Randomized clinical trial comparing survival after D1 or D2 gastrectomy for gastric cancer

BACKGROUND

It is still unclear whether D2 lymphadenectomy improves the survival of patients with gastric cancer and should therefore be performed routinely or selectively. The aim of this multicentre randomized trial was to compare D2 and D1 lymphadenectomy in the treatment of gastric cancer.

METHODS

Between June 1998 and December 2006, patients with gastric adenocarcinoma were assigned randomly to either D1 or D2 gastrectomy. Intraoperative randomization was implemented centrally by telephone. Primary outcome was overall survival; secondary endpoints were disease-specific survival, morbidity and postoperative mortality.

RESULTS

A total of 267 eligible patients were allocated to either D1 (133 patients) or D2 (134) resection. Morbidity (12.0 versus 17.9 per cent respectively; P = 0.183) and operative mortality (3.0 versus 2.2 per cent; P = 0.725) rates did not differ significantly between the groups. Median follow-up was 8.8 (range 4.5-13.1) years for surviving patients and 2.4 (0.2-11.9) years for those who died, and was not different in the two treatment arms. There was no difference in the overall 5-year survival rate (66.5 versus 64.2 per cent for D1 and D2 lymphadenectomy respectively; P = 0.695). Subgroup analyses showed a 5-year disease-specific survival benefit for patients with pathological tumour (pT) 1 disease in the D1 group (98 per cent versus 83 per cent for the D2 group; P = 0.015), and for patients with pT2-4 status and positive lymph nodes in the D2 group (59 per cent versus 38 per cent for the D1 group; P = 0.055).

CONCLUSION

No difference was found in overall 5-year survival between D1 and D2 resection. Subgroup analyses suggest that D2 lymphadenectomy may be a better choice in patients with advanced disease and lymph node metastases.

REGISTRATION NUMBER

ISRCTN11154654 (http://www.controlled-trials.com).

A novel biomarker-based analysis reliably predicts nodal metastases in anal carcinoma: preliminary evidence of therapeutic impact

AIM

Routine prophylactic inguinal irradiation in anal cancer may cause significant toxicity associated with overtreatment bias. The aim of this study was to determine the risk of regional node metastases in anal carcinoma by identifying predictive molecular biomarkers.

METHOD

Clinicohistopathological data from 50 pretreatment anal carcinoma biopsies were collected. Immunohistochemical analyses with antibodies against Ki67, p53, epidermal growth factor receptor (EGFR) and YKL-40 were performed. Statistical correlations between biomarkers and clinicopathological features and outcomes were studied. Sentinel lymph node biopsy was performed in a subset of 36 patients.

RESULTS

All patients had undergone synchronous radiochemotherapy; tumour recurrence had developed in 26%, and 16% had died. YKL-40 tumour expression correlated with lymph node metastasis, whereas no inguinal node metastases were found in any of the (14%) patients presenting with a YKL-40/EGFR-negative tumour. YKL-40 expression and node metastasis were both significantly associated with shorter overall and disease-free survival. Tumour grade significantly correlated with disease-free survival only. HIV, tumour histological type, Ki67, p53 and EGFR were not associated with outcome.

CONCLUSION

YKL-40 expression in anal carcinoma is correlated with a poor outcome and can predict lymph node metastases. The combined absence of YKL-40 and EGFR expression in a first biopsy of anal carcinoma reliably selects a subset of patients without inguinal metastases. Such patients could be spared sentinel lymph node biopsy and/or inguinal radiotherapy.

Value of staging squamous cell carcinoma of the anal margin and canal using the sentinel lymph node procedure: an update of the series and a review of the literature

Background:

Inguinal metastases in patients affected by anal cancer are an independent prognostic factor for local failure and overall mortality. Since 2001, sentinel lymph node biopsy was applied in these patients. This original study reports an update of personal and previous published series, which were compared with Literature to value the incidence of inguinal metastases T-stage related and the overall incidence of false negative inguinal metastases at sentinel node.

Methods:

In all, 63 patients diagnosed with anal cancer submitted to inguinal sentinel node. Furthermore a research in the Pub Med database was performed to find papers regarding this technique.

