Lymph node dissection around the splenic artery for gastric cancer--a comparative study of pancreatectomy and pancreas-preserving operation]

From 1977 to 1988, four hundred and sixty-five patients received total or proximal gastrectomy for advanced gastric cancer without leaving a tumor mass at National Cancer Center Hospital. Of these, 182 patients received distal pancreatectomy (PS) and 123 received pancreas-preserving operation with removal of the splenic artery (PP). The 5-year survival rate for the PS group (32.0%) was significantly lower than 61.0% for the PP group. Concerning grades of cancer stage, the 5-year survival rates for the PP group were better than those for the PS group in stages 1, 2 and 3. Seventy-four of the 465 patients were found to have histologically proven metastatic nodes around the splenic artery. Their 5-year survival rates were 9.2% for the PS group (n = 46) and 32.7% for the PP group (n = 13) respectively. Considering the difference in the background factors, these data suggest the effectiveness of the pancreas-preserving operation for advanced gastric cancer even with microscopic lymph node metastasis around the splenic artery. The pancreas-preserving operation with removal of the splenic artery might be indicated for the patient without definite macroscopically metastatic lymph node around the splenic artery.     

Surgery for aortic regurgitation caused by Behcet's disease: a clinical study of 11 patients

Surgical treatment for aortic regurgitation (AR) caused by Behcet's disease is difficult due to the need to manipulate fragile, inflamed tissue. Valve detachment following aortic valve replacement (AVR) and suture detachment are serious postoperative complications. We investigated the surgical results in 11 patients. Between 1981 and July 1999, 11 patients, 9 males and 2 females, with AR caused by Behcet's disease underwent surgery. The age of these patients ranged from 33 to 60 years (mean, 45+/-8 years). The surgical procedures for AR were AVR in six patients and valved conduit operation in five patients. No patient died during the hospital stay. In a follow-up period ranging from 3 to 204 months (mean, 93+/-64 months) two patients died. Prosthetic valve detachment or suture detachment necessitating redo-operation occurred in four patients (36%) who then underwent a valved conduit procedure as a reoperation. Prosthetic valve detachment was higher in patients with AVR than in patients with a valved conduit operation. Valved conduit reconstruction is indicated in patients with AR caused by Behcet's disease in whom prevention of valve detachment is difficult even by current valve fixation methods.     

Quality control of surgical technique in a multicenter, prospective, randomized, controlled study on the surgical treatment of gastric cancer.

To evaluate the effect of lymph node dissection on gastric cancer patients operated upon with curative intent, we are carrying out a multicenter, prospective, randomized, controlled study in the Netherlands. The trial compares conventional gastrectomy to gastrectomy with extended lymph node dissection. In the first four months, a Japanese supervisor attended all the extended surgery and instructed many Dutch surgeons, including the eight consulting surgeons; since then, all extended gastrectomies have been attended by one of the consulting surgeons. The study coordinator attended all conventional cases. This assured that the quality of the extended surgery was as good as the Japanese standard, of which excellent results have been reported. To achieve this quality control, randomization before surgery was obligatory for practical reasons. Curability assessment at laparotomy, however, is done quite objectively with histological proof, except for the judgement of irresectability. Although this has resulted in many non-curative cases being randomized but subsequently not given the allocated surgery, the sample size should be sufficient to allow analysis according to randomization or the initial "intention to treat." This is the first protocol for a multicenter trial in surgical oncology to have such excellent surgical quality control and to assure a quality as high as that in the original report with uniformity in the level of technique. In studies comparing surgical techniques, it is vital that attention should be given to surgical quality control, otherwise survival rates may show little improvement and fail to make any impact on surgical practice.     

Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial.

PURPOSE: The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years. PATIENTS AND METHODS: Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years. RESULTS: A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P <.001) and mortality (4% v 10%; P =.004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P =.53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years. CONCLUSION: Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.     

Incidence of nodal metastasis around the superior border of the pancreas based on number of metastatic perigastric nodes

Received for publication on Jul. 17, 1998; accepted on Oct. 14, 1998     

Plasma atrial natriuretic peptide concentration inversely correlates with left atrial collagen volume fraction in patients with atrial fibrillation: plasma ANP as a possible biochemical marker to predict the outcome of the maze procedure.

OBJECTIVES: We hypothesized that the plasma atrial natriuretic peptide (ANP) level reflects atrial degenerative change and may predict the outcome of the maze procedure. BACKGROUND: Although a larger preoperative left atrial dimension and longer duration of atrial fibrillation (AF) have been reported in patients with persistent AF than in those with sinus rhythm (SR), these individual factors were not enough to predict the outcome of the maze procedure. METHODS: Preoperative plasma ANP levels were measured in consecutive 62 patients who underwent the Kosakai's modified maze procedure. Moreover, we performed histological and molecular biological examinations in the resected left atrial tissues. RESULTS: The preoperative plasma ANP was lower in the AF group (n = 13) than it was in the SR group (n = 49) (p < 0.001). Multiple logistic regression analysis revealed that duration of AF and plasma ANP were independently associated with postoperative cardiac rhythm. Among 41 patients with a higher plasma ANP or shorter duration of AF than the median value, SR was restored in 95% of patients. In contrast, in 21 patients with a lower plasma ANP and a longer duration of AF than the median value, SR was restored only in 48% of patients. Histological examination revealed that the collagen volume in the left atrial tissue was higher in AF than it was in SR and inversely correlated with plasma ANP. In addition, the messenger RNA expressions of ANP, collagen type I and type III were lower in AF than they were in SR. CONCLUSIONS: These results suggest that a combination of plasma ANP and/or duration of AF may predict the success rate for the maze operation. Advanced atrial degenerative change may result in a decrease of atrial ANP secretion.