A Comparison of Endoscopic Ultrasonography with Transabdominal Ultrasonography of Water-Filled Stomach in the Accuracy of Staging of Gastric Cancer

Background/Aims: There was no single method satisfying accuracy, patient compliance and cost in preoperative staging of gastric cancer. A transabdominal ultrasonography of water-filled stomach (TUS) was compared with endoscopic ultrasonography (EUS) for TN staging in operated gastric cancer. Methods: We performed EUS conventionally and TUS immediately after 600 mL deaerated water ingested in 40 patients with gastric cancer prior to operation. All the cases were operated and the histological findings were compared with the results of preoperative TN staging. Results: The overall T-staging accuracy rate of TUS was 62.5% and 55.0% for EUS. Both TUS and EUS could differentiate EGC from AGC in 85.0%. There was no statistical difference in the accuracy for the depth of cancer invasion between EUS and TUS. Differentiation of the cancer defined within the gastric wall (T3) from the cancer invading adjacent organs (T4) was possible in 92.5% for TUS and 87.5% for EUS. The accuracy of determining the depth of invasion was tent to be lower in fundus than in antrum and body. Lymph node metastasis was correctly diagnosed in 67.5% for TUS and in 70.0% for EUS. Conclusions: TUS may be a considered to be a relatively accurate and simple method for preoperative staging of gastric cancer in the absence of available EUS.ope

Percutaneous Needle Decompression during Laparoscopic Gastric Surgery: A Simple Alternative to Nasogastric Decompression

Laparoscopic gastric surgeries are routinely performed with use of a nasogastric tube to decompress the upper gastrointestinal tract. A distended upper gastrointestinal tract can complicate successful laparoscopic gastric surgery as the distention compromises not only the visual field but also the laparoscopic manipulation of the stomach. Since nasogastric intubation is not without risks, we have attempted laparoscopic-assisted gastric cancer surgeries without nasogastric tubes. In this article we describe a simple method of aspirating gastric contents using a 9 cm long 19-gauge needle inserted percutaneously during laparoscopic-assisted gastrectomy. First, a 9 cm long 19-gauge disposable needle was introduced through the abdominal wall. This needle was then introduced to the stomach through the anterior wall and the stomach gases and fluids were aspirated by connecting the needle to suction. Thus, a collapsed upper gastrointestinal tract was easily obtained. We performed this procedure instead of nasogastric decompression on twenty-two patients with gastric cancer who underwent laparoscopic-assisted distal subtotal gastrectomy with lymph node dissection. The results were good with only one patient experiencing wound infection (4.5%) and one patient with postoperative acalculus cholecystitis (4.5%). There were no patients with either intraabdominal infection or anastomotic leakage and none of the patients needed postoperative nasogastric decompression, except the patient who experienced acaculus cholecystitis. Percutaneous needle aspiration is a very simple and efficient technique with little risk of postoperative complications. It can be used as an alternative to nasogastric tube decompression of the gastrointestinal tract for laparoscopic-assisted gastrectomy.ope

Randomomized Prosective Trial of Drain Use after Gastric Resections for Gastric Cancer Patients

Purpose: Drainage of the peritoneal cavity after abdominal surgery has been routinely practiced, although few data exist to scientifically support the efficacy of such an approach. In gastric cancer surgery, drainage is regarded as an essential procedure to keep the peritoneal cavity clear after extended lymphadenectomy and, also, to facilitate early detection of hemorrhage, and anastomotic or duodenal stump leakage. In this context, we planned a randomized prospective trial of drainage use after gastrectomy with extended lymphadenectomy. Methods: Between February and July 2001, 170 patients who underwent gastrectomy with extended lymphadenectomy were randomly allocated to either a non-drainage (n=84) or drainage group (n=86). The primary outcome measure was the complication rate. Additional outcome measures were operation time, requirements of rescue analgesics, changes in the level of serum albumin and hemoglobin, and hospital stay. Results: Demographic details, preoperative physical status, and pathologic features were not different between the two groups. Incidences of total gastrectomy and splenectomy among total gastrectomies were similar in both groups. However, operation time was shorter in the non-drainage group than in the drainage group (P=0.022). There were no differences in surgical outcome, including changes in hemoglobin and albumin levels, requirement for rescue analgesics, time to flatus or soft diet, and length of hospital stay. Complication rates were not different between the two groups (P=0.691), nor in the patterns of complication in either group. There was no operative mortality or reoperation. Conclusion: Based on these results, routine abdominal drainage should not be mandatory or even standard after gastrectomy with extended lymphadenectomy for gastric cancer.ope

