Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States p...Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy(D1). United States and Northern Europe are considered the scientific leaders in medicine and evidencebased procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan(107898 in 2012) than in the entire European Union(81592), or in South Korea(31269) than in the entire United States(21155). For quite a long time evidence-based medicine(EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature(2008-2012) and surgical guidelines. We searched PubMed for papers using the key words "lymphadenectomy or D1 or D2" AND "gastric cancer" from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts' opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.展开更多
BACKGROUND Mediastinal leakage(ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their...BACKGROUND Mediastinal leakage(ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIM To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group(ECCG).METHODS Seven Italian surgical centers(five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies(n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017.Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTS Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8%(95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy(HE), respectively, and doubled(20%) after totally minimally invasive esophagectomy(TMIE)(P = 0.016). No other predictive factors were found. The 30-and 90-d overall mortality rates were 1.4% and 3.2%,respectively; the 30-and 90-d leak-related mortality rates were 5.1% and 10.2%,respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%,respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases.Endoscopic treatment had the lowest mortality rate(6.9%). Removal of the gastric tube with stoma formation was necessary in 8(13.6%) cases.CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group.However, the general and specific(leak-related) mortality rates were low. Early treatment(surgical or endoscopic) of severe leaks is mandatory to limit related mortality.展开更多
文摘Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy(D1). United States and Northern Europe are considered the scientific leaders in medicine and evidencebased procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan(107898 in 2012) than in the entire European Union(81592), or in South Korea(31269) than in the entire United States(21155). For quite a long time evidence-based medicine(EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature(2008-2012) and surgical guidelines. We searched PubMed for papers using the key words "lymphadenectomy or D1 or D2" AND "gastric cancer" from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts' opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.
文摘BACKGROUND Mediastinal leakage(ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIM To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group(ECCG).METHODS Seven Italian surgical centers(five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies(n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017.Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTS Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8%(95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy(HE), respectively, and doubled(20%) after totally minimally invasive esophagectomy(TMIE)(P = 0.016). No other predictive factors were found. The 30-and 90-d overall mortality rates were 1.4% and 3.2%,respectively; the 30-and 90-d leak-related mortality rates were 5.1% and 10.2%,respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%,respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases.Endoscopic treatment had the lowest mortality rate(6.9%). Removal of the gastric tube with stoma formation was necessary in 8(13.6%) cases.CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group.However, the general and specific(leak-related) mortality rates were low. Early treatment(surgical or endoscopic) of severe leaks is mandatory to limit related mortality.
