Nueva Aplicación de Value Stream Mapping – VSM (futuro)

The importance of palliation is obvious in treating gastric cancer, since more than two-thirds of patients present with advanced disease ^{57 , 58} . While surgery, radiotherapy and chemotherapy have all been implemented for palliation, chemotherapy appears to be the best option for prolonging survival and improving quality of life ^{59 , 60} . Median survival for patients with metastatic disease is between 6 and 9 months ⁶¹ . Combination chemotherapy demonstrates improved response rates without a signifi-cant difference in survival when compared with mono-therapy ⁶¹. ECF regimens are most often used, but irinotecan- or taxane-based regimens have also been shown to be effective ⁶¹ . Nevertheless, prognosis remains poor for patients with metastatic disease and response to palliative treatment is limited at best.

OUTCOMES

The chief outcome measure for the efficacy of surgery for established gastric cancer is long-term patient survival.

Figures for this vary greatly depending on the stage of the tumor at the time of operation. As with short-term out-comes, specialist units report considerably better survival figures than cross-sectional surveys. The majority of cancer recurrence in gastrectomy occurs during the first 2 years after the operation. For established gastric cancer, the commonest cause of failure is recurrence in the perito-neal cavity, followed by locoregional disease originating from the regional lymph nodes or the resection margin.

Since the overall mean survival figure is so highly depen-dent on the stage distribution of the population, it is not a useful parameter for comparing results between centers, but overall figures of 30–40% 5-year survival are now frequently reported for apparently curative resections from major Western centers, and much higher figures have been reported ⁶² .

Mortality

Figures for operative mortality have in fact improved steadily over the past 3 decades, in common with those for most other major abdominal operations. Mortality results remain highly variable depending on the patient population and the setting, and the difference between

results reported from specialist expert centers and those from confidential surveys and population data is enormous. The National Cancer Center Hospital in Tokyo has published an account of 1000 consecutive gastrectomies without a death ⁶³ , whilst a contemporary confidential survey of British hospitals showed a mean mortality rate of 10.3% ²³ . Publications from high volume expert centers in countries with well developed health systems currently report mortality rates under 5%, and often under 3% ^{64 – 66} . Total gastrectomy is consistently at least twice as dangerous as distal gastrectomy ^{23 , 65 , 67} , although there are some notable exceptions to this rule ⁶⁸ . Mortality results are critically dependent on case selec-tion, and need to be interpreted with an eye to the phi-losophy underlying this. This is often difficult to determine from published reports. Apart from selection of procedure, the factor with the strongest association with increased mortality is co-morbid pathology. Studies using the POSSUM system and the ASA scale show strong correlations between decreasing fitness and opera-tive risk ^{23 , 24 , 67 , 69} . Age is certainly a risk factor, although interestingly not an independent one in studies using logistic regression to factor out the effect of fitness ⁷⁰ . Sex is a factor in some series, female patients doing better than males. In common with other forms of major cancer surgery, gastrectomy morbidity is associated with uncor-rected preoperative malnutrition ⁷⁰ and mortality with unit case volume ^{71 – 73} .

Postoperative complications

Gastrectomy shares many postoperative complications with other major abdominal operations. The most common serious complications are respiratory failure/

infection and anastomotic leak (including leakage from the duodenal stump). In elderly Western populations cardiac arrythmias, failure and perioperative infarction and venous thrombo-embolism are also significant and dangerous complications, whereas these are much less frequently reported in series from East Asian countries.

Enteric fistulas can occur after anastomotic leakage, and trauma to the pancreas in radical operations can result in pancreatitis, pancreatic fistula, or abscess formation, the last being extremely dangerous as it tends to erode local vessels and cause major hemorrhage. The spleen is always at risk of damage during total gastrectomy, especially in obese patients with multiple capsular adhesions, and this can necessitate splenectomy (as can local or nodal exten-sion of the tumor). The resultant depresexten-sion of opsoniza-tion increases the risk of both early and late infecopsoniza-tion.

One clear lesson from the trials of radical ‘D2’ surgery was that resection of the spleen and distal pancreas both add very significantly to the risks of morbidity, and

therefore should only be carried out if oncologically essen-tial for complete tumor resection. Bleeding and wound dehiscence are relatively rare, but the issue of hospital acquired infection has grown in importance over the past decade, and the risk of acquiring invasive methicillin-resistant Staphylococcus aureus (MRSA) infection or Clostridium difficile colitis is now a significant problem in many hospitals.

In addition to the complications described, the normal uncomplicated course of events after a gastrec-tomy will include a number of expected but undesirable health consequences. The weakness and tiredness associ-ated with any major surgery usually takes several months to resolve completely, and in the case of gastrectomy this is further added to by the nutritional problems induced by removal of part or all of the stomach. Patients can expect to have a smaller appetite and small capacity, and to lose weight for some time after leaving hospital until they reach a stable metabolic state. The long-term nutri-tional consequences of gastrectomy are well recognized.

As well as protein-calorie malnutrition (which is much worse in total gastrectomy but tends to improve after 3 years in survivors) there are specific problems with cal-cium, vitamin C, iron, and vitamin B12 absorbtion.

These can be dealt with by supplements except for the osteoporosis associated with calcium malabsorption.

Dumping, a syndrome comprising faintness, hypoten-sion, sweating and sometimes diarrhea, occurs occasion-ally or to a mild degree in many gastrectomized patients, but to a severe extent in relatively few. Treatment is mainly by dietary manipulation, although various authors have claimed success for surgical revisions to slow transit.

Bile reflux can cause devastating symptoms of reflux, vomiting and anorexia, and can be dramatically improved by creating or lengthening a Roux loop. Diarrhea and postprandial pain affect a significant minority of patients, often for reasons which cannot be definitively demon-strated. Despite this catalogue, the majority of 5-year survivors live relatively normal lives with well-controlled or minor symptoms only.

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INTRODUCTION

Despite accounting for 90% of the surface area of the gastrointestinal tract (GIT) tumors of the small bowel are rare, contributing in the order of 3% of all GIT neoplasms.

True benign tumors including hamartomas, hyperplastic and inflammatory polyps account for approximately 20%

of lesions; tumors with malignant potential such as ade-nomatous polyps, gastrointestinal stromal tumors and non-malignant carcinoids amount to 30% of the total, leaving 50% of small bowel tumors which are considered malignant at presentation. In the past, patients were rarely diagnosed preoperatively but advances in imaging tech-niques have opened up opportunities for less invasive and more accurate diagnosis and staging. Taken alongside a

of lesions; tumors with malignant potential such as ade-nomatous polyps, gastrointestinal stromal tumors and non-malignant carcinoids amount to 30% of the total, leaving 50% of small bowel tumors which are considered malignant at presentation. In the past, patients were rarely diagnosed preoperatively but advances in imaging tech-niques have opened up opportunities for less invasive and more accurate diagnosis and staging. Taken alongside a