[Water for the preparation of upper gastrointestinal endoscopy after gastrectomy].

For patients who have undergone gastrectomy for gastric cancer, a follow-up by upper gastrointestinal endoscopy is required. However, it is sometimes very difficult to observe the remnant stomach due to a significant amount of residual food. We evaluated the reduction of food residue by drinking water as preparation before upper gastrointestinal endoscopy in postpartial gastrectomy patients. We compared two groups. In the water group, patients drank 500 mL water after dinner on the evening before endoscopy, and on the day of endoscopy they drank 350 mL water before the examination. In the control group, patients drank nothing after dinner, and nothing on the day of endoscopy. In the water group, food residue in the remnant stomach was reduced. In patients who underwent proximal gastrectomy or pylorus-preserving gastrectomy, food residue in the remnant stomach was not reduced by drinking water. However, in patients with distal gastrectomy, food residue was reduced by drinking water. Drinking water before upper gastrointestinal endoscopy is safe with no risk of complications, and our results suggested that drinking water effectively reduced food residue in the remnant stomach before endoscopic examination.

Ultrasonic scalpel for gastric cancer surgery: a prospective randomized study.

BACKGROUND: The aim of the study was to evaluate the potential advantages of the ultrasonic scalpel compared with the conventional technique in gastric cancer surgery. METHODS: Patients with resectable adenocarcinoma of the stomach were randomly assigned to ultrasonic scalpel or conventional technique. We used the HARMONIC FOCUS (Ethicon Endo-Surgery, Inc.) as ultrasonic scalpel. RESULTS: Between February 2010 and December 2010, 60 patients with resectable gastric cancer were enrolled into the study. Operative time was significantly shorter with the ultrasonic arm than with the conventional arm (median 238.5 vs. 300.5 min; P = 0.0004). Blood loss was also significantly lower in the ultrasonic arm than in the conventional arm (median 351.0 vs. 569.5 ml; P = 0.016). Clavien-Dindo grades of postoperative complications were similar in the two groups. From a questionnaire survey of operators, the ultrasonic scalpel significantly reduced the stress of lymph node dissection (3.67 vs. 2.87; P = 0.0006). However, in assisting surgeons, the contributions to surgery, study, and technical improvement of the ultrasonic group were lower than in the conventional group. CONCLUSIONS: This study shows that the ultrasonic scalpel is a reliable and safe tool for open gastric cancer surgery.

[A case study of advanced gastric cancer patient treated with S-1+paclitaxel/lentinan].

A 47 -year-old male presented with gastric cancer, with right cervical and para-aortic lymph node metastases. The patient had not undergone a curative operation, but was treated with immunochemotherapy in combination with S-1 60 mg/m2(2 weeks administration and 2 weeks rest), paclitaxel 60 mg/m²(day 1, 8, 15), and Lentinan 2mg/body(day 1, 8, 15). After 3 courses of this treatment, no hot-spots were identified on cervical and para-aorta lymph nodes by PET-CT examination. We decided to perform total gastrectomy with D3 lymphadenectomy and Roux-en Y reconstruction. On histopathological examination, no malignancy was seen in the lymph nodes and the main tumor was judged to be grade 2. With this combined immunochemotherapy, the patient had a favorable outcome without side effects, which proved effective for far advanced gastric cancer.

Primary squamous cell carcinoma in the gastric remnant.

A 67-year-old male developed primary gastric squamous cell carcinoma (SCC) 13 years after undergoing distal gastrectomy for gastric cancer. Gastroscopy revealed a type 2 gastric remnant tumor and tumor biopsies revealed poorly differentiated carcinoma. The patient underwent remnant gastrectomy with lateral segment hepatectomy, splenectomy, partial resection of diaphragm, and distal partial esophagectomy. The histological findings revealed SCC without an adenocarcinoma component in the gastric remnant tumor. The patient died 13 months after surgery due to multiple-organ metastasis of gastric SCC. The post-operative prognosis of gastric SCC cases tends to poorer than that of gastric adenocarcinoma. Early diagnosis is important to improve the prognosis of primary gastric SCC and pathogenetic analysis of gastric SCC may contribute to improving the diagnosis and treatment of carcinogenesis and the prognosis of gastric SCC.

