Tailored treatment for signet ring cell gastric cancer

Gastric cancer with Laur\ue8n diffuse types is increasing in the West. The raising trend is more evident when considering signet ring cells (SRC) histology. However, to control the biologic potential of this GC subtype, some hypotheses of tailored therapeutic strategies for SRC cancers have been made. A review of the literature was performed using the key words "signet ring cells" AND "gastric cancer". Results of literature review were descriptively reported. Endoscopic submucosal dissection (ESD), according to the Japanese extended criteria, could be a therapeutic option for early SRC tumours. However, according to the evidences from more recent studies, indications for ESD to these tumours types should be carefully considered. Concerning the optimal surgical treatment, considering the high lymphotropism and infiltrating behaviour of SRC histotype, the extension of gastric resection should be wider than for intestinal type cancer and laparoscopic surgery should be performed carefully. Moreover, D3 lymphadenectomy could provide a benefit in diffuse-type and SRC histology. The role of surgery in gastric cancer with peritoneal carcinomatosis is still debated and studies on this topic should stratify the good results according to GC histotype. Finally, despite the evidences of chemoresistance in SRC, ongoing randomized trials suggest that multimodal therapy could be the best treatment. Based on the assumption that SRC tumours have specific features, they deserve a specific multimodal treatment. However, a preliminary step to generate strong evidences in this field is the standardization of terminology used to define signet ring cells carcinoma

Acute bleeding obstruction pancreatitis after Roux-en-Y anastomosis in total gastrectomy: a single center experience

Anastomotic intraluminal bleeding is a well-known complication after total gastrectomy. Nevertheless, few data are published on acute bleeding obstruction pancreatitis (BOP) due to a bleeding from the jejunojejunostomy (JJ). In this paper we describe our experience. A total of 140 gastrectomies for EGJ cancer were performed in our Institute from January 2012 to January 2017. All reconstructions were performed with a Roux-en-Y anastomosis: a mechanical end-to-side esophago-jejunostomy and a mechanical end-to-side JJ. Three patients suffered from a bleeding at the JJ with a consequent BOP. We analyzed the time of diagnosis, the treatment and the outcomes. The three patients presented anemia at the laboratory findings on postoperative day (POD) 1. In patient I laboratory findings of acute pancreatitis were found in POD 2. CT scan was performed and showed signs of BOP. Endoscopic treatment was tried without success. Therefore, patient underwent surgery: JJ take down, bleeding control and anastomosis rebuild were performed. In spite of this the patient died of MOF in POD 4. Patient II had a persistent anemia treated with blood transfusions until POD 3, when laboratory tests showed increased lipase and bilirubin levels. Patient was successfully treated with endoscopy but several blood transfusions and a prolonged recovery were necessary. Patient III had laboratory findings of acute pancreatitis on POD 1. Immediate surgery was performed and patient was discharged on POD 9 without sequelae. BOP is a rare but deadly complication after Roux-en-Y anastomosis. An early diagnosis and an aggressive treatment seem to improve the outcome

ERAS Protocols for Gastrectomy

The interest in the Enhanced Recovery After Surgery (ERAS) protocols on gastrectomy for cancer is fairly new and mainly comes from Eastern series. Gastrectomy is a major abdominal operation and is still burdened by a 30% overall morbidity and a 4.5% mortality. The ERAS protocol aims to optimize the patient’s condition and reduce surgical and anesthesiologic stress in order to reduce complications and secondarily reduce hospitalization. Two recent meta-analyses evidenced a reduction in length of hospital stay, bowel recovery and cost reduction, while also reporting, however, a higher risk for readmission in patients treated with an ERAS protocol. In this chapter we discuss the importance of implementing a multidisciplinary team focusing on gastrectomy-specific items starting from preoptimization up to discharge. Preoptimization should focus on inspiratory muscle training and optimization of the nutritional status, especially for patients undergoing neoadjuvant treatment. A minimally invasive approach can reduce surgical stress and should be considered in accordance with the current oncological guidelines. Anesthesia should focus on a goal-directed fluid approach and on a defined multimodal analgesia plan. The goal of the postoperative management is an early mobilization and resumption of oral intake through the avoidance of unnecessary tubes. Discharge should be based on defined criteria and the patient’s network

Utility of Abdominal Drain in Gastrectomy (ADiGe) Trial: study protocol for a multicenter non-inferiority randomized trial

