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Summary Multimodal therapeutic strategies combining chemotherapy, radiation therapy and surgery have been shown to be feasible and to have a positive impact on outcomes by decreasing the risk of locoregional recurrence and often by increasing overall survival. The advantages of neoadjuvant chemo(radio)therapy include optimal tumor control combined with better tolerance and compliance to treatment while also increasing the number of candidates for surgery. Whereas indications for neoadjuvant therapy are increasing, its impact on surgical treatment and postoperative outcomes are not well-known. Surgeons frequently believe that chemo(radio)therapy may amplify intraoperative difficulties, thereby increasing postoperative morbidity and mortality. The aim of this review was to report the state of the art regarding: (i) the role of chemo(radio)therapy; (ii) its impact on surgical indications and modalities; and (iii) its impact on postoperative outcomes for the most frequently encountered gastro-intestinal cancers, i.e. esophageal, rectal, pancreatic, and anal canal cancer. [ABSTRACT FROM AUTHOR]

Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage. Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures. Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed. Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer. [ABSTRACT FROM AUTHOR]

Résumé L’envahissement ganglionnaire est un évènement précoce et représente le principal facteur pronostique du cancer de l’œsophage. Bien que la chirurgie ait été pendant un temps challengée par la radiochimiothérapie exclusive dans les carcinomes épidermoïdes localement avancés de l’œsophage, elle est redevenue pour la majorité des patients opérables le traitement de référence car permettant un meilleur contrôle locorégional de la maladie et une survie prolongée. Pour obtenir ces résultats, la chirurgie et notamment le curage ganglionnaire doivent répondre à des critères de qualité. La définition des groupes ganglionnaires cibles du cancer de l’œsophage et de la jonction œso-gastrique, l’extension du curage ganglionnaire et son impact sur la survie sont discutés dans la présente revue, en s’appuyant sur les résultats des articles de plus haut niveau de preuve disponibles dans la littérature. Lymph node invasion is an early event in the oesophageal carcinogenesis and represents the main prognostic factor in the curative setting. Even though the primacy of surgical resection has been challenged by the definitive radiochemotherapy for locally advanced squamous cell carcinomas of the oesophagus, surgery is now again a gold standard, in combination with (radio)chemotherapy, to improve locoregional disease control and long term survival. Surgery, especially lymphadenectomy, has consequently to be standardized through quality criteria. Lymph node stations invaded in œsophageal and junctional cancers, lymphadenectomy, and its impact on outcomes are discussed in this review based on the highest level of evidence published data. [ABSTRACT FROM AUTHOR]

Summary: Aim of the study: To establish an inventory of the training facilities available to residents and chief-residents in visceral and digestive surgery in France and to assess their satisfaction and their expectations. Participants and methods: An anonymous questionnaire was sent by E-mail in 2011 to all residents and chief-residents in visceral and digestive surgery in France. The questionnaire addressed demographic characteristics, educational resources used and desired, as well as the current medical and university curriculum. The practical and theoretical aspects of training were evaluated. Results: Of 208 residents, 63% responded to the survey (96 residents and 35 chief-residents). Daily practice of surgery and the reading of English-language articles were the two most frequently used teaching resources. Surgical training was judged satisfactory by 41.2% of respondents. In multivariate analysis, only the function of chief-resident (p <0.001) and authorship as first author of scientific papers (p =0.041) were associated with a feeling of satisfaction. Surgical training on animals, use of online course materials, and the establishment of a mentoring process during residency were rated favorable by more than 80%. Conclusions: The majority of residents and chief-residents in visceral and digestive surgery in France believe their training is unsatisfactory. However, this dissatisfaction decreases progressively throughout the training period. Strengthening of companionship through tutoring, better information on existing resources, and improved access to surgical training in animals should enhance satisfaction. [Copyright &y& Elsevier]

