Endoscopic Ultrasonography (EUS) in Preoperative Staging of Gastric Cancer - Demand and Reality

Exact pretherapeutic staging is considered to be essential for decision-making in the therapeutic algorithm of gastric cancer.The aim of the study was to characterize the role and value of EUS in the diagnostic and therapeutic management of gastric cancer in daily surgical practice.Material and methods. Thousand one hundred thirty nine patients with primary gastric cancer from 80 hospitals of each profile of care were enrolled in this systematic clinical prospective multicenter observational study over a time period of 12 months. The characteristics of the diagnostic management, in particular, of EUS were documented. The preoperative EUS findings were compared with the T stage (T1 to T4) and the N category (N+ or N-) revealed by the histopathologic investigation of the surgical specimen. By the mean of X2 test, the impact of EUS on the therapeutic decision-making was determined.Results. Pretherapeutic EUS was only performed in 27.4% (n=312) of all patients. Overall, the diagnostic accuracy for the T stage was 42.6% in average. The subgroup analysis showed the following results: T1, 31.5%; T2, 42.6%; T3, 65.2%; T4, 17.6%. The correct predictive value of the N category was 71.3% reaching a sensitivity of 69.7% and a specificity of 73.3%. Overstaging was observed in 45.8%, understaging in only 10.8%. Additional diagnostic information by EUS was only provided in 4.7% of subjects.Conclusions. The present study indicates the variability, limited reliability and only moderate acceptance of EUS in diagnosing gastric cancer in daily practice. In particular, the prediction of the T stage does not reach the data reported in the literature, which were mostly achieved in specific EUS studies

T stage-dependent lymph node and distant metastasis and the accuracy of lymph node assessment in rectal cancer

<jats:title>Summary</jats:title><jats:sec> <jats:title>Objective</jats:title> <jats:p>To analyze data obtained in a representative number of patients with primary rectal cancer with respect to lymph node diagnostics and related tumor stages.</jats:p> </jats:sec><jats:sec> <jats:title>Methods</jats:title> <jats:p>In pT2-, pT3-, and pT4 rectal cancer lesions, the impact of investigated lymph nodes on the frequency of pN+ status, the cumulative risk of metachronous distant metastases, and overall survival was studied by means of a prospective multicenter observational study over a defined period of time.</jats:p> </jats:sec><jats:sec> <jats:title>Results</jats:title> <jats:p>From 2000 to 2011, the proportion of surgical specimens with ≥ 12 investigated lymph nodes increased significantly, from 73.6% to 93.2% (<jats:italic>p</jats:italic> < 0.001; the number of investigated lymph nodes from 16.2 to 20.8; <jats:italic>p</jats:italic> < 0.001). Despite this, the percentage of pN+ rectal cancer lesions varied only non-significantly (39.9% to 45.9%; <jats:italic>p</jats:italic> = 0.130; median, 44.1%). For pT2-, pT3-, and pT4 rectal cancer lesions, there was an increasing proportion of pN+ findings correlating significantly with the number of investigated lymph nodes up to <jats:italic>n</jats:italic> = 12 investigated lymph nodes. Only in pT3 rectal cancer was there a significant increase in pN+ findings in case of > 12 lymph nodes (<jats:italic>p</jats:italic> = 0.001), but not in pT2 (<jats:italic>p</jats:italic> = 0.655) and pT4 cancer lesions (<jats:italic>p</jats:italic> = 0.256). For pT3pN0cM0 rectal cancer, the risk of metachronous distant metastases and overall survival did not depend on the number of investigated lymph nodes.</jats:p> </jats:sec><jats:sec> <jats:title>Conclusion</jats:title> <jats:p>In rectal cancer, at least <jats:italic>n</jats:italic> = 12 lymph nodes are to be minimally investigated. The investigation of fewer lymph nodes is associated with a higher risk of false-negative pN0 findings. In particular, in pT3 rectal cancer, the investigation of more than 12 lymph nodes lowers the risk of false-negative pN0 findings. An upstaging effect by the investigation of a possibly maximal number of lymph nodes could not be detected.</jats:p> </jats:sec&gt

Impact of Fast-Track Concept Elements in the Classical Pancreatic Head Resection (Kausch-Whipple Procedure)

The aim of the study was to determine statistically significant factors with an impact on the early postoperative surgical outcome.Material and methods. The influence of applied fast-track components on surgical results and early postoperative outcome in 143 consecutive Kausch-Whipple procedure patients was evaluated in a single-center retrospective analysis of a prospective collection of patient-associated pre-, peri- and postoperative data from 1997-2006.Results. The in-hospital mortality rate was 2.8% (n=4). Fast-track measures were shown to have no effect on the morbidity rate in the multi-variate analysis. Over the study period, a decrease of intraoperative infusion volume from 14.2 mL/kg body weight/h in the first year to 10.7 mL/kg body weight/h in the last year was accompanied by an increase in patients requiring intraoperative catecholamines, up from 17% to 95%. The administration of ropivacain/sufentanil via thoracic peri-dural catheter injection initiated in 2000 and now considered the leading analgesic method, was used in 95% of the cases in 2006. Early extubation rate rose from 16.6% to 57.9%.Conclusions. Fast-track aspects in the perioperative management have become more important in several surgical procedure even in those with a greater invasiveness such as Kausch-Whipple. However, such techniques used in peri-operative management of Kausch-Whipple pancreatic-head resections had no impact on the morbidity rate. In addition, the low in-hospital mortality rate was particularly attributed to surgical competence