Evaluation of the safety and efficacy of esophagojejunostomy after totally laparoscopic total gastrectomy using a trans-orally inserted anvil: a single-center comparative study.

BACKGROUND: Although laparoscopic surgery is frequently performed for the treatment of gastric cancer, laparoscopic total gastrectomy is not widely performed because of its technical difficulty. Since December 2007 we have performed esophagojejunostomy after totally laparoscopic total gastrectomy (TLTG) in more than 110 cases in our institution by using a circular stapler with a trans-orally inserted anvil. We performed a single-center comparative study to evaluate the safety and efficacy of esophagojejunostomy using a trans-orally inserted anvil in patients who underwent TLTG for the treatment of gastric cancer. METHODS: In the present study, we examined 329 patients with gastric cancer who underwent esophagojejunostomy using a circular stapler after total gastrectomy. Data on the clinicopathological features, operative time, amount of intraoperative blood loss, and incidence of anastomosis-related complications among the surgical groups were obtained by reviewing the medical records, which were then analyzed. RESULTS: Approximately 67% of the patients were men, and the average patient age was 64.0 years (range 26-93 years). In addition, 166 (50.5%) and 163 (49.5%) patients underwent open and laparoscopic surgery, respectively. Leakage following esophagojejunostomy was noted in 7 (4.2%) of 166 patients who underwent total gastrectomy with open laparotomy, and 0 of 46 patients who underwent laparoscopic-assisted total gastrectomy (LATG). However, only 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil exhibited leakage following esophagojejunostomy. Anastomotic stenosis of the esophagojejunostomy was observed in 5 (3.0%) of 166 patients who underwent total gastrectomy with open laparotomy, 2 (4.3%) of 46 patients who underwent LATG, and 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil. CONCLUSIONS: We believe that esophagojejunostomy using a trans-orally inserted anvil after TLTG for gastric cancer is a safe and useful surgical procedure.

[Full-layer resection of the gastric wall, focusing on the "nonexposure technique"].

Recently, endoscopic submucosal dissection (ESD) has been widely accepted as a curative, less-invasive treatment for early-stage gastric cancer. Laparoscopic gastrectomy is generally indicated in cases in which ESD could not be completed. When severe scar formation occurs in intramucosal cancer, it is often difficult to complete ESD and laparoscopic surgery must be performed. However, laparoscopic gastrecctomy for intramucosal cancer with deep ulcer scars may be overtreatment. Therefore, we developed a combined endoscopic and laparoscopic technique to perform full-thickness resection of the gastric wall. Laparoscopic and endoscopic cooperative surgery (LECS) has recently been highlighted by Hiki et al. LECS has been performed in various clinical situations, and the lesion-lifting method reported by Ohgami et al. is a beneficial application of the LECS technique. CLEAN-NET is a combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique. CLEAN-NET allows us to perform full-thickness gastric wall resection without any leakage of gastric contents into the abdominal cavity. We have so far performed CLEAN-NET in 39 consecutive patients. The results were clinically satisfactory, indicating that CLEAN-NET may have the potential to become a standard treatment option for T1N0 gastric cancer.

Prognostic impact of detecting viable circulating tumour cells in gastric cancer patients using a telomerase-specific viral agent: a prospective study.

BACKGROUND: The identification of circulating tumour cells (CTCs) in peripheral blood is a useful approach to estimate prognosis, monitor disease progression, and measure treatment effects in various malignancies. However, clinical relevance of CTCs is controversial. We attempted to detect viable CTCs in the peripheral blood of gastric cancer patients using a telomerase-specific viral agent. METHODS: We took a 7.5-ml blood sample from 65 treatment-negative gastric cancer patients before surgery and 10 healthy volunteers. We detected viable CTCs in the blood samples after incubating them with a telomerase-specific, replication-selective, oncolytic adenoviral agent carrying the green fluorescent protein (GFP) gene (OBP-401). GFP-positive CTCs were defined as having a diameter of at least 7.735 µm; this threshold was determined by receiver operating characteristic curve analysis. GFP-positive cells were counted under a fluorescence microscope. RESULTS: There was a significant difference in overall survival among the patients with 0-4 and those with ≥5 GFP-positive CTCs in the stage I-IV disease group and stage II-IV advanced disease group. The number of GFP-positive CTCs was not related to cancer stage. Among the pathological findings, the number of GFP-positive CTCs was only significantly related to venous invasion, although there were trends towards more GFP-positive CTCs with disease progression (tumour depth, lymph node metastasis, distant metastasis, lymphatic invasion, and histological type). CONCLUSIONS: There was a significant relationship between the number of GFP-positive CTCs and overall survival in the patients with gastric cancer. The detection of CTCs using OBP-401 may be useful for prognostic evaluation. TRIAL REGISTRATION: University Hospital Medical Information Network in Japan, UMIN000002018.

