Transhiatal distal esophagectomy for Siewert type II cardia cancer can be a treatment option in selected patients

BACKGROUND

While surgical treatment of Siewert I and III (S1,S3) Esophagogastric Junction (EGJ) cancer is codified, the efficay of transhiatal procedure with anastomosis in the lower mediastinum for Siewert II (S2) still remains a dibated topic.

METHODS

This is a large multicenter retrospective study. The results of 598 consecutive patients submitted to resection with curative intent from January 2000 to January 2017 were reported. Clinical and oncological outcomes of different procedures performed in S2 tumor were analyzed to investigate the efficacy of transhiatal approach.

RESULTS

The 5-year overall survival rate (OS) was poor (32%) for all Siewert types. The most performed operations in S2 cancer were proximal gastrectomy + transthoracic esophagectomy (TTE or Ivor-Lewis procedure, 60%), total gastrectomy + transhiatal distal esophagectomy with anastomosis in the chest (THE, 24%) and total gastrectomy + transthoracic esophagectomy (TGTTE, 15%). Cardiovascular and pulmonary complications were higher after TTE. On the contrary, surgical complications were significantly higher after THE. Postoperative mortality was similar. The distribution of TNM stages was different in the 3 types of procedures: patients submitted to THE had an earlier stage disease. With this bias, OS after THE was higher than after TTE but the difference was not significant (49.85% vs 28.42%, p = 0.0587).

CONCLUSIONS

Despite a higher rate of postoperative surgical complications, OS after total gastrectomy and transhiatal distal esophagectomy was at least comparable to that of transthoracic approach in less advanced S2 tumors. Therefore, THE with anastomosis in the chest could be a treatmen option in earlier S2 tumors.

Neoadjuvant chemotherapy for gastric cancer. Is it a must or a fake?

AIM

To investigate the neoadjuvant chemotherapy (NAC) effect on the survival of patients with proper stomach cancer submitted to D2 gastrectomy.

METHODS

We proceeded to a review of the literature with PubMed, Embase, ASCO and ESMO meeting abstracts as well as computerized use of the Cochrane Library for randomized controlled trials (RCTs) comparing NAC followed by surgery (NAC + S) with surgery alone (SA) for gastric cancer (GC). The primary outcome was the overall survival rate. Secondary outcomes were the site of the primary tumor, extension of node dissection according to Japanese Gastric Cancer Association (JGCA) performed in both arms, disease-specific (DSS) and disease-free survival (DFS) rates, clinical and pathological response rates and resectability rates after perioperative treatment.

RESULTS

We identified a total of 16 randomized controlled trials comparing NAC + S (n = 1089) with SA (n = 973) published in the period from January 1993 - March 2017. Only 6 of these studies were well-designed, structured trials in which the type of lymph node (LN) dissection performed or at least suggested in the trial protocol was reported. Two out of three of the RCTs with D2 lymphadenectomy performed in almost all cases failed to show survival benefit in the NAC arm. In the third RCT, the survival rate was not even reported, and the primary end points were the clinical outcomes of surgery with and without NAC. In the remaining three RCTs, D2 lymph node dissection was performed in less than 50% of cases or only recommended in the “Study Treatment” protocol without any description in the results of the procedure really perfomed. In one of the two studies, the benefit of NAC was evident only for esophagogastric junction (EGJ) cancers. In the second study, there was no overall survival benefit of NAC. In the last trial, which documented a survival benefit for the NAC arm, the chemotherapy effect was mostly evident for EGJ cancer, and more than one-fourth of patients did not have a proper stomach cancer. Additionally, several patients did not receive resectional surgery. Furthermore, the survival rates of international reference centers that provide adequate surgery for homogeneous stomach cancer patients’ populations are even higher than the survival rates reported after NAC followed by incomplete surgery.

CONCLUSION

NAC for GC has been rapidly introduced in international western guidelines without an evidence-based medicine-related demonstration of its efficacy for a homogeneous population of patients with only stomach tumors submitted to adequate surgery following JGCA guidelines with extended (D2) LN dissection. Additional larger sample-size multicentre RCTs comparing the newer NAC regimens including molecular therapies followed by adequate extended surgery with surgery alone are needed.

EVOLUTION OF THE IEC AND EN STANDARDS FOR INDIVIDUAL MONITORING OF IONISING RADIATION

This article presents the evolution of the International Electrotechnical Commission (IEC) and the European standards for individual monitoring of ionising radiation issued, respectively, from the committees IEC/Sub Committee 45B and European Committee for Electro-technical Standardization/Technical Committee 45B 'Radiation protection instrumentation'. Standards for passive individual photon and beta dosimetry systems as well as those for active individual monitors are discussed. A neutron ambient dose equivalent (rate) meter standard and a technical report concerning the determination of uncertainty in measurement are also covered.

Bariatric surgery improves urinary incontinence but not anorectal function in obese women

BACKGROUND

While the association between obesity and urinary incontinence (UI) in women has been clearly documented, the relationship with anal incontinence (AI) is less well defined; moreover, while bariatric surgery has been shown to improve UI, its effect on AI is still unclear.

METHODS

A total of 32 obese women were studied by means of PFDI-20 and PFIQ-7 questionnaires and anorectal manometry before and after bariatric surgery and compared with 71 non-obese women.

RESULTS

Obese women showed worse overall questionnaire results (OR 5.18 for PFDI-20 and 2.66 for PFIQ-7). Whereas obese women showed worse results for urinary sub-items and a higher urge UI incidence (43.8 vs 18.3 %, p = 0.013), they did not show worsening in colorecto-anal symptoms. Post-operatively, median PFDI-20 total score did not change (24.2 vs 26.6, p = ns), while there was an improvement in urinary score (14.6 vs 8.3, p < 0.001); median PFIQ-7 improved (4.8 vs 0.0, p = 0.044), but while the urinary score improved (2.4 vs 0.0, p = 0.033), the colorecto-anal score did not change significantly. Although after surgery urge UI decreased from 43.8 to 15.6 % (p = 0.029), the incidence of any AI increased from 28.1 to 40.6 % (p = ns) and flatus incontinence increased from 18.8 to 37.5 % (p = ns). Anorectal manometry did not show significant changes after surgery.

CONCLUSIONS

Obese women had worse questionnaire results, but while showing a higher incidence of UI, they did not experience anorectal function worsening. After bariatric surgery, there was a slight improvement in PFD symptoms related to UI, but anorectal function did not change significantly and flatus incontinence increased.

IEC standards for individual monitoring of ionising radiation

This paper presents IEC/SC 45B 'Radiation protection instrumentation' and its standards for individual monitoring of ionising radiation: IEC 61526 Ed. 3 for active personal dosemeters and IEC 62387-1 for passive integrating dosimetry systems. The transposition of these standards as CENELEC (European) standards is also discussed together with the collaboration between IEC/SC 45B and ISO/TC 85/SC 2.