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PubMedDate not supplied

[Total gastrectomy for gastric cancer: can the type of lymphadenectomy condition the long-term results?].

INTRODUCTION: Gastric cancer is the second tumor for frequency in the world. Surgery is still the only curative treatment. Good results in terms of long distance survival, postoperative morbidity and mortality have been achieved in the last years. The extension of lymphadenectomy is an important and discussed matter and it is not clear if lymphadenectomy may contribute to improve the surgical results. The Japanese surgeons were the first ones, in the 60's, to introduce a D2-D3 extended lymphadenectomy, but the real benefits of this technique are still being discussed. Indeed lymphonodal metastasis seem to be one of the most important prognostic factors in the gastric cancer and the level and the number of metastatic nodes are useful to predict the patients' survival. The aim of this study is to value the D2 lymphadenectomy in the patients who were treated with total gastrectomy for gastric adenocarcinoma, comparing the results both with the D1 lymphadenectomy and the D3-D4, paying attention to the survival rates related with the lymphonodal dissection. PATIENTS AND METHOD: From 1998 to 2004, we studied 87 patients with gastric cancer. Out of 78 patients treated surgically, 9 were judged unresectable. Out of 69 patients treated surgically, one died before surgery and so he was put away by this study. All the patients were treated with total gastrectomy and a GI tract reconstruction by Roux's Y termino-lateral esophageal-jejunal anastomosis. In 20 patients we also made a splenectomy. We followed the Japanese Research Society for Gastric Cancer guidelines, according to which nodes are gathered into 16 levels and divided in 4 groups (N1-N4) depending on the cancer localization. The extension of the lymphadenectomy has been classified according to the level of the removed nods. The patients were divided into 3 groups. First group: patients undergone a total gastrectomy with D1 lymphadenectomy. Second group: patients undergone D2 lymphadenectomy. Third group: patients undergone D3 and D4 lymphadenectomy. The data we obtained let us value the survival rate. RESULTS: Out of the 78 patients treated, 69 were resected with a 88.5% resection rate (69/78). Perioperatory mortality was 1.4% (1/69). Global survival was 53.8% (44/68). The 5 years survival for the Ia stage was 82.6%, 89.3% for the Ib stage, 67.8% for the II stage, 56.6% for the IIIa, 16.8% for the IIIb and 0% for the IV stage. In addition the 5 years survival in the patients without lymphnodal metastasis was 79%, much higher than the 30.6% obtained in the patients with lymphonodal metastasis (p <0.0001). In the patients who underwent D1 lymphadenectomy, survival was 73.4%, while we obtained a result of 70.4% and 13.8% respectively in the D2 and D3-D4 (p <0.05). In the advanced stages (IIIa, IIIb, IV), the survival rate in the patients with lymphadenectomy D2 vs D1 vs D3-D4 was 38.9% vs 0% vs 36.3% (p <0.0001). The survival rate based on the extension of the lymphadenectomy in the patients with lymphonodal metastasis resulted to be much higher in those patients who underwent a D2 lymphadenectomy (43.5% in 5 years) compared both to D1 (0% in 6 months) and (29.5% in 5 years) D3-D4 lymphadenectomy. CONCLUSIONS: The relation between long distance survival and extension of the lymphadenectomy in the patients with gastric adenocarcinoma is still being discussed. Different studies show the importance of a careful lymphadenectomy as the main mean for a better long distance survival in the patients with gastric cancer. Other studies showed a link between gastric cancer prognosis and number of positive nodes. If more than 7-8 nodes are affected with metastasis, prognosis is usually poor. Therefore the presence of nod metastasis has a negative influence in the prognosis of this tumor; for this reason D2 lymphadenectomy is the technique to be used for the treatment of the gastric adenocarcinoma, both for a good staging and a better long distance survival, but particularly in the advanced cancers which are, at the moment, the highest number of cases that reach the surgeon's attention.

Gastrectomy↗
PubMedDate not supplied

Evaluation of reconstruction after proximal gastrectomy: prospective comparative study of jejunal interposition and jejunal pouch interposition.

