Laparoscopy Assisted versus Open Distal Gastrectomy with D2 Lymph Node Dissection for Advanced Gastric Cancer: Design and Rationale of a Phase II Randomized Controlled Multicenter Trial (COACT 1001)

PURPOSE: Laparoscopy-assisted distal gastrectomy for early gastric cancer has gained acceptance and popularity worldwide. However, laparoscopy-assisted distal gastrectomy for advanced gastric cancer is still controversial. Therefore, we propose this prospective randomized controlled multi-center trial in order to evaluate the safety and feasibility of laparoscopy assisted D2-gastrectomy for advanced stage gastric cancer. MATERIALS AND METHODS: Patients undergoing distal gastrectomy for advanced gastric cancer staged cT2/3/4 cN0/1/2/3a cM0 by endoscopy and computed tomography are eligible for enrollment after giving their informed consent. Patients will be randomized either to laparoscopy-assisted distal gastrectomy or open distal gastrectomy. Sample size calculation revealed that 102 patients are to be included per treatment arm. The primary endpoint is the non-compliance rate of D2 dissection; relevant secondary endpoints are three-year disease free survival, surgical and postoperative complications, hospital stay and unanimity rate of D2 dissection evaluated by reviewing the intraoperative video documentation. DISCUSSION: Oncologic safety is the major concern regarding laparoscopy-assisted distal gastrectomy for advanced gastric cancer. Therefore, the non-compliance rate of clearing the N2 area was chosen as the most important parameter for the technical feasibility of the laparoscopic procedure. Furthermore, surgical quality will be carefully reviewed, that is, three independent experts will review the video records and score with a check list. For a long-term result, disease free survival is considered a secondary endpoint for this trial. This study will offer promising evidence of the feasibility and safety of Laparoscopy-assisted distal gastrectomy for advanced gastric cancer.Trial Registration: NCT01088204 (international), NCCCTS-09-448 (Korea).

An Approach to Diagnosing Gastrointestinal Stromal Tumors Using Immunohistochemistry of c-kit and PDGFRA with Molecular Analysis

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors in the gastrointestinal tract. Recently, many methods for the diagnosis of GIST have been developed including molecular diagnosis. METHODS: We selected 90 cases of GIST that had presented at Kyungpook National University Hospital between 1998 and 2007. Tissue microarrays were made using core areas of tumor tissues. Immunohistochemical staining for c-kit, protein kinase C-theta, and platelet-derived growth factor receptor alpha (PDGFRA) was done. Direct sequencing of hot spot exonal areas for c-kit and PDGFRA were done using extracted DNAs of all 90 paraffin block tissues. RESULTS: Among the 90 cases, 83.3% (75/90) were c-kit positive, 16.6% (15/90) were c-kit negative, 93.3% (84/90) were PDGFRA positive, and 6.6% (6/90) cases were PDGFRA negative. Fifteen cases of c-kit negative GIST included 1 case of PDGFRA negative and 5 cases of PDGFRA negative GIST were ckit positive. The one case in which both c-kit and PDGFRA were negative, showed a c-kit mutation in exon 11. CONCLUSIONS: Combined immunohistochemical staining of c-kit, discovered on GIST 1 (DOG1) and PDGFRA is helpful for the diagnosis of GIST. When all staining tests are negative for immunoreactivity, c-kit mutation analysis for exon 11, 9 should be done. Genotyping of kit and PDGFRA do not need to be examined initially, if it is only for the diagnosis of GIST.

Usefulness of the Sequential Organ Failure Assessment (SOFA) Score in Patients with Sepsis due to Intra-abdominal Infection

PURPOSE: To determine the usefulness of the Sequential Organ Failure Assessment (SOFA) score for prediction of mortality in operated patients with sepsis due to intra-abdominal infection. METHODS: Eighty-eight septic patients operated on from January 2004 to June 2008 were evaluated retrospectively. The SOFA scores were measured four times in each patient: initial score, post-op (post-operation) score, POD1 (first post-operative day) score, and POD2 (second post-operative day) score. The maximum score and mean score were obtained from these measurements. These scores were compared between groups of patients classified by mortality. D scores (D0, D1, D2) reflecting the differences between subsequent scores were compared between the surviving group and deceased group according to re-operation. RESULTS: The initial, post-op, POD1, POD2, maximum, and mean scores showed statistically significant differences between the surviving group and deceased group. D1 and D2 showed statistically significant differences between surviving group and deceased group. CONCLUSION: The sequential measurement of SOFA score is a useful prediction system for patients with sepsis due to intra-abdominal infection.

