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483. Laparoscopic Esophageal Resection with Intrathoracic Anastomosis - Functional and Safe
ABSTRACTS Conclusions: Cox-2 seems to have a important role in determining survival in patients affected by relapsed gastric cancer. It may represent an important prognostic factor in particular for patients with peritoneal involvement. 477. Prognostic Role of Vascular Endothelial Growth Factor and Cyclooxygenase- 2 Protein Expressions in Intestinal Type Gastric Adenocarcinoma A. Tamburini1, S. Pozzi1, E. Orsenigo1, L. Albarello2, E. Mazza3, C. Staudacher1 1 University Vita-Salute San Raffaele, Gastrointestinal Surgery, Milan, Italy 2 University Vita-Salute San Raffaele, Pathology, Milan, Italy 3 San Raffaele Hospital, Medical Oncology, Milan, Italy Background: Despite great advances in diagnostic and surgical techniques and perioperative treatments have been made, prognosis of gastric cancer is still hardly definable. At the present the concept of gastric carcinogenesis, while confirming the Correa model, draws attention to growth factors (gastrin, Hepatic growth factor, TGFa, VEGF) that seems to be responsible for excessive proliferation of tumor cells. Moreover Cox 2 * PG2 system plays a role in cell proliferation, apoptosis and angiogenesis and this system is believed to operate in gastric mucosa after HP infection. The aim of our study was to analyze the prognostic role of VEGF and Cox-2 expression in patients with gastric intestinal gastric adenocarcinoma. We decided to select only intestinal type for his peculiar pathogenetic features and clinical evolution, that make it remarkably different from diffuse type. Methods: A cohort of 116 patients, curatively resected for gastric cancer were included in our study. Only intestinal type gastric cancer were enrolled. Patients with metastatic disease, previous malignancies, in a chronic therapy with NSAIDs or who underwent neoadjuvant treatment ~ and Cox-2Os ~ expressions were were excluded from the study. VEGFOs immunohistochemically determined on surgical samples using monoclonal antibodies. Using a semiquantitative method positivity of samples was assessed according to percentage of positive cells with a cut off of 5% for Cox-2 and of 70% for VEGF. Moreover, for VEGF an additional score was assessed according to intensity of staining. Results: No significance was found for overall (OS) and disease free (DFS) survival considering percentage of expression of Cox-2 in whole patients cohort. However, selecting only nodes negative (N0) patients, a statistically significant association was found between Cox-2 expression and OS and DFS respectively Considering VEGF expression, the intensity of staining, rather than percentage of expression area resulted significantly associated to OS and a clear trend is observed for DFS.When we considered the simultaneous expression of Cox-2 and VEGF we found a statistical correlation with OS (p¼0.050). A stronger correlation was found when N+ cases were selected. Conclusions: VEGF and Cox-2 may have a prognostic value in patients affected by intestinal type gastric cancer, and can help in identifying high risk patients in order to plan targeted therapies that may to reduce the relapse risk and improve prognosis 478. Total Gastrectomy with Pancreatoduodenectomy for Advanced Gastric Cancer O.I. Kit1, V.F. Kasatkin1, A.U. Maximov1, V.S. Trifanov1 1 Rostov Scientific Research Institute of Oncology, Rostov on Don, Russian Federation Background: Treatment of gastric cancer, with tumor invading the pancreatic head or duodenum stays an open problem. This situation sounds dire if complete tumor clearance could be achieved by combination of pancreatoduodenectomy with total gastrectomy. Some favourable results after this procedure have been reported recently. Material and methods: Between 1983 and 2010 117 patients with locally advanced gastic cancer with infiltration of pancreatic head or duodenum were operated in Rostov research oncological institute, they were the
