A novel operative technique on proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter.

BACKGROUND/AIMS: This article describes the surgical techniques and postoperative status for proximal gastrectomy reconstructed by interposition of a jejunal J pouch with preservation of the vagal nerve and lower esophageal sphincter. METHODOLOGY: We have performed a new technique for reducing postgastrectomy sequelae such as reflux esophagitis, early dumping syndrome, and microgastria in early gastric cancer located in the proximal third of the stomach. The technique consists of proximal gastrectomy with preservation of the hepatic, pyloric, celiac branch of the vagal nerve, and abdominal esophagus (lower esophageal sphincter), and reconstruction by interposition of a jejunal J pouch. To reserve pyloric function, pyloroplasty can be omitted by preservation of the pyloric branch from the vagal nerve. To restore loss of reservoir function, the reconstruction is performed with an interposed jejunal J pouch. Sacrifice of the mesenteric arcades is kept to a minimum to preserve the autonomic nerve and blood flow in the mesentery. RESULTS: All of the patients who underwent this operation were able to eat an adequate amount of food at 6 months after surgery and they were satisfied with their postoperative status. And that, we have not experienced postgastrectomy disorders such the dumping syndrome and reflux esophagitis. CONCLUSIONS: Therefore, this method is useful for preventing the postoperative disorders in patients with early gastric cancer located in the proximal third of the stomach.     

Serious complications after a proximal gastrectomy with a jejunal pouch interposition for gastric cancer

Proximal gastrectomy with jejunal interposition is a common surgical method in Japan, because the procedure has been shown to give a better post-operative quality of life. Some complications are associated with it. However, esophageal candidiasis and linear marginal ulcer along the gastrojejunal anastomosis after the surgical method has never previously been reported. We herein report a case of a patient who developed serious complications after proximal gastrectomy with jejunal interposition. A 68-year-old man underwent proximal gastrectomy with a jejunal pouch interposition for reconstruction for type 1 gastric cancer. Twenty-three months after the procedure, he complained of dysphagia and epigastric pain. Esophagogastroduodenoscopy showed esophageal candidiasis. The patient improved symptomatically following antifungal medication with fluconazole. Eleven months later, the patient developed severe pneumonia. In subsequent days, a melena episode occurred. Esophagogastroduodenoscopy revealed a linear marginal ulcer along three-fourths of the gastrojejunal anastomosis. The ulcer was drug resistant. The patient died of respiratory failure. Jejunal pouch interposition after a proximal gastrectomy can be associated with significant complications. Further studies are required to identify the best condition of the procedure.     

Effects of mosapride citrate on patients after vagal nerve, lower esophageal sphincter, and pyloric sphincter-preserving nearly total gastrectomy reconstructed by jejunal J pouch interposition, and postoperative quality of life

BACKGROUND/AIMS: Vagal nerve and pylorus-preserving nearly total gastrectomy reconstructed by interposition of a jejunal J pouch (hereinafter called NTGP) is a function-preserving operation for early gastric cancer. However, some patients after NTGP have suffered from postprandial food stasis in the substitute stomach, and postprandial stasis leads to abdominal symptoms. To clarify the clinical effect of mosapride citrate (hereinafter called MS) for prevention of food stasis in the substitute stomach for patients after NTGP, we studied the clinical effects of MS before and after administration of MS. METHODOLOGY: In a total of 24 patients (18 males, 6 females; aged 44-70 years, average 58.1 years) during 5 years after NTGP for early gastric cancer (D1 lymph node dissection, curability A), the relationship between their postoperative quality of life (QOL) and emptying function of the substitute stomach (hereinafter called EFS) was compared using a radioisotope method before MS therapy and after MS therapy at an oral dose of 15mg/day for 3 months. RESULTS: The interviews showd that after MS therapy, patients had more evident appetite and ate more food with a slight increase in body weight (0.52Kg) compared with patients before MS therapy. Before and after MS therapy, patients had no early dumping symtoms, while patients after MS therapy clearly had fewer symptoms such as reflux esophagitis, nausea, and abdominal pain compared with before MS therapy. After MS therapy, patients also had significantly decreased abdominal fullness compared with before MS therapy (p = 0.0046). Endoscopically, we found reflux esophagitis in 4 patients before MS therapy but in no patients after MS therapy. All patients before MS therapy showed residual contents in the substitute stomach, but only 10 patients after MS therapy showed residual contents in the substitute stomach. There was a significant difference between before and after MS therapy (p = 0.0016). Regarding EFS, the time to 50% residual rate before MS therapy (98.7 +/- 13.0 min) was significantly slower than that after MS therapy (83.2 +/- 13.8 min) (p = 0.0134). After MS therapy (37.0 +/- 4.9%), the residual rates at 120 minutes were significantly decreased compared with patients before MS therapy (44.8 +/- 5.3%) (p = 0.0028). Patients after MS therapy clearly had improved stasis of substitute stomach compared with before MS therapy. CONCLUSIONS: It was considered that MS therapy subsequently improves abdominal fullness due to the postprandial food stasis in the substitute stomach, contributing to the improvement of QOL of patients after NTGP.     