Postoperative long-term evaluation of interposition reconstruction compared with Roux-en-Y after total gastrectomy in gastric cancer: prospective randomized controlled trial.

BACKGROUND: The postoperative clinical superiority of the interposition of jejunum reconstruction (INT) to Roux-en-Y reconstruction (RY) after total gastrectomy has not been clarified. Postoperative quality of life (QOL) was evaluated between the 2 methods by a multi-institutional prospective randomized trial. METHODS: A total of 103 patients with gastric cancer were prospectively randomly divided into groups for RY (n = 51) or INT reconstruction (n = 52) after total gastrectomy. They were stratified by sex, age, institute, histology, and degree of lymph node dissection. Postoperatively, body mass index (BMI) and nutritional conditions were measured serially, and QOL and postoperative squalor scores were evaluated at 3, 12, and 60 months and compared between the 2 groups. RESULTS: After removing patients who did not complete the follow-up survey or censured cases, 24 patients in the RY group and 18 patients in the INT group were clinically available and their postoperative status was assessed. QOL scores were increased and complication scores were improved in the postoperative periods (P < .01). Postoperative BMI significantly deteriorated compared with preoperative BMI in each group. The postoperative QOL and complication scores at 60 months after surgery were significantly better than those at 3 months after surgery in each group (P < .01). However, there was no significant difference of QOL scores and postoperative complication scores between the 2 reconstruction groups. The nutritional condition in the INT group was nearly the same as that in the RY group. CONCLUSIONS: Although our patient sample was small and patients who did not complete the follow-up survey were present, we could not identify any clinical difference between INT and RY after total gastrectomy 60 months after surgery. The safer and simpler RY method may be a more suitable reconstruction method than INT after total gastrectomy.

[Effectiveness of between--hospital cooperation in staging laparoscopy].

INTRODUCTION: It is difficult to perform the staging of laparoscopy within the restricted time at a high-volume center. We thus started between-hospital cooperation as of April 2008. In this hospital cooperation, we perform surgery after laparoscopic examination at a cooperating hospital. MATERIALS AND METHODS: Staging laparoscopy was indicated for patients with T3 or T4 gastric cancer. These patients underwent staging laparoscopy at Maki Hospital before their scheduled surgery at our own hospital. RESULTS: Between April 2008 and January 2009, 14 patients underwent staging laparoscopy. We received the laparoscopic findings and confirmed the histopathological examination for median 11 days. The median duration from the day that we requested Maki Hospital to the day that patients underwent surgery was 34 days. No patient had laparoscopic complications. Of the 14 patients, 4 patients had peritoneal metastasis. Ten patients did not have peritoneal metastasis or positive cytology. Of these patients, 9 patients underwent surgery. R0 resection was achieved in 7 of 9 patients. False-negative results were obtained in two cases because of positive peritoneal cytology. CONCLUSION: Hospital cooperation may enable us to perform short-term staging laparoscopy. However, false-negative results were obtained in two cases because of positive peritoneal cytology. Further improvement must be made to assure the diagnostic accuracy of this procedure.

Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer.