869 subjects of our study. Clinical, operative data, morbidity and mortality rates were collected and analyzed. Results: 22 patients underwent total gastrectomy with pancreatoduodenectomy. Median operating time was 7,5h. The postoperative morbidity rate was 73,3%. Operation related death was 9%. The overall 1-year survival rate was 27,3%. The 3 and 5 year survival rate was equal to 9,09%. Conclusion: If R0 resection for gastric cancer can be achieved by pancreatoduodenectomy combined with total gastrectomy, this operation should be performed for patients with gastric cancer invading pancreatic head or duodenum. 481. Predicting Blood Transfusion Requirements in Patients Undergoing Oesophagectomy C. Schneider1, A. Boddy1, J. Fukuta1, W. Groom1, C. Streets1 1 Bristol Royal Infirmary, Division of Surgery, Bristol, United Kingdom Introduction: Oesophagectomy remains a procedure associated with major morbidity and a significant risk of mortality. The need for perioperative, allogenic blood transfusions has been reported to have a negative impact on patient outcome following resection of oesophageal cancer. Recently minimal invasive Oesophagectomy (MIO, total and laparoscopic assisted) has been increasingly performed in England. This is mirrored by the practice in our unit, which is a regional center for oesophago-gastric surgery. The aim of this study was to determine predictors for perioperative transfusion requirements in this setting. Methods: Consecutive patients undergoing Oesophagectomy at our unit between January 2010 and December 2011 were identified retrospectively. Patients were divided in two groups depending on perioperative transfusion requirements (TX - transfusion group; NTX - no transfusion group). Multivariate binary logistic regression analysis was performed to determine which factors independently predicted blood transfusion requirements during index admission. Results: Out of 96 patients undergoing Oesophagectomy 9 had to be excluded due to incomplete data. The mean pre-operative Hb for the TX group was significantly lower than in the NTX group (12.0 vs. 12.9, p¼0.026, t-test). The estimated operative blood loss (EBL) was significantly greater in the TX group compared to the NTX group (p¼0.008, Mann Whitney). Factors analysed by regression analysis included EBL, pre-operative Hb, significant complications (anastomotic leak, chyle leak or return to theatre or ITU), patient age and type of Oesophagectomy (Ivor-Lewis-, laparoscopic assisted-, minimal invasive Oesophagectomy). Pre-operative Hb (OR 0.57, 95% CI 0.40-0.81) and suffering a significant complication (OR 4.32, 95% CI 1.38-13.50) were independent predictors for receiving a blood transfusion at any point during hospital admission. When only blood transfusions within 24 hours of surgery were considered, the operative estimated blood loss was the only significant variable. Type of Oesophagectomy and patient age were not independently significant predictors of blood transfusion. Analyses including ROC and Loess fit line fitting were employed to determine the optimal preoperative Hb, which was estimated at Hb>12-13. Conclusion: Preoperative haemoglobin concentration and significant postoperative complications but not type of surgery, were independent predictors of transfusion requirements at any point during index admission. Anaemia in patients requiring Oesophagectomy, may be amenable to optimisation. Other specialties have reported good results with preoperative intravenous iron therapy in patients with anaemia. We are planning to reevaluate our transfusion practice after changes in the preoperative optimisation of anaemic patients have been implemented. 483. Laparoscopic Esophageal Resection with Intrathoracic Anastomosis - Functional and Safe F. van Workum1, J. Franken2, F. Polat2, F. van den Wildenberg2, C. Rosman2 1 Academisch Ziekenhuis Nijmegen, Surgery, Nijmegen, The Netherlands 2 Canisius-Wilhelmina Ziekenhuis, Surgery, Nijmegen, The Netherlands
870
ABSTRACTS
Background: The introduction of neoadjuvant chemoradiation therapy, centralization and minimal invasive esophagectomy has reduced peri-operative mortality and morbidity to an acceptable level. However, functional results after esophageal resection remain poor, with reported rates of esophageal stenosis and dilatation of 40% and frequent recurrent laryngeal nerve damage. Aim: To describe the functional results after laparoscopic esophageal resection with intrathoracic anastomosis. Methods: From January 2011 until March 2012, 27 consecutive patients underwent laparoscopic and thoracoscopic esophageal resection with gastric tube reconstruction and a stapled, intrathoracic end-to-side anastomosis in a large teaching hospital. Demographic, clinical and functional parameters were collected prospectively. Results: Mean age was 65 and 85% of patients were male. Ninety-six percent received neoadjuvant chemoradiation therapy. None of the 27 patients developed an esophageal stenosis, there were no dilatations and no recurrent laryngeal nerve damage was observed. In all patients, a radical resection was achieved. In the first 3 months, 4 out of 9 patients developed an anastomotic leakage, all requiring re-operation. One patient died. After revising the technique of anastomosis from double stapling using the Orvil into single stapling using a 28mm EEA stapler with an omental wrap in March 2011, no further patients developed an anastomotic leakage, the re-operation rate was 11%, and there was no in hospital mortality. Conclusions: Laparo-thoracoscopic esophageal resection with gastric tube reconstruction and stapled intrathoracic end-to-side anastomosis with omental wrap is a safe technique that improves functional outcome. 