Role of D2 gastrectomy in gastric cancer with clinical para-aortic lymph node metastasis

BACKGROUND Owing to the technical difficulty of pathological diagnosis, imaging is still the most commonly used method for clinical diagnosis of para-aortic lymph node metastasis(PALM) and evaluation of therapeutic effects in gastric cancer, which leads to inevitable false-positive findings in imaging. Patients with clinical PALM may have entirely different pathological stages(stage IV or not), which require completely different treatment strategies. There is no consensus on whether surgical intervention should be implemented for this group of patients. In particular, the value of D2 gastrectomy in a multidisciplinary treatment(MDT)approach for advanced gastric cancer with clinical PALM remains unknown.AIM To investigate the value of D2 gastrectomy in a MDT approach for gastric cancer patients with clinical PALM.METHODS In this real-world study, clinico-pathological data of all gastric cancer patients treated at the Cancer Hospital, Chinese Academy of Medical Sciences between 2011 and 2016 were reviewed to identify those with clinically enlarged PALM. All the clinico-pathological data were prospectively documented in the patient medical record. For all the gastric cancer patients with advanced stage disease,especially those with suspicious distant metastasis, the treatment methods were determined by a multidisciplinary team.RESULTS In total, 48 of 7077 primary gastric cancer patients were diagnosed as having clinical PALM without other distant metastases. All 48 patients received chemotherapy as the initial treatment. Complete or partial response was observed in 39.6%(19/48) of patients in overall and 52.1%(25/48) of patients in the primary tumor. Complete response of PALM was observed in 50.0%(24/48)of patients. After chemotherapy, 45.8%(22/48) of patients received D2 gastrectomy, and 12.5%(6/48) of patients received additional radiotherapy. The postoperative major complication rate and mortality were 27.3%(6/22) and 4.5%(1/22), respectively. The median overall survival and progression-free survival of all the patients were 18.9 and 12.1 mo, respectively. The median overall survival of patients who underwent surgical resection or not was 50.7 and 12.8 mo,respectively. The 3-year and 5-year survival rates were 56.8% and 47.3%,respectively, for patients who underwent D2 resection. Limited PALM and complete response of PALM after chemotherapy were identified as favorable factors for D2 gastrectomy.CONCLUSION For gastric cancer patients with radiologically suspicious PALM that responds well to chemotherapy, D2 gastrectomy could be a safe and effective treatment and should be adopted in a MDT approach for gastric cancer with clinical PALM.     

A novel surgical procedure of vagal nerve, lower esophageal sphincter, and pyloric sphincter-preserving nearly total gastrectomy reconstructed by single jejunal interposition, and postoperative quality of life

BACKGROUND/AIMS: For early gastric cancer total gastrectomy (TG) has so far been essentially unavoidable. We performed the nearly TG reconstructed by single jejunal interposition preservation of the vagal nerve, lower esophageal sphincter (LES) and pyloric sphincter (D1 or D2 lymph node dissection, curability A) as a function-preserving surgical technique (i.e. NTG) to improve postoperative quality of life (QOL). In this report, the application criteria and points of the technique are outlined. QOL in patients after NTG was also compared with those after TG. METHODOLOGY: Sixteen subjects who underwent NTG (12 men and 4 women subjects at age 30 to 70 years, mean 55.6 years) were interviewed to inquire about abdominal symptoms and compared with 20 patients after conventional TG (excision with D2 lymph node, radical curability A) reconstructed by single jejunal interposition without preserving the vagal nerve, LES, and pyloric sphincter (i.e. TGI; 14 men and 6 women at age 26 to 70 years, mean 54.8 years). The former was named group A and the latter group B. Included were cases with early cancer localizing at the upper third and middle stomach, 2cm or further in distance from oral-side margin of the cancer to esophagogastric mucosal junction; and 3.5cm or further in distance from anal-side margin of the cancer to the pyloric sphincter. In excision with the lymph node, hepatic and celiac branches were preserved. To preserve LES, the abdominal esophagus was completely preserved. The pyloric antrum was also preserved at 1.5cm from the pyloric sphincter. The substitute stomach was created as a 30-cm-long single jejunal segment having orthodromic peristaltic movement. RESULTS: The operative procedure in group A significantly improved postoperative gastrointestinal symptoms such as appetite loss (p=0.0004), weight loss (p=0.0369), reflux esophagitis (RE) (p=0.0163), early dumping syndrome (p=0.0163), endoscopic RE (p=0.0311), and postgastrectomy cholecystolithiasis (p=0.0163) compared with group B. Oral intake per one meal 5 years after operation compared with that before operation was better in group A than in group B (p=0.0703). Postoperative epigastric fullness was significantly detected in group A compared with group B (p=0.0072). CONCLUSIONS: The proposed surgical technique of NTG is a function-preserving surgery appropriate to improve QOL of subjects with early gastric cancer. There was a defect in this technique of postprandial feeling of epigastric fullness. We think that a gut motility improvement agent is necessary to improve postprandial epigastric fullness after NTG.     

