Adherence to Guidelines for Diagnosis, Staging, and Treatment for Gastric Cancer in Italy According to the View of Surgeons and Patients
Abstract
:1. Introduction
2. Materials and Methods
3. Statistical Analysis
4. Results
5. Discussion
Limitations of This Study
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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(a) |
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What type of medical specialty do you have? |
General surgery |
Gastrointestinal surgery |
Emergency surgery |
How old are you? |
<40 years old |
>40 < 60 years old |
>60 years old |
What type of hospital do you work at? |
University hospital |
Non-university hospital |
How many hospital beds are there in the hospital where you work? |
<200 hospital beds |
>200 <500 hospital beds |
>500 hospital beds |
How many cases of gastric cancer do you manage annually? |
<10 |
>10 < 20 |
>20 < 50 |
>50 |
Are you part of the MDTM? |
Yes, I am a member of MDTM |
No, I am not a member of MDTM |
There isn’t a MDTM in the hospital where I work |
Do you discuss gastric cancer patients at MDTM? |
Always |
Never |
Only in controversial management |
There isn’t a MTDM in the hospital where I work |
If you are part of a MDTM, when do you usually discuss GC patients? |
Only after the completion of clinical staging |
After completion of clinical staging and surgery |
For the histological typing on the endoscopic biopsy of the tumor before treatment, what type of diagnosis do you consider decisive (and do you repeat the examination if it is not available)? |
Adenocarcinoma |
Adenocarcinoma with histological features (grading, WHO, or Lauren classification) |
Adenocarcinoma with histological features and biomolecular characterization |
Have you ever referred a patient for genetic counseling? |
Yes |
No |
What type of CT scan do you require for abdominal clinical staging (cTNM)? |
Abdominal CT scan with intravenous contrast |
Abdominal CT scan with intravenous contrast and gastric hydro-distension |
Do you require an ultrasound endoscopy for the clinical staging (cT) of the tumor? |
Always |
Never |
Only for EGC |
Only for AGC |
Do you require whole-body PET-CT for detecting distant metastatic disease (cM)? |
Always |
Never |
Only in cases of suspected metastasis on previous exams |
In case of LAGC, do you usually perform SL before neoadjuvant chemotherapy? |
No |
Yes |
If feasible, do you perform a mini-invasive approach (laparoscopic/robotic)? |
Always |
Never |
Only for EGC |
Only for distant tumors |
Do you perform a mediastinal lymphadenectomy on an EGJ tumor? |
Never |
Only in Siewert 1 |
Only in Siewert 1-2 |
Always (Siewert 1-2-3) |
In cases of middle or lower-third gastric cancer, what type of gastrectomy do you perform? |
Subtotal gastrectomy |
Total gastrectomy |
In the case of EGC with signet ring cells, what type of lymphadenectomy do you perform? |
D1 |
D1 plus |
D2 |
D2 plus PAND |
In the case of LAGC, what type of lymphadenectomy do you usually perform? |
D1/D1 plus |
D2 |
D2 plus PAND |
In your experience, which factors would affect the type of lymphadenectomy? Score for each factor using numbers from 0 (poor) to 5 (very good), allocating weights to show the importance of each of these factors. |
Tumor staging |
Surgical skills |
Patient age |
Patient comorbidity |
Patient frailty |
Nutritional status |
Surgical approach |
Anatomic conditions |
Which type of reconstruction after gastric surgery do you prefer? |
Roux-en-Y reconstruction |
Billroth II reconstruction |
How do you manage post-operative pain? |
Epidural analgesia |
Tap block |
