The benefit of laparoscopy-assisted distal gastrectomy compared with conventional open distal gastrectomy: a case-matched control study

BACKGROUND/AIMS: Laparoscopy-assisted distal gastrectomy is a surgical procedure which is safe, useful, and technically feasible for patients with early gastric cancer. The aim of this study is to determine whether laparoscopy-assisted distal gastrectomy is also superior to conventional open distal gastrectomy. METHODOLOGY: The study comprised 27 consecutive patients with early gastric cancer who were admitted to our hospital from 1997 to 2000 and underwent distal gastrectomy. Ten patients underwent laparoscopy-assisted distal gastrectomy; and 17 conventional open distal gastrectomy. RESULTS: Estimated blood loss was 17.7 +/- 12.1 g during laparoscopy-assisted distal gastrectomy, and 250.0 +/- 160.8 g during conventional open distal gastrectomy. The difference was statistically significant (p < 0.001). The day of ambulation (2.7 +/- 0.7 vs. 1.0 +/- 0.0), and start of liquid diet (6.9 +/- 1.2 vs. 4.3 +/- 0.5) were significantly delayed in conventional open distal gastrectomy compared with laparoscopy-assisted distal gastrectomy (p < 0.001, p < 0.05). At the 3rd postoperative day, the serum C-reactive protein level in laparoscopy-assisted distal gastrectomy decreased significantly more than that in conventional open distal gastrectomy (4.2 +/- 1.7 vs. 9.4 +/- 2.5: p < 0.05). No postoperative complication was found in laparaoscopy-assisted distal gastrectomy. CONCLUSIONS: Laparoscopy-assisted distal gastrectomy is a safe and useful operation for most early gastric cancers. Laparoscopy-assisted distal gastrectomy has been superior to conventional open distal gastrectomy.     

Minilaparotomy for early gastric cancer

BACKGROUND/AIMS: From the experience of laparoscopic-assisted distal gastrectomy, it was considered that a gastrectomy with lymph node dissection could be performed through a minilaparotomy, placed as for gastroduodenostomy in laparoscopic-assisted distal gastrectomy. METHODOLOGY: Ten patients with early gastric cancer underwent gastrectomy with lymph node dissection via minilaparotomy. Minilaparotomy was performed via a seven-centimeter midline incision placed at the mid-upper abdomen. Two six-centimeter-wide Kent retractors were used to suspend the abdominal wall on each side, and a multipurpose surgical arm to retract the liver. The abdominal wound could be moved horizontally by pulling these retractors to the right or left. This movable wound allowed direct visualization of almost all the operative field for gastrectomy. RESULTS: No operation was converted to a standard open gastrectomy. The patients who had a tumor in the lower third of the stomach underwent complete D2 lymph node dissection. In the patients who underwent pylorus-preserving gastrectomy, near complete D2 lymph node dissection was performed. Mean operation time was 175 minutes. No significant complication was encountered. CONCLUSIONS: It was concluded that minilaparotomy could be used as an alteration to the standard open gastrectomy.     

Lymphatic invasion in small differentiated-type mucosal gastric cancer

Endoscopic resection for early gastric cancer is indicated for patients who are at negligible risk of lymph node metastasis. A 71-year-old female underwent endoscopic resection for a 15-mm differentiated-type mucosal gastric tumor, as recommended in the Japanese treatment guidelines. A histological examination revealed lymphatic invasion. Therefore, we performed laparoscopy-assisted distal gastrectomy and D1+ lymph node dissection. A histological examination detected no.3 lymph node metastasis, but no residual cancer cells were observed at the site of the endoscopic resection. This case is rare as lymphatic invasion and lymph node metastasis are highly unusual in small differentiated-type mucosal gastric cancer. Having experienced this case, we consider that en-bloc endoscopic resection of such lesions is extremely important, as it allows precise histological examinations to be performed, which can determine the necessity of additional treatment.     

