Resection Of Gastrointestinal Cancer Research Articles

Mo1652b The Need for Perioperative Transfusion Guidelines: Significant Surgeon and Hospital Variation in Blood Transfusion Utilization Following Upper Gastrointestinal Cancer Resection

Mo1652b The Need for Perioperative Transfusion Guidelines: Significant Surgeon and Hospital Variation in Blood Transfusion Utilization Following Upper Gastrointestinal Cancer Resection

Laparoscopy-assisted combined resection for synchronous gastrointestinal multiple primary cancers

BackgroundSynchronous gastrointestinal multiple primary cancers (SGMPC) is infrequent. This study aimed to investigate the feasibility and outcomes of laparoscopy-assisted combined resection for SGMPC. Material and methodsWe retrospectively reviewed 16 cases of SGMPC underwent either open or laparoscopy-assisted combined resection in the Third Affiliated Hospital of Sun Yat-sen University from Jan. 2005 to Jan. 2014. ResultsSixteen cases contained synchronous colon cancers (n = 10), gastric and rectal cancer (n = 5), gastric and duodenal cancer (n = 1). Either laparoscopy-assisted or open procedure was performed. Compared with the open group, the laparoscopy group presented less blood loss (77.1 ± 46.3 ml vs. 145.0 ± 75.9 ml, P = 0.047) and shorter incision length (5.2 ± 0.7 cm vs. 16.4 ± 1.9 cm, P = 0.000), while no differences in operative time (228.3 ± 38.8 min vs. 188.8 ± 47.7 min, P > 0.05) and postoperative hospital stay (10.0 ± 3.4 days vs. 12.0 ± 4.8 days, P > 0.05). Two cases of postoperative complications occurred in the open group and one case of incision infection occurred in the laparoscopy one. Upon follow-up, 2 cases of open group (50.0%) and 8 cases of laparoscopy group (66.7%) were under status of disease free survival. ConclusionsLaparoscopy-assisted combined resection for SGMPC is feasible, safe and effective.

Clinical efficacy of laparoscopic resection for synchronous gastrointestinal multiple primary cancers

Objective To investigate the safety and feasibility of laparoscopic resection for synchronous gastrointestinal multiple primary cancers.Methods The clinical data of 19 patients with synchronous gastrointestinal multiple primary cancers who received laparoscopic resection at the Third Affiliated Hospital of Sun Yat-Sen University from January 2009 to January 2014 were retrospectively analyzed.Patients were followed up via in-and out-patient examination,phone call or mail till April 2014 or death of the patients.Results The operation was successfully carried out on all the patients.Three patients received laparoscopic assisted distal gastrectomy + anterior resection of rectum; 1 received laparoscopic distal gastrectomy + pancreaticoduodenectomy ; 1 received laparoscopic assisted right hemicolectomy + gastric body wedge resection ; 4 received laparoscopic assisted right hemicolectomy + anterior resection of rectum; 4 received laparoscopic assisted left hemicolectomy + anterior resection of rectum; 6 received laparoscopic assisted proctosigmoidectomy.The mean operation time,length of assisted incision,volume of blood loss were 228 minutes (range,145-380 minutes),5 cm (range,4-7 cm) and 86 mL (range,10-250 mL),respectively.No patients were converted to open surgery.The mean number of lymph nodes dissected was 39 (range,21-58),and 3 lymph nodes (range,0-6) were positive.The time of drainage tube removal,time to food intake and duration of postoperative hospital stay were 3 days (range,2-6 days),4 days (range,2-7 days) and 10 days (range,7-21 days),respectively.One patient was complicated with incisional infection and was cured by symptomatic treatment.The mean time of follow-up was 24 months (range,3-48 months).One patient missed the follow-up,12 survived without tumor,4 were alive with tumor,and 2 died due to tumor related factors.Conclusion Laparoscopic resection for the treatment of synchronous gastrointestinal multiple primary cancer is safe and feasible,with advantages of little trauma and fast recovery. Key words: Gastrointestinal neoplasms ; Multiple primary neoplasms ; Synchronous ; Laparoscopy

Functional outcomes and quality of life after proximal gastrectomy with esophagogastrostomy using a narrow gastric conduit.