A case of esophageal cancer with mesojejunal lymph node metastasis after total gastrectomy

A 56-year-old man was diagnosed with esophageal cancer by upper gastrointestinal endoscopy for examination of dysphagia. The patient had undergone total gastrectomy and jejunal interposition 4 years previously for a gastric cancer at the pT1N0M0 stage according to the UICC-TNM classification. Enhanced CT findings revealed a 3-cm-diameter mass located near the superior mesenteric artery. We conducted subtotal esophagectomy associated with partial jejunectomy including mesojejunectomy. The mass was histologically diagnosed to be mesojejunal lymph node metastasis from esophageal cancer. Mesojejunal lymph node metastasis from esophageal cancer developing after total gastrectomy has been reported in only three cases including ours. The present lymph node metastases may have occurred via the newly developed lymphatic drainage route through the esophagojejunostomy, and this metastatic lymph node can be considered the regional lymph node. Therefore, resection of the interposed jejunal limb with mesojejunectomy may be rational in surgery on esophageal cancer developing after total gastrectomy.     

Solitary lymph node metastasis of gastric cancer as a basis for sentinel lymph node biopsy

BACKGROUND/AIMS: In order to examine the biology of sentinel lymph node of stomach cancer, we investigated solitary lymph node metastases that were hypothesized to represent sentinel lymph node. METHODOLOGY: In the 4,620 primary gastric cancers between 1964 and 1997, 1271 cases with a localized tumor were selected and the localization of the solitary metastases in relation to the primary tumors were studied. RESULTS: Of the 130 tumors with a single basin metastasis, only 71% of the tumors in the upper third, 75% of the middle and 80% of the lower involved the node basins in the close vicinity. In the anterior wall and the greater curvature the rates of adjacent metastasis were more than 90%, while in the posterior wall and the lesser curvature they were 76% and 43%, respectively. Metastases of the remaining cases were found at more distant basins. CONCLUSIONS: In stomach cancer sensitivity of sentinel lymph node biopsy would be very low by the exploration of the adjacent basin especially for the lesions in the lesser curvature and posterior wall.     

食管癌环氧化酶-2的高表达与淋巴转移的关系

目的　探讨环氧化酶 -2 (COX -2 )在食管癌中的表达情况及其与淋巴结转移的关系。方法　应用免疫组织化学方法(SP法 ) ,检测 1999～ 2 0 0 1年手术切除的 76例食管癌病人中COX -2的表达。其中有食管旁淋巴结转移者 18例 ,胃左动脉旁淋巴结转移者 11例。结果　COX -2在食管癌中的表达率为 81 6 %,主要为癌组织的表达 ,而在癌旁组织几乎不表达 ;食管癌旁和胃左动脉旁淋巴结转移组COX -2的表达水平均高于未转移组 (P <0 0 0 1)。结论　食管癌中COX -2的高度表达与食管癌的发生、发展及淋巴结转移有关 ,提示COX -2可能是防治食管癌的一个靶位。     

Lowered expression of galectin-2 is associated with lymph node metastasis in gastric cancer

Background  

Lymph node metastasis (LNM) is recognized as an important factor in the progression of tumor malignancy. It is required to discover molecular markers for the prediction of LNM in gastric cancers (GCs).     

The significance of abdominal para‐aortic lymph node metastasis in patients with lower thoracic esophageal cancer

Para‐aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.     