Gasless laparoscopy-assisted colon surgery utilizing mini-laparotomy and a subcutaneous abdominal wall lift system

BACKGROUND/AIMS: This study was performed to investigate the technical aspects and perioperative results of using a subcutaneous abdominal wall lift system for laparoscopy-assisted colectomy. METHODOLOGY: We attempted a laparoscopy-assisted colectomy for 19 patients and completed 16 cases using mini-laparotomy and a subcutaneous abdominal wall lift system, observing monitor images via laparoscopy or direct views through mini-laparotomy. All 5 surgeons had no experience of laparoscopy-assisted colectomy but considerable experience of laparoscopic cholecystectomy. RESULTS: The operating time ranged from 120 to 360 minutes with an average of 188. Intraoperative blood loss ranged from 20 to 300 mL with an average of 116 mL. No postoperative major complications occurred, but 5 cases suffered wound infection. CONCLUSIONS: Laparoscopy-assisted colon surgery utilizing a subcutaneous abdominal wall system and mini-laparotomy was feasible as minimally invasive surgery for colorectal diseases, even for surgeons with little previous experience.     

Laparoscopic gastrectomy for cancer

There are three procedures for the management of early gastric cancer (EGC): laparoscopic wedge resection (LWR), intragastric mucosal resection (IGMR), and laparoscopic gastrectomy. LWR or IGMR can be applied to treat EGC without the risk of lymph node metastasis. However, owing to the recent technical advances in endoscopic mucosal resection for EGC, the use of laparoscopic local resection for these lesions has gradually decreased. On the other hand, laparoscopic gastrectomy with lymph node dissection, such as laparoscopy-assisted distal gastrectomy, is widely accepted for the treatment of EGC with the risk of lymph node metastasis. To establish the acceptability of laparoscopic gastrectomy with D2 lymph node dissection against advanced gastric cancers, safe techniques and new instruments must be developed. The following advantages of laparoscopic surgery for the treatment of gastric cancer have been well demonstrated: clinical course after operation, pulmonary function, immune response. In the future, laparoscopic surgeons have to design and implement education and training systems for standard laparoscopic procedures, evaluate clinical outcomes by multicentric randomized control trial studies, and clarify the oncological aspects of laparoscopic surgery in basic studies.     

Gasless laparoscopy-assisted distal gastrectomy is feasible and useful for non-obese patients with early gastric cancer

BACKGROUND/AIMS: To evaluate the feasibility and usefulness of gasless laparoscopy-assisted distal gastrectomy except when treating obese patients compared with open distal gastrectomy for early cancer. METHODOLOGY: We treated 92 patients with distal gastrectomy for early gastric cancer consecutively. Patients with massive submucosal invasion and/or LN swelling were allocated for the open method, and patients with slightly invasive submucosal cancer were allocated for gasless laparoscopy-assisted surgery. As exceptions we employed open surgery for overweight patients and gasless laparoscopy for elderly and/or feeble patients. RESULTS: We attempted to perform open and laparoscopy-assisted surgery on 52 and 40 patients, respectively. Three cases in the laparoscopy-assisted group were converted to open surgery because of obesity. The age was older and BMI was lower in the laparoscopy-assisted group. In terms of operative time and blood loss as well as postoperative recovery, the results for the laparoscopy-assisted group were superior to those of the open surgery group. There were no cases of cardiopulmonary complications for the laparoscopy-assisted group. CONCLUSIONS: Gasless laparoscopy-assisted distal gastrectomy is feasible and useful for early gastric cancer except when treating obese patients.     

Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons

BACKGROUND/AIMS: A randomized study was performed to evaluate morbidity and mortality after D2 (level 1 and 2 lymphadenectomy) and D4 (D2 plus lymphadenectomy of para-aortic lymph nodes) dissection for advanced gastric cancer. METHODOLOGY: Two hundred and fifty-six patients with advanced gastric adenocarcinoma were enrolled (128 to each group). Patients were randomly allocated into D2 (N = 128) or D4 (N = 128) group. The first and second tiers of lymph nodes are removed in D2 dissection. In D4 gastrectomy, the paraaortic lymph nodes were additionally removed. RESULTS: There was no indication of significant distribution bias with regard to age, sex, T-grade, and N-grade between the two groups. Operation time of D4 gastrectomy (369 +/- 120 min) was significantly longer than that of D2 gastrectomy (273 +/- 1103 min), and blood loss of the D4 group (872 +/- 683 mL) was significantly greater than that of the D2 group 571 +/- 527 mL (P < 0.001). Five (4%) and two (2%) medical complications developed in the D2 and D4 groups, respectively. Surgical complications developed in 28 (22%) and 48 patients (38%) after D2 and D4 gastrectomy. The most common complications were anastomotic leakage, pancreatic fistula, and abdominal abscess. Pancreatic fistula developed in 6 (19%) of 32 patients after D4 plus pancreatosplenectomy, but the incidence of pancreatic fistula after D2 gastrectomy plus pancreatosplenectomy was low (6%, 1/16). Two patients died within 30 days of operation (0.8%, 2/256), and each patient belonged to the D2 and D4 group. CONCLUSIONS: Although there is a significantly higher surgical complication rate in D4 dissection, D4 dissection can be done safely as D2 dissection when performed by well-trained surgeons.     

Lymph node dissection in surgical treatment for remnant stomach cancer

BACKGROUND/AIMS: Lymphatic flow and the incidence of lymph node metastasis in remnant stomach cancer after distal gastrectomy are obscure. There is consequent controversy about appropriate lymph node dissection in such cases. METHODOLOGY: Thirty-three consecutive patients with remnant stomach cancer and 44 consecutive patients primary gastric cancer in the upper third of the stomach were investigated retrospectively about lymphatic flow by injection of activated carbon particles, and about the incidence of lymph node metastasis. RESULTS: Lymphatic flow and the incidence of lymph node metastasis in remnant stomach cancer after distal gastrectomy without lymph node dissection were the same as those in primary gastric cancer in the upper third of the stomach. Lymphatic flow after distal gastrectomy with lymph node dissection frequently streamed toward the para-aortic lymph nodes through the lymph nodes along the greater curvature and the suprapancreatic lymph nodes. Lymphatic flow toward the jejunal and colonic mesentery was observed regardless of the method of reconstruction. This lymphogenesis was clearly observed, especially in patients with tumors invading the anastomosis site of Billroth-II reconstruction. Station Nos. 110 (lower paraesophageal) and 111 (supradiaphragmatic) lymph nodes were also stained, despite being considered sites of distant metastasis irrespective of the method of reconstruction. CONCLUSIONS: On the basis of the evidence of altered lymphatic flow and the incidence of lymph node metastases in remnant stomach cancer, left upper abdominal evisceration with para-aortic lymph node dissection should be performed in advanced remnant stomach cancer.     

D2 dissection in laparoscopic and open gastrectomy for gastric cancer

AIM: To evaluate the radicalness and safety of laparoscopic D2 dissection for gastric cancer. METHODS: Clinicopathological data from 209 patients with gastric cancer, who underwent radical gastrectomy with D2 dissection between January 2007 and February 2011, were analyzed retrospectively. Among these patients, 131 patients underwent laparoscopyassisted gastrectomy (LAG) and 78 underwent open gastrectomy (OG). The parameters analyzed included operative time, blood loss, blood transfusion, morbidity, mortality, the number of harvested lymph nodes (HLNs), and pathological stage.RESULTS: There were no significant differences in sex, age, types of radical resection [radical proximal gastrectomy (PG + D2), radical distal gastrectomy (DG + D2) and radical total gastrectomy (TG + D2)], and stages between the LAG and OG groups (P 0.05). Among the two groups, 127 cases (96.9%) and 76 cases (97.4%) had 15 or more HLNs, respectively. The average number of HLNs was 26.1 ± 11.4 in the LAG group and 24.2 ± 9.3 in the OG group (P = 0.233). In the same type of radical resection, there were no signifi cant differences in the number of HLNs between the two groups (PG + D2: 21.7 ± 7.5 vs 22.4 ± 9.3; DG + D2: 25.7 ± 11.0 vs 22.3 ± 7.9; TG + D2: 30.9 ± 13.4 vs 29.3 ± 10.4; P 0.05 for all comparisons). Tumor free margins were obtained in all cases. Compared with OG group, the LAG group had signifi cantly less blood loss, but a longer operation time (P 0.001). The morbidity of the LAG group was 9.9%, which was not signifi cantly different from the OG group (7.7%) (P = 0.587). The mortality was zero in both groups. CONCLUSION: Laparoscopic D2 dissection is equivalent to OG in the number of HLNs, regardless of tumor location. Thus, this procedure can achieve the same radicalness as OG.     

