BackgroundMany gastric cancer patients in Western countries are diagnosed as metastatic with a median overall survival of less than twelve months using standard chemotherapy. Innovative treatments, ...like targeted therapy or immunotherapy, have recently proved to ameliorate prognosis, but a general agreement on managing oligometastatic disease has yet to be achieved. An international multi-disciplinary workshop was held in Bertinoro, Italy, in November 2022 to verify whether achieving a consensus on at least some topics was possible.MethodsA two-round Delphi process was carried out, where participants were asked to answer 32 multiple-choice questions about CT, laparoscopic staging and biomarkers, systemic treatment for different localization, role and indication of palliative care. Consensus was established with at least a 67% agreement.ResultsThe assembly agreed to define oligometastases as a “dynamic” disease which either regresses or remains stable in response to systemic treatment. In addition, the definition of oligometastases was restricted to the following sites: para-aortic nodal stations, liver, lung, and peritoneum, excluding bones. In detail, the following conditions should be considered as oligometastases: involvement of para-aortic stations, in particular 16a2 or 16b1; up to three technically resectable liver metastases; three unilateral or two bilateral lung metastases; peritoneal carcinomatosis with PCI ≤ 6. No consensus was achieved on how to classify positive cytology, which was considered as oligometastatic by 55% of participants only if converted to negative after chemotherapy.ConclusionAs assessed at the time of diagnosis, surgical treatment of oligometastases should aim at R0 curativity on the entire disease volume, including both the primary tumor and its metastases. Conversion surgery was defined as surgery on the residual volume of disease, which was initially not resectable for technical and/or oncological reasons but nevertheless responded to first-line treatment.
Abstract Background Median survival in patients with unresectable locally advanced pancreatic cancer lies in the range of 9–15 months. Radiofrequency ablation (RFA) may prolong survival, but data on ...its safety and efficacy are scarce. Methods A systematic literature search was performed in PubMed, EMBASE and the Cochrane Library with the syntax ‘(radiofrequency OR RFA) AND (pancreas OR pancreatic)’ for studies published until 1 January 2012. In addition, a search of the proceedings of conferences on pancreatic disease that took place during 2009–2011 was performed. Studies with fewer than five patients were excluded as they were considered to be case reports. The primary endpoint was survival. Secondary endpoints included morbidity and mortality. Results Five studies involving a total of 158 patients with pancreatic cancer treated with RFA fulfilled the eligibility criteria. These studies reported median survival after RFA of 3–33 months, morbidity related to RFA of 4–37%, mortality of 0–19% and overall morbidity of 10–43%. Pooling of data was not appropriate as the study populations and reported outcomes were heterogeneous. Crucial safety aspects included ensuring a maximum RFA tip temperature of < 90 °C and ensuring minimum distances between the RFA probe and surrounding structures. Conclusions Radiofrequency ablation seems to be feasible and safe when it is used with the correct temperature and at an appropriate distance from vital structures. It appears to have a positive impact on survival. Multicentre randomized trials are necessary to determine the true effect size of RFA and to minimize the impacts of selection and publication biases.
Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal ...cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early‐stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot‐assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.
Abstract Background To potentially improve outcomes in pancreatic resection, robot‐assisted pancreatic surgery has been introduced. This technique has possible advantages over laparoscopic surgery, ...such as its affordance of three‐dimensional vision and increased freedom of movement of instruments. A systematic review was performed to assess the safety and feasibility of robot‐assisted pancreatic surgery. Methods The literature published up to 30 September 2011 was systematically reviewed, with no restrictions on publication date. Studies reporting on over five patients were included. Animal studies, studies not reporting morbidity and mortality, review articles and conference abstracts were excluded. Data were extracted and weighted means were calculated. Results A total of 499 studies were screened, after which eight cohort studies reporting on a total of 251 patients undergoing robot‐assisted pancreatic surgery were retained for analysis. Weighted mean operation time was 404 ± 102 min (510 ± 107 min for pancreatoduodenectomy only). The rate of conversion was 11.0% (16.4% for pancreatoduodenectomy only). Overall morbidity was 30.7% ( n = 77), most frequently involving pancreatic fistulae ( n = 46). Mortality was 1.6%. Negative surgical margins were obtained in 92.9% of patients. The rate of spleen preservation in distal pancreatectomy was 87.1%. Conclusions Robot‐assisted pancreatic surgery seems to be safe and feasible in selected patients and, in left‐sided resections, may increase the rate of spleen preservation. Randomized studies should compare the respective outcomes of robot‐assisted, laparoscopic and open pancreatic surgery.
