Ulysses Ribeiro Junior

Complications of gastrectomy with lymphadenectomy in gastric cancer

BackgroundCurrently, gastrectomy and extended lymphadenectomy (LN) is the treatment of choice for gastric cancer. Although a survival rate benefit of D2 LN compared to D1 LN has been shown, the D2 LN procedure is not fully employed, due to possible higher morbidity and mortality rates. These higher rates are being questioned in more recent series, in which D1 and D2 LN complication rates have been similar. The aim of this study was to analyze the immediate postoperative complications of patients submitted to total or subtotal gastrectomy with D1 or D2 LN (according to the Japanese guidelines for gastric cancer) at the Gastrointestinal Surgery Division of the Medical School of São Paulo University, between January 2001 and April 2003.MethodsOne hundred consecutive patients were studied; 61 were men and 39, women. Total gastrectomy was performed in 52 patients (13 with D1 LN and 39 with D2 LN), and subtotal gastrectomy was performed in 48 (11 with D1 LN and 37 with D2 LN). Total or subtotal gastrectomy with D1 or D2 LN was performed according to the tumor extent and histological classification (Lauren’s diffuse or intestinal type), considering the patient’s general condition and the gastric cancer stage. Roux-en-Y reconstruction was performed in almost all patients.ResultsNo difference was observed regarding complications and mortality related to the extent of the gastrectomy. Although morbidity was higher in the D1 group, no significant difference was observed. Mortality was higher in the D1 group, and this was probably related to their poor surgical condition and more advanced tumors.ConclusionAccording to these results, it appears that total or subtotal gastrectomy with D2 LN in gastric cancer treatment, performed according to the Japanese guidelines, can be considered a safe procedure, with acceptable morbidity and mortality, when performed by a trained surgical team.

Double pylorus: case report and review of the literature

Double pylorus is an unusual condition in which a double communication between the gastric antrum and the duodenal bulb occurs. It may be congenital, or it may be acquired complication of peptic ulcer disease. We present a case of double pylorus in a gentleman with epigastric pain and previous history of peptic ulcer disease. The relationship between Helicobacter pylori and this disease was assessed. A review of the literature, the role of associated diseases and the role of H. pylori are discussed.

Gastrointestinal stromal tumor of the rectum treated with neoadjuvant Imatinib followed by transanal endoscopic microsurgery

The gastrointestinal stromal tumor (GIST) is a rare type of tumor that expresses CD117 oncogene that can be detected by immunohistochemistry2. The most common sites of GISTs are stomach (70%), and small intestine (20%), while rectum is comprised in only 3% of the cases5. Although a rare condition, the GIST located in the distal rectum may require an abdominoperineal resection. There is no data to support the use of Imatinib (Gleevec from Novartis, Basel, Switzerland), a selective inhibitor of tyrosine quinase, as neoadjuvant therapy. However, the last session consensus for the treatment of GIST, suggests that this form of therapy can be used in some cases where anal sphincter is involved7. The objective of this report is to describe a case of GIST distal rectum in the rectovaginal septum with partial invasion of the anal sphincter, which was successfully treated by neoadjuvant therapy with imatinib followed by the technique of transanal endoscopic microsurgery (TEM). The results are compared with experience in the literature.

Risk factors associated with the development of gastric cancer — case-control study

INTRODUCTION It is estimated that about 1 million (952,000) new cases of gastric cancer occurred worldwide in 2012.1 Except for non-melanoma skin cancer, stomach cancer is currently the fifth most common cancer in the world. The National Cancer Institute (Inca)2 estimated for Brazil 12,920 new cases of stomach cancer in men and 7,600 in women in the biennium 2016-2017. Adenocarcinoma is the histological type most commonly found in gastric tumours. It accounts for more than 95% of gastric neoplasms, and is practically a synonym of gastric cancer. Other neoplasms found in the stomach include gastrointestinal stromal tumours, leiomyomas, lymphomas, and neuroendocrine tumours. Risk factors commonly associated with the development of gastric cancer include chronic infection with Helicobacter pylori (H. pylori), low fruit and vegetable intake, high salt intake, smoking, and alcohol consumption3. The World Health Organization (WHO) classifies H. pylori as a group 1 carcinogen

Advanced age does not increase morbidity in pancreaticoduodenectomy

Background Due to rising life expectancy of population, very complex surgical procedures such as pancreaticoduodenectomy (PD), are more commonly being performed in elderly patients. The objective of this study was to evaluate the safety of PD in patients older than 75 years old and the risk factors associated with severe complications. Methods Patients who underwent PD for periampullary tumors were retrospectively reviewed and divided into two groups, A (<75 years) and B (>75 years). The primary endpoint was severe postoperative complications (Clavien 3 or greater). Secondary endpoints were mortality and any complications. Results Ninety consecutive patients underwent PD for periampullary tumors in the studied period, 70 in group A and 20 in group B. Clinical and pathological characteristics of both groups were equivalents except for age. There were no difference regarding the incidence of severe complications (17% vs. 10%, P=0.72) or all complications (50% vs. 50%, P>0.999). Although mortality was greater in group A (8.6% vs. 0%), it was not statistically significant (P=0.333). On multivariate analyses, only male sex, obesity and American Society of Anesthesiology Score of 3 or 4 were associated with severe postoperative complications. Conclusions Poor clinical status, obesity and male gender are associated with severe complications in PD, but not age greater than 75 years, therefore PD can be considered safe in elderly patients and age itself should not be a contraindication for PD.