BACKGROUND: A better method for detecting early peritoneal progression is needed. This study evaluated the feasibility and accuracy of second-look laparoscopy for patients with gastric cancer treated using systemic chemotherapy after gastrectomy. METHODS: Second-look laparoscopy was conducted for patients who had no clinical evidence of distant metastases but had peritoneal metastases or positive peritoneal cytology results without visible metastatic disease at initial surgery, patients who underwent systemic chemotherapy over a 6-month period after surgery, and patients who had no clinical evidence of disease based on imaging study after completion of primary chemotherapy. RESULTS: Between November 2004 and April 2008, 21 patients underwent second-look laparoscopy. At the initial surgery, 13 of these patients underwent total gastrectomy and 8 patients underwent distal gastrectomy. One or two sheets of adhesion barrier were received by 18 patients. The median interval between initial surgery and second-look laparoscopy was 9.8 months (range, 6.6-17.5 months). All second-look procedures were completed laparoscopically, and no patients required conversion to laparotomy. None of the 21 patients experienced postlaparoscopy complications. Whereas 12 patients showed no pathologic evidence of disease, 9 patients showed disease at second-look laparoscopy. There was a significant difference in median survival between the groups with negative and positive results (p = 0.017). The median survival for the negative group has not been determined. All the patients in the positive group received further chemotherapy while showing a good performance status (PS). Six patients were PS 0, and 3 patients were PS 1. The median survival time for this group was 10.1 months. CONCLUSIONS: Second-look laparoscopy was a safe and promising approach to reassessment of peritoneal disease for patients with gastric cancer. The incidence of complications was low, particularly in this group of patients, all of whom had undergone prior gastrectomy.

[Evaluation of the preserved function of the remnant stomach in pylorus preserving-gastrectomy by gastric emptying scintigraphy].

This study evaluated the preserved function of the remnant stomach by gastric emptying scintigraphy 1 year postoperatively in 49 patients who underwent pylorus-preserving gastrectomy (PPG), and it investigated whether this examination method is a useful tool for evaluation. The residual stomach function was classified as rapid, intermediate, and delayed emptying types according to gastric emptying curves. Then, the relationships were examined between the gastric emptying types and postprandial symptoms, food intake status, body weight changes, and endoscopic findings. Seventy-three percent of the PPG patients were classified as belonging to the intermediate emptying type, and the remainder (27%) to the delayed type. The frequencies of complaints such as epigastric fullness, nausea, and vomiting were high in the delayed emptying-type patients. The intermediate emptying-type patients consumed larger amounts of food and gained more weight than the delayed emptying-type patients. In conclusion, gastric function was evaluated by gastric emptying scintigraphy in PPG patients. This method might be useful not only for evaluating the motor function of the remnant stomach, but also for predicting postoperative status. Although PPG is a function-preserving operation, it should be considered that a quarter of the patients showed delayed emptying type which related to poor quality of life.

Assessment of the preserved function of the remnant stomach in pylorus-preserving gastrectomy by gastric emptying scintigraphy.

BACKGROUND: This study evaluated the preserved function of the remnant stomach by gastric emptying scintigraphy in patients who underwent pylorus-preserving gastrectomy (PPG), and it investigated whether this examination method is a useful tool for evaluation. MATERIALS AND METHODS: The residual stomach function was evaluated by gastric emptying scintigraphy in 45 patients with early gastric cancer who had undergone PPG. Function was classified as rapid, intermediate, and delayed emptying types according to gastric emptying curves. Then, the relationships were examined between the gastric emptying types and postprandial symptoms, food intake status, body weight changes, and endoscopic findings. RESULTS: Seventy-three percent of the PPG patients were classified as belonging to the intermediate emptying type, and the remainder to the delayed emptying type. The frequencies of complaints such as epigastric fullness, nausea, and vomiting were high in the delayed emptying-type patients. The intermediate emptying-type patients consumed larger amounts of food and gained more weight than the delayed emptying-type patients. It was difficult to estimate gastric emptying function from endoscopic findings. CONCLUSIONS: Gastric function was evaluated by gastric emptying scintigraphy in PPG patients. This method might be useful not only for evaluating the motor function of the remnant stomach, but also for predicting postoperative status.

Posterior esophagopexy with dome formation to prevent reflux in interposed jejunal pouch reconstruction after total gastrectomy.

