Valerio Papa

Is malnutrition still a risk factor of postoperative complications in gastric cancer surgery

OBJECTIVE & AIMS The present study aimed at retrospectively evaluating the incidence of mortality and major and minor postoperative complications in patients who underwent surgery for gastric cancer between 2000 and 2006 stratified according to the preoperative percentage weight loss, serum albumin levels and body mass index (BMI). METHODS One hundred and ninety-six patients affected by gastric cancer admitted to the Division of Digestive Surgery of the Catholic University of Rome between January 2000 and December 2006 were considered eligible and were included in the study. According to the weight loss, patients were divided into three groups: (1) 0-5%; (2) 5.1-10%; (3) >10%. On the basis of serum albumin levels, were divided into three groups: (1) <3.0 g/dl; (2) 3.0-3.4 g/dl; (3) >3.5 g/dl. According to BMI, were divided into four groups: (1) <18.5 kg/m(2); (2) 18.5-24.9 kg/m(2); (3) 25.0-29.9 kg/m(2); (4) >30.0 kg/m(2). Postoperative complications and mortality were reported. Complications were classified by objective criteria as major or minor, and as infectious or non-infectious. RESULTS The postoperative mortality was 0%. Major infectious complications occurred in 20 patients (10.2%), major non-infectious in 18 (9.2%), minor infectious in 21 (10.7%), whereas minor non-infectious complications were absent. The rate of major infectious, major non-infectious and minor infectious postoperative complications was similar in patients with absent or light weight loss (8.8%, 8.8%, 10.6%, respectively), mild weight loss (15.3%, 11.5%, 9.6%, respectively), or severe weight loss (6.4%, 6.4%, 12.9%, respectively). Similarly, the rate of postoperative complications did not differ between patients with serum albumin <3.0 g/dl (10.8%, 8.1%, 8.1%, respectively); between 3.0 and 3.4 (8.8%, 13.3%, 17.7%, respectively) or > or =3.5 g/dl (10.5%, 7.9%, 8,7%, respectively). According to BMI, the rate of postoperative complications was: 11.7%, 5.8%, and 5.8% for BMI <18.5 kg/m(2); 9.4%, 8.2%, and 11.7% for BMI between 18.5 and 24.9 kg/m(2); 10.7%, 10.7%, and 9.2% for BMI between 25 and 29.9 kg/m(2); 10.3%, 10.3% and 13.7% for BMI >30 kg/m(2). Then, we evaluated the postoperative morbidity only in patients who underwent total gastrectomy or distal subtotal gastrectomy associated with extended lymphadenectomy. In this group of patients, the rate of postoperative complications was comparable in patients with 0-5% (8.8%, 7.7%, 10%, respectively), 5.1-10% (14.6%, 9.7%, 9.7%, respectively), and >10% (7.1%, 7.1%, 14.3%, respectively) weight loss. Also stratifying the patients according to the serum albumin levels, the rate of postoperative complications did not differ significantly (serum albumin <3.0 g/dl: 14.8%, 11.1%, 14.8%, respectively; serum albumin between 3.0 and 3.4 g/dl: 6.2%, 12.5%, 15.6%, respectively; serum albumin > or =3.5 g/dl: 10.4%, 5.8%, 7.0%, respectively). According to BMI, the rate of postoperative complications was: 7.6%, 0%, and 7.6% for BMI <18.5 kg/m(2); 9.5%, 9.5%, and 11.1% for BMI between 18.5 and 24.9 kg/m(2); 12.5%, 8.3%, and 10.4% for BMI between 25 and 29.9 kg/m(2); 9.5%, 9.5% and 9.5% for BMI >30 kg/m(2). CONCLUSION The present study suggests that weight loss and hypoalbuminemia are not associated with an increased risk of mortality and morbidity in patients who underwent surgery for gastric cancer. This study may represent a stimulus for further studies aiming at evaluating the actual role of malnutrition in the development of postoperative complications in major abdominal surgery.

