Para-aortic lymphadenectomy in surgery for gastric cancer: current indications and future perspectives

Involvement of para-aortic nodes (PAN) has been detected at pathological examination in 10-25% of locally advanced gastric cancer. Based on these data of nodal diffusion, the lymphadenectomy of para-aortic stations would be desirable in locally advanced gastric cancer. However, the debate on the oncological benefit of para-aortic nodes dissection is still not solved. A review of the literature was performed and papers reporting either the rate of para-aortic nodal metastases or the long-term survival outcomes after D2+ para-aortic nodes dissection (PAND) or D3 lymphadenectomy were descriptively reported. The literature survey yielded 14 studies. Most of the papers show the outcome of series of advanced gastric cancer treated with surgery alone, while starting from 2012, 3 articles report the outcomes of D2 + PAND or D3 lymphadenectomy after preoperative chemotherapy. The rate of PAN metastases ranges between 8.5 and 28% in surgical series. Survival outcomes largely improved in series of patients treated with multimodal approach compared to those of surgery alone. In patients with clinically detected para-aortic nodal metastases, preoperative chemotherapy followed by PAND is indicated. More data are needed to clarify the indication to prophylactic PAND in the era of multimodal treatment, anyway super-extended lymphadenectomies have to be performed by experienced surgeons in dedicated centres

Extension of lymphadenectomy for gastric cancer:Audit at European specialist centres.

Gastric cancer is still one of the leading causes of cancer-related deaths worldwide, and its treatment management differs between Eastern Asia and Western countries. Screening program, early diagnosis, and surgical treatment was primarily established in Japan and was rapidly disseminated to other countries. In other parts of the world, such as the USA and Western Europe, the incidence of gastric cancer has declined, and efforts for screening and early detection have not been an issue of higher priority over the management of other diseases. Thus, gastric cancer in the West is often more advanced and is either inoperable or needs more radical surgery for resection. The only treatment method that can potentially cure gastric cancer is the surgical approach. Depending on the extension of the tumor, surgeons may execute an operation that involves removing all or part of the stomach with some nearby lymph nodes (lymphadenectomy). Lymphadenectomy is a crucial step during surgical operation that involves the removal of one or more lymph nodes located in the drainage area of a tumor, in which there is a high possibility of lymph node metastasis. The Japanese guidelines define the criteria of lymphadenectomy procedure into D1 D1+ or D2 according to the type of gastrectomy executed. The extent of lymphadenectomy has long been a subject of debate. Indeed, Japanese surgeons introduced extended lymphadenectomy (D2), which has also been progressively adopted in Europe and included in almost all international guidelines. However, the procedure requires a long learning curve, which involves a high volume of interventions; therefore, US guidelines do not recommend the D2, and many Italian and European centres do not yet perform this procedure. Indeed, the current European Consensus guidelines recommend D2 dissection in regional specialist centres for patients with moderate comorbidity. However, compliance with guidelines is unclear, and in some recent RCTs, the standard approach of surgical treatment is at the "surgeon's discretion." This study aims to evaluate the current practice of D2 lymphadenectomy in Europe to determine any variation in practice and compare it with the Japanese guidelines. The study consists of two parts: first, a questionnaire based on hypothetical clinical scenarios was administered to expert surgeons belonging to European Chapter of the International Gastric Cancer Association from high-volume European centers. They were asked to select the appropriate lymphadenectomy extension for each hypothetical case and the associated lymph node stations to remove. In the second part of the study, the same surgeons were asked to collect their data about gastric cancer gastrectomies performed in 2015 for comparative analysis. The study results show that the expert surgeons of high-volume centres are quite in agreement with the choice of D2 lymphadenectomy in the different clinical scenarios. The surgical choice seems to have been influenced by the tumor stage, site, and histology of the tumor. More specifically, the D2 procedure is recommended for cases with diffuse histology compared to tumors with intestinal histology. However, the selection of the D2 dissection procedure rarely conformed to Japanese guidelines: the choice of lymph node stations revealed the presence of a wide variation in execution. In the review of the gastrectomy experience, it was observed that a high surgical standard was achieved: in fact, in 97% of gastric cancer gastrectomies after D2, an adequate number of lymph nodes (≥15 nodes) were removed. In conclusion, even if an adequate lymphadenectomy was obtained in almost all cases in dedicated centers, there is still significant variability in the number of recovered lymph nodes. The histology of the tumor largely influences the surgeon's choice regarding the extent of the lymphadenectomy; however, the role of histology in the planning of surgical procedures is not considered in the current guidelines and must be verified in prospective studies

