An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, ...histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients.
The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival.
The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics.
NCT03222895 , date of registration: July 19th, 2017.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Early oral feeding (EOF) is believed to be a crucial item of Enhanced Recovery After Surgery (ERAS) programs. Though this is widely accepted for colorectal surgery, evidence for early oral feeding ...after gastrectomy is scarce. The aim of this review is to assess the evidence of safety and benefits of early oral feeding after gastrectomy in patients with gastric cancer.
A systematic literature search of Pubmed, Embase and Cochrane was performed for eligible studies published till September 2018. Studies were analyzed and selected by predetermined criteria.
After having assessed 23 eligible articles, a total of four randomized controlled trials (RCT) remained who fully met all requirements to be included in this review. All four RCTs compared early oral feeding (n = 320) with conventional care (n = 334) after gastrectomy. In all four studies, EOF was associated with a decreased length of hospital stay ranging from −1.3 to −2.5 days when compared to conventional care. A faster time to first flatus was recorded in all four studies in the EOF group, ranging from −6.5 hours to −1.5 days. Furthermore, EOF does not increase postoperative complication risk when compared to conventional care.
Current evidence for early oral feeding after gastrectomy is promising, proving its safety, feasibility and benefits. However, most studies have been conducted amongst an Asian population. Well powered and larger randomized controlled trials performed amongst a Western population is needed.
•Early oral feeding promotes enhanced recovery after stomach surgery.•Studies show it is safe, feasible & beneficial after surgery for stomach cancer.•Earlier food intake does not increase complication risk after stomach surgery.•Early oral feeding leads to faster recovery and a shorter hospital stay.
Barrett's esophagus (BE) is associated with an increased risk of developing esophageal adenocarcinoma (EAC). Patients with a known diagnosis of BE are usually advised to participate in an endoscopic ...surveillance program, but its clinical value is unproven. Our objective was to compare patients participating in a surveillance program for BE before EAC diagnosis with those not participating in such a program, and to determine predictive factors for mortality from EAC.
All patients diagnosed with EAC between 1999 and 2009 were identified in the nationwide Netherlands Cancer Registry. These data were linked to Pathologisch-Anatomisch Landelijk Geautomatiseerd Archief, the Dutch Pathology Registry. Prior surveillance was evaluated, and multivariable Cox proportional hazards regression analysis was performed to identify predictors for all-cause mortality at 2-year and 5-year follow-up.
In total, 9,780 EAC patients were included. Of these, 791 (8%) patients were known with a prior diagnosis of BE, of which 452 (57%) patients participated in an adequate endoscopic surveillance program, 120 (15%) patients in an inadequate program, and 219 (28%) patients had a prior BE diagnosis without participating. Two-year (and five-year) mortality rates were lower in patients undergoing adequate surveillance (adjusted hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.64-0.92) when compared with patients with a prior BE diagnosis who were not participating. Other factors associated with lower mortality from EAC were lower tumor stage (stage I vs. IV, HR=0.19, 95% CI=0.16-0.23) and combining surgery with neoadjuvant chemo/radiotherapy (HR=0.66, 95% CI=0.58-0.76).
Participation in a surveillance program for BE, but only if adequately performed, reduces mortality from EAC. Nevertheless, it remains to be determined whether such a program is cost-effective, as more than 90% of all EAC patients were not known to have BE before diagnosis.
Background
The possible advantages of laparoscopic (assisted) total gastrectomy (LTG) versus open total gastrectomy (OTG) have not been reviewed systematically. The aim of this study was to ...systematically review the short-term outcomes of LTG versus OTG in the treatment of gastric cancer.
Methods
A systematic search of PubMed, Cochrane, CINAHL, and Embase was conducted. All original studies comparing LTG with OTG were included for critical appraisal. Data describing short-term outcomes were pooled and analyzed.
Results
A total of eight original studies that compared LTG (
n
= 314) with OTG (
n
= 384) in patients with gastric cancer fulfilled quality criteria and were selected for review and meta-analysis. LTG compared with OTG was associated with a significant reduction of intraoperative blood loss (weighted mean difference = 227.6 ml; 95 % CI 144.3–310.9;
p
< 0.001), a reduced risk of postoperative complications (risk ratio = 0.51; 95 % CI 0.33–0.77), and shorter hospital stay (weighted mean difference 4.0 = days; 95 % CI 1.4–6.5;
p
< 0.001). These benefits were at the cost of longer operative time (weighted mean difference = 55.5 min; 95 % CI 24.8–86.2;
p
< 0.001). In-hospital mortality rates were comparable for LTG (0.9 %) and OTG (1.8 %) (risk ratio = 0.68; 95 % CI 0.20–2.36).