The Prognostic Value of the Preoperative Lymphocyte Count in Patients with Gastric Cancer

PURPOSE: The aim of this study was to evaluate the prognostic value of the peripheral blood lymphocyte count before surgery in those patients with gastric cancer. MATERIALS AND METHODS: The study group was comprised of a series of 1,054 patients who underwent curative gastrectomy. The appropriate lymphocyte count cutoff value was determined. The prognostic factors were evaluated by univariate and multivariate analyses. RESULTS: The lymphocyte count cutoff value was 1,500/ul. The patients were classified into two groups: Group A had a lymphocyte count > or =1,500/ul (n=765) and Group B had a lymphocyte count <1,500/ul (n=289). There were statistically significant differences between the groups according to their age (P<0.001), the tumor stage (P=0.038) and the tumor size (P<0.001). The 5- and 10-year survival rates of Group A were 80.1% and 76.6%, respectively and those of Group B were 72.4% and 63.5%, respectively (P=0.002). When multivariate analysis was performed by the Cox proportional hazards model, the lymphocyte count was not an independent prognostic factor. CONCLUSION: Although the prognosis of patients with a high lymphocyte count was better than that of the patients with a low lymphocyte count, our results did not support using the preoperative peripheral blood lymphocyte count as an independent prognostic factor for patients with gastric cancer.

Genetic Expression Pattern of Gastric Carcinomas According to Cellular Mucin Phenotypes

BACKGROUND: Gastric carcinomas (GCs) have recently been reclassified according to the mucin phenotypes. We aimed to characterize the relationship between the mucin phenotypes and the genetic alterations or the clinicopathologic parameters of GCs. METHODS: Immunohistochemistry was performed for MUC1, MUC5AC, MUC6, MUC2, CD10, p53, hMLH1, CerbB2 and E-cadherin in 150 GCs. The mucin phenotypes of the GCs were classified as 4 phenotypes: gastric, intestinal, mixed and unclassified. RESULTS: MUC1, MUC5AC, MUC6, MUC2 and CD10 were expressed in 63.3%, 42.7%, 14.0%, 24.7% and 14.0% of the GCs, respectively. The mucin phenotypes of the GCs corresponded to the gastric type in 31.3%, the intestinal type in 20.0%, the mixed type in 15.3% and the unclassified type in 33.3%. The incidence of a p53 overexpression was higher in the gastric or mixed phenotype than in the intestinal or unclassified phenotype. MUC5AC expression, p53 overexpression and the gastric or mixed phenotype were associated with poor patient survival by multivariate analysis. CONCLUSION: This study suggests the gastric or mixed mucin phenotype may more likely go through the p53 pathway in carcinogenesis and the mucin phenotype may be considered as a prognostic indicator.

Docetaxel plus cisplatin combination chemotherapy in patients with advanced gastric cancer / 대한내과학회지

BACKGROUND: We evaluated the efficacy and toxicity of docetaxel plus cisplatin combination as first-line chemotherapy for advanced gastric cancer. METHODS: Patients with metastatic or recurrent gastric adenocarcinoma, performance score

Comparison of Old and New TNM Classification of Gastric Cancer / 대한암학회지

PURPOSE: We analyzed the appropriateness of the changes regarding the classification of gastric cancer in the fifth edition of the UICC TNMclassification of malignant tumors. MATERIALS AND METHODS: Gastrectomy was performed in 727 patients with gastric cancer between 1990 and 1994. The pN, pM and stage of each patient was reclassified according to the 5th edition. The previous and present pN, pM and stage of each patient were compared. RESULTS: Although ten cases of pNO were reclassified as pNX because the number of dissected regional lymph nodes was less than 15, there revealed a good correlation between old and new pN classification. Survival distribution according to the old pN classification identified significant differences among subgroups of patients. And this was true for the new pN classification. Nine pM1 patients who had involved hepatoduodenal lymph node were reclassified into pMO. Although 97 patients were down-staged and 30 patients were up-staged, comparison of stage according to two classifications revealed good correlation. Both survival distributions according to the new and old stage grouping identified significant differences among subgroups of patients. CONCLUSION: The classification of lymph node metastasis and stage grouping in gastric cancer should be more scientific and rational in future revisions.

Implication of the Accessory Left Hepatic Artery in Curative Surgery for Gastric Cancer

We designed this study to identify the anatomic variations of the accessory left hepatic artery and to identify the influence on the hepatic function when this vessel is sacrificed during a systematic lymphadenectomy for gastric cancer. The surgical records of 100 patients who underwent curative surgery for gastric cancer, including ligation of the left gastric artery at its origin, were reviewed. The liver function was assessed by measuring the serum glutamic oxaloacetic transaminase, the glutamic pyruvic transaminase, and the alkaline phosphatase activities preoperatively and on the seventh postoperative day. The frequency of metastasis in the lymph nodes around the left gastric artery was reviewed. In 44 of the 100 cases, an accessory left hepatic artery was encountered. The accessory left hepatic artery joined with the left hepatic artery before reaching the liver in 21 of 44 cases and ran into the left lobe of the liver without confluence in 23. The diameter of the accessory left hepatic artery was greater than that of the left hepatic artery in only 17% of the cases. Metastasis in the lymph nodes around the left gastric artery was identified in 11 cases. The observed hepatic dysfunctions 7 days after operation were mild and transient, even after sacrifice of the accessory left hepatic artery. There were no postoperative complications related to the decreased liver function in these patients. These data suggest that ligation of the left gastric artery at its origin, irrespective of the presence of an accessory left hepatic artery, is necessary to improve the oncological quality of surgery without significant complication during curative surgery for gastric cancer.

