Leandro Barchi

MINIMALLY INVASIVE SURGERY FOR GASTRIC CANCER: TIME TO CHANGE THE PARADIGM

ABSTRACT Introduction: Minimally invasive surgery widely used to treat benign disorders of the digestive system, has become the focus of intense study in recent years in the field of surgical oncology. Since then, the experience with this kind of approach has grown, aiming to provide the same oncological outcomes and survival to conventional surgery. Regarding gastric cancer, surgery is still considered the only curative treatment, considering the extent of resection and lymphadenectomy performed. Conventional surgery remains the main modality performed worldwide. Notwithstanding, the role of the minimally invasive access is yet to be clarified. Objective: To evaluate and summarize the current status of minimally invasive resection of gastric cancer. Methods: A literature review was performed using Medline/PubMed, Cochrane Library and SciELO with the following headings: gastric cancer, minimally invasive surgery, robotic gastrectomy, laparoscopic gastrectomy, stomach cancer. The language used for the research was English. Results: 28 articles were considered, including randomized controlled trials, meta-analyzes, prospective and retrospective cohort studies. Conclusion: Minimally invasive gastrectomy may be considered as a technical option in the treatment of early gastric cancer. As for advanced cancer, recent studies have demonstrated the safety and feasibility of the laparoscopic approach. Robotic gastrectomy will probably improve outcomes obtained with laparoscopy. However, high cost is still a barrier to its use on a large scale.

Gastric Cancer: Aspects of Minimal Invasive Technique

Gastric Cancer is a predominately a male disease that usually affects two males for every female1, 2. Despite a decrease in incidence reported all over the world it continues to be the fourth cause of death for malignant disease. There has been also an increase in the number of females, and in old age patients3, 4. In western countries the diagnosis is mostly of advanced cancer in contrast with the eastern countries where most of the cases are of early cancer (about 50%).

Favorable minimal invasive surgery in the treatment of superior mesenteric artery syndrome: Case report

Highlights • Sistematic review emphasizing technical advances, proper recognition of the surgical field and its effectiveness on the wilkie’s syndrome treatment.

Robotic digestive tract reconstruction after total gastrectomy for gastric cancer: a simple way to do it

Intracorporeal digestive tract reconstruction after minimally invasive total gastrectomy may be challenging, even when using the da Vinci® Surgical System. This may be due to intrinsic difficulties during oesophago–jejunal anastomosis (EJA). The aim of this study was to describe a simple way to perform digestive tract reconstruction after robotic total gastrectomy (RTG) for gastric cancer and the results of its application in a small series of cases.

GASTRIC NEUROENDOCRINE TUMOR: REVIEW AND UPDATE

INTRODUCTION The frequency of gastric neuroendocrine tumors is increasing. Reasons are the popularization of endoscopy and its technical refinements. Despite this, they are still poorly understood and have complex management. AIM Update the knowledge on gastric neuroendocrine tumor and expose the future perspectives on the diagnosis and treatment of this disease. METHOD Literature review using the following databases: Medline/PubMed, Cochrane Library and SciELO. Search terms were: gastric carcinoid, gastric neuroendocrine tumor, treatment. From the selected articles, 38 were included in this review. RESULTS Gastric neuroendocrine tumors are classified in four clinical types. Correct identification of the clinical type and histological grade is fundamental, since treatment varies accordingly and defines survival. CONCLUSION Gastric neuroendocrine tumors comprise different subtypes with distinct management and prognosis. Correct identification allows for a tailored therapy. Further studies will clarify the diseases biology and improve its treatment.

Duodenal fistula: The most lethal surgical complication in a case series of radical gastrectomy

BACKGROUND Despite all advances regarding the surgical treatment of gastric cancer (GC), duodenal stump fistula (DF) continues to negatively affect postoperative outcomes. This study aimed to assess DF regarding its incidence, risk factors, management and impact on overall survival. METHODS We retrospectively analyzed 562 consecutive patients who underwent gastrectomy for GC between 2009 and 2017. Clinicopathological characteristics analysis was performed comparing DF, other surgical fistulas and patients with uneventful postoperative course. RESULTS DF occurred in 15 (2.7%) cases, and 51 (9%) patients had other surgical fistulas. Tumor located in the lower third of the stomach (p = 0.021) and subtotal gastrectomy (p = 0.002) were associated with occurrence of DF. The overall mortality rate was 40% for DF and 15.7% for others surgical fistulas (p = 0.043). The median time of DF onset was on postoperative day 9 (range 1-75). Conservative approach was performed in 8 patients and surgical intervention in 7 cases. Age (OR 7.41, p = 0.012) and DF (OR 9.06, p=0.020) were found to be independent risk factors for surgical mortality. Furthermore, patients without fistula had better long-term survival outcomes comparing to patients with any type of fistulas (p = 0.006). CONCLUSION DF is related with distal tumors and patients submitted to subtotal gastrectomy. It affects not only the postoperative period with high morbidity and mortality rates, but may also have a negative impact on long-term survival.

Management of postoperative complications of lymphadenectomy

Gastric cancer remains a disease with poor prognosis, mainly due to its late diagnosis. Surgery remains as the only treatment with curative intent, where the goal is radical resection with free-margin gastrectomy and extended lymphadenectomy. Over the last two decades there has been an improvement on postoperative outcomes. However, complications rate is still not negligible even in high volume specialized centers and are directly related mainly to the type of gastric resection: total or subtotal, combined with adjacent organs resection and the extension of lymphadenectomy (D1, D2 and D3). The aim of this study is to analyze the complications specific-related to lymphadenectomy in gastric cancer surgery.

