Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer. Surg Endosc. 2009;23:2307-2313. [PMID: 19184202 DOI: 10.1007/s00464-008-0324-z]

Follow-up after curative resection for gastric cancer: Is it time to tailor it?

There is still no consensus on the follow-up frequency and regimen after curative resection for gastric cancer. Moreover, controversy exists regarding the utility of follow-up in improving survival, and the recommendations of experts and societies vary considerably. The main reason to establish surveillance programs is to diagnose tumor recurrence or metachronous cancers early and to thereby provide prompt treatment and prolong survival. In the setting of gastric malignancies, other reasons have been put forth: (1) the detection of adverse effects of a previous surgery, such as malnutrition or digestive sequelae; (2) the collection of data; and (3) the identification of psychological and/or social problems and provision of appropriate support to the patients. No randomized controlled trials on the role of follow-up after curative resection of gastric carcinoma have been published. Herein, the primary retrospective series and systematic reviews on this subject are analyzed and discussed. Furthermore, the guidelines from international and national scientific societies are discussed. Follow-up is recommended by the majority of institutions; however, there is no real evidence that follow-up can improve long-term survival rates. Several studies have demonstrated that it is possible to stratify patients submitted to curative gastrectomy into different classes according to the risk of recurrence. Furthermore, promising studies have identified several molecular markers that are related to the risk of relapse and to prognosis. Based on these premises, a promising strategy will be to tailor follow-up in relation to the patient and tumor characteristics, molecular marker status, and individual risk of recurrence.

Follow-up: the evidence

There is currently no consensus on the best strategy for the follow-up of patients who have undergone surgical treatment with curative intent for gastric cancer. The wide variation in recommendations for surveillance among international experts and hospital schedules clearly reflects a lack of an established body of evidence on this subject. Consequently, most of the international guidelines aimed at early detection of disease recurrence gloss over details concerning the mode, duration, and intensity of surveillance since they cannot be based on an acceptable grade of recommendation. Very few report anything other than the detection of recurrences or death as the primary endpoints, and, given the poor survival of patients with recurrent gastric cancer, the prognostic effect of early detection seems doubtful. In recent years, an increasing focus on evidence-based medicine, which has coincided with a growing concern about costs and efficiency in medicine, has caused a reevaluation of most surveillance practices. In this paper, we review and discuss the current body of evidence and follow-up practices after curative resection of gastric cancer.

Re-laparoscopy in the diagnosis and treatment of postoperative complications following laparoscopic colorectal surgery

BACKGROUND

Laparoscopic colorectal surgery has increasingly become the standard of care in the management of both benign and malignant colorectal disease. We herein describe our experience with laparoscopy in the management of complications following laparoscopic colorectal surgery.

METHODS

Between November 2010 and July 2012, data were prospectively collected for all patients requiring surgical intervention for colorectal cancer. This was performed by a full-time colorectal cancer data manager.

RESULTS

A total of 203 patients had surgery for colorectal cancer during this period, 154 (75.9%) of which were performed laparoscopically and 49 (24.1%) performed by open surgery. Ten patients (4.9%) underwent surgery for complications of which 7 were following laparoscopic surgery. Two of these 7 patients had an exploratory laparotomy due to abdominal distension and haemodynamic instability. Laparoscopic surgical intervention was successful in diagnosing and treating the remaining 5 patients. Three of these patients developed small bowel obstruction which was managed by re-laparoscopy while in 2 patients there was a significant suspicion of an anastomotic leakage despite appropriate diagnostic imaging which was out ruled at laparoscopy.

CONCLUSIONS

Laparoscopy can frequently be used to diagnose and treat complications following laparoscopic colorectal surgery. This is another benefit associated with laparoscopic colorectal surgery which is rarely described and allows the benefits associated with the laparoscopic approach to be maintained.

Risk factors of peritoneal recurrence in eso-gastric signet ring cell adenocarcinoma: results of a multicentre retrospective study

INTRODUCTION

The poor prognosis of signet ring cell (SRC) eso-gastric adenocarcinoma (EGA) might be explained by its great affinity for the peritoneum. The aim of this study was to identify predictors of peritoneal carcinomatosis recurrence (PCR) after curative surgery and hence identify high risk patients.

METHODS

A retrospective national survey was conducted over 19 French surgical centers between 1997 and 2010. Patients with non-metastatic disease who benefited from curative surgery without postoperative death were included. Event-free patients who did not reach the time point of 24 months were excluded.

RESULTS

In a cohort of 3010 patients, 1050 were SRC EGA and 424 patients met the selection criteria. The tumor location was mainly gastric (68.9%) and a total gastrectomy was performed in 218 patients (51.4%). Chemoradiotherapy or chemotherapy alone was given preoperatively to 71 (16.7%) and postoperatively to 150 (35.4%) patients. After a median follow-up of 54 months, recurrence was diagnosed in 214 patients (50.5%) within a mean delay of 17 ± 10.7 months. PCR was diagnosed in 81 patients (19.1%). In multivariable analysis, four factors were identified as predictors of PCR: linitis plastica (p < 0.001; OR = 4.83), tumor invasion of/or through the peritoneal serosa (p = 0.022; OR = 1.58), lymph node involvement (p = 0.005; OR = 1.7) and tumors of gastric origin (p = 0.026; OR = 2.36), with PCR rates of 55%, 26%, 23% and 22%, respectively.

CONCLUSION

Identification of strong predictors for PCR among this large series of SRC EGA patients helps to identify subgroups of patients that may benefit from specific therapeutic strategies such as prophylactic hyperthermic intraperitoneal chemotherapy.