Prophylactic lymph node dissection for early gastric cancer invading submucosa

BACKGROUND/AIMS: Prophylactic lymph node dissection for gastric cancer patients was considered to prolong survival time and D2 lymph node dissection was a standard treatment for early gastric cancer invading submucosa without lymph node metastasis. We investigated the possibility of minimizing the extent of prophylactic lymph node dissection for early gastric cancer invading submucosa if there was no evidence of lymph node metastasis. METHODOLOGY: We analyzed data on 404 patients with early gastric cancer invading the submucosa who underwent gastrectomy from 1979 to 1998 in the National Kyushu Medical Center, Fukuoka, Japan. The postoperative survival rate of patients with standard D2 dissection was compared with cases of those with limited D2 dissection which was defined as confined as D2 dissection dissections No.7 (lymph nodes were those along the left gastric artery), No.8 (lymph nodes along the anterosuperior common hepatic artery) and No.9 (lymph nodes along the celiac artery). RESULTS: Of the 404 patients, 52 and 17 had lymph node metastasis in group 1 and group 2 nodes, respectively. Of 17 patients with lymph node metastasis in group 2, 14 (82.4%) had metastasis confined to No.7, 8 and 9 of group 2 nodes. The 5-year survival rate of patients with submucosal cancer without lymph node metastasis was 94.4% after limited D2 dissection and 97.3% after standard D2 dissection, respectively. CONCLUSIONS: The appropriate prophylactic lymph node dissection for early gastric cancer invading the submucosa without lymph node metastasis was considered to be minimized to limited D2 dissection.     

腹腔镜早期胃癌根治术的临床研究

目的:探讨腹腔镜胃癌根治术在早期胃癌治疗中的临床应用。方法:回顾性分析2004年10月至2009年12月间79例接受腹腔镜胃癌根治术的早期胃癌患者的临床资料,包括手术方式、手术时间、术中失血、术后排气时间、术后住院天数、并发症、术后病理和随访等。结果:除1例中转开腹手术外,其余78例均在腹腔镜下完成胃切除和淋巴结清扫,其中腹腔镜远端胃切除术74例,近端胃切除术2例,全胃切除术2例;腹腔镜下D1+α式淋巴结清扫34例,D1+β式淋巴结清扫15例,D2式淋巴结清扫29例。手术时间为(202.9±45.6)min,术中失血(144.5±146.5)mL,术后排气时间(2.8±1.0)d,术后住院天数为(11.3±5.6)d,8例(10.1%)患者出现腹腔内出血、吻合口漏、小肠梗阻等,经手术和非手术治疗后痊愈。手术上、下切缘距离肿瘤为(4.0±1.9)cm和(3.6±1.7)cm,手术平均清扫淋巴结(13.1±6.5)枚,其中有3例(3.8%)发现淋巴结转移。术后随访2～64个月,均无肿瘤复发和远处转移。结论:腹腔镜胃癌根治术是治疗早期胃癌安全、可行、微创、有效的手术方法。     

Segmental gastrectomy with radical lymph node dissection for early gastric cancer

AIM: To describe a new surgical technique and evaluate the early results of segmental gastrectomy (SG) with modified D2 lymph node (LN) dissection for early gastric cancer (EGC). METHODS: Fourteen patients with EGC underwent SG with modified D2 dissection from 2006 to 2008. Their operative results and postoperative courses were compared with those of 17 patients who had distal gastrectomy (DG) for EGC during the same period. RESULTS: Operating time, blood loss, and hospital stay were similar between the 2 g...     