Results:

In our series, detection rate was 98.4%. Inguinal metastases were evidentiated in 13 patients (20.6%). Our median follow-up was 35 months. In our series, no false negative nodes were observed.

Conclusion:

Sentinel node technique in the detection of inguinal metastases in patients affected by anal cancer should be considered as a standard of care. It is indicated for all T stages in order to select patients to be submitted to inguinal radiotherapy, avoiding related morbidity in negative ones. An overall 3.7% rate of false negative must be considered acceptable.

Magnetic air capsule robotic system: proof of concept of a novel approach for painless colonoscopy

BACKGROUND

Despite being considered the most effective method for colorectal cancer diagnosis, colonoscopy take-up as a mass-screening procedure is limited mainly due to invasiveness, patient discomfort, fear of pain, and the need for sedation. In an effort to mitigate some of the disadvantages associated with colonoscopy, this work provides a preliminary assessment of a novel endoscopic device consisting in a softly tethered capsule for painless colonoscopy under robotic magnetic steering.

METHODS

The proposed platform consists of the endoscopic device, a robotic unit, and a control box. In contrast to the traditional insertion method (i.e., pushing from behind), a "front-wheel" propulsion approach is proposed. A compliant tether connecting the device to an external box is used to provide insufflation, passing a flexible operative tool, enabling lens cleaning, and operating the vision module. To assess the diagnostic and treatment ability of the platform, 12 users were asked to find and remove artificially implanted beads as polyp surrogates in an ex vivo model. In vivo testing consisted of a qualitative study of the platform in pigs, focusing on active locomotion, diagnostic and therapeutic capabilities, safety, and usability.

RESULTS

The mean percentage of beads identified by each user during ex vivo trials was 85 ± 11%. All the identified beads were removed successfully using the polypectomy loop. The mean completion time for accomplishing the entire procedure was 678 ± 179 s. No immediate mucosal damage, acute complications such as perforation, or delayed adverse consequences were observed following application of the proposed method in vivo.

CONCLUSIONS

Use of the proposed platform in ex vivo and preliminary animal studies indicates that it is safe and operates effectively in a manner similar to a standard colonoscope. These studies served to demonstrate the platform's added advantages of reduced size, front-wheel drive strategy, and robotic control over locomotion and orientation.

Natural orifice transluminal endoscopic surgery (NOTES) and colorectal cancer?

Surgical techniques and technologies are rapidly evolving. In the field of colorectal surgery the transanal video-assisted approach was introduced by Buess, 30 years ago, with transanal endoscopic microsurgery (TEM). In more recent years different techniques and technologies have been proposed, including natural orifice specimen extraction (NOSE), natural orifice transluminal endoscopic surgery (NOTES) and single-access surgery. Furthermore, a better understanding of the prognostic and risk factors of rectal cancer has allowed TEM to expand its indications to local resection of selected tumours, and more recently there have been proposals for sentinel node biopsy in colon and rectal cancer.

Long-term functional results and quality of life after transanal endoscopic microsurgery

BACKGROUND

Of the few studies that have investigated quality-of-life (QoL) outcomes after transanal endoscopic microsurgery (TEM), the majority have reported only short-term follow-up data. This study assessed long-term clinical and instrumental outcomes (QoL, sexual, urinary and sphincter function) after TEM for extraperitoneal rectal cancer.

METHODS

Preoperative and postoperative anorectal function was assessed in consecutive patients with benign rectal lesions or early rectal cancer, based on clinical scores and anorectal manometry.

RESULTS

Between January 2000 and July 2005, 93 patients undergoing TEM completed the 60-month study protocol. The mean Wexner continence score increased from baseline at 3 months, began to decline within 12 months, and had returned to the preoperative value at 60 months. Urgency was reported by 65·0, 30·0 and 5 per cent of patients at 3, 12 and 60 months respectively (P < 0·050). A significant improvement was noted in various clinical and QoL scores at 12 and 60 months. Postoperative manometry values at 3 months were significantly lower than at baseline (P < 0·050), but had returned to preoperative values at 12 months. Tumour size of 4 cm or above was the only factor that significantly (P = 0·008) affected the rectal sensitivity threshold, the urge to defaecate threshold and the maximum tolerated volume at 3 months after TEM.