Outcomes of clinical T4M0 extra-peritoneal rectal cancer treated with preoperative radiochemotherapy and surgery: A prospective evaluation of a single institutional experience

BACKGROUND Our objective was evaluate the outcome of primary clinical T4M0 extraperitoneal rectal cancer treated by neoadjuvant radiochemotherapy. Prognosis of clinical T4 rectal cancer is poor. Preoperative chemoradiation therapy may be beneficial. The results obtained are unclear due to lack of objective and strictly applied staging methods. METHODS Patients with primary, clinical, T4MO, extraperitoneal rectal cancer, defined by transrectal ultrasonography, computed tomography or magnetic resonance imaging, were considered. Intraoperative radiotherapy and adjuvant chemotherapy were employed in some patients after curative resection (R0). Variables influencing the possibility to perform an R0 resection and a sphincter-saving procedure were investigated as predictors of outcome. RESULTS 100 patients were included. R0 resection was performed in 78 patients. R0 resection rate was greater in females (93% vs 67%) and in responders to neoadjuvant chemoradiation (94% vs 60%). The ability to perform a sphincter-saving procedure was 57%, greater in middle rectal location (85% vs 51%) and in responders to the chemoradiation (70% vs 47%). Median follow-up was 31 months (range, 4-136). Local recurrences were found in 7 patients (10%). Five-year local control in R0 patients was 90% and better in the IORT group (100%). Distant relapse occurred in 24 patients (30%). Five-year overall survival was 59%, and was better after an R0 versus an R1 or R2 resection (68% vs 22%). Overall and disease free survival in R0 patients improved after overall downstaging. Adjuvant chemotherapy given in addition to the neoadjuvant therapy did not appear to offer benefit in improving survival. CONCLUSION A multimodal approach enabled us to obtain a 5-year overall survival of about 60%. IORT increased local control. The role of adjuvant chemotherapy needs to be further investigated.

Impact of the latest TNM classification for gastric cancer: Retrospective analysis on 94 D2 gastrectomies

