Background
The objectives of this national study were to examine the short-term safety and long-term survival benefit associated with surgical resection of hepatic metastases from gastric cancer.
...Methods
Patients from the Hospital Episode Statistics database were classified by disease and treatment approach. Gastric cancer: 1. Without liver metastases treated by gastrectomy (GG). 2. With liver metastases treated by gastrectomy and hepatectomy (GGH). 3. With liver metastases treated by gastrectomy without hepatectomy (GGNH). 4. With liver metastases treated with no surgery (GNS). Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics.
Results
During the study period, 87,482 were patients diagnosed with gastric cancer, of whom 13,841 underwent partial or total gastrectomy. Of those who underwent gastrectomy, 336 had a diagnosis of liver metastases and 78 of these had a hepatectomy. Propensity-matched analysis showed no significant differences in 30- or 90-day mortality between the GGH and GG groups. The GGH group had significantly improved 1-year mortality (35.9 % vs. 50.0 %,
p
= 0.049) and 5-year mortality (61.5 % vs. 75.7 %,
p
= 0.031) compared to the GGNH group, and compared to the GNS group, the GCH group had 1-year mortality (35.9 % vs. 84.6 %,
p
< 0.001) and 5-year mortality (61.5 % vs. 90.8 %,
p
< 0.001).
Conclusions
This study showed that hepatectomy for synchronous gastric cancer hepatic metastases may carry survival benefits in selected patients. The data presented should not be a rationale to change current clinical practice but rather a stimulus to prospectively study the role of surgery in a selected group of patients who are currently treated with palliative chemotherapy.
Background
Neoadjuvant therapy reduces fitness, muscle mass, and quality of life (QOL). For patients undergoing chemotherapy and surgery for esophagogastric cancer, maintenance of fitness is ...paramount. This study investigated the effect of exercise and psychological prehabilitation on anaerobic threshold (AT) at cardiopulmonary exercise testing (CPET). Secondary endpoints included peak oxygen uptake (peak VO
2
), skeletal muscle mass, QOL, and neoadjuvant therapy completion.
Methods
This parallel-arm randomized controlled trial assigned patients with locally advanced esophagogastric cancer to receive prehabilitation or usual care. The 15-week program comprised twice-weekly supervised exercises, thrice-weekly home exercises, and psychological coaching. CPET was performed at baseline, 2 weeks after neoadjuvant therapy, and 1 week preoperatively. Skeletal muscle cross-sectional area at L3 was analyzed on staging and restaging computed tomography. QOL questionnaires were completed at baseline, mid-neoadjuvant therapy, at restaging laparoscopy, and postoperatively at 2 weeks, 6 weeks and 6 months.
Results
Fifty-four participants were randomized (prehabilitation group,
n
= 26; control group,
n
= 28). No difference in AT between groups was observed post-neoadjuvant therapy. Prehabilitation resulted in an attenuated peak VO
2
decline {−0.4 95% confidence interval (CI) −0.8 to 0.1 vs. −2.5 95% CI −2.8 to −2.2 mL/kg/min;
p
= 0.022}, less muscle loss −11.6 (95% CI −14.2 to −9.0) vs. −15.6 (95% CI −18.7 to −15.4) cm
2
/m
2
;
p
= 0.049, and improved QOL. More prehabilitation patients completed neoadjuvant therapy at full dose prehabilitation group, 18 (75%) vs. control group, 13 (46%);
p
= 0.036. No adverse events were reported.
Conclusions
This study has demonstrated some retention of cardiopulmonary fitness (peak VO
2
), muscle, and QOL in prehabilitation subjects. Further large-scale trials will help determine whether these promising findings translate into improved clinical and oncological outcomes.
Trial Registration
ClinicalTrials.gov NCT02950324.
During unresolved infections, some viruses escape immunological control and establish a persistant reservoir in certain cell types, such as human immunodeficiency virus (HIV), which persists in ...follicular helper T cells (TFH cells), and Epstein-Barr virus (EBV), which persists in B cells. Here we identified a specialized group of cytotoxic T cells (TC cells) that expressed the chemokine receptor CXCR5, selectively entered B cell follicles and eradicated infected TFH cells and B cells. The differentiation of these cells, which we have called 'follicular cytotoxic T cells' (TFC cells), required the transcription factors Bcl6, E2A and TCF-1 but was inhibited by the transcriptional regulators Blimp1, Id2 and Id3. Blimp1 and E2A directly regulated Cxcr5 expression and, together with Bcl6 and TCF-1, formed a transcriptional circuit that guided TFC cell development. The identification of TFC cells has far-reaching implications for the development of strategies to control infections that target B cells and TFH cells and to treat B cell-derived malignancies.
Background
This study compares the peri-operative and long-term oncological outcomes for laparoscopic subtotal gastrectomy (LSG) versus open subtotal gastrectomy (OSG) for adenocarcinoma of the ...stomach in a Western population.
Methods
A retrospective, intention-to-treat analysis study was conducted for consecutive patients undergoing gastrectomy with curative intent for adenocarcinoma of the stomach between November 2006 and October 2016. Univariate analysis was used to compare peri-operative outcomes between LSG and OSG. Logistic regression with bootstrapping validation was used to identify independent risk factors for predicting 2-year overall survival.
