Recurrence of gastric cancer in the jejunal stump after radical total gastrectomy

This is a very rare case of the recurrence of gastric cancer in the jejunal stump after radical total gastrectomy with Roux-en-Y reconstruction.In January 2008,a 65-year-old man underwent radical total gastrectomy with Roux-en-Y reconstruction for stageⅠB gastric cancer of the upper body.At a follow-up in December2011,the patient had a recurrence of gastric cancer on gastroduodenal fibroscopy.The gastroduodenal fibroscopic biopsy specimens show a well-differentiated tubular adenocarcinoma.Computed tomography showed no lymphadenopathy or hepatic metastases.At laparotomy,there was a tumor in the jejunal stump involving the pancreatic tail and spleen.Therefore,the patient underwent jejunal pouch resection,distal pancreatectomy and splenectomy.The patient was diagnosed with gastric cancer on histopathological examination.     

Selecting lymph node–positive patients for adjuvant therapy after radical prostatectomy and extended pelvic lymphadenectomy: An outcome analysis of 100 node-positive patients managed without adjuvant therapy

ObjectiveThe aim of the study is to evaluate the effect of deferred androgen deprivation therapy on biochemical recurrence (BCR) and other survival parameters in node-positive prostate cancer patients after robot-assisted radical prostatectomy with bilateral extended pelvic lymph node dissection (RARP + EPLND).Materials and methodsOf the 453 consecutive RARP procedures performed from 2011 to 2018, 100 patients with no prior use of androgen deprivation therapy were found to be lymph node (LN) positive and were observed, with initiation of salvage treatment at the time of BCR only. Patients were divided into 1 or 2 LNs (67)—and more than 2 LNs (33)—positive groups to assess survival outcomes.ResultsAt a median follow-up of 21 months (1–70 months), the LN group (p < 0.000), preoperative prostate-specific antigen (PSA, p = 0.013), tumor volume (TV, p = 0.031), and LND (p = 0.004) were significantly associated with BCR. In multivariate analysis, only the LN group (p = 0.035) and PSA level (p = 0.026) were statistically significant. The estimated BCR-free survival rates in the 1/2 LN group were 37.6% (27%–52.2%), 26.5% (16.8%–41.7%), and 19.9% (9.6%–41.0%) at 1, 3, and 5 years, respectively, with a hazard of developing BCR of 0.462 (0.225–0.948) compared with the more than 2 LN-positive group. Estimated 5-year overall survival, cancer-specific, metastasis-free, and local recurrence-free survival rates were 88.4% (73.1%–100%), 89.5% (74%–100%), 65.1% (46.0%–92.1%), and 94.8% (87.2%–100.0%), respectively, for which none of the factors were significant. Based on cutoff values for PSA, TV, and LND of 30 ng/mL, 30%, and 10%, respectively, the 1/2 LN group was substratified, wherein the median BCR-free survival for the low- and intermediate-risk groups was 40 and 12 months, respectively.ConclusionsNearly one fourth and one fifth of 1/2 node-positive patients were BCR-free at 3 and 5 years after RARP + EPLND. Further substratification using PSA, TV, and LN density may help in providing individualized care regarding the initiation of adjuvant therapy.     

The effectiveness of extended lymph node dissection for gastric cancer performed in Costa Rica under the supervision of a Japanese surgeon: a comparison with surgical results in Japan

OBJECTIVE: In 1996, the Gastric Cancer Detection Center in Costa Rica (CR) initiated extended lymph node (D2) dissection for gastric cancer patients. We present an analysis of the surgical results compared with those in Japan. BACKGROUND: D2 dissection for gastric cancer is a standard surgical procedure in Japan, whereas it is still controversial in the West because of its poor survival benefit and high morbidity and mortality. METHODS: Between January 1996 and March 2000, 199 gastric cancer patients in Costa Rica underwent gastrectomy with D2 dissection (CR group). A Japanese surgeon performed or assisted on every gastrectomy with Costa Rican surgeons. During the same period, 497 gastric cancer patients underwent D2 dissection at Tokyo Women's Medical University (TWMU), Tokyo, Japan (TWMU group). RESULTS: The operative morbidity was 39.0% in the CR group and 27.0% in the TWMU group (P < .05). The 30-day postoperative mortality in the CR group and the TWMU group was 5% and 0.2%, respectively (P < .05). The 5-year survival rate in the CR group and the TWMU group was 98.0% and 99.3% in stage IA, 88.6% and 94.4% in stage IB, 77.8% and 76.9% in stage II, 60.1% and 66.4% in stage IIIA, 27.2% and 47.2% in stage IIIB, and 39.7% and 27.6% in stage VI, respectively (not significant in any stage). The overall 5-year survival rate in the CR group and the TWMU group was 72.5% and 69.7%, respectively (not significant). CONCLUSIONS: D2 dissection performed at the same level of quality as in Japan consequently produced the same long-term survival in Costa Rica as in Japan.     

