Influence of Percutaneous Transhepatic Gallbladder Aspiration and Drainage for Severe Acute Cholecystitis on the Surgical Outcomes of Subsequent Laparoscopic Cholecystectomy: Post Hoc Analysis of the CSGO-HBP-017 (CSGO-HBP-017C).

OBJECTIVE: Percutaneous transhepatic gallbladder aspiration (PTGBA) and/or drainage (PTGBD) are useful approaches in the management of acute cholecystitis in patients who cannot tolerate surgery because of poor general condition or severe inflammation. However, reports regarding its effect on the surgical outcomes of subsequent laparoscopic cholecystectomy (LC) are sparse. The aim of this retrospective study was to investigate the influence of PTGBA on surgical outcomes of subsequent LC by comparing the only-PTGBA group, including patients who did not need the additional-PTGBD, versus the additional-PTGBD group, including those who needed the additional-PTGBD after PTGBA. PATIENTS AND METHODS: We conducted a post hoc analysis of our multi-institutional data. This study included 63 patients who underwent LC after PTGBA, and we compared the surgical outcomes between the only-PTGBA group (n = 56) and the additional-PTGBD group (n = 7). RESULTS: No postoperative complications occurred among the 63 patients, and the postoperative hospital stay was 11 ± 12 days. Fourteen patients (22.2%) had a recurrence of cholecystitis, of whom 7 patients (11.1%) needed the additional-PTGBD after PTGBA. Significantly longer operative time (245 ± 74 vs 159 ± 65 min, P = 0.0017) and postoperative hospital stay (22 ± 27 vs 10 ± 9 d, P = 0.0118) and greater intraoperative blood loss (279 ± 385 vs 70 ± 208 mL, P = 0.0283) were observed among patients in the additional-PTGBD group compared with the only-PTGBA group, whereas the rates of postoperative complications (Clavien-Dindo grade ≥3: 0% each) and conversion to open surgery (28.6% vs 8.9%, P = 0.1705) were comparable. CONCLUSION: PTGBA for acute cholecystitis could result in good surgical outcomes of subsequent LC, especially regarding postoperative complications. However, we should keep in mind that the additional-PTGBD after PTGBA failure, which sometimes happened, would be associated with increased operative difficulty and longer recovery.

Effect of Preserving the Percutaneous Gallbladder Drainage Tube Before Laparoscopic Cholecystectomy on Surgical Outcome: Post Hoc Analysis of the CSGO-HBP-017.

BACKGROUND: When percutaneous transhepatic gallbladder drainage (PTGBD) is followed by laparoscopic cholecystectomy (LC), there is no consensus regarding whether the drainage tube should be preserved or removed before LC. We hypothesized that the surgical results of LC might differ between cases with PTGBD tube preservation versus removal. Here, we investigated how drainage tube preservation or removal affected the surgical outcome of LC. METHODS: Using data from our previous multicenter study, we compared LC outcomes after PTGBD between patients with PTGBD tube preservation versus removal. This study included 208 patients who underwent LC over 12 days after PTGBD. In 83 cases, the PTGBD tube was preserved until LC, and in 125 cases, the tube was removed before LC. The results were verified by propensity score matching with 50 patients in each group. RESULTS: Cases with tube preservation versus removal exhibited significantly longer surgery duration (174 ± 105 min vs 145 ± 61 min, P = .0118) and postoperative hospital stay (14 ± 16 days vs 7 ± 7 days, P < .0001), a significantly higher postoperative complication rate (13.2% vs 3.2%, P = .0061), and a marginally higher incidence of open conversion (12.0% vs 4.8%, P = .0547). Propensity score matching verified the inferior surgical outcomes in cases with tube preservation. CONCLUSIONS: These results imply that when LC is performed > 12 days after PTGBD, the surgical outcome may be inferior when the drainage tube is preserved rather than removed before LC.

[A Case of Anal Canal Adenocarcinoma with Perianal Pagetoid Spread without a Macroscopic Finding].

