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•The prognosis of patients with metastatic gastric cancer is poor.•Currently the standard of care for these patients remains palliative treatment.•Surgical resection of liver only ...metastases can lead to favorable outcomes.•Patients undergoing surgical resection for gastric cancer liver metastases need to be carefully selected.
The prognosis of patients with metastatic gastric cancer remains dismal, with palliative treatment as standard of care. However, encouraging results have been reported for surgical resection of liver only metastatic gastric cancer in carefully selected patients. A systematic review of articles published from 2000 onwards was conducted according to PRISMA guidelines. Twenty-nine studies were included in qualitative and quantitative analysis. Meta-analysis of proportions pointed out 29.1 % 5ySR (I 2 = 39 %). The pooled weighted median of MSTs was 31.1 months. T stage > 2, metastasis greatest dimension ≥ 5 cm, the presence of multiple metastases and bilobar disease resulted among the strongest predictors of mortality. Funnel plots, Egger’s tests, and P-curve analyses failed to show significant publication bias. Based on strict selection criteria and robust statistical analyses, our results show that, in very carefully selected patients without extrahepatic disease, surgical resection with curative intent may significantly improve overall survival.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Lymph nodes (LNs)' metastases have a well-known detrimental impact on the survival outcomes of patients suffering from pancreatic cancer of the body and tail. However, the extent of the ...lymphadenectomy for this tumor location is still debated. The aim of this study was to systematically review the current literature to explore the incidence and the prognostic impact of non-peripancreatic lymph nodes (PLNs) in patients suffering from pancreatic cancer of the body and tail. A systematic review was conducted according to PRISMA and MOOSE guidelines. The primary endpoint was to assess the impact of non-PLNs on overall survival (OS). As a secondary endpoint, the pooled frequencies of different non-PLN stations' metastatic patterns according to tumor location were explored. Eight studies were included in data synthesis. An increased risk of death for patients with positive non-PLNs was detected (HR: 2.97; 95% CI: 1.81-4.91;
< 0.0001). Meta-analysis of proportions pointed out a 7.1% pooled proportion of nodal infiltration in stations 8-9. The pooled frequency for station 12 metastasis was 4.8%. LN stations 14-15 were involved in 11.4% of cases, whereas station 16 represented a site of metastasis in 11.5% of cases. Despite its potential beneficial effect on survival outcome, a systematic extended lymphadenectomy could not be recommended yet for patients suffering from PDAC of the body/tail.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Complete mesogastric excision (CME) has been advocated to allow for a more extensive retrieval of lymph nodes, as well as lowering loco-regional recurrence rates. This study aims to analyze the ...short-term outcomes of D2 radical gastrectomy with CME compared to standard D2 gastrectomy. A systematic review of the literature was conducted according to the Cochrane recommendations until 2 July 2023 (PROSPERO ID: CRD42023443361). The primary outcome, expressed as mean difference (MD) and 95% confidence intervals (CI), was the number of harvested lymph nodes (LNs). Meta-analyses of means and binary outcomes were developed using random effects models to assess heterogeneity. The risk of bias in included studies was assessed with the RoB 2 and ROBINS-I tools. There were 13 studies involving 2009 patients that were included, revealing a significantly higher mean number of harvested LNs in the CME group (MD: 2.55; 95% CI: 0.25-4.86; 95%;
= 0.033). The CME group also experienced significantly lower intraoperative blood loss, a lower length of stay, and a shorter operative time. Three studies showed a serious risk of bias, and between-study heterogeneity was mostly moderate or high. Radical gastrectomy with CME may offer a safe and more radical lymphadenectomy, but long-term outcomes and the applicability of this technique in the West are still to be proven.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Abstract
Background
Entero-colovesical fistula is a rare complication of various benign and malignant diseases. The diagnosis is prominently based on clinical symptoms; imaging studies are necessary ...not only to confirm the presence of the fistula, but more importantly to demonstrate the extent and the nature of the fistula. There is still a lack of consensus regarding the
if, when and how
to repair the fistula. The aim of the study is to review the different surgical treatment options, focus on surgical indications, and explore cumulative recurrence, morbidity, and mortality rates of entero-vesical and colo-vesical fistula patients.
Methods
A systematic review of the literature was conducted according to PRISMA guidelines. Random effects meta-analyses of proportions were developed to assess primary and secondary endpoints. I
2
statistic and Cochran’s Q test were computed to assess inter-studies’ heterogeneity.