进展期胃癌腹腔镜第3站淋巴结清扫术

Advanced gastric cancer is usually dealt with D2 radical dissection. There are different opinions as to whether it is necessary to perform D3 radical lymphadenectomy.Some scholars thought that properly...     

Laparoscopically assisted distal gastrectomy with standard radical lymph node dissection for gastric cancer

Background Laparoscopically assisted distal gastrectomy (LADG) with limited lymph node dissection (D1+alpha) has been used to treat a subset of patients with early gastric cancer. Technical advances have expanded indications for LADG to more advanced gastric cancers. However, little data are available on the feasibility or advantages of LADG with standard radical D2 lymph node dissection for patients with gastric cancer. Methods This study reviewed the clinical features of 37 patients who underwent LADG with D2 lymph node dissection for preoperatively diagnosed gastric carcinoma, then compared the results with the features of 31 patients who underwent conventional open distal gastrectomy (ODG) with D2 lymph node dissection. Results The laparoscopic procedure was not converted to laparotomy in any patient. There was no operative mortality and no serious morbidity among the patients who underwent LADG with D2 lymph node dissection. As compared with the ODG group, the LADG group had less operative blood loss (p < 0.001), earlier recovery of bowel activity (p = 0.012), and a shorter duration of fever after surgery (p = 0.015), despite the longer operation time (p = 0.007). Conclusions According to this study, LADG with D2 lymph node dissection is feasible and provides several advantages similar to those of limited lymph node dissection (D1+alpha). Depending on surgeons’ technical proficiency, LADG can be used with standard radical lymph node dissection for patients with gastric cancers.     

淋巴结转移率对胃癌根治术后患者预后的评估价值

目的评估淋巴结转移率（MLR）分期系统对胃癌根治术后患者预后评估的价值。方法依据MLR分期及第6版、第7版UICC指南N分期这3种分期方法,对1042例胃癌D2根治术后患者进行预后分析。比较3种分期方法预测预后的齐性、相关性和梯度变化曲线,以及受试者工作特征（ROC）曲线下面积（AUC）。结果1042例患者术后5年生存率为47．5％,单因素和多因素预后分析显示,MLR分期（P〈0．01）和第7版N分期（P〈0．05）均为1042例胃癌患者的独立预后因素。MLR分期预测预后的AUC为0．754．高于第6版N分期的0．692和第7版N分期的0．705。与第6版、第7版N分期比较,MLR分期预测预后具有更好的齐性和线性曲线,Akaike信息标准化值更低（7240．017比7364．073和7325．731）。结论MLR分期对胃癌根治术患者的预后预测价值优于UICC指南中的N分期．有望成为一种新的淋巴结分期方法。     

两种手术方案治疗进展期胃中上部癌的临床对比研究

目的:探讨D2淋巴结清扫术与全系膜切除术治疗进展期胃中上部癌的临床疗效及安全性。方法:选取2011年5月至2014年1月收治的100例进展期胃中上部癌患者,分为对照组(n=50)与观察组(n=50),分别采用D2淋巴结清扫术与全系膜切除术,比较两组患者手术相关临床指标、术后并发症发生率、随访复发率及生存率。结果:观察组手术时间、术中出血量均优于对照组(P0.05),两组淋巴结清扫数量、首次排气时间、首次下床活动时间、住院时间、术后并发症发生率及随访复发率差异无统计学意义(P0.05),观察组随访生存率高于对照组(P0.05)。结论:全系膜切除术治疗进展期胃中上部癌可有效缩短手术时间,减少医源性创伤,并有助于提高远期生存率,优于D2淋巴结清扫术。     

