Curative surgery for gastric cancer: Study of 166 consecutive patients

From January 1980 to December 1991 we operated on 295 patients with a gastric carcinoma. In 166 cases (56.3%) surgery was performed with curative intent. In 93 patients (56%) a subtotal gastrectomy was performed, and in 73 cases (44%) a total gastrectomy. In all the cases a D-2 type lymphadenectomy was used. The global morbidity rate was 23%, and in-hospital mortality was 3.6%. The morbidity and mortality rates of these two operations were statistically different. Global 5-year survival estimate for the whole series is 61.3%. Univariate and multivariate analysis according to T and N (TNM classification), the number of positive nodes resected, and the relation of positive per resected nodes, revealed statistically different outcomes. This kind of quantitative classification allowed identification of high risk groups irrespective of site of nodal involvement. Tumors classified as intestinal or diffuse type by the Lauren classification had similar survival curves and 5-year survival estimates (p=0.834). By univariate and multivariate analysis this classification did not reveal a prognostic value in this group of patients. In our opinion, tumor penetration and lymph node involvement are at present the most reliable prognostic factors available.

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Resumen En el período enero 1980 a diciembre 1991 se operaron 295 pacientes con carcinoma gástrico. En 166 (56.3%), la cirugía fue realizada con intención curativa; en 93 (56%) se realizó gastrectomía subtotal y en 73 (44%) gastrectomía total. En la totalidad de los casos se realizó linfadenectomía D-2. La mortalidad global fue 23% y la mortalidad hospitalaria 3.6%. Las tasas de mortalidad y morbilidad de estas dos operaciones aparecieron significativamente diferentes. La sobrevida global a cinco años estimada para la totalidad de la serie es de 61.3%. Los análisis uni y multivariables de acuerdo con la clasificación TNM, el número de ganglios positivos resecados y la relación positivos/resecados revelaron resultados estadísticamente diferentes. Este tipo de clasificación cuantitativa permitió la identificación de Grupos de alto riesgo independientes del lugar de la invasión ganglionar. Los tumores clasificados como intestinales o difusos (clasificación de Lauren), registraron similares curvas de sobrevida y de sobrevida estimada a cinco años (P=0.834). Mediante el análisis univariable y multivariable esta clasificación no demostró tener valor pronóstico en nuestro Grupo de pacientes. En nuestra opinión, el grado de penetración del tumor y la invasión ganglionar son los factores de pronóstico más confiables.

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Résumé Entre Janvier 1980 et Décembre 1991, nous avons opéré 295 patients ayant un cancer gastrique. Chez 166 (56.3%), l'exérèse a été jugée curative. Chez 93 (56%) des cas, il s'agissait d'une gastrectomie subtotale alors que dans 73 (44%) cas, une gastrectomie totale a été pratiquée. Dans tous les cas une lymphadénectomie du type D-2 lui a été associée. La morbidité globale a été de 23% et la mortalité hospitalière de 3.6%. La morbidité et la mortalité des deux types d'intervention différaient de façon statistiquement significative. La survie à 5 ans de la série en entier a été de 61.3%. Une analyse uni et multifactorielle a pu mettre en évidence une différence statistiquement significative en ce qui concerne la survie par rapport à la classification T-N (TNM), le nombre de ganglions réséqués et le nombre de ganglions envahis/nombre de ganglions enlevés. Cette analyse a permis d'identifier les malades à haut risque, indépendamment du site de l'envahissement lymphatique. La courbe de survie et la survie estimée à 5 ans étaient identiques selon que la tumeur a été classée intestinale ou diffuse selon Lauren. Cette classification n'a pas, pourtant, de valeur pronostique d'après les analyses uni et multifactorielle. A notre avis, la pénétration tumorale et le degré d'envahissement lymphatique sont les deux facteurs pronostiques les plus constants.