Abstract: Introduction: The poor prognosis of signet ring cell (SRC) eso-gastric adenocarcinoma (EGA) might be explained by its great affinity for the peritoneum. The aim of this study was to identify predictors of peritoneal carcinomatosis recurrence (PCR) after curative surgery and hence identify high risk patients. Methods: A retrospective national survey was conducted over 19 French surgical centers between 1997 and 2010. Patients with non-metastatic disease who benefited from curative surgery without postoperative death were included. Event-free patients who did not reach the time point of 24 months were excluded. Results: In a cohort of 3010 patients, 1050 were SRC EGA and 424 patients met the selection criteria. The tumor location was mainly gastric (68.9%) and a total gastrectomy was performed in 218 patients (51.4%). Chemoradiotherapy or chemotherapy alone was given preoperatively to 71 (16.7%) and postoperatively to 150 (35.4%) patients. After a median follow-up of 54 months, recurrence was diagnosed in 214 patients (50.5%) within a mean delay of 17 ± 10.7 months. PCR was diagnosed in 81 patients (19.1%). In multivariable analysis, four factors were identified as predictors of PCR: linitis plastica (p < 0.001; OR = 4.83), tumor invasion of/or through the peritoneal serosa (p = 0.022; OR = 1.58), lymph node involvement (p = 0.005; OR = 1.7) and tumors of gastric origin (p = 0.026; OR = 2.36), with PCR rates of 55%, 26%, 23% and 22%, respectively. Conclusion: Identification of strong predictors for PCR among this large series of SRC EGA patients helps to identify subgroups of patients that may benefit from specific therapeutic strategies such as prophylactic hyperthermic intraperitoneal chemotherapy. [Copyright &y& Elsevier]

Abstract: Neoadjuvant chemoradiotherapy is the gold standard of the treatment of advanced oesophageal squamous cell carcinoma. The role of surgery after chemoradiotherapy is still debated. Feasibility of curative resection depends on dose of radiotherapy, morbimortality rates, and nutrition status at the end of the protocol especially for non-responders patients. Adding surgery to radiochemotherapy improves local tumour control but does not increase overall survival of patients with advanced oesophageal squamous cell carcinoma. According to the two randomised trials published on the subject, surgery is not recommended after chemoradiotherapy for responders. Recommendations of French National Thesaurus are: exclusive chemoradiotherapy as reference, esophagectomy for residual tumour as alternative for operable patients. Surgery may be proposed for selected non-responders patients and some complete pathology response in expert center. [Copyright &y& Elsevier]

Abstract: Aim of the study. – Cervical and upper-third thoracic oesophageal carcinomas are considered as a single pathological entity. The aim of this study was to compare postoperative and oncological results after surgical resection in these two locations. Material and methods. – Postoperative and oncological results were compared retrospectively in 155 patients who underwent surgery for carcinoma of the cervical (C group, n = 21) or upper-third thoracic (TS group, n = 134) œsophagus. Results. – The two groups were comparable regarding the pre-, peroperative and histological data. Postoperative mortality and morbidity rates in the C and TS groups were 4.8% and 10.4% (P= 0.413) and 57.1 and 50.7% (P= 0.585), respectively. R0 resection and recurrence rates were 61.9% and 73.1% (P= 0.289) and 50.0% and 51.1% (P= 0.941), respectively. Five-year survival rates were 0% and 35% in the overall population (P= 0.098) and 0 and 49% in the R0 population (P= 0.047), respectively. By multivariate analysis, cervical location of the tumour was found to be an independent factor of poor prognosis (relative risk= 3.1, 95% confidence interval= 1.3–7.8, P= 0.014). Conclusion. – Prognosis after surgical resection of cervical oesophagus carcinoma is very poor. Surgery in this location should be proposed in case of chemoradiation failure. [Copyright &y& Elsevier]

Aim of the study. – To analyse the clinical and pathological parameters of 5–year survival patients after curative oesophageal resection for cancer and to identify factors predictive of long-term survival.Methods. – The data of 370 patients who underwent oesophagectomy with curative intent from January 1982 for oesophageal squamous cell carcinoma (n = 320) or adenocarcinoma (n = 50) were reviewed. After excluding postoperative deaths (n = 20), these patients were surviving (S group, n = 113) or dead (NS group, n = 237) with a 60–month follow-up. Uni– and multivariate analysis allowed comparison between the two groups.Results. – Postoperative mortality and morbidity rates were 4.0% and 37.6%, respectively. Parameters related to 5–year survival were: absence of preoperative malnutrition or dysphagia, transhiatal resection, no reoperation, limited tumour, histological response to neoadjuvant treatment, absence of lymph node capsular invasion, number of invaded lymph nodes ≤ 4, invaded lymph node ratio ≤ 0.1, absence of tumour recurrence or metachronous primary cancer. On multivariate analysis, factors predictive of 5–year survival were: absence of preoperative dysphagia (P < 0.001), stage 0-I-IIA tumour (P<0.001) and absence of metachronous cancer (P = 0.016).Conclusion. – Complete surgical resection allows 5–year survival. Factors predictive of long-term survival assessed in preoperative evaluation, dysphagia and tumour stage, should be useful to select patients for neoadjuvant treatment. [Copyright &y& Elsevier]