Pathologic complete response implies a fewer number of lymph nodes in specimen of rectal cancer patients treated by neoadjuvant therapy and total mesorectal excision

Studies have suggested that the use of neoadjuvant chemoradiation results in a lower lymph nodes yield in rectal cancer patients. OBJECTIVE To evaluate factors associated with less than 12 lymph nodes harvested on patients with rectal cancer treated with preoperative chemoradiotherapy followed by total mesorectal excision. PATIENTS This was a cohort/retrospective single cancer center study. Low and mid locally advanced rectal cancer or T2N0 under risk of sphincter resection underwent chemoradiotherapy followed by total mesorectal excision with curative intent. Chemotherapy consisted of 5-FU and leucovorin IV. Total dose of pelvic radiation was 5040 Gys. All patients were staged and restaged by digital rectal examination, proctoscopy, colonoscopy, CT of abdomen and chest, and MRI of the pelvis. Patients were stratified in two groups: ≥12 and < 12 L N retrieved. The possible factors affecting number of LN were analyzed. RESULTS 95 patients met the inclusion criteria. Mean LN harvest was 23.2 (3-67). 81 patients (85%) had ≥12 L N. Gender, age, tumor size, tumor stage, tumor location, length of specimen, presence of LN involvement, type of surgery, and surgical access showed no association with number of LN retrieved. Only pathological complete response showed a statistically significant association with <12 L N on univariate (p = 0.004) and multivariate analyses (p = 0.002). LIMITATIONS Data were collected retrospectively. The number of patients disparity between the two groups. CONCLUSIONS Complete pathologic response is associated with <12 L N harvested. Thus, the number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection in patients with pathologic complete response.

Efficacy of 3-Dimensional Endorectal Ultrasound for Staging Early Extraperitoneal Rectal Neoplasms

BACKGROUND: Adequate oncologic staging of rectal neoplasia is important for treatment and prognostic evaluation of the disease. Diagnostic methods such as endorectal ultrasound can assess rectal wall invasion and lymph node involvement. OBJECTIVE: The purpose of this study was to correlate findings of 3-dimensional endorectal ultrasound and pathologic diagnosis of extraperitoneal rectal tumors with regard to depth of rectal wall invasion, lymph node involvement, percentage of rectal circumference involvement, and tumor extension. DESIGN: Consecutive patients with extraperitoneal rectal tumors were prospectively assessed by 3-dimensional endorectal ultrasound blind to other staging methods and pathologic diagnosis. PATIENTS: Patients who underwent endorectal ultrasound followed by surgery were included in the study. SETTINGS: The study was conducted at a single academic institution. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values, area under curve, and &kgr; coefficient between 3-dimensional endorectal ultrasound and pathologic diagnosis were determined. Intraclass correlation coefficient was calculated for tumor extension and percentage of rectal wall involvement. RESULTS: Forty-four patients (27 women; mean age = 63.5 years) were evaluated between September 2010 and June 2014. Most lesions were malignant (72.7%). For depth of submucosal invasion, 3-dimensional endorectal ultrasound showed sensitivity of 77.3%, specificity of 86.4%, positive predictive value of 85.0%, a negative predictive value of 79.2%, and an area under curve of 0.82. The weighted &kgr; coefficient for depth of rectal wall invasion staging was 0.67, and there was no agreement between 3-dimensional endorectal ultrasound and pathologic diagnosis for lymph node involvement (&kgr; = –0.164). Intraclass correlation coefficient for lesion extension and percentage of rectal circumference involvement were 0.45 and 0.66. A better correlation between 3-dimensional endorectal ultrasound and pathologic diagnosis was observed in tumors <5 cm and with <50% of rectal wall involvement. LIMITATIONS: The relatively small sample size of patients with early rectal lesions referred directly for surgery could represent a potential selection bias. CONCLUSIONS: Three-dimensional endorectal ultrasound was effective for determining rectal wall invasion and lesion extension in tumors <5 cm and with <50% of rectal wall invasion but was limited for detecting lymph node involvement in early rectal lesions.

Bloodstream Infection due to BacterialCo-Infection in Patients with RectalCarcinoma: Report of Two Cases

In this study, we reported the bacterial co-infection causing bacteremia in two of 38 patients diagnosed with rectal carcinoma. 10 mL of blood of each patient were cultured in BHI broth. From positive blood cultures, aliquots were streaked on MacConkey agar (aerobiosis), and Bacteroides-bile-esculin agar and kanamycinblood agar (anaerobiosis). Bacteria were identified by using API-20A kit and confirmed by 16s rDNA sequencing. The bacterial identification showed the presence of Escherichia coli, Bacteroides fragilis and Enterococcus faecalis. The use of DNA sequencing showed to be a tool for rapid screening of blood infections than the classic microbiological methods, and provides an accurate and effective microbial identification in sepsis process. Patients with intestinal malignancy can produce bacteremia with nonspecific or atypical symptoms.