BACKGROUND/AIMS: To prevent various distresses after proximal gastrectomy, reconstruction by interposed jejunal pouch has been advocated as an organ-preserving surgical strategy to ensure favorable quality of life for the patients. METHODOLOGY: Proximal gastrectomy was performed in 9 patients with gastric cancer in the upper third of the stomach. Four patients were randomly selected for reconstruction by jejunal pouch interposition (JPI group), while 5 had reconstruction by jejunal interposition (JI group). The patients who underwent JPI and JI were followed up to evaluate resumption of normal diet, change in body weight, and clinical symptoms. RESULTS: The JPI group showed a significant dietary advantage. Three months after surgery, JPI patients could eat more than 80% of the volume of their preoperative meals, whereas JI patients ate less than 50%. The percentage of postoperative body weight loss was higher in the JI group than in the JPI group because the volume of the remnant stomach was more adequate in the latter. Moreover, it was easier to enter the remnant stomach and duodenum for endoscopic fiberscopy in the JPI group for the treatment of hepato-biliary pancreatic disease. CONCLUSIONS: JPI is an effective method for preservation of gastric function after proximal gastrectomy.

Adult↗
PubMed2006

Comparing the effects of minimal low-flow desflurane with that of semi-close high flow desflurane on perioperative cytokine response in patients undergoing gastrectomy.

BACKGROUND: Anesthetic techniques may influence the perioperative cytokine response. We investigate two anesthetic techniques: minimal low-flow anesthesia (LFA) and semi-closed high flow anesthesia (HFA) with desflurane on the effect of cytokine response in gastrectomy. METHODS: Forty patients scheduled to undergo elective gastrectomy were randomly allocated to LFA (0.3 mL/min) or HFA (2 L/min) group. Blood was sampled for measurement of tumor necrosis factor (TNF), interleukin (IL)-6, IL-8, and IL-1 receptor antagonist (RA) at scheduled intervals. Hemodynamic responses, desflurane concentrations, numbers of patient using cardiovascular agents, and frequency of vaporizer manipulations were recorded during the operation. RESULTS: For patients in the LFA group, production of IL-8 was significantly less increased at the end of the surgical procedure; however there was no significant difference in total production between groups. There was no significant difference in TNF, IL-6, and IL-1RA production throughout the observed period. The desflurane vaporizer was adjusted more frequently (4 [13-6] versus 2 [1-3] times) for patients in the HFA group, and more patients in this group required the use of cardiovascular agents (10 versus 4) than patients in the LFA group during the operation. CONCLUSIONS: The current study demonstrates that smaller increase in cytokine production in the LFA than HFA with desflurane for the patients receiving gastrectomy.

Aged↗
PubMedDate not supplied

[Total gastrectomy in the surgery of malignant stomach neoplasms].

An analysis of surgical treatment of 100 patients with malignant tumors of the stomach with using total gastrectomy has shown that postoperative lethality made up 90%, unfavorable results of using total gastrectomy being associated with insufficient sutures of the esophageal-intestinal anastomosis. The modified method used allows to elevate reliability of the esophageal intestinal anastomosis, to shorten the time of operative procedure. Total gastrectomy followed by chemotherapy in the postoperative period prolongs the patient's life, but does not secure against recurrences of the disease in later terms.

Adenocarcinoma↗
PubMed2006

[A case of stump MALT lymphoma after partial gastrectomy].

Gastrectomy is known to be a risk factor for adenocarcinoma in remnant stomach. It is suggested that reflux of bile juice or duodenal secretion to remnant stomach induces atrophic gastritis, intestinal metaplasia, and gastric adenocarcinoma. Malignant lymphoma in remnant stomach after gastrectomy is very rare. Only about thirty cases are reported in the world, and there is no case report in Korea. Gastric MALT (mucosa-associated lymphoid tissue) lymphoma is associated with Helicobacter pylori infection but the mechanism of lymphoma development in remnant stomach is still unknown. We report a case of low grade gastric MALT lymphoma of gastric stump after 10 years from partial gastrectomy.

