Short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy with a very small remnant stomach for cStage I proximal gastric carcinoma

Background

Total or proximal gastrectomy is usually performed for early proximal gastric carcinoma, but the optimal type of gastrectomy is still unknown. We evaluated short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy (LsTG) in comparison with laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG).

Methods

We analyzed 113 patients who underwent LsTG (n = 38), LTG (n = 48), or LPG (n = 27) for cStage I gastric cancer located in the upper third of the stomach. Postoperative morbidities, nutritional status including body weight, serum albumin, hemoglobin, the prognostic nutritional index (PNI), and endoscopic findings at 1 year after surgery were compared between LsTG and both LTG and LPG.

Results

Operation time and intraoperative blood loss were similar among the three groups. The incidence of postoperative morbidities was lower in LsTG than in LTG. The degree of body weight loss was significantly smaller in LsTG than in LTG at 6 and 12 months. At 12 months, LsTG resulted in better serum albumin and PNI than LPG, and better hemoglobin than LTG. Endoscopic examination demonstrated that one LsTG patient and two LPG patients had reflux esophagitis. Remnant gastritis was observed more frequently in LPG than in LsTG. No LsTG patient had bile reflux, although it was observed in four LPG patients.

Conclusions

LsTG with a very small remnant stomach had favorable short-term outcomes and nutritional status compared with LTG and LPG, so it may be a better treatment option for cStage I proximal gastric carcinoma.

     

Effect of rikkunshito, a Japanese herbal medicine, on gastrointestinal symptoms and ghrelin levels in gastric cancer patients after gastrectomy

Background

Gastric cancer patients who undergo gastrectomy suffer from a post-gastrectomy syndrome that includes weight loss, dumping syndrome, reflux esophagitis, alkaline gastritis, and finally malnutrition. It is important to ameliorate the post-gastrectomy symptoms to restore postoperative quality of life (QoL). The aim of this study was to investigate the effect of rikkunshito, a Japanese herbal medicine, on postoperative symptoms and ghrelin levels in gastric cancer patients after gastrectomy.

Methods

Twenty-five patients who had undergone gastrectomy received 2.5 g of rikkunshito before every meal for 4 weeks, and a drug withdrawal period was established for the next 4 weeks. Changes in gastrointestinal hormones, including ghrelin, and appetite visual analog scale scores were measured, and QoL was estimated by using the European Organization for Research and Treatment of Cancer core questionnaire QLQ-C30. The Dysfunction After Upper Gastrointestinal Surgery for Cancer (DAUGS) scoring system was used to evaluate gastrointestinal symptoms after gastrectomy.

Results

Sixteen men and nine women (mean age 61.9 years) were enrolled in the study. All patients had either stage I (n = 24) or II (n = 1) disease and had undergone either distal gastrectomy (n = 17) or total gastrectomy (n = 8) by a laparoscopy-assisted approach. The mean ratio of the acyl-/total ghrelin concentration increased significantly after rikkunshito administration (Pre: 7.8 ± 2.1, 4 weeks: 10.5 ± 1.7 %, p = 0.0026). The total DAUGS score, as well as the scores reflecting limited activity due to decreased food consumption, reflux symptoms, dumping symptoms, and nausea and vomiting significantly improved after rikkunshito administration.

Conclusions

The present study demonstrated a significant attenuation of gastrointestinal symptoms after gastrectomy by treatment with rikkunshito. Rikkunshito is potentially useful to minimize gastrointestinal symptoms after gastrectomy.     

Long-term outcomes of patients who underwent limited proximal gastrectomy

Background

Because the incidence of early gastric cancers has been increasing in Asian countries, postoperative quality of life has received considerable attention in addition to oncological outcomes.

Methods

Eighty-four patients with clinically early gastric cancers were enrolled in this retrospective study. Among them, 35 patients underwent total gastrectomy (TG) and 49 patients underwent limited proximal gastrectomy (PG). Blood chemistry, changes in body weight, and oncological outcomes were compared between the two groups.