Results
Twenty-two studies were included in the analysis with a total of 861 patients. Meta-analyses of proportions pointed out 5, 22.2, and 4.9% rates for recurrence, complications, and mortality respectively. A single-stage procedure was performed in 75.5% of the cases, whereas a multi-stage operation in 15.5% of patients. Palliative surgery was performed in 6.2% of the cases. In 2.3% of the cases, the surgical procedure was not specified. Simple and advanced repair of the bladder was performed in 84.3% and 15.6% of the cases respectively.
Conclusions
Although burdened by a non-negligible rate of complications, surgical repair of entero-colovesical fistula leads to excellent results in terms of primary healing. Our review offers opportunities for significant further research in this field.
Level of Evidence
Level III according to ELIS (SR/MA with up to two negative criteria).
Colorectal cancer (CRC) patients frequently develop liver metastases. Different treatment strategies are available according to the timing of appearance, the burden of metastatic disease, and the ...performance status of the patient. Systemic treatment (ST) represents the cornerstone of metastatic disease management. However, in select cases, combined ST and surgical resection can lead to remarkable survival outcomes. In the present multicentric cohort study, we explored the efficacy of a conversion strategy in a selected population of left-sided RAS/BRAF wild-type CRC patients with liver-limited metastatic disease. Methods: The primary endpoint was to compare survival outcomes of patients undergoing ST not leading to surgery, liver resection after conversion ST, and hepatic resection with perioperative ST. Furthermore, we explored survival outcomes depending on whether the case was discussed within a multidisciplinary team. Results: Between 2012 and 2020, data from 690 patients respecting the inclusion criteria were collected. Among these, 272 patients were deemed eligible for the analysis. The conversion rate was 24.1% of cases. Fifty-six (20.6%) patients undergoing surgical resection after induction treatment (i.e., ultimately resectable) had a significant survival advantage compared to those receiving systemic treatment not leading to surgery (176 pts, 64.7%) (5-year OS 60.8% and 11.7%, respectively, Log Rank test p < 0.001; HR = 0.273; 95% CI: 0.16−0.46; p < 0.001; 5-year PFS 22.2% and 6.3%, respectively, Log Rank test p < 0.001; HR = 0.447; 95% CI: 0.32−0.63; p < 0.001). There was no difference in survival between ultimately resectable patients and those who had liver resection with perioperative systemic treatment (potentially resectable—40 pts) (5-year OS 71.1%, Log Rank test p = 0.311. HR = 0.671; 95% CI: 0.31−1.46; p = 0.314; 5-year PFS 25.7%, Log Rank test p = 0.305. HR = 0.782; 95% CI: 0.49−1.25; p = 0.306). Conclusions: In our selected population of left-sided RAS/BRAF wild-type colorectal cancer patients with liver-limited disease, a conversion strategy was confirmed to provide a survival benefit. Patients not deemed surgical candidates at the time of diagnosis and patients judged resectable with perioperative systemic treatment have similar survival outcomes.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Inhibition of angiotensin II synthesis seems to decrease hepatocellular carcinoma recurrence after radical therapies; however, data on the adjuvant role of angiotensin II receptor 1 blockers ...(sartans) are still lacking. Aim of the study was to evaluate whether sartans delay time to recurrence and prolong overall survival in hepatocellular carcinoma patients after radiofrequency ablation. Data on 215 patients were reviewed. The study population was classified into three groups: 113 (52.5%) patients who received neither angiotensin-converting enzyme inhibitors nor sartans (group 1), 59 (27.4%) patients treated with angiotensin-converting enzyme inhibitors (group 2) and 43 (20.1%) patients treated with sartans (group 3). Survival outcomes were analyzed using Kaplan-Meier analysis and compared with log-rank test. In the whole study population, 85.6% of patients were in Child-Pugh A-class and 89.6% in Barcelona Clinic Liver Cancer A stage. Median maximum tumor diameter was 30 mm (10-40 mm) and alpha-fetoprotein was 25 (1.1-2100) IU/mL. No differences in baseline characteristics among the three groups were reported. Median overall survival was 48 months (42-51) in group 1, 51 months (42-88) in group 2, and 63 months (51-84) in group 3 (
= 0.15). Child-Pugh stage and Model for End-staging Liver Disease (MELD) score resulted as significant predictors of overall survival in multivariate analysis. Median time to recurrence was 33 months (24-35) in group 1, 41 (23-72) in group 2 and 51 months (42-88) in group 3 (
= 0.001). Number of nodules and anti-angiotensin treatment were confirmed as significant predictors of time to recurrence in multivariate analysis. Sartans significantly improved time to recurrence after radiofrequency ablation in hepatocellular carcinoma patients but did not improve overall survival.
