Optimal surgical management for esophagogastric junction carcinoma

Objectives

Esophagogastric junction carcinoma incidence is increasing worldwide. However, surgical strategies for this cancer remain controversial. This study aimed to clarify the optimal surgical strategy for esophagogastric junction carcinoma.

Methods

We retrospectively reviewed a database of 68 consecutive patients with esophagogastric junction carcinoma [Japanese classification of gastric carcinoma (Nishi’s definition): adenocarcinoma, N = 53; squamous cell carcinoma, N = 15] who underwent curative surgical resection at Keio University Hospital between January 2000 and September 2008.

Results

In both adenocarcinoma and squamous cell carcinoma, most lymph node metastases were located in the lesser curvature area. Mediastinal lymph node metastasis was observed in 4 patients (7.5 %) with adenocarcinoma and 7 patients (46.7 %) with squamous cell carcinoma. No patient presented with lymph node metastases in the pyloric region. The therapeutic value of extended lymph node dissection was 0, except for lymph node station numbers 1, 2, 3, 4sa, 7, and 110. Extended lymph node dissection in the lesser curvature area showed a high therapeutic value. The para-aortic lymph node was the most frequent nodal recurrence site. All patients with tumor centers located below the esophagogastric junction (N = 37) did not develop mediastinal lymph node metastasis or recurrence.

Conclusions

Proximal gastrectomy through a transhiatal approach may be the optimal surgical strategy for esophagogastric carcinoma. Mediastinal lymph node dissection through a thoracic approach seems unnecessary, particularly when the tumor center is located below the esophagogastric junction. To confirm the necessity of para-aortic nodal dissection, further studies are required.     

Esophagogastric tube reconstruction with stapled pseudo-fornix in laparoscopic proximal gastrectomy: a novel technique proposed for Siewert type II tumors

Purpose

The incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors.

Methods

Laparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis.

Results

Fifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315 min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication.

Conclusions

This new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.     

Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis

Background

Esophagectomy is a challenging operation with considerable potential for postoperative complications, including chylothorax.

Methods

Because no randomized controlled trial or metaanalysis is available to clarify the incidence of chylothorax in esophageal cancer surgery, the authors analyzed their own institutional data for 1,856 patients and performed a systematic review using the MEDLINE database (9,794 patients) to identify risk factors, compare success rates of therapeutic approaches, and investigate long-term outcomes.

Results

The overall institutional chylothorax rate was 2 % (n = 39). Reoperation was performed for 69 % of the patients. No significant difference was noted between the transthoracic and transhiatal approaches. Regression analysis showed neoadjuvant treatment (odds ratio [OR], 0.302; p = 0.001) and tumor type (OR, 0.304; p = 0.002) to be independent risk factors. The systematic review included 12 studies. Chylothorax occurred for 2.6 % of the patients. Treatment favored reoperation in five studies (70–100 %) and a conservative approach in four studies (58–72 %), with equal mortality rates. No significant difference was found between the transthoracic and transhiatal approaches.

Conclusion

Chylothorax rates are low in high-volume centers (2–3 %). No significant difference was noted between the transthoracic and transhiatal approaches. Neoadjuvant treatment and tumor type were shown to be independent risk factors. Treatment concept (reoperation vs conservative treatment) did not affect long-term survival.     

The Influence of Surgical Factors on Persisting Symptoms 3 Years after Esophageal Cancer Surgery: A Population-Based Study in Sweden

Background

Little is known about the long-term effects of surgical approach and type of anastomosis in the surgical treatment of esophageal cancer on patient-reported outcomes.

Methods

A Swedish nationwide, population-based cohort study included patients undergoing esophagectomy for esophageal cancer in 2001–2005. The predefined exposures included surgical approach (transhiatal or transthoracic) and anastomotic technique (hand-sewn or mechanical). The outcomes were esophageal-specific symptoms 3 years after the surgery. Symptoms were measured using the cancer-specific quality of life questionnaire, the QLQ-C30, supplemented by an esophageal cancer-specific module (QLQ-OES18), both developed by the European Organisation for Research and Treatment of Cancer. Logistic regression models were used to estimate relative risk, expressed as odds ratios (OR) with 95 % confidence intervals (CI), of experiencing symptoms as assessed by the questionnaires.

