This study aimed to investigate which gastric cancer patients could benefit the most from staging laparoscopy.
A retrospective cohort study was carried out, including 316 (216 cM- and 100 cM+) ...gastric cancer patients who had undergone staging laparoscopy between 2010 and 2020 in seven GIRCG centers. A model including easily-accessible clinical, biochemical and pathological markers was constructed to predict the risk of carcinomatosis. ROC curve and decision curve analyses were used to verify its accuracy and net benefit.
In the cM-population staging laparoscopy could detect 67 cases who had peritoneal carcinomatosis or positive cytology, for a yield of 30.5%. In cM-patients, intestinal type tumors (0.25, 0.12–0.51; p = 0.002), cT4 tumors (2.18, 1.11–4.28; p = 0.023) and cancers of the lower third (0.31, 0.14–0.70; p = 0.004) were associated with the presence of peritoneal carcinomatosis and/or positive cytology. The ROC curve analysis of the model including the three variables showed an AUC of 0.75 (0.68–0.81, p < 0.001). The decision curve analyses showed that the model had a higher net benefit than the treating all strategy between threshold probabilities of 15 and 50%.
Staging laparoscopy is a useful tool to address the patient with gastric cancer to the most adequate treatment. In cM-patients the assessment of the location of the tumor, the Lauren's histotype and the cT status may help in providing additional elements in indicating or not the use of staging laparoscopy.
Mass lesions located in the wall of the stomach (and also of the bowel) are referred to as "intramural." The differential diagnosis of such lesions can be challenging in some cases. As such, it may ...occur that an inconclusive fine needle aspiration (FNA) result give way to an unexpected diagnosis upon final surgical pathology. Herein, we present a case of an intramural gastric nodule mimicking a gastric gastrointestinal stromal tumor (GIST).
A 47-year-old Caucasian woman, who had undergone splenectomy for trauma at the age of 16, underwent gastroscopy for long-lasting epigastric pain and dyspepsia. It revealed a 15 mm submucosal nodule bulging into the gastric lumen with smooth margins and normal overlying mucosa. A thoraco-abdominal computed tomography scan showed in the gastric fundus a rounded mass (30 mm in diameter) with an exophytic growth and intense enhancement after administration of intravenous contrast. Endoscopic ultrasound scan showed a hypoechoic nodule, and fine needle FNA was inconclusive. Gastric GIST was considered the most probable diagnosis, and surgical resection was proposed due to symptoms. A laparoscopic gastric wedge resection was performed. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. The final pathology report described a rounded encapsulated accumulation of lymphoid tissue of about 4 cm in diameter consistent with spleen parenchyma implanted during the previous splenectomy.
Splenosis is a rare condition that should always be considered as a possible diagnosis in splenectomized patients who present with an intramural gastric nodule.
The advantages of using the robotic platform may not be clearly evident in left colectomies, where the surgeon operates in an “open field” and does not routinely require intraoperative suturing. ...Current evidences are based on limited cohorts reporting conflicting outcomes regarding robotic left colectomies (RLC). The aim of this study is to report a bi-centric experience with robotic left colectomy in order to help in defining the role of the robotic approach for these procedures. This is a bi-centric propensity score matched study including patients who underwent RLC or laparoscopic left colectomy (LLC) between January 1, 2012 and May 1, 2022. RLC patients were matched to LLC patients in a 1:1 ratio. Main outcomes were conversion to open surgery and 30-day morbidity. In total, 300 patients were included. Of 143 (47.7%) RLC patients, 119 could be matched. After matching, conversion rate (4.2 vs. 7.6%,
p
= 0.265), 30-day morbidity (16.1 vs. 13.7%,
p
= 0.736), Clavien–Dindo grade ≥ 3 complications (2.4 vs 3.2%,
p
= 0.572), transfusions (0.8 vs. 4.0%,
p
= 0.219), and 30-day mortality (0.8 vs 0.8%,
p
= 1.000) were comparable for RLC and LLC, respectively. Median operative time was longer for RLC (296 min 260–340 vs. 245, 195–296,
p
< 0.0001). Early oral feeding, time to first flatus, and hospital stay were similar between groups. RLC has safety parameters as well as conversion to open surgery comparable with standard laparoscopy. Operative time is longer with the robotic approach.