484. Clinicopathologic Features, Treatment Patterns and Outcome of Marjolin’s Ulcer in a Tertiary Care Cancer Centre P. Ramanathan1, S.V.S. Deo1, N.K. Shukla1, T.S. Subi1, D. Jha1 1 All India Institute of Medical Sciences, Surgical Oncology, Delhi, India Aim: To study the clinicopathologic features,treament and outcome of Marjolin’s ulcer in a tertiary care cancer centre. Materials and methods: Retrospective analysis of database in Department of Surgical Oncology, AIIMS was done . Thirty one histopathologically Marjolin’s ulcer proven cases were identified and clinopathologic features, treatment patterns and disease relapse studied in detail from 1995 to 2011. Results: Total of 31 cases of Marjolin’s ulcer was identified out of 7000 cases with a prevalence of 0.44%. It contributes to 13.65% of all squamous cell carcinoma of skin cancers. Median age was 40.41 yrs and male versus female ratio was 22:9. Burns [23cases], trauma[5], eczema [2],leprosy[1] were the predisposing conditions leading to Marjoiln’s ulcer. Median time to develop marjolin’s ulcer from initial insult was 20.35yrs. Majority involved the extremities(24/31) and 15 presented with locally advanced stage . Among extremity marjolin group 10 patients underwent limb salvage surgery, 14 had amputations and 9 had therapeutic regional
lymph node dissection for clinically positive nodes. During follow-up 11 patients had relapse of disease(Local 3, Regional 8). Finally 17/31 (54%) had nodal involvement. Conclusion: In our experience Marjolin’s ulcer constituted 13.65% of SCC skin. Contrary to the literature more than 50% had regional nodal involvement and 45% required amputations showing delayed clinical presentation and aggressive disease pattern. However majority of these patients can be cured with a radical surgical approach including lymphadenectomy. 485. R0 Resection in Gastric Cancer - a Different Path in the Elderly? D. D’Ugo1, A. Biondi1, M. Degiuli2, R. Persiani1, F.C.M. Cananzi1, A. Tufo1, F. D’Angelo1, F. Santullo1, F. Sicoli1, G. Doglietto1 1 Catholic University of Sacred Heart, Surgery, Roma, Italy 2 San Giovanni Battista Hospital, Surgery, Turin, Italy Background: The aim of this study was to evaluate the possibility of a different path to achieve R0 resection in patients > 70-years old, affected by resectable gastric cancer. Materials and methods: This is a multicentric retrospective study based on an analysis of 1465 patients with gastric adenocarcinoma who underwent surgery with curative intent between January 1980 and December 2009. Patients were divided into two age groups (<70 vs. >70 years) and were evaluated with respect to postoperative morbidity and mortality and long term survival. Results: Postoperative morbidity and mortality in elderly and non elderly groups were 24.8% vs 20.6% and 2.6% vs 3.7%, respectively (p¼ns). In patients<70 years at multivariate analysis multivisceral resection (HR: 2.243, 95%CI 1.487-3.383, p<0.001) was an independent predictor of surgical complications and total gastrectomy resulted in higher rate of medical complications (HR: 1.671, 95%CI 1.049-2.662, p¼0.031). In elderly group, multivisceral resection was independently associated with surgical complications (HR: 1.988, 95%CI 1.124-3.516, p¼0.018) and total gastrectomy with non-surgical complications (HR: 2.007, 95%CI 1.165-3.459, p¼0.012) and higher postoperative mortality (HR: 4.319, 95%CI 1.571-11.873; p¼0.005); D1 lymph node dissection was predictive of a lower postoperative mortality rate (HR: 0.219, 95% CI 0.080-0.603; p¼0.003). 5-years overall survival rates significantly differed in young and elderly patients (58.9% vs 38.9%) whilst 5-yrs cancer related survival (67.3% vs 63.4% p¼ns) did not show significant difference between the young and elderly groups. Conclusions: On the basis of our data and the results published in the recent literature, it may be definitely stated that age should not be a factor in the selection of treatment for gastric cancer patients. Curative surgery can be performed as safely in elderly patients as in younger patients, with comparable postoperative results and long term survival rates, even though the life expectancy of elderly patients is shorter. To what extent these patients might benefit from multimodal therapeutic protocols, remains controversial and should be investigated in further studies.
