Marco Ceroni

Total esophagogastrectomy plus extended lymphadenectomy with transverse colon interposition: A treatment for extensive esophagogastric junction cancer

AIM To review the post-operative morbidity and mortality of total esophagogastrectomy (TEG) with second barrier lymphadenectomy (D2) with interposition of a transverse colon and to determine the oncological outcomes of TEG D2 with interposition of a transverse colon. METHODS This study consisted of a retrospective review of patients with a cancer diagnosis who underwent TEG between 1997 and 2013. Demographic data, surgery protocols, complications according to Clavien-Dindo classifications, final pathological reports, oncological follow-ups and causes of death were recorded. We used the TNM 2010 and Japanese classifications for nodal dissection of gastric cancer. We used descriptive statistical analysis and Kaplan-Meier survival curves. A P-value of less than 0.05 was considered statistically significant. RESULTS The series consisted of 21 patients (80.9% men). The median age was 60 years. The 2 main surgical indications were extensive esophagogastric junction cancers (85.7%) and double cancers (14.2%). The mean total surgery time was 405 min (352-465 min). Interposition of a transverse colon through the posterior mediastinum was used for replacement in all cases. Splenectomy was required in 13 patients (61.9%), distal pancreatectomy was required in 2 patients (9.5%) and resection of the left adrenal gland was required in 1 patient (4.7%). No residual cancer surgery was achieved in 75.1% of patients. A total of 71.4% of patients had a postoperative complication. Respiratory complications were the most frequently observed complication. Postoperative mortality was 5.8%. Median follow-up was 13.4 mo. Surgery specific survival at 5 years of follow-up was 32.8%; for patients with curative surgery, it was 39.5% at 5 years. CONCLUSION TEG for cancer with interposition of a transverse colon is a very complex surgery, and it presents high post-operative morbidity and adequate oncological outcomes.

Gastrectomía totalmente laparoscópica por neoplasias gástricas: Experiencia en un centro público

Background: The laparoscopic approach for the treatment of gastric tumors has many advantages. Aim: To evaluate the results of a laparoscopic gastrectomy program developed in a public hospital. Patients and Methods: Retrospective review of epidemiological, perioperative and follow-up data of patients who were treated with a laparoscopic gastrectomy due to gastric tumors between 2006 and 2013. A totally laparoscopic technique was used for all cases. Complications were evaluated according to the Clavien-Dindo classification. Results: Fifty one patients, aged 65 (36-85) years, underwent a laparoscopic gastrectomy. In 22 patients a total gastrectomy was performed. Conversion rate to open surgery was 8%. Operative time was 330 (90-500) min and bleeding was 200 (20-500) ml. Median hospital stay was 7 (3-37) days. Postoperative morbidity was present in 17 (33%) patients, 3 (6%) patients had complications grade 3 or higher and one patient died (1.9%). Tumor pathology was adenocarcinoma in 39 patients. A complete resection was achieved in 97%. Twenty nine patients (74%) with gastric adenocarcinoma had early gastric cancer and 84% of patients were in stage one. Median lymph node count was 24. Median follow-up was 26 (1-91) months. There was no cancer related mortality among patients subjected to a curative resection. Overall survival for patients with adenocarcinoma was 92% at 3 years. Conclusions: This study supports the feasibility and safety of a laparoscopic gastrectomy program in a public hospital; with low morbidity, adequate lymph node dissection and long-term survival. This approach must be considered an option for selected patients with gastric cancer.BACKGROUND The laparoscopic approach for the treatment of gastric tumors has many advantages. AIM To evaluate the results of a laparoscopic gastrectomy program developed in a public hospital. PATIENTS AND METHODS Retrospective review of epidemiological, perioperative and follow-up data of patients who were treated with a laparoscopic gastrectomy due to gastric tumors between 2006 and 2013. A totally laparoscopic technique was used for all cases. Complications were evaluated according to the Clavien-Dindo classification. RESULTS Fifty one patients, aged 65 (36-85) years, underwent a laparoscopic gastrectomy. In 22 patients a total gastrectomy was performed. Conversion rate to open surgery was 8%. Operative time was 330 (90-500) min and bleeding was 200 (20-500) ml. Median hospital stay was 7 (3-37) days. Postoperative morbidity was present in 17 (33%) patients, 3 (6%) patients had complications grade 3 or higher and one patient died (1.9%). Tumor pathology was adenocarcinoma in 39 patients. A complete resection was achieved in 97%. Twenty nine patients (74%) with gastric adenocarcinoma had early gastric cancer and 84% of patients were in stage one. Median lymph node count was 24. Median follow-up was 26 (1-91) months. There was no cancer related mortality among patients subjected to a curative resection. Overall survival for patients with adenocarcinoma was 92% at 3 years. CONCLUSIONS This study supports the feasibility and safety of a laparoscopic gastrectomy program in a public hospital; with low morbidity, adequate lymph node dissection and long-term survival. This approach must be considered an option for selected patients with gastric cancer.

