Background
Data on ERAS for gastrectomy are scarce, and the majority of the studies come from Eastern countries. Patients in the West are older and suffer from more advanced tumors that impair their ...clinical condition and often require neoadjuvant treatment. This retrospective study assessed the feasibility and safety of an Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy in a Western center.
Methods
We conducted a single-center study of 351 patients operated for gastric cancer: 103, operated from January 2015 to December 2016, followed the standard pathway, while 248, operated from January 2017 to December 2019, followed the ERAS program. The primary outcomes considered were length of hospital stay (LOS) and direct costs. Secondary outcomes were 90-day morbidity and mortality, readmission rate, and compliance with ERAS items. A propensity score (PS) was built on confounding variables.
Results
Compliance with ERAS items after the program was ≥ 70%. Univariable analysis evidenced a 2-day median reduction in LOS and a median cost reduction of €826 per patient in the ERAS group. PS-based multivariable analysis confirmed a significant, 2-day decrease in median LOS and a €1097 saving after ERAS introduction. Ninety-day mortality decreased slightly in ERAS group, while complications and readmissions did not change significantly. When complications were included in the multivariable analysis, ERAS retained its significance, although the effects on LOS and cost were blunted to a median reduction of 1 day and €775, respectively.
Conclusions
ERAS for gastrectomy improved patients’ recovery and reduced hospital costs without changes in morbidity, mortality, or readmission.
A phase II intensive neoadjuvant chemo-radiotherapy (nCRT) protocol for esophageal cancer (EC) was previously tested at our Center with promising results. We here present an observational study to ...evaluate the efficacy of the protocol also in "real life" patients.
We retrospectively reviewed 122 ECs (45.1% squamous cell (SCC) and 54.9% adenocarcinoma (ADC)) treated with induction docetaxel, cisplatin, and 5-fluorouracil (TCF), followed by concomitant TCF and radiotherapy (50-50.4 Gy/25-28 fractions), between 2008 and 2017. Primary endpoints were overall survival (OS), event-free survival (EFS) and pathological complete response (pCR).
With a median follow-up of 62.1 months (95% CI 50-67.6 months), 5-year OS and EFS rates were 54.8% (95% CI 44.7-63.9) and 42.7% (95% CI 33.1-51.9), respectively. A pCR was observed in 71.1% of SCC and 37.1% of ADC patients (
= 0.001). At multivariate analysis, ypN+ was a significant prognostic factor for OS (Hazard Ratios (HR) 4.39 95% CI 2.36-8.18;
< 0.0001), while pCR was a strong predictor of EFS (HR 0.38 95% CI 0.22-0.67;
< 0.0001).
The nCRT protocol achieved considerable long-term survival and pCR rates also in "real life" patients. Further research is necessary to evaluate this protocol in a watch-and-wait approach.
Background and Objective
The aim of this study was to assess the ability of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (
18
F-FDG PET/CT) to provide functional information ...useful in predicting pathological response to an intensive neoadjuvant chemo-radiotherapy (nCRT) protocol for both esophageal squamous cell carcinoma (SCC) and adenocarcinoma (ADC) patients.
Material and Methods
Esophageal carcinoma (EC) patients, treated in our Center between 2014 and 2018, were retrospectively reviewed. The nCRT protocol schedule consisted of an induction phase of weekly administered docetaxel, cisplatin, and 5-fluorouracil (TCF) for 3 weeks, followed by a concomitant phase of weekly TCF for 5 weeks with concurrent radiotherapy (50–50.4 Gy in 25–28 fractions). Three
18
F-FDG PET/CT scans were performed: before (PET
1
) and after (PET
2
) induction chemotherapy (IC), and prior to surgery (PET
3
). Correlation between PET parameters maximum and mean standardized uptake value (SUV
max
and SUV
mean
), metabolic tumor volume (MTV), and total lesion glycolysis (TLG), radiomic features and tumor regression grade (TGR) was investigated.