This table relates to abstract 485: R0 Resection in Gastric Cancer - a Different Path in the Elderly?
Sex ASA classification Tumor location
Lauren classification Tumor size
Female Male 1-2 3-4 Upper Third Medium Third Lower Third Linitis Plastica Gastric Stump Intestinal type Diffuse type Mean (cm)
70 years (n¼927)
>70 years (n¼538)
p
371 (40%) 556 (60%) 799 (86.2%) 128 (13.8%) 124 (13.4%) 262 (28.3%) 463 (50%) 27 (2.9%) 50 (5.4%) 412 (50.5%) 404 (49.5%) 4.1 + 2.7
236 (43.9%) 302 (56.1%) 430 (80%) 108 (20%) 68 (12.7%) 165 (30.7%) 248 (46.2%) 16 (3%) 40 (7.4%) 299 (63.5%) 172 (36.5%) 4.5 + 2.9
ns* 0.002 ns*
<0.001* 0.009+
869 subjects of our study. Clinical, operative data, morbidity and mortality rates were collected and analyzed. Results: 22 patients underwent total gastrectomy with pancreatoduodenectomy. Median operating time was 7,5h. The postoperative morbidity rate was 73,3%. Operation related death was 9%. The overall 1-year survival rate was 27,3%. The 3 and 5 year survival rate was equal to 9,09%. Conclusion: If R0 resection for gastric cancer can be achieved by pancreatoduodenectomy combined with total gastrectomy, this operation should be performed for patients with gastric cancer invading pancreatic head or duodenum. 481. Predicting Blood Transfusion Requirements in Patients Undergoing Oesophagectomy C. Schneider1, A. Boddy1, J. Fukuta1, W. Groom1, C. Streets1 1 Bristol Royal Infirmary, Division of Surgery, Bristol, United Kingdom Introduction: Oesophagectomy remains a procedure associated with major morbidity and a significant risk of mortality. The need for perioperative, allogenic blood transfusions has been reported to have a negative impact on patient outcome following resection of oesophageal cancer. Recently minimal invasive Oesophagectomy (MIO, total and laparoscopic assisted) has been increasingly performed in England. This is mirrored by the practice in our unit, which is a regional center for oesophago-gastric surgery. The aim of this study was to determine predictors for perioperative transfusion requirements in this setting. Methods: Consecutive patients undergoing Oesophagectomy at our unit between January 2010 and December 2011 were identified retrospectively. Patients were divided in two groups depending on perioperative transfusion requirements (TX - transfusion group; NTX - no transfusion group). Multivariate binary logistic regression analysis was performed to determine which factors independently predicted blood transfusion requirements during index admission. Results: Out of 96 patients undergoing Oesophagectomy 9 had to be excluded due to incomplete data. The mean pre-operative Hb for the TX group was significantly lower than in the NTX group (12.0 vs. 12.9, p¼0.026, t-test). The estimated operative blood loss (EBL) was significantly greater in the TX group compared to the NTX group (p¼0.008, Mann Whitney). Factors analysed by regression analysis included EBL, pre-operative Hb, significant complications (anastomotic leak, chyle leak or return to theatre or ITU), patient age and type of Oesophagectomy (Ivor-Lewis-, laparoscopic assisted-, minimal invasive Oesophagectomy). Pre-operative Hb (OR 0.57, 95% CI 0.40-0.81) and suffering a significant complication (OR 4.32, 95% CI 1.38-13.50) were independent predictors for receiving a blood transfusion at any point during hospital admission. When only blood transfusions within 24 hours of surgery were considered, the operative estimated blood loss was the only significant variable. Type of Oesophagectomy and patient age were not independently significant predictors of blood transfusion. Analyses including ROC and Loess fit line fitting were employed to determine the optimal preoperative Hb, which was estimated at Hb>12-13. Conclusion: Preoperative haemoglobin concentration and significant postoperative complications but not type of surgery, were independent predictors of transfusion requirements at any point during index admission. Anaemia in patients requiring Oesophagectomy, may be amenable to optimisation. Other specialties have reported good results with preoperative intravenous iron therapy in patients with anaemia. We are planning to reevaluate our transfusion practice after changes in the preoperative optimisation of anaemic patients have been implemented. 