     

Palliative gastrojejunostomy in unresectable cancer and gastric outlet obstruction: a retrospective cohort study

IntroductionPalliative gastrojejunostomy is a surgical technique that allows restoration of oral intake among patients with gastric outlet obstruction (GOO) caused by unresectable neoplasms. Research suggests standard treatment for malignant GOO should be laparoscopic gastrojejunostomy (LGJ). This study presents the clinical outcomes of palliative gastrojejunostomy and compares results from LGJ and open gastrojejunostomy (OGJ) at our centre.MethodsWe performed a retrospective analysis on patients who underwent palliative gastrojejunostomy for GOO caused by unresectable neoplasms between 2008 and 2018. We included demographic variables, time to recover intestinal transit, time to recover oral intake, hospital stay, complications and global survival.ResultsA total of 39 patients underwent palliative gastrojejunostomy (20 OGJ, 19 LGJ). Patients in the LGJ group recovered oral intake and intestinal transit faster than those in the OGJ group (3 vs 5 days, p<0.05). There were no statistically significant differences in median operating time, hospital stay or postoperative complications between the two groups. No intraoperative complications occurred. The estimated global survival was 178 days, with no significant difference between the groups.ConclusionsPalliative LGJ allows earlier restoration of oral intake and does not increase morbidity or mortality. Palliative LGJ should be considered the standard treatment for these patients.     

Airway management of patients undergoing oral cancer surgery: a retrospective study

OBJECTIVE: This retrospective study aims to describe the airway management and benefits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery. METHODS AND RESULTS: The medical records of 260 patients undergoing surgery for oral cancer were reviewed for airway management during the perioperative period. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted and decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx or larynx by tumour, or radiation fibrosis. In 53 patients intubation was undertaken under spontaneous ventilation. In 20 cases the trachea was extubated in the immediate postoperative period. In 220 cases patients were extubated next morning in the intensive care unit. In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective tracheostomies were done in 17 cases. Three patients remained intubated for 24-48 h because of a high suspicion of airway obstruction following extubation due to a large pectoralis major flap. These three patients received a tracheostomy because of increased oropharyngeal and laryngeal oedema. In three cases emergency tracheostomies were performed due to upper airway obstruction after extubation and in one case prolonged elective ventilation was required due to severe chest infection. CONCLUSION: Oral cancer patients have a potentially difficult airway but, if managed properly during perioperative period, morbidity and mortality can be reduced or avoided. Oral cancer patients can be managed safely without the routine use of a tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in oral cancer patients except in some selected patients.     

Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients

This review was prompted by continued public and professional interest of necrotizing fasciitis as well as worldwide increases in the incidence of streptococcal invasive infections. Our objective was to outline the clinical course of necrotizing fasciitis and delineate factors relating to mortality among 163 diagnosed patients. Over 14 years patients diagnosed with necrotizing fasciitis were reviewed for patient history, comorbid conditions, and progression of clinical course. A logistic regression model was used to identify factors increasing mortality risk among necrotizing fasciitis patients. Nearly 17 per cent of the patients showed no identifiable antecedent trauma. Seventy-one per cent of tissue culture-positive patients (145) had multibacterial infections. Although no streptococcal species were recovered from one-third of these culture-positive patients there was an increase in mortality noted with beta-Streptococcus infections. Ninety-six per cent of the patient deaths were correlated with variables organized into the following categories: 1) patient history (intravenous drug use and age <1 or >60 years), 2) comorbid conditions (cancer, renal disease, and congestive heart failure), 3) characteristics of clinical course (trunk involvement, positive blood cultures, peripheral vascular disease, and positive cultures for beta-streptococcus or anaerobic bacteria), and 4) quantitative timeline of clinical course (time: injury to diagnosis, diagnosis to treatment). Mortality is correlated to patient history, comorbid conditions, and progression of clinical course. Necrotizing fasciitis can occur idiopathically and is generally a polymicrobial infection that sometimes occurs in the absence of streptococci. Clearly the mortality and morbidity associated with necrotizing fasciitis can be decreased with clinical awareness, early diagnosis, adequate surgical debridement, and intensive supportive care.     

Laparoscopic versus open surgery for obese patients with rectal cancer: a retrospective cohort study

Purpose

To evaluate the advantages of laparoscopic surgery for rectal cancer in obese patients.

Methods

We collected clinical data from consecutive patients who underwent anterior resection for rectal cancer between 2008 and 2015 to compare the surgical outcomes of a laparoscopic surgery group (LG) with those of an open surgery group (OG) stratified by obesity. Obesity was defined as a body mass index ≥25.