Results
Fifty-four patients (35 ADC, 19 SCC; 48 cT3/4; 52 cN+) were eligible for the analysis. Pathological response to nCRT was classified as major (TRG1-2, 41/54, 75.9%) or non-response (TRG3-4, 13/54, 24.1%). A major response was statistically correlated with SCC subtype (p = 0.02) and smaller tumor length (p = 0.03). MTV and TLG measured prior to IC (PET
1
) were correlated to TRG1-2 response (p = 0.02 and p = 0.02, respectively). After IC (PET
2
), SUV
mean
and TLG correlated with major response (p = 0.03 and p = 0.04, respectively). No significance was detected when relative changes of metabolic parameters between PET
1
and PET
2
were evaluated. At textural quantitative analysis, three independent radiomic features extracted from PET
1
images (JointEnergy and InverseDifferenceNormalized of GLCM and LowGrayLevelZoneEmphasis of GLSZM) were statistically correlated with major response (p < 0.0002).
Conclusions
18
F-FDG PET/CT traditional metrics and textural features seem to predict pathologic response (TRG) in EC patients treated with induction chemotherapy followed by neoadjuvant chemo-radiotherapy. Further investigations are necessary in order to obtain a reliable predictive model to be used in the clinical practice.
Although the Japan Clinical Oncology Group (JCOG) 9501 trial did not find that prophylactic D3 lymphadenectomy led to any survival advantage over D2 lymphadenectomy, it did find that the prognosis of ...subserosal and N0 gastric cancer patients improved. The aim of this retrospective observational study was to compare survival after D2 or D3 lymphadenectomy in different patient subgroups.
The study considered all of the patients who underwent D2 or D3 lymphadenectomy at a high-volume center in Verona (Italy) between 1992 and 2011. After excluding patients with Bormann IV or neuroendocrine tumors, early gastric cancers, or non-curative resections, the analysis involved 301 R0 patients: 100 who underwent D2, and 201 who underwent D3 lymphadenectomy. Post-operative deaths and deaths due to recurrences were considered as terminal events in the survival analysis.
The D2 patients were significantly older than the D3 patients at baseline (69.8 ± 2.3 vs. 62.2 ± 10.7 years). The median number of retrieved nodes was 29 (interquartile range: 24.5-39) after D2, and 43 (34-52) after D3. The five-year disease-related survival rate was similar after D2 (44%, 95% confidence interval (CI) 34-54%) and D3 (41%, 34-48%) (
= 0.766). A Cox model controlling for sex, age, tumor site, Laurén histology, and T and N stages showed that the risk of cancer-related death after D3 was similar to that recorded after D2 (hazard ratio 0.97, 95% CI 0.67-1.42). There was a significant interaction between the T status and the extension of the lymphadenectomy (
= 0.012), with the prognosis being better after D2 in T2 and T4b patients, and after D3 in T3 patients.
The findings of this study suggest that D3 lymphadenectomy is not routinely indicated for patients with advanced gastric cancer, although differences in survival after D3 across T tiers deserve further consideration.
Abstract
The optimal treatment for esophageal cancer in elderly patients is still debated and data on postoperative results are limited. This retrospective international study aims to clarify the ...impact of age on clinical and oncological outcomes after esophagectomy. All patients that underwent esophagectomy for cancer between 2007 and 2016 at two European high-volume Centers have been included in the study. Patients were divided into three groups according to their age: young-age group (YAG) (18–69), middle-age group (70–74) and old-age group (>74). Primary outcome was 5-year overall survival (OS), while secondary outcomes considered were 5-year disease free survival and disease related survival, 90-day morbidity and mortality, readmission rate and radicality. A total of 575 patients were included. No differences emerged in terms of morbidity and length of stay, while mortality increased with aging from 2% in YAG to 4.8% in old-aged (P = 0.003). Old-age patients had less neoadjuvant treatment (P < 0.001), a less aggressive mediastinal lymphadenectomy and presented a more advanced pathological stage. As expected, OS decreased significantly for older patients compared with the other two age groups (P = 0.044) but, on the other hand, disease free and disease related survival were comparable between the groups. Age itself should not be considered a contraindication to esophagectomy. Although in patients older than 75 years postoperative mortality is significantly increased, esophagectomy could be still an option in selected patients, favoring the use of minimally invasive techniques and enhanced recovery protocols.