Gastro-oEsophageal Cancers (GECs) are severe diseases whose management is rapidly evolving. The European Society of Surgical Oncology (ESSO) is committed to the generation and spread of knowledge, ...and promotes the multidisciplinary management of cancer patients through its core curriculum. The present work discusses the approach to GECs, including the management of oligometastatic oesophagogastric cancers (OMEC), the diagnosis and management of peritoneal metastases from gastric cancer (GC), the management of Siewert Type II tumors, the importance of mesogastric excision, the role of robotic surgery, textbook outcomes, organ preserving options, the use of molecular markers and immune check-point inhibitors in the management of patients with GECs, as well as the improvement of current clinical practice guidelines for the management of patients with GECs. The aim of the present review is to provide a concise overview of the state-of-the-art on the management of patients with GECs and, at the same time, to share the latest advancements in the field and to foster the debate between surgical oncologists treating GECs worldwide. We are sure that our work will, at the same time, give an update to the advanced surgical oncologists and help the training surgical oncologists to settle down the foundations for their future practice.
Aim
Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for ...stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage.
Methods
The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient‐, disease‐, treatment‐ and postoperative outcome‐related factors on anastomotic leak after univariable and multivariable analysis was measured.
Results
A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30‐day leak‐related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection.
Conclusions
While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high‐risk patients eligible for protective stoma construction.
To evaluate the effect of patient blood management (PBM) since its introduction, we analyzed the need for transfusion and the outcomes in patients undergoing abdominal surgery for different types of ...tumor pre- and post-PBM. Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery between 2017 and 2020 were included. The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (pre-PBM) versus after the implementation (post-PBM). A total of 1302 patients were included in the analysis (445 pre-PBM vs. 857 post-PBM). The number of transfused patients per year decreased significantly after the introduction of PBM. A strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery. With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (7.7% vs. 55% after PBM;
p
= 0.049); this was similar in liver surgery (17.6% vs. 58.3% after PBM;
p
= 0.04). Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%;
p
= 0.002) and a decrease in the Hb trigger for transfusion (8.5, 8.2–9.5 vs. 8.2, 7.7–8.4 g/dl;
p
= 0.039) was reported after the PBM introduction. After the implementation of a PBM protocol, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery.
Purpose
No evidences supporting or not the use of intra-abdominal drain (AD) in minimally invasive right colectomies have been published. This study aims to assess the outcomes on its use after ...robotic or laparoscopic right colectomies.
Methods
This is a multicenter propensity score matched study including patients who underwent minimally invasive right colectomy with (AD group) or without (no-AD group) the use of AD between February 1, 2007, and January 31, 2018. AD patients were matched to no-AD patients in a 1:1 ratio. Main outcomes were postoperative morbidity and mortality and anastomotic leak.
Results
A total of 653 patients were included. Of 149 (22.8%) no-AD patients, 124 could be matched. The rate of postoperative complications (AD
n
= 26, 21% vs. no-AD
n
= 26, 21%;
p
= 1.000), mortality (AD
n
= 2, 1.6% vs. no-AD
n
= 1, 0.8%;
p
= 1.000), anastomotic leak (AD
n
= 2, 1.6% vs. no-AD
n
= 5, 4.0%;
p
= 0.453), and wound infection (AD
n
= 9, 7.3% vs. no-AD
n
= 6, 4.8%;
p
= 0.581) did not significantly differ between the groups. Time to oral feeding was significantly shorter in the no-AD group 2 (1–3) vs. 3 (2–3),
p
= 0.0001. The median length of hospital stay was 8 (IQR 7–9) in the AD group while it was 6 (IQR 5–9) in the no-AD group (
p
= 0.010).