Results

A total of 268 patients were analyzed, with 157 in the LG (44 obese and 113 non-obese) and 111 in the OG (25 obese and 86 non-obese). The rates of complications between the LG and the OG were 18.5 vs. 11.6 % (p = 0.18) for the non-obese patients and 18.2 vs. 20.0 % (p = 1.0) for the obese patients, respectively, without a significant difference. Operative time was longer in the LG than in the OG, but the difference between the non-obese and obese patients was not significant, being 266 vs. 189 min (p < 0.0001) and 260 vs. 254 min (p = 0.96), respectively. Blood loss was much lower in the LG for both obese and non-obese patients, being 10 vs. 435 mL (p < 0.0001) and 10 vs. 275 mL (p < 0.0001), respectively.

Conclusion

There were no significant differences between LG and OG in operative time or complications for obese patients with rectal cancer, and blood loss was much lower in the LG. Thus, laparoscopic surgery is a safe and minimally invasive approach for obese patients with rectal cancer.

     

Positive results of combined therapy of surgery and intraperitoneal hyperthermic perfusion for far-advanced gastric cancer.

To evaluate the clinical efficacy of intraperitoneal hyperthermic perfusion (IPHP) for far-advanced gastric cancer, particularly with peritoneal seeding, we investigated the survival times of 59 patients who underwent distal subtotal gastrectomy, total gastrectomy, or total gastrectomy combined with concomitant resection of some of the remaining intra-abdominal organs. In all the 30 patients given IPHP, no cancer cells were present posthyperthermically in the lavage from the Douglas pouch. The 30 patients given IPHP lived longer than the 29 patients not given IPHP (p = 0.001), with a 1-year survival rate of 80.4% in the former group compared to 34.2% in the latter. With respect to a comparison of survival time of patients with peritoneal seeding, 7 patients not given IPHP had a 6-month survival rate of 57.1% and did not survive more than 9 months, whereas 20 patients given IPHP had 1- and 2-year survival rates of 78.7% and 45.0%, respectively; here the difference was significant (p = 0.001). The IPHP and control groups without peritoneal metastasis included 10 and 22 patients, respectively, and the 1-year survival rates are 85.4% and 45.3%, respectively. The survival rates of the former exceeded those of the latter, with p = 0.015 by the generalized Wilcoxon test. Thus this combined therapy offers the promise of extended survival for patients with far-advanced gastric cancer.     

Esophageal and gastric malignancies after bariatric surgery: a retrospective global study

BackgroundBariatric surgery can influence the presentation, diagnosis, and management of gastrointestinal cancers. Esophagogastric (EG) malignancies in patients who have had a prior bariatric procedure have not been fully characterized.ObjectiveTo characterize EG malignancies after bariatric procedures.SettingUniversity Hospital, United Kingdom.MethodsWe performed a retrospective, multicenter observational study of patients with EG malignancies after bariatric surgery to characterize this condition.ResultsThis study includes 170 patients from 75 centers in 25 countries who underwent bariatric procedures between 1985 and 2020. At the time of the bariatric procedure, the mean age was 50.2 ± 10 years, and the mean weight 128.8 ± 28.9 kg. Women composed 57.3% (n = 98) of the population. Most (n = 64) patients underwent a Roux-en-Y gastric bypass (RYGB) followed by adjustable gastric band (AGB; n = 46) and sleeve gastrectomy (SG; n = 43). Time to cancer diagnosis after bariatric surgery was 9.5 ± 7.4 years, and mean weight at diagnosis was 87.4 ± 21.9 kg. The time lag was 5.9 ± 4.1 years after SG compared to 9.4 ± 7.1 years after RYGB and 10.5 ± 5.7 years after AGB. One third of patients presented with metastatic disease. The majority of tumors were adenocarcinoma (82.9%). Approximately 1 in 5 patients underwent palliative treatment from the outset. Time from diagnosis to mortality was under 1 year for most patients who died over the intervening period.ConclusionThe Oesophago-Gastric Malignancies After Obesity/Bariatric Surgery study presents the largest series to date of patients developing EG malignancies after bariatric surgery and attempts to characterize this condition.     

