Subtotal Distal Resection Research Articles

Spleen-preserving D2 subtotal distal resection of the stomach and corpocaudal resection of the pancreas after neoadjuvant induction chemotherapy and chemoradiotherapy: case report and literature review

Background. Stomach cancer is one of the most common cancers worldwide. Long-term treatment outcomes in patients with locally advanced gastric cancer with invasion to adjacent structures are poor. In clinical recommendations of the Ministry of Health of the Russian Federation, it is recommended to treat these patients with perioperative chemotherapy according to the FLOT scheme. The effectiveness of neoadjuvant chemoradiotherapy is studied in many multicenter studies involving randomized clinical trials. Case description. We present a case of a successful treatment of a patient with locally advanced gastric cancer (сT4bN2M0 – IVA stage). The patient received neoadjuvant therapy (2 cycles according to the FLOT scheme) followed by chemoradiotherapy (total dose of 46 Gy with the concurrent chemotherapy with capecitabine and oxaliplatin). Neoadjuvant therapy was well tolerated (grade 1 gastrointestinal and hematological toxicity). The patient underwent distal subtotal resection of the stomach with D2 lymph node dissection and distal subtotal resection of the pancreas with preservation of the spleen. No postoperative complications were observed. Histological examination revealed complete pathological response of the primary tumor, including the area of earlier invasion into the pancreas; metastasis in one lymph node of the small omentum. The patient is alive with no evidence of disease 20 months after surgery. Conclusion. The feasibility of conducting safe multimodal neoadjuvant therapy followed by organ-preserving surgery in a patient with locally advanced gastric cancer (сT4bN2M0) was shown. The effective neoadjuvant therapy resulted in the achievement of complete pathologic response, which is a favorable prognostic factor.

Nonel approaches in the field of gastric cancer surgical treatment

The aim of the study: to estimate the impact of different cellular phenotype of gastric tumors on the survival of patients treated according to standard protocols.
 Object and methods of research.The work presents the results of a study conducted on the basis of two medical institutions - the National Cancer Institute and the abdominal oncology and surgery department of the Odessa Regional Oncology Center. 221 patients underwent surgery for gastric cancer (GC) in the period 2007-2013. The average age of patients was 60.88 ± 10.5 years, men - 180, women - 41. Of the total number of operated, 143 patients underwent surgery in the amount of gastrectomy, 78 - subtotal distal resection.
 Results. All patients included in the study underwent radical surgery. Tumors removed during surgery were examined using histological, cytological, immunohistochemical methods and genetic tests. The obtained results are monitored for the presence/absence of clinical parallels and mathematical correlations. It was concluded that some combinations of immunohistochemical (IHC) markers were effective in separating groups of patients with different biology of gastric cancer.
 Conclusions. Performing more advanced operations (including the use of D2 lymph dissections) is the most effective option for surgical treatment of microsatellite-unstable and Epstein-Barr virus-associated gastric cancer.

Health-related quality of life after curative resection for gastric adenocarcinoma.

BACKGROUNDWith improved survival in gastric cancer patients, health-related quality of life has become an important clinical endpoint alongside primary oncological outcomes.AIMTo investigate health-related quality of life after various surgical procedures for gastric cancer treatment.METHODSThe validated Slovenian version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (QLQ-C30) and its gastric cancer-specific module (QLQ STO-22) was sent for self-completion to patients that underwent curative resection for gastric adenocarcinoma between January 2014 and December 2018 at our centre. In total, 116 patients responded. Scores were compared between patients after subtotal distal vs total gastrectomy and patients after subtotal distal gastrectomy with Billroth II vs Roux-en-Y reconstruction.RESULTSInterestingly, the extent of resection did not influence daily functioning; however, more dysphagia and eating restrictions were reported in patients after total gastrectomy when compared to patients after subtotal distal gastrectomy. Moreover, patients with Billroth II reconstruction after subtotal distal resection experienced worse physical and role functioning and reported more pain, fatigue and reflux compared to Roux-en-Y reconstruction.CONCLUSIONBased on our results, Roux-en-Y reconstruction after subtotal distal gastrectomy should be preferred over Billroth II reconstruction. The data obtained from this study will help surgeons when preoperatively informing their patients about expected functional outcomes after gastrectomy and enable them to ensure proper supportive care of their patients in the postoperative period.