Conclusions
In conclusion, the use of AD after minimally invasive right colectomies has no influence on postoperative morbidity and mortality rates.
The Italian Research Group for Gastric Cancer developed a prospective database about stage IV gastric cancer, to evaluate how a pragmatic attitude impacts the management of these patients.
We ...prospectively collected data about metastatic gastric cancer patients thanks to cooperation between radiologists, oncologists and surgeons and we analyzed survival and prognostic factors, comparing the results to those obtained in our retrospective study.
Three-hundred and eighty-three patients were enrolled from 2018 to September 2022. We observed a higher percentage of laparoscopic exploration with peritoneal lavage in the prospective cohort. In the registry only 3.6 % of patients was submitted to surgery without associated chemotherapy, while in the retrospective population 44.3 % of patients were operated on without any chemotherapy. At univariate and multivariate analyses, the different metastatic sites did not show any survival differences among each other (OS 20.0 vs 16.10 vs 16.7 months for lymphnodal, peritoneal and hepatic metastases, respectively), while the number of metastatic sites and the type of treatment showed a statistical significance (OS 16,7 vs 13,0 vs 4,5 months for 1, 2 and 3 different metastatic sites respectively, p < 0.001; 24,2 vs 12,0 vs 2,5 months for surgery with/without chemotherapy, chemotherapy alone and best supportive treatment respectively, p < 0.001).
Our data highlight that the different metastatic sites did not show different survivals, but survival is worse in case of multiple localization. In patients where a curative resection can be achieved, acceptable survival rates are possible. A better diagnostic workup and a more accurate staging impact favorably upon survival.
To validate a nodal regression system for gastric cancer and to verify its impact on prognosis.
This is an ancillary study which included 47 patients of the GASTRODOC trial. The dedicated ...pathologists of each Institute were invited to revise all the lymph nodes included in the surgical specimens in order to classify the regression according to the grading system proposed by Tsekrekos et al. The association of the nodal regression system and the clinico-pathological characteristics and prognosis were investigated.
According to the classification of Tsekrekos et al., there were 19 (40.4%) patients with grade a, 14 (29.8%) with grade b and 14 (29.8%) with grade c nodal regression. This regression system showed significant statistical associations with pathological N status (p < 0.001), residual tumor classification (p = 0.003) and Becker regression system (p = 0.011). At multivariable analysis only Tsekrekos’ grading regression system was significantly associated with the PFS (HR 10.1, 95% CI 1.3–75.5; p = 0.025).
The analyzed nodal regression system is significantly associated with Becker's regression system and it has a strong correlation with prognosis.
•A nodal regression system for gastric cancer has been recently proposed.•Its validation is an important step for its generalizability.•This system was correlated with the T regression system.•The proposed regression system displayed a significant correlation with progression free survival.
Background
Outside the US, FLS certification is not required and its teaching methods are not well standardized. Even if the FLS was designed as “stand alone” training system, most of Academic ...Institution offer support to residents during training. We present the first systematic application of FLS in Italy.
Our aim was to evaluate the role of mentoring/coaching on FLS training in terms of the passing rate and global performance in the search for resource optimization.
Methods
Sixty residents in general surgery, obstetrics & gynecology, and urology were selected to be enrolled in a randomized controlled trial, practicing FLS with the goal of passing a simulated final exam. The control group practiced exclusively with video material from SAGES, whereas the interventional group was supported by a mentor.
Results
Forty-six subjects met the requirements and completed the trial. For the other 14 subjects no results are available for comparison. One subject for each group failed the exam, resulting in a passing rate of 95.7%, with no obvious differences between groups. Subgroup analysis did not reveal any difference between the groups for FLS tasks.
Conclusion
We confirm that methods other than video instruction and deliberate FLS practice are not essential to pass the final exam. Based on these results, we suggest the introduction of the FLS system even where a trained tutor is not available. This trial is the first single institution application of the FLS in Italy and one of the few experiences outside the US.
Trial Number: NCT02486575 (
https://www.clinicaltrials.gov
).
PDF
