The management of gastric cancer has become increasingly complex, highlighting the importance of clinical guidelines to ensure standardized care. The Second Brazilian Consensus on Gastric Cancer was developed to guide clinical practice across the country.
The aim of this study was to evaluate the degree of implementation of the 2nd Brazilian Consensus recommendations in cancer reference centers in Brazil.
This multicenter study involved 18 cancer centers that prospectively collected data over a one-year period. Notably, 21 key statements from the Consensus were assessed. Adherence was defined as following the recommendation in more than 80% of applicable cases.
Of the 21 statements, 11 (52.4%) met the predefined adherence threshold. The selective use of endoscopic ultrasound and PET-CT was consistent with the recommendations. However, diagnostic laparoscopy was underutilized, performed in only 24.7% of patients. Preoperative nutritional therapy, another key recommendation, was provided in just 42% of cases. D2 lymphadenectomy was performed in 79.8% of surgeries, but only 63.3% of specimens included ≥25 lymph nodes, the recommended minimum for adequate staging. Minimally invasive surgery (MIS) was performed in approximately 25% of early distal tumors but was rarely used in advanced proximal tumors. Despite not being recommended for early stage tumors, omentectomy and bursectomy were still performed in a significant number of T1/T2 cases. Preoperative chemotherapy was used in 35.4% of distal tumors ≥IB and 54.3% of proximal tumors, showing partial adherence to this recommendation.
Just over half of the II Brazilian Consensus recommendations were implemented in routine practice. There was strong adherence to D2 lymphadenectomy and MIS for early distal tumors. However, there is still room for improvement in areas such as diagnostic laparoscopy, nutritional support, adequate lymph node retrieval, and using more neoadjuvant chemotherapy to enhance care and follow national guidelines.
The development of consensus statements and clinical guidelines supports decision-making in clinical practice. However, recommendations formulated by experts may not always reflect real-world clinical practice. In this study, 21 key statements from the 2nd Brazilian Consensus on Gastric Cancer were evaluated across multiple cancer reference centers. It was found that, in 10 of these statements, current clinical practice diverged from the consensus recommendations.
Some consensus statements may be revised in future editions to better reflect the realities of clinical practice in the national context. To enhance adherence to the recommendations, broad dissemination of the study results is essential, alongside the implementation of educational initiatives and institutional policies aimed at promoting guideline compliance. These measures may contribute to closing the gap between consensus recommendations and everyday clinical practice, ultimately improving patient outcomes.
Surgical resection represents the main treatment for resectable nonmetastatic gastric gastrointestinal stromal tumors. Despite the feasibility and safety of laparoscopic resection, its standard use in gastric tumors larger than 5 cm is yet to be established.
This study aimed to compare the current evidence on laparoscopic resection with the classical open surgical approach in terms of perioperative, postoperative, and oncological outcomes.
The PubMed, Scopus, and Web of Science databases were consulted. Articles comparing the approach to gastric gastric gastrointestinal stromal tumors larger than 5 cm by open and laparoscopic surgery were eligible. A post hoc subgroup analysis based on the extent of the surgery was performed to evaluate the operative time, blood loss, and length of hospital stay.
A total of nine studies met the eligibility criteria. In the study, 246 patients undergoing laparoscopic surgery and 301 patients undergoing open surgery were included. The laparoscopic approach had statistically significant lower intraoperative blood loss (p=0.01) and time to oral intake (p<0.01), time to first flatus (p<0.01), and length of hospital stay (0.01), compared to the open surgery approach. No significant differences were found when operative time (0.25), postoperative complications (0.08), R0 resection (0.76), and recurrence rate (0.09) were evaluated. The comparative subgroup analysis between studies could not explain the substantial heterogeneity obtained in the respective outcomes.
The laparoscopic approach in gastric gastrointestinal stromal tumors larger than 5 cm compared to the open surgical approach is a technically safe and feasible surgical method with similar oncological results.
The COVID-19 pandemic has overloaded healthcare systems worldwide. Other diseases, such as neoplasms, including gastric cancer, remained prevalent and had their treatment compromised.
The aim of this study was to evaluate the impact of the COVID-19 pandemic on the treatment of gastric cancer and adherence to the recommended preoperative COVID-19 screening protocol.
A retrospective study evaluated patients diagnosed with gastric adenocarcinoma who underwent surgical treatment between 2015 and 2023.