Minimally invasive surgery for gastric cancer in Brazil: current status and perspectives—a report from the Brazilian Laparoscopic Oncologic Gastrectomy Group (BLOGG)

The minimally invasive surgery for gastric cancer in Brazil has begun about two years after the first laparoscopic gastrectomy (LG) performed by Kitano in Japan, in 1991. Although the report of first surgeries shows the year of 1993, there was no dissemination of the technique until the years 2010. At that time with the improvement of optical devices, laparoscopic instruments and with the publications coming from Asia, several Brazilian surgeons felt encouraged to go to Korea and Japan to learn the standardization of the LG. After that there was a significant increase in that type of surgery, especially after the IRCAD opened a branch in Brazil. The growing interest for the subject led some services to begin their own experience with the LG and, since the beginning, the results were similar with those found in the open surgery. Nevertheless, there were some differences with the papers published initially in Japan and Korea. In those countries, the surgeries were laparoscopic assisted, meaning that, in the majority of cases, the anastomoses were done through a mini-incision in the end of the procedure. In Brazil since the beginning it was performed completely through laparoscopic approach due to the skills acquired by Brazilian surgeons in bariatric surgeries. Another difference was the stage. While in the east the majority of cases were done in T1 patients, in Brazil, probably due to the lack of early cases, the surgeries were done also in advanced cases. The initial experience of Zilberstein et al. revealed low rates of morbidity without mortality. Comparing laparoscopic and open surgery, the group from Barretos/IRCAD showed shorter surgical time (216×255 minutes), earlier oral or enteral feeding and earlier hospital discharge, with a smaller number of harvested lymph nodes (28 in laparoscopic against 33 in open surgery). There was no significant difference regarding morbidity, mortality and reoperation rate. In the first efforts to publish a multicentric study the Brazilian Gastric Cancer Association (BGCA) collected data from three institutions analyzing 148 patients operated from 2006 to 2016. There were 98 subtotal, 48 total and 2 proximal gastrectomies. The anastomoses were totally laparoscopic in 105, laparoscopic assisted in 21, cervical in 2, and 20 open (after conversion). The reconstruction methods were: 142 Roux-en-Y, two Billroth I, and three other types. The conversion rate was 13.5% (20/148). The D2 dissection was performed in 139 patients. The mean number of harvested lymph nodes was 34.4. If we take only the D2 cases the mean number was 39.5. The morbidity rate was 22.3%. The mortality was 2.7%. The stages were: IA-59, IB-14, IIA-11, IIB-15, IIIA-9, IIIB-19, IIIC-11 and stage IV-three cases. Four patients died from the disease and 10 are alive with disease. The participating services have already begun the robotic gastrectomy with satisfactory results. The intention of this group is to begin now a prospective multicentric study to confirm the data already obtained with the retrospective studies.

Técnica simplificada de reconstrução do trato digestivo após gastrectomia para câncer gástrico

RACIONAL - Cada vez mais a cirurgia laparoscopica esta sendo aplicada no tratamento cirurgico do câncer gastrico. A reconstrucao do trato gastrointestinal totalmente feita por laparoscopia tambem tem sido um desafio para aqueles que desenvolveram este procedimento. OBJETIVO - Descrever reconstrucao simplificada apos gastrectomia total ou subtotal para o câncer gastrico por laparoscopia e os resultados de sua aplicacao em uma serie de casos. METODOS- Nos ultimos quatro anos, 75 pacientes foram operados com câncer gastrico e dois com GIST. Trinta e quatro eram mulheres e 43 homens. A idade variou de 38 a 77 anos com media de 55 anos. Nos dois pacientes com GIST em um foi realizada gastrectomia total e no outro gastrectomia subtotal. Nos outros 75 pacientes foram aplicados 21 gastrectomias totais e 54 subtotais. Em todos os cânceres, a gastrectomia foi completada com linfadenectomia D2 com pelo menos 37 linfonodos retirados. Foi utilizada nas operacoes modificacao tecnica laparoscopica proposta pelos autores consistindo em anastomose latero-lateral esofago jejunal em GT e de modo semelhante na GST e restabelecimento da continuidade digestiva tambem no abdomen superior. RESULTADOS- O intra-operatorio e a evolucao pos-operatoria imediata transcorreu sem intercorrencias, exceto por um caso de sangramento devido a abertura de clipe, sendo necessaria re-intervencao. O tempo operatorio foi de cerca de 300 minutos, nao havendo diferenca entre GT e GST. O numero de nodulos linfaticos retirados variou de 28 a 69, com media de 37. O estadiamento pos-operatorio mostrou um caso em T4 N2 M0; 13 em T2 N0 MO; 27 em T2 N1 M0; 24 em T3 N1 M0; e 10 em T3 N2 M0. Como complicacao, em apenas um caso foi observado no 10o dia do pos-operatorio uma pequena fistula da anastomose esofagojejunal com fechamento espontâneo. CONCLUSAO - A evolucao dos pacientes, sem complicacoes e mortalidade e com apenas um pequeno vazamento de anastomose sem repercussoes sistemicas, e forte indicio da viabilidade tecnica inovadora deste metodo.