Aim of the study: To determine therapeutic and prognostic implications of an associated head and neck primary cancer in patients undergoing oesophagectomy for squamous cell carcinoma of the oesophagus.Patients and methods: Between 1982 and 2000, 868 patients with oesophageal cancer were operated in our institution, including 78 (9%) who underwent oesophagectomy for associated oesophageal and head and neck cancers; the latter was synchronous (n = 52) or anterior metachronous (n = 26). Influence of head and neck cancer on the treatment of oesophageal carcinoma was analysed retrospectively in terms of surgical therapeutic strategy and survival.Results: Oesophageal resection consisted of oeso-pharyngolaryngectomy (n = 14, 17.9%), subtotal oesophagectomy (n = 62, 79.5%) and cervical oesophagectomy (n = 2, 2.6%). Radical resection (R0) was obtained in 85% of cases. Postoperative mortality rate was 5 % (4/78). Main complications were pulmonary (18% = 14/78) and anastomotic leaks (14% = 11/78), all of them cervical. Follow-up (mean = 25 ± 27 months) was complete for all 78 patients. Five-year survival after R0 resection was 25%. Survival pronostic factors were denutrition, complete resection, and pT status of oesophageal tumor.Conclusion: In patients with associated carcinomas of œsophagus and head and neck, agressive treatment —including an oesophagectomy— allowed a 5-year survival rate more than 25% without increased mortality or morbidity rates, compared with patients operated on for isolated œsophageal carcinoma. [Copyright &y& Elsevier]

Background: The choice of surgical strategy for patients with adenocarcinoma of the oesophagogastric junction is controversial. This study was performed to analyse the surgical results of a 20-year experience with these lesions. Methods: From January 1981 to January 2001, 126 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. The treatment of choice was oesophagectomy for type I tumours, and extended gastrectomy for type II and III lesions. Morbidity, mortality and survival were determined retrospectively. Results: Fifty-six patients (44·4 per cent) had type I tumours, 44 (34·9 per cent) type II and 26 (20·6 per cent) type III. Primary resection was performed in 113 patients (89·7 per cent). Oesophagectomy with resection of the proximal stomach was carried out in 65 patients (51·6 per cent) and extended total gastrectomy with transhiatal resection of the distal oesophagus in 61 (48·4 per cent). In-hospital mortality and morbidity rates were 4·8 and 34·1 per cent respectively. The overall 3- and 5-year survival rates were 40·9 and 25·1 per cent respectively, and were not affected by the surgical approach. Survival was significantly associated with R0 resection, pathological node-positive category, postoperative complications and tumour differentiation. Conclusion: Postoperative mortality, morbidity and long-term survival did not appear to be affected by surgical approach. Further prospective studies are needed to confirm the equivalence between transthoracic and transabdominal approaches. [ABSTRACT FROM AUTHOR]

Aim of the study: To elucidate hospital mortality, morbidity and actuarial survival rates of patients with carcinoma of the hypopharynx and cervical œsophagus and to identify the technique of choice for reconstruction after pharyngolaryngectomy.Patients and methods: We reviewed the records of 209 patients who underwent total pharyngolaryngectomy between May 1982 and January 2000. The majority of patients had advanced cancer: hypopharyngeal in 131 cases and cervical œsophageal in 78 cases. Follow-up was complete for all patients. Chi 2 and log rank tests were used, with a limit of significance of 5%.Results: The postoperative mortality and morbidity rates were 4.8% and 38.3%, respectively. Alimentary continuity was achieved using the stomach (127 patients), colon (5 patients), or free jejunal autograft (77 patients). The 1-year and 5-year survival rates were 62% and 24%, respectively. There was no significant difference with regard to the survival between gastric transposition and free jejunal autograft, but there were fewer complications in the gastric pull-up group with regard to the respiratory complications (33% vs 47.0%, p < 0.05), local recurrences (15.8% vs 33.8%, p = 0.004) and survival without dysphagia (76% vs 89%, p < 10–5).Conclusion: Surgical ablation is a viable option for advanced hypopharyngeal and cervical œsophageal neoplasms, and stomach interposition is the preferred method of reconstruction. [Copyright &y& Elsevier]

Abstract We report two clinical cases of primary granulocytic sarcoma of the pancreas that were diagnosed on the surgical specimen. Atypical clinical and morphological presentations may have lead to pretherapeutic biopsies of the pancreatic mass in order to indicate primary chemotherapy. Literature review of this rare clinical presentation may help physicians to anticipate diagnostic and therapeutic strategies.