Resección laparoscópica de divertículo esofágico epifrénico secundario a acalasia

Correspondencia: Dr. Jaime Zamarín M. Santa Rosa 1234, Santiago, Chile. jaimezamarin@hotmail.com Paciente de sexo femenino de 43 años, con historia de dos años de disfagia lógica y baja de peso. El estudio endoscópico reveló estenosis concéntrica de esófago inferior, asociado a divertículo a 40 cm de arcada dentaria. El estudio radiológico se presenta en Figura 1. La manometría demostró severa alteración de motilidad del cuerpo esofágico e imposibilidad de franquear esfínter esofágico inferior, sugerente de Acalasia. Se abordó vía laparoscópica, realizándose diverticulectomía esofágica con stappler lineal (Figura 2), cardiomiotomía de Heller y fonduplicatura anterior. La paciente evolucionó sin complicaciones, con resolución de los síntomas preoperatorios. El control radiológico se ilustra en Figura 3.

Andropausia y trastornos del ánimo

Mood disorders in older men are an important public health problem. These disorders are frequently under-diagnosed and treated due to their form of presentation with nonspecific symptoms, superposition of symptoms of medical disease, and patients’ reluctance to seek medical attention. This condition is highly lethal and is estimated to be 4 to 10 times more frequent in men than in women older than 65 years. The present article discusses some of the following questions: What is andropause? How is it diagnosed? What influence does it have on the genesis, course and treatment of mood disorders? Is there a subpopulation of men with depression who could benefit from testosterone replacement therapy? A search was performed of MEDLINE (between January 1990 and July 2005) combining the terms “hypogonadism and depression” or “testosterone and depression”. Articles referring to testosterone and depressive disorders or testosterone administration and monitoring of depressive symptoms were included. The Scielo database was searched, using the terms: “andropause and depression in the older man” to include local epidemiological data. Lastly, a search was performed of references to review articles and case reports published in the same date range. The exact role of testosterone in major depression is still not clearly defined. There is evidence to support a weak association between low testosterone levels and depressive symptoms in older men. Hypogonadism may cause poor response to antidepressants in patients with masked depression, who could benefit from short-term testosterone therapy. Further clinical studies are required to evaluate the real efficacy of testosterone in dysthymic disorder in this population.

National Trend in Laparoscopic Gastrectomy for Gastric Cancer: Analysis of the National Register in Chile

Introduction: The laparoscopic approach for the treatment of gastric cancer has many advantages. However, outside Asia there are few large case series. Aim: To evaluate postoperative morbidity, long-term survival, changes in indication, and the results of laparoscopic gastrectomy. Methods: We included all patients treated with a laparoscopic gastrectomy from 2005 to 2014. We compared results across 2 time periods: 2005–2011 and 2012–2014. Median follow-up was 39 months. Results: Two hundred and eleven patients underwent a laparoscopic gastrectomy (median age 64 years, 55% male patients). In 135 (64%) patients, a total gastrectomy was performed. Postoperative morbidity occurred in 29%. A significant increase in the indication of laparoscopic surgery for stages II–III (32 vs. 45%; p = 0.04) and higher lymph node count (27 vs. 33; p = 0.002) were observed between the 2 periods. The 5-year overall survival was 72%. According to the stage, the 5-year overall survival was 85, 63, and 54% for stage I, II, and III respectively (p < 0.001). Conclusions: There was an acceptable rate of postoperative complications and the long-term survival was in accordance with the disease stage. There was a higher indication of laparoscopic surgery in stages II–III disease, and higher lymph node count in the latter period of this study.

Two-Layer Hand-Sewn Esophagojejunostomy in Totally Laparoscopic Total Gastrectomy for Gastric Cancer

Purpose Different esophagojejunostomy (EJ) reconstruction methods are used after totally laparoscopic total gastrectomy (TLTG), and none is considered a standard technique. This report describes a 2-layer hand-sewn EJ technique during TLTG; we also evaluated postoperative morbidity associated with this technique. Materials and Methods This retrospective cohort study included all consecutive patients who underwent TLTG for gastric cancer (GC) from 2012 to 2016 at 2 affiliated teaching hospitals. All participating surgeons performed standardized intracorporeal 2-layer hand-sewn EJ. Results We included 51 patients who underwent TLTG for GC and standardized EJ anastomosis. Twenty-seven (53%) were male, and the median age was 60 (36–87) years. The average operative time was 337±71 minutes and intraoperative bleeding was 160±107 mL. There were no open conversions related to EJ. Postoperative morbidity was observed in 9 (17.0%) patients. There was no postoperative mortality. EJ leakage was observed in 2 patients (3.8%) and 1 patient (1.9%) developed EJ stenosis. Patients with leakage were managed non-operatively and the patient with stenosis required endoscopic dilation. The median length of hospital stay was 8 (6–29) days. Conclusions Two-layer hand-sewn EJ during TLTG for GC is a feasible and safe technique. This method avoids a laparotomy for reconstruction and the disadvantages associated with laparoscopic introduction of mechanical staplers for EJ, and provides an alternative for alimentary tract reconstruction after TLTG.

Prevención de la recurrencia peritoneal en el tratamiento quirúrgico del cáncer gástrico

Prevention of peritoneal recurrence of gastric cancer The peritoneal cavity is the main site of gastric cancer recurrence after curative surgery. When this re currence occurs, patients may experience bowel obstruction, dehydration and multiple hospital admissions. The therapeutic options that may decrease the rate of peritoneal recurrence and increase five years survival are intraoperative hyperthermic chemotherapy, extensive intraoperative peritoneal lavage and routine bursectomy. We herein review the oncological results of curative surgery for gastric cancer, its failure patterns and the risk factors for peritoneal recurrence. We also review the studies aiming to prevent peritoneal carcinomatosis.