Results

Postoperative hemoglobin levels and body weights were significantly lower in the TG group than in the PG group, and there were no significant differences in the levels of other nutritional indicators such as serum total protein and total cholesterol. However, the overall survival rates of patients in the PG group were similar to those of patients in the TG group (5-year survival rates, 95 versus 97 %, respectively; p = 0.86).

Conclusions

Limited proximal gastrectomy with regional lymph node dissection has possible positive effects on maintaining body weight and preventing postgastrectomy anemia with similar oncological outcomes to total gastrectomy in patients with early gastric cancers.     

Endoscopic submucosal dissection for early gastric cancer in anastomosis site after distal gastrectomy

Background

Detection of early gastric cancer (EGC) in the remnant stomach is increasing because of follow-up endoscopic surveillance programs. Endoscopic treatment appears to be desirable for EGC in the remnant stomach because it is less invasive than surgical resection.

Methods

In this retrospective study, to evaluate the feasibility of endoscopic submucosal dissection (ESD) for EGC in an anastomotic site, treatment results of ESD for EGC in an anastomotic site and in remnant stomach not involving an anastomotic site were compared. In total, 11 EGC lesions of anastomotic sites in 11 patients and 22 EGC lesions of remnant stomach not involving an anastomotic site in 21 patients were treated by ESD.

Results

All lesions were successfully treated by en bloc resection. There were three patients with perforations in the anastomotic site group. Although resected specimen size and tumor size were larger in the anastomotic site group than in the non-anastomotic site group (P < 0.01), the procedure duration was far longer in the anastomotic site group than in the non-anastomotic site group (P < 0.01). The speed of the procedure was faster in the non-anastomotic site group than in the anastomotic site group (P < 0.05).

Conclusions

Although ESD for EGC in an anastomotic site is a time-consuming procedure and requires advanced techniques compared with ESD for EGC not involving an anastomotic site, a high en bloc resection rate was achieved. ESD by endoscopists with sufficient experience appears to be a feasible treatment for EGC in an anastomotic site.     

Long-term outcomes of Roux-en-Y and Billroth-I reconstruction after laparoscopic distal gastrectomy

Background

Laparoscopic distal gastrectomy (LDG) is an established procedure for the treatment of early gastric cancer. Roux-en-Y (R-Y) or Billroth-I (B-I) reconstruction is generally performed after LDG in Japan. The aim of this retrospective cohort study was to compare the effectiveness of R-Y and B-I reconstructions and thereby determine which has better clinical outcomes.

Methods

We analyzed data from 172 patients with gastric cancer who underwent LDG. Reconstruction was done by R-Y in 83 patients and B-I in 89. All patients were followed up for 5 years. Evaluated variables included symptoms, nutritional status, endoscopic findings, gallstone formation, and later gastrointestinal complications.

Results

Scores for the amount of residue in the gastric stump, remnant gastritis, and bile reflux, calculated according to the “residue, gastritis, bile” scoring system, were significantly lower in the R-Y group (score 0 vs. 1 and more; p = 0.027, <0.001, and <0.001, respectively). The proportion of patients with reflux esophagitis was significantly lower in the R-Y group (p < 0.001). Relative values (postoperative 5 years/preoperative) for body weight, serum albumin level, and total cholesterol level were similar in the two groups (p = 0.59, 0.56, and 0.34, respectively). Gallstone formation did not differ between the groups (p = 0.57). As for later complications, the incidence of gastrointestinal ulcer was 4.5 % in the B-I group, and that of ileus was 3.6 % in the R-Y group, but differences between the groups were not significant (p = 0.12, 0.11, respectively).

Conclusions

As compared with B-I, R-Y was associated with lower long-term incidences of both bile reflux into the gastric remnant and reflux esophagitis.     

