 vs. 22.0 %, p?=?0.05) and the metabolic syndrome (22.6 vs. 10.0 %, p?=?0.05) compared with those without nonalcoholic steatohepatitis. Presence and severity of hepatic steatosis, lobular inflammation, and hepatocyte ballooning were more common among nonalcoholic steatohepatitis patients (all p?<?0.001). Macrovascular (35.5 vs. 11.3 %, p?=?0.01) and any vascular (48.4 vs. 26.7 %, p?=?0.02) tumor invasion were more common among patients with nonalcoholic steatohepatitis. There were no differences in recurrence-free (median, 17.0 versus 19.4 months, p?=?0.42) or overall (median, 31.5 versus 36.3 months, p?=?0.97) survival after surgical resection between patients with and without nonalcoholic steatohepatitis.

Conclusions

Nonalcoholic steatohepatitis affects up to 20 % of patients with resectable intrahepatic cholangiocarcinoma.     

Predictors of Unsuccessful Laparoscopic Resection of Gastric Submucosal Neoplasms

Background

While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome.

Methods

From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months.

Results

Patients were 62?±?14 years and 56 % male. Mean tumor size was 5.5?±?4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p?<?0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p?<?0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1–1.3; p?=?0.13).

Conclusions

Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.     

A Multi-institutional Analysis of Open Versus Minimally-Invasive Surgery for Gastric Adenocarcinoma: Results of the US Gastric Cancer Collaborative

Background

Surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of gastric adenocarcinoma are limited.

Methods

Between 2000 and 2012, 880 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. Clinicopathological characteristics, operative details, and outcomes were stratified by operative approach (open vs. MIS) and analyzed.

Results

Overall, 70 (8 %) patients had a MIS approach. Patients who underwent a MIS resection were more likely to have a smaller tumor (open 4.5 cm vs. MIS 3.0 cm, p?p?p?=?0.03) and median lymph node yield was good in both groups (open 17 vs. MIS 14, p?=?0.10). MIS had a similar incidence of complications (open 33.1 % vs. MIS 20 %, p?=?0.07) and a similar length of stay (open 9 days vs. MIS 7 days, p?=?0.13) compared with open surgery. In the propensity-matched analysis, median recurrence-free and overall were not impacted by operative approach.

Conclusion

An MIS approach to gastric cancer was associated with adequate lymph node retrieval, a high incidence of R0 resection, and comparable long-term oncological outcomes versus open gastrectomy.     

The evaluation of surgical treatment for gastric cancer patients with noncurative resection

Purpose

This study aims to analyze the results of treatment in a series of 233 gastric cancer patients who underwent a noncurative resection.

Methods

We performed a retrospective study of patients with noncurative treatment for advanced gastric cancer who were divided into three treatment groups: total gastrectomy (TG, n?=?150), distal gastrectomy (DG, n?=?44), and nonresection (NR, bypass procedure or chemotherapy only, n?=?39).

Results

In multivariate analysis, surgical treatment (TG) and an absence of chemotherapy were significant independent prognostic factors for a poor survival. In the late period, the overall survival rate was significantly lower in the TG group than in the DG group (p?=?0.005) and was marginally lower than in the NR group (p?=?0.054). The resection group had a poorer compliance for chemotherapy than the NR group, and the TG group had a poorer compliance than the DG group (p?<?0.01). The morbidity rate was higher in the TG group than in the DG group (p?<?0.05).

Conclusions

TG is considered to be inappropriate for the treatment of noncurative gastric cancer because of the poor prognosis, high morbidity rates, and poor compliance for chemotherapy associated with the procedure. However, noncurative DG was acceptable and postoperative chemotherapy should be used in selected patients.     

Prognostic Factors in Patients with Node-Negative Gastric Cancer: A Single Center Experience from China

Background and Objectives

Lymph node metastasis was the most important prognostic factor in gastric cancer. Patients with node-negative gastric cancer presented better survival. However, some of them would die of the disease. The aim of this study was to evaluate the prognostic factors of patients with node-negative gastric cancer.

Methods

From 1996 to 2007, 4,426 patients had undergone curative D2 gastrectomy for gastric cancer at the Fudan University Shanghai Cancer Center. Patients with node-negative gastric cancer who underwent curative D2 gastrectomy with more than 15 lymph nodes dissected were selected into this study. The prognostic value of pathological features was investigated.