Continuous subcutaneous infusion |
Intravenous analgesia |
Do you usually insert NGT after a gastrectomy? |
No |
Yes |
Do you routinely insert at least one abdominal drain? |
No |
Yes |
When does the patient usually start oral water intake? |
I POD |
From or after II POD |
When do you usually stop an intravenous infusion? |
I POD |
II POD |
From or after III POD |
Do you routinely require a post-operative anastomotic leak test? |
Never |
Always |
Only after a total gastrectomy |
Is a nutritionist involved in patient follow-up after discharge? |
No, never |
Yes, always |
Only for patients with difficulties in resuming regular nutrition by mouth |
In your experience, who manages the oncological follow-up? |
Always the surgeon |
Always the oncologist |
Always the family doctor |
Depends on tumor staging and the treatment performed |
(b) |
When did you undergo a gastrectomy? |
1996–2000 |
2001–2005 |
2006–2010 |
2011–2015 |
2016–2020 |
2021 |
How old were you at the time of the surgery? |
<40 years old |
>40 < 60 years old |
>60 < 80 years old |
>80 years old |
What are your Italian regions of origin? |
From northern Italy |
From central Italy |
From southern Italy |
In which Italian region did you undergo surgery? |
In Northern Italy |
In Central Italy |
In Southern Italy |
How many hospital beds are there in the hospital where you underwent surgery? |
<200 hospital beds |
>200 <500 hospital beds |
>500 hospital beds |
Which specialist did you initially consult after the GC diagnosis? |
Surgeon |
Oncologist |
Other |
Was your gastrectomy performed as an emergency surgery after your access to the emergency department? |
Yes |
No |
After GC diagnosis, were you advised to continue treatment at a more specialized center? |
Yes |
No |
Were you given a multidisciplinary discussion report (surgeon–oncologist–radiotherapist, etc.)? |
Yes |
No |
I don’t know |
Did you undergo an abdominal CT scan prior to surgery? |
Yes and I could not drink anything before the exam |
Yes and I had to drink at least half a liter of water before the exam |
In addition to the esophagogastroscopy and CT scan, did you undergo other exams before surgery? |
Abdominal ultrasound |
Abdominal MRI |
Ultrasound endoscopy |
Whole-body PET-CT |
Nothing |
Did you undergo neoadjuvant therapy before surgery? |
Yes |
No |
If you had received neoadjuvant chemotherapy, did you undergo SL before starting chemotherapy? |
No |
Yes |
Which surgical technique was used to perform your gastrectomy? |
Open approach |
Laparoscopic/robotic approach |
Where was the location of your GC? |
Cardia |
Fundus |
Body |
Antrum |
If your tumor was located in the esophagus-stomach area, did the surgery also involve the chest? |
No |
Yes |
I don’t know |
If the tumor was in the medium or lower part of the stomach, how much stomach was removed? |
Part of the stomach |
Entire stomach |
Do you know which type of anastomosis was performed to restore intestinal continuity after gastrectomy? |
Roux-en-Y reconstruction |
Billroth II reconstruction |
I don’t know |
From your histopathology report, how many lymph nodes were removed during the surgery? (Only for patients with LAGC) |
<16 |
≥16 |
Referring to your histological examination, could you specify T? |
1 |
2 |
3 |
4 |
Referring to your histological examination, could you specify N? |
1 |
2 |
3 |
4 |
Did you have a distant metastasis diagnosis before or during surgery? |
No |
Yes |
I don’t know |
If you had a distant metastasis, where were they? |
Peritoneal metastasis |
Liver metastasis |
Distant lymph nodes |
Other |
What other diseases were you suffering from at the time of the surgery? |