Long-term outcome of endoscopic submucosal dissection is comparable to that of surgery for early gastric cancer: a propensity-matched analysis

Background

Data concerning the long-term outcomes of endoscopic submucosal dissection (ESD) versus surgery for early gastric cancer (EGC) are limited. We aimed to compare the long-term outcomes of ESD and surgery for patients with EGC.

Methods

Data were reviewed from patients treated by ESD or surgery for EGC in 2005–2010. The primary outcome was overall survival (OS). Secondary outcomes were disease-specific survival (DSS), disease-free survival (DFS), recurrence-free survival (RFS), treatment-related complications, and hospital stay duration.

Results

Among 617 patients, 342 underwent ESD and 275 underwent surgery. The 5-year OS rates were similar between the ESD group and the surgery group (96.9% vs 98.1%, P = 0.581). In a propensity-score-matched analysis of 117 pairs, there were no significant differences in the OS rates (96.5% vs 99.1%, P = 0.125) and DSS rates (100% vs 99.1%, P = 0.317) between the ESD group and the surgery group. The ESD group had a significantly lower DFS rate (90.3% vs 98.0%, P = 0.002), a significantly lower RFS rate (95.1% vs 98.0%, P = 0.033), a significantly higher early complication rate (6.7% vs 1.5%, P < 0.001), a significantly lower late complication rate (0% vs 9.1%, P < 0.001), and a significantly shorter median hospital stay (3 days vs 10 days, P < 0.001) than the surgery group.

Conclusions

ESD and surgery have comparable OS rates in patients with EGC. ESD has benefits, including a lower late complication rate and shorter hospital stay. However, RFS and DFS rates might be lower after ESD than after surgery.

     

Colonoscopy reduced distal colorectal cancer risk and excess cancer risk associated with family history

Purpose

Colonoscopy efficacy at preventing proximal colorectal cancer (CRC) is questioned, and little is known about efficacy in high-risk versus medium-risk populations. We investigated the relationship between colonoscopy screening, family history of colorectal cancer (FHCC), and CRC risk by site.

Methods

Among 92,078 women of the E3N prospective cohort, 692 CRCs have been diagnosed after a median follow-up of 15.4 years. Cox proportional hazard models estimated adjusted hazards ratios according to subsites of cancer and FHCC.

Results

A personal history of colonoscopy (PHC; n = 37,470) was associated with decreased rectal and distal colon cancer risks (hazard ratio (HR) = 0.57; 95 % Confidence Interval (CI) = 0.42–0.78 and HR = 0.37; 95 % CI = 0.26–0.52, respectively), but not proximal colon cancer risk (HR = 0.87; 95 % CI = 0.64–1.18). In women with no prior colonoscopy, those with FHCC had a 80 % higher CRC risk than those without FHCC. In women with previous colonoscopy, CRC risk was similar in women with and without FHCC (p for interaction = 0.04).

Conclusions

Results showed colonoscopy ability to prevent distal cancers, but not proximal cancers in women. Colonoscopy screening also reduced the excess risk of women with FHCC to that of women with no FHCC.     

Total vs proximal gastrectomy for adenocarcinoma of the upper third of the stomach: a propensity-score-matched analysis of a multicenter western experience (On behalf of the Italian Research Group for Gastric Cancer–GIRCG)

Background

The aim of this study is to compare surgical outcomes including postoperative complications and prognosis between total gastrectomy (TG) and proximal gastrectomy (PG) for proximal gastric cancer (GC). Propensity-score-matching analysis was performed to overcome patient selection bias between the two surgical techniques.

Methods

Among 457 patients who were diagnosed with GC between January 1990 and December 2010 from four Italian institutions, 91 underwent PG and 366 underwent TG. Clinicopathologic features, postoperative complications, and survivals were reviewed and compared between these two groups retrospectively.

