Looking for a strategy in treating peritoneal gastric cancer carcinomatosis: an Italian multicenter Gastric Cancer Research group’s analysis

Background The present study provides a snapshot of Italian patients with peritoneal metastasis from gastric cancer treated by surgery in Italian centers belonging to the Italian Research Group on Gastric Cancer. Prognostic factors affecting survival in such cohort of patients were evaluated with the final aim to identify patients who may benefit from radical intent surgery. Methods It is a multicentric retrospective study based on a prospectively collected database including demographics, clinical, surgical, pathological, and follow-up data of patients with gastric cancer and synchronous macroscopic peritoneal metastases. Patients were surgically treated from January 2005 to January 2017. We focused on patients with macroscopic peritoneal carcinomatosis (PC) treated with upfront surgery in order to provide homogeneous evidences. Results Our results show that patients with peritoneal carcinomatosis cannot be considered all lost. Strictly selected cases (R0/R1 and P1 patients) could benefit from an aggressive surgical approach performing an extended lymphadenectomy and HIPEC treatment. Conclusion The main result of the study is that GC patients with limited peritoneal involvement can have a survival benefit from a surgery with “radical oncological intent”, that means extended lymphadenectomy and R0 resection. The retrospective nature of this study is an important bias, and for this reason, we have started a prospective multicentric study including Italian stage IV patients that hopefully will give us more answers.

The white test for intraoperative screening of bile leakage: a potential trigger factor for acute pancreatitis after liver resection—a case series

Background Acute pancreatitis after liver resection is a rare but serious complication, and few cases have been described in the literature. Extended lymphadenectomy, and long ischemia due to the Pringle maneuver could be responsible of post-liver resection acute pancreatitis, but the exact causes of AP after hepatectomy remain unclear. Cases presentation We report here three cases of AP after hepatectomy and we strongly hypothesize that this is due to the bile leakage white test. 502 hepatectomy were performed at our center and 3 patients (0.6%) experienced acute pancreatitis after LR and all of these three patients underwent the white test at the end of the liver resection. None underwent additionally lymphadenectomy to the liver resection. All patient had a white-test during the liver surgery. We identified distal implantation of the cystic duct in these three patients as a potential cause for acute pancreatitis. Conclusion The white test is useful for detection of bile leakage after liver resection, but we do not recommend a systematic use after LR, because severe acute pancreatitis can be lethal for the patient, especially in case of distal cystic implantation which may facilitate reflux in the main pancreatic duct.

723 TWO- VS. THREE-FIELD LYMPHADENECTOMY FOR ESOPHAGEAL CANCER. A SYSTEMATIC REVIEW AND META-ANALYSIS OF SHORT- AND LONG-TERM OUTCOMES.

Nowadays, there is still no consensus about the benefits of adding neck lymphadenectomy to the traditional two-fields esophagectomy. An extended lymphadenectomy could potentially increase operation time and the risks for postoperative complications. However, extended lymphadenectomy allows resection of cervical nodes at risk for metastases, potentially increasing long-term survival rates. This study aims to estimate whether cervical prophylactic lymphadenectomy for esophageal cancer influences short- and long-term outcomes through a systematic review of literature and meta-analysis. Methods A systematic review was conducted in PubMed, Embase, Cochrane Library Central, and Lilacs (BVS). The inclusion criteria were: (1) studies that compare two-field vs. three-field esophagectomy; (2) adults (>18 years); (3) articles that analyze short- or long-term outcomes; and (4) clinical trials or cohort studies. The results were summarized by forest plots, with effect size (ES) or risk difference (RD) and 95% CI. Results Twenty-five articles were selected, comprising 8,954 patients. Three-field lymphadenectomy was associated to higher operation time (ES: -1.51; 95%CI -1.84, −1.18) and higher blood loss (ES: -0.24; 95%CI: −0.37, −0.11). Also, neck lymphadenectomy inputs additional risk for pulmonary complications (RD: 0.03; 95%CI: 0.01, 0.05). No difference was noted for morbidity (RD: 0.01; 95%CI: −0.01, 0.03); leak (−0.02; 95%CI: −0.07, 0.03); postoperative mortality (RD: 0.00; 95%CI: −0.00, 0.01), and hospital stay (ES: -0.05; 95%CI -0.20, 0.10). Three-field lymphadenectomy allowed higher number of retrieved lymph nodes (MD: -1.51; 95%CI -1.84, −1.18), but did not increase the overall survival (HR: 1.11; 95%CI: 0.96, 1.26). Conclusion Prophylactic neck lymphadenectomy for esophageal cancer should be performed with caution once it is associated with poorer short-term outcomes compared to traditional two-field lymphadenectomy and does not improve long-term survival. Future esophageal cancer studies should determine the subgroup of patients who could benefit from prophylactic neck lymphadenectomy in long-term outcomes.