Heart diseases |
Diabetes |
Liver disease |
Arterial hypertension |
During the post-operative period, did you have NGT? |
No |
Yes |
During the post-operative period, after how many days did you start to drink water? |
I POD |
From or after II POD |
During post-operative period, did you have at least one abdominal drain? |
No |
Yes |
Have you been examined by a nutritionist after surgery? |
No |
Yes, but I didn’t have nutritional problems |
Yes because I had nutritional problems |
Who monitored you during your oncological follow-up? |
The surgeon |
The oncologist |
The family doctor |
Surgeons | Patients |
---|---|
What type of CT scan do you require for abdominal clinical staging (cTNM)? | Did you undergo an abdominal CT scan prior to surgery? |
Abdominal CT scan with intravenous contrast | Yes and I could not drink anything before the exam |
Abdominal CT scan with intravenous contrast and gastric hydro-distension | Yes and I had to drink at least half a liter of water before the exam |
In case of LAGC, do you usually perform SL before neoadjuvant chemotherapy? | If you had received neoadjuvant chemotherapy, did you undergo SL before starting chemotherapy? |
No | No |
Yes | Yes |
If feasible, do you perform a mini-invasive approach (laparoscopic/robotic)? | Which surgical technique was used to perform your gastrectomy? |
No | Open approach |
Yes | Laparoscopic/robotic approach |
In cases of middle or lower-third gastric cancer, what type of gastrectomy do you perform? | If the tumor was in the medium or lower part of the stomach, how much stomach was removed? |
Subtotal gastrectomy | Part of the stomach |
Total gastrectomy | Entire stomach |
In the case of LAGC, what type of lymphadenectomy do you usually perform? | From your histopathology report, how many lymph nodes were removed during the surgery? (Only for the patient with LAGC) |
D1/D1 plus | <16 |
≥D2 | ≥16 |
Which type of reconstruction after gastric surgery do you prefer? | Do you know which type of anastomosis was performed to restore intestinal continuity after gastrectomy? |
Roux-en-Y reconstruction | Roux-en-Y reconstruction |
Billroth II reconstruction | Billroth II reconstruction |
Do you usually insert NGT after gastrectomy? | During the post-operative period, did you have NGT? |
No | No |
Yes | Yes |
Do you routinely insert at least one abdominal drain? | During the post-operative period, did you have at least one abdominal drain? |
No | No |
Yes | Yes |
When does the patient usually start oral water intake? | During the post-operative period, after how many days did you start to drink water? |
I POD | I POD |
From or after II POD | From or after II POD |
Is a nutritionist involved in patient follow-up after discharge? | Have you been examined by a nutritionist after surgery? |
No, never | No |
Yes, always | Yes, but I didn’t have nutritional problems |
Only for patients with difficulties resuming regular nutrition by mouth | Yes because I had nutritional problems |
Questions | Guidelines |
---|---|
Type of CT scan for abdominal clinical staging | Abdominal CT scan with intravenous contrast and gastric hydro-distension [5,13]. |
Staging laparoscopy in advanced gastric cancer | Staging laparoscopy is recommended in all stage IB-III gastric cancers that are considered potentially resectable to exclude radiologically and macroscopically occult peritoneal metastatic disease [5,8,13,14]. |