Results

After propensity-score matching had been done, 150 patients (75 TG patients, 75 PG patients) were included in the analysis. The PG group had smaller tumors, shorter resection margins, and smaller numbers of retrieved lymph nodes than the TG group. N stages and 5-year survival rates were similar after TG and PG. Postoperative complication rates after PG and TG were 25.3 and 28%, respectively, (P = 0.084). Rates of reflux esophagitis and anastomotic stricture were 12 and 6.6% after PG and 2.6 and 1.3% after TG, respectively (P < 0.001 and P = 0.002). 5-year overall survival for PG and TG group was 56.7 and 46.5%, respectively (P = 0.07). Survival rates according to the tumor stage were not different between the groups. Multivariate analysis showed that type of resection was not an independent prognostic factor.

Conclusion

Although PG for upper third GC showed good results in terms of survival, it is associated with an increased mortality rate and a higher risk of reflux esophagitis and anastomotic stricture.

     

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy in terms of nutritional status or quality of life in early gastric cancer patients

Background

This study aimed to evaluate the surgical outcomes of laparoscopic proximal gastrectomy (LPG) reconstructed by the double-tract method in comparison to those of laparoscopic total gastrectomy (LTG).

Early gastric cancer: diagnosis, staging, and clinical impact. Evaluation of 530 patients. New elements for an updated definition and classification

Background

The prevention and early diagnosis of gastric cancer permit clinicians to discover the tumor in the initial phase, during which time it can be completely eradicated, endoscopically or surgically. Since Murakami gave the definition of early gastric cancer (EGC) in 1971, many authors have identified various subtypes of EGC with different morphological characteristics and clinical behaviour.

Methods

We evaluated retrospectively 530 patients: the median follow-up time was 10.4 months (range 0.3–29.2). All tumors were classified according to the macroscopic and microscopic criteria proposed by the Japanese Society of Gastroenterology and Endoscopy and Lauren, respectively. The infiltrative growth pattern was evaluated according to Kodama’s classification. Only tumor-related death was considered as an endpoint of interest for the survival analysis.

Results

The overall survival rates of our patients were 94 % (95 % CI, 92–96) and 90 % (95 % CI, 87–93) at 5 and 10 years, respectively. Only 44 patients (8.3 %) died of the disease. Kodama’s type (p < 0.0001), lymph node status, both for number and pathological stage according to the 7th Edition of TNM (p < 0.0001), and depth of infiltration (p = 0.0006) were significant prognostic factors in univariate analysis. The multivariate analysis identified Kodama’s PENA type (HR, 3.91; 95 % CI, 2.08–7.33; p < 0.0001) and lymph node status for more than three positive nodes versus negative nodes (HR, 12.78; 95 % CI, 5.37–30.43; p < 0.0001) as the only independent prognostic factors in our series.

Conclusion

Lymph node status, especially when more than three lymph nodes are involved, is the most important prognostic factor in EGC. However, it is also important to evaluate the infiltrative growth pattern of the cancers in their early phase according to Kodama’s classification, considering PEN A type lesions to be more aggressive than the other EGC types. Then, we propose new elements for an updated definition and classification of EGC, with an important clinical impact on the treatment of patients.     

Early initiation of adjuvant chemotherapy improves survival of patients with pancreatic carcinoma after surgical resection

Purpose

Adjuvant chemotherapy is accepted as a standard treatment after surgical resection of pancreatic carcinoma; however, the optimal timing between surgery and initiation of adjuvant chemotherapy has not been reported. The aim of this study was to determine the optimal timing of adjuvant chemotherapy after surgical resection of pancreatic carcinoma.

Methods

Records of 104 patients who received adjuvant chemotherapy after curative surgical resection of pancreatic carcinoma were reviewed retrospectively. Patients were grouped according to whether they received initial adjuvant chemotherapy within 20 days after surgery (≦20 days, n = 57) or more than 20 days after surgery (>20 days, n = 47). Relationships between time to initiation of adjuvant chemotherapy, other clinicopathological factors, and survival were analyzed.