Aged↗
PubMed2006

[Clinical study of continual jejunal interposition after subtotal gastrectomy].

OBJECTIVE: To explore the clinical effect of continual jejunal interposition in digestive tract reconstruction after subtotal gastrectomy. METHODS: Thirty-four patients with distal gastric cancer were divided randomly into two groups. In group A, the digestive continuity was reconstructed by continual jejunal interposition in 16 patients after subtotal gastrectomy. In group B, the digestive tract of other 18 cases were reconstructed by Billroth II procedure. The postoperative comp1ications, nutritional status, food intake and gastroscopic results were compared. RESULTS: There were no complications such as anastomotic leakage or obstruction in the two groups. The Visick scoring of group A was better than that of group B, and the difference was significant one year after operation (mu= 1.98, P< 0.05). All patients retrieved 85% of preoperative food intake per meal in group A, while only l4 patients got such results in group B. The weight loss was significantly higher in group B than that in group A(t = - 2.181, P= 0.037) after operation. The serum albumin level after operation in group A was significantly higher than that in group B (t=2.125, P=0.041), the level one year after operation in group A was also significantly higher than that before operation (t= - 2.175, P= 0.011). Gastroscopy one year after operation revealed fluent stoma,no bile reflux,and no congestion and edema in stomal mucosa and interposed jejunum in group A, while bile retention in 11 cases (61.1%), stomal inflammation in 13 cases (72.2%), and stomal ulcer in 2 cases (11.1%) in group B. CONCLUSION: Continual jejunal interposition after subtotal gastrectomy can recover physiological continuity of digestive tract and improve the quality of 1ife without reflux gastritis.

Digestive System Surgical Procedures↗
PubMed2006

[Comparative study on three types of digestive reconstruction after total gastrectomy].

OBJECTIVE: To investigate the rational digestive reconstruction after total gastrectomy for gastric malignancy. METHODS: Three types of digestive reconstruction were performed after total gastrectomy in 189 cases with gastric carcinoma. The operating time, morbidity and mortality, food intake, digestive tract symptoms, nutritional status at 1 and 3 years after surgery and 1-, 3-, 5-year cumulative survival were compared. RESULTS: There were no significant differences among the three procedures in operative morbidity and mortality, postoperative food intake, nutritional status (Hemoglobin, total protein and labium), and incidences of diarrhea and dumping syndrome (P > 0.05). The overall 1-, 3-, 5-year survival rates were 75.3%, 38.2% and 20.5% respectively, and there were no significant differences among the three groups (P > 0.05). Orr-type and P-type esophagojejunostomy had an advantage of anti-esophageal reflux, and were obviously superior to Moynihan-type anastomosis (P< 0.01). Compared with P-type reconstruction, Orr-type reconstruction was simpler with shorter operating time, and less complications. CONCLUSIONS: Orr-type Roux-en-Y esophagojejunostomy can be recommended as an adaptable method of digestive reconstruction after total gastrectomy for gastric cancer because of its avoiding reflux esophagitis, maintaining better nutritional status and quality of life, and simpler procedure.

Adult↗
PubMed2006

[Improvements in quality of life and survival of patients with T4 gastric cancer which invaded organs after multivisceral resections through the extension of palliative gastrectomy and post-operative chemotherapy].