CONCLUSION

TEM had no long-term effect on anorectal function or QoL. Lower anal resting pressure at early follow-up was not associated with defaecation problems in patients who were continent before surgery.

[Inguinal hernia repair: an experimental study on mesh migration with the tension-free suturless technique. 10 year follow-up]

AIM

Can the tension-free suturless technique, used in the surgical treatment of inguinal hernia, to be the gold standard for treatment of inguinal hernia?

METHODS

The tension-free suturless technique is often criticized as a fundamental principle: do not have suture. The criticism stems from concern that the mesh can migrate and cause damage to important anatomical structures. We conducted a study on the mobility of prosthesis on 33 patients, by using titanium clips that we have fixed on the meshes corner, X-rays over time, done at last, a follow-up of ten years.

RESULTS

The study shows that the prosthesis moves together with the anatomical space in which there is the forces present in the inguinal canal: gravity, intra-abdominal pressure, reactive force ascending gait. Across thirty-three patients have relapsed in the first six months and two recurrences in ten years, in the reconstitution of the neo-orifice, through which passes the cord. In the remaining patients the mesh were relocated upward and medially (as identified by the clips of the increase of 10-15%).

CONCLUSION

Our study shows that the mesh migrates upwards and medially. Migration is more or less, depending on the patient's age and quality of its tissue. Fix the prosthesis is good practice to secure at the flag on the inguinal ligament leads to two advantages: not to frustrate the principle tension-free, since the fixed prosthesis on one side does not create moments of tension, and prevent the prosthesis returns to the opening road to relapse.

Pancreatitis-associated protein-I and pancreatitis-associated protein-III expression in a rat model of kainic acid-induced seizure

The pancreatitis-associated protein (PAP) family (also known as the regenerating gene (Reg) family) is a group of 16 kDa secretory proteins structurally classified as the calcium dependent-type lectin superfamily. Some PAP family members are expressed in neurons following peripheral nerve injury and traumatic brain injury. To determine whether PAP family members are expressed in non-traumatic brain injury, expressions were analyzed following kainic acid (KA)-induced seizure. PAP-I (also known as Reg2 in rat and RegIII-beta in mouse) and pancreatitis associated protein-III (PAP-III; RegIII-gamma in mouse) messenger ribonucleic acid (mRNA) was transiently expressed in some restricted areas, such as the hippocampus and parahippocampal area; expression was observed immediately at a maximal level 1 day after seizure. Expression disappeared within 3 days after seizure. In situ hybridization (ISH) and immunohistochemistry revealed neuronal PAP-I and PAP-III expression in the hippocampal dentate gyrus, perirhinal and entorhinal cortices, and the posterior cortical nucleus of the amygdala. The number of PAP-III mRNA-positive neurons was significantly greater than PAP-I mRNA-positive neurons. The majority of positive neurons co-localized with c-Jun, but not with glutamic acid decarboxylase (GAD). These results may suggest that PAP-I and PAP-III induction in non-GABAergic neurons would protect neurons against damage following seizure.

Enterovesical fistulas: diagnosis and management

Enterovesical fistula (EVF) is an abnormal communication between the intestine and the bladder. It represents a rare complication of inflammatory or neoplastic disease, and traumatic or iatrogenic injuries. The most common aetiologies are diverticular disease and colorectal carcinoma. Over 75% of affected patients describe pathognomonic features of pneumaturia, faecaluria and recurrent urinary tract infections. The diagnosis of EVF can be challenging, and frequently patients are monitored for months before the condition is recognised and treated effectively. Diagnostic tools include laboratory tests, imaging studies and endoscopic procedures. Although conservative management can be attempted in selected patients, in most cases, the treatment is mainly based on surgical interventions. Recently, the laparoscopic approach to EVF has been shown to be safe and effective. Although it is a rare condition in a general surgery setting, EVF is a challenging condition leading to high morbidity and mortality rates.