Results

The rate of postoperative complication was significantly lower than in the ≦20 days group compared with the >20 days group (P = 0.003); no significant difference in other clinicopathological factors was found. Multivariate analysis revealed that time to initiation of adjuvant chemotherapy was an independent prognostic factor of disease-free survival (P = 0.009) and overall survival (P = 0.037). The ≦20 days group had longer 5-year overall survival rates than did the >20 days group (52 vs. 26 %, P = 0.013) as well as longer 5-year disease-free survival rates (53 vs. 22 %, P = 0.007).

Conclusions

Adjuvant chemotherapy for patients with resected pancreatic carcinoma should be initiated as soon as possible after surgical resection. Prevention of postoperative complication is needed to enable early initiation.     

Clinicopathological characteristics and prognosis of signet ring cell carcinoma of the stomach

Background

Signet ring cell carcinoma (SRC) of the stomach is a histological type based on microscopic characteristics. Although the distinctive clinicopathological features of SRC have been reported, results are inconsistent and survival outcomes are uncertain.

Methods

We retrospectively studied 769 patients with gastric carcinoma who underwent gastrectomy in our institute from 1999 to 2009. Among them, 326 patients (42.4 %) had early gastric cancer (EGC) and 443 patients (57.6 %) had advanced gastric cancer (AGC). Sex, age, tumor location, macroscopic type, tumor size, microscopic invasion, and survival rate were compared between patients with SRC, differentiated-, and undifferentiated-type gastric carcinomas.

Results

Fifty-one patients (15.6 %) had SRC in EGC; there were significant differences in sex, age, location, macroscopic type, and size between SRC and the differentiated histological type. However, there was no difference between SRC and undifferentiated-type gastric carcinoma, except for the macroscopic type. Fifty-seven patients (12.9 %) had SRC in AGC. Sex, age, location, size, macroscopic type, perineural invasion, N stage, and hepatic metastasis were significantly different between SRC and the differentiated histological type. Undifferentiated-type gastric carcinoma differed in sex, macroscopic type, and hepatic metastasis. The overall survival rate differed between SRC and other cell types (P < 0.001). Among all the study patients, age [hazard ratio (HR) 1.013, P = 0.041] and tumor, node, and metastasis (TNM) stage (HR 2.350, P < 0.001) were important factors for predicting survival. Omitting patients with palliative resection or metastases, TNM stage was still an important factor for survival (HR 2.077, P < 0.001).

Conclusions

Patients with SRC showed similar clinicopathological features with undifferentiated histology. The survival of patients with SRC reflected a better prognosis in patients with undifferentiated gastric carcinoma. However, when narrowing the patients to those with EGC only, survival in EGC patients exhibited no difference between histological types. Among AGC patients, SRC patients had a worse prognosis than other cell types.     

Risk of lymph node metastases from intramucosal gastric cancer in relation to histological types: how to manage the mixed histological type for endoscopic submucosal dissection

Background

The behavior of early gastric cancer (EGC) with mixed-type histology (differentiated and undifferentiated) is incompletely understood. This study aimed to clarify the clinicopathological features of EGC with mixed-type histology in relation to lymph node (LN) metastasis.

Methods

Clinicopathological data from 410 patients who underwent surgical resection for intramucosal EGC were reviewed. Lesions were classified into four types according to the proportion of differentiated and undifferentiated components at histopathology: pure differentiated (PD) type, mixed predominantly differentiated (MD) type, mixed predominantly undifferentiated (MU) type, and pure undifferentiated (PU) type. We examined the clinicopathological differences between PD and MD, and between PU and MU, and the rate of LN metastasis according to tumor size and ulceration.