The best surgical approach for tumors of the proximal stomach remains controversial. For proximal gastrectomy (PG), the evidence regarding quality of life (QoL) and functional outcomes is controversial. Moreover, there are limited data from non-Asian settings. All patients who underwent PG from September 2005 to July 2013 were identified from an institutional database. Demographic, perioperative and pathologic characteristics were retrieved. Symptom scores (0 = best/4 = worst) for reflux symptoms, dysphagia and validated QoL metrics (FACT scale, where a higher score is better) were assessed during early and late follow-up. Eligible patients for analysis were those with no evidence of recurrence. Of 465 upper gastrointestinal cancer resections, 50 were PG for adenocarcinoma (42; 84%), neuroendocrine carcinoma (5; 10%) or other pathologies (3; 6%). R0 resection was achieved in 44 (89.8%) of 49 patients with malignant tumors. Median lymph node collection was 32 (range 7-57). QoL scores did not differ from preoperative to early follow-up but increased compared to both at late follow-up [preoperative, 125 (interquartile range 105-140); early follow-up, 122.5 (97-142); late follow-up, 147 (132-159); p < 0.05]. At early and late follow-up, 9 (21.4%) of 42 and 10 (33.3%) of 30 patients reported reflux symptoms, but most were mild. Endoscopic signs of esophagitis were found in 7 (29%) of 24 patients, but only two of these reported reflux symptoms. Conversely only three of eight patients with reflux symptoms had esophagitis on endoscopy. Global QoL is not reduced early after PG, and increases compared to baseline at late follow-up. Although reflux symptoms are reported by a quarter of patients, most are mild, and there is little correlation with esophagitis. PG should remain a viable option in the management of proximal gastric tumors.

P-0161 - The Provision of a Pre-Operative Immunomodulating Diet in Patients Undergoing Radical Resection for Upper Gastrointestinal Cancers Does not Reduce the Risk of Post-Operative Chest Infection

P-0161 - The Provision of a Pre-Operative Immunomodulating Diet in Patients Undergoing Radical Resection for Upper Gastrointestinal Cancers Does not Reduce the Risk of Post-Operative Chest Infection

Molecular assessment of surgical-resection margins of gastric cancer by mass-spectrometric imaging

Surgical resection is the main curative option for gastrointestinal cancers. The extent of cancer resection is commonly assessed during surgery by pathologic evaluation of (frozen sections of) the tissue at the resected specimen margin(s) to verify whether cancer is present. We compare this method to an alternative procedure, desorption electrospray ionization mass spectrometric imaging (DESI-MSI), for 62 banked human cancerous and normal gastric-tissue samples. In DESI-MSI, microdroplets strike the tissue sample, the resulting splash enters a mass spectrometer, and a statistical analysis, here, the Lasso method (which stands for least absolute shrinkage and selection operator and which is a multiclass logistic regression with L1 penalty), is applied to classify tissues based on the molecular information obtained directly from DESI-MSI. The methodology developed with 28 frozen training samples of clear histopathologic diagnosis showed an overall accuracy value of 98% for the 12,480 pixels evaluated in cross-validation (CV), and 97% when a completely independent set of samples was tested. By applying an additional spatial smoothing technique, the accuracy for both CV and the independent set of samples was 99% compared with histological diagnoses. To test our method for clinical use, we applied it to a total of 21 tissue-margin samples prospectively obtained from nine gastric-cancer patients. The results obtained suggest that DESI-MSI/Lasso may be valuable for routine intraoperative assessment of the specimen margins during gastric-cancer surgery.

Major abdominal cancer resections in cirrhotic patients: How frequent is postoperative hepatocellular decompensation?