Results

Among the 178 included patients, there was an 84 % participation rate. No statistically significant differences were found regarding surgical approach. However, point estimates indicate that patients operated on with a transhiatal approach had a lower risk for symptoms of nausea and vomiting (OR = 0.5, 95 % CI 0.1–1.9), diarrhea (OR = 0.5, 95 % CI 0.2–1.8), and trouble swallowing (OR = 0.4, 95 % CI 0–3), and a slightly higher risk for loss of appetite (OR = 2, 95 % CI 0.7–5.6) compared with patients operated on with a transthoracic approach. Anastomotic technique did not seem to influence the risk for any of the selected symptoms.

Conclusions

Surgical approach and type of anastomosis do not seem to influence the risk of general and esophageal-specific cancer symptoms 3 years after surgery for esophageal cancer.     

Comparison of the 6th and 7th Editions of the UICC-AJCC TNM Classification for Esophageal Cancer

Background

The new 7th edition of the Union for International Cancer Control?CAmerican Joint Committee on Cancer (UICC-AJCC) tumor, node, metastasis (TNM) staging system is the ratification of data-driven recommendations from the Worldwide Esophageal Cancer Collaboration database. Generalizability remains questionable for single institutions. The present study serves as a validation of the 7th edition of the TNM system in a prospective cohort of patients with predominantly adenocarcinomas from a single institution.

Methods

Included were patients who underwent transhiatal esophagectomy with curative intent between 1991 and 2008 for invasive carcinoma of the esophagus or gastroesophageal junction. Excluded were patients who had received neoadjuvant chemo(radio)therapy, patients after a noncurative resection and patients who died in the hospital. Tumors were staged according to both the 6th and the 7th editions of the UICC-AJCC staging systems. Survival was calculated by the Kaplan?CMeier method, and multivariate analysis was performed with a Cox regression model. The likelihood ratio chi-square test related to the Cox regression model and the Akaike information criterion were used for measuring goodness of fit.

Results

A study population of 358 patients was identified. All patients underwent transhiatal esophagectomy for adenocarcinoma. Overall 5-year survival rate was 38%. Univariate analysis revealed that pT stage, pN stage, and pM stage significantly predicted overall survival. Prediction was best for the 7th edition, stratifying for all substages.

Conclusions

The application of the 7th UICC-AJCC staging system results in a better prognostic stratification of overall survival compared to the 6th edition. The fact that the 7th edition performs better predominantly in patients with adenocarcinomas who underwent a transhiatal surgical approach, in addition to findings from earlier research in other cohorts, supports its generalizability for different esophageal cancer practices.     

Ösophaguskarzinom

Background

The central element of the multimodal therapy concept for esophageal carcinomas is operative resection. This is a complex visceral surgical intervention that calls for standardized and interdisciplinary perioperative management. Continuous control of results is essential for evaluating therapy concepts.

Method

Data of patients who had undergone thoracoabdominal resection of an esophageal carcinoma were recorded and evaluated in a prospective single center study within the framework of internal quality control.

Results

In the time span between 1 January 1997 and 31 December 2005, 193 patients with esophageal carcinoma were treated. Of these, 97 (50.7%) received single-stage abdominothoracal resection without neoadjuvant primary therapy. In 70% of these cases, an advanced tumor stage was present (UICC IIb or higher). R0 resection was achieved in 83 patients (85.5%). The rate of hospital mortality was found to be 6.2% (n=6). In a follow-up examination rate of 95.6%, an overall 5-year survival rate of 25% was found for all resected patients and 30% for those who received curative resection.

Conclusion

The long-term results reached by surgery alone are comparable to those published in the current literature but are still not satisfying. A more individual approach to therapy with increased selection of patients for the application of modern neoadjuvant concepts could lead to an improvement in prognosis.     

Depth of Submucosal Tumor Infiltration and its Relevance in Lymphatic Metastasis Formation for T1b Squamous Cell and Adenocarcinomas of the Esophagus

Background

Surgery for early esophageal carcinoma has been challenged by less invasive endoscopic approaches. Selecting patients in need for surgical intervention according to their risk of lymphatic spread is mandatory.

Objective

The aim of this study was to evaluate risk factors for lymphatic metastasis formation in T1b esophageal carcinomas.