Laparoscopy-assisted total gastrectomy with trans-orally inserted anvil(OrVilTM):A single institution experience

AIM:To investigate the feasibility of laparoscopyassisted total gastrectomy(LATG)using trans-orally inserted anvil(OrVilTM)in terms of operative characteristics and short term outcomes. RESULTS:Characteristics of 27 patients with gastric cancer who underwent LATG from October 2009 to October 2012 in the Foshan Affiliated Hospital of South Medical University were retrospectively reviewed. Among these patients,six were reconstructed by minilaparotomy and 21 by OrVilTM.The clinicopathological characteristics,total operation time,total blood loss, abdominal incision and complications of anastomosis including stenosis and leakage,were compared between the groups undergoing LATG with OrVilTM and the group undergoing minilaparotomy. RESULTS:The operations were successfully performed on all the patients without intraoperative complications or conversion to open surgery.Two(10%)patients received palliative procedure under laparoscope who were prepared for LATG preoperatively.One case had hepatic metastatic carcinoma and 1 case had tumor recurrence near the anastomosis 8 mo after surgery.The mean follow-up duration was 10 mo(range,2-24 mo). Operation time was significantly reduced by the use of OrVilTM(198.42±30.28 min vs 240.83±8.23 min). The postoperative course with regard to occurrence of stenosis and leakage was not different between the two groups.There were no significant differences in estimated blood loss.The upper abdominal incision was smaller in OrVilTM group than in minilaparotomy group (4.31±0.45 cm vs 6.43±0.38 cm). CONCLUSION:LATG using OrVil TM is a technically feasible surgical procedure with sufficient lymph node dissection,less operation time and acceptable morbidity.     

Laparoscopic resection of synchronous gastric cancer and primary small intestinal lymphoma: A case report

Synchronous gastric cancer and primary small intestinal lymphoma are extremely rare. A 49-year-old woman was referred to our hospital with a history of upper abdominal pain for two weeks and was diagnosed with synchronous cancer. During hospitalization, the patient underwent laparoscopic distal gastrectomy + resection of bilateral ovaries + partial resection of both small intestine and descending colon. Pathological examination revealed a synchronous cancer consisting of early gastric cancer with poorly differentiated adenocarcinoma located in mucosa, with lymph node metastasis (3+/29) (T1N1M0, stage IB); and diffuse large B cell lymphoma of small intestine involving descending colon and bilateral ovaries, with lymph node metastasis (2+/5) (Ann Arbor IIE). The patient recovered well, without any obvious complications and was discharged on post-operative day 7. The patient received six cycles of chemotherapy after operation. She has been doing well with no evidence of recurrence for 13 mo.     

Risk factors for lymph node metastasis and evaluation of reasonable surgery for early gastric cancer