We report a case of anal canal cancer with Pagetoid spread without a macroscopic skin lesion. A 54-year-old man was admitted to a hospital with complaints of bloody stools. Endoscopic examination revealed a polyp in the anal canal, and endoscopic mucosal resection was performed. Pathological examination revealed an adenocarcinoma accompanied by Pagetoid spread and the positive surgical margin. We additionally performed trans-anal resection twice, but the resected horizontal margin was positive. Mapping biopsy of rectal mucosa and perianal skin revealed adenocarcinoma in only rectal mucosa. Abdominoperineal resection was performed. Histopathological examination showed invasive adenocarcinoma with pagetoid spread and that the surgical margin was negative. Pagetoid spread of anal canal adenocarcinoma usually showed macroscopic abnormal findings, but in this case, there was no skin lesion. It suggests that preoperative mapping biopsy is helpful for determining the excision range. It is necessary to keep in mind that anal canal adenocarcinoma with no skin lesion may cause Pagetoid spread.

Preoperative risk score to predict subtotal cholecystectomy after gallbladder drainage for acute cholecystitis: Secondary analysis of data from a multi-institutional retrospective study (CSGO-HBP-017B).

INTRODUCTION: Subtotal cholecystectomy (STC) has become recognized as a "bailout procedure" to prevent bile duct injury in patients undergoing laparoscopic cholecystectomy (LC). Predictors of conversion to STC have not been identified because LC difficulty varies based on pericholecystic inflammation. We analyzed data from patients enrolled in a previously performed multi-institutional retrospective study of the optimal timing of LC after gallbladder drainage for acute cholecystitis (AC). These patients presumably had a considerable degree of pericholecystic inflammation. METHODS: In total, 347 patients who underwent LC after gallbladder drainage for AC were analyzed to examine preoperative and perioperative factors predicting conversion to STC. RESULTS: Three hundred patients underwent total cholecystectomy (TC) and 47 underwent conversion to STC. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (P < .01), severity of cholecystitis (P = .04), previous history of treatment for common bile duct stones (CBDS) (P < .01), and surgeon experience (P = .03) were significantly associated with conversion to STC. Logistic regression analyses showed that ECOG PS (odds ratio 0.2; P < .0001) and previous history of treatment for CBDS (odds ratio 0.37; P = .0073) were independent predictors of conversion to STC. Our predictive risk score using these two variables suggested that a score ≥2 could discriminate between TC and STC (P < .0001). CONCLUSION: Poor ECOG PS and previous history of treatment for CBDS were significantly associated with conversion to STC after gallbladder drainage for AC.

Randomized phase II study of gemcitabine and S-1 combination therapy versus gemcitabine and nanoparticle albumin-bound paclitaxel combination therapy as neoadjuvant chemotherapy for resectable/borderline resectable pancreatic ductal adenocarcinoma (PDAC-GS/GA-rP2, CSGO-HBP-015).

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease, and multimodal strategies, such as surgery plus neoadjuvant chemotherapy (NAC)/adjuvant chemotherapy, have been attempted to improve survival in patients with localized PDAC. To date, there is one prospective study providing evidence for the superiority of a neoadjuvant strategy over upfront surgery for localized PDAC. However, which NAC regimen is optimal remains unclear. METHODS: A randomized, exploratory trial is performed to examine the clinical benefits of two chemotherapy regimens, gemcitabine plus S-1 (GS) and gemcitabine plus nab-paclitaxel (GA), as NAC for patients with planned PDAC resection. Patients are enrolled after the diagnosis of resectable or borderline resectable PDAC. They are randomly assigned to either NAC regimen. Adjuvant chemotherapy after curative resection is highly recommended for 6 months in both arms. The primary endpoint is tumor progression-free survival time, and secondary endpoints include the rate of curative resection, the completion rate of protocol therapy, the recurrence type, the overall survival time, and safety. The target sample size is set as at least 100. DISCUSSION: This study is the first randomized phase II study comparing GS combination therapy with GA combination therapy as NAC for localized pancreatic cancer. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000021484 . This trial began in April 2016.

Comparison of Clinical Outcomes Between Laparoscopic and Open Extensive Resection for Complicated Appendicitis: Retrospective Observational Study.