Results
The final analysis included 79 patients. When comparing LSG (
n
= 30) to OSG (
n
= 49), there was no difference in the number of resected lymph nodes (36 (IQR 24.3–44) vs. 42 (IQR 28–59),
p
= 0.165), a reduction in intra-operative blood loss (150 ml (IQR 100–250) vs. 553 ml (IQR 338–1075),
p
< 0.001) and an increase incidence of post-operative bleeding (3 patients vs. 0,
p
= 0.024), respectively. Five-year overall survival for LSG (
n
= 22) versus OSG (
n
= 20) was 63.6% and 50% (
p
= 0.372), respectively. The number of positive lymph nodes OR 0.64 (CI 0.47–0.88),
p
= 0.006 was the only significant independent risk factor for 2-year overall survival. Pre-operative ASA grading and operative approach did not influence survival outcomes at 2 years.
Conclusion
This study suggests that LSG is comparable to OSG in Western patients with respect to oncological quality and peri-operative morbidity. Two-year overall survival is predicted by the number of positive lymph nodes and not the operative access employed for resection.
Most patients with esophageal adenocarcinoma (EAC) present with de novo tumors. Although this could be due to inadequate screening strategies, the precise reason for this observation is not clear. We ...compared survival of patients with prevalent EAC with and without synchronous Barrett esophagus (BE) with intestinal metaplasia (IM) at the time of EAC diagnosis.
Clinical data were studied using Cox proportional hazards regression to evaluate the effect of synchronous BE-IM on EAC survival independent of age, sex, TNM stage, and tumor location. We analyzed data from a cohort of patients with EAC from the Mayo Clinic (n=411; 203 with BE and IM) and a multicenter cohort from the United Kingdom (n=1417; 638 with BE and IM).
In the Mayo cohort, BE with IM had a reduced risk of death compared to patients without BE and IM (hazard ratio HR 0.44; 95% CI, 0.34–0.57; P<.001). In a multivariable analysis, BE with IM was associated with longer survival independent of patient age or sex, tumor stage or location, and BE length (adjusted HR, 0.66; 95% CI, 0.5–0.88; P=.005). In the United Kingdom cohort, patients BE and IM had a reduced risk of death compared with those without (HR, 0.59; 95% CI, 0.5–0.69; P<.001), with continued significance in multivariable analysis that included patient age and sex and tumor stage and tumor location (adjusted HR, 0.77; 95% CI, 0.64–0.93; P=.006).
Two types of EAC can be characterized based on the presence or absence of BE. These findings could increase our understanding the etiology of EAC, and be used in management and prognosis of patients.
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Surgical treatments for esophageal cancers Allum, William H.; Bonavina, Luigi; Cassivi, Stephen D. ...
Annals of the New York Academy of Sciences,
September 2014, Volume:
1325, Issue:
1
Conference Proceeding, Journal Article
Peer reviewed
Open access
The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients ...who develop high‐grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long‐term quality of life in patients following esophagectomy.
Background Laparoendoscopic single site (LESS) surgery may have perceived benefits of reduced visible scarring compared to conventional laparoscopic (LAP) totally extraperitoneal (TEP) hernia ...repairs. We reviewed the literature to compare LESS TEP inguinal hernia repairs with LAP TEP repairs. Methods We searched electronic databases for research published between January 2008 and January 2012. Results A total of 13 studies reported on 325 patients. The duration of surgery was 40–98 minutes for unilateral hernia and 41–121 minutes for bilateral repairs. Three studies involving 287 patients compared LESS TEP ( n = 128) with LAP TEP ( n = 159). There were no significant differences in operative duration for unilateral hernias ( p = 0.63) or bilateral repairs ( p = 0.29), and there were no significant differences in hospital stay ( p > 0.99), intraoperative complications ( p = 0.82) or early recurrence rates ( p = 0.82). There was a trend toward earlier return to activity in the LESS TEP group ( p = 0.07). Conclusion Laparoendoscopic single site surgery TEP hernia repair is a relatively new technique and appears to be safe and effective. Advantages, such as less visible scarring, mean patients may opt for LESS TEP over LAP TEP. Further studies with clear definitions of outcome measures and robust follow-up to assess patient satisfaction, return to normal daily activities and recurrence are needed to strengthen the evidence.
Background
Minimal access surgery for oesophago-gastric cancer is topical and demanding, and approaches vary significantly. There is little data on the hybrid technique of laparoscopic-assisted ...two-phase oesophago-gastrectomy (LA2OG). Here we aim to review our experience, which exceeds 10 years, of this technique for oesophageal malignancy.
Methods
From June 1998 to May 2009, 111 patients underwent LA2OG. Patients included 84 men and 27 women with mean age 65 years (range 35–85 years). Retrospective analysis of indications, outcome, staging, complications and survival was performed.
Results
The majority of resections (96%) were performed for gastro-oesophageal junction or distal oesophageal pathology. Indications included adenocarcinoma (84.7%), squamous cell carcinoma (7.2%) and high-grade dysplasia (5.4%). Of patients, 67.6% received neoadjuvant chemotherapy. The median time for the laparoscopic phase was 207 min (range 105–600 min), and 420 min (range 210–780 min) overall. Estimated blood loss was 330 ml (range 100–1,200 ml). Median critical care and post-operative stays were 3 and 14 days, respectively. Over time, the radicality of surgery increased. From 1998 to 2001 median lymph node yield was 5, from 2002 to 2005 it was 12 nodes, and from 2006 to 2009 it was 28 nodes (
p
< 0.001). The overall complication rate was 38.7%, minor in 24.3%, with anastomotic leak rate of 5.5%. Median survival was 38.5 ± 5.4 months. Thirty-day and in-hospital mortality were 1.8 and 2.7%, respectively.
Conclusions
Two-stage laparoscopic-assisted oesophago-gastrectomy is a safe staged method of developing minimal access surgery for oesophago-gastric cancer. This study provides a useful reference for comparison with other minimally invasive methods.
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