The reported incidence of postoperative liver failure in cirrhotic patients is highly varied with diverse risk factors identified to predict risk, mainly drawn from organ or disease-specific studies. We aimed to assess risk factors for the development of postoperative liver failure in a specific cohort of patients with cirrhosis undergoing abdominal cancer resection. From November 2007 to October 2012, 30 cirrhotic patients who underwent curative resection for abdominal cancer were analyzed. The postoperative trends in liver function were followed and the incidence of postoperative liver failure was demonstrated. Among the 30 patients, the tumors were located in the stomach (n = 5), pancreas (n = 5), colon/rectum (6), liver (n = 11), gallbladder (n = 1), and retroperitoneum (n = 2). Eighteen (60 %) patients experienced postoperative liver failure of which 7 (23 %) patients required deviation from the clinical course or management. There was one mortality due to grade C liver failure and hepatorenal syndrome. On multivariate analysis, only age (>55 years) was found to be statistically significant to predict postoperative liver failure (p = 0.024). Liver dysfunction remains a major problem during the postoperative phase of major gastrointestinal cancer resections. However, less than one fourth of well-selected patients will develop significant postoperative liver failure. This incidence may be further reduced if the selection is restricted to younger patients.

Postoperative chemoradiotherapy following pancreaticoduodenectomy

The purpose of this research was to analyze the relationship between dose-volumetric parameters and the development of diabetes mellitus (DM) in patients treated with chemoradiotherapy (CRT) following curative resection for upper gastrointestinal (GI) cancers. Medical records of patients who underwent postoperative CRT following curative resection, either pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD) for upper GI cancers including pancreas, biliary, ampullary, and duodenal cancers, between January 2006 and December 2008 were retrospectively reviewed. A total of 42patients who were regularly followed for at least 2years were included for analysis. Dose-volumetric parameters such as remnant pancreatic volume, mean dose, maximum dose (Dmax), and percentage of volume receiving specific dose or more were obtained from pre- and postoperative CT scan images and treatment plan. Dmax and V50 (percentage of volume receiving at least 50Gy) were statistically significant factors for the development of DM (p = 0.013, p = 0.031, respectively). The sensitivity and specificity of Dmax was 0.875 and 0.559, with cut-off value of 51.1Gy, respectively. V50 had sensitivity of 0.875 and specificity of 0.618 for cut-off value of 16 %. No patient-related factor other than pretreatment cerebrovascular events was associated with the development of DM. On multivariate analysis, V50 was the only factor with statistical significance (p = 0.028), whereas Dmax showed borderline significance (p = 0.079). V50 was the only independent factor associated with the development of diabetes and may function as guideline to predict the development of DM in patients receiving CRT following curative resection.

Comparison of Three Different Minimally Invasive Procedures of Distal Gastrectomy for Nonoverweight Patients with T1N0-1 Gastric Cancer

Laparoscopic-assisted distal gastrectomy has recently come to be a standard procedure for the treatment of early gastric cancer (1 - 5) in select patients. The minimal invasiveness associated with laparoscopic procedures for the resection of gastrointestinal cancer has been repeatedly explained in part by the short incision that is required. (6 - 11) We used two different approaches to perform distal gastrectomies for the resection of gastric cancer as minimally invasive alternatives to a standard laparoscopic approach prior to our surgical team's complete mastery of the skills required for laparoscopic oncological surgery for gastric cancer. (9 , 12) If the minimal invasiveness associated with laparoscopic-assisted gastrectomy can be explained by the small incision, a gastrectomy via a small incision without the use of a pneumoperitoneum may provide a similar outcome in patients. However, to our knowledge, such a comparison has not been previously made. We compared the minimal invasiveness of three different approaches (minilaparotomy, minilaparotomy approach with laparoscopic assistance, and standard laparoscopic-assisted approach) to performing a distal gastrectomy for T1N0-1 gastric cancer in nonoverweight patients (body mass index, ≤ 25 kg/m(2)) performed within a limited study period.

Post-Resection Surveillance in GI Cancers.

Recurrence after curative resection of gastrointestinal (GI) cancers is common. Early detection of resectable recurrences may result in a curative resection. In un-resectable recurrences, early detection may improve the quality of life by palliation or with the use of newer chemotherapeutic drugs. The guidelines regarding follow-up of patients after curative resection of GI cancers are from the West which is very different from the Indian population in terms of a disease pattern and social milieu. The guidelines which are commonly used are also not strictly followed. We have proposed in this article the protocols which we follow at our centre after curative resection of GI cancer and how these are different from the guidelines proposed by the West.