435 Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials Comparing Standard Versus Extended Lymphadenectomy Pancreatoduodenectomy For Adenocarcinoma of The Head of Pancreas

Aim To compare baseline demographics, operative, and survival outcomes of randomized controlled trials (RCTs) comparing standard versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer Method we performed a meta-analysis of baseline demographics, operative, and survival outcomes of RCTs comparing standard versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. Moreover, we performed trial sequential analysis (TSA) to determine whether the available evidence is conclusive and to assess the risk of type 1 or type 2 errors. Results Overall, 724 patients from 5 RCTs were included. There was no difference between standard and extended lymphadenectomy in terms of pancreatic fistula (OR0.64, P = 0.11), delayed gastric emptying (OR 0.68, P = 0.40), bile leak (OR 0.33, P = 0.06), wound infection (OR 0.53, P = 0.06), abscess (OR 0.83, P = 0.63), total complications (OR 0.73, P = 0.27), postoperative mortality (OR 1.01, P = 0.85), and overall survival (HR 1.10, P = 0.46). TSA suggested that meta-analysis was conclusive with low risk of type 2 error. Conclusions Robust evidence from randomized controlled trials (Level 1) suggests no difference in postoperative and survival outcomes between standard and extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The findings were consistent in patients with positive and negative lymph node status and in studies from the West or East.

70 IMPACT OF LYMPH NODE YIELD ON SURVIVAL IN PATIENTS UNDERGOING NEOADJUVANT CHEMORADIOTHERAPY FOLLOWED BY SURGERY FOR LOCALLY ADVANCED ESOPHAGEAL CANCER

A survival benefit of neoadjuvant chemoradiotherapy (nCRT) added to surgery has been demonstrated and therefore is regarded as standard of care for patients with locally advanced esophageal cancer in many countries. It remains unclear whether it is necessary to perform extended lymphadenectomy for patients with esophageal squamous cell carcinoma (ESCC) after nCRT. This study aimed to evaluate the impact of lymph node yield (LNY) on survival in ESCC patients undergoing nCRT plus esophagectomy. Methods Patients receiving R0 resection for locally advanced ESCC were included from the prospective randomized NEOCRTEC5010 trial [surgery (S) alone vs nCRT plus S]. With Cox proportional hazard regression models, the association between survival and LNY as a categorical variable (<20 vs ≥20 nodes) was analyzed in the nCRT group as well as the pCR subgroup. Results Compared with the S group, the nCRT group achieved a better 5-year OS (65.9% vs 55.8%; P = 0.010). Less LNY [20 (IQR 15–27) vs 26 (IQR 19–35); P < 0.001] and positive nodes [0 (IQR 0–1) vs 1 (IQR 0–2.5); P < 0.001] were harvested in nCRT group compared to S group. The number of LNY was significantly associated with OS [HR, 0.363; 95% CI, 0.208–0.635; P < 0.001] and DFS (HR, 0.423; 95% CI, 0.249–0.719; P = 0.001) for patients in nCRT group. Furthermore, an increased LNY was not associated with worse postoperative complications. Conclusion The benefit of a higher lymph node yield on overall and disease-free survival is identified for the patients with ESCC who received nCRT followed by esophagectomy. Therefore, an extended lymphadenectomy should be the standard of care after nCRT.

745 YIELD OF EXTENDED AND TOTAL MEDIASTINAL LYMPHADENECTOMY IN OESOPHAGEAL CANCER

The extent of lymphadenectomy in oesophageal cancer surgery is currently controversial, although current evidence shows that survival is directly related to the number of lymph nodes removed during surgery. Methods Descriptive study of patients with oesophageal cancer who underwent oesophagectomy with extended and total mediastinal lymphadenectomy using a minimally invasive approach (right prone thoracoscopy, laparoscopy and left cervicotomy) in our hospital for 2 years (2019 and 2020). Extended lymphadenectomy was indicated in patients with adenocarcinoma of the distal oesophagus, while total lymphadenectomy was indicated in patients with squamous tumours and adenocarcinoma of the middle oesophagus. The characteristics of the series studied and the results obtained in the 90 days postoperatively are described. Results 26 patients, mean age 65 ± 7.8 years, were operated. 21 with total mediastinal lymphadenectomy and 5 with extended lymphadenectomy. 80.7% received neoadjuvant treatment (CROSS scheme). The mean number of lymph nodes removed was 33.6 ± 14.3, with a 50% probability of being affected. As much in the lymphadenectomy of the right (106R) as in the left (106 L) recurrent groups, it was more frequently affected in the distal oesophagus adenocarcinomas. Postoperative morbidity was not negligible, with anastomotic leak rate of 7.7% (thoracic location) and 23.1% (cervical location) the majority mild, 23.1% of recurrent injury and 11.5% of chylothorax. Mortality at 90 days was 15.38%. Conclusion Based on our results, extended and total lymphadenectomy increases as much the global number of lymph nodes removed as the lymph nodes cancer-positive. In addition, it supports the performance of wide lymphadenectomies also in adenocarcinomas of the distal oesophagus. We cannot forget the greater radicalism is taxed with significant morbidity. We should remember the limitation of this study is the low number of cases, the extent of lymphadenectomy continues to be a matter of controversy.