Lymphatic vessel invasion detected by monoclonal antibody D2-40 as a predictor of lymph node metastasis in T1 colorectal cancer

Objective  When selecting patients who are at high risk for lymph node metastasis, the detection of lymphatic vessel invasion (LVI) is important. We investigated LVI detected by D2-40 staining as a predictor of lymph node metastasis in T1 colorectal cancer. Materials and methods  Clinicopathological factors including LVI were investigated in 136 patients who underwent colectomy with lymph node dissection for T1 colorectal cancer. We used immunostaining with monoclonal antibody D2-40 to detect LVI. Results  Lymph node metastases were found in 18 patients (13.2%), and LVI were detected in 45 (33%); lymph node metastasis was more frequently observed in LVI-positive groups (13/45 vs 5/91, p < 0.001). Both univariate and multivariate analyses revealed that LVI detected by D2-40 and a poorly differentiated histology at the invasion front were independent risk factors of lymph node metastasis. Conclusion  LVI detected by D2-40 is important for the prediction of lymph node metastasis.     

Risk of lymph node metastasis in mixed-type early gastric cancer determined by the extent of the poorly differentiated component

AIM: To predict the rate of lymph node (LN) metastasis in diffuse- and mixed-type early gastric cancers (EGC) for guidelines of the treatment.METHODS: We reviewed 550 cases of EGC with diffuse- and mixed-type histology. We investigated the clinicopathological factors and histopathological components that influence the probability of LN metastasis, including sex, age, site, gross type, presence of ulceration, tumour size, depth of invasion, perineural invasion, lymphovascular invasion, and LN metastasis status. We reviewed all slides and estimated the proportions of each tumour component; pure diffuse type, mixed-predominantly diffuse type (diffuse > intestinal type), mixed-predominantly intestinal type (intestinal > diffuse type), and mixed diffuse = intestinal type. We calculated the extents of the respective components.RESULTS: LN metastasis was observed in 12.9% (71/550) of early gastric cancers cases [15/288 mucosal EGCs (5.2%) and 56/262 submucosal EGCs (21.4%)]. Of 550 cases, 302 were diffuse-type and 248 were mixed-type EGCs. Of 248 mixed-type EGCs, 163 were mixed-predominantly diffuse type, 82 were mixed-predominantly intestinal type, and 3 were mixed diffuse = intestinal type. Mixed-type cases with predominantly diffuse type histology showed a higher frequency of LN metastasis (20.2%) than cases of pure diffuse type (9.3%) and predominantly intestinal type (12.2%) histology. We measured the dimensions of each component (intestinal and diffuse type) to determine the association of the extent of each component with LN metastasis in mixed-type gastric carcinoma. The total tumour size and the extent of poorly differentiated components was associated with LN metastasis, while that of signet ring cell components was not.CONCLUSION: We recommend careful identification and quantitative evaluation of mixed-type early gastric cancer components after endoscopic resection to determine the intensity of the treatment.     

Development and validation of a nomogram for preoperative prediction of lymph node metastasis in pathological T1 esophageal squamous cell carcinoma

Endoscopic resection is increasingly used to treat patients with pathological T1 (pT1) esophageal squamous cell carcinoma (ESCC) because of its small surgical trauma. However, reports of the risk factors for lymph node metastasis (LNM) have been controversial. Therefore, we aim to build a nomogram to individually predict the risk of LNM in pT1 ESCC patients, to make an optimal balance between surgical trauma and surgical income.One hundred seventy patients with pT1 esophageal cancer in our hospital were analyzed retrospectively. Logistic proportional hazards models were conducted to find out the risk factor associated with LNM independently, and those were imported into R library “RMS” for analysis. A nomogram is generated based on the contribution weights of variables. Finally, decision analysis and clinical impact curve were used to determine the optimal decision point.Twenty-five (14.7%) of the 170 patients with pT1 ESCC exhibited LNM. Multivariable logistic regression analysis showed that smoking, carcinoembryonic antigen, vascular tumor thromboembolus, and tumor differentiation degree were independent risk factors for LNM. The nomogram had relatively high accuracy (C index of 0.869, 95% confidence interval: 0.794–0.914, P < .0001). The decision curve analysis provided the most significant clinical benefit for the entire included population, with scores falling just above the total score of 85 in the nomogram.Smoking, carcinoembryonic antigen, vascular tumor thromboembolus, and tumor differentiation degree may predict the risk of LNM in tumor 1 ESCC. The risk of LNM can be predicted by the nomogram.     