Methods

Histopathological specimens following surgical resection for T1b esophageal carcinomas were reevaluated for overall submucosal layer thickness, depth of submucosal tumor infiltration, tumor length as well as lymphatic and vascular infiltration. Depth of tumor infiltration to overall submucosal thickness was divided in thirds (SM1, SM2, and SM3) and factors influencing lymphatic metastasis formation were assessed.

Results

A total of 67 patients with pT1b tumors were analyzed, including 36 adenocarcinomas (53.7 %) and 31 squamous cell carcinomas (46.3 %). Lymph node involvement was seen in 22.4 % (15/67) patients without significant differences between SM1 3/11 (27.3 %), SM2, 4/18 (22.2 %), and SM3 (8/38) (21.8 %) (p?=?0.909) carcinomas. On binomial log-regression models, only lymphangioinvasion and tumor length >2 cm was significantly associated with lymph node involvement.

Conclusion

As depth of submucosal tumor infiltration did not correlate with the formation of lymph node metastases and in regard of the risk of lymphatic spread in these cases, surgical resection is warranted in pT1b carcinomas.     

Minimally invasive esophagectomy for esophageal squamous cell carcinoma: a case–control study of thoracoscope versus mediastinoscope assistance

Objective

Minimally invasive esophagectomy (MIE) has been widely applied for esophageal carcinoma treatment. Thoracoscope-assisted transthoracic esophagectomy (TATTE) and mediastinoscope-assisted transhiatal esophagectomy (MATHE) are two kinds of MIE. The objective of this study is to compare these two methods with respect to surgical safety and survival.

Methods

Single-institution experience with MATHE and TATTE was analyzed to assess morbidity, adequacy of tumor clearance, and survival. A pair-matched case–control study was performed to compare 54 patients who underwent either MATHE or TATTE between July 2000 and December 2009. Patients were matched by age, sex, comorbidity, forced expiratory volume in 1?s (FEV1), tumor location, and stage.

Results

Statistically significant differences between the MATHE group and the TATTE group were: shorter operative time for MATHE (194.4?min) versus TATTE (228.1?min), less blood loss during operation in the TATTE group (142.6?ml) versus the MATHE group (214.6?ml), and more lymph nodes retrieved in the TATTE group (19.1 nodes) versus the MATHE group (11.4 nodes). There was no difference in survival between the groups.

Conclusions

MATHE and TATTE are both technically feasible. TATTE can provide better visibility. TATTE has less blood loss compared with MATHE. More adequate tumor clearance in terms of lymph node dissection can be achieved with TATTE.     

Laparoendoscopic Transgastric Resection of a Submucosal Mass at the Gastroesophageal Junction

Introduction

Traditional management of gastric submucosal lesions usually involves wedge resection. However, lesions close to the gastroesophageal junction are difficult to manage with wedge resection without compromising the lower esophageal sphincter. This video highlights an interesting combined laparoscopic and endoscopic technique for safe resection of a submucosal lesion adjacent to the gastroesophageal junction.

Methods

A 66-year-old male was evaluated by gastroenterology for melena. Upper endoscopy with subsequent endoscopic ultrasound demonstrated a 2-cm submucosal lesion adjacent to the gastroesophageal junction. Biopsies were indeterminate, and the remainder of his workup was negative. A combined laparoendoscopic technique was utilized to safely resect the lesion while protecting the gastroesophageal junction. This was accomplished using three 5-mm trocars placed directly through the abdominal wall into the stomach using endoscopic guidance. All muscle layers were resected en bloc with the specimen, leaving the serosa intact.

Results

The patient did well and was discharged home on postoperative day?1. Final pathology demonstrated a leiomyoma with negative margins.

Conclusion

Submucosal lesions adjacent to the gastroesophageal junction can be safely and effectively managed using a laparoendoscopic approach. This technique provides improved visualization and facilitates an adequate resection compared to endoscopy or laparoscopy alone.     

Surgical Endoscopic Vacuum Therapy for Anastomotic Leakage and Perforation of the Upper Gastrointestinal Tract

Introduction

Emergency operations for perforations and anastomotic leakage of the upper gastrointestinal tract are associated with a high overall morbidity and mortality rate. An endoscopic vacuum therapy (EVT) has been established successfully for anastomotic leakage after rectal resection but only limited data exist for EVT of the upper GI tract.

