Selection of locally advanced gastric carcinoma by preoperative staging laparoscopy

BACKGROUND

The present study is a prospective evaluation of immediate preoperative laparoscopy compared to ultrasound/computed tomography (US/CT) staging for gastric cancer in a series of 100 patients observed at two major Italian hospitals from April 1995 through September 1996.

METHODS

After a complete preoperative work-up all c-M0 patients underwent laparoscopy immediately prior to an eventual surgical exploration. pTNM was considered as the gold standard for the evaluation of the results.

RESULTS

Laparoscopy detected 21 unsuspected M+ cases out of 100. As regards locally advanced tumors, laparoscopy showed a sensibility of 69.7% for T3 and 89.6% for T4, significantly higher than US/CT staging (23.2% and 48.3%, respectively; p < 0.02). In this series laparoscopic staging altered clinical staging in 58% of cases.

CONCLUSIONS

This procedure plays two crucial roles in the preoperative evaluation of advanced gastric cancer: It makes it possible to avoid unnecessary surgical exploration in M+ cases and, to date, it represents the most reliable and economic tool for the selection of locally advanced tumors in the light of neoadjuvant treatment.

Immediately preoperative laparoscopic staging for gastric cancer

BACKGROUND

This ongoing study is a prospective evaluation of immediately preoperative video-laparoscopy compared to ultrasound/computed tomography (US/CT) staging for gastric cancer. An analysis of the first 70 cases is reported.

METHODS

TNM staging is used to compare the US/CT findings and the laparoscopic findings with the gold standard for pathologic findings in resected specimens.

RESULTS

In our series 47 out of 70 cases are locally advanced cancers (stages III and IV): In this subset the predictive value of laparoscopic staging is 86.4%. Laparoscopy shows an overall staging accuracy of 68.6%, compared to 32.8% for US/CT. The difference is statistically significant as regards the T factor (T3: 69.7% vs 12. 1%, p < 0.002; T4: 84.2% vs 42.1%, p < 0.05); as regards the M factor, laparoscopy appears the most specific method for detecting peritoneal seeding.

CONCLUSIONS

This procedure plays a crucial role in determining the resectability of the tumor, thus avoiding unnecessary laparotomies. A meticulous staging becomes mandatory when applying modem treatment options (e.g., neo-adjuvant chemotherapy) to locally advanced cancers; in this context the use of staging laparoscopy will have a relevant impact on future treatment.

Double stapling technique for low colorectal anastomoses after anterior resection for rectal cancer

A group of 26 patients submitted to anterior colorectal resections for carcinoma is reported: all of the anastomoses were performed using the so-called "Double Stapling Technique" (DST), first introduced by Knight and Griffen in 1980. The technical results are discussed, in the light of recent reports. "DST" offers clear advantages, over both traditional hand-stitched and end-to-end stapled anastomosis. This procedure is considered cost-effective and time-saving and offers lower intra-operative risks. It permits optimal sterility of the operative field and lower risk of neoplastic spreading. Furthermore it eliminates some technical problems such as the preparation of the distal purse-string suture and the inequality between the two intestinal stumps to be anastomosed.

Extent of axillary dissection preceding irradiation for carcinoma of the breast

"Limited" surgery and irradiation have become more popular therapeutic options for women with stage I and stage II breast cancer, and surgical attention to the axilla is part of this approach. To understand the limitations of whatever axillary procedure is recommended, we undertook a retrospective analysis of the records of 277 women who had undergone radical or modified radical mastectomy. Of this group, 127 had metastases to at least one axillary or interpectoral lymph node. Skip metastases occurred in 13% of women with positive nodes; two women (1.6%) had metastases only to level III nodes, and two women had metastases only to interpectoral nodes. The extremely uncommon occurrence of metastases to level III alone or to interpectoral nodes alone, but the greater likelihood of skip metastases to level II, argues for both level I and level II axillary dissection preceding irradiation for patients with invasive carcinomas of the breast.