Laparoscopic subtotal distal gastrectomy for distal gastric cancer

To analyze the primary results of laparoscopic distal gastrectomy in patients with distal gastric cancer. There were 21 laparoscopic distal gastrectomies in patients with distal gastric cancer. Mean age of patients was 63.7±6.3 years. According to TNM staging system, cancer stage 1 was detected in 90% of patients (n=19), stage 2a - in 10% (n=2) of patients. Time of distal gastrectomy was 190.4±51.6 min, blood loss - 90.3±51.2 ml. The number of excised lymph nodes was 21.2±5.1. We were able to achieve R0 resection edge in all patients. Length of hospital-stay was 7.6±2.3 days, incidence of postoperative complications - 23.8%. Complications Clavien-Dindo grade IIIb-V were observed in 9.5% of patients (n=2). Overall postoperative mortality was 4.7% (n=1). No progression of the underlying disease has been revealed in any patient throughout the follow-up period (since May 2018). To date, the maximum median follow-up is 25 months of overall and disease-free survival. Laparoscopic subtotal distal resection is an appropriate intervention ensuring R0 resection edge in most cases.

Laparoscopic subtotal distal resection for distal gastric cancer

To analyze the primary experience of laparoscopic distal gastrectomy in patients with distal gastric cancer. There were 21 laparoscopic distal gastrectomies in patients with antrum malignancies. Mean age of patients was 63.7±6.3 years. According to TNM staging system, cancer stage I was detected in 90% of patients (n=19), stage IIa - in 10% (n=2) of patients. Duration of distal gastrectomy was 190.4±51.6 minutes, blood loss - 90.3±51.2 ml. The number of harvested lymph nodes was 21.2±5.1. We were able to reach R0 resection edge in all patients. Length of hospital-stay was 7.6±2.3 days, incidence of postoperative complications - 23.8%. Complications Clavien-Dindo grade IIIb-V were observed in 9.5% of patients (n=2). Overall postoperative mortality was 4.7% (n=1). No progression of the underlying disease has been revealed in any patient throughout the follow-up period (since May 2018). To date, the maximum median follow-up is 25 months of overall and disease-free survival. Laparoscopic subtotal distal resection is appropriate intervention ensuring R0 resection edge in most cases.

Distal subtotal gastrectomy and gastreectomy in surgical treatment of patients with gastric cancer: a systematic review and meta-analysis

Objective To analyze the randomized controlled trials (RCTs) devoted to distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer. Material and methods RCTs were searched in the electronic library, the Cochrane Community database, and PubMed database. A systematic review and meta-analysis were carried out in accordance with the recommendations of the Cochrane Community experts (Higgins et al. 2019). Mathematical calculations of a meta-analysis were made using RevMan 5.3 software package. Statistical criteria were calculated for relative risk (RR), hazard ratio (HR), 95% confidence interval (95% CI) and significance level (p). Results Seven primary RCTs were selected. A total number of 1463 surgical interventions with D2 lymphadenectomy were observed (805 patients underwent distal subtotal gastrectomy, 658 - gastrectomy). Postoperative mortality is significantly higher (6.5% and 2.6%) after gastrectomy compared to subtotal distal gastrectomy (RR 2.2, 95% CI 1.34-3.64, I2 0%, fixed effect model). Postoperative complications are also significantly more common (28% and 14%) after gastrectomy (RR 1.72, 95% CI 1.16-2.55, I2 heterogeneity 49%, random effect model). Differences in overall five-year survival after gastrectomy and subtotal distal resection (51.6% and 60.8%) are insignificant (HR 0.74, 95% CI 0.45-1.22, I2 90%, random effect model, general reverse inversion). Conclusion The choice of distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer is not regulated by evidence-based medicine. The boundaries of minimal surgical clearance from the tumor edge vary from 2.5 cm to 6 cm. An updated meta-analysis shows that postoperative mortality and morbidity are significantly higher after gastrectomy compared to distal subtotal gastrectomy while overall 5-year survival is similar.