Methods

We report on a series of nine patients treated with EVT for defects of the upper intestinal tract between March 2011 and May 2012. In four patients, initial endoscopic sponge placement was performed in combination with open surgical revision. Median follow-up was 189 (range, 51?C366) days.

Results

In total, 52 vacuum sponges were placed in upper GI defects of nine patients. Indication for EVT were anastomotic leakage after esophageal resection or gastrectomy (n?=?5) and iatrogenic or spontaneous esophageal perforations (n?=?4). The mean number of sponge insertions was six (range, 1?C13) with a mean changing interval of 3.5?days (range, 2?C5). A successful vacuum therapy for upper intestinal defects was achieved in eight of nine patients (89?%).

Conclusion

EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. If necessary the endoscopic procedure can be combined with operative revision for better control of the local septic focus.     

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.     

Optimal dose of preoperative enteral immunonutrition for patients with esophageal cancer

Purpose

A preoperative immunonutrition pharmaceutics diet (IMPACT) significantly reduced the incidence of postoperative infectious complications, but the optimal regimen still remains unclear. We evaluated the optimal dose of a preoperative IMPACT for patients with esophageal carcinoma and the incidence of postoperative complications based on the dose of IMPACT.

Methods

This study design was a prospective nonrandomized study. Twenty patients with thoracic esophageal carcinoma who underwent a right transthoracic subtotal esophagectomy were divided into two groups. These patients were administered immunonutrition of 500 ml/day (IMP500) or 1000 ml/day (IMP1000) for 7 days before the operation.

Results

The incidence of postoperative mortality and morbidity was not different between the IMP500 group and the IMP1000 group. No difference was observed in the perioperative changes in inflammatory, immunological and nutritional variables between the two groups. There were no adverse effects in the IMP500 group, but four patients (40%) had diarrhea and four patients (40%) had appetite loss in the IMP1000 group. In the IMP1000 group, only four patients (40%) could take 1000 ml, but others reduced the quantity of IMPACT because of diarrhea and discomfort.

Conclusion

This study suggests that 500 ml of IMPACT is recommended as an optimal dose for patients with esophageal cancer.     

Mortality After Esophageal and Gastric Cancer Resection

Background

Contrasting findings on trends and determinants of operative mortality after surgery for esophageal and gastric cancer have been reported from population-based studies.

Methods

Discharge records of residents in the Veneto Region (northeastern Italy) with a diagnosis of esophageal or gastric cancer and intervention codes for esophagectomy or gastrectomy were extracted for the years 2000–2009. In-hospital, 30-day, 90-day, and perioperative (30-day?+?in-hospital) mortality were computed. The influence of patient and hospital variables on in-hospital mortality was assessed through multilevel models.

Results

Overall, 6,500 resections were performed in the period of 2000–2009, with a 10?% decline in the second half of the study period. In-hospital mortality was 4.6?% (5.3?% in 2000–2004 and 3.8?% in 2005–2009) and was higher for extended total gastrectomy and total esophagectomy. In 2005–2009 mortality declined for all resection types except extended total gastrectomy (8.0?%). For esophageal procedures, 30-day mortality was lower than in-hospital or perioperative mortality. A protective effect of procedural volume was found for esophageal but not for gastric resections; among gastric procedures, mortality was higher in male patients and in extended total gastrectomy patients.

Conclusions

Analyses of discharge records allowed investigation at a population level of time trends (downward mainly for esophageal resections) and determinants of perioperative mortality (hospital volume, gender, and procedure type).     

Sentinel lymph node biopsy in early-stage breast cancer patients: improved survival through better staging?

Purpose

The objective of this review is to summarize the evidence demonstrating that the sentinel lymph node (SLN) procedure is not only associated with significantly less morbidity compared to the axillary dissection, but may also result in better staging and improved patient outcomes.

Methods

A search of MedLine and PubMed articles using the terms “sentinel lymph node biopsy”, “breast cancer”, “staging”, “morbidity”, “survival”, and “outcomes” was conducted.