483. Laparoscopic Esophageal Resection with Intrathoracic Anastomosis - Functional and Safe F. van Workum1, J. Franken2, F. Polat2, F. van den Wildenberg2, C. Rosman2 1 Academisch Ziekenhuis Nijmegen, Surgery, Nijmegen, The Netherlands 2 Canisius-Wilhelmina Ziekenhuis, Surgery, Nijmegen, The Netherlands
870
ABSTRACTS
Background: The introduction of neoadjuvant chemoradiation therapy, centralization and minimal invasive esophagectomy has reduced peri-operative mortality and morbidity to an acceptable level. However, functional results after esophageal resection remain poor, with reported rates of esophageal stenosis and dilatation of 40% and frequent recurrent laryngeal nerve damage. Aim: To describe the functional results after laparoscopic esophageal resection with intrathoracic anastomosis. Methods: From January 2011 until March 2012, 27 consecutive patients underwent laparoscopic and thoracoscopic esophageal resection with gastric tube reconstruction and a stapled, intrathoracic end-to-side anastomosis in a large teaching hospital. Demographic, clinical and functional parameters were collected prospectively. Results: Mean age was 65 and 85% of patients were male. Ninety-six percent received neoadjuvant chemoradiation therapy. None of the 27 patients developed an esophageal stenosis, there were no dilatations and no recurrent laryngeal nerve damage was observed. In all patients, a radical resection was achieved. In the first 3 months, 4 out of 9 patients developed an anastomotic leakage, all requiring re-operation. One patient died. After revising the technique of anastomosis from double stapling using the Orvil into single stapling using a 28mm EEA stapler with an omental wrap in March 2011, no further patients developed an anastomotic leakage, the re-operation rate was 11%, and there was no in hospital mortality. Conclusions: Laparo-thoracoscopic esophageal resection with gastric tube reconstruction and stapled intrathoracic end-to-side anastomosis with omental wrap is a safe technique that improves functional outcome. 484. Clinicopathologic Features, Treatment Patterns and Outcome of Marjolin’s Ulcer in a Tertiary Care Cancer Centre P. Ramanathan1, S.V.S. Deo1, N.K. Shukla1, T.S. Subi1, D. Jha1 1 All India Institute of Medical Sciences, Surgical Oncology, Delhi, India Aim: To study the clinicopathologic features,treament and outcome of Marjolin’s ulcer in a tertiary care cancer centre. Materials and methods: Retrospective analysis of database in Department of Surgical Oncology, AIIMS was done . Thirty one histopathologically Marjolin’s ulcer proven cases were identified and clinopathologic features, treatment patterns and disease relapse studied in detail from 1995 to 2011. Results: Total of 31 cases of Marjolin’s ulcer was identified out of 7000 cases with a prevalence of 0.44%. It contributes to 13.65% of all squamous cell carcinoma of skin cancers. Median age was 40.41 yrs and male versus female ratio was 22:9. Burns [23cases], trauma[5], eczema [2],leprosy[1] were the predisposing conditions leading to Marjoiln’s ulcer. Median time to develop marjolin’s ulcer from initial insult was 20.35yrs. Majority involved the extremities(24/31) and 15 presented with locally advanced stage . Among extremity marjolin group 10 patients underwent limb salvage surgery, 14 had amputations and 9 had therapeutic regional