Conclusion
LTG shows better short term outcomes compared with OTG in eligible patients with gastric cancer. Future studies should evaluate 30- and 60-day mortality, radicality of resection, and long-term follow-up in LTG versus OTG, preferably in randomized trials.
Introduction
Guidelines on how to adjust activity in patients with a history of liver surgery who are undergoing yttrium-90 radioembolisation (
90
Y-RE) are lacking. The aim was to study the ...variability in activity prescription in these patients, between centres with extensive experience using resin microspheres
90
Y-RE, and to draw recommendations on activity prescription based on an expert consensus.
Methods
The variability in activity prescription between centres was investigated by a survey of international experts in the field of
90
Y-RE. Six representative post-surgical patients (i.e. comparable activity prescription, different outcome) were selected. Information on patients’ disease characteristics and data needed for activity calculation was presented to the expert panel. Reported was the used method for activity prescription and whether, how and why activity reduction was found indicated.
Results
Ten experts took part in the survey. Recommendations on activity reduction were highly variable between the expert panel. The median intra-patient range was 44 Gy (range 18–55 Gy). Reductions in prescribed activity were recommended in 68% of the cases. In consensus, a maximum D
Target
of 50 Gy was recommended.
Conclusion
With a current lack of guidelines, large variability in activity prescription in post-surgical patients undergoing
90
Y-RE exists. In consensus, D
Target
≤50 Gy is recommended.
Key points
•
BSA method does not account for a decreased remnant liver volume after surgery.
•
In post-surgical patients, a volume-based activity determination method is recommended.
•
In post-surgical patients, a mean D
Target
of ≤ 50Gy should be aimed for.
Background
Anastomotic leaks are associated with significant risk of morbidity, mortality and treatment costs after oesophagectomy. The aim of this study was to evaluate international variation in ...unit-level clinical practice and resource availability for the prevention and management of anastomotic leak following oesophagectomy.
Method
The Oesophago-Gastric Anastomosis Audit (OGAA) is an international research collaboration focussed on improving the care and outcomes of patients undergoing oesophagectomy. Any unit performing oesophagectomy worldwide can register to participate in OGAA studies. An online unit survey was developed and disseminated to lead surgeons at each unit registered to participate in OGAA. High-income country (HIC) and low/middle-income country (LMIC) were defined according to the World Bank whilst unit volume were defined as < 20 versus 20–59 versus ≥60 cases/year in the unit.
Results
Responses were received from 141 units, a 77% (141/182) response rate. Median annual oesophagectomy caseload was reported to be 26 (inter-quartile range 12–50). Only 48% (68/141) and 22% (31/141) of units had an Enhanced Recovery After Surgery (ERAS) program and ERAS nurse, respectively. HIC units had significantly higher rates of stapled anastomosis compared to LMIC units (66 vs 31%,
p
= 0.005). Routine post-operative contrast-swallow anastomotic assessment was performed in 52% (73/141) units. Stent placement and interventional radiology drainage for anastomotic leak management were more commonly available in HICs than LMICs (99 vs 59%,
p
< 0.001 and 99 vs 83%,
p
< 0.001).
Conclusions
This international survey highlighted variation in surgical technique and management of anastomotic leak based on case volume and country income level. Further research is needed to understand the impact of this variation on patient outcomes.
Worldwide, the standard treatment for locally advanced esophageal cancer with curative intent is perioperative chemotherapy or preoperative chemoradiotherapy followed by open transthoracic ...esophagectomy (OTE) with gastric conduit reconstruction. Minimally invasive esophagectomy (MIE) was developed to improve the postoperative outcome by reducing the surgical trauma, with comparable short-term oncologic results. However, MIE is a highly complex procedure associated with a long learning curve.
In 2003, robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RAMIE) was developed to overcome the technical limitations of MIE. Robotic surgery benefits from a stable 3-dimensional, magnified view and articulated instruments enabling precise dissection with 7 degrees of freedom of movement.
In this review, the development of RAMIE within our hospital is described using a 5-stage development process for the assessment of surgical innovation (IDEAL).
Hiatal Hernia After Esophagectomy for Cancer Brenkman, Hylke J.F., MD; Parry, Kevin, MD; Noble, Fergus, PhD ...