Adenocarcinoma of the gastroesophageal junction (GEJ) Siewert type II can be resected by transthoracic esophagectomy or transhiatal extended gastrectomy. Both allow for a complete tumor resection, ...yet there is an ongoing controversy about which surgical approach is superior with regards to quality of life, oncological outcomes and survival. While some studies suggest a better oncological outcome after transthoracic esophagectomy, others favor transhiatal extended gastrectomy for a better postoperative quality of life. To date, only retrospective studies are available, showing ambiguous results.
This study is a multinational, multicenter, randomized, clinical superiority trial. Patients (n = 262) with a GEJ type II tumor resectable by both transthoracic esophagectomy and transhiatal extended gastrectomy will be enrolled in the trial. Type II tumors are defined as tumors with their midpoint between ≤1 cm proximal and ≤ 2 cm distal of the top of gastric folds on preoperative endoscopy. Patients will be included in one of the participating European sites and are randomized to either transthoracic esophagectomy or transhiatal extended gastrectomy. The trial is powered to show superiority for esophagectomy with regards to the primary efficacy endpoint overall survival. Key secondary endpoints are complete resection (R0), number and localization of tumor infiltrated lymph nodes at dissection, post-operative complications, disease-free survival, quality of life and cost-effectiveness. Postoperative survival and quality of life will be followed-up for 24 months after discharge. Further survival follow-up will be conducted as quarterly phone calls up to 60 months.
To date, as level 1 evidence is lacking, there is no consensus on which surgery is superior and both surgeries are used to treat GEJ type II carcinoma worldwide. The CARDIA trial is the first randomized trial to compare transthoracic esophagectomy versus transhiatal extended gastrectomy in patients with GEJ type II tumors. Several quality control measures were implemented in the protocol to ensure data reliability and increase the trial's significance. It is hypothesized that esophagectomy allows for a higher rate of radical resections and a more complete mediastinal lymph node dissection, resulting in a longer overall survival, while still providing an acceptable quality of life and cost-effectiveness.
The trial was registered on August 2nd 2019 at the German Clinical Trials Register under the trial-ID DRKS00016923 .
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The postoperative 30-day mortality and morbidity of gastric cancer surgery has markedly improved over the past years due to minimally invasive techniques, perioperative rehabilitation programs and ...centralization of care. However, there is still need for improvement as postoperative complications may have a serious negative impact on the efficacy of surgical treatment of gastric cancer. High-quality clinical research is a very important tool to analyze treatment outcomes and evaluate new treatment strategies. The meticulous registration of gastric cancer patient data is the basis of high-quality surgical research. In the past 11 years, the Dutch upper gastrointestinal cancer audit (DUCA) database has vast experience in data registration and maintenance of patients with upper gastrointestinal cancer. The effective measures it has taken in data registration, data quality control, data application and use, and data security have maintained quality at a high level. These data has been used for medical care quality
ABSTRACT
Initial results of the ROBOT, which randomized between robot-assisted minimally invasive esophagectomy (RAMIE) and open transthoracic esophagectomy (OTE), showed significantly better ...short-term postoperative outcomes in favor of RAMIE. However, it is not yet clarified if RAMIE is equivalent to OTE regarding long-term outcomes. The aim of this study was to report the long-term oncological results of the ROBOT trial in terms of survival and disease-free survival. This study is a follow-up study of the ROBOT trial, which was a randomized controlled trial comparing RAMIE to OTE in 112 patients with intrathoracic esophageal cancer. Both the trial protocol and short-term results were previously published. The primary outcome of the current study was 5-year overall survival. Secondary outcomes were disease-free