A magnetic internal mechanism for precise orientation of the camera in wireless endoluminal applications

BACKGROUND AND STUDY AIMS

The use of magnetic fields to control operative devices has been recently described in endoluminal and transluminal surgical applications. The exponential decrease of magnetic field strength with distance has major implications for precision of the remote control. We aimed to assess the feasibility and functionality of a novel wireless miniaturized mechanism, based on magnetic forces, for precise orientation of the camera.

MATERIALS AND METHODS

A remotely controllable endoscopic capsule was developed as proof of concept. Two intracapsular moveable permanent magnets allow fine positioning, and an externally applied magnetic field permits gross movement and stabilization. Performance was assessed in ex vivo and in vivo bench tests, using porcine upper and lower gastrointestinal tracts.

RESULTS

Fine control of capsule navigation and rotation was achieved in all tests with an external magnet held steadily about 15 cm from the capsule. The camera could be rotated in steps of 1.8 degrees . This was confirmed by ex vivo tests; the mechanism could adjust the capsule view at 40 different locations in a gastrointestinal tract phantom model. Full 360 degrees viewing was possible in the gastric cavity, while the maximal steering in the colon was 45 degrees in total. In vivo, a similar performance was verified, where the mechanism was successfully operated every 5 cm for 40 cm in the colon, visually sweeping from side to side of the lumen; 360 degrees views were obtained in the gastric fundus and body, while antrally the luminal walls prevented full rotation.

CONCLUSIONS

We report the feasibility and effectiveness of the combined use of external static magnetic fields and internal actuation to move small permanent intracapsular magnets to achieve wirelessly controllable and precise camera steering. The concept is applicable to capsule endoscopy as to other instrumentation for laparoscopic, endoluminal, or transluminal procedures.

Robotic versus manual control in magnetic steering of an endoscopic capsule

BACKGROUND AND STUDY AIMS

Capsular endoscopy holds promise for the improved inspection of the gastrointestinal tract. However, this technique is limited by a lack of controlled capsule locomotion. Magnetic steering has been proposed by the main worldwide suppliers of commercial capsular endoscopes and by several research groups. The present study evaluates and discusses how robotics may improve diagnostic outcomes compared with manual magnetic steering of an endoscopic capsule.

MATERIALS AND METHODS

An endoscopic capsule prototype incorporating permanent magnets was deployed in an ex vivo colon segment. An operator controlled the external driving magnet manually or with robotic assistance. The capsule was maneuvered through the colon, visualizing and contacting targets installed on the colon wall. Procedure completion time and number of targets reached were collected for each trial to quantitatively compare manual versus robotic magnetic steering ( T-test analysis with P = 0.01). Then, through a set of in vivo animal trials, the efficacy of both approaches was qualitatively assessed.

RESULTS

In ex vivo conditions, robotic-assisted control was superior to manual control in terms of targets reached (87 % +/- 13 % vs 37 % +/- 14 %). Manual steering demonstrated faster trial completion time (201 +/- 24 seconds vs 423 +/- 48 seconds). Under in vivo conditions, the robotic approach confirmed higher precision of movement and better reliability compared with manual control.

CONCLUSIONS

Robotic control for magnetic steering of a capsular endoscope was demonstrated to be more precise and reliable than manual operation. Validation of the proposed robotic system paves the way for automation of capsular endoscopy and advanced endoscopic techniques.

Laparoscopic-assisted transgastric cholecystectomy and secure endoscopic closure of the transgastric defect in a survival porcine model

BACKGROUND AND STUDY AIMS

Natural orifice transluminal endoscopic surgery holds promise for surgical interventions. Before the feasibility of this technique can be established, however, secure sealing of the transluminal access needs to be thoroughly investigated.