The Annals of thoracic surgery,
04/2017, Letnik:
103, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Background Hiatal hernia (HH) after esophagectomy is becoming more relevant due to improvements in survival. This study evaluated and compared the occurrence and clinical course of HH after open and ...minimally invasive esophagectomy (MIE). Methods The prospectively recorded characteristics of patients treated with esophagectomy for cancer at 2 tertiary referral centers in the United Kingdom and the Netherlands between 2000 and 2014 were reviewed. Computed tomography reports were reviewed to identify HH. Results Of 657 patients, MIE was performed in 432 patients (66%) and open esophagectomy in 225 (34%). A computed tomography scan was performed in 488 patients (74%). HH was diagnosed in 45 patients after a median of 20 months (range, 0 to 101 months). The development of HH after MIE was comparable to the open approach (8% vs 5%, p = 0.267). At the time of diagnosis, 14 patients presented as a surgical emergency. Of the remaining 31 patients, 17 were symptomatic and 14 were asymptomatic. An elective operation was performed in 10 symptomatic patients, and all others were treated conservatively. During conservative treatment, 2 patients presented as a surgical emergency. An emergency operation resulted in a prolonged intensive care unit stay compared with an elective procedure (3 vs 0 days, p < 0.001). In-hospital deaths were solely seen after emergency operations (19%). Conclusions HH is a significant long-term complication after esophagectomy, occurring in a substantial proportion of the patients. The occurrence of HH after MIE and open esophagectomy is comparable. Emergency operation is associated with dismal outcomes and should be avoided.
Abstract Purpose To explore the value of diffusion-weighted magnetic resonance imaging (DW-MRI) for the prediction of pathologic response to neoadjuvant chemoradiotherapy (nCRT) in esophageal cancer. ...Material and methods In 20 patients receiving nCRT for esophageal cancer DW-MRI scanning was performed before nCRT, after 8–13 fractions, and before surgery. The median tumor apparent diffusion coefficient (ADC) was determined at these three time points. The predictive potential of initial tumor ADC, and change in ADC (ΔADC) during and after treatment for pathologic complete response (pathCR) and good response were assessed. Good response was defined as pathCR or near-pathCR (tumor regression grade TRG 1 or 2). Results A pathCR after nCRT was found in 4 of 20 patients (20%), and 8 patients (40%) showed a good response to nCRT. The ΔADCduring was significantly higher in pathCR vs. non-pathCR patients (34.6% ± 10.7% mean ± SD vs. 14.0% ± 13.1%, p = 0.016), as well as in good vs. poor responders (30.5% ± 8.3% vs. 9.5% ± 12.5%, p = 0.002). The ΔADCduring was predictive of residual cancer at a threshold of 29% (sensitivity of 100%, specificity of 75%, PPV of 94%, and NPV of 100%), and for poor pathologic response at a threshold of 21% (sensitivity of 82%, specificity of 100%, PPV of 100%, and NPV of 80%). Conclusions In this exploratory study, the treatment-induced change in ADC during the first 2–3 weeks of nCRT for esophageal cancer seemed highly predictive of histopathologic response. Larger series are warranted to verify these results.
Background
The relation between gastric cancer characteristics and lymph node (LN) metastatic patterns is not fully clear, especially following neoadjuvant chemotherapy (NAC). This study analyzed ...nodal metastatic patterns.
Methods
Individual LN stations were analyzed for all patients from the LOGICA-trial, a Dutch multicenter randomized trial comparing laparoscopic versus open D2-gastrectomy for gastric cancer. The pattern of metastases per LN station was related to tumor location, cT-stage, Lauren classification and NAC.
Results
Between 2015–2018, 212 patients underwent D2-gastrectomy, of whom 158 (75%) received NAC. LN metastases were present in 120 patients (57%). Proximal tumors metastasized predominantly to proximal LN stations (no. 1, 2, 7 and 9;
p
< 0.05), and distal tumors to distal LN stations (no. 5, 6 and 8; OR > 1,
p
> 0.05). However, distal tumors also metastasized to proximal LN stations, and vice versa. Despite NAC, each LN station (no. 1–9, 11 and 12a) showed metastases, regardless of tumor location, cT-stage, histological subtype and NAC treatment, including station 12a for cT1N0-tumors. LN metastases were present more frequently in diffuse versus intestinal tumors (66% versus 52%;
p
= 0,048), but not for cT3–4- versus cT1–2-stage (59% versus 51%;
p
= 0.259). However, the pattern of LN metastases was similar for these subgroups.
Conclusions
The extent of lymphadenectomy cannot be reduced after NAC for gastric cancer. Although the pattern of LN metastases is related to tumor location, all LN stations contained metastases regardless of tumor location, cT-stage (including cT1N0-tumors), histological subtype, or NAC treatment. Therefore, D2-lymphadenectomy should be routinely performed during gastrectomy in Western patients.
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