Correlation between preoperative systemic inflammation and postoperative infection in patients with gastrointestinal cancer: a multicenter study

Our aim was to examine the association between postoperative infection and preoperative systemic inflammation in patients undergoing resection of gastrointestinal cancer. We studied 862 patients who underwent elective gastrointestinal cancer surgery at six institutions. The levels of C-reactive protein and albumin were included as parameters of preoperative systemic inflammation measured using the Glasgow prognostic score. The Glasgow prognostic score was calculated based on the admission data as follows: patients with an elevated level of C-reactive protein (>1.0 mg/dl) and hypoalbuminemia (<3.5 g/dl) were allocated a score of 2, while patients showing one or none of these blood chemistry abnormalities were allocated a score of 1 or 0, respectively. The significance of the Glasgow prognostic score for predicting postoperative infection was analyzed using a multivariate analysis. After surgery, 182 (21 %) patients developed postoperative infections. According to a multivariate analysis, the Glasgow prognostic score (p < 0.01) was independently associated with an increased risk of developing a postoperative infection. When the postoperative infections were divided into surgical site infections and remote site infections, the Glasgow prognostic score was significantly associated with an increased risk of developing remote site infections. Preoperative systemic inflammation is associated with postoperative infection in patients undergoing resection of gastrointestinal cancer.

Mo1650 Full-Thickness Endoscopic Resection of Gastrointestinal Cancer: From Animal Experiments to Humans

Transition of Natural Orifice Translumenal Endoscopic Surgery (NOTES) from animal lab to clinical practice in humans for many years was hindered by lack of reliable closure of the translumenal entry site into the peritoneal cavity.

Fluorescence-Guided Surgery and Fluorescence Laparoscopy for Gastrointestinal Cancers in Clinically-Relevant Mouse Models

There are many challenges that face surgeons when attempting curative resection for gastrointestinal cancers. The ability to properly delineate tumor margins for complete resection is of utmost importance in achieving cure and giving the patient the best chance of prolonged survival. Targeted tumor imaging techniques have gained significant interest in recent years to enable better identification of tumor lesions to improve diagnosis and treatment of cancer from preoperative staging modalities to optimizing the surgeon's ability to visualize tumor margins at the initial operation. Using unique characteristics of the tumor to fluorescently label the tissue can delineate tumor margins from normal surrounding tissue, allowing improved precision of surgical resection. In this paper, different methods of fluorescently labeling native tumor are discussed as well as the development of fluorescence laparoscopy and the potential role for fluorescence-guided surgery in the treatment of gastrointestinal cancers.

Full-thickness endoscopic resection of gastrointestinal cancer: from animal lab to humans

Background: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are currently used for resection of early gastrointestinal (GI) tract cancer, limited to superficial layers of the gastric and colonic wall. These techniques are technically difficult, labor intensive and cannot be used when tumor cannot be lifted with submucosal injection and/or involves deeper layers of GI tract wall. Aim: To study technical feasibility and safety of full-thickness colonic resection in a live porcine model and the first clinical experience in humans. Methods: We performed endoscopic full-thickness resections of gastric and colonic wall in nine 50-kg domestic pigs. After resection the defects in GI tract wall were sutured with Overstitch® endoscopic suturing device Apollo Endosurgery Inc, Austin, TX). Three animals were sacrificed post procedure. Six animals were survived for 14 days and subsequently sacrificed for postmortem examination. Then endoscopic full-thickness resection of the colonic wall was performed in a patient with actively bleeding colon cancer, who was not a surgical candidate due to severe concomitant medical problems. Results: Large (3–5 cm) full-thickness endoscopic resections of gastric (3 animals) and colonic (4 animals) wall were easily achieved using hook knife, IT-knife and polypectomy snare (all made by Olympus, Tokyo, Japan). Suturing with the Overstitch® endoscopic suturing device was technically easy and achieved airtight closure of the GI tract in all animals. Postmortem examination reveal good full-thickness healing of the GI tract wall at the sites of resection. After gaining significant experience in endoscopic suturing we performed full-thickness endoscopic resection on a 64-year old man with actively bleeding colon cancer located at hepatic flexure. The patient required anticoagulation and was not able to tolerate even laparoscopic resection due to severe heart problems. The cancer was 2 × 4 cm and could not be lifted with submucosal injection of normal saline. After endoscopic resection, 4 × 6 cm full-thickness defect in colonic wall was completely closed with continuous suture line. The patient had no pain post procedure and was discharged home in 3 days. Follow-up endoscopy in 3 and 6 months revealed good healing of colonic wall without any residual cancer or strictures. Conclusion: This is the first reported purely endoscopic, full-thickness resection of GI tract cancer in humans. This procedure can be used even when EMR and ESD are not possible and can potentially become another valuable alternative to laparoscopy and open surgery.