Abstract Background Open transthoracic oesophagectomy is the standard treatment for infracarinal resectable oesophageal carcinomas, although it is associated with high mortality and morbidity rates of 2 to 10% and 30 to 50%, respectively, for both the abdominal and thoracic approaches. The worldwide popularity of laparoscopic techniques is based on promising results, including lower postoperative morbidity rates, which are related to the reduced postoperative trauma. We hypothesise that the laparoscopic abdominal approach (laparoscopic gastric mobilisation) in oesophageal cancer surgery will decrease the major postoperative complication rate due to the reduced surgical trauma. Methods/Design The MIRO trial is an open, controlled, prospective, randomised multicentre phase III trial. Patients in study arm A will receive laparoscopic-assisted oesophagectomy, i.e., a transthoracic oesophagectomy with two-field lymphadenectomy and laparoscopic gastric mobilisation. Patients in study arm B will receive the same procedure, but with the conventional open abdominal approach. The primary objective of the study is to evaluate the major postoperative 30-day morbidity. Secondary objectives are to assess the overall 30-day morbidity, 30-day mortality, 30-day pulmonary morbidity, disease-free survival, overall survival as well as quality of life and to perform medico-economic analysis. A total of 200 patients will be enrolled, and two safety analyses will be performed using 25 and 50 patients included in arm A. Discussion Postoperative morbidity remains high after oesophageal cancer surgery, especially due to major pulmonary complications, which are responsible for 50% of the postoperative deaths. This study represents the first randomised controlled phase III trial to evaluate the benefits of the minimally invasive approach with respect to the postoperative course and oncological outcomes in oesophageal cancer surgery. Trial Registration NCT00937456 (ClinicalTrials.gov)

Summary Nutrition is part of the treatment plan. Nutritional support as well as immunonutrition have been shown to decrease the rate of postoperative complications. Many issues remain to be investigated to better understand underlying mechanisms and to offer patients a personalized approach. [ABSTRACT FROM AUTHOR]

Summary Surgery for cancers of the digestive tract is associated with a high risk of postoperative complications. Peri-operative nutritional support is part of the treatment plan, with a demonstrated positive impact on postoperative course. The aim of this good clinical practices guide is to help surgeons and physicians in improving malnutrition screening and implementing perioperative nutritional care. [ABSTRACT FROM AUTHOR]

Summary ERAS programs are based on a combination of perioperative measures with a proven efficacy, that combined with each other lead to an enhanced recovery after surgery through a synergistic pathway. Such programs help to decrease postoperative morbidity and to reduce length of hospital stay. Beside immunonutrition, carbohydrate loading until 2 hours before surgery and early postoperative oral feeding are safe and allows enhanced recovery after surgery. [ABSTRACT FROM AUTHOR]

Summary: While the prevalence of distal gastric cancer is decreasing in the western world, there has been an alarming rise in the incidence of esophagogastric junction adenocarcinoma (EGJA) during recent decades. Current reports show that the prognosis of EGJA remains poor. Therapy strategies are complex due to the anatomical location of the junction between the esophagus and stomach. Surgery, based on Siewert''s classification and associated with regional lymphadenectomy, is the mainstay of treatment. Transthoracic esophagectomy is recommended for type I EGJA, while total gastrectomy is recommended for type III EGJA; both approaches can be considered for type II EGJA. Surgery alone can be indicated only for stage I and IIa tumors. Perioperative chemotherapy should be considered for stage IIb, III and non-metastatic stage IV tumors. Adjuvant chemoradiation can be proposed for tumors with high-risk of recurrence in the absence of neoadjuvant therapy. Neoadjuvant chemoradiation can be proposed for predominantly esophageal EGJA, and might well become a standard treatment for all EGJA tumors in the near future. A multidisciplinary approach is essential for optimal diagnosis and management. [Copyright &y& Elsevier]

Summary: Several reconstruction techniques are possible after gastrectomy. The best reconstruction is one, that maintains satisfactory nutritional status and quality of life while keeping postoperative morbidity as low as possible. The aim of this study was to describe the different reconstruction techniques that can be proposed after distal and total gastrectomy, heeding to the French guidelines on the use of mechanical sutures in these indications. We then conducted a review of randomized trials dealing with reconstruction techniques after distal and total gastrectomy. After distal gastrectomy, Roux-en-Y reconstruction seems superior to Billroth I and Billroth II reconstructions in terms of functional outcomes and long-term endoscopic results and should be chosen in patients with benign disease or superficial tumors. Otherwise, Billroth II should be preferred over Billroth I reconstruction because of lower postoperative morbidity and better oncologic margins. After total gastrectomy, Roux-en-Y reconstruction remains the easiest solution, with satisfactory functional results. Addition of a pouch reservoir after Roux-en-Y reconstruction seems to improve short-term functional outcome after total gastrectomy with better potential for nutritional intake. In the long-term, quality of life seems better mainly in patients with small-resected tumors associated with a good prognosis. [ABSTRACT FROM AUTHOR]