Background The operative approach to large retrohepatic tumors can be challenging because of the difficulty in exposing the inferior vena cava (IVC) and controlling bleeding. The anterior approach to ...the IVC associated with the hanging maneuver for liver transection, originally described in large hepatic tumors, may also facilitate removal of large masses set behind the liver. Methods A prospective cohort of 10 patients with large retrohepatic tumors involving the IVC was selected according to restrictive criteria (ie, single low-grade tumor, sufficient liver remnant, normal hepatic function, absence of cholestasis, and symptoms secondary to lower vena cava obstruction). In all cases, the anterior approach and the hanging maneuver were applied intentionally to expose the IVC without any liver mobilization. Depending on tumor invasiveness, either IVC-preserving ( n = 7) or IVC-removing ( n = 3) strategies were applied. Our aim was to assess the safety of the technique and the possible benefits for patient outcome. Results The cohort represented less than 1% of a series of 1,168 major hepatectomies performed in our unit between 2005 and 2011. The median age of the patients was 58; adrenal tumors and retroperitoneal sarcomas accounted for 70% of the series. Total vascular liver exclusion was necessary in 3 patients. Median operative time was 420 min. R0 resection was obtained in all cases, with no mortality and 40% overall morbidity. Overall survival was 83% at 5 years. Conclusion The transhepatic, anterior approach to the IVC is a safe procedure that improves vascular control, facilitates vein repair or reconstruction, and allows potentially curative resection of large retrohepatic tumors. This approach should be the preferred choice to be adopted in properly selected patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background & Aims The efficacy of sorafenib in the post-liver transplantation (LT) setting has been scarcely studied. The aim of this study was to evaluate the efficacy of sorafenib, compared to best ...supportive care (BSC), in two cohorts of patients which presented with hepatocellular carcinoma (HCC) recurrence after LT. Methods Data from patients who developed presentation or progression of HCC recurrence after LT not amenable to surgical/locoregional treatments (untreatable presentation/progression, UP) were retrieved. The cohort of patients receiving sorafenib starting from 2007 was compared to that of patients receiving BSC in the previous era. Disease outcome was investigated in terms of survival from recurrence or from UP by means of univariate and multivariate Cox regression models with event times left-truncated at the date of UP. Results Of a total of 39 patients, 24 received BSC and 15 sorafenib. The two groups were well matched at baseline, with time-related imbalances regarding mTOR-based immunosuppression and median time from LT to recurrence, significantly higher in the sorafenib group. Patients’ outcome in the sorafenib group was significantly improved (median survival from recurrence 21.3 vs. 11.8 months, HR = 5.2, p = 0.0009; median survival from UP 10.6 vs. 2.2 months, HR = 21.1, p <0.0001). The only factor associated with survival after HCC recurrence in multivariate analysis was treatment with sorafenib (HR = 4.0; p = 0.0325). No severe adverse event was registered in this post-LT setting. Conclusions Although the use of historical controls weakens final interpretation, sorafenib seems to be associated with an acceptable safety profile and benefit in survival in HCC patients suffering recurrence after LT.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The anterior approach (AA), whether or not associated with the liver hanging maneuver (LHM), has been advocated to improve survival and postoperative outcomes in HCC patients undergoing major liver ...resection. This systematic review and meta-analysis of randomized controlled trials aims to explore intra/perioperative and long-term survival outcomes of AA ± LHM compared to CA regardless of tumor histology.
The study was conducted according to the Cochrane recommendations searching the PubMed, Scopus, and EMBASE databases until January 27, 2024 (PROSPERO ID: CRD42024507060). Only English-language RCTs were included. The primary outcome, expressed as hazard ratio (HR) and 95 % confidence intervals (CI), was the overall and disease-free survival. Random effects models were developed to assess heterogeneity. The risk of bias in included studies was assessed with the RoB 2 tool. The certainty of evidence was assessed following GRADE recommendations.
Six RCTs, for a total of 736 patients were included. A significant survival benefit was highlighted for patients undergoing AA ± LHM in terms of overall (HR: 0.65; 95 % CI: 0.62–0.68; p < 0.0001) and disease-free survival (HR: 0.65; 95 % CI: 0.63–0.68; p < 0.0001). AA ± LHM was associated with a longer duration of surgery (WMD: 29.5 min; 95 % CI: 17.72–41.27; p = 0.004), and a lower intraoperative blood loss (WMD: 24.3; 95 % CI: 31.1 to −17.5; p = 0.0014). No difference was detected for other postoperative outcomes. The risk of bias was low.
AA ± LHM provides better survival outcomes compared to CA. Furthermore, AA ± LHM is related to a modest reduction in intraoperative blood loss, at the price of a slightly longer duration of hepatectomy. Regarding other postoperative outcomes, the two techniques appear comparable.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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