Lymphatic involvement in early gastric cancer: prevalence and prognosis in France.

BACKGROUND: The prognosis of early gastric cancer (EGC) is considered better than that of invasive gastric carcinoma, with a 5-year survival rate of more than 90% after surgery. The prevalence of lymph node metastasis in EGC ranges from 8% to 20% and is associated with a poor prognosis. HYPOTHESIS: The main prognostic factor of EGC in patients in France is lymphatic involvement. DESIGN, SETTING, AND PATIENTS: From January 1979 to December 1988, 332 patients with EGC were operated on in 23 centers of 2 of the French Associations for Surgical Research. Clinical, pathological, and therapeutic data were reviewed, and the reckoning point was in June 1996. MAIN OUTCOME MEASURES: The cumulative 5- and 7-year specific survival rates of EGC with or without lymphatic involvement. RESULTS: The cumulative 5- and 7-year specific survival rates of 332 patients with EGC (mean follow-up time, 80 months), excluding both operative and unrelated mortality, were 92% and 87.5%, respectively. Thirty-four patients (10.2%) had metastatic lymphatic spread: 13 exclusively in the lymphatic vessels close to the tumor, 17 in at least 1 lymph node, and 4 in both the lymphatic vessels and nodes. The rate of lymph node involvement (regardless of lymphatic vessel involvement) correlated significantly with submucosal invasion (P =. 05) and histologic undifferentiation (P =.03). Lymphatic vessel involvement correlated positively with lymph node involvement (P =. 003). Since 5- and 7-year survival rates of the 13 patients with EGC who had lymphatic vessel involvement without lymph node involvement did not differ significantly from those of patients who had EGC with lymph node involvement (85% and 84% vs 72% and 63%, respectively [P =.42]), all patients with lymph node and/or lymphatic vessel involvement were considered unique. Prognosis was poorest in these patients according to both univariate analysis (94% for 298 without node or vessel involvement vs 78% for 34 with node and/or vessel involvement; P =.006) and multivariate analysis (P =.01). Submucosal invasion was a prognostic factor independent of lymphatic involvement (P =.05). Five- and 7-year survival rates did not differ when the group of 211 patients for whom less than 15 lymph nodes were retrieved were compared with those (n = 51) for whom 15 or more lymph nodes were retrieved (95.5% vs 92% and 95.5% vs 88%, respectively), whether according to univariate (P =.21) or multivariate (P =.31) analysis. CONCLUSIONS: Our results suggest that both lymph node and lymphatic vessel involvement are important prognostic factors in patients with EGC. Lymphadenectomy in EGC is important to identify the high-risk population for whom prognosis is worse. The extent of lymphadenectomy (at least 15 nodes) in these patients, however, does not alter prognosis.

Treatment and prognosis of early multiple gastric cancer.

AIM: Early gastric cancer (EGC) may have a 5-year survival rate of over 90% following surgery. Early multifocal gastric cancer (EMGC) accounts for between 8.3 and 17% of all EGCs. A multicenter retrospective study is reported of prevalence, characteristics, prognosis and type of resection for EMGC patients. METHOD: 333 patients with EGC were operated on, between January 1979 and December 1988, and followed to June 1996. RESULTS: 33 EGC patients had EMGC. There was no significant difference in clinico-pathological features between EGC and EMGC. 21 cases of EMGC underwent a subtotal gastrectomy and 12 underwent a total gastrectomy. Recurrences after subtotal gastrectomy were, respectively, 10 and 18% for EGC and EMGC patients (p=0.2). The cumulative 5 years specific survival rate for 298 EGC and 34 EMGC were 94 and 90%, respectively (p=0.9). Five-year survival rates after subtotal gastrectomy were 92 and 90% for EGC and EMGC patients, respectively (p=0.8). CONCLUSION: EGC and EMGC had the same clinico-pathological features and prognosis. A careful follow up of the stomach remnant is essential.

Routine intraoperative cholangiography is feasible and efficient during laparoscopic cholecystectomy.

BACKGROUND/AIMS: This is the evaluation of the feasibility and results of routine laparoscopic intraoperative cholangiography. PATIENTS AND METHODS: A multicentric prospective study in 315 consecutive patients undergoing elective or urgent laparoscopic cholecystectomy. RESULTS: The success rate was 94%. Mean duration of intraoperative cholangiography was 12 min. Sixteen of 18 failures were related to a narrow cystic duct. One cystic duct avulsion (ligated under laparoscopy) and 2 false positive cholangiograms (1 transcystic exploration, 1 conversion) were noted. Intraoperative cholangiography revealed aberrant bile ducts possibly at risk to injury from dissection in four patients (1.3 per cent). Intraoperative cholangiography disclosed unsuspected stones in 10 patients (4%). Forty-five patients had a preoperative suspicion of choledocholithiasis: choledocholithiasis were found at intraoperative cholangiography in 3 of 13 patients who had preoperative endoscopic sphincterotomy for stone extraction, in 1 of 11 patients with normal preoperative endoscopic cholangiography, and in 11 of 21 patients undergoing surgery alone (57%). CONCLUSION: If complete clearance of choledocholithiasis is to remain the objective of surgical treatment of biliary lithiasis including laparoscopic cholecystectomy, then routine intraoperative cholangiography is feasible and efficient.