BACKGROUND: The feasibility and safety of laparoscopic extensive resection (ER) for complicated appendicitis (CA) has not been clarified. We assessed the feasibility of laparoscopic ER versus open ER for CA. METHODS: We retrospectively enrolled consecutive 983 patients who underwent emergency surgery for appendicitis, including 91 patients who underwent ER for CA, between April 2007 and October 2019. RESULTS: Thirty-three patients underwent laparoscopic ER, and 58 patients underwent open ER. There were no significant differences in the reasons for performing ER between laparoscopic ER and open ER. The rates of suspicious for malignant tumor did not differ between laparoscopic and open ER [15.2% (5/33) vs. 17.2% (10/58)]. Blood loss was less in laparoscopic ER than in open ER (P=0.028). Superficial surgical site infection was less frequent in laparoscopic ER than in open ER (P=0.047). In addition, laparoscopic ER tended to be associated with a shorter hospital stay, lower rate of postoperative ileus, and higher rate of intra-abdominal abscess. CONCLUSION: Laparoscopic ER is feasible, and it is associated with less intraoperative blood loss and a lower frequency of postoperative superficial surgical site infection than open ER.

[A Case of Recurrent Hepatocellular Carcinoma Successfully Treated by Radiation Therapy].

We report a case of recurrent hepatocellular carcinoma(HCC)successfully treated by radiation therapy. A 79-year-old woman was diagnosed with HCC and underwent liver resection. Seven months after resection, CT and MRI detected a new HCC, and she had a surgery again. One year after the surgery, CT and MRI detected local recurrence, and she underwent the third operation. Three months after the operation, the third liver recurrence was treated by transcatheter arterial chemoembolization( TACE). Four months later, a new lesion was detected and treated by stereotactic body radiation therapy(SBRT) twice. She remains alive without recurrence 27 months after the last radiation therapy. Very few evidence is reported of radiation therapy for HCC, but this case suggests that radiation therapy provides a benefit for patients with HCC after other treatments.

[A Case of Advanced Rectal Cancer with the Metastatic Abdominal Aortic Bifurcation Lymph Node Performed by Laparoscopic Surgery after Chemotherapy].

A 63-year-old underwent examination for constipation and was found to have an unresectable advanced rectal cancer. Metastatic abdominal aortic bifurcation lymph node and lung metastasis were suspected upon CT(cT3N3M1a[PUL1], cStage Ⅳa), and chemotherapy was administered(CapeOX plus Bmab). After 4 courses of chemotherapy, the size of the primary tumor and the lymph nodes decreased(PR). We performed laparoscopic rectum resection and abdominal aortic bifurcation lymph node. The pathological diagnosis indicated partial response(residual cancer cells)(Grade 1a). After 4 courses of chemotherapy(CapeOX), we performed pulmonary partial resection for metastatic lung cancer. This case suggests that laparoscopic resection of rectum after chemotherapy with CapeOX plus Bmab for locally advanced rectal cancer is a potential- ly effective procedure.

Optimal timing of laparoscopic cholecystectomy after gallbladder drainage for acute cholecystitis: A multi-institutional retrospective study.

BACKGROUND: There is no consensus on the optimal timing of laparoscopic cholecystectomy (LC) after gallbladder drainage for acute cholecystitis (AC). To obtain evidence for a consensus, we investigated surgical outcomes of LC after gallbladder drainage with respect to the time elapsed from gallbladder drainage to surgery in a multi-institutional retrospective study. METHODS: This study enrolled 347 patients who underwent LC after gallbladder drainage for AC at 15 institutions. Surgical outcome of LC was investigated in the cases based on the interval from gallbladder drainage to surgery. RESULTS: The median interval from gallbladder drainage to surgery of the patients was 34 days, with a mean ± standard deviation of 58 ± 99 days. Patients were divided into four groups based on quartiles of the interval: Group A, cases with an interval of 1-12 days; Group B, cases with an interval of 13-34 days; Group C, cases with an interval of 35-73 days; and Group D, cases with an interval of ≥74 days. Surgical outcomes, which were evaluated with respect to intraoperative blood loss, operation time, postoperative hospital stay, rate of intraoperative accident, conversion from laparoscopic to open surgery, and postoperative complication, were worse in Group B than in the other groups. The finding was verified by propensity score-matched analysis. CONCLUSIONS: Surgical outcome of LC after gallbladder drainage for AC was inferior in Group B compared with the other groups. This finding could be useful for determining the optimal timing of LC after gallbladder drainage for AC.

[A Case of Advanced Gastric Cancer with Peritoneal Metastasis Achieved Pathological Complete Response by Chemotherapy(SOX Regimen)].