THE COMPARATIVE ASPECTS OF TWO MODIFICATIONS OF GASTRIC RESECTION ACCORDING T. BILLROTH TECHNIQUE IN ONCOLOGIC PRACTICE

The surgical intervention implying total ablation of tumor, continues to be the only method giving hope for recovery of patient despite a significant number of combined and complex methods of treatment of the given disease. However, many positions of the given conception underwent cardinal changes. Nowadays, most of authors recommend after gastric resection to restore to the extent possible natural anatomic relationships that provides best functional results. At the same time, certain researchers give preference to Billroth-II mode and at that some of them are devoted opponents of gastric resection by Billroth-I mode in case of cancer. This opinion is based on supposition that gastric resection by Billroth-II mode provides in greater extent radicalism in case of treatment of malignant neoplasms of given localization. The main factor restraining application of this most physiological operation is established opinion alleging its oncologic non-efficacy. The thesis is substantiated that intervention into modification of operation according Billroth method does not result in increasing of number of post-operative complications and that there is no differences also in distant results of surgical treatment of gastric cancer in case of application of both modes of restoration of continuity of digestive tract after sub-total distal resection. At the same time, quality of life of patients becomes better after reconstruction of digestive tract using gastroduodenal anastomosis. Most of researchers, studying indications to sub-total gastric resection using method Billroth-I, assume that it is reasonable to apply this particular mode of restoration of continuity of gastrointestinal tract only in case of early cancer, its exophytic forms (stage I and II) located in area of stomach angle or its low one third of its body and absence of metastases into regional lymphatic nodes.

QUALITY OF LIFE IN THE ELDERLY PATIENTS AFTER SURGERY FOR GASTRIC CANCER

The problem of the quality of life of elderly gastric cancer patients after surgical treatment, is still insufficiently studied. Functional results of the management of 91 patients, underwent surgical treatment at the age of 75 years and older, are represented. 35 patients underwent gastrectomy, 56 patients - subtotal distal resection. The quality of life was assessed at the second year after surgery according to both the Performance Scales for the Karnofsky & ECOG Scores, as well as the modified form of EORTC QLQ-STO 22. Only 40% of patients were fully recovered after total gastrectomy and 57.1% of cases - after gastric resection. 28.6% and 35.7% of patients respectively were incapable for full activity and required support. Patients with severe disability and cases needed a significant care amounted to 28.6% and 2.8% in the group of patients after gastrectomy and only 3.6% in the group of cases after the gastric resection. Thus, in elderly patients with gastric cancer after surgical treatment, a significant deterioration of the quality of life is observed, and therefore the tactic of minimization of the radical surgical intervention in this age group is reasonable.

The application of the operation according to the method Billroth-I in cancer patients: past and present

Surgery that involves complete removal of the tumor remains the only method which gives hope for cure of the patient, despite the significant number of combined and complex treatment methods of this disease. However, many provisions of this concept have changed drastically. It is shown that most authors today recommend after resection of the stomach to restore, if possible, the natural anatomical relationship, which provides the best functional results. At the same time noted that some researchers prefer the second method Billroth, some of them are staunch opponents of resection of the stomach according to the method Billroth-I in cancer. This opinion is based on the assumption that resection of the stomach according to the second embodiment Billroth better allows radicalism in the treatment of malignant neoplasms of this localization. The main constraint to the use of the most physiological surgery is the conventional wisdom about supposedly her cancer nerdycellist. The author substantiates the position that the intervention in the modification operations according to the method Billroth-I does not increase the number of postoperative complications, no differences in long-term results of surgical treatment of gastric cancer for two methods of reconstruction of digestive tract continuity after Subtotal distal resection. At the same time, the quality of life of patients better after the reconstruction of the digestive tract with gastroduodenal anastomosis. Exploring the indications for distal Subtotal gastrectomy according to the method Billroth-I, the majority of authors deem this method of restoring continuity of the gastro-intestinal tract only when early cancer, exophytic forms (I – II stage), located in the angle of the stomach or lower third of his body, and the absence of metastases in regional lymph nodes.

D2 lymphadenectomy in the management of gastric cancer.

Gastric carcinoma is a significant cause of death in Ireland. Surgery offers the best option of cure, but the five-year survival following resection remains dismal at 10-15%. Experience from Japan and from some Western units suggest that an extended (D2) lymphadenectomy in association with gastrectomy increases the prospect of cure, but concern about the morbidity and mortality of this operation and lack of evidence from randomised studies has limited its acceptance. This study reports the experience of a specialist upper gastrointestinal unit with D2 gastrectomy in a four-year audit. Sixty-two resections were performed for gastric cancer. Nineteen patients were deemed unsuitable for the D2 procedure and underwent a more limited lymphadenectomy (D0 or D1). Forty-three patients underwent D2 resection, 12 with an oesophagogastrectomy, 22 with total gastrectomy and nine with a sub-total distal resection. Eight patients undergoing D2 resection had extended resections, five with splenectomy and three with a distal pancreatectomy. Post-operative complications occurred in 31% of patients. Thirty-day and 90-day mortality were zero. Median survival was 822 days in the D2 group (range 120-1,320). These results show that a D2 gastrectomy can be performed with a low morbidity and mortality and a median survival of greater than two years.