AIM: To give the evidence for rationalizing surgical therapy for early gastric cancer with different lymph node status. METHODS: A series of 322 early gastric cancer patients who underwent gastrectomy with more than 15 lymph nodes retrieved were reviewed in this study. The rate of lymph node metastasis was calculated. Univariate and multivariate analyses were performed to evaluate the independent factors for predicting lymph node metastasis. RESULTS: No metastasis was detected in No.5, 6 lymph nodes (LN) during proximal gastric cancer total gastrectomy, and in No.10, 11p, 11d during for combined resection of spleen and splenic artery and in No.15 LN during combined resection of transverse colon mesentery. No.11p, 12a, 14v LN were proved negative for metastasis. The global metastastic rate was 14.6% for LN, 5.9% for mucosa, and 22.4% for submucosa carcinoma, respectively. The metastasis in group Ⅱ?was almost limited in No.7, 8a LN. Multivariate analysis identified that the depth of invasion, histological type and lymphatic invasion were independent risk factors for LN metastasis. No metastasis from distal cancer (≤ 1.0 cm in diameter) was detected in group Ⅱ?LN. The metastasis rate increased significantly when the diameter exceeded 3.0 cm. All tumors (≤ 1.0 cm in diameter) with LN metastasis and mucosa invasion showed a depressed macroscopic type, and all protruded carcinomas were > 3.0 cm in diameter. CONCLUSION: Segmental/subtotal gastrectomy plus D1/D1 No.7 should be performed for carcinoma (≤ 1.0 cm in diameter, protruded type and mucosa invasion).Subtotal gastrectomy plus D2 or D1 No.7, 8a, 9 is the most rational operation, whereas No.11p, 12a, 14v lymphadenectomy should not be recommended routinely for poorly differentiated and depressed type of submucosa carcinoma (> 3.0 cm in diameter). Total gastrectomy should not be performed in proximal, so does combined resection or D2 /D3 lymphadenectomy.     

Surgical outcome of 483 patients with early gastric cancer: prognosis, postoperative morbidity and mortality, and gastric remnant cancer

BACKGROUND/AIMS: The aim of this retrospective study was to evaluate the characteristics, treatment, postoperative morbidity, mortality, and prognosis of early gastric cancer patients as well as the incidence of gastric remnant cancer after curative surgery based on an analysis of the surgical results of Nippon Medical School Hospital over the past 10 years (1991-2000). METHODOLOGY: Out of 1057 patients with gastric cancer (all stages), 483 patients (301 males and 182 females; mean age 60.9 years) underwent surgery for early gastric cancer. Early gastric cancer, defined as that invading the m or sm layer regardless of lymph node metastasis, was classified according to the Japanese Classification of Gastric Carcinoma. The survival rate was calculated using the Kaplan-Meier method. RESULTS: The stages of the 483 patients were as follows: stage Ia patients, 443 cases; stage Ib, 29 cases; stage II, 7 cases; and stage IV, 4 cases. The overall 5- and 10-year survival rates were 95.9% and 95.9% for stage Ia, 82.9% and 80.2% for stage Ib, 73.2% and 68.6% for stage II and 0% for stage IV, respectively. No difference was observed in the 5- and 10-year survival rates between patients with D1 and D2 dissections in cases without lymph node metastasis. In patients with n1 positive sm cancer, however, the 5-year survival rate of the patients who underwent D2 dissection was 91.0% while that of those who underwent D1 dissection was 80.0% (P<0.05). The incidences of postoperative morbidity from various cancers included 4.2% from surgical site infections, 1.6% from anastomotic dehiscence, 1.6% from intestinal obstructions, and 3.9% from respiratory and/or heart dysfunction. Three patients (0.6%) died of multiple organ failure. Five patients who had undergone gastrectomy for early gastric cancer were diagnosed as having early cancer in the gastric remnant during a periodic follow-up endoscopy and underwent regastrectomy. CONCLUSIONS: The prognosis of early gastric cancer is usually excellent, and the morbidity and mortality rates are satisfactory. D2 lymph node dissection is necessary in patients with n1 positive sm cancer. Periodic follow-up endoscopies in gastrectomized patients may be useful for the early detection of gastric remnant cancer.     

Is prophylactic placement of drains necessary after subtotal gastrectomy？

AIM： To determine the evidence-based values of prophylactic drainage in gastric cancer surgery.
METHODS： One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups.
RESULTS： No significant differences were observed between the drain group and no-drain group in terms of operating time （171 ± 42 rain vs 156 ± 39 rain）, number of post-operative days until passage of flatus （3.7 ± 0.5 d vs 3.5 ± 1.0 d）, number of post-operative days until initiation of soft diet （4.9±0.7 d vs 4.8±0.8 d）, length of post-operative hospital stay （9.3±2.2 d vs 8.4±2.4 d）, mortality rate （5.4% vs 3.8%）, and overall postoperative complication rate （21.4% vs 19.2%）.
CONCLUSION： Prophylactic drainage placement is not necessary afer subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.     

