Esophagojejunal anastomosis leakage is one of the major complications after total gastrectomy for gastric cancer and is an independent predictor of survival. Our aim is to systematically review the literature and discuss the reported therapeutic approaches to identify the best therapeutic approach. Pubmed, EMbase, Cochrane Library, CILEA Archive, BMJ Clinical Evidence, and Up ToDate databases were screened limiting the research to articles written in English from January 1992 through December 2013. This way a total of 474 manuscripts were retrieved for furthermore evaluation. Eleven manuscripts were considered eligible and the study is focused on those works. We analyzed a total of 3,893 patients and 114 cases of esophagojejunal anastomosis leakage. Different treatments were grouped into three main categories: conservative approach (66 cases), endoscopic approach (21 cases), and surgical approach (27 cases). The overall mortality rate is 26.32 per cent and surgical approach showed the higher rate. According to the reported data, a complete resolution of the leakage can be achieved in an interval ranging from 7 to 28 days in the group treated conservatively. Conservative approach should always be considered as the treatment of choice. Reoperation may be necessary in case of wide dehiscence or when other treatments fail; therefore, the high mortality rate related to this procedure is due to the comorbidities of patients undergoing relaparotomy. Finally, endoscopic approach with endoclips seems promising but needs furthermore studies.
Purpose Upfront resectable pancreatic cancer in the left pancreas is increasingly resected through the minimally invasive approach. Robotic distal pancreatectomy (RDP) is an upcoming alternative for laparoscopic distal pancreatectomy (LDP). Yet, the oncological efficacy of RDP is uncertain. The aim of this study is to compare the oncological and surgical outcomes between RDP and LDP. Methods An international retrospective cohort study in consecutive patients treated with RDP or LDP in upfront resectable pancreatic cancer in 34 high-volume (>50 MIDP total experience) centers from 11 countries (2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019). The primary outcomes were R0 resection and lymph node yield. Kaplan-Meier estimates were used for survival rates. Results Overall, 542 patients were included, 103 (19%) underwent RDP and 439 (81%) LDP. Preoperative characteristics were similar. RDP was associated with a higher median lymph-node yield (18 vs 16, P=0.021) and a comparable R0-resection rate (76% vs 69%, P=0.40). RDP was associated with a longer operative time (290 min vs 240 min, P<0.001) and less conversions (5% vs 17%, P=0.001) without emergency conversions (i.e. for bleeding), compared to 29% for LDP. A higher rate of major morbidity (Clavien-Dindo 3) (26% vs 16%, P=0.017) was observed after RDP, but 30-day mortality (2% vs 1%, P=0.24) and in-hospital mortality (2% vs 0.4%, P=0.26) did not differ significantly. Median length of stay was longer following RDP (10 vs 8 days, P=0.001). The 3-year survival rate [34% vs 38%, P=0.73] and median overall survival [28 months (95% CI, 9-47) vs 31 months (95% CI, 25-37), P=0.73] did not differ significantly. Conclusion For upfront resectable pancreatic cancer, RDP was associated with a similar R0 resection rate, but a higher lymph node yield compared to LDP. Given the contradicting outcomes in conversion rate, morbidity rate, operative time, and hospital stay, randomized trials are required in centers that have surpassed the learning curve.
Nodal ratio (NR) has been demonstrated to be an important prognostic factor in patients with gastric cancer. The aim of this study is to evaluate the prognostic role of nodal ratio comparing it with the new TNM (2010) classification. One hundred forty-two patients were submitted to potentially curative gastrectomy for cancer. Patients with low performance status underwent D1.5 lymphadenectomy, whereas the other patients underwent D2–D2.5 lymphadenectomy. Nodal staging was classified according to 2010 International Union Against Cancer/American Joint Committee on Cancer classification. Kaplan-Meier method was used to evaluate survival, stratified for nodal classes and nodal status. Total gastrectomy was performed in 39 per cent of cases and distal gastrectomy in 61 per cent. Mean number of resected nodes was 25.5. Whereas N status was strictly related to the number of resected nodes, the NR was independent from the extension of the lymphadenectomy. Overall five-year survival was 81 per cent for N0 patients, 72 per cent for N1, and 26 and 23 per cent for N2 and N3, respectively. Patients with NR0 had 81 per cent five-year survival, whereas NR1 67 per cent, NR2 51 per cent, and NR3 22 per cent. NR seems to be a simple method to predict the prognosis of patients with gastric cancer; unlike N status, it is independent from the number of resected nodes, and therefore it is particularly useful in case of inadequate lymphadenectomy.
Background. Early-stage hepatocellular carcinoma could benefit from upfront liver resection (LR) or liver transplantation (LT), but the optimal strategy in terms of tumor-related outcomes is still debated. We compared the oncological outcomes of LR and LT for hepatocellular carcinoma, stratifying the study population into a low-, intermediate-, and high-risk class according to the risk of death at 5-y predicted by a previously developed prognostic model. The impact of tumor pathology on oncological outcomes of low- and intermediate-risk patients undergoing LR was investigated as a secondary outcome. Methods. We performed a retrospective multicentric cohort study involving 2640 patients consecutively treated by LR or LT from 4 tertiary hepatobiliary and transplant centers between 2005 and 2015, focusing on patients amenable to both treatments upfront. Tumor-related survival and overall survival were compared under an intention-to-treat perspective. Results. We identified 468 LR and 579 LT candidates: 512 LT candidates underwent LT, whereas 68 (11.7%) dropped-out for tumor progression. Ninety-nine high-risk patients were selected from each treatment cohort after propensity score matching. Three and 5-y cumulative incidence of tumor-related death were 29.7% and 39.5% versus 17.2% and 18.3% for LR and LT group (P = 0.039), respectively. Low-risk and intermediate-risk patients treated by LR and presenting satellite nodules and microvascular invasion had a significantly higher 5-y incidence of tumor-related death (29.2% versus 12.5%; P < 0.001). Conclusions. High-risk patients showed significantly better intention-to-treat tumor-related survival after upfront LT rather than LR. Cancer-specific survival of low- and intermediate-risk LR patients was significantly impaired by unfavorable pathology, suggesting the application of ab-initio salvage LT in such scenarios.
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