lymph node dissection for clinically positive nodes. During follow-up 11 patients had relapse of disease(Local 3, Regional 8). Finally 17/31 (54%) had nodal involvement. Conclusion: In our experience Marjolin’s ulcer constituted 13.65% of SCC skin. Contrary to the literature more than 50% had regional nodal involvement and 45% required amputations showing delayed clinical presentation and aggressive disease pattern. However majority of these patients can be cured with a radical surgical approach including lymphadenectomy. 485. R0 Resection in Gastric Cancer - a Different Path in the Elderly? D. D’Ugo1, A. Biondi1, M. Degiuli2, R. Persiani1, F.C.M. Cananzi1, A. Tufo1, F. D’Angelo1, F. Santullo1, F. Sicoli1, G. Doglietto1 1 Catholic University of Sacred Heart, Surgery, Roma, Italy 2 San Giovanni Battista Hospital, Surgery, Turin, Italy Background: The aim of this study was to evaluate the possibility of a different path to achieve R0 resection in patients > 70-years old, affected by resectable gastric cancer. Materials and methods: This is a multicentric retrospective study based on an analysis of 1465 patients with gastric adenocarcinoma who underwent surgery with curative intent between January 1980 and December 2009. Patients were divided into two age groups (<70 vs. >70 years) and were evaluated with respect to postoperative morbidity and mortality and long term survival. Results: Postoperative morbidity and mortality in elderly and non elderly groups were 24.8% vs 20.6% and 2.6% vs 3.7%, respectively (p¼ns). In patients<70 years at multivariate analysis multivisceral resection (HR: 2.243, 95%CI 1.487-3.383, p<0.001) was an independent predictor of surgical complications and total gastrectomy resulted in higher rate of medical complications (HR: 1.671, 95%CI 1.049-2.662, p¼0.031). In elderly group, multivisceral resection was independently associated with surgical complications (HR: 1.988, 95%CI 1.124-3.516, p¼0.018) and total gastrectomy with non-surgical complications (HR: 2.007, 95%CI 1.165-3.459, p¼0.012) and higher postoperative mortality (HR: 4.319, 95%CI 1.571-11.873; p¼0.005); D1 lymph node dissection was predictive of a lower postoperative mortality rate (HR: 0.219, 95% CI 0.080-0.603; p¼0.003). 5-years overall survival rates significantly differed in young and elderly patients (58.9% vs 38.9%) whilst 5-yrs cancer related survival (67.3% vs 63.4% p¼ns) did not show significant difference between the young and elderly groups. Conclusions: On the basis of our data and the results published in the recent literature, it may be definitely stated that age should not be a factor in the selection of treatment for gastric cancer patients. Curative surgery can be performed as safely in elderly patients as in younger patients, with comparable postoperative results and long term survival rates, even though the life expectancy of elderly patients is shorter. To what extent these patients might benefit from multimodal therapeutic protocols, remains controversial and should be investigated in further studies.
This table relates to abstract 485: R0 Resection in Gastric Cancer - a Different Path in the Elderly?
Sex ASA classification Tumor location
Lauren classification Tumor size
Female Male 1-2 3-4 Upper Third Medium Third Lower Third Linitis Plastica Gastric Stump Intestinal type Diffuse type Mean (cm)
70 years (n¼927)
>70 years (n¼538)
p
371 (40%) 556 (60%) 799 (86.2%) 128 (13.8%) 124 (13.4%) 262 (28.3%) 463 (50%) 27 (2.9%) 50 (5.4%) 412 (50.5%) 404 (49.5%) 4.1 + 2.7
236 (43.9%) 302 (56.1%) 430 (80%) 108 (20%) 68 (12.7%) 165 (30.7%) 248 (46.2%) 16 (3%) 40 (7.4%) 299 (63.5%) 172 (36.5%) 4.5 + 2.9
ns* 0.002 ns*
<0.001* 0.009+