survival and recurrence patterns. Analysis was by intention to treat. During the recruitment period, 109 patients were included in the survival analysis (RAMIE n = 54, OTE n = 55). Majority of patients had clinical stage III or IV (RAMIE 63%, OTE 55%) and received neoadjuvant chemoradiotherapy (80%). Median follow-up was 60 months (range 31–60). The combined 5-year overall survival rates for RAMIE and OTE were 41% (95% CI 27–55) and 40% (95% CI 26–53), respectively (log rank test P = 0.827). The 5-year disease-free survival rate was 42% (95% CI 28–55) in the RAMIE group and 43% (95% CI 29–57) in the OTE group (log rank test P = 0.749). Out of 104 patients, 57 (55%) developed recurrent disease detected at a median of 10 months (range 0–56) after surgery. No statistically difference in recurrence rate nor recurrence pattern was observed between both groups. Overall survival and disease-free survival of RAMIE are comparable to OTE. These results continue to support the use of robotic surgery for esophageal cancer.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Background Thoracic chyle leakage is a major complication of esophagectomy. In this study our treatment strategy for chyle leakage was evaluated and its risk factors were identified. Methods ...According to the Esophagectomy Complications Consensus Group recommendations, chyle leakage was classified as follows: I, enteric dietary modifications; II, total parenteral nutrition (TPN); and III, interventional or surgical therapy. It was graded as A, less than 1,000 mL per day; or B, more than 1,000 mL per day. In our protocol, chyle leakage less than 500 mL per day was treated with a low-fat diet; more than 1,000 mL per day, with TPN, and 500 to 1,000 mL per day, with a low-fat diet or TPN depending on whether the chyle leakage was increasing or decreasing at diagnosis and the clinical condition. Surgery was reserved for refractory leakages. Results In total 371 patients were included. Chyle leakage incidence was 21%, consisting of 51% grade A and 49% grade B leakage. Chyle leakage severity was associated with length of stay (grade A, median 17 days versus B, 25 days; p = 0.006). Independent risk factors were a transthoracic approach (odds ratio 4.8, p = 0.002), neoadjuvant chemoradiotherapy (odds ratio 2.6, p = 0.002), and preoperative body mass index (exp(B) 0.92, p = 0.031). Treatment consisted of low-fat diet in 53%, TPN in 37%, and surgery in 10% of the patients. Low-fat diet and TPN successfully treated 87% of chyle leaks. Chyle leakages treated by TPN first were significantly more severe compared with those treated first by low-fat diet, and were significantly associated with electrolyte deficiencies, increased complication severity, and length of stay, but not with 90-day mortality. Conclusions A step-up treatment strategy, starting with dietary modifications, solved nearly 90% of chyle leaks conservatively. A minority of chyle leaks required surgery.
Background Cryoablation (CA), radiofrequency ablation (RFA), and laser induced thermotherapy (LITT) are alternative therapies for patients with unresectable liver tumors. We investigated whether ...there are different inflammatory and coagulative responses between these techniques. Methods Livers of 48 rats were subjected to either CA, RFA, LITT, or sham operation ( n = 12 in each group). Blood was withdrawn before, and 1, 3, 6, and 24 h after ablation. Liver enzymes as well as inflammatory and coagulation parameters were determined. Whole liver sections from the coagulated liver lobe were stained for quantification of necrosis and morphologic examination. Results Histologic examination showed similar volume of complete destruction of liver parenchyma after CA, RFA, or LITT. Transaminase levels as well as the inflammatory response upon CA, as reflected by white blood cell count and cytokine levels, were significantly higher than following RFA or LITT. The systemic intravascular procoagulative state in rats that underwent CA, as reflected by platelets, and levels of sensitive markers for activation of coagulation and fibrinolyis, was also significantly higher. Conclusion CA of liver in rats induces greater inflammatory and coagulative responses than RFA or LITT. The combined activation of inflammation and coagulation may importantly contribute to the higher morbidity after CA.
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