A Clincial Analysis of Acalculous Cholecystitis

Acalculous cholecystitis is an inflammation of the gallbladder in the absence of gallstones. Diagnosing this condition is often difficult because of the patient's debilitated medical condition and because of the limitation of biliary imaging technique. Nonetheless, its recognition and therapy are critically important, for if left untreated, many patients will die. During 10 years and 6 months from January 1986 to June 1996, 52 patients underwent assessment and treatment for acalculous cholecystitis at the Department of Surgery, Kyungpook National University Hospital. A clinical analysis of those patients was done and the following results were obtained: The incidence rate was 3.5%. The most prevalent age group was the seventh decade (13cases), and the male-to-female ratio was 1.4 : 1. Possible etiologic factors were found in 25 cases (48.1%). These factors were surgery in 5 cases (9.6%), trauma in 5 cases (9.6%), sepsis in 5 cases (9.6%), clonorchiasis in 5 cases (9.6%), and others in 5 cases(9.6%). Neither Ascariasis nor Salmonellosis was found as a predisposing factor in this study.The main cardinal symptoms and physical signs were similar to those of calculous cholecystitis. The sensitivities of diagnostic imaging by ultrasonography and computed tomography were 88.4% and 100%, respectively. Of the 52 patients, 46 cases underwent cholecystectomy, and 6 cases were initially treated by percutaneous transhepatic cholecystostomy. Of these 6 cases, two patients had cholecystostomies during subsequent abdominal operations for other conditions. Two patients had the cholecystostomy tube removed 2 months after an uneventful recovery and have had no further biliary problems. The other two patients died. The operative findings were cholecystitis only in 26 cases (56.5%), cholecystitis with localized peritonitis in 18 cases (39.1%), and cholecystitis with generalized peritonitis in 2 cases (4.3%). Postoperative complications occurred in 16 cases (34.8%), and wound infection was the most common complication (62.5% of all complications).The overall mortality was 9.6%. Conclusively, acalculous cholecystitis had high morbidity and mortality in this study. Once the diagnosis of acalculous cholecystitis is made, the gallbladder should be drained or removed. A decision as to the best approach depends on the specific situation and will require close cooperation between the internist, the surgeon, and the radiologist.

A Caae of Gastrocolie Fistula Secondary to Benign Gastric Ulcer / 대한소화기내시경학회지

Gastrocolic fistula is a rare lesion which is caused most commonly by carcinoma of colon or stomach. The less common causes of gastrocolic fistula are follows: trauma, faulty gastrocolic anastomosis during gastrectomy, benign gastric ulcer, syphilis, carcinoid tumor, tuberculosis, intraperitoneal abscess, lymphoma, perforated diverticulum of colon, and ulcerative colitis. The locations of fistulae are mostly between greater curvature of stomach and distal half of the transverse colon. In the case of penetrating benign gastric ulcer and gastrcolic fistula, it is usually associated either with asipirin or with prolonged steroid administration. A 36-year-old male who had an unusual gastrocolic fistula secondary to non-surgically treated benign gastric ulcer is presented. The exitence of a gastrocolic fistula was dernonstrated by radiological examination of the colon and the stomach. In this patient, the colonoscope passde through the fistula and the stomach could be examined. Careful preparation was carried out preoperatively with intravenous fluids and blood transfusions. Resection of the distal stomch, fistulous tract, and segment of the transverse colon was then accamplished.

A Case of Gastrocolic Fistula Secondary to Colon Cancer / 대한소화기내시경학회지

Gastrocelic fistula of malignant origin is a rare complication, usually due to gastric or colon cancer. Possible other etiologic factors resulting in gastrocolic fistula are peptic ulcer, trauma, carcinoid tumor, intestinal tuberculosis, Crohn's disease, lymphoma, intraabdominal abscess, diverticulitis and etc. At the present, earlier diagnosis and treatment of gastric and colon cancer may explain the low frequency of malignant gastrocolic fistula than the past but the review of Korean literatures revealed only two reports of gastrocolic fistula secondary to gastric cancer and another from benign gastric ulcer. Yet, there has been no report of fistula due to colon cancer. We experienced a case of colon cancer with postural dizziness, fecal eructation who was diagnosed as gastrocolic fistula by endoscopy, barium enema, UGI series and finally underwent operation. Therefore, we report this case with the review of literatures.