Author response to: Synchronous resection of primary colorectal cancer with liver metastases: Two birds with one stone?Siriwardena, Ajith K
doi: 10.1093/bjs/znac146pmid: 35578898
Dear Editor Thanks to Dr Yaqub for the interesting letter on the needlepoint article on the management of patients with colorectal cancer and synchronous liver metastases1. Yaqub states that ‘High-quality trials are needed to evaluate the role of systemic therapy, oncological outcomes, and healthcare system implications before we can recommend simultaneous resections for synchronous colorectal liver metastases’. The difficulty with this view arises when considering the practicalities of any trial designed to compare synchronous to staged surgery. Patients with extrahepatic and/or pulmonary metastases would be excluded as would those with an urgent presentation and individuals with either a locally advanced primary tumour or up-front unresectable hepatic metastases. Once all these cohorts are excluded, the remaining patients constitute a minority of any population with colorectal cancer and synchronous disease and it is unrealistic to seek funding for a major clinical trial to address the management of only a small proportion of the cohort with the disease in question. Further, for those minority with up-front resectable hepatic metastases and a resectable primary tumour, there is sufficient evidence that synchronous surgery can be undertaken safely (with similar survival to staged surgery) to make randomization unethical. It would certainly be difficult as well as unethical to recruit appropriately informed patients with disease resectable by one operative procedure to have two operations. Yaqub is correct in the contention that there is a need for better identification of those patients with synchronous disease who are suitable for synchronous surgery. Realistically, this information will need to be derived by a more nuanced approach than a simplistic randomized trial. Nomograms considering patient fitness, distribution of disease, volume, number, location of liver metastases, and extent of hepatectomy required for clearance together with information on the primary tumour and its nodal status are a more sophisticated approach but are feasible and will advance current management. Reference 1 Siriwardena AK . Synchronous resection of primary colorectal cancer with liver metastases: two birds with one stone? BJS 2022 ; 109 : 303 – 305 Google Scholar Crossref Search ADS WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Author response to: Outcomes after totally minimally invasive versus hybrid and open Ivor Lewis oesophagectomy: Results from the International Esodata Study Groupvan der Wilk, Berend J; Lagarde, Sjoerd M; van Berge Henegouwen, Mark I
doi: 10.1093/bjs/znac148pmid: 35578832
Dear Editor We thank the authors for their interest in our study on totally minimally invasive oesophagectomy (TMIE) versus hybrid versus open oesophagectomy1. It is interesting to note results on their mentioned previous study; a decrease in infectious post-operative complications and overall complication rate without a compromise in anastomotic leakage or oncological outcomes for the TMIE. These results partly conflict with our results, in which an increased anastomotic leakage rate was seen for TMIE compared with hybrid or open oesophagectomy. We agree with the authors that it is hard to concisely compare the anastomotic leakage rate for both techniques in such a large international study. Therefore, we concluded that there were no clear benefits for either surgical technique when used nowadays in daily clinical practice. An earlier study comparing TMIE complications between a randomized controlled trial (RCT) setting and performance in daily clinical practice has confirmed the earlier mentioned conflicts in results as well. In our view, the choice of technique should therefore depend on centre experience, volume, and surgeon preference. It should be noted, however, that all centres in our study were high-volume centres. It could still be that proficiency gain curve influenced the results of our study. A robust RCT would be the most concise comparison between surgical techniques. Even after the publication of such an RCT, however, much effort should be put in the implementation of TMIE technique as emphasized by previously published studies. We do agree with the authors that an (inter)national education programme could help to efficiently pass the proficiency gain curve and decrease the associated morbidity. If the anastomotic leakage rates do indeed become comparable between all techniques, we agree that the minimally invasive procedure is advantageous over the hybrid or open procedure. Reference 1 van der Wilk BJ , Hagens ERC, Eyck BM, Gisbertz SS, van Hillegersberg R, Nafteux P et al. Outcomes after totally minimally invasive versus hybrid and open Ivor Lewis oesophagectomy: results from the International Esodata Study Group . Br J Surg 2022 ; 109 : 283 – 290 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]
Comment on: Outcomes after totally minimally invasive versus hybrid and open Ivor Lewis oesophagectomy: Results from the International Esodata Study GroupAskari, Alan; Jayanthi, Naga Venkatesh Gupta
doi: 10.1093/bjs/znac143pmid: 35578833