The aim of this study was to determine whether the latest edition of tumor-node-metastasis (TNM) classification provides reliable prognostic information. The fifth edition of TNM Classification of Malignant Tumors has introduced for gastric cancer the numeric count of involved lymph nodes whereas their topographic location was considered in earlier editions. For our study, data from 94 patients who underwent D2-gastrectomy were reviewed. The N-factor was scored according to both the Japanese Research Society for Gastric Cancer (JRSGC) classification (n) and, retrospectively, the latest TNM classification (N). Actuarial survival was calculated for both groups. The two staging systems showed similar stratification of actuarial survival with relation to N-stage; in the JRSGC classification no statistical differences were observed between nl and n2 patients (62.7% vs. 52.5%; p=NS), whereas the 5th TNM classification showed a significant difference between Nl and N2 patients (68.5% vs. 45.0%; p=0.04), and between Nl and the new category of N3 patients (68.5% vs. 45.0%, p=0.03). It appears, therefore, that the numeric count of involved nodes may represent a more reliable indicator for single-case prognosis. Reclassification of all node-positive patients in our series caused an overall stage modification in 32.9% (31/94); 22 of those patients were reclassified to a less favorable stage (23.4%). In addition, 11.7% of patients (6/51) who were previously designated nl were reclassified as N2, shifting from an expected actuarial survival after 72 months of 62.7% to 33.3%.RésuméLa cinquième édition de la classification TNM pour cancer gastrique a introduit la notion d’un certain nombre de ganglions envahis, et au lieu d’une classification uniquement en rapport avec le site. Le but de cette étude a été de vérifier si la dernière classification TNM permettait une information pronostique fiable. On a recueilli les données provenant de 94 patients ayant eu une gastrectomie D2. Le facteur ganglionnaire a été évalué selon la classification japonaise (Japanese Research Society for Gastric Cancer) (JRSGC) («n») et, rétrospectivement, selon la dernière classification TNM («N»). La survie actuarielle a été calculée pour les deux groupes. Les deux systèmes de staging ont montré une stratification similaire de survie actuarielle en rapport avec le stade N. Selon le système de classification JRSGC, on n’a noté aucune différence statistiquement significative entre les patients ni et n2 (62.7% vs. 52.5%; p=NS) alors que selon la 5è classification TNM, on a trouvé une différence statistiquement significative entre les patients NI et N2 (68.5% vs. 45.0%; p 0.04) ainsi qu’entre les patients NI et la nouvelle catégorie N3 (68.5% vs. 45.0%, p=0.03). Le compte numérique des ganglions envahis pourrait donc représenter un indicateur plus fiable. La reclassification de tous les patients ayant des ganglions envahis dans notre série a été responsable d’une modification de stade chez 32.9% (31/94) patients; 22 de ces patients ont eu une classificaiton moins favorable (23.4%). 11.7% des patients (6/51) qui ont été classés antérieurement “n1” ont été reclassés N2; dans ces cas, la survie actuarielle à 72 mois est passée de 62.7% à 33.3%.ResumenLa 5a edición TNM para el cáncer gástrico introduce el concepto del número de adenopatías afectadas ya que la localización topográfica de las mismas fue tenida en cuenta anteriormente. El objetivo de este estudio fue verificar si la última clasificación TNM permite obtener una información pronostica fiable. Se revisó toda la información de 94 pacientes que sufrieron una gastrectomía D2. El factor N se atribuyó de acuerdo tanto con la clasificación (n) de la Sociedad japonesa de investigación para el cáncer gástrico (JRSGC) como, retrospectivamente, de acuerdo con la última clasificación TNM (N). La curva actuarial de supervivencia se calculó para ambos grupos. Ambos sistemas de estadificación mostraron una estratificación similar, desde el punto de vista de supervivencia actuarial, para los pacientes en estadio N. Por lo que se refiere a la clasificación JRSGC no se observaron diferencias entre los pacientes ni y n2 (62.7% vs 52.5%,p=NS). Mientras que con la 5a clasificación TNM se constató una diferencia significativa entre los pacientes NI y N2 (68.5% vs 45.0%, p 0.04) y también entre los NI y la nueva categoría N3 (68.5% vs 45.0%, p=0.003). El número de adenopatías afectadas podría representar un indicador fiable en el pronóstico de casos aislados. La reclasificación de todos los pacientes con ganglios positivos de nuestra serie ocasionó una modificación global de estadio en el 32.9% (31/94); 22 de estos pacientes estaban hipergraduados hacia un estadio menos favorable (23.4%). El 11.7% de los pacientes (6/51) que se habían asignado previamente a la categoría ni se reclasificaron en la N2, desplazándose, de una expectativa actuarial de supervivencia tras 72 meses, del 62.7% al 33.3%.

Retroperitoneal soft tissue sarcoma: prognostic factors and therapeutic approaches.

Aims and Background Retroperitoneal sarcomas are a rare group of malignant soft tissue tumors with a generally poor prognosis. The aim of the study was to assess clinical, pathological and treatment-related factors affecting prognosis in patients with retroperitoneal sarcomas. Methods and Study Design The hospital records of 73 patients who underwent surgical exploration at our unit for primary retroperitoneal sarcomas between 1984 and 2003 were reviewed. Factors influencing overall and disease-free survival were analyzed for all patients and for those who underwent complete surgical resection. Results The complete resectability rate was 69.8% (51/73). Operative mortality and morbidity rates were 2.7% and 21.9%, respectively. For patients who underwent complete resection, the 5-year survival rate was 58.3%, whereas it was 0% in cases of incomplete or no resection (P <0.001). Local recurrence rate was 37.2%. Incomplete gross surgical resection and microscopic infiltration of margins were the most important independent predictors of a poor prognosis. Conclusions The present study confirmed the importance of an aggressive surgical management for retroperitoneal sarcomas to offer these patients the best chance for long-term survival.