Current practice on the use of prophylactic drain after gastrectomy in Italy: the Abdominal Drain in Gastrectomy (ADiGe) survey

Evidence against the use of prophylactic drain after gastrectomy are increasing and ERAS guidelines suggest the benefit of drain avoidance. Nevertheless, it is unclear whether this practice is still widespread. We conducted a survey among Italian surgeons through the Italian Gastric Cancer Research Group and the Polispecialistic Society of Young Surgeons, aiming to understand the current use of prophylactic drain. A 28-item questionnaire-based survey was developed to analyze the current practice and the individual opinion about the use of prophylactic drain after gastrectomy. Groups based on age, experience and unit volume were separately analyzed. Response of 104 surgeons from 73 surgical units were collected. A standardized ERAS protocol for gastrectomy was applied by 42% of the respondents. Most of the surgeons, regardless of age, experience, or unit volume, declared to routinely place one or more drain after gastrectomy. Only 2 (1.9%) and 7 surgeons (6.7%) belonging to high volume units, do not routinely place drains after total and subtotal gastrectomy, respectively. More than 60% of the participants remove the drain on postoperative day 4-6 after performing an assessment of the anastomosis integrity. Interestingly, less than half of the surgeons believe that drain is the main tool for leak management, and this percentage further drops among younger surgeons. On the other hand, drain's role seems to be more defined for duodenal stump leak treatment, with almost 50% of the surgeons recognizing its importance. Routine use of prophylactic drain after gastrectomy is still a widespread practice even if younger surgeons are more persuaded that it could not be advantageous

Multicenter Study of Presentation, Management, and Postoperative and Long-Term Outcomes of Septegenerians and Octogenerians Undergoing Gastrectomy for Gastric Cancer

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

Management of critically ill surgical patients Case reports

The acute abdomen (AA) still remains a challenging situation for surgeons. New pathological conditions have been imposed to our attention in this field in recent years. The definition of abdominal compartmental syndrome (ACS) in surgical practice and the introduction of new biological matrices, with the concepts of tension-free (TS) repair of incisional hernias, prompted us to set up new therapeutic strategies for the treatment of patients with AA. Thus we reviewed the cases of AA that we observed in recent years in which we performed a laparostomy in order to prevent or to treat an ACS. They are all cases of acute abdomen (AA), but from different origin, including chronic diseases, as in the course of inflammatory bowel disease (IBD), and acute pancreatitis. In all the cases, the open abdominal cavity was covered with a polyethylene sheet. The edges of the wound were sutured to the plastic sheet, and a traction exerted by a device that causes a negative pressure was added. This method was adopted in several cases without randomization, and resulted in excellent patient's outcomes

Gastric conduit perforation after Ivor Lewis esophagectomy successfully treated with endoscopic vacuum therapy (E-VAC): a case report

Gastric conduit perforation is a life-threatening complication after esophagectomy and currently there is no consensus about its optimal management. Endoscopic vacuum therapy (E-VAC) is a promising technique for the treatment of leaks and perforations after upper gastro-intestinal surgery. We report the case of a 65years-old male patient who underwent an Ivor Lewis esophagectomy for esophago-gastric junction adenocarcinoma. He referred to our Emergency Department for septic shock and right hydropneumothorax. We performed an emergency thoracoscopy with intraoperative esophagogastroduodenoscopy which showed a pre-pyloric perforation of the gastric conduit. The perforation was initially treated with unsuccessful primary surgical closure and subsequently by means of E-VAC, firstly placed intraluminal and then intracavitary. With the latter technique, we assisted to a progressive clinical improvement until the definitive healing of the perforation. To our knowledge, this is the first case of a gastric tube perforation after esophagectomy successfully treated with E-VAC