Palliative operations for incurable gastric cancer

The experiences of 206 patients who underwent palliative operations for advanced gastric carcinoma have been reviewed to evaluate the effect of treatment. Gastroenterostomy for obstruction alleviates vomiting for most patients, but significant palliation followed operation in only 1/3 of cases. The procedure was accomplished with an acceptable mortality rate, and the average period of postoperative hospitalization was 13 days. The results of palliative partial gastrectomy for patients having obstructive symptoms preoperatively were only slightly better than those following gastroenterostomy. Approximately 1/3 of the patients lived in relative comfort for more than a year. The poor progress of 6 patients who received total gastrectomy supports the opinion that total gastrectomy is not a satisfactory palliative operation. Palliative esophagogastrectomy for patients with dysphagia gave results similar to, or possibly better than, palliative resections for distal lesions. Although the results following the use of prostheses for inoperable malignant stricturing of the esophagogastric junction were disappointing, the procedure had significant advantages when compared with the marked limitations and disadvantages of jejunostomy and the transient relief afforded by transesophageal dilatation. Review of the records of patients who had had a feeding jejunostomy confirmed the general opinion that this procedure seldom is indicated in the management of advanced gastric carcinoma.

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Résumé L'efficacité des opérations palliatives pour cancer gastrique avancé a été revue dans une série de 206 cas. La gastroentérostomie pour obstruction supprime les vomissements dans la majorité des cas, mais ne donne une palliation valable que dans 1/3 des cas; la mortalité est acceptable et la durée d'hospitalisation est, en moyenne, de 13 jours après l'opération. Chez les malades ayant des symptomes d'obstruction, les résultats de la gastrectomie palliative sont à peine meilleurs que ceux de la gastroentérostomie: ±1/3 des patients ont une survie confortable pendant plus d'un an. Les résultats décevants de 6 gastrectomies totales confirment l'inutilité de cette opération à titre palliatif. En cas de dysphagie, l'oesogastrectomie palliative donne des résultats comparables à ceux des résections pour lésions distales, peut-être même meilleurs. Les résultats des prothèses internes pour les lésions inopérables sténosant la jonction oesogastrique ont été décevants; la méthode est cependant supérieure à la jéjunostomie, dont le bénéfice est minime et les inconvénients majeurs, et à la dilatation oesophagienne dont les résultats sont fugaces. L'analyse des dossiers de malades avec jéjunostomie d'alimentation confirme l'opinion générale: cette opération est rarement indiquée dans le cancer gastrique avancé.

     

晚期胃癌转化治疗的发展现状与研究前景

晚期胃癌的治疗一直是胃癌治疗中的难点。Ⅳ期胃癌由于存在转移灶,往往难以达到根治性切除。转化治疗是指通过化疗、靶向治疗、免疫治疗等非外科手段,使肿瘤退缩甚至部分局部病灶消失,从而使得初始难以行根治性手术的病人获得R0切除机会。目前晚期胃癌的治疗仍以姑息手术和对症治疗为主,晚期胃癌的转化治疗尚未形成共识。评价胃癌转化治疗效果的主要指标是转化治疗后R0切除率、疾病控制率以及客观缓解率等实体瘤的疗效评价标准(response evaluation criteria in solid tumor, RECIST)。不同治疗手段和方案的疗效各异。转化治疗的最终目的是争取R0手术机会,故转化治疗后手术的合理实施也是关键问题。Yoshida提出的四分类法是目前最为普遍接受的手术决策依据。目前晚期胃癌的转化治疗仍困难重重,缺乏高质量研究。深入研究肿瘤微环境和开发新的治疗方法或许是今后研究的大方向。     

Multivisceral resection for locally advanced gastric cancer: A retrospective study

BackgroundMultivisceral resection may be the exclusive radical procedure for cT4b gastric cancer patients. However, most surgeons refuse to select surgery because of the theoretical higher mortality, morbidity and poorer prognosis.MethodsWe retrospectively reviewed cT4b gastric cancer patients who underwent surgery from January 1,1997 to December 31,2018. The primary endpoint was overall survival. Short-term results and prognostic values of clinical and pathologic factors were also analyzed.ResultsPatients underwent multivisceral resection had an acceptable mortality and morbidity. The overall 5-year survival rate of multivisceral resection was higher than that of palliative surgery (P < 0.05). And independent prognostic factors of multivisceral resection were R+ resection, extensive lymph node involved (>15), vascular cancer emboli, and postoperative chemotherapy.Conclusions: cT4b gastric cancer patients underwent multivisceral resection experience acceptable mortality and morbidity. The independent prognostic factors for multivisceral resection were completeness of resection, extensive lymph node involvement (>15), vascular cancer emboli, and postoperative chemotherapy.     