Results

Breast cancer staging includes axillary evaluation as an integral component. Over the past two decades, sentinel lymph node biopsy has evolved as a technique that has an improved morbidity over traditional axillary dissection. The sentinel node(s) undergo a more intensive pathologic examination than traditional axillary contents. In the node-negative group of patients, this may have led to stage migration and potentially improved disease-free and overall survival.

Conclusion

The SLN procedure is not only associated with significantly less morbidity compared to the axillary lymph node dissection, it may also result in more accurate staging, better axillary tumor control and improved survival.     

“En bloc” resection of sacral chordomas by combined anterior and posterior surgical approach: a monocentric retrospective review about 29 cases

Purpose

“En bloc” resection of sacral chordomas (SC) with wide margins is statistically linked with a decrease of local recurrence (LR). Nevertheless, surgery potentially leads to complications and neurological deficits. The effectiveness of radiotherapy (RT) and chemotherapy (CT) remains controversial. The aim of the study was to evaluate the margins of tumor resection, the morbidity of “En bloc” resection of SC by combined anterior and posterior surgical approach and to look for predictive factors on survival and LR.

Methods

We performed sacrococcygectomy by surgical combined approach in 29 SC between 1985 and 2012. We analyzed overall survival and survival to LR with survival analysis using Kaplan–Meier method. Complications and morbidity were reported.

Results

The mean follow-up was of 77.9 months (0–241 months). We found 18 (62.1 %) postoperative infections and 7 (24.1 %) wound dehiscences. Eighteen patients had tumor wide margins (62.1 %), 6 marginal (20.7 %) and 4 intralesional (13.8 %). Seven patients had a LR (24.1 %). OS rate was 84.4 % at 5 and 10 years, survival rate with LR was 64 and 56 %, respectively, after 5 and 10 years. Quality of margins (p = 0.106), tumor volume (p = 0.103), postoperative RT (p = 0.245) and postoperative local infection (p = 0.754) did not have effect on LR.

Conclusion

“En bloc” resection by combined surgical approach seems to be a relevant alternative especially for SC invading the high sacrum above S3. Nevertheless, it yet remains the problem of postoperative infection. Systematic Adjuvant RT might allow better control on LR in association with surgery.     

Survival and quality of life after minimally invasive esophagectomy: a single-surgeon experience

Background

Reports on quality of life (QOL) after minimally invasive esophagectomy (MIE) have been limited. This report compares perioperative outcomes, survival, and QOL after MIEs with open transthoracic esophagectomy (TTE) and open transhiatal esophagectomy (THE).

Methods

After institutional review board approval, retrospective review of a prospectively maintained database identified patients who underwent esophageal resection for esophageal cancer at Creighton University between August 2003 and August 2010. Patients with preoperative stage 4 disease, emergent procedures, laparoscopic transhiatal esophagectomies, or esophagojeujunostomies were excluded from the study. The study patients were categorized as having undergone open TTE, open THE, or MIE. Overall survival (OS) was the interval between diagnosis and death or follow-up assessment. Disease-free survival (DFS) was the interval between surgery and recurrence, death, or follow-up assessment. For the patients who survived at least 1?year after surgery, QOL was assessed using European Organization for Research and Treatment of Cancer (EORTC-QLQ, version 3.0) and esophageal module (EORTC-QLQ OES 18) questionnaires.

Results

The study criteria were satisfied by 104 patients. Lymph node harvest with MIE (median = 20) was similar to that with open TTEs (median = 19) and significantly higher (P?P?Conclusions MIEs offer a safe and viable alternative to open esophagectomies because they reduce the need and volume of intraoperative blood product transfusion and postoperative respiratory complications without compromising oncological clearance, survival, and QOL.     

Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients

Introduction

Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation.

Methods

An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were “sleeve gastrectomy” OR “gastric sleeve” AND “leak.” We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation.

Results

The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI)?>?50?kg/m²] and 2.2% for BMI?2. Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful.

Conclusions

Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI?2) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30?days is critical to avoid catastrophe, because most leaks will happen after patient discharge.     

Outcome of superior mesenteric-portal vein resection during pancreatectomy for borderline ductal adenocarcinoma: results of a prospective comparative study

Background

Approximately 20 % of patients affected by pancreatic ductal adenocarcinoma are amenable to surgical resection. Several tumours are reported as “borderline resectable” because of their proximity to the major vessels. In the effort to achieve a radical tumour removal, vein resection has been proposed, but its oncological benefits remain debated.