Do all the European surgeons perform the same D2? The need of D2 audit in Europe

Although D2 lymphadenectomy is the standard of care for radical intent surgical treatment of gastric cancer, the real compliance with D2 dissection in Europe is still unknown. The aim of the present study is to analyze the variation in lymph-node harvesting reported after D2 dissection in European series and to present a European project aiming at evaluating the real compliance with D2 lymphadenectomy. A PubMed search for papers using the key words "D2 lymphadenectomy" and "gastric cancer" from 2008 to 2017 was undertaken. Only studies by European authors in English language reporting the number of retrieved lymph nodes after D2 lymphadenectomy were included. The results of literature review were descriptively reported. The literature survey yielded 16 studies: 2 RCTs, 3 observational multicentre studies, and 11 observational monocentric studies. A large variability was found in the number of retrieved nodes, which, overall, was the lowest in the surgical series from Eastern Europe (16.6 and 19.9 in the Lithuanian and Hungarian series, respectively) and the highest in an Italian RCT. The within-study variability was also quite high, especially in multicentre RCTs and observational studies. Sample size tended to have a larger effect on the variability of lymph nodes retrieved than on its actual value. However, in both cases, the relation was not significant, due to the low number of studies considered. There is a large variability in the number of retrieved nodes after D2 dissection in European series. This reflects, at least partly, different approaches to D2 lymphadenectomy by European surgeons and may be responsible of the different outcomes observed in patients with gastric cancer across Europe. Therefore, there is the need to standardize the practice of D2 gastrectomy in Europe and to define possible variations of D2 procedures according to tumour's characteristics

The effect of aging on short- and long-term results after esophagectomy: an international multicenter retrospective analysis

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

Clinical pathways in gastric cancer care

The diagnostic–therapeutic pathways (DTPs) are emerging as useful instruments for clinical management of complex diseases as gastric cancer, whose treatment is challenging and requires a multidisciplinary approach. However, the DPTs of patients with gastric cancer are still not defined yet. The aim of this study was to define the optimal DPT to be applied for patients with gastric cancer in the Veneto region. Rather than defining the ideal DTPs a priori, we conducted a preliminary research by analyzing the differences in the actual DPTs for patients with gastric cancer among different hospitals (hub and spokes) in Veneto. Then, the final DPT was elaborated based on the current available best clinical evidences; however, also the areas of homogeneity among the actual DPTs of the included centers as well as the critical issues that had emerged by our preliminary analysis were taken into account for pathway design. High heterogeneity in actual DTPs of patients with gastric cancer was observed among the analyzed centres. Moreover, some of the major criticisms have been found at crucial points of the current pathways. Based on these data, a reference path that is applicable to the whole-regional health network was constructed. The reference DTP is focused on multidisciplinary team management of patients with gastric cancer. Clinical pathways are essential tools to properly manage complex diseases such as gastric cancer. As such, more efforts should be done to implement their use

Should we still use prophylactic drain in gastrectomy for cancer? A systematic review and meta-analysis

Prophylactic drain in gastrectomy for cancer is still widely used, although some evidence has disputed this practice and spreading enhanced recovery protocol has been pushing towards surgical simplification. This study aimed at assessing the impact of drain placement on important clinical outcomes, evaluating the results of randomised controlled trials (RCTs), or cohort studies whenever information provided by the former was scarce. PubMed, PMC, Cochrane Library, CNKI and Wanfang databases were searched from January 1990 to February 2019, both for RCTs and cohort studies comparing use or avoidance of prophylactic drain in gastric cancer patients undergoing gastrectomy. All RCTs and cohort studies were rated according to Jadad score and Newcastle-Ottawa-Scale, respectively. Meta-analysis was separately performed on RCTs and cohort studies. The following clinical outcomes were considered: anastomotic leak, reoperation rate, additional drain procedure, length of stay, postoperative morbidity, postoperative mortality, readmission rate and drain related complications. Overall, 3 RCTs (330 patients) and 7 cohort studies (2897 patients) were included. Seven studies came from Eastern Countries. Meta-analysis on RCTs evidenced that drain avoidance halves overall morbidity (RR = 0.47, 95%CI 0.26-0.86, p = 0.014) and slightly reduces length of stay (SMD -0.24, 95%CI -0.51-0.03, p = 0.083). Only one postoperative death occurred in the drain group. The other outcomes were either not reported or reported just by one RCT each. Meta-analysis on cohort studies, despite higher statistical power, did not highlight any significant difference. This meta-analysis showed that prophylactic drain avoidance can reduce morbidity and length of stay, while not significantly affecting other major surgical outcomes