Influence of Comorbidity and Age on 1-, 2-, and 3-Month Postoperative Mortality Rates in Gastrointestinal Cancer Patients

Studies on the impact of comorbidity and age on postoperative outcome after gastrointestinal tumor resection are scarce. In this study we investigated the impact of comorbidity and age on 30-, 60-, and 90-day mortality after resection of esophageal, gastric, periampullary, colon, and rectal cancer. The study included 8,583 patients recorded in the population-based Netherlands Cancer Registry, regions Eindhoven (Eindhoven Cancer Registry) and Mid and South Limburg, who underwent resection for cancer stage I-III. Patients were diagnosed between 2005 and 2010. Age was categorized as <65, 65-74, and ≥75 years. Comorbidity was present in more than two-thirds (n = 5,910) of patients. The 30-day mortality rates ranged from 0.5 % for rectal cancer patients <65 years to 12.8 % for gastric cancer patients ≥75 years. Patients with comorbidity who underwent esophageal tumor resection had the highest mortality rates, ranging from 8.4 % for 30-day to 12.0 % for 90-day mortality, while rectal cancer patients had the lowest rates, that is, 4.3-6.4 %, respectively. In multivariable analyses, cardiac disease (odds ratio [OR] = 1.74, 95 % confidence interval [95 % CI] = 1.32-2.30), vascular disease (OR = 1.41, 95 % CI = 1.02-1.95) and previous malignancies (OR = 1.38, 95 % CI = 1.02-1.86) in colon cancer, and cardiac disease (OR = 1.81, 95 % CI = 1.10-2.98) and vascular disease (OR = 1.95, 95 % CI = 1.11-3.42) in rectal cancer were associated with the highest 30-day mortality. Postoperative mortality extends beyond 30 days. Comorbidity and older age are associated with early postoperative mortality after gastrointestinal cancer resection. Underlying comorbidity should be identified preoperatively with attention to patients' specific needs to optimally attenuate risk prior to surgery. A less aggressive treatment approach may well be considered in these groups.

Robot-Assisted Endoscopic Submucosal Dissection Is Effective in Treating Patients With Early-Stage Gastric Neoplasia

Endoscopic submucosal dissection (ESD) is a new technique for endoscopic resection of early-stage gastrointestinal cancers. Though ESD achieves high rate of en bloc resection, it is technically difficult to master. The development of a novel robotic endoscopic system that has 2 arms attached to an ordinary endoscope-Master and Slave Transluminal Endoscopic Robot (MASTER)-has improved the performance of complex endoluminal procedures. We evaluated the efficacy of MASTER-assisted ESD in treatment of patients with early-stage gastric neoplasia. We performed a multicenter prospective study of 5 patients with early-stage gastric neoplasia, limited to the mucosa. After markings and circumferential mucosal incision, all submucosal dissections were performed using the MASTER system. We measured baseline demographics, tumor characteristics, and perioperative and clinical outcomes. All patients underwent successful MASTER-assisted ESD. The mean submucosal dissection time was 18.6 minutes (median, 16 minutes; range, 3-50 minutes). No perioperative complications were encountered. Three patients were discharged from the hospital within 12 hours and 2 on the third day after the procedures. Two patients were found to have intramucosal adenocarcinoma, 1 had high-grade dysplasia, 1 had low-grade dysplasia, and 1 had a hyperplastic polyp. The resection margins were clear of tumors in all 5 patients. No complications were observed at the 30-day follow-up examination. Follow-up endoscopic examinations revealed that none of the patients had residual or recurrent tumors. A flexible endoscopy robotic system can be used to perform ESD and effectively treat patients with early gastric neoplasia.