For patients with a locally advanced gastric cancer, palliative gastrectomy could improve local complications, such as bleeding or obstruction, but had no impact on prognosis. This study was designed to evaluate improvements in quality of life and survival of patients with T4 gastric cancer which invaded organs exhibiting bleeding or obstruction, after multivisceral resections of these organs through the extension of palliative gastrectomy and postoperative chemotherapy. Multivisceral resections were performed on 6 patients with T4 gastric cancer with local complications, such as bleeding or obstruction, at the Department of Surgery of Fujisaki hospital from 2003-2005. The sites of the organs invaded were the pancreas in five cases, and transverse colon and gallbladder in one case. The invaded organs were resected completely in five cases, and partially in one case. Surgical margins were microscopically negative in four cases. Anatomical leakage (sutured failure) occurred to none of the patients. All in all, the oral ingestion after the surgery went well. Chemotherapy (TS-1 plus CDDP) was started with 3 patients during their stay in the hospital. In addition, post-operative chemotherapy (TS-1) at the outpatient clinic was performed on 5 of the 6 patients. More than 1 year of the performance test (PS 0 or 1 in ECOG) went well for 4 patients. Two of the 4 patients could resume their work. The median survival time was more than 419.5 days. In conclusion, we consider that multivisceral resections through the extension of palliative gastrectomy and postoperative chemotherapy for patients with T4 gastric cancer could improve quality of life and prognosis.

Aged↗
PubMed1991

[Reconstruction of the digestive tract after total gastrectomy. A comparison of Roux anastomosis with Nakayama's beta-anastomosis].

Digestive tract reconstruction following total gastrectomy can be classified into two types according to whether the duodenal tract is excluded or preserved. Two groups of patients who underwent digestive tract reconstruction excluding the duodenal tract following total gastrectomy due to cancer were compared retrospectively: Nakayama's anastomosis was used in 20 patients (57%), and a Roux-en-Y anastomosis was performed in 15 (43%). The main technical difference between the two groups consists in the distance between esophagojejunostomy and jejunojejuno anastomosis: 20 cm in the case of Nakayama's technique and 50 cm in the case of the Roux-en-Y reconstruction. Results showed that 40% of patients with Roux-en-Y anastomoses were asymptomatic compared to 60% of patients with Nakayama's beta-anastomosis (chi-square test, p = 0.36). The most frequent symptom in patients with Roux-en-Y reconstructions was a feeling of postprandial fullness (33%), whereas pyrosis (25%) was the most common compliant in patients with Nakayama's reconstruction. Endoscopy revealed the presence of esophagitis in 35% of patients with Nakayam's beta-anastomosis compared to 6.5% in patients with Roux-en-Y anastomosis (chi-square test, p = 0.012). Results confirm that a minimum distance of at least 50 cm between the esophagojejunal and jejunojejunal anastomoses is decisive in reducing the frequency of reflux esophagitis after total gastrectomy.

Adult↗
PubMed1991

Gastric hyperplastic changes and thymidine uptake after partial gastrectomy in rats.

Foveolar hyperplastic changes have been recently considered to be the most distinctive histological finding after partial gastrectomy, and their relationship with bile reflux has been proven. The present study was undertaken to establish whether an increase in 3H-thymidine uptake--which is an expression of increased gastric mucosal proliferative activity--might correspond to these hyperplastic changes. Histology and thymidine uptake values were assessed and compared in nineteen rats operated upon either by means of a Polya gastrectomy (11), or with a Roux-en-Y biliary diversion (8). Thymidine uptake values and the extent of gastric hyperplastic changes were greater in the Polya than in the Roux-en-Y group. Moreover, a significant correlation was found between thymidine uptake values and the extent of hyperplastic changes. The relationship between hyperplastic changes and post-gastrectomy increased mucosal proliferative activity would thus seem to have been demonstrated. Since bile acids have been shown to stimulate cell proliferation in ileal and colonic mucosa, a rôle for bile reflux can be hypothesized for the increased cell proliferation activity in the gastric stump.

Animals↗
PubMed1991

Gastric hyperplastic changes and thymidine uptake after partial gastrectomy in rats.