Surgical approach | Laparoscopic gastric resection for GC is an option that should be considered in patients with EGC; laparoscopic surgery is feasible also for AGC, but solid data on the advantages and oncologic efficacy of this approach coming from randomized trials are lacking [5,6]. Trials from East Asia in early and advanced (T2–T4a) gastric cancer have shown that laparoscopic distal gastrectomy is non-inferior with regard to oncological outcomes, with improved short-term outcomes [8,14]. |
Gastrectomy in middle or lower-third gastric cancer | Distal gastrectomy should be preferred when an adequate proximal resection margin can be obtained for distal tumors [5,8,14]. |
Lymphadenectomy | The standard treatment for potentially curative resection is D2, even after neoadjuvant treatment [5,8,14]. Lymph node dissection for T1 tumors may be confined to perigastric lymph nodes and include local N2 nodes [8,14]. |
Type of reconstruction after gastric surgery | 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 [5]. |
Use of a nasogastric tube after a gastrectomy | Nasogastric tubes should not be used routinely in the setting of enhanced recovery protocols in gastric surgery [6]. |
Use of abdominal drain | The use of abdominal drainage to reduce related complications and accelerate patient recovery is not recommended; however, the level of evidence is low. In particular, the use of drainage after total gastrectomy is still widely debated in the context of the ERAS programs [6]. |
Timing to start oral water intake | Early administration of oral liquids from the first post-operative day [6]. |
Nutritionist involvement after discharge | Follow-up should include lifetime monitoring of the nutritional sequelae of gastrectomy, including, but not limited to, adequate vitamin B12, iron, and calcium replacement [6]. |
Surgeons (125) | |
---|---|
Age | |
<40 | 48 (39%) |
>40 < 60 | 54 (43%) |
>60 | 23 (18%) |
Number of cases of gastric cancer managed annually | |
<10 | 11 (9%) |
>10 < 20 | 37 (30%) |
>20 < 50 | 54 (43%) |
>50 | 23 (18%) |
Number of hospital beds in the hospital where surgeons work | |
<200 hospital beds | 12 (10%) |
>200 <500 hospital beds | 40 (32%) |
>500 hospital beds | 73 (58%) |
Characteristics | Patients (125) |
---|---|
Year of gastrectomy | |
2008–2010 | 7 (6%) |
2011–2015 | 24 (19%) |
2016–2020 | 67 (54%) |
2021 | 27 (21%) |
Age at the time of surgery | |
<40 | 10 (8%) |
>40 < 60 | 61 (49%) |
>60 < 80 | 53 (42%) |
>80 | 1 (1%) |
Origin of the patient | |
From northern Italy | 42 (33%) |
From central Italy | 51 (41%) |
From southern Italy | 32 (26%) |
Number of patients who have chosen to be operated on in a hospital in a region other than that of their origin | 41 (33%) |
Number of hospital beds in the hospital where the patient underwent surgery | 82 * |
<200 hospital beds | 14 (17%) |
>200 <500 hospital beds | 19 (23%) |
>500 hospital beds | 49 (60%) |
Gastric cancer location | |
Cardia | 31 (25%) |
Fundus | 22 (18%) |
Body | 33 (26%) |
Antrum | 39 (31%) |
Type of gastrectomy | |
Total gastrectomy | 89 (71%) |
Subtotal gastrectomy | 36 (29%) |
Answers | Surgeons (125) | Patients (125) | p Value ** |
---|---|---|---|
Type of CT scan for abdominal clinical stadiation | 125 | 125 | 0.44 |
Abdominal CT scan | 66 (53%) | 73 (58%) | |
Abdominal CT scan with gastric hydro-distension | 59 (47%) | 52 (42%) | |
Staging laparoscopy in advanced gastric cancer | 125 | 53 | <0.05 |
No | 17 (14%) | 37 (70%) | |
Yes | 108 (86%) | 16 (30%) | |
Surgical approach | 125 | 125 | <0.05 |
Open | 19 (15%) | 99 (79%) | |
Laparoscopic/robotic approach | 106 (85%) | 26 (21%) | |
Surgical approach (since 2011) | 125 | 118 | <0.05 |
Open | 19 (15%) | 92 (78%) | |
Laparoscopic/robotic approach | 106 (85%) | 26 (22%) | |