근치적 위절제술 후 발생한 재발성 소장폐색증의 복강경 유착박리술

Purpose: Laparoscopic surgery for patients with a prior history of a radical gastrectomy has been considered a relative contraindication because of severe adhesion. Many surgeons prefer conservative management for a small bowel obstruction (SBO) after gastric cancer surgery for fear that more adhesion could occur after an open adhesiolysis. We report our initial experience of laparoscopic adhesiolysis (LA) for recurrent SBO after gastric cancer surgery. Methods: This study performed a retrospective examination of 11 patients who underwent LA for a recurrent SBO after gastric cancer surgery between March 2005 and October 2005. Those with a SBO due to cancer recurrence or metastasis were excluded. Results: The mean duration for LA after the gastrectomy was 46 months (range: 8～166 months). In all patients, LA was successfully performed without an open conversion. The mean operation time was 77 minutes (range: 45～110 minutes). None of the patients required a bowel resection. There were two postoperative complications; one peritoneal abscess due to leakage and one wound infection, which were all treated conservatively. The mean hospital stay after surgery was 5.0 days (range: 4～7 days) for patients without complications. Ten out of 11 patients showed weight loss after the gastrectomy. The mean weight loss was 12.9 kg (range: 5～24 kg). Among those 11 patients, 9 patients gained weight with a mean increase of 3.7 kg (range: 1～6 kg), 1 patient lost weight due to periampullary cancer and 1 patient showed no change in weight. None of the patients suffered from a SBO after LA during the mean follow up period of 14 months (range: 9～16 months). Conclusion: Although the initial experience of LA was small, LA can be applied safely and effectively for patients with a recurrent SBO after a radical gastrectomy.ope

Randomized controlled trial comparing gastrectomy plus chemotherapy with chemotherapy alone in advanced gastric cancer with a single non-curable factor: Japan Clinical Oncology Group Study JCOG 0705 and Korea Gastric Cancer Association Study KGCA01

A randomized controlled trial has started in both Japan and Korea to evaluate the role of gastrectomy in the management of incurable advanced gastric cancer (AGC). Patients with AGC diagnosed as having a single non-curable factor are randomized to gastrectomy plus chemotherapy or chemotherapy alone. Surgeons at 33 specialized centers in Japan and at 15 high-volume hospitals in Korea will recruit 330 patients. Primary end-point is overall survival, and secondary end-points are progression-free survival and adverse events associated with either gastrectomy or chemotherapy.ope

Usefulness of Immunohistochemistry for Microsatellite Instability Screening in Gastric Cancer

BACKGROUND/AIMS: The usefulness of immunohistochemistry to screen for the microsatellite instability (MSI) phenotype in gastric cancer remains unclear. Moreover, the prognostic value of MSI phenotypes in gastric cancer has been debated. METHODS: The clinicopathologic parameters and survival outcomes of 203 MSI-high (MSI-H) and 261 microsatellite-stable (MSS) advanced gastric cancers (AGCs) were compared. Next, we compared the immunohistochemistry results for hMLH1 and hMSH2 with those of a polymerase chain reaction (PCR)-based method. Kaplan-Meier curves and a Cox proportional hazard regression model were used to conduct survival analyses. RESULTS: The MSI-H AGCs were correlated with older age (p<0.001), female gender (p=0.018), distal location (p<0.001), larger size (p=0.016), and intestinal type (p<0.001). Multivariate analysis revealed that the MSI-H phenotype was an independent favorable factor that was related to overall survival in patients with AGC (p<0.001). Compared with the PCR-based analysis, immunohistochemistry exhibited high sensitivity (91.1%) and specificity (98.5%) in the detection of MSI phenotypes. CONCLUSIONS: MSI-H gastric cancers have distinct clinicopathologic features and better prognoses, which suggests the necessity of MSI analysis in gastric cancer. Immunohistochemistry can be a useful and reliable screening method in the assessment of MSI status in gastric cancer.ope

Follicular dendritic cell sarcoma presenting as a submucosal tumor of the stomach

Follicular dendritic cell (FDC) sarcomas, especially those of extranodal origin, are extremely rare, and this entity could easily be missed without a high index of suspicion. We report a case of FDC sarcoma presenting as a submucosal tumor of the stomach in a 45-year-old man. The mass was a spindle and epithelioid mesenchymal tumor with many individually scattered and perivascular aggregates of lymphocytes. Immunohistochemical and ultrastructural studies confirmed the diagnosis. Although more than 50 cases of this tumor have been documented in the English literature, to our knowledge the presentation of FDC sarcoma as a submucosal tumor of the stomach has never been recorded. This case highlights the occurrence of FDC sarcoma as a submucosal tumor of the gastrointestinal tract. We believe that FDC sarcoma should be included in the differential diagnosis of spindle or epithelioid cell tumors of the gastrointestinal hollow viscus to prevent this still under-recognized tumor from being overlooked.ope