Foveolar hyperplastic changes have been recently considered to be the most distinctive histological findings following partial gastrectomy, and their relationship to bile reflux has been proven. The present study was undertaken in order to determine whether an increase in 3H-thymidine uptake, which is an expression of increased gastric mucosal proliferative activity, might correspond to these hyperplastic changes. Histology and thymidine uptake values were assessed and compared in nineteen rats operated upon either with a Polya gastrectomy (11) or with a Roux-en-Y biliary diversion (8). Thymidine uptake values and the extent of gastric hyperplastic changes were greater in the Polya than in the Roux-en-Y group. Moreover, a significant correlation was found between thymidine uptake values and the extent of hyperplastic changes. Therefore, the relationship between hyperplastic changes and increased mucosal proliferative activity post-gastrectomy would seem to have been proven. Since bile acids have been shown to be able to stimulate cell proliferation in ileal and colonic mucosa, a role for bile reflux in the increased cell proliferation activity in the gastric stump can be hypothesized.

Anastomosis, Roux-en-Y↗
PubMed1991

[Use of mechanical staplers in Billroth II gastrectomy].

Some considerations on the use of staplers, use currently classified as "elective" and "of convenience", are shown. The Author wishes a change in this classification especially for what elective subtotal gastrectomy is concerned. In fact, the use of staplers in subtotal gastrectomy for tumors of the pyloric antrum and for complicated ulcer assures considerable advantages in terms of quickness, safety and sterility. Finally, the Author describes in detail a Billroth II subtotal gastrectomy performed with staplers.

Gastrectomy↗
PubMed1991

[Gastrectomy for advanced gastric carcinoma with serosal involvement].

Four hundred and eighty five gastric cancer patients underwent gastrectomy in the past 6 years and of those 332 patients (68.2%) were found to have only serosal involvement (se) or adjacent organ invasion (sei). Simple gastrectomy (SG) was carried out in 144 cases while radical gastrectomy (RG), which included systemic lymphadenectomy, was performed in 188 cases. This type of operation was chosen by the operators arbitrarily except in the presence of non-curative factors such as multiple liver metastasis, peritoneal seeding and distant metastasis, in which case SG was always used to relieve gastrointestinal obstruction or bleeding. The operative mortality of SG was 2.7% and that of RG was 3.2%. On average, 15.8 lymph nodes were taken out per patient in SG and 33.6 lymph nodes in RG. The chance of nodal metastasis was higher in sei than in se. According to the Japanese General Rules of Gastric Cancer Study, we found that for gastric cancer with serosal involvement: (1) the long term result of RG was superior to SG in both stage 3 and 4 patients, (2) when absolute curative resection was achieved, the result was the best in stage 3 patients, (3) no patient in stage 4 who underwent absolute non-curative resection survived for more than 42 months, therefore this result was the worst. RG is recommended for advanced gastric cancer patients with serosal involvement whenever the patient's condition permits and in absence of the unresectable non-curative factors.

Gastrectomy↗
PubMed1991

Total gastrectomy for gastric cancer in the elderly.

Of 1070 patients with gastric cancers, 292 patients underwent total gastrectomy during 13 years. Sixty patients were more than 70 years of age and 232 were under 69 years. The incidence of well-differentiated carcinomas and poorly differentiated carcinomas was the same in the elderly patients, whereas the latter was dominant in the young patients. However, there was no significant difference between the two groups regarding location, size, macroscopic patterns, extent of lymph metastases, or stage classification. The rates of preoperative surgical risk factors were significantly different between the two groups (p less than 0.01): 90.0% for the elderly and 34.9% for the young patients. However, the rates of postoperative morbidity and mortality were 31.7% and 3.3% for the elderly and 24.1% and 1.3% for the young patients, respectively, with no significant difference. The 5- and 10-year survival rates after curative total gastrectomy were 48.6% and 23.2% for the elderly compared with 49.4% and 33.6% for the young patients, respectively, with no significant difference. A 5-year survival rate after noncurative operation was 0% for the elderly and 6.4% for the young patients. These results indicate that, when performed for cure, total gastrectomy with systematic lymphadenectomy can provide good long-term results for elderly, as well as young, patients.

Age Factors↗
PubMed1991

[Combined gastrectomy with extensive lymph node excision in the surgical treatment of cancer of the stomach].