Pancreatic Regeneration after Subtotal Distal Resection in Rats

Forty male Wistar rats were randomly allocated to four treatment groups after 90% distal pancreatectomy: group A (control) received saline (0.5 ml subcutaneously); group B received bombesin (BBS; 10 μg/kg intraperitoneally); group C received octreotide (2.5 μg/kg subcutaneously), and group D received BBS and octreotide. All substances were injected three times a day until sacrifice after 28 days. BBS increased pancreas weight (p = 0.003) and DNA synthesis (p < 0.001), as measured by a bromodeoxyuridine nuclear-labeling index (BrdU LI). The simultaneous administration of octreotide significantly decreases the remnant pancreas weight (p = 0.016) as compared to group B rats; however the BrdU LI is not significantly reduced in group D as compared to group B. BBS administration promotes regeneration of the remnant pancreas in terms of hypertrophy and hyperplasia. Although octreotide appears to significantly reduce the pancreatic weight increase induced by BBS, it does not reduce DNA synthesis and cell proliferation.

Early gastric cancer: diagnosis, surgical treatment and follow-up of 45 cases.

The 5-year survival rate of early gastric cancer (EGC) is 85%-100% after "curative" resection, as compared to 20%-30% in advanced gastric cancer (AGC). Because of this relatively high cure rate, the interest in the diagnosis and therapy of EGC has been steadily increasing. The present study, based on 45 EGCs, is aimed at a critical evaluation of the diagnostic procedures and surgical options. Forty-five patients with early gastric cancer (27 men and 18 women; median age, 62 years; range, 28-84) were diagnosed and operated on. They represented 22.5% of all patients with gastric cancer (200) treated in the period July 1987 to January 1998. Forty-one patients were from the northeastern part of Italy. The most frequent symptom was epigastric pain (84%). Barium upper gastrointestinal radiography findings were strongly suggestive of malignancy in 41 cases (91%). Preoperative histopathological diagnosis of adenocarcinoma was performed in 43 cases (95.5%). In two cases (4.5%) severe epithelial dysplasia (associated with ulcer) was the first diagnosis, but the final diagnosis on the basis of the resected specimens was a well differentiated adenocarcinoma. The primary surgical procedure included i) subtotal distal resection (37 cases) with Billroth 11 (33) and Billroth I (4) reconstructions; ii) total gastrectomy (3) for proximal neoplastic extension; iii) proximal gastric resection (2) for cardial cancer; iv) degastro-total gastrectomy (3) for cancer of the stump. Two patients, previously treated with conservative surgery, underwent degastro-total gastrectomy for neoplastic microfocal extension to the margin of resection and for early anastomotic recurrence, respectively. Mural infiltration was limited to the mucosa and submucosa in 27 and 18 cases, respectively. Lymph node metastases were found in three mucosal and five submucosal tumor cases, involving either the first or the second echelon. No operative deaths or postsurgical complications occurred in this series. In the follow-up period (median, 36 months; range, 3-120) four patients died due to other causes; one developed liver metastases, another developed oropharyngeal cancer and two died of biopsy-proven lung cancer without evidence of gastric cancer recurrence. The clinical presentation of EGC is aspecific. Preoperative endoscopy with biopsy remains the most sensitive diagnostic procedure. For treatment, subtotal distal gastric resection with lymphadenectomy is the "gold standard" but in some instances total gastrectomy may be indicated. Accurate pathological examination establishes the depth of infiltration, as well as the superficial extension of tumors and the lymph node status. Although the prognosis of EGC is favorable, a medium-term follow-up should be planned.

Surgery for early gastric cancer: a European one-center experience.

Between 1972 and 1995 a total of 251 patients with early gastric cancer underwent resection in our department of surgery. At the time of the operation 10.8% of the patients were proved to have lymph node involvement, and two already had distant metastases. A subtotal gastric resection was performed in 59.8% of cases (n = 150), a total gastrectomy in 33.8% (n = 85), and either a proximal or an atypical resection in 6.4% (n = 16). Since 1985 subtotal distal resection and total gastrectomy were accompanied by a systematic lymphadenectomy of compartments I and II. The overall postoperative morbidity was 18.3%, and the hospital mortality, 4.9%; it was only 1.6% within the last decade. Concerning these short-term results there were no statistically significant differences between the different surgical procedures. The cumulative overall 5-year-survival rate was 82.6%. There was no statistically significant influence of either the different surgical procedures or the histologic types according to the Japanese classification of early gastric cancer.