Graphical abstract
Background
The association between compliance to an enhanced recovery protocol (ERAS) and outcome after surgery for gastric cancer has been poorly investigated, particularly in Western patients. The ...aim of the study was to evaluate whether the rate of adherence to the ERAS program was correlated with outcome and time of discharge.
Methods
A prospective, observational, multicenter study was designed to be performed at Italian referral centers for gastric surgery. The protocol was discussed and approved by the Italian Research Group on Gastric Cancer. Twenty-three ERAS domains were applied. A multivariate logistic regression was used to assess the association between ERAS compliance and overall and major complication rates. The Poisson regression model (measured as mean ratios) was used to assess the association of ERAS compliance rate and length of stay (LOS).
Results
Eight centers participated and 290 subjects with a median age of 73 years were enrolled. The overall rates of adherence to pre-, intra-, and postoperative ERAS items were 69.8%, 60.3%, and 82.5%, respectively. At the multivariate model, there was an association between overall rate of morbidity and an overall ERAS compliance rate greater than 70% (OR 0.413; 95% CI 0.235–0.7240; P 0.002). A similar association was found for major complications (OR 0.328; 95% CI 0.151–0.709; P 0.005). The Poisson regression showed that in patients with ERAS compliance rate >70%, LOS was reduced of approximately 20% (mean ratio 0.812; 95% CI 0.694–0.950; P 0.009).
Conclusions
These results suggest a moderate compliance to an ERAS program and a significant association between adherence and outcomes.
Background
The optimal treatment strategy for elderly patients with gastric cancer is still controversial. This study aimed to assess the impact of age on short- and long-term outcomes after ...treatment for primary gastric cancer.
Methods
From January 2004 to December 2014, a total of 507 patients underwent gastrectomy for gastric adenocarcinoma at two high-volume upper gastrointestinal (GI) centers. The patients were classified into three groups as follows: group A (patients ≤ 69 years old,
n
= 266), group B (patients 70–79 years old,
n
= 166), and group C (patients ≥ 80 years old,
n
= 75). Clinicopathologic characteristics as well as, short- and long-term outcomes were compared between the groups.
Results
The patients in groups B and C had more comorbidities, whereas the younger subjects (group A) had more advanced tumor stages. Less extensive surgery was performed in the groups B and C. Older patients (age ≥ 70 years) had more postoperative medical complications. Moreover, group C had a higher postoperative mortality rate (8.1%) than group A (1.8%) or group B (1.9%). In the multivariable analysis, age older than 80 years (group C) was a negative independent factor for overall survival (OS) (hazard ratio HR, 2.36) compared with group A, whereas group B seemed to have a comparable risk (HR, 1.37). Notably, the three groups did not show significant differences in disease-related survival (DRS).
Conclusion
The data suggest that patients 70–79 years of age show a risk of postoperative death comparable with that of younger subjects. However, patients older than 80 years should be carefully selected for surgical treatment due to the increased risk of postoperative mortality.
The treatment of leak after esophageal and gastric surgery is a major challenge. Over the last few years, endoscopic vacuum therapy (E-VAC) has gained popularity in the management of this ...life-threatening complication. We reported our initial experience on E-VAC therapy as rescue treatment in refractory anastomotic leak and perforation after gastro-esophageal surgery. From September 2017 to December 2019, a total of 8 E-VAC therapies were placed as secondary treatment in 7 patients. Six for anastomotic leak (3 cervical, 1 thoracic, 2 abdominal) and 1 for perforation of the gastric conduit. In 6 cases, E-VAC was placed intracavitary; while in the remaining 2, the sponge was positioned intraluminal (one patient was treated with both approaches). A total of 60 sponges were used in the whole cohort. The median number of sponge insertions was 10 (range: 5–14) with a median treatment duration of 41 days (range: 19–49). A complete healing was achieved in 4 intracavitary (67%) and in 1 intraluminal (50%) E-VAC. We observed only one E-VAC-related complication: a bleeding successfully managed endoscopically. E-VAC therapy seems to be a safe and effective tool in the management of leaks and perforations after upper GI surgery, although with longer healing time when it is used as secondary treatment.
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