Reprogramming of gastrointestinal cancer cells

Cell reprogramming reverts cells to multipotent, preprogrammed states by re-establishing epigenetic markers. It can also induce considerable malignant phenotype modification. Because key events in cancer relapse and metastasis, including epithelial-mesenchymal transition phenotypes, are regulated primarily by reversible and transient epigenetic modifications rather than the accumulation of irreversible and stable genetic abnormalities, studying dynamic mechanisms regulating these biological processes is important. Transcription factors for induced pluripotent stem cells and non-coding microRNAs allow pluripotent phenotype induction. We present the current knowledge of the possible applications of cell reprogramming in reducing aggressive phenotype expression, which can induce tumor cell hibernation and maintain appropriate phenotypes, thereby minimizing relapse and metastasis after surgical resection of gastrointestinal cancer.

Clinical improvement of membranous nephropathy after endoscopic resection of double early gastrointestinal cancers

A-52-year-old man presented to our hospital with nephrotic syndrome caused by membranous nephropathy. Early gastric adenocarcinoma confined to the submucosa, and well-differentiated adenocarcinoma in a sigmoid adenoma were detected by screening endoscopy. Two years after complete endoscopic resection of these tumors, the estimated 24-h urinary protein excretion decreased, and serum total protein and albumin returned to their normal levels although he had no immunosuppressive therapy. Thus, this case was considered to be a case of secondary membranous nephropathy to cancer, although whether the pathogenesis was due to circulating or in situ immune complexes is unknown. The suspected antigen component of this immune complex can include carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9). In our patient, however, serum CEA and CA19-9 were within normal values during the clinical course, and detected cancers were early stage and very small. Recently, the existence of anti-mucin 1 (MUC1) antibodies before carcinogenesis and their usefulness for early detection of cancer were reported. We tried to stain tumors and glomeruli for MUC1 but, although we had positive findings in both tumors but not in glomeruli, the role of MUC1 in the pathogenesis of membranous nephropathy is unknown. To the best of our knowledge, paraneoplastic nephrosis caused by double early cancers expressing MUC1 in the gastrointestinal tract has not been previously reported.

The relationship between hospital volume and post-operative mortality rates for upper gastrointestinal cancer resections: Scotland 1982–2003

Background Centralisation of surgical treatment of cancer has resulted in improved outcomes. We aimed to determine evidence of benefit for specialised management of upper gastrointestinal cancer in high-volume centres in Scotland. Methods Discharge records of patients undergoing oesophagectomy, gastrectomy, hepatectomy or pancreatectomy between 1982 and 2003 were identified. Hospital data were analysed on a year-by-year basis to derive ‘hospital-years’. Hospital-years were divided into quartiles by volume, and were analysed with regard to in-hospital mortality during the operative admission [Chi-square test ( χ 2) and Chi-square test for trend ( χ 2 trend)]. Results 10,625 patients and 982 in-hospital deaths were included. In-hospital mortality rates declined during the study period: oesophagectomy 11.7–7.9%; gastrectomy 11.2–7.2%; hepatectomy 11.1–3.0%; and pancreatectomy 8.3–4.9%. For all resections except gastrectomy, mortality decreased as quartile of hospital-year volume increased (oesophagectomy: χ 2 p = 0.006, χ 2 trend p = 0.001; hepatectomy: χ 2 p = 0.004, χ 2 trend p = 0.003; pancreatectomy: χ 2 p = 0.002, χ 2 trend p = 0.001). ORs of death were lower for oesophagectomy (OR = 0.58; 95%CI = 0.39, 0.88; p = 0.009) and pancreatectomy (OR = 0.35; 95%CI = 0.19, 0.64; p < 0.001) in hospital-years within highest-volume quartiles compared with lowest. Scattergraphs of all resection types demonstrated inverse power relationships between number of resections per hospital-year and mortality. Conclusion Concentration of cancer care has had major effects on health service delivery in Scotland. Centralisation should be supported in surgical management of upper gastrointestinal cancer.

A randomised control trial of early enteral nutrition v. conventional management in patients undergoing major resection for upper gastrointestinal cancer: a comparison of fluid management

A randomised control trial of early enteral nutrition v. conventional management in patients undergoing major resection for upper gastrointestinal cancer: a comparison of fluid management - Volume 68 Issue OCE1