Results

This study included 234 patients with node-negative gastric cancer. The 5-year overall survival in these patients was 85?%. The factors correlating significantly with overall survival on univariate analysis included age (P?=?0.016), depth of invasion (P?=?0.000), tumor size (P?=?0.013), tumor site (P?=?0.000), histological grade (P?=?0.009), lymphatic tumor emboli (P?=?0.014), vascular tumor emboli (P?=?0.005), and nervous invasion (P?=?0.033). Multivariate analysis showed that lymphatic tumor emboli (hazard ratio (HR)?=?7.270), vascular tumor emboli (HR?=?3.010), and depth of invasion (HR?=?2.735) were defined as independent prognostic factors.

Conclusion

Among patients with node-negative gastric cancer and higher risk for recurrence, the use of adjuvant therapies should be considered.     

Differences of the Lymphatic Distribution and Surgical Outcomes Between Remnant Gastric Cancers and Primary Proximal Gastric Cancers

Background

Although remnant gastric cancer (RGC) following distal gastrectomy is located in the proximal stomach, little is known about the differences of the lymphatic distribution and surgical outcomes between RGC and primary proximal gastric cancer (PGC).

Methods

Between 1997 and 2008, 1,149 patients underwent gastrectomy for gastric cancer. Of these, 33 (2.9%) RGC patients and 207 (18.5%) PGC patients were treated at our department. We reviewed their hospital records retrospectively.

Results

Compared with the PGC patients, those with RGC had a slightly higher age at onset (p?=?0.09), higher incidence of undifferentiated cancer (p?=?0.06), higher incidence of vascular invasion (p?=?0.09), and higher incidence of T4 (p?=?0.07). Gastrectomy for RGC involved greater blood loss (p?p?=?0.01), combined resection, and high incidence of complications. However, the survival rate for RGC patients was similar to that for PGC patients (p?=?0.67). 2) Patients with RGC had a different pattern of lymph node metastasis compared with that in PGC. Particularly in advanced RGC with pT2?CT4 tumors, RGC frequently demonstrated jejunal mesentery lymph node metastases (RGC vs. PGC, 35% vs. 0%) and splenic hilar lymph node metastases (RGC vs. PGC, 17% vs. 10%). The jejunal mesentery lymph node metastases were detected only following Billroth II reconstruction (Billroth I vs. Billroth II, 0% vs. 67%).

Conclusion

Although the clinical behaviors of the two gastric cancers were different, the survival rates were similar. The pattern of metastasis indicates that the jejunal mesentery and splenic hilar lymph nodes should be specifically targeted for en bloc resection during complete gastrectomy in RGC.     

Treatment and Outcome of Patients with Gastric Remnant Cancer After Resection for Peptic Ulcer Disease

Background

To study the pathology, treatment, and outcome of patients with gastric remnant cancer (GRC) after resection for peptic ulcer disease (PUD).

Methods

Review of a prospective gastric cancer database identified patients with GRC after gastrectomy for PUD. Clinicopathologic and treatment-related variables were obtained. Multivariate analysis was performed for factors associated with disease-specific survival (DSS).

Results

From January 1985 to April 2010, 4402 patients with gastric adenocarcinoma were treated at our institution and 105 patients (2.4%) had prior gastrectomy for PUD. Prior resections were most often Billroth II (N = 97, 92%). The median time from initial resection to development of GRC was 32 years (3–60 years), and the majority of tumors were located at the gastrointestinal anastomosis (N = 72, 69%). Median DSS was 1.3 years (0.6–2.1 years). Patients who had resection had a significantly better outcome than patients who did not have resection (median DSS 5 vs 0.35 years, P < .0001). Factors associated with DSS on multivariate analysis included advanced T-stage (HR 16.5 (CI 2.2–123.4), P = .0006) and lymph node metastasis (HR 1.1 (CI 1.0–1.2), P < .0001). Stage-specific survival following R0 resection was similar to patients with conventional gastric cancer.

Conclusions

Patients have a lifetime risk for the development of GRC following resection for PUD. As with conventional gastric cancer, determinants of survival of patients with GRC include advanced T stage and nodal metastasis. Patients with GRC amenable to curative resection exhibit the best DSS and have stage-specific outcomes similar to patients with conventional gastric cancer.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.     

Outcome Analysis of Single Incision vs Traditional Multiport Sleeve Gastrectomy: A Matched Cohort Study

Background

Single incision laparoscopy remains controversial due to technical challenges which may cause suboptimal outcomes. This study aims to evaluate the feasibility and equivalency of the single incision sleeve gastrectomy (SISG) when compared to the traditional multiport sleeve gastrectomy (MPSG) approach in a matched cohort evaluating technical aspects and postoperative results.