Predictive factors for omitting lymphadenectomy in patients with node‐positive breast cancer treated with neo‐adjuvant systemic therapy

A pathologic complete response (pCR) in the axilla occurs in 30%‐40% of patients with initially node‐positive breast cancer after neo‐adjuvant chemotherapy (NACT). Debate persists about whether to perform systematic axillary lymphadenectomy (ALND) in patients with initial node‐positive disease and clinical complete response after NACT. We aimed to identify predictive factors of axillary pCR (ypN0) after NACT. This retrospective study analyzed data for all patients with initial biopsy‐proven node‐positive disease who underwent ALND after NACT between June 2008 and December 2016 at our institution. Clinical and pathologic features, recurrence and specific mortality rates were compared between patients who achieved an axillary pCR and those who did not (ypN0 vs ypN+, respectively). A total of 331 patients were included, of whom 128 (38.7%) became ypN0 after NACT. Among patients with >2 suspicious axillary lymph nodes before treatment, 54 (38%) achieved ypN0 status. The independent predictors of ypN0 were Ki‐67 > 30 (OR 1.98; 95% CI, 1.146‐3.381), HER2 positivity (OR 2.6; 95% CI, 1.354‐5.108), nonluminal molecular‐like subtype (OR 4.15; 95% CI, 2.068‐5.108), and clinical complete response, defined as negative clinical and ultrasonographic findings (OR 2.8; 95% CI, 1.110‐7.081). After a mean follow‐up of 61 months, distant disease‐free and overall survival rates were higher in patients with ypN0 disease (HR 4.14; 95% CI, 2.03‐8.43) than ypN+ patients. Complete clinical response and the presence of nonluminal molecular‐like subtypes independently predicted ypN0. Patients meeting these criteria might be suitable form omitting ALND and just performing targeted axillary procedures to patients meeting these criteria.     

The role of extended pelvic lymphadenectomy with radical prostatectomy for high-risk prostate cancer

IntroductionThe role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer (PCa) is controversial. Despite extensive research in both patterns of lymphatic drainage and the clinical effect of lymph node involvement, the exact role of PLND in PCa is yet to be defined.MethodsA systematic search of the MEDLINE database was performed, and all relevant articles were reviewed in depth.ResultsWe included 84 relevant articles in our review and subdivided the information into the following categories: preoperative patient evaluation, procedure/extent of dissection, complications, and robotic surgery era. Most authors agree that the greatest benefit is seen in patients with high-risk PCa undergoing RP. Multiple imaging modalities have been evaluated for assistance in patient selection, but the use of preoperative nomograms appears to be the most helpful selection tool. The role of limited PLND vs. extended PLND (e-PLND) is yet to be defined, though many authors agree that e-PLND is preferred in the setting of high-risk PCa. Although PLND is associated with a higher incidence of complications, especially lymphocele formation, it is unclear whether e-PLND leads to more complications than limited PLND. The introduction of minimally invasive surgery may have had a negative effect on implementation of PLND in the appropriate patients undergoing RP.ConclusionDespite a lack of prospective, randomized trials evaluating PLND in RP, there does appear to be a consistent benefit in patients with high-risk disease.     

Prognostic factors for survival after salvage surgery for locoregional recurrence of colon cancer

Background

Although locoregional recurrence after rectal cancer resection has been extensively investigated, studies of salvage surgery for locoregionally recurrent colon cancer are scarce. This study aimed to determine the predictors of postsalvage survival for locoregionally recurrent colon cancer.

Methods

We studied 45 consecutive patients who underwent macroscopically complete resection of locoregionally recurrent colon cancer between April 1988 and December 2007. The primary end point was cancer-specific survival, and 20 clinical variables were analyzed for their prognostic significance.

Results

Cancer-specific 5-year survival for the entire cohort of 45 patients was 46%. Multivariate survival analysis showed that margin status (P = .0311), number of locoregional recurrent tumors (P = .0002), pathological grade (P = .0416), largest tumor diameter (P = .0247), and distant metastasis (P = .0006) were independently associated with cancer-specific survival.

Conclusions

Salvage surgery for locoregional recurrence of colon cancer can provide a chance for long-term survival in selected patients.     