A total of 769 patients with gastric cancer were evaluated and organized into two groups: (i) pre-COVID group and (ii) COVID group. The pre-COVID group consisted of 527 patients operated on between 2015 and 2019, and the COVID group consisted of 242 patients from 2020 to 2023. The average number of surgical procedures per year in the pre-COVID group was 105 and 81 in the COVID group. There was a statistically significant difference between ASA classification (p=0.002) and clinical staging (p=0.015), which were worse in the COVID group. We observed an increase in diagnostic surgeries (p=0.026), with an increase in the minimally invasive route (p<0.001). In patients undergoing curative surgery, there was a greater indication for postoperative ICU (p=0.022) and neoadjuvant chemotherapy (p<0.001). There was no difference in 30- and 90-day mortality.
The surgical and oncological outcomes for patients operated on during the pandemic remained uncompromised, even though many presented with more advanced initial stages and poorer clinical performance. High adherence to protocols and a low rate of complications related to coronavirus indicate that surgeries were performed safely during this period.
Gastric stump neoplasia is defined as a neoplasia that arises in the gastric remnant after at least 5 years of interval from the first gastric resection.
The aim of this study was to analyze 51 patients who underwent total and subtotal gastrectomy and multi-visceral resections in patients with gastric stump cancer.
The hospital records of 51 patients surgically treated for gastric stump cancer between 1989 and 2019 were reviewed. The following data were analyzed: sex, age group, the interval between the first surgery and the diagnosis of gastric stump cancer, location of the ulcer that motivated the gastrectomy, type of reconstruction, tumor resectability, surgery performed, reconstruction of the digestive tract, associated surgical procedures, postoperative complications using the Clavien-Dindo classification, disease staging, and survival.
There were 43 (83.3%) men, with a mean age of 66.9 years. The mean interval between the initial gastrectomy and surgery for the treatment of gastric stump neoplasia was 34.7 years. All had previously undergone Billroth II reconstruction. Most patients underwent total gastrectomy (35 cases – 68.6%), followed by subtotal gastrectomy (6 cases – 11.8%), and the remainder were considered unresectable (10 patients – 19.6%), undergoing jejunostomy for nutritional support. Multi-visceral resections consisted of splenectomies, cholecystectomies, hepatectomies, partial colectomies, pancreatectomies, enterectomies, and nephrectomies. Among the patients who had the lesion resected, the mean follow-up time was 34.2 months (standard deviation: 47.6 months), the overall survival at 3 years was 43.6%, and the survival at 5 years was 29.7%.
The treatment of gastric stump neoplasia is still challenging and difficult, and personalized follow-up strategies should be focused on high-risk patients, offering opportunities for early intervention, better clinical outcomes, and long-term survival.
Laparoscopic gastrectomy offers advantages in the postoperative period compared to the open approach. Most studies have been performed on distal gastrectomies; however, laparoscopic total gastrectomy (LTG) is not universally accepted. AIM: The aim of this study was to assess the results of LTG, on postoperative morbidity outcomes and long-term survival.
This is a retrospective cohort study from a prospective database of patients who underwent LTG, from 2005 to 2022, due to early and advanced gastric cancer. A totally laparoscopic technique was utilized, and the Roux-en-Y reconstruction was performed in all cases. Postoperative complications and long-term survival were evaluated.
A total of 100 patients were included (men 57, age 64 years, and body mass index 26). A D2 lymphadenectomy was performed in 68 cases. The postoperative hospitalization period was 8 days (6–62 days). Postoperative complications occurred in 26%, with 7% esophago-jejunal anastomosis leak, 4% abdominal collections, and 2% gastrointestinal bleeding. In 7% of cases, the complication was considered Clavien 3 or greater. Operative mortality was 1%. The pathology findings confirmed advanced gastric cancer in 50 cases. The median lymph node count was 38, and surgery was considered R0 in 99%. The median follow-up was 50 months. Overall 5-year survival was 74%. Survival in T1 cases was 95% at 5 years. For stage I, survival was 95%, and for stages II and III, it was 52% and 43%, at 5 years, respectively.
These results support the feasibility and oncological adequacy of minimally invasive total gastrectomy. Postoperative morbidity has an acceptable rate. Long-term survival was in accordance with the disease stage.
The hospitals’ volume, specialization, availability of all oncological services, and experience in performing complex surgeries have a favorable impact on gastric cancer (GC) treatment.
The aim of this study was to compare the results of GC treatment according to the type of oncological hospital in the State of São Paulo.
Patients diagnosed with GC between 2000 and 2022 in qualified hospitals for cancer treatment were evaluated by data extracted from the hospital cancer registry. Patients were assessed according to the type of hospital for cancer treatment: Oncology High Complexity Assistance Unit (UNACON) and Oncology High Complexity Care Center (CACON), which has greater complexity.