Clinicopathological features associated with lymph node metastasis in early gastric cancer: Analysis of a single-institution experience in China

BACKGROUND:

An accurate assessment of potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the number of invasive procedures used in cancer therapy is critical for improving the patient’s quality of life.

OBJECTIVE:

To evaluate the clinicopathological features associated with lymph node metastasis of early gastric cancer in patients from a single institution in China.

METHODS:

A retrospective review of data from 410 patients surgically treated for early gastric cancer at the First Affiliated Hospital (Nanjing, China) between 1998 and 2007, was conducted. The clinicopathological variables associated with lymph node metastasis were evaluated.

RESULTS:

Lymph node metastasis was observed in 12.20% of patients. The macroscopic type, tumour size, location in the stomach, depth of gastric carcinoma infiltration, and presence of vascular or lymphatic invasion showed a positive correlation with the incidence of lymph node metastasis by univariate analysis. Multivariate analyses revealed histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion to be significantly and independently related to lymph node metastasis. The depth of gastric carcinoma infiltration was the strongest predictive factor for lymph node metastasis. For intramucosal cancer, tumour size was the unique risk factor for lymph node metastasis. For submucosal cancer, histological classification and tumour size were independent risk factors for lymph node metastasis.

CONCLUSIONS:

Histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion are independent risk factors for lymph node metastasis in patients with early gastric cancer in China. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible for highly selected cancers.     

Reduction rate of lymph node metastasis as a significant prognostic factor in esophageal cancer patients treated with neoadjuvant chemoradiation therapy

Tumor regression is used widely as a measure of tumor response following radiation therapy or chemoradiation therapy (CRT). In cases of esophageal cancer, a different pattern of tumor shrinkage is often observed between primary tumors and metastatic lymph nodes (MLNs). Regression of MLNs surrounded by normal tissue may be a more direct measure of the response to CRT than regression of a primary tumor as exfoliative mechanical clearance does not participate in shrinkage of MLNs. In this study we evaluated the significance of the reduction rate (RR) of MLNs as a prognostic factor in esophageal cancer patients treated with neoadjuvant CRT. Forty-two patients with marked MLNs were selected from 93 patients with esophageal carcinoma who had received neoadjuvant CRT. The RRs of the primary tumor and the MLNs were calculated from computed tomography scans. In 20 patients, surgical resection was carried out following CRT. Univariate analysis was used to determine which of the following variables were related to survival: size of the primary tumor and MLNs; RRs of both lesions; degree of lymph node (LN) metastasis; clinical stage; and surgical resection. Multivariate analysis was then performed to assess the prognostic relevance of each variable. The primary tumor was larger than the MLNs in 69% of patients before CRT and in 40% of patients after CRT. In 79% of the patients, the RR of the primary tumor was greater than the RR of the MLNs. The results of the univariate analyses showed that a high RR of the MLNs and surgical resection after CRT were associated with significantly improved survival. The multivariate analysis demonstrated that the RR of MLNs had the strongest influence on survival. The RR of LN metastasis should be evaluated as an important prognostic predictor in patients with marked LN metastasis of esophageal cancer treated with CRT.     

A rare case of esophageal cancer (T2N0) with a solitary cerebellar metastasis

A 72-year-old man with a history of distal gastrectomy was diagnosed with esophageal cancer (EC). A subtotal esophagectomy and the residual total gastrectomy were performed via a right-sided thoracotomy and laparotomy with D2 lymph node dissection followed by reconstruction with a retrosternal right colonic interposition. The pathological diagnosis was Mt, 65 mm, moderately differentiated squamous cell carcinoma, pT2, ly0, v2, pN0, sM0, pStage II. The patient suddenly developed neurological symptoms 10 days after the operation, and brain magnetic resonance imaging detected a single solid left cerebellar tumor. This tumor was completely excised, and pathological diagnosis confirmed the tumor as an EC metastasis. He received adjuvant chemotherapy with cisplatin + 5-fluorouracil. Seven months later, he developed multiple brain metastases; however, no evidence of local recurrence or other metastatic sites was found. He died 8 months after the surgery. Solitary cerebellar metastasis from EC in which the primary tumor is T2N0 is rare, and the mechanism of this metastatic pattern is of particular interest. Our case study suggests that even if the primary tumor is in the limited stage and other metastatic sites are not identified at presentation, it seems reasonable to perform preoperative imaging of the brain for all patients with EC.