Jejunal pouch interposition (JPI) reconstruction after total gastrectomy has proven effective for improving postoperative quality of life; however, evaluation of bile reflux into the esophagus shows that the reflux of digestive juice is not sufficiently prevented. Therefore, in addition to the conventional reconstruction technique, we created an artificial pouch to prevent the reflux of digestive juice from the jejunal pouch into the esophagus, and performed a new surgical technique based on the Hill's posterior gastropexy. No postoperative complications were observed and the postoperative measurement showed a decrease in the duration of bile reflux into the esophagus. Thus, our new surgical procedure seems to effectively prevent bile reflux.

Role of pyloroplasty after proximal gastrectomy for cancer.

BACKGROUND/AIMS: The necessity of pyloroplasty as a drainage procedure after proximal gastrectomy remains controversial in terms of the postoperative quality of life. The aim of this retrospective study was to evaluate whether pyloroplasty is necessary after proximal gastrectomy. METHODOLOGY: Thirty-five patients who underwent proximal gastrectomy with jejunal interposition between 1993 and 2000 were studied. They were divided into two groups: Group A, jejunal interposition without pyloroplasty (n=17); Group B, jejunal interposition with pyloroplasty (n=18). The subjects were interviewed and examined to assess their symptoms, food intake and body weight at 6, 12, and 24 months after the operation. Endoscopy and a radioisotope gastric emptying test were performed one year postoperatively. RESULTS: A low incidence of epigastric fullness, nausea, and vomiting and a high frequency of patients with greater than 80% of pre-illness food intake were found in Group B. A high recovery of bodyweight was also achieved in Group B. On the other hand, a high incidence of reflux gastritis or bile regurgitation was found in Group B. Gastric emptying was significantly delayed in Group A. CONCLUSIONS: Pyloroplasty as a drainage procedure after proximal gastrectomy is necessary in terms of the clinical symptoms, dietary intake, recovery of body weight, or gastric emptying.

Comparison of intraperitoneal continuous infusion of floxuridine and bolus administration in a peritoneal gastric cancer xenograft model.

PURPOSE: To identify the optimal schedule for intraperitoneal (i.p.) infusion of floxuridine (FUDR) against peritoneal micrometastases from gastric cancer. METHODS: The efficacy of continuous i.p. infusion of FUDR was compared with that of bolus i.p. administration in peritoneal gastric cancer (MKN45) xenografts. The FUDR continuous delivery system in this study was in the form of injectable poly(lactic-coglycolic) acid (PLGA) microspheres intended for i.p. injection. Animals were treated by continuous i.p. infusion using FUDR-loaded microspheres or bolus i.p. administration of FUDR. RESULTS: In vitro testing demonstrated that FUDR was released slowly from the microspheres at a rate of approximately 5% of the total encapsulated drug per day. In in vivo studies, the peritoneal level was found to persist and was approximately 5- to 50-fold higher than that of plasma for more than 2 weeks following a single injection of the microspheres. An in vitro MTT assay showed that exposure time clearly influenced the cytotoxic potency of FUDR. In vivo, continuous infusion was more effective against peritoneal tumor than bolus administration at equivalent doses. However, compared with bolus administration, toxicity was increased, resulting in a reduced maximum tolerated dose (MTD) with continuous infusion. When the treatment was carried out at each MTD (continuous 1 mg/kg, bolus 600 mg/kg), continuous infusion had no advantage in inhibiting tumor growth. CONCLUSIONS: Owing to the higher toxicity and the equal efficacy of continuous infusion compared with bolus administration, continuous infusion is not recommended in i.p. FUDR treatment.

Combined S-1 and cisplatin preoperative chemotherapy for patients with advanced gastric cancer: report of five cases.

BACKGROUND/AIMS: A high response rate with acceptable toxicities is required in the setting of neoadjuvant chemotherapy. Five cases (3 stage IV, 2 stage IIIb) of advanced gastric cancer were successfully treated by neoadjuvant chemotherapy consisting of a combination of S-1 and cisplatin. METHODOLOGY: All 5 patients were men younger than age 60, with no severe complications. S-1 was administered orally