经自然腔道取出标本的全腹腔镜远端胃癌根治术（Uncut Roux-en-Y吻合）七例报告

目的探讨经自然腔道取出标本的全腹腔镜远端胃癌根治术（Uncut Roux-en-Y吻合）的安全性、可行性及近期效果。 方法回顾性分析2017年1月至2017年5月淄博市临淄区人民医院实施的全腹腔镜远端胃癌D2根治术（胃空肠Uncut Roux-en-Y吻合）7例的临床资料。 结果7例病例均在全腹腔镜下成功完成,经自然腔道（阴道或直肠）取标本,无中转开腹,无术中并发症,无手术相关死亡。手术中位时间为280（260~320）min,其中消化道重建时间为45（35~55）min,术中中位失血为90（30~120）ml。术后中位排气时间2（1~3）d,手术后中位住院天数8（7~13）d。无吻合口漏、Roux滞留综合征（RSS）和直肠狭窄等相关并发症发生。 结论腹部无辅助切口经自然腔道取标本的全腹腔镜远端胃癌根治术（胃空肠Uncut Roux-en-Y吻合）安全、可行,既避免术后胆汁反流性胃炎,又避免了Roux-en-Y吻合的Roux滞留综合征;经自然腔道标本取出,进一步减少创伤,减轻术后疼痛,手术时间无明显延长。     

Laparoscopic Gastrectomy for Early Gastric Cancer after Endoscopic Mucosal Resection

Abstract: In 1991, we first performed a simple technique of Iaparoscopy-assisted Bill-roth I gastrectomy for patients with mucosal gastric cancer. Endoscopic mucosal resection (EMR) sometimes fails to completely resect the early gastric cancer lesion, nor does it give full histopathology of the resected stomach. The aim of this study was to review the surgical and pathological findings of eight patients who underwent laparoscopic gastrectomy after EMR for early gastric cancer. Of 54 patients with early gastric cancer who were treated with laparoscopic gastrectomy between 1994 and 1998, eight patients underwent surgery after EMR. The resected margin of the EMR specimens was positive in three and suspicious in five; and three underwent laparoscopic wedge resection of the stomach, while five underwent Iaparoscopy-assisted distal gastrectomy with regional lymph node dissection. All but one resected stomach had residual cancer tissue in the mucosa or submucosa, and three patients had multiple gastric cancers. The results indicated that remnant cancer tissue might be present when the resected margin of the EMR specimen was positive or suspicious. Partial resection or distal gastrectomy under laparoscopy is useful for such patients who have undergone EMR for early gastric cancer. (Dig Endooc 1999; 11:132–136)     

Successfully treated metachronous liver metastasis of alpha-fetoprotein-producing early gastric cancer: case report

We treated a 57-year-old male with liver metastasis derived from an alpha-fetoprotein-producing early gastric cancer. Eleven months after distal gastrectomy with D2 lymph node dissection, the patient underwent hepatectomy of segment 4 to resect a liver tumor 3 cm in diameter found by abdominal computed tomography. Immunohistochemical examination of the stomach and liver specimens, using anti-alpha-fetoprotein antibody, showed partial alpha-fetoprotein expression in both the primary gastric and metastatic hepatic tumors. The patient's serum alpha-fetoprotein level had been elevated at 302 ng/mL before hepatectomy, but the level remained below 5 ng/mL postoperatively. The patient remains alive without tumor recurrence 3 years after hepatectomy. There have been few previous reports of good outcome after curative resection of a metachronous liver metastasis derived from alpha-fetoprotein-producing gastric cancer. The assessment of serum alpha-fetoprotein level may be useful for detecting and monitoring liver metastasis in gastric cancer, especially for alpha-fetoprotein-producing tumors.