Among the 33,774 patients, 23,387 (69.2%) were treated at CACONs and 10,387 (30.8%) in UNACONs. CACON patients were younger, had a higher level of education, and had a more advanced cTNM stage compared to UNACON (all p<0.001, p<0.05). The time from diagnosis to treatment was over 60 days in 49.8% of CACON’s patients and 39.4% of UNACON’s (p<0.001, p<0.05). Surgical treatment was performed in 18,314 (54.2%) patients. The frequency pN0 (40.3 vs 32.4%) and pTNM stage I (23 vs 19.5%) were higher in CACON. There was no difference in overall survival (OS) between all adenocarcinoma cases treated at CACON and UNACON (9.3 vs 10.3 months, p=0.462, p>0.05). However, considering only patients who underwent curative surgery, the OS of patients treated at CACON was better (24.4 vs 18 months, p<0.001).
Patients with GC who underwent gastrectomy at CACONs had better survival outcomes, suggesting that the centralization of complex cancer surgery may be beneficial.
Mechanic sutures represent an enormous benefit for digestive surgery in decreasing postoperative complications. Currently, the advantages of motorized stapler are under evaluation.
To compare the efficacy of mechanic versus motorized stapler in gastric surgery, analyzing rate of leaks, bleeding, time of stapling, and postoperative complications.
Ninety-eight patients were submitted to gastric surgery, divided into three groups: laparoscopic sleeve gastrectomy (LSG) (n=47), Roux-en-Y gastric bypass (LRYGB) (n=30), and laparoscopic distal gastrectomy (LDG) (n=21). Motorized staplers were employed in 61 patients. The number of firings, number of clips, time of total firings, total time to complete the surgery, and postoperative outcome were recorded in a specific protocol.
Patients submitted to LSG, LRYGB, and LDG recorded a shorter time to complete the procedure and a smaller number of firings were observed using motorized stapler (p<0.0001). No differences were identified regarding the number of clips used in patients submitted to LSG. In the group that used mechanic stapler to complete gastrojejunostomy, jejuno-jejuno-anastomosis, and jejunal transection, it was observed more prolonged time of firing and total time for finishing the procedure (p=0.0001). No intraoperative complications were found comparing the two devices used. Very similar findings were noted in the group of patients undergoing LDG.
The motorized stapler offers safety and efficacy as demonstrated in prior reports and is relevant since less total time of surgical procedure without intraoperative or postoperative complications were confirmed.
One anastomosis gastric bypass (OAGB) has gained prominence in the search for better results in bariatric surgery. However, its efficacy and safety compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remain ill-defined.
To compare the efficacy and safety of OAGB relative to RYGB and SG in the treatment of obesity.
We systematically searched PubMed, EMBASE, Cochrane Library, Lilacs, and Google Scholar databases for randomized controlled trials comparing OAGB with RYGB or SG in the surgical approach to obesity. We pooled outcomes for body mass index, percentage of excess weight loss, type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease. Statistical analyses were performed with R software (version 4.2.3).
Data on 854 patients were extracted from 11 randomized controlled trials, of which 422 (49.4%) were submitted to OAGB with mean follow-up ranging from six months to five years. The meta-analysis revealed a significantly higher percentage of excess weight loss at 1-year follow-up and a significantly lower body mass index at 5-year follow-up in OAGB patients. Conversely, rates of type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease were not significantly different between groups. The overall quality of evidence was considered very low.
Our results corroborate the comparable efficacy of OAGB in relation to RYGB and SG in the treatment of obesity, maintaining no significant differences in type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease rates.
Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries.
To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients.
A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI.
Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival.
Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival.
Curative treatment for gastric cancer involves tumor resection, followed by transit reconstruction, with Roux-en-Y being the main technique employed. To permit food transit to the duodenum, which is absent in Roux-en-Y, double transit reconstruction has been used, whose theoretical advantages seem to surpass the previous technique.
To compare the clinical evolution of gastric cancer patients who underwent total gastrectomy with Roux-en-Y and double tract reconstruction.
A systematic review was carried out on Web of Science, Scopus, EmbasE, SciELO, Virtual Health Library, PubMed, Cochrane, and Google Scholar databases. Data were collected until June 11, 2022. Observational studies or clinical trials evaluating patients submitted to double tract (DT) and Roux-en-Y (RY) reconstructions were included. There was no temporal or language restriction. Review articles, case reports, case series, and incomplete texts were excluded. The risk of bias was calculated using the Cochrane tool designed for randomized clinical trials.
Four studies of good methodological quality were included, encompassing 209 participants. In the RY group, there was a greater reduction in food intake. In the DT group, the decrease in body mass index was less pronounced compared to preoperative values.
The double tract reconstruction had better outcomes concerning body mass index and the time until starting a light diet; however, it did not present any advantages in relation to nutritional deficits, quality of life, and post-surgical complications.
Desenvolvido por Surya MKT