完全3D腹腔镜与开腹远端胃癌D2根治Roux-en-Y吻合术围术期疗效对比研究

目的比较完全3D腹腔镜与开腹两种手术方式在远端胃癌D₂根治Roux-en-Y吻合术中的围术期疗效。方法回顾性分析解放军总医院第一医学中心普通外科2017年1月至2019年12月采用D₂根治性Roux-en-Y吻合术治疗远端胃癌193例病人的临床资料,其中114例行完全3D腹腔镜手术,79例行开腹手术。比较两组病人的手术时间、术中出血量、手术切口长度、术后拔除胃管时间、术后排气时间、总住院时间、淋巴结清扫数目和术后近期并发症发生情况等。结果两组病人年龄、性别、体质量指数、肿瘤体积、肿瘤TNM分期等临床基线资料差异无统计学意义(P>0.05);完全3D腹腔镜手术组的术中出血量[(56.23±24.14)mL比(121.39±47.78)mL]、手术切口长度[(4.46±0.97)cm比(21.57±3.20)cm]、术后拔除胃管时间[(13.57±1.16)h比(58.62±27.3)h]、术后排气时间[(42.72±23.50)h比(64.25±26.05)h]、总住院时间[(7.17±1.24)d比(10.75±1.24)d]均少于或短于开腹手术组,差异有统计学意义(P<0.05);而在淋巴结清扫数目和术后近期并发症发生情况方面,两组差异无统计学意义(P>0.05)。结论完全3D腹腔镜远端胃癌D₂根治Roux-en-Y吻合术可以达到较好的清扫目的和临床疗效,且手术创伤小、术后恢复快,是安全、有效、可行的。     

Outpatient orthopedic surgery: a retrospective study of 1996 patients

Outpatient surgical procedures performed at the Centre Hospitalier de l'Université Laval on 1996 patients (1091 men, 905 women) were studied retrospectively. Lower-limb surgery accounted for 66.5% of the procedures. The mean age of the 1996 patients was 40.7 years. General anesthesia was used in 91.5% of the cases. After surgery, the patients were discharged according to the criteria described by Wetchler and Kortilla. The unanticipated hospital admission rate was 6.3% and the complication rate was 1.3% with no life-threatening conditions. Proper selection and preparation of the patient and strict criteria for safe discharge after day surgery are mandatory for the patient's safety and satisfaction.     

Palliative surgery for unresectable pancreatic and periampullary cancer: a reappraisal

This study aimed to reappraise short-term and long-term results of palliative biliary and gastric bypass surgery in patients with unresectable pancreatic head carcinoma found at explorative laparotomy. We retrospectively analyzed 83 consecutive patients whose pancreatic head carcinoma appeared unresectable at laparotomy (vascular involvement [57%], liver metastases [24%], distant metastatic lymph nodes [11%], peritoneal implants [8%]) and who underwent palliative surgical concomitant biliary and gastric bypass. Postoperative mortality and morbidity rates were 4.8% and 26.5%, respectively. Postoperativedelayed gastric emptying occurred in 9 patients (10%). Antecolic (46%) and retrocolic (54%) gastrojejunostomies did not differ for the duration of nasogastric suction, the delay of oral intake, and the incidence of delayed gastric emptying. Mean hospital stay was 16 +- 8 days. Median survival was 9 months (range 1–44). Late cholangitis occurred in 2 patients (2.4%) treated medically. One recurrent jaundice required transhepatic stenting 9 months from surgery. Four late gastric outlet obstructions occurred (4.8%) with a mean delay of 8 months from surgery. These data demonstrate that, in patients with unresectable pancreatic head carcinoma at laparotomy, palliative concomitant biliary and gastric bypass in a single procedure is safe and long-term efficient. This strategy remains to be compared to endoscopic palliation in this setting.     