RETROPERITONEAL SCHWANNOMAS: DIAGNOSTIC AND THERAPEUTIC IMPLICATIONS

AIMS AND BACKGROUND Schwannomas are a rare group of soft-tissue tumors that are derived from the peripheral nerve sheath and rarely develop in the retroperitoneum. METHODS AND STUDY DESIGN We reviewed the clinicopathological features of 4 patients referred to our unit between October 1999 and March 2004 who on radiological examination were diagnosed with pancreatic, adrenal, psoas and retroperitoneal fat tissue tumors and subsequently underwent surgical treatment. RESULTS The preoperative diagnosis was incorrect in all cases. At time of surgery, we found a mass probably arising from the adrenal gland in 2 patients, a lesion originating from the femoral nerve in 1 patient, and a retroperitoneal mass without a clear site of origin in 1 patient. Pathological evaluation revealed schwannomas in all cases, with no signs of malignancy. Complete surgical excision was performed in all patients without any major postoperative complications. At the time of writing all patients are alive with no evidence of local or distant recurrence. CONCLUSIONS Radical surgical excision is considered the best treatment for these neoplasms, resulting in a very good longterm prognosis.

preoperative Radiotherapy Combined With Intraoperative Radiotherapy Improve Results of Total Mesorectal Excision in Patients With T3 Rectal Cancer

PURPOSE: The survival advantage of preoperative radiotherapy in patients with rectal cancer is still a matter of debate, because its incremental benefit in the total mesorectal excision setting is unclear. This study was designed to evaluate early and long-term results of preoperative radiotherapy plus intraoperative radiotherapy in a homogeneous population of T3 middle and lower rectal cancer patients submitted to total mesorectal excision. METHODS: A series of 113 patients with middle and lower T3 rectal cancer consecutively submitted to total mesorectal excision at a single surgical unit from 1991 to 1997 were divided into two groups according to type of neoadjuvant treatment: preoperative radiotherapy (38 Gy) plus intraoperative radiotherapy (10 Gy; n = 69), and no preoperative treatment (total mesorectal excision; n = 44). Standard statistical analyses were used to evaluate early (downstaging, intraoperative factors, hospital morbidity, and mortality rates) and long-term results (recurrence and survival). RESULTS: Overall, 68.2 percent of patients were downstaged by the preoperative regimens (T0 specimens in 3 cases). Postoperative complications were comparable in the two groups. Five-year, disease-specific survival was 81.4 and 58.1 percent in preoperative radiotherapy plus intraoperative radiotherapy group and total mesorectal excision group, respectively (P = 0.052). Corresponding figures for disease-free survival were 73.1 and 57.2 percent in the two groups, respectively (P = 0.096). The rates of local recurrence at five years were 6.6 and 23.2 percent in preoperative radiotherapy plus intraoperative radiotherapy and total mesorectal excision groups, respectively (P = 0.017). CONCLUSIONS: Preoperative radiotherapy plus intraoperative radiotherapy associated with total mesorectal excision reduce local recurrence rate and improve survival in T3 rectal cancer compared with total mesorectal excision alone.

Four Hundred Consecutive Total Gastrectomies for Gastric Cancer: A Single-Institution Experience

HYPOTHESIS Although total gastrectomy (TG) has been generally accepted as the treatment of choice for upper and middle gastric cancers, some issues are still debated. The objective of this retrospective study was to analyze short- and long-term results of TG (radical and palliative) in a series of 400 patients consecutively admitted to our surgical unit. DESIGN Retrospective cohort study. SETTING Primary and referral hospital care. PATIENTS Hospital records of 400 patients who consecutively underwent TG between January 1981 and June 2005 were reviewed. MAIN OUTCOME MEASURES Surgical complications and survival. RESULTS Three hundred twelve patients underwent radical procedures, and 88 patients underwent palliative procedures. The incidence of postoperative complications was higher among patients who underwent palliative TG (33 of 88 [37.5%]) compared with patients who underwent curative TG (75 of 312 [24.0%]) (P =.01). Mortality was higher among patients who underwent palliative TG (6 of 88 [6.8%]) compared with patients who underwent curative TG (11 of 312 [3.5%]) (P =.18). Five-year survival was 61.8% after curative TG and 12.8% after palliative TG. Ten-year survival was 47.3% after curative TG and 0.0% after palliative TG. CONCLUSIONS This study among 400 consecutive patients who underwent TG at the same surgical unit shows that this surgical procedure in experienced hands can lead to excellent short- and long-term results.

Chilaiditi's syndrome.