Neuroendocrine Carcinoma of the Stomach

Purpose: The aim of this study was to investigate the histopathologic characteristics and the clinical outcome of neuroendocrine carcinoma of the stomach. Methods: The medical records of 16 patients diagnosed with neuroendocrine carcinoma between 1990 and 2001 at the Department of Surgery, Yonsei University College of Medicine were reviewed. Results: There were 13 male and 3 female patients. The mean age at the time of diagnosis was 62.8 years. The presenting symptoms were epigastric pain or postprandial abdominal discomfort in ten patients, melena in two, and weight loss in one, the remaining three were diagnosed incidentally. Ten patients had a tumor in the upper or middle one third of the stomach and the remaining six patients had a tumor in the distal one third. The mean size of the tumor was 5.3 cm ranging from 2 cm to 9 cm. The tumor extended beyond the serosa in ten patients (invading the pancreas in one patient, and was limited to the muscle layer proper in five patients, and to the submucosal layer in only one patient. Regional lymph node metastasis was noted in 11 patients. Tumor cells extended to the perigastric lymph nodes in 5 patients and the extra-perigastric lymph nodes in 6 patients, including paraaortic lymph nodes metastasis in 2 patients. Liver metastasis was present in one patient. Seven pa1ients were alive without any evidence of recurrence at a mean follow-up of 75.7 months (range 9~125), and one other was alive with a recurrent disease in the peritoneal cavity. The remaining eight patients died of disease recurrence or progression at an average of 10.6 months after diagnosis. Conclusion: Neuroendocrine carcinoma of the stomach is more likely to develop in the male and is usually found at an advanced stage at the time of diagnosis. It also has a tendency to infiltrate deeply into the gastric wall with frequent regional lymph node metastasis, Neuroendocrine carcinoma is a peculiar histologic subtype of gastric cancer which takes an aggressive clinical course.ope

A randomized controlled trial of Roux-en-Y gastrojejunostomy vs. gastroduodenostomy with respect to the improvement of type 2 diabetes mellitus after distal gastrectomy in gastric cancer patients.

The purpose of this study is to compare the effect of diabetes control induced by Roux-en-Y gastrojejunostomy(RY) vs Billroth-I reconstruction(BI) after distal gastrectomy in patients with early gastric cancer(EGC) and type 2 diabetes(T2DM). Forty EGC patients with T2DM, aged 20-80 years, who were expected to undergo curative distal gastrectomy were randomized 1:1 to RY(n = 20) or BI(n = 20). Diabetes medication status, biochemical and hormonal data including blood glucose, HbA1c, insulin, C-peptide, HOMA-IR, ghrelin, leptin, GLP-1, PYY, and GIP were evaluated for 12 months after surgery. Although pre- and postoperative 12-month fasting and postprandial glucose levels did not show a significant difference, HbA1c, C-peptide, and HOMA-IR levels were significantly improved at 12 months after surgery in both BI and RY groups. Sixty percent of RY patients and 20% of BI patients decreased their medication satisfying FBS<126 mg/dL and HbA1c<6.5% and 5% of BI patients stopped their medication satisfying the criteria of FBS<126 mg/dL and HbA1c<6.0%. The improvement patterns were more sustainable with less fluctuation in RY than in BI. On hormonal analysis, ghrelin and leptin levels were decreased and PYY and GIP levels were increased at 12 months after surgery in both groups without significant difference according to the reconstruction type and diabetic improvement status except ghrelin. In gastric cancer surgery, RY reconstruction showed better and more durable diabetes control compared to BI during the first year after surgery. Gastric cancer surgery led to decreased ghrelin and leptin and increased PYY and GIP, which might have a role in improving insulin resistance and glucose homeostasis.ope

Early gastric carcinoma with signet ring cell histology.

There has been much controversy surrounding the biologic behavior and prognosis of early stage gastric signet ring cell carcinoma (SRC). To clarify the biologic behavior of early stage gastric SRC (early SRC), we compared the clinicopathologic features and prognosis of early SRC with other histologic types. A total of 933 patients with early gastric carcinoma who had undergone gastrectomy from 1987 to 1995 were retrospectively analyzed. Among them, 263 patients with SRC were compared to 670 patients with other histologic types. Younger patients more often had SRC than non-SRC. Additionally, the proportion of females was greater in SRC than in non-SRC. Signet ring cell carcinoma had a larger proportion of mucosa-confined lesions and a lower rate of lymph node metastasis than non-SRC. Even after stratifying the clinicopathologic characteristics, SRC showed a lower rate of lymph node metastasis than non-SRC. When the lymph node metastasis rate was compared between SRC and undifferentiated histology other than SRC, SRC demonstrated a lower lymph node metastasis rate. Multivariate analysis showed that SRC histology was a negative independent risk factor for lymph node metastasis in early gastric carcinoma. The prognosis of SRC was significantly better than that of non-SRC (P = 0.0104). Early gastric carcinoma with SRC is a distinct type of gastric carcinoma in terms of clinicopathologic features and prognosis. The favorable prognosis and lower rate of lymph node metastasis in early SRC suggest that the patients with early gastric carcinoma with SRC could be candidates for less invasive surgeries for an improved quality of life.ope