Intracranial pressure monitoring after elective intracranial surgery. A retrospective study of 514 consecutive patients

A retrospective study of 514 consecutive patients whose intracranial pressure (ICP) was monitored after elective supratentorial or infratentorial surgery is reported. Of the 412 patients operated on in the supratentorial region, 76 (18.4%) had a postoperative sustained ICP elevation exceeding 20 torr. Abnormally high ICP occurred after 13 (12.7%) of the 102 infratentorial operations. Risk factors for postoperative ICP elevation were: resection of glioblastoma in 27.2% of cases, repeat surgery in 42.9% of cases, and protracted surgery (greater than 6 hours) in 41.7% of cases. Of the 89 patients with elevated ICP, 47 (52.8%) had an associated clinical deterioration. In 19 of these, the rise in ICP occurred before this deterioration was noticed, leading as a rule to quick diagnostic and management response. In eight patients clinical deterioration was noticed before the rise in ICP, and in 20 it happened simultaneously. The higher the level of ICP elevation, the greater were the chances of associated deterioration. The most common findings on computerized tomography scanning in 35 of 89 patients with elevated ICP were brain edema (19 cases) and bleeding in the tumor bed (15 cases). Mannitol, thiopental, additional hyperventilation, and reintubation (in patients who were previously extubated) were used to reduce ICP, in addition to surgical decompression whenever indicated. Thirteen patients with raised ICP and clinical deterioration underwent reoperation. The postoperative infection rate was 1.2% (six cases). In only one patient could infection be attributed to ICP monitoring. It was concluded that ICP monitoring is advantageous in the immediate postoperative management after elective intracranial surgery and is almost risk-free. It should therefore be used liberally, especially when risk factors for ICP elevation can be identified prior to the end of surgery.     

Palliative surgery for rectal cancer in a national cohort

Objective Whether resection of the primary tumour is of benefit to patients with incurable rectal cancer (RC) remains a matter of debate. In this study we analyse prospectively recorded data from a national cohort. Method Among 4831 patients diagnosed with RC between 1997 and 2001, 838 (17%) patients were treated with palliative surgery. Patients were stratified according to disease stage, age and type of surgery. Results A significantly longer median survival, 12 (range 10–13) months, was observed in patients treated with resection of the primary tumour compared with 5 (range 4–6) months in patients treated with nonresective procedures (P < 0.001). Median survival in months was significantly (P < 0.001) related to age (13; < 60 years of age, 10; 60 to 69 years, 7; 70 to 79 years, 6; ≥ 80 years of age). In patients over 80 years, survival was similar regardless of the treatment. Thirty‐day mortality varied from 2.5% to 20%, according to age groups. Conclusion The longer survival observed in patients with resection of the primary tumour may partly be explained by patient selection. Elderly patients (≥ 80 years) had a similar survival, irrespective of resection of the primary tumour or not. Careful consideration of the individual patient, extent of disease and treatment‐related factors are important in decision‐taking for palliative treatment for patients with advanced RC.     

快速康复外科理念在胃癌患者中的临床研究

【摘要】 目的 探讨快速康复外科理念在胃癌患者中临床应用的安全性和有效性。方法 回顾性研究184例胃癌患者临床资料,一组为快速康复外科组,另一组为传统治疗组,每组92例。比较两组患者的手术及术后恢复相关评价指标。结果 快速康复外科组与传统治疗组相比,在手术时间(182±43 min vs 190±46 min,P=0.68)、术中出血量(179±64 mL vs 182.59±74.65 mL,P=0.52)、淋巴结清扫数(21.2±7.2个vs 20.8±8.7个, P=0.59)、术后并发症(8.70% vs 10.87%,P=0.17)比较无显著性差异。而术后首次排气时间(3.6±0.6 d vs 5.0±0.8 d,P<0.01)、术后住院天数(7.1±1.4 d vs 11.5±2.0 d,P<0.001)和住院总费用(40583±3693元 vs 46438±6311元,P<0.001)比较有显著性差异。结论 快速康复外科理念应用于胃癌患者安全有效,可明显加快胃癌患者术后康复进程。