[A case of effective treatment of oral TS-1 and intravenous MMC administration for multiple metastases of gastric cancer].

A 49-year old man underwent distal gastrectomy (D3) for circumferential type 3 cancer at the gastric antrum and cholecystectomy in September 2002. During the surgery, multiple metastases were observed predominantly in the left lobe of the liver, and lateral segmentectomy was performed as non-curative (curability-C) resection leaving the small metastases in the right lobe of the liver. Based on the results of chemo-sensitivity tests (5-FU 15.0%, CDDP 34.0%, MMC 35.3%, TXT 0.0%), we started to administer TS-1 (100 mg/day for 4 weeks followed by a 2-week rest interval) and MMC (10 mg/body on day 1). Due to leukocytopenia, the regimen was changed to TS-1 (100 mg/day for 4 weeks followed by a 2-week rest interval) and MMC (4 mg/body every other week [day 1, 14]) from the second course. Levels of tumor markers dropped and liver metastatic lesions remarkably decreased in size by CT after the third course. In conclusion, a combination of TS-1/MMC may be regarded as one option for postoperative adjuvant chemotherapy for outpatients.

Comparison of Clinicopathological Characteristics in the Patients with Cardiac Cancer with or without Esophagogastric Junctional Invasion: A Single-Center Retrospective Cohort Study.

Background. This study addresses clinicopathological differences between patients with gastric cardia and subcardial cancer with and without esophagogastric junctional invasion. Methods. We performed a single-center, retrospective cohort study. We studied patients who underwent curative surgery for gastric cardia and subcardial cancers. Tumors centered in the proximal 5 cm of the stomach were classed into two types, according to whether they did (Ge) or did not (G) invade the esophagogastric junction. Results. A total of 80 patients were studied; 19 (73.1%) of 26 Ge tumors and 16 (29.6%) of 54 G tumors had lymph nodes metastases. Incidence of nodal metastasis in pT1 tumors was significantly higher in the Ge tumor group. No nodal metastasis in cervical lymph nodes was recognized. Only two patients with Ge tumors had mediastinal lymph node metastases. Incidence of perigastric lymph node metastasis was significantly higher in those with Ge tumors. Ge tumors tended to be staged as progressive disease using the esophageal cancer staging manual rather than the gastric cancer staging manual. Conclusion. Because there are some differences in clinicopathological characteristics, it is thought to be adequate to distinguish type Ge from type G tumor.

Prognostic impact of prophylactic splenectomy for upper-third gastric cancer: a cohort study.

AIM: The aim of this study was to investigate the effect of splenectomy on survival outcomes and recurrence in patients who underwent curative surgery for gastric cancer. PATIENTS AND METHODS: This is a retrospective study of 129 patients who underwent upper-third gastric cancer curative resection with lymphadenectomy. Forty-two patients (32%) also underwent splenectomy. RESULTS: The median follow-up period was 33 months. Approximately 40% of the patients had lymph node metastases; four of them had nodal involvement along the splenic artery and 5 had nodal involvement at the splenic hilum. No patients in the pT1-2 group with nodal metastases had involvement of the splenic hilar lymph nodes. There was no significant association between splenectomy and either overall or disease-free survival in the patients. CONCLUSION: Splenectomy should not be performed in patients with pT1-2 tumors for prophylactic lymphadenectomy.

Clinicopathological characteristics and optimal management for esophagogastric junctional cancer; a single center retrospective cohort study.