A 68-year-old woman was presented with anorexia. Upper gastrointestinal endoscopy revealed type 4 gastric cancer at corpus of the stomach. Peritoneal metastasis was detected by staging laparoscopy. After a diagnosis of cT4aN1M1, cStage ⅣB advanced gastric cancer, we performed chemotherapy(SOX regimen; S-1 100 mg/body on day 1-14, followed by 7 days of rest, oxaliplatin 130 mg/m2 on day 1). After the 3 courses of chemotherapy, the primary tumor had been reduced. Second staging laparoscopy revealed no peritoneal metastasis. Then, we performed total gastrectomy with D2 lymph node dissection. Histopathological examination revealed no residual cancer cells, indicating a pathological complete response (Grade 3). We report a case of advanced gastric cancer with peritoneal metastasis achieved pathological complete response by chemotherapy.

[A Case of Laparoscopic Surgery for Advanced Rectal Cancer with Lateral Lymph Node Metastasis Resected after Neoadjuvant Chemotherapy].

A 62-year-old man with diarrhea and metastases was found to harbor 2 rectal cancers. Both lateral lymph nodes were suspected based on CT and PET-CT(cT3N3M0, cStage Ⅲb). We planned to administer neoadjuvant chemotherapy(NAC) (CapeOX plus Bmab). After 4 courses of NAC, the sizes of both the primary tumor and lymph nodes decreased(partial response: PR). We performed laparoscopic abdominoperineal resection of the rectum(APR)with dissection of both lateral lymph nodes. The therapeutic effect was PR(few residual cancer cells)(Grade 2). After 4 courses of adjuvant chemotherapy (CapeOX), there have been no signs of recurrence for 8 months. This case suggests that laparoscopic APR after NAC with CapeOX plus Bmab for locally advanced rectal cancer is a potentially effective procedure.

[A Case of Ascending Colon Cancer with Intestinal Malformation Treated via Laparoscopic Surgery].

A 66-year-old man attended a health check-up after a positive fecal occult blood test. Colonoscopy revealed a 2 cm type 2 lesion near the ascending colon and the upper lip ofBauhin 's valve. Contrast-enhanced computed tomography ofthe abdominal region revealed aplasia ofthe ligament ofTreitz, with the duodenum running through the center. Three-dimensional vascular construction revealed intestinal malrotation, in which the superior mesenteric artery was present on the right side of the superior mesenteric vein. A diagnosis ofascending colon cancer(T2N0M0, cStage I )was made, and a laparoscopic ileocecal resection was performed. The ascending colon was not fixed to the abdominal wall, and the colon was widely depressed within the pelvis. Because no adhesion was noted, vascular processing was performed after converting to extracorporeal manipulation via a small incision in the umbilical region. The controlling vessel was the ileocolic artery, and D2 dissection was performed. The patient suffered no postoperative complications and was discharged on hospital day 13. Most reports ofintestinal malrotation concern pediatric patients, and reports ofadult cases are relatively rare. The intestinal malrotation was confirmed intraoperatively, and the procedure was performed safely. This suggests that if intestinal malrotation can be confirmed, laparoscopic surgery can be safely performed.

[A case of metastatic gastric cancer originating from transverse colon cancer].

Metastatic gastric cancer is uncommon, and metastasis of colorectal cancer to the stomach is extremely rare. We report a case of metastatic gastric cancer that originated from transverse colon cancer. A 52-year-old woman underwent a left hemicolectomy and D3 lymph node dissection based on a diagnosis of transverse colon cancer. The pathology results were as follows: mucinous adenocarcinoma, type 2, 6 × 11 cm, ss, ly1 v1, pm (-), dm (-), n1 (+), P0, H0, M0, Stage IIIa. The patient received XELOX as postoperative adjuvant therapy for 6 months. One year and 3 months after the left hemicolectomy, gastroscopy revealed a submucosal tumor in the lower body of the stomach and an incipient cancer in the cardia of the stomach, and a colonoscopy revealed an incipient cancer in the transverse colon. An endoscopic ultrasonography fine needle aspiration biopsy of the submucosal tumor in the lower body of the stomach was performed. Histology showed that this tumor was a mucinous adenocarcinoma similar to the primary transverse colon cancer, which led to a diagnosis of metastatic gastric cancer originating from transverse colon cancer. Distant metastasis was not detected. Endoscopic submucosal dissection of the incipient gastric cancer was performed, as were distal gastrectomy and partial colectomy. Peritoneal dissemination and para-aortic lymph node recurrence were detected 7 months after the second surgery.

