Georgios Baltogiannis

Laparoscopic total gastrectomy: further progress in gastric cancer

Gastrectomy with extended D2 lymphadenectomy preserving the spleen and pancreas has been the standard approach for distal gastric cancer. However, for proximal advanced ([T2) tumors, splenectomy usually is performed to dissect the splenic hilum (no. 10) and lymph nodes along the splenic artery (no. 11). The risk of residual positive lymph nodes at these nodal stations (nos. 10 and 11) is calculated to be approximately 15 and 25%, respectively. The pancreas should be preserved except when achievement of a complete tumor resection (R0) requires distal pancreatectomy [1–9]. This surgical strategy has become the preferred procedure for open surgery. What about laparoscopic surgery for tumors located in the proximal or middle third of the stomach? Laparoscopically assisted distal gastrectomy has been performed widely in Asian countries [10], and more currently, totally laparoscopic distal gastrectomy without minilaparotomy is performed even in the West [11] for distal gastric cancers. But is laparoscopic total gastrectomy technically feasible and safe? Should the spleen be preserved or resected with the laparoscopic approach? Sakuramoto et al. [12] have provided useful data for approaching these questions. Between 2004 and 2007, these authors performed pancreasand spleen-preserving total gastrectomy with D1?beta or D2 lymph node dissection and Roux-en-Y reconstruction for 74 patients with cancer located in the upper or middle third of the stomach. Of these 74 patients, 30 underwent laparoscopically assisted total gastrectomy (LATG), and 44 underwent open total gastrectomy (OTG). Although the operating time was longer by 95 min for LATG than for OTG (p \ 0.001), blood loss less (p \ 0.001) and the hospital stay was significantly shorter, by 5 days (p\0.05), in the LATG group than in the OTG group. The number of lymph nodes harvested was high not only in the OTG group (n = 51) but also in the LATG group (n = 43). Given that anastomotic leakage, abdominal abscess, and pancreatic leakage occurred for 6 patients (13.6%) in the OTG group but for none of the 30 patients in the LATG group, the authors conclude that LATG is superior to OTG for proximal or middle-third tumors because it provides better quality of life (QOL) and fewer complications. This study [12] supports the conclusion that not only laparoscopic distal gastrectomy but also laparoscopic total gastrectomy is technically feasible, safe, and effective. The results of laparoscopic spleen-preserving total gastrectomy are excellent. Minimal postoperative morbidity and a high number of lymph nodes dissected and examined certainly reflect surgeons and hospitals performing a high volume of laparoscopic gastrectomies. We discuss only some oncologic principles. The authors carefully selected the patients for laparoscopic surgery, including mostly those with early-stage disease. Nevertheless, spleen preservation for patients with advanced serosa-positive (T3) and node-positive disease is associated with a substantial risk of splenic hilum-positive lymph nodes. Thus, preservation of the spleen may be with increased risk of residual disease in these nodes (station no. 10), nodal recurrence, and death. Despite efforts, it E. Hanisch Klinik fur Allgemein, Viszeral, und Endokrine Chirurgie, Asklepios Klinik in Langen, Langen, Germany

Gastric Volvulus and Wandering Spleen: A Rare Surgical Emergency

Gastric volvulus is a rare but potentially life-threatening clinical entity due to possible gastric necrosis. A wandering spleen may also be associated with gastric volvulus. Patients presenting with the triad epigastralgia, vomiting followed by retching, and difficulty or inability to pass a nasogastric tube into the stomach are likely to have gastric volvulus. The operating surgeon should include this rare entity in the differential diagnosis when dealing with a patient with such a clinical profile. Herein, we present a case of gastric volvulus associated with a wandering spleen in a 28-year-old Caucasian woman and we provide a brief review of the literature on this issue.