Surgical approach (since 2019) | 125 | 57 | <0.05 |
Open | 19 (15%) | 40 (70%) | |
Laparoscopic/robotic approach | 106 (85%) | 17 (30%) | |
Gastrectomy in middle or lower-third gastric cancer | 125 | 72 | <0.05 |
Subtotal gastrectomy | 119 (95%) | 24 (33%) | |
Total gastrectomy | 6 (5%) | 48 (67%) | |
Lymphadenectomy | 125 | 91 * | <0.05 |
D1/D1 plus | 4 (3%) | 32 (35%) | |
≥D2 | 121 (97%) | 59 (65%) | |
Lymphadenectomy (since 2011) | 125 | 87 | <0.05 |
D1/D1 plus | 4 (3%) | 30 (34%) | |
≥D2 | 121 (97%) | 57 (66%) | |
Lymphadenectomy (since 2019) | 125 | 45 | <0.05 |
D1/D1 plus | 4 (3%) | 13 (29%) | |
≥D2 | 121 (97%) | 32 (71%) | |
Type of reconstruction after gastric surgery | 125 | 125 | 0.14 |
Roux-en-Y reconstruction | 97 (78%) | 107 (86%) | |
Billroth II reconstruction | 28 (22%) | 18 (14%) | |
Use of a nasogastric tube after a gastrectomy | 125 | 125 | 0.98 |
No | 31 (25%) | 30 (24%) | |
Yes | 94 (75%) | 95 (76%) | |
Use of abdominal drains | 125 | 123 * | 0.64 |
No | 10 (8%) | 7 (6%) | |
Yes | 115 (92%) | 116 (94%) | |
Timing to start oral water intake | 125 | 113 * | <0.05 |
POD 1 | 31 (25%) | 11 (10%) | |
≥POD2 | 94 (75%) | 102 (90%) | |
Nutritionist involvement after discharge | 125 | 125 | <0.05 |
No | 4 (3%) | 44 (35%) | |
Yes | 76 (61%) | 36 (29%) | |
Only for patients with nutritional problems | 45 (36%) | 45 (36%) |
Factors Answers (n. surgeons) | ||||||||
---|---|---|---|---|---|---|---|---|
Score * | Tumor Staging | Surgical Skills | Patient Age | Patient Comorbidity | Patient Frailty | Nutritional Status | Surgical Approach | Anatomic Conditions |
1 | 2.4% (3) | 14.3% (18) | 5.6% (7) | 4.8% (6) | 4% (5) | 9.5% (12) | 39.7% (50) | 13.5% (17) |
2 | 7.1% (9) | 12.7% (16) | 8.7% (11) | 12.7% (16) | 11.1% (14) | 14.3% (18) | 17.5% (22) | 23.8% (30) |
3 | 22.2% (28) | 18.3% (23) | 29.4% (37) | 31% (39) | 31% (39) | 37.3% (47) | 25.4% (32) | 38.1% (48) |
4 | 29.4% (37) | 28.6% (36) | 34.9% (44) | 28.6% (36) | 27.8% (35) | 26.2% (33) | 10.3% (13) | 17.5% (22) |
5 | 38.9% (49) | 26.2% (33) | 21.4% (27) | 23% (29) | 26.2% (33) | 12.7% (16) | 7.1% (9) | 7.1% (9) |
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© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Fabbi, M.; Milani, M.S.; Giacopuzzi, S.; De Werra, C.; Roviello, F.; Santangelo, C.; Galli, F.; Benevento, A.; Rausei, S. Adherence to Guidelines for Diagnosis, Staging, and Treatment for Gastric Cancer in Italy According to the View of Surgeons and Patients. J. Clin. Med. 2024, 13, 4240. https://doi.org/10.3390/jcm13144240
Fabbi M, Milani MS, Giacopuzzi S, De Werra C, Roviello F, Santangelo C, Galli F, Benevento A, Rausei S. Adherence to Guidelines for Diagnosis, Staging, and Treatment for Gastric Cancer in Italy According to the View of Surgeons and Patients. Journal of Clinical Medicine. 2024; 13(14):4240. https://doi.org/10.3390/jcm13144240
Chicago/Turabian StyleFabbi, Manrica, Marika Sharmayne Milani, Simone Giacopuzzi, Carlo De Werra, Franco Roviello, Claudia Santangelo, Federica Galli, Angelo Benevento, and Stefano Rausei. 2024. "Adherence to Guidelines for Diagnosis, Staging, and Treatment for Gastric Cancer in Italy According to the View of Surgeons and Patients" Journal of Clinical Medicine 13, no. 14: 4240. https://doi.org/10.3390/jcm13144240
APA StyleFabbi, M., Milani, M. S., Giacopuzzi, S., De Werra, C., Roviello, F., Santangelo, C., Galli, F., Benevento, A., & Rausei, S. (2024). Adherence to Guidelines for Diagnosis, Staging, and Treatment for Gastric Cancer in Italy According to the View of Surgeons and Patients. Journal of Clinical Medicine, 13(14), 4240. https://doi.org/10.3390/jcm13144240