[A case of primary carcinoma associated with anal fistula].

A 47-year-old man with no history of anal fistula was admitted to our hospital with a complaint of perianal pain. Computed tomography (CT) imaging revealed perianal abscess. Incision and drainage were performed under spinal anesthesia. Ten months after drainage, magnetic resonance imaging revealed anal fistula on the left side of the anus. Subsequently, core-out and seton procedures were performed for ischiorectalis type III anal fistula. Pathological examination of the resected specimen of anal fistula revealed a moderately differentiated adenocarcinoma, leading to the diagnosis of carcinoma associated with anal fistula. No distant metastases or enlarged lymph nodes were observed on positron emission tomography (PET)/CT. We performed abdominoperineal resection with wide resection of ischiorectalis fat tissue. The pathology results were tub2, A, ly0, v0, n0, PM0, DM0, RM0, H0, P0, M0, Stage II. Negative pressure wound therapy was performed for perineum deficiency, after which rapid wound healing was observed. Left inguinal lymph node recurrence was detected 8 months after surgery, for which radiotherapy was administered. Distant metastasis was detected 11 months after surgery. The patient died 21 months after surgery.

[A case of gastric cancer with liver metastasis had a good reaction to S-1/CDDP chemotherapy after S-1 chemotherapy was ineffective].

A woman in her sixties underwent total gastrectomy for gastric cancer. The pathological diagnosis was pT3, pN3, sH0, pCY0, sP0, sM0, fStage IV. Chemotherapy with S-1 was used after surgical treatment. Because a CT scan after three courses chemotherapy showed the paraaortic lymph nodes swelling, combination chemotherapy with S-1 and docetaxel was used as a second-line chemotherapy. When the CT scan after 8 courses of this combination chemotherapy revealed multiple liver metastases, the chemotherapy was changed to CPT-11 monotherapy and paclitaxel monotherapy as the third-and fourth-line chemotherapy, respectively. In spite of those chemotherapies, the metastatic disease progressed, and therefore, combination chemotherapy with S-1 and CDDP was used as the fifth-line chemotherapy. After 6 courses of this treatment, serum CEA and CA19-9 levels dropped into the normal range. Multiple liver metastases were markedly reduced, and were considered as a partial response(PR). The patient is still alive, maintaining the effect of PR for 17 months without any adverse effects except appetite loss and vomiting of grade 2.

Pilot study of a combination of S-1 and paclitaxel for patients with peritoneal metastasis from gastric cancer.

BACKGROUND: This pilot study was carried out to evaluate the efficacy of chemotherapy for patients with peritoneal dissemination from gastric cancer or positive lavage cytology diagnosed by staging laparoscopy. METHODS: Sixteen patients were enrolled. Paclitaxel was administered at 120 mg/m(2) on day 1 and S-1 was administered orally at 80 mg/m(2) for 14 consecutive days, followed by a 1-week rest, as one course. After five courses of this therapy, the primary gastric tumors were evaluated and second-look laparoscopy was performed for patients showing partial response or stable disease with clinical benefit. RESULTS: Partial response or stable disease with clinical benefit was confirmed in seven and five patients, respectively, and these patients underwent second-look laparoscopy. No viable cancer cells were detected on cytopathological investigation during second-look laparoscopy in 9 patients who underwent surgical treatment. The intent-to-treat response rate for gastric tumor was 44% and the rate of disappearance of peritoneal metastasis was 38% (6 cases) at surgery. The median survival time was 555 days. Leucopenia of grade 3 and neutropenia of grade 3 were recognized in two and three patients, respectively. CONCLUSION: This chemotherapy regimen may be an acceptable option for patients with peritoneal dissemination. We plan to study this regimen further in gastric cancer patients with peritoneal dissemination.

[The effects of gastrojejunostomy for patients with advanced gastric cancer accompanied by peritoneal dissemination].