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Merkel cell carcinoma metastatic to the stomach.

Merkel cell carcinoma (MCC) is an uncommon, highly aggressive cutaneous neoplasm of neuroendocrine origin, associated with a newly discovered Merkel cell polyomavirus. In the majority of cases, the presentation is that of a flesh-coloured, red or blue, firm, non-tender intracutaneous mass that grows rapidly over a few weeks to months and that may ulcerate. It is estimated that 470 cases occur in the USA each year. Survival is reported to be poor, with a 3-year rate of only 55%. Most patients (70–80%) with MCC present with localized disease. Tumour usually develops in sun-exposed areas, most commonly the head and the neck region, followed by the extremity and the trunk. Rare occurrences in sun-protected areas, such as the oral mucosa, the vulva and the penis, are reported. Distant metastasis is present in 1–4% of patients, the common metastatic sites being the skin (28%), lymph nodes (27%), liver (13%), lung (10%) and brain (6%). Metastatic involvement of the gastrointestinal tract by MCC is exceedingly rare; there have been only three previous reports of gastric metastasis of MCC in the literature. In all cases, tumour presented with a severe gastrointestinal bleeding, and in all patients, but the present, the follow-up was extremely poor. A 72-year-old woman was admitted to our unit with a 1-month history of light-headedness, epigastric abdominal pain, haematemesis and loss of weight. The patient’s past medical history was remarkable for a cutaneous MCC presenting as a right-sided groin mass. The tumour was treated with surgery, chemotherapy (carboplatin and etoposide) and radiotherapy (50.4 Gy). When the patient presented to our attention 2 years later, on physical examination a voluminous epigastric mass was palpable, and laboratory values were notable for a decreased haemoglobin level of 6.3 g/dL and an increased level of neuronspecific enolase (103.1 ng/mL). The patient was stabilized with blood transfusion and subsequently underwent an esophagogastroduodenoscopy, which showed a voluminous irregular mass with a 1-cm ulcer along the greater curvature of the stomach. Multiple cold forceps biopsies were taken. Computed tomography scan (Fig. 1) showed a circumferential thickening of the gastric body, ‘linitis plastica’-like. Histopathologic evaluation of biopsy specimens disclosed homogenous and uniform round cells infiltrating the lamina propria (Fig. 2). Immunohistochemical analysis revealed intense staining for chromogranin, synaptophysin and Anti-Cytokeratin (CAM 5.2), consistent with the diagnosis of metastatic MCC. At laparotomy (Fig. 3), a grossly apparently exophytic lesion involving the greater curvature of the stomach was found. The patient was operated on, and a Billroth II resection was performed. Definitive histological findings confirmed a metastatic MCC of the stomach. The patient received other two cycles of adjuvant chemotherapy, and is still alive with no clinical and radiological evidence of recurrence within 24 months of follow-up. Gastric metastasis is an extremely rare complication in the evolution of cancers and is associated with a very bad short-term prognosis. The most common tumours that metastasize to the stomach are melanoma, lung and breast cancers. According to autoptic studies, the incidence of gastric metastasis in neoplastic patients is very low (0.2–1.7%).

Prevention and treatment of venous thromboembolism in patients with IBD: a trail still climbing.

Abstract:Venous thromboembolism (VTE) represents one of the most common and life-threatening extraintestinal complications of inflammatory bowel disease (IBD). Therefore, the prevention of VTE is essential and foremost involves the assessment of individual patient risk factors for VTE and, consequently, the correction of those risk factors that are modifiable. Mechanical and pharmacological prophylaxis are highly effective at preventing VTE in patients hospitalized for acute disease, and they are recommended by the leading guidelines for hospitalized patients with IBD. Unfortunately, several recent surveys reported that prophylaxis against VTE is still poorly implemented because of concerns about its safety and a lack of awareness of the magnitude of thrombotic risk in patients with IBD. Therefore, further efforts are required to increase the thromboprophylaxis rate in these patients to bridge the gap between the best care and standard care and, consequently, to avoid preventable VTE-associated morbidity and mortality. This review provides insight on the critical points that persist on the prevention and treatment of VTE in patients with IBD.