Dear Editor We read with interest the analysis from the International Esodata Study Group published in the January 2022 edition of the BJS1 where a higher leak rate was reported in the Totally Minimally Invasive Esophagectomy (TMIE) group compared with Hybrid Minimally Invasive Esophagectomy (HMIE). Data from our region have demonstrated that in specialist centres with a dedicated TMIE service, TMIE results in reduced peri-operative complications/morbidity and length of hospital compared with HMIE with equivocal anastomotic leak rates with no oncological compromise. These findings are further corroborated by large meta-analyses. Given that the analysis contained data from 29 hospitals across 20 countries, it is likely that there were differences in surgical technique, clinical practice and importantly experience of surgeons in TMIE. Without a standardized TMIE programme/approach, it is probable that some units may not be performing TMIE in either large numbers or as a routine technique, making a fair comparison of anastomotic leak rate between TMIE/HMIE and open oesophagectomy challenging. We see this as an opportunity to learn from our fellow colorectal colleagues who transitioned from an open technique to now ubiquitously practiced minimally invasive approach in a little over a decade without compromise in surgical or oncological quality, thanks (at least in part) to the Lapco programme. Such a dedicated national (and perhaps international) TMIE training programme is required to improve skillsets and outcomes in TMIE. A programme of this magnitude would require careful consideration, allocation of funds, and dedicated set-up as well as backing of national bodies such as the AUGIS, RCSEng, ASiT, and Roux Group. As the current study itself demonstrated, TMIE resulted in lower peri-operative complication rates, length of hospital stay, despite a higher anastomotic leak rate. Therefore, by improving leak rates through structured training and standardization of TMIE, the technique would improve overall post-operative outcomes. Reference 1 van der Wilk BJ , Hagens ERC, Eyck BM, Gisbertz SS, van Hillegersberg R, Nafteux P et al. Outcomes after totally minimally invasive versus hybrid and open Ivor Lewis oesophagectomy: results from the International Esodata Study Group . Br J Surg 2022 ; 109 : 283 – 290 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Author response to: Short- and long-term outcomes of selective use of Frey or extended lateral pancreaticojejunostomy in chronic pancreatitisKempeneers, Marinus A; Boermeester, Marja A
doi: 10.1093/bjs/znac152pmid: 35595275
Dear Editor In their letter, Prof. Julianov and Dr Saroglu questioned the arguments to recommend extended lateral pancreaticojejunostomy as the procedure of choice in chronic pancreatitis with a dilated pancreatic duct and normal pancreatic head size1. We acknowledge that the referred guidelines both stated that no recommendation can be made regarding the surgical technique in patients with a dilated main pancreatic duct and a normal-sized pancreatic head. However, the most important reason that no recommendation could be made was that studies with a direct comparison of these two techniques are lacking. This is exactly the reason for our study and thus not misleading. With our study, we aimed to describe and provide evidence for such a surgical strategy in a large, long-term cohort. In current guidelines, the Frey procedure is indicated in patients with a dilated pancreatic duct and enlarged pancreatic head and this is also our current surgical strategy. We showed that both procedures for their indications provided good pain relief at long-term. However, we observed that the complication rate after Frey was significantly higher in our cohort and discussed other literature in which we also observed a trend of higher complications in Frey. Our conclusion regarding the Frey procedure is based on these higher complication rates but as suggested, confirmation in replication studies is needed. The argument to perform a pancreaticojejunostomy to the entire length of the pancreas is that chronic pancreatitis is a progressive inflammatory disease eventually involving the entire pancreas and pancreatic duct. In our opinion, when performing a partial pancreaticojejunostomy, patients are at risk for new duct obstructions in the other segments with subsequent pain. We do not have published evidence for this argument, but we have the clinical experience to corroborate this observation. Moreover, this line of reasoning is also why others consider total pancreatectomy with islet auto-transplantation is performed. In the light of the study limitations, we still think that selective use of the Frey procedure and extended lateral pancreaticojejunostomy for their described indications is recommended. However, replication studies from other countries, for example, a cohort of corresponding authors, will drive further knowledge. Reference 1 Kempeneers MA , van Hemert AKE, van der Hoek M, Issa Y, van Hooft JE, Nio CY et al. Short- and long-term outcomes of selective use of Frey or extended lateral pancreaticojejunostomy in chronic pancreatitis . Br J Surg 2022 ; 109 : 363 – 371 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]
Comment on: Increasing frequency of gene copy number aberrations is associated with immunosuppression and predicts poor prognosis in gastric adenocarcinomaLiu, Kai; Hu, Jian kun
doi: 10.1093/bjs/znac159pmid: 35552616
Dear Editor We read with great interest the research from Silva et al.1, which broaden our knowledge on the association between chromosomal status (chromosome-stable (CS), chromosomal instable (CIN)) and prognosis of gastric cancer. However, some points deserve further discussion. The authors should have performed a subgroup analysis of patients with and without chemotherapy. Chemotherapy response and tumour regression grade (TRG) should have been addressed by the authors. Different subtypes of gastric cancer might have distinct responses to chemotherapy and have a significant impact on survival. An earlier study showed that patients with CIN had the most benefit from adjuvant chemotherapy; CS subtype was associated with a poor prognosis. Another study also demonstrated that tumours with a high level of CIN were more likely to benefit from chemotherapy. In addition, chemotherapy may have induced changes in the expression of CIN-associated genes. Second, aberrant p53 expression is associated with the level of CIN. Another study showed that the level of CIN combined with TRG could select a subgroup of patients with a good response to neoadjuvant chemotherapy. Third, the author indicated that stage IV gastric cancers more frequently were CIN. This might be a factor influencing survival data. Clearly, the prognosis of CIN and CS is still controversial and the underlying mechanism needs further investigation. Reference 1 Silva ANS , Saito Y, Yoshikawa T, Oshima T, Hayden JD, Oosting J et al. Increasing frequency of gene copy number aberrations is associated with immunosuppression and predicts poor prognosis in gastric adenocarcinoma . Br J Surg 2022 ; 109 : 291 – 297 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]