Methods

Our aim is to investigate morbidity, mortality and survival after pancreatectomy with vein resection.

Results

Forty patients underwent pancreatectomy and vein resection (group A), and 20 patients (group B) underwent bilio-enteric and/or gastro-entero bypass. In group A, cancer vein invasion was microscopically proven in 14 cases (35 %). Vein infiltration, tumour differentiation and node-positive disease were not adverse prognostic variables. No difference in survival was seen over a 1-year follow-up. After this period, group A showed significant survival benefits with a longer stabilisation of the disease (p?=?0.005). Tumour-free resection margins and adjuvant chemoradiotherapy were the most important prognostic factors (p?<?0.05).

Conclusions

Suspicion of vein infiltration should not be a contraindication to resection. Pancreatectomy can be safely performed with an acceptable morbidity and better survival trend.     

Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery

Background

Efforts to improve approaches to the so called “parametrium” with minimally invasive and less dangerous techniques have led to a better study of the anatomic location and composition of that region. Nevertheless, many misconceptions and confusions about the anatomy of the posterior parametrium and its structures still remain. This study aimed to review anatomic and surgical data and to identify several clear landmarks and surgical steps for a nerve-sparing approach to posterior parametrectomy in the course of radical pelvic surgery with or without rectal resection.

Methods

The literature and anatomic dissections of fresh, embalmed, and formalin-fixed female pelvis cadavers were reviewed. The authors’ laparotomic and laparoscopic case series also was reviewed for deep-infiltrating endometriosis as well as uterine, ovarian, and rectal cancer.

Results

The anatomic entity commonly termed the “posterior parametrium” can be identified as the conjunction of three important anatomic structures (ligaments): the cranial structure (uterosacral ligaments), the caudad structure (rectovaginal ligaments), and the laterocaudad structure (lateral rectal ligaments). Identification of these structures (containing autonomic innervations for pelvic viscera) may allow an accurate nerve-sparing surgical approach in many radical pelvic operations.

Conclusions

The incidences of urinary, rectal, and sexual morbidity after radical pelvic surgical procedures for oncologic diseases (rectal/ovarian cancer, advanced endometrial/cervical cancer, posterior pelvic recurrences) and deep severe endometriosis can be reduced by better knowing and dissecting the right embryo-anatomic planes of the so-called “posterior parametrium.”     

Significant Variation of Resected Meso-esophageal Tissue Volume in Two-Stage Subtotal Esophagectomy Specimens: A Retrospective Morphometric Study

Background

Differences in the extent and quality of surgical resection for esophageal cancer may influence the pathological staging and patient outcome. There are no data in the literature qualitatively and/or quantitatively characterizing esophagectomy specimens.

Methods

Macroscopic images of 161 esophagectomy specimens were analyzed retrospectively. The extent of resection was qualitatively classified as “muscularis propria,” “intra-meso-esophageal,” or “meso-esophageal.” The volume of meso-esophageal tissue was quantified morphometrically. The number of muscle defects per specimen was counted. Results were related to clinicopathological variables, including survival.

Results

Sixty-two (39 %) specimens were classified as “muscularis propria,” 65 (40 %) as “intra-meso-esophageal,” and 34 (21 %) as “meso-esophageal.” The morphometrically measured meso-esophageal tissue volume was different between the three types (P < 0.001). The specimen type was related to the total number of lymph nodes (P = 0.02), number of metastatic lymph nodes (P = 0.024), and depth of tumor invasion (P = 0.013), but not related to extramural tumor volume, circumferential resection margin status, or the surgeon performing the resection. The number of muscle defects per specimen was similar in all resection types. The resection specimen classification was related to survival in patients treated by surgery alone (P = 0.027).

Conclusions

This is the first study to quantify and classify the volume of tissue resected during esophagectomy. Our study shows significant variation of the resected tissue volume impacting pathological tumor staging. This variation was not associated with individual surgeon performance. A prospective, multicenter study is needed to validate our results and to investigate the potential biological mechanisms influencing the resectable volume of meso-esophageal tissue in cancer patients.