The authors discuss experience in combined gastrectomy in 206 patients with gastric carcinoma. They encountered 72 various postoperative complications which were not fatal. Fourteen patients died, which made up a total postoperative mortality of 6.8%. The most frequent and threatening complication was incompetence of the esophago-intestinal++ anastomosis, which occurred in 17 cases (8.3%) and was the cause of death of 6 patients (42.9%). The incidence of purulent and pleuropulmonary complications was 19.9 and 3.4%, respectively. Extensive lymphadenectomy was performed in combined gastrectomy in 40 cases, which accounted for 42.6% of all combined interventions. The incidence of complication was lowest in this group of patients (15%), and there were only 2 fatal outcomes (5%). The authors believe that total gastrectomy with omentectomy, splenectomy, resection of the lower esophagus, and extensive lymphadenectomy is the method of choice in surgical treatment of gastric carcinoma.

Adult↗
PubMed1990

Meta-analysis of the risk of gastric stump cancer: detection of high risk patient subsets for stomach cancer after remote partial gastrectomy for benign conditions.

Controversy about gastric cancer risk after partial gastrectomy exists, especially in the United States. Therefore, we performed a meta-analysis to determine overall relative risk and weighted mean relative risk for subsets of postgastrectomy patients, define possible high risk patients suitable for surveillance, and assess for publication bias which would overestimate risk. If 2 studies were excluded because of heterogeneity, overall relative risk (RR) for gastric stump cancer in 22 studies analyzed was 1.66 [95% confidence limits (CL), 1.54-1.79]. With these 2 studies included, the RR summarized with a random effects model to account for study heterogeneity was 1.46 (95% CL, 1.18-1.82). No obvious evidence of publication bias was detected. Patients 15 years or more postoperative had a weighted mean RR of 1.48 (95% CL, 1.31-1.67) and patients 5-14 years postoperative had a RR of 0.91 (95% CL, 0.71-1.17) (P = 0.026). Patients operated upon for gastric ulcer had a weighted mean RR of 2.12 (95% CL, 1.73-2.59) and patients with duodenal ulcers had a RR of 0.84 (95% CL, 0.66-1.05) (P = 0.001). The weighted mean RR for females was 1.79 (95% CL, 1.39-2.29) and for males 1.43 (95% CL, 1.27-1.62) (P = 0.074). For Billroth II gastrectomy the weighted mean RR was 1.60 (95% CL, 1.15-2.18) and for Billroth I gastrectomy 1.20 (95% CL, 1.01-1.42) (P = 0.220). Although differences in risk between subsets of postagastrectomy patients seen to exist, recommendations concerning endoscopic surveillance await further studies of cost-benefit analysis.

Female↗
PubMed1990

[Results of total gastrectomy in the treatment of adenocarcinoma of the cardia in advanced stages].

Over an 8 year period, 66 patients with adenocarcinoma of the cardia in advanced stages underwent total gastrectomy. The operative morbidity rate was 7.5% and the post-operative mortality rate (1 month) was 1.5%. The post-operative 1,3,4, and 5 year survival rates were 69%, 30.7%, 20% and 13.8% respectively. The quality of life after surgery was improved. Pathologic type, lymph node metastasis, incomplete resection and post-operative chemotherapy were the main factors influencing post-operative survival. Indications for total gastrectomy and the advantages of transthoracic total gastrectomy are discussed.

Adenocarcinoma↗
PubMed1990

Early and late results of total gastrectomy in treatment of advanced adenocarcinoma of the cardia.

Sixty-six patients with advanced adenocarcinoma of the cardia underwent total gastrectomy between 1978 and 1986. The operative morbidity rate was 7.5% and the hospital mortality rate (1 month) was 1.5%. The postoperative 1, 3, 4, and 5 year survival rates were 69%, 30.7%, 20% and 13.8% respectively. The quality of life after surgery was improved. Pathological type, lymph node metastasis, completeness of resection and postoperative chemotherapy were the main factors influencing postoperative survival time. Indications for total gastrectomy and the advantages of transthoracic total gastrectomy are discussed.

Adenocarcinoma↗