Results

Moderately differentiated adenocarcinoma was the primary component in MD relative to PD (90.7 vs. 46.1 %). Signet ring cell carcinoma was the main component in PU relative to MU (81.5 vs. 33.3 %). LN metastasis was more common in MU than PU (19.0 vs. 6.0 %). For intramucosal tumors larger than 20 mm without lymphovascular invasion and without ulceration, the rate of LN metastasis was 0 % for MD and 24 % for MU. For intramucosal lesions less than 30 mm with ulceration but without lymphovascular invasion, the rate of LN metastasis was 0 % for MD and 20 % for MU.

Conclusions

Histologically mixed-type EGC with a predominantly undifferentiated component should be managed as an undifferentiated-type tumor. Further investigation is required to determine whether mixed-type EGC with a predominantly differentiated component could be managed the same way as a differentiated-type EGC.     

The safety and feasibility of early postoperative oral nutrition on the first postoperative day after gastrectomy for gastric carcinoma

Background

Unlike the wide acceptance of early enteral nutrition after colorectal surgery, little information is available regarding the feasibility of immediate oral nutrition after gastric cancer surgery. This study evaluated the feasibility and safety of oral nutrition on the first postoperative day after gastrectomy.

Methods

From September 2010 to March 2011, 74 consecutive gastric cancer patients received an oral diet on the first postoperative day after gastrectomy. Surgical outcomes, including hospital stay, morbidity, and mortality, were compared with a conventional diet group (n = 96, before September 2010), in which an oral diet was started on the third or fourth postoperative day.

Results

No significant differences were found in the clinicopathological characteristics or operation types between the two groups. Average diet start times in the early diet (ED) and conventional diet (CD) groups were 1.8 and. 3.2, respectively (p < 0.001). The mean hospital stay was significantly shorter in the ED group (7.4 vs. 8.9 days, p = 0.004). There was no significant difference in postoperative morbidity (p = 0.947) between the two groups. Gastrointestinal-related complications, such as anastomosis leakage or postoperative ileus, were also similar in the two groups. Overall compliance to early oral nutrition in the ED group was 78.5 %, and an old age (≥70 years) was found to affect the compliance to early postoperative oral nutrition.

Conclusions

Postoperative oral nutrition is safe and feasible on the first postoperative day after gastrectomy. However, elderly patients require careful monitoring when applying early oral nutrition after gastrectomy.     

Subclinical pretreatment sensory deficits appear to predict the development of pain and numbness in patients with multiple myeloma undergoing chemotherapy

Purpose

Chemotherapy-induced peripheral neuropathy is a major complication in the treatment for cancer, including multiple myeloma (MM). Patients may develop painful and non-painful (e.g., numbness) neuropathy symptoms that impair function and often persist after therapy is terminated. This study tested the hypothesis that baseline subclinical neuropathy, as assessed by sensory thresholds, is related to the development of neuropathy symptoms (e.g., pain and numbness) in patients with MM undergoing treatment with chemotherapy.

Methods

Patients (n = 56) who had undergone two or fewer cycles of induction therapy and who had no evident neuropathy were assessed using quantitative sensory tests to determine multiple-modality sensory thresholds. Patient-reported pain and numbness were assessed through induction therapy (16 weeks) via the MD Anderson Symptom Inventory. A subset of participants (n = 15) continued reporting on their symptoms for an additional 16 weeks (“maintenance phase”).

Results

Patients with sharpness detection deficits at baseline (n = 11, 20 % of sample) reported less severe pain and numbness during induction therapy and less numbness during maintenance therapy (P < 0.05). During the maintenance phase, patients with warmth detection deficits (n = 5, 38 % of sample) reported more severe pain and numbness, and those with skin temperature deficits (n = 7, 47 % of maintenance sample) reported more severe pain (P < 0.05). These deficits were related to patient reported difficulty walking, a common symptom of peripheral neuropathy.

Conclusion

Our results suggest that baseline subclinical sensory deficits may be related to a patient’s risk for developing chemotherapy-induced peripheral neuropathy.     

Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy

Background

No optimal method of reconstruction for proximal gastrectomy has been established because of problems associated with postoperative reflux and anastomotic stenosis. It is also important that the reconstruction is easily performed laparoscopically because laparoscopic gastrectomy has become widely accepted in recent years.

Methods

We have developed a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY). The remnant stomach is fixated to the diaphragmatic crus on the dorsal side of the esophagus. The esophagus and the remnant stomach are overlapped by a length of 5 cm. A linear stapler is inserted in two holes on the left side of the esophageal stump and the anterior gastric wall. The stapler is rotated counterclockwise on its axis and fired. The entry hole is closed, and the right side of the esophagus is fixated to the stomach so that the esophagus sticks flat to the gastric wall. The surgical outcomes of the SOFY method were compared with those of esophagogastrectomy different from SOFY.

Results

Thirteen of the 14 patients in the SOFY group were asymptomatic without a proton pump inhibitor, but reflux esophagitis was observed in 5 of the 16 patients in the non-SOFY group and anastomotic stenosis was observed in 3 patients. Contrast enhancement findings in the SOFY group showed inflow of Gastrografin to the remnant stomach was extremely good, and no reflux into the esophagus was observed even with patients in the head-down tilt position.

Conclusions

SOFY can be easily performed laparoscopically and may overcome the problems of postoperative reflux and stenosis.

     

Duodenal stump fistula after gastric surgery for malignancies: a retrospective analysis of risk factors in a single centre experience

Background

Duodenal stump fistula (DSF) is the most severe surgical complication after gastrectomy. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with DSF after gastrectomy.

Methods

All procedures involving total or sub-total gastrectomy for cancer, performed between January 1987 and June 2012 in a single institution, were prospectively entered into a computerized database. Risk factors analysis was performed between DSF patients, patients with complete uneventful postoperative course and patients with other major surgical complications.

Results

Over this 25 years period, 1287 gastrectomies were performed. DSF was present in 32 cases (2.5 %). Mean post-operative onset was 6.6 days. 19 patients were treated conservatively and 13 surgically. Mean DSF healing time was 31.2 and 45.2 days in the two groups, respectively. Mortality was registered in 3 cases (9.37 %), due to septic shock (2 cases) and bleeding (1 case). In monovariate analysis, heart disease (p < 0.001), pre-operative lymphocytes number (p = 0.003) and absence of manual reinforcement over duodenal stump (p < 0.001) were found to be DSF-specific risk factors, whereas liver cirrhosis (p = 0.002), pre-operative albumin levels (p < 0.001) and blood losses (p = 0.002) were found to be non-DSF-specific risk factors. In multivariate analysis heart disease (OR 5.18; p < 0.001), liver cirrhosis (OR 13.2; p < 0.001), bio-humoral nutritional status impairment (OR 2.29; p = 0.05), blood losses >300 mL (OR 4.47; p = 0.001) and absence of manual reinforcement over duodenal stump (OR 30.47; p < 0.001) were found to be independent risk factors for DSF development.

Conclusions

Duodenal stump fistula still remains a life-threatening complication after gastric surgery. Co-morbidity factors, nutritional status impairment and surgical technical difficulties should be considered as important risk factors in developing this awful complication.     

Early phase II study of robot-assisted distal gastrectomy with nodal dissection for clinical stage IA gastric cancer

Background

Robot-assisted distal gastrectomy (RADG) is increasingly performed in Japan and Korea and is thought to have many advantages over laparoscopic gastrectomy. However, a prospective study investigating the safety of RADG has never been reported. The present study evaluated the safety of RADG with nodal dissection for clinical stage IA gastric cancer.

Methods

This single-center, prospective phase II study included patients with clinical stage IA gastric cancer located within the lower two-thirds of the stomach. The primary endpoint was the incidence of postoperative intraabdominal infectious complications including anastomotic leakage, pancreas-related infection, and intraabdominal abscess. The secondary endpoints included all in-hospital adverse events, RADG completion rate, and survival outcome.