Comment on: Synchronous resection of primary colorectal cancer with liver metastases: Two birds with one stone?Yaqub, Sheraz
doi: 10.1093/bjs/znac144pmid: 35580831
Dear Editor I read with interest the needlepoint article arguing that there is no clinical equipoise between simultaneous or staged resection for synchronous limited liver-only colorectal metastases1. Based on one randomized trial (METASYNC) and a prospective cohort study (CoSMIC), the author finds it unethical to randomize to two operative procedures given the equivalent outcomes in these two studies. On the contrary, a large international, multi-institution, retrospective study describing trends and outcomes of simultaneous surgery2, concluded that the mortality and morbidity rates associated with synchronous resections increased incrementally based on the extent of liver and colorectal resections. The authors suggest that both the extent of hepatectomy as well as the type of colectomy should be considered when deciding the appropriate treatment strategy for patients with synchronous colorectal liver metastases. Unfortunately, there are several limitations in the METASYNC randomized trial which makes it worrisome to draw the conclusion that we have adequate high-level evidence to not pursue future randomized trials on this topic. Firstly, although 10 centres in France were involved in the trial, the overall recruitment time was a decade. Even this was not enough time to reach the calculated sample size (estimated sample size 222 patients; included 105 patients of whom 48 synchronous and 52 staged resections, and assessed for primary endpoint 39 and 38 patients, respectively). This was in spite of broad inclusion criteria, accepting major hepatectomy, bi-lobar liver metastases, and patients with rectal cancer. As the trial was underpowered to answer the primary outcome, the question still stands: for whom is simultaneous resection beneficial? Although simultaneous resection of both primary tumour and liver-only limited liver metastases sounds appealing and reasonable, there is still clinical equipoise. High-quality trials are needed to evaluate the role of systemic therapy, oncological outcomes, and healthcare system implications before we can recommend simultaneous resections for synchronous colorectal liver metastases. References 1 Siriwardena AK . Synchronous resection of primary colorectal cancer with liver metastases: two birds with one stone? BJS 2022 ; 109 : 303 – 305 Google Scholar Crossref Search ADS WorldCat 2 Tsilimigras DI , Sahara K, Hyer JM, Diaz A, Moris D, Bagante F et al. Trends and outcomes of simultaneous versus staged resection of synchronous colorectal cancer and colorectal liver metastases . Surgery 2021 ; 170 : 160 – 166 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]
Comment on: Short- and long-term outcomes of selective use of Frey or extended lateral pancreaticojejunostomy in chronic pancreatitisJulianov, Alexander; Saroglu, Azize
doi: 10.1093/bjs/znac151pmid: 35594522
Dear Editor We have read with interest the article by Kempeneers et al.1, which discusses the procedure choice in patients with chronic pancreatitis and a dilated pancreatic duct. Although the authors presented an intriguing concept, some of the statements and conclusions in their publication merit further discussion. The author’s statement that according to guidelines a lateral pancreaticojejunostomy (LPJ) is indicated in case of a dilated pancreatic duct and a normal pancreatic head size is misleading. In fact, according to the cited HaPanEU guideline, ‘no recommendation can be made for the preferred surgical technique in these patients’ (author’s reference 2), and according to the second cited guideline, ‘both the extended lateral pancreaticojejunostomy and Frey procedure seem to provide equivalent pain control in patients’ (authors’ reference 14). Furthermore, the author’s conclusion that the Frey procedure is not required or advised in patients without an enlarged pancreatic head contradicts the widely accepted concept and observations that opening only the principal duct at the head of the gland does not provide adequate drainage of the parenchyma in most patients because of obstructed duct confluences. Do authors observe that, in patients without pancreatic head enlargement, the branch duct confluences at the head are patent? Finally, there are no arguments provided by the authors as to why pancreatectomy was performed along the body and tail of the gland in all patients with a dilated pancreatic duct. A substantial proportion of these patients have uniformly dilated ducts with no main/branch duct obstructions along the body or tail of the pancreas. What is the benefit of extending surgery to non-obstructed ducts? Considering the study results and all of the above, there are still no strong arguments to recommend extended LPJ as the procedure of choice in chronic pancreatitis with a dilated pancreatic duct and normal pancreatic head size. Reference 1 Kempeneers MA , van Hemert AKE, van der Hoek M, Issa Y, van Hooft JE, Nio CY et al. Short- and long-term outcomes of selective use of Frey or extended lateral pancreaticojejunostomy in chronic pancreatitis . Br J Surg 2022 ; 109 : 363 – 371 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)