A new procedure with stomach-lifting techniques to simplify laparoscopy-assisted distal gastrectomy and extraperigastric lymph node dissection for gastric cancer

Laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection for gastric cancer is a complicated procedure that generally requires advanced laparoscopic surgical skill. We devised a simplified but effective laparoscopic procedure that provides a better visual field to perform safe lymph node dissection more quickly. First, a mini-laparotomy is done and a clear visual field is created by pulling a mini-retractor to the right or left. The laparoscopic procedure is made easier and safer by taping the stomach body, and by using the fringe of an abdominal wall sealing device (Lapdisk) placed behind the stomach, and a scope holder for the snake-retractor. The lymph nodes along the common hepatic vessels, left gastric vessels, and celiac artery (extraperigastric lymph nodes) are then dissected laparoscopically. The suprapyloric and infrapyloric lymph nodes are dissected through the mini-laparotomy incision and gastroduodenostomy is done using an anastomotic device. We performed laparoscopy-assisted distal gastrectomy (LADG) in 70 patients with gastric carcinomas located in the distal stomach (mean body mass index: 24.3). The mean operating time was 170 min and blood loss was minimal. All patients recovered well with minimal pain and good postoperative quality of life. We conclude that our simple and practical procedure for LADG with extraperigastric lymph node dissection can be performed safely and easily.     

胰后入路保留胰脾的原位脾门淋巴结清扫在腹腔镜胃癌根治术中的应用

Laparoscopic pancreas- and spleen-preserving splenic hilar lymph nodes dissection is still difficult to accomplish,which restrains its application in total gastrectomy for advanced proximal gastric can...     

D3 lymph node dissection in gastric cancer: Evaluation of postoperative mortality and complications

Since November 1995 we have been performing a D3 lymph node dissection in patients undergoing an operation for gastric cancer with a curative intent. The aim of the present study was to evaluate whether this procedure results in an increased postoperative mortality or complication rate in a Western population. Between November 1995 and August 1997 the postoperative courses of 76 patients were retrospectively assessed (45.3 lymph nodes per patient, lymph node ratio: 0.16). The patient outcome was compared with data from a historic control group of patients (n = 383) in whom the newly established D2 dissection was studied in our department. Regarding the demographic, clinical, and tumor-pathologic data, and the choice of resection and reconstructive procedures, the two groups differed only slightly. The postoperative mortality of 1% was lower (vs 6.8%) while the overall complication rate of 34% (vs 32.1%) was identical. In particular, no anastomotic leakage (vs 9.4%) and fewer nonsurgical complications (17.1% vs 27.9%) occurred. The reoperation rate was 1% vs 9.7%. However, in 6% of the patients drainage tubes had to be inserted under computed tomographic guidance. The average hospital stay remained unchanged (21.9 vs 20.7 days). A D3 dissection was shown to be feasible while demonstrating no disadvantages in the patients when compared with the D2 procedure. Received: August 17, 1999 / Accepted: March 24, 2000     

Risk factors and management of intra-abdominal infection after extended radical gastrectomy

Background

This study elucidated risk factors and management for intra-abdominal infection after extended radical gastrectomy.

Methods

From 1988 to 2004, 2,076 patients with gastric cancer underwent extended radical gastrectomy at Taipei Veterans General Hospital. Risk factors for intra-abdominal infection were determined by analyzing clinicopathological factors, operative procedure, combined organ resection, operative time, blood loss, and associated disease(s). Management modalities were summarized.

Results

The overall complication rate was 18.7%. Eighty (3.9%) patients were found to have intra-abdominal infections. Age, prolonged operation time, and combined organ resection were the precipitating factors. These patients were categorized into 3 groups: intra-abdominal abscess with adequate drainage, intra-abdominal abscess without anastomotic leakage, and intra-abdominal abscess because of leakage. Adequate drainage was the primary treatment. Mortality rate was 22.5% (18), and the most common cause of mortality was intra-abdominal abscess caused by leakage.

Conclusions

Although expert surgical skills can minimize the incidence of intra-abdominal infection, management also requires experience and training.     

Laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection for early gastric cancer

Background There has been a trend toward minimally invasive treatment of early gastric cancer. We report the preliminary results of laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection. Methods Six patients underwent laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection between February 2002 and October 2005 at Mie University Hospital. These patients first underwent laparoscopic sentinel lymph node biopsy and then laparoscopy-assisted distal gastrectomy with lymphadenectomy. Results No patient underwent conversion to open surgery during the operation. None of the patients had any postoperative complications. The mean length of postoperative hospital stay was 11.3 days. Sentinel lymph nodes were identified laparoscopically in five patients. There were 20 sentinel and 85 nonsentinel lymph nodes in the six patients. Postoperatively, tissue sections showed that none of the lymph nodes were metastasized. Immunohistochemistry with D2-40 antibody showed that there were normal lymphatics in the submucosal layer with mucosal defects at the endoscopic mucosal resection site. No patients had any tumor recurrence during followup. Conclusions Laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection was a safe and curative procedure. Endoscopic mucosal resection before sentinel lymph node biopsy was acceptable for early gastric cancer.     

Lateral Lymph Node Metastasis Is a Major Cause of Locoregional Recurrence in Rectal Cancer Treated with Preoperative Chemoradiotherapy and Curative Resection

Background In rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative resection, we evaluated the effect of clinical parameters on lateral pelvic recurrence and made an attempt to identify a risk factor for lateral pelvic recurrence. Methods The study involved 366 patients who underwent preoperative CRT and curative resection between October 2001 and December 2005. Clinical parameters such as gender, age, tumor size, histologic type, cT and cN classification, ypT and ypN classification, circumferential resection margin, tumor regression grade, chemotherapeutic regimen, and lateral lymph node size were analyzed to identify risk factors associated with lateral pelvic recurrence. Results Of the 366 patients, 29 patients (7.9%) had locoregional recurrence: 6 (20.7%) with central pelvic recurrence and 24 (82.7%) had lateral pelvic recurrence, of which 1 had simultaneous central and lateral pelvic recurrence. Multivariate analysis showed that ypN classification and lateral lymph node size were significantly associated with lateral pelvic recurrence (P < .001). Of 250 ypN0 patients, lateral pelvic recurrence developed in 1.4%, 2.9%, and 50% of patients with lateral lymph node sizes of <5, 5-9.9, and ≥10 mm, respectively (P < .001). Of 116 ypN+ patients, lateral pelvic recurrence developed in 4.3%, 35.7%, and 87.5% of patients with lateral lymph node sizes of <5, 5–9.9, and ≥10 mm, respectively (P < .001). Conclusions In our study, lateral pelvic recurrence was a major cause of locoregional recurrence, and ypN+ and lateral lymph node size were risk factors for lateral pelvic recurrence.     

胃癌根治术后胃瘫综合征的临床分析

目的探讨胃癌根治术后胃瘫综合征（PGS）发生的病因、诊断和治疗方法。方法以2003年1月至2007年4月间我院收治的500例胃癌根治术患者为研究对象,回顾性分析12例并发PGS患者的临床资料,分析其临床表现、诊治过程和高危因素。结果焦虑或抑郁、术前有胃流出道梗阻患者更易发生PGS（P〈0．01）;毕Ⅱ式胃肠吻合较毕Ⅰ式更易发生PGS（P〈0．05）;经非手术治疗,PGS患者均可康复,平均治愈时间（28．64±15．74）d,其中肠内和肠外营养患者平均治愈时间较全肠外营养患者明显缩短（P〈0．05）。结论术后PGS是由多个因素导致的;X线上消化道造影和胃镜检查是主要的诊断方法,营养支持和胃肠动力药物等非手术治疗有效,应尽量避免再次手术。     

腹腔镜胃癌根治术8例报告

目的：探讨腹腔镜胃癌根治术的可行性。方法2005年2～4月行腹腔镜胃癌根治术8例，其中远端胃根治性切除6例，根治性全胃切除和近端胃根治性切除各1例。结果：8例均在腹腔镜下完成手术，无中转开腹手术。远端胃根治性切除术时间（340±62）min，近端胃根治性切除362min，全胃根治性切除423min。术中出血量：远端胃根治性切除术100～250ml，平均140ml；全胃根治性切除术300ml；近端胃根治性切除170ml，术中均未输血。清扫淋巴结18～37枚，平均23枚。无手术并发症。排气时间38～56h，平均42．4h；进流食时间2～5d，平均2．5d。8例术后随访12～14个月，无复发和转移。结论：早期及较早的进展期胃癌行腹腔镜根治手术是可行的。