BACKGROUND: Esophagogastric junctional (EGJ) cancer occurs in the mucosa near the esophagogastric junction, and has characteristics of both esophageal and gastric malignancies; its optimal treatment strategy is controversial. METHODS: We conducted a single-center retrospective cohort study of the patients who underwent curative surgery with lymphadenectomy for EGJ cancer. Tumor specimens were categorized by histology and location into four types-centered in the esophagus < 5 cm from EGJ (type E), which were subtyped as (i) squamous-cell carcinoma (SQ) or (ii) adenocarcinoma (AD); (iii) any histological tumor centered in the stomach < 5 cm from EGJ, with EGJ invasion (type Ge); (iv) any histological tumor centered in the stomach < 5 cm from EGJ, without EGJ invasion (type G)-and classified by TNM system; these were compared to patients' clinicopathological characteristics and survival outcomes. RESULTS: A total of 92 EGJ cancer patients were studied. Median follow-up of surviving patients was 35.5 months. Tumors were categorized as 12 type E (SQ), 6 type E (AD), 27 type Ge and 47 type G; of these 7 (58.3%), 3 (50%), 19 (70.4%) and 14 (29.8%) and 23 patients, respectively, had lymph node metastases. No patients with type E (AD) and Ge tumors had cervical lymph node metastasis; those with type G tumors had no nodal metastasis at cervical and mediastinal lymph nodes. Multivariate analysis showed that type E (AD) tumor was an independent prognostic factor. CONCLUSIONS: We should distinguish type Ge tumor from type E (AD) tumor because of the clinicopathological and prognostic differentiation. Extended gastrectomy with or without lower esophagectomy according to tumor location and lower mediastinal and abdominal lymphadenectomy are recommended for EGJ cancer. TRIAL REGISTRATION: University Hospital Medical Information Network in Japan, UMIN000008596.

Surgical outcomes and clinicopathological characteristics of patients who underwent potentially noncurative endoscopic resection for gastric cancer: a report of a single-center experience.

Background. Standard treatment of early gastric cancer (EGC) after endoscopic resection with risk factors of nodal metastases and incomplete resection is controversial. We investigated optimal management for the patients with potentially noncurative EGC after endoscopic resection. Methods. We retrospectively examined clinicopathological data and surgical outcomes of all patients with clinically solitary gastric adenocarcinoma who underwent curative surgery after a single peroral endoscopic resection at the Digestive Disease Center of Showa University Northern Yokohama Hospital between April 2001 and December 2012. Fisher's exact test was used for univariate analysis. For multivariate analysis, stepwise multiple linear regression was used to identify independent predictors related to lymph node metastasis and remnant of primary tumor. Results. A total of 41 patients were studied. Four patients (9.8%) had lymph node metastases. Primary tumors remained in 6 patients (14.6%). Only venous invasion was statistically significant to lymph node metastasis (P = 0.017). With respect to remnant of the primary tumor, pT1b2 tumor invasion (P = 0.015) and horizontal margin (P = 0.013) were statistically significant. Conclusions. Surgery with limited lymphadenectomy is recommended for tumors with venous invasion or pT1b2 tumor invasion, and additional endoscopic resection may be allowed for tumors with horizontal involvement.

Fine-needle aspiration biopsy and endoscopic ultrasound for pretreatment pathological diagnosis of gastric gastrointestinal stromal tumors.

Background. Although it is possible to visualize gastrointestinal stromal tumors (GIST) of the stomach by endoscopy, their pretreatment histological diagnosis is often difficult. The aim of this study was to investigate predictors of accurate preoperative pathological diagnosis of gastric GIST. Material and Methods. We retrospectively studied patients with gastric GIST who had undergone pretreatment endoscopic biopsy and surgery, and examined their clinicopathological data. Results. Twenty-three patients were eligible. Thirty-four endoscopic biopsies (mean 2.6, range 1-8) were obtained. Preoperative pathological diagnoses of GIST were made in 18 patients. Precise diagnoses were made in 18 (52.9%) of the 34 biopsies. Endoscopic ultrasound (EUS) resulted in precise diagnoses in 11 (91.7%) of the 12 biopsy specimens. Fine-needle aspiration (FNA) biopsy resulted in precise diagnoses in 11 (84.6%) of the 13 biopsy specimens. The accuracy of pathological diagnosis by EUS-guided FNA biopsy was 100%. The procedure of EUS-guided FNA biopsy had no complications or recurrent disease. In a multivariate analysis, only EUS achieved a significantly superior rate of diagnosis (odds ratio, 11.884; 95% confidence interval, 1.204-289.230; P = 0.034). Conclusion. EUS-guided FNA biopsy is the most accurate for pretreatment pathological diagnosis of gastric GIST and for prevention of both of early complications and disease recurrence.