Results

From May 2012 to November 2012, 18 eligible patients were enrolled for this study. The incidence of intraabdominal infectious complication was 0 % (90 % CI, 0–12.0 %). The overall incidence of in-hospital adverse events was 22.2 % (90 % CI, 8.0–43.9 %). No patient required conversion to laparoscopic or open gastrectomy; thus, the RADG completion rate was 100 %.

Conclusions

This early phase II study suggested that RADG might be a safe and feasible procedure for stage IA gastric cancer, providing experienced surgeons perform the surgery. This conclusion should be clarified in subsequent late phase II studies with a larger sample size.     

High-throughput mutation profiling identifies novel molecular dysregulation in high-grade intraepithelial neoplasia and early gastric cancers

Background

There is still no widely accepted molecular marker available to distinguish between gastric high-grade intraepithelial neoplasia (HG-IEN) and invasive early gastric cancer (EGC).

Methods

HG-IEN and EGC lesions coexisting in the same patient were manually microdissected from a series of 15 gastrectomies for EGC; 40 ng DNA was used for multiplex PCR amplification using the Ion AmpliSeq Cancer Panel, which explores the mutational status of hotspot regions in 50 cancer-associated genes.

Results

Of the 15 EGCs, 12 presented at least one somatic mutation among the 50 investigated genes, and 6 of these showed multiple driver gene somatic mutations. TP53 mutations were observed in 9 cases; APC mutations were identified in 3 cases; and ATM and STK11 were mutated in 2 cases. Seven HG-IEN lesions shared an identical mutational profile with the EGC from the same patient; 13 mutations observed in APC, ATM, FGFR3, PIK3CA, RB1, STK11, and TP53 genes were shared by both HG-IEN and ECG lesions. CDKN2A, IDH2, MET, and RET mutations were observed only in EGC. TP53 deregulation was further investigated in an independent series of 75 biopsies corresponding to all the phenotypic lesions occurring in the EGC carcinogenetic cascade. p53 nuclear immunoreaction progressively increased along with the dedifferentiation of the lesions (P < 0.001). Overall, 18 of 20 p53-positive lesions showed a TP53 mutated gene.

Discussion

Our results support the molecular similarity between HG-IEN and EGC and suggest a relevant role for TP53 in the progression to the invasive phenotype and the use of immunohistochemistry as a surrogate to detect TP53 gene mutations.     

Is the eCura system useful for selecting patients who require radical surgery after noncurative endoscopic submucosal dissection for early gastric cancer? A comparative study

Background

We have established a risk-scoring system, termed the “eCura system,” for the risk stratification of lymph node metastasis in patients who have received noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to clarify whether this system contributes to the selection of patients requiring radical surgery after ESD.

Methods

Between 2000 and 2011, 1,969 patients with noncurative ESD for EGC were included in this multicenter study. Depending on the treatment strategy after ESD, we had patients with no additional treatment (n = 905) and those with radical surgery after ESD (n = 1,064). After the application of the eCura system to these patients, cancer recurrence and cancer-specific mortality in each risk category of the system were compared between the two patient groups.

Results

Multivariate Cox analysis revealed that in the high-risk category, cancer recurrence was significantly higher (hazard ratio = 3.13, p = 0.024) and cancer-specific mortality tended to be higher (hazard ratio = 2.66, p = 0.063) in patients with no additional treatment than in those with radical surgery after ESD, whereas no significant differences were observed in the intermediate-risk and low-risk categories. In addition, cancer-specific survival in the low-risk category was high in both patient groups (99.6 and 99.7%). A limitation of this study is that it included a small number of cases with undifferentiated-type EGC (292 cases).

Conclusions

The eCura system is a useful aid for selecting the appropriate treatment strategy after noncurative ESD for EGC. However, caution is needed when applying this system to patients with undifferentiated-type EGC.