UNLABELLED: We evaluated the efficacy of gastrojejunostomy for advanced gastric cancer patients with peritoneal dissemination. PATIENTS AND METHODS: We evaluated the clinical outcome of 11 patients (average age 73.5 years for 8 men) who received gastrojejunostomy for gastric outlet obstruction caused by advanced gastric cancer with peritoneal dissemination between October 2003 and December 2008. We performed stomach-partitioning gastrojejunistomy with tube jejunostomy. RESULTS: Three patients with performance status 3 and severe peritoneal dissemination deteriorated during the early postoperative days and were transferred to terminal care. These three patients died after 23, 26 and 60 days. The other 8 patients were discharged from hospital between 10 and 35 days postoperatively (median hospital stay 16 days) and received chemotherapy with S-1 on an outpatient basis. All patients died within one year except the one who showed a partial response to chemotherapy and lived for 40 months (MST: 8 months in all patients). DISCUSSION: It seemed that there was little adaptation to gastrogejunostomy as palliation surgery for patients with poor performance status (PS 3) and severe peritoneal dissemination.

[Case report--a long-term surviving patient who received lymph node dissection of skip metastasis from rectosigmoid cancer to bilateral lateral lymph nodes].

Skip metastasis in colorectal cancer consists of about 10% of lymph node metastases. We report a rare long-term surviving patient of skip metastasis to lateral nodes after lymph node dissection. A forty-two years old female received anterior resection for advanced rectosigmoid cancer. Because pathological stage of the patient was stage IIIa (T3N1M0), standard adjuvant chemotherapy was provided. Serum CEA increased just two years after the first operation. PET scan showed abnormal FDG uptake in lymph nodes along the aorta. Lymph nodes along the inferior mesenteric artery (IMA), bilateral common iliac artery and aorta were dissected. There were metastases to nodes along the common iliac artery but no metastasis along the IMA was observed. So we diagnosed it as skip metastasis. The patient is still alive without any metastasis after 6 years from the second operation.

[A case of epidermoid cyst in the intrapancreatic accessory spleen mimicking pancreatic malignant tumor].

We report a rare case of an epidermoid cyst in the intrapancreatic accessory spleen with producing CA19-9. A 42-year-old woman was referred to department of internal medicine of our hospital due to growing cystic lesion at the pancreatic tail. Laboratory tests on admission revealed a high serum CA19-9 (102.0 U/mL). Ultrasound sonography detected a 25-mm monolocular cystic tumor with thick capsule and septum. The capsule and septum was enhanced on computed tomography. Endoscopic examination of upper gastrointestinal tract and colon revealed normal. CA19-9 was elevated up to 147.3 U/mL after 2-month follow-up, and she was referred to department of digestive surgery. We suspected a mucinous cystic neoplasm or endocrine tumor, and distal pancreatectomy was performed. The surgical specimen showed a septate cyst surrounded by brown solid tissue resembling normal spleen. The patient was discharged on postoperative day 11. Histological diagnosis was an epidermoid cyst originated from an intrapancreatic accessory spleen. Immunohistochemical analysis of CA19-9 in the epidermoid cyst showed clear staining of the inner epithelium of the cyst. The serum CA19-9 value was confirmed to decline to normal 1 month after resection.

[Outcome of therapy for type 4 gastric cancer with peritoneal metastasis--diagnosis by laparoscopy and effect of chemotherapy].

UNLABELLED: Laparoscopy (st-lap) was performed for type 4 advanced gastric cancer cases, and chemotherapy was performed for P1 or CY1[ P(+)] cases. We present the results here. SUBJECTS: The subjects were type 4 advanced gastric cancer cases from October 2002 to December 2007 who underwent st-lap, as well as 7 P0 and CY0 [P(-)] cases (the operative group), and 18 P(+) cases which underwent chemotherapy (the chemotherapy group). The administration of S-1 (80 mg/m2: days 1-14)+PTX (120 mg/m2: day 1) every 3 weeks was the basic regimen of chemotherapy. RESULTS: After 5- course of chemotherapy, st-lap was performed in 11-PR case(61%) and 4-SD case, in which clinical symptoms had improved. An operation was performed for 11-P(-) case. Overall, there was 8-P(-) case(44%). The 1-and 3-year survival rates in the chemotherapy group in the 11 cases for which an operation was performed were 82 and 36%, respectively, and the 7 non-operative cases were 57 and 14%, respectively. Although there were no significant differences, the outcome was more favorable in the operative group. The 1-and 2-year survival rates in the operative and chemotherapy groups were 72, 39, 51 and 34%, respectively, and there was no significant difference. DISCUSSION: It was suggested that in cases of type 4 advanced gastric cancer, chemotherapy was necessary not only in P(+) but also in P(-) cases. Further investigation regarding the necessity of resection and choice of therapeutic regimen is required.