PATIENTS AND METHODS

Following antibiotic prophylaxis and gastric disinfection, nine pigs underwent transgastric cholecystectomy by means of a flexible endoscope with the aid of a transabdominal 5-mm trocar. The gastric wall was punctured and dilated. The gallbladder was retracted with a laparoscopic grasper. The cystic duct and artery were dissected with a flexible monopolar ball electrode. The cystic duct was interrupted with flexible scissors between endoclips. Cholecystectomy was completed and the gallbladder was retrieved through the stomach. The gastric defect was closed using a single modified over-the-scope clip (OTSC) (Ovesco, Tübingen, Germany) and grasping the serosal and muscle layer of the gastric wall. The animals were sacrificed 4 weeks later.

RESULTS

Laparoscopic-assisted transgastric cholecystectomy was successful in all cases without significant perioperative complications. All animals survived without postoperative complications. The mean operating time was 128 minutes (range, 85 - 205 minutes). The gastric defect closure resulted in inversion of the gastric wall layers within an average time of 6.8 +/- 5 minutes. At 4 weeks postoperative, only minimal thin adhesions were observed in the right hypochondrium.

CONCLUSIONS

We found gastric closure using the OTSC to be a reliable tool for closing the transgastric access. Laparoscopic-assisted transgastric cholecystectomy by means of a flexible endoscope was technically feasible, but remains a demanding procedure.

Clinical experience with a new endoscopic over-the-scope clip system for use in the GI tract

BACKGROUND

The newly designed over-the-scope clip (OTSC) seems to overcome several limitations of current clipping system, such as size and opening-closing force, allowing better control of gastric or colonic bleeding and/or deep wall defect or perforation.

AIMS

The aim of this retrospective analysis was to describe the new endoscopic device and evaluate our first clinical experience.

PATIENTS AND METHODS

We treated with the OTSC system 9 patients (range, 58-85 years; 6 men, 3 women) with bleeding and/or deep wall lesions of the GI tract. The OTSC system is composed of an application cap, which is mounted onto the distal tip of the endoscope and a connected releasing mechanism, installed on the handle of the scope. The rotation of the handle allows the release of the clip by a two tube sliding mechanism.

RESULTS

All applications resulted successful, i.e. haemostasis was achieved, and/or wall defects could be closed. No complication was observed that could be ascribed to the clip itself or to the technique.

CONCLUSIONS

The OTSC system is a new endoscopic tool for compression of large tissue areas and its indications are nonvaricose bleedings difficult to control and lesions or perforations of the GI tract. The initial clinical use of this clipping device proved to be efficient and effective.

Pseudospin soliton in the nu=1 bilayer quantum Hall state

We investigate a domain structure of pseudospins, a soliton lattice in the bilayer quantum Hall state at total Landau level filling factor nu = 1, in a tilted magnetic field, where the pseudospin represents the layer degree of freedom. An anomalous peak in the magnetoresistance Rxx appears at the transition point between the commensurate and incommensurate phases. The Rxx at the peak is highly anisotropic for the angle between the in-plain magnetic field B parallel and the current, and indicates a formation of the soliton lattice aligned parallel to B parallel. The temperature dependence of the Rxx peak reveals that the dissipation is caused by thermal fluctuations of pseudospin solitons. We also study a phase diagram of the bilayer nu = 1 system, and the effects of density imbalance between the two layers.

[Mid and long term results in the laparoscopic surgical treatment of gastroesophageal reflux]

AIM

The advent of laparoscopic surgery produced a new interest in the surgical treatment of many benign and functional gastrointestinal diseases; one of the most commonly treated is the gastroesophageal reflux disease (GERD). In this paper the Authors report their 15 years experience in the laparoscopic surgical management of GERD.

METHODS

From October 1991 to June 2005, 581 patients with GERD were treated by a laparoscopic fundoplication with a 360 degrees wrap (524 cases) or with a 270 degrees wrap (29 cases) or with a Collis gastroplasty (28 cases).

RESULTS

The absence of intraoperative mortality, a low conversion to open surgery (0.7%) and a low postoperative morbidity (2.4%) with good clinical and instrumental long term results let the Authors to think that GERD represent an ideal indication for laparoscopic surgery.

CONCLUSIONS

Good results are possible in the laparoscopic management of GERD with a precise selection of patients and with a good open and laparoscopic surgical experience in the management of functional esophageal diseases.