Methods

This is a retrospective analysis of prospectively collected data in a consecutive cohort of 113 SG (MPSG?=?77, SISG?=?36). The 36 patients who underwent SISG were included as the case group. Thirty-six MPSG patients were included in the control group, in 1:1 ratio with cases after matching for BMI, age, race, gender, and additional demographic data. Operative time (OT) in minutes and length of stay (LOS) in days was measured and excess weight loss (EWL) at 6 months and 1 year was collected and evaluated.

Results

Mean BMI was equivalent (SISG 43.06, MPSG 43.72, p?=?0.36). Mean OT for the SISG was 116.78 and 118.25 for the MPSG (p?=?0.84), and mean LOS was 1.80 for the SISG and 1.75 for the MSPG (p?=?0.75). EWL at 6 months was 58.4 % for the SISG and 58.5 % for the MPSG (p?=?0.98) and 72.3 and 74.1 % (p?=?0.77) for 1 year, respectively. There were no leaks in either group. There was one reoperation for postoperative bleeding in the MPSG group.

Conclusions

Sleeve gastrectomy can be performed safely using single incision techniques with equivalent outcomes for weight loss.     

Clinical Outcomes for Neuroendocrine Tumors of the Duodenum and Ampulla of Vater:A Population-Based Study

Background

Previous case series report that neuroendocrine tumors (NETs) of the ampulla of Vater have worse overall survival (OS) than NETs in the duodenum. We aimed to compare the OS of patients with ampullary NETs to patients with duodenal NETs.

Methods

This retrospective comparative cohort study used the Surveillance, Epidemiology, and End Results (SEER) registry from 1988 to 2009. OS was evaluated using Kaplan–Meier estimates and Cox proportional hazard regression.

Results

Ampullary NETs (n?=?120) were larger (median size 18 vs. 10 mm, p?<?0.001), higher grade (poorly and undifferentiated tumor 42 % vs. 12 %, p?<?0.001), higher SEER historic stage (distant metastasis 16 % vs. 7 %, p?<?0.001), and more often resected (78 % vs. 60 %, p?<?0.001) than duodenal NETs (n?=?1,360). Median OS was significantly worse for patients with ampullary NETs than with duodenal NETs (98 vs. 143 months, p?=?0.037). Local resection was performed for 50.5 % of the resected ampullary NETs and resulted in similar OS compared to locally resected duodenal NETs (HR 1.37, 95 % CI 0.76–2.48, p?=?0.291).

Conclusions

While ampullary NETs are more advanced at presentation and have worse OS than duodenal NETs, long-term survival is possible with proximal small bowel NETs. For locally resected NETs, OS is similar between ampullary and duodenal NETs.     

Systematic Review and Meta-analysis of Laparoscopic Versus Open Distal Gastrectomy

Background

Laparoscopic distal gastrectomy has been increasingly utilized in the treatment of gastric adenocarcinoma. This study aims to compare the morbidity/mortality and postoperative outcomes of laparoscopic-assisted versus open distal gastrectomy since 2000.

Methods

A comprehensive search of MEDLINE and EMBASE was conducted including studies published between 2000 and present.

Results

Seventeen studies with a total of 7,109 distal gastrectomies (3,496 lap vs 3,613 open) were included. Across all studies, postoperative morbidity rates for laparoscopic gastrectomy were lower than that of open [median (range) 10 (0–36)?% vs 17 (0–43)?%]. Meta-analysis of postoperative morbidity rates in prospective studies only yielded pooled odds ratio of 0.52 (95 % CI 0.33–0.81) (P?=?0.004). In-hospital mortality rates were comparable between the two (range: laparoscopic 0–3.3 vs open 0–6.7 %). The long-term oncological outcomes of resection were difficult to analyze given variable reporting but appeared similar between the two. Meta-analysis of prospective studies showed that laparoscopic-assisted distal gastrectomy was associated with significantly shorter hospital length of stay [standard mean difference (SMD)?=??0.78 (95 % CI?=??1.0 to ?0.56)], comparable intraoperative bleeding [SMD?=?0.64 (95 % CI?=??1.3–0.0430) P?=?0.066] and longer operative time compared to open gastrectomy [1.9 (95 % CI 0.05–3.8) P?=?0.045, with P?<?0.001].

Conclusion

This study supports the use of laparoscopic-assisted distal gastrectomy for treatment of gastric adenocarcinoma with evidence of comparable, if not better, short-term postoperative parameters when compared to open distal gastrectomy. The long-term oncological outcomes appear similar but may require more evaluation.