Background: Prophylactic use of abdominal drain in gastrectomy has been questioned in the last 15 years, and a 2015 Cochrane meta-analysis on four RCTs concluded that there was no convincing evidence to the routine drain placement in gastrectomy. Nevertheless, the authors evidenced the moderate/low quality of the included studies and highlighted how 3 out of 4 came from Eastern countries. After 2015, only retrospective studies have been published, all with inconsistent results. Methods: ADiGe (Abdominal Drain in Gastrectomy) Trial is a multicenter prospective randomized non-inferiority trial with a parallel design. It aimed to verify whether avoiding routine use of abdominal drain is burdened with complications, particularly an increase in postoperative invasive procedures. Patients with gastric cancer, scheduled for subtotal or total gastrectomy with curative intent, are eligible for inclusion, irrespective of previous oncological treatment. The primary composite endpoint is reoperation or percutaneous drainage procedures within 30 postoperative days. The primary analysis will verify whether the incidence of the primary composite endpoint is higher in the experimental arm, avoiding routine drain placement, than control arm, undergoing prophylactic drain placement, in order to falsify or support the null hypothesis of inferiority. Secondary endpoints assessed for superiority are overall morbidity and mortality, Comprehensive Complications Index, incidence and time for diagnosis of anastomotic and duodenal leaks, length of hospital stay, and readmission rate. Assuming one-sided alpha of 5%, and cumulative incidence of the primary composite endpoint of 6.4% in the control arm and 4.2% in the experimental one, 364 patients allow to achieve 80% power to detect a non-inferiority margin difference between the arm proportions of 3.6%. Considering a 10% drop-out rate, 404 patients are needed. In order to have a balanced percentage between total and subtotal gastrectomy, recruitment will end at 202 patients for each type of gastrectomy. The surgeon and the patient are blinded until the end of the operation, while postoperative course is not blinded to the patient and caregivers. Discussion: ADiGe Trial could contribute to critically re-evaluate the role of prophylactic drain in gastrectomy, a still widely used procedure. Trial registration: Prospectively registered (last updated on 29 October 2020) at ClinicalTrials.gov with the identifier NCT04227951

Small type O-IIa de novo colon cancer treated with curative endoscopic full-thickness resection (EFTR)

no abstract availabl

The amount of cells with Signet Ring Cell morphology has a prognostic impact in poorly cohesive gastric carcinoma

no available

Management, short and long-term outcomes in septegenerians and octegenerians undergoing gastrectomy for cancer

Aims: At present, the recommended treatment strategy in these pa- tients who present with gastric cancer is still controversial. We con- ducted a multicentre cohort study to assess the impact of age in gastric cancer management and outcomes. Methods: A retrospectively collected database demonstrated that 507 patients underwent gastrectomy for gastric adenocarcinoma from January 2004 to December 2014 at two high volume centres (London Royal Marsden Hospital and Verona University hospital). Patients were classified into three groups: Group A included all pa- tients aged 69 years old or less (n Z 266), Group B included 166 patients between 70e79 years (n Z 166), and Group C included pa- tients over 80 years and over (n Z 75). We analysed the data to eval- uate any differences between the groups in terms of patient characteristics, disease characteristics, treatment strategy, surgical outcome, overall survival and oncological outcome after gastrectomy. Results: Groups B and C were associated with a higher ASA and comorbidities (p < 0.001). They were less likely to receive peri-opera- tive chemotherapy (p Z 0.000). Group A presented with more advanced disease in terms of histological subtype (p Z 0.000) and increased metastatic burden (16.3%). In Groups B and C less aggres- sive surgery was performed. Group A had a higher rate of surgical complications (p Z 0.011). Group C demonstrated more medical com- plications (p Z 0.021). Group C had a higher postoperative mortality rate (8.1%, p Z 0.010). Using a Cox multivariable analysis, Group C (p Z 0.001) had a significantly less OS compared to A and B. Of note, DRS did not show significant differences in the three groups. Conclusions: Our data suggests that patients between the age of 70e79 years have a comparable OS risk as that of younger patients un- dergoing gastrectomy for gastric cancer. Patients over 80 years were found to have undergone less aggressive surgery and have more medical comorbidities. Their OS risk was higher. Elderly patients with gastric cancer should be rigorously assessed and medically optimised prior to undergoing surgical management in order to improve overall outcomes

The impact of experience on short- and long-term outcomes on gastric ESD: a western series

Endoscopic submucosal dissection (ESD) represents the standard of care for early gastric cancer in Eastern countries. Nevertheless, in the West, this procedure is not widespread. Aim of the study was to confirm the feasibility and the efficacy of ESD in the West. A total of 60 ESD were performed between January 2005 and December 2014 by two expert endoscopists. The analysis, based on a retrospective collected database, was conducted by dividing the study period in three subgroups. Clinical and technical outcomes have been compared. Rates of complete, curative and en bloc resection did not significantly change among the study periods. Three cases of perforation occurred (5%), one in each period. The operation time significantly decreased from the second to the third period (p\u2009<\u20090.001). When adjusting for gender, tumor size and site in multivariable analysis, operation time decreased by nearly 90 min from the first to the second period, and by more than 3 h from the first to the last period. The median follow-up was 33 months. No cases of local or lymphnodal recurrence were detected during the study period. One patient presented a synchronous lesion, whilst four metachronous lesions have been discovered after a median follow-up of 11 months. Our experience supports the feasibility and safety of ESD in the West, if an adequate learning curve is accomplished. Long-term outcomes are comparable to the Eastern series