Open versus laparoscopic versus robotic gastrectomy for cancer: need for comparative-effectiveness quality

New technologies and medical devices may improve both health care and research toward the development of new drugs. But they are a major driver of increases in U.S. health care expenditures, which have grown by an estimated 71% since 2000 [1]. In an economic crisis, cost effectiveness for new therapies (e.g., robotic surgery) should be considered. The U.S. market for drugs and devices is regulated by the Food and Drug Administration (FDA), which scrutinizes clinical trial data for evidence of safety and efficacy. Although the FDA has been criticized for missteps and inefficiencies in its approval process, more relevant is FDA oversight of the labeling and promotion of medical products. Indeed, the FDA does not require the inclusion of statements regarding a product’s comparative effectiveness. Clinicians, patients, and payers would be less willing to pay more for a new treatment such as robotic surgery without proof that it improves health outcomes. Comparative-effectiveness research is the current standard strategy for drawing robust conclusions about new drugs, medical devices, and surgical techniques [2]. Randomized phase 3 trials are the best tools for ultimate decisions in medicine. The current standard of care in the treatment of resectable gastric cancer includes gastrectomy and adjuvant chemotherapy with or without radiotherapy [3–5]. It is thought that the quality of surgery [6] including a standardized D2 lymphadenectomy can improve the survival of patients with stage 2 or 3 disease [7–12]. New techniques for improving patient outcomes include endoscopic submucosal resection for early gastric cancer, laparoscopic gastrectomy, and robotic surgery. All these new treatments should provide evidence of their superiority over open D2 gastrectomy before they are widely used. Oncologic outcomes are the principal priority in the treatment of cancer patients. Although minimally invasive surgery improves quality of life (QOL), it should be ensured that these techniques do not increase recurrence risk and mortality. In a recent issue of Surgical Endoscopy, Kim et al. [13] provided comparison-effectiveness information regarding robotic surgery versus laparoscopic or open gastrectomy for the treatment of gastric cancer. The authors compared the results of robotic gastrectomy using the da Vinci surgical system with those for 11 laparoscopic and 12 open gastrectomies performed during the same period (31 December 2007 to 30 June 2008). At baseline, no significant difference in clinicopathologic characteristics or tumor stage was observed between the three groups. The total number of lymph nodes retrieved (TNODS) and used as a quality control measure in gastric, colorectal, and other cancers, did not differ significantly among the groups. Robotic surgery was associated with significantly less blood loss and a shorter postoperative hospital stay. The postoperative morbidity was similar in the three groups. No open or laparoscopic conversion was performed in the robotic group. Kim and colleagues concluded that experienced laparoscopic surgeons can safely perform robotic surgery for gastric cancer, improving the short-term outcomes. This study provides encouraging data on the use of robotic surgery for gastric cancer. But it is a small retrospective with no information on long-term survival or G. Glantzounis D. Ziogas (&) G. Baltogiannis University of Ioannina, Ioannina, Greece e-mail: deziogas@hotmail.com

Laparoscopic sphincter-preserving rectal cancer surgery: a highly demanding procedure

Most patients with potentially curable middle or lower rectal cancer at diagnosis prefer or require a sphincterpreserving surgical procedure. Currently, laparoscopic low anterior resection (LLAR) is thought to offer the best possible postoperative quality of life (QOL) [1, 2]. However, what are the risks of postoperative complications and local or locoregional failures? Are there standardized criteria for a safe and effective LLAR? Is preoperative (neoadjuvant) chemoradiotherapy beneficial to all patients or only in selected cases? To evaluate these questions, Fukunaga et al. [3] performed a retrospective analysis which was reported in the January 2010 issue of this journal. Clinicopathologic treatment and follow-up data of 98 patients with middle (n = 51) or low-lying rectal cancer (n = 47) who underwent laparoscopic rectal surgery were studied. Depending on the distal distance of the distal tumor border to the anal verge, the patients were classified as having lower (\8 cm) or middle (C8 cm) rectal cancer. Total mesorectal excision (TME) was performed in all patients. Pelvic anatomy was accurately visualized by endoscopic magnification so autonomic nerves could be preserved. Conversion to open surgery was necessary in five patients because of difficulties with rectal transection in three early cases and a large tumor and adhesions in the other two. Overall, the postoperative complication rate was 32.2%, with an anastomotic leakage rate of 13.1%. Recurrence occurred in 12 patients: 3 local, 2 lymph nodes, and 7 distant failures. Although the Fukunaga et al. study is limited by its retrospective nature and small number of patients, it provides precise data on short-term and long-term risks associated with LLAR. Anastomotic leakage and locoregional recurrence are substantial and should be seriously considered when preparing to perform this surgical procedure. Can these risks be prevented? For evidence-based good clinical practice, when performing a LLAR certain criteria should be kept in mind. In contrast to the conclusive evidence associated with laparoscopic colectomy [4], there is no such evidence for LLAR. Although six randomized controlled trials of LLAR have been published, they have several limitations [1]. The oncological principles of open surgery also should be kept in mind for sphincter-saving resection: Because of a better view of the pelvis via the laparoscopic technique, a more accurate and precise TME can be achieved laparoscopically (LTME) [1, 2, 5, 6]. The distal distance from the tumor for preventing local recurrence has been an important topic. Currently, there is consensus that at least 2-cm distal tumor-free surgical margins are required. Adequate lymphadenectomy is also crucial to avoid nodal failures and to obtain accurate nodal staging which is important for deciding on adjuvant treatment. There is currently agreement on high ligation of the inferior mesenteric artery and splenic flexure mobilization [1, 2]. A trend in favor of laparoscopic surgery also expands the indications for other common gastrointestinal tumors, including gastric cancer [5, 7–9]. It appears that the quality of the surgery affects the patient’s oncological and QOL outcomes. Standardized LLAR can be performed probably more safely and efficiently by high-volume surgeons. However, there are several questions and controversies. For example, there is limited evidence that LLAR improves local control by C. G. Katsios (&) G. Baltogiannis Department of Surgery, University of Ioannina, School of Medicine, 451 10 Ioannina, Greece e-mail: chkatsios@gmail.com

Surgical site infections in general surgery operations in North West Greece: A prospective pilot study

Aim-BackgroundSurgical site infections (SSIs) are an important cause of morbidity and mortality that add to the cost of hospitalization. The aim of the present pilot study is to assess the incidence rate of SSIs and associated risk factors in the Department of Surgery at the University Hospital of Ioannina.MethodsA prospective active surveillance study was performed for patients undergoing general surgery from December 2010 to May 2011. Patients were inspected daily for the development of SSIs for a period of 30 days in accordance with the standard definitions for SSIs and protocols as outlined by the National Nosocomial Infections Surveillance (NNIS) system. Univariate analysis was applied to evaluate the association between potential risk factors and SSIs.ResultsSixteen of the 207 patients developed SSIs (rate 7.7%). The majority were women (81.2%). The most common microorganisms were gram negative (61.5%). Univariate analysis showed that females, an ASA score >2, increased duration (>24 hrs) of chemoprophylaxis, and an NNIS score >1 were associated with an increased risk for SSIs.ConclusionThis pilot study identified factors associated with increased SSI rates. The continuation of the study is expected to provide helpful information toward ways of preventing and reducing SSIs.

New target therapies for patients with neuroendocrine tumors of the pancreas

New target therapies for patients with neuroendocrine tumors of the pancreas Georgios Baltogiannis, Christos Katsios & Dimitrios H Roukos To cite this article: Georgios Baltogiannis, Christos Katsios & Dimitrios H Roukos (2011) New target therapies for patients with neuroendocrine tumors of the pancreas, Expert Review of Gastroenterology & Hepatology, 5:5, 563-566 To link to this article: http://dx.doi.org/10.1586/egh.11.55

Letter to the Editor: Breast Cancer in Young Women in Africa: Are There Genetic and Clinical Differences with European Ancestry Patients?

SocieteInternationale de Chirurgie 2010 Recently the human genomes from Europe, the United States, Asia, and Africa have been completely sequenced, revealing some genetic differences between people from different ancestry. Similarly, most recently cancer genomes of four patients with myeloid leukemia, lung cancer, and melanoma have been reported with a complete DNA sequencing and a full catalogue of driver mutations for these cancer types. As cheaper next-generation DNA sequencing technology becomes available, we hope that in the coming years, a full screen of breast cancer genomes will be completed. Until hundreds of cancer genomes from patients with breast cancer from Africa and rest of the world become available for robust genetic comparisons, clinical data comparisons are useful.

Moving from lymph node metastasis in gastric cancer to biological markers.

Searching a robust prognostic factor, the report by Fukudaet al. [1] in the 2009 November issue of World Journal ofSurgery evaluates whether lymph node ratio could be usedas an optimal predictor of survival in gastric cancer.Metastases to lymph nodes in gastric cancer have beenthe most important prognostic factor in gastric cancer. Inday-to-day clinical practice for decision-making aboutadjuvant systemic treatment after a complete surgicalresection (R0), two factors dominantly guide this decision:lymph node status (pN), and tumor depth invasion into thegastric wall (pT).More currently, there is a debate between the scientificcommunityinthewesternworldandJapanorAsiancountries.Whichisthemorereliableprognosticfactor:theabsolutetotalnumber of metastatic lymph nodes proposed by the Interna-tional Union Against Cancer/American Joint Committee onCancer (UICC/AJCC) or the location and number of meta-static nodes proposed by the Japanese Gastric Cancer Asso-ciation (JGCA)? Both systems have strengthens andlimitations.Toimprovetheprognosticpowerofbothsystems,researchers recently evaluated whether the presence of mi-crometastases or isolated tumor cells in patients with node-negative disease could further improve prognosis and adju-vant treatment decisions in these patients.Based on the results of their retrospective study, Fukudaet al. [1] concluded that the metastatic lymph node ratio(MLR) is an important prognostic factor that should beconsidered. In this study, multivariate analyses revealedthat the MLR was the most significant prognostic factorcompared with UICC/AJCC or JGCA staging systems.Although MLR has already been demonstrated to be aprognostic marker, this study has several weaknesses tosupport the superiority of MLR vs. UICC and JGCA sys-tems. It is a small study (n

Advances and high demands in totally robotic surgery for rectal cancer

Open low anterior resection for tumors located in the lower third of the rectum has three goals: precision of total mesorectal excision (TME), safe distal margins to prevent local recurrence after a sphincter-preserving procedure, and high ligation of the inferior mesenteric artery with splenic flexure mobilization. Can these surgical aims be achieved with a minimally invasive approach such as laparoscopic or robotic surgery? Park et al. [1] highlight this question in their report on robotic surgery for rectal cancer in the March issue of Surgical Endoscopy. The standard of care for patients with resectable rectal cancer includes TME. This surgical strategy can improve both oncologic and quality-of-life (QOL) outcomes for patients with rectal cancer. Sphincter-preserving surgery, if feasible from an oncologic point of view, is crucial for the patient’s QOL. Therefore, low anterior resection (LAR) currently is thought to be the optimal surgical treatment if local recurrence can be ensured. Yet the criteria for LAR have not been completely standardized. To date, laparoscopic LAR (LLAR), including laparoscopic total mesorectal excision (LTME), is not recommended by recent guidelines as the standard approach. Evidence for the superiority of LLAR over open LAR still is scarce. Despite this lack of strong evidence, positive results from retrospective studies and small randomized controlled trials of LLAR have been reported [2]. These superior findings for LLAR have led to a progressively wider acceptance of laparoscopic surgery [3]. It is expected that the application of laparoscopic surgery will be improved dramatically for gastrointestinal cancer treatment over the next years, although strong evidence currently exists only for laparoscopic colectomy used to manage colon cancer [4–11]. Compared with LLAR, robotic surgery may improve outcomes particularly for low-lying rectal cancer patients. However, attention is required for TME that can decrease the risk of locoregional recurrence, but decreasing the blood supply to the remaining rectum stump at the same time may increase the risk of colorectal anastomosis leakage [2, 3]. This anastomosis failure raises the question of protective temporal ileostoma. Another important topic of concern is whether the high ligation of the inferior mesenteric artery with splenic flexure mobilization suggests an overtreatment and whether it is useful only for selected patients with node-positive rectal cancer. Can a totally robotic surgery for rectal cancer including splenic flexure mobilization be safely performed? Park et al. [1] developed a totally robotic surgery technique for rectal cancer. They designed a six-port system, including a camera port, for performing rectal cancer surgery from the splenic flexure to the pelvic diaphragm in one setup. The authors evaluated the feasibility and safety of this technique for 45 patients with rectal cancer. The conversion rate to laparotomy was 2.2%, and the 30-day morbidity rate was 11%. The authors concluded that totally robotic surgery for rectal cancer using their technique was feasible and safe. New surgical techniques can be associated with increased morbidity and mortality. Indeed, progress can be achieved only by translating innovation into clinical practice, and this strategy, at least in the initial stages, can satisfy increased postoperative risks. On the other hand, however, caution is suggested and careful consideration of many variables. Although the authors report that no C. Katsios (&) G. Baltogiannis Department of Surgery, University of Ioannina, School of Medicine, Ioannina TK 451 10, Greece e-mail: chkatsios@gmail.com

Laparoscopic surgery for rectal cancer: the standard of care?

In a recent issue of the Surgical Endoscopy, Miyajima et al.[1] reported their results with laparoscopic surgery forrectal cancer. Although theirs was a retrospective studywith no level 1 evidence from randomized controlled trials,the data provided by authors still may be important andworthy of consideration.In the treatment of gastrointestinal cancers, the qualityof surgery plays a central role in achieving both goodquality of life and favorable oncologic outcomes [2]. Forexample, appropriate lymph node dissection seems to beimportant for reducing locoregional recurrence. Althoughcontroversy still exists, at least 15 or, according to others,20 lymph nodes should be resected and pathohistologicallyexamined for accurate nodal staging, which is important foradjuvant treatment decisions [3–7].Particularly for rectal cancer, surgical quality stronglyaffects quality of life and survival. Total mesorectal exci-sion, sphincter-preserving surgery, and sigmoid mesentericlymph node dissection currently are increasingly acceptedfor optimal treatment of distal rectal tumors.All these goals can be better achieved with laparoscopictechniques. Indeed, recent advances in laparoscopic gas-trointestinal surgery allow improved postoperative mor-bidity and quality of life without any worsening ofoncologic outcomes [8, 9]. However, concern arises whenrandomized controlled trials, required to prove the safetyand efficacy of laparoscopic procedure versus open rectalsurgery, are lacking [10, 11].Therefore, the results for 1,057 selected patients withrectal cancer who underwent laparoscopic surgery between1994 and 2006 in 28 Japanese centers [1] may attract ourconsideration. Most of the 938 patients underwent rectalanterior resection, and a conversion to open procedure wasrequired for only 7.3% of these patients. Postoperativesurgical complications were observed for 235 patients(22%), including anastomotic leakage in 84 patients (9%).The local recurrence rate was only 1%, and the overallrecurrence rate was 6.6% for the 1,011 patients who hadundergone a pathohistologically confirmed completeresection. Further evaluation, if feasible, with phase 3 trialsrequires the possibility of expanding indications forsphincter-preserving laparoscopic rectal resection so morepatients can benefit from this technique.The low local and overall recurrence rates reported fromthis large retrospective study provides further evidence forthe safety and efficiency of laparoscopic rectal resection.The refinement and new generation of robotic da Vincisystems will further improve patient outcomes [12].Undoubtedly, new technologies drive the future. Inclinical practice, the second-generation da Vinci S highdefinition (HD) surgical system likely will become thetechnique required especially for low anterior rectumresection. In biomedical sciences, new research based onnext-generation DNA sequencing is increasingly incorpo-rated into research projects to assist us in understanding thecomplex heterogeneity of cancer. The past three decadeshave seen important advances in conventional single-pro-tein-coding gene research. But cancer mortality stillremains high, reflecting the need for new directions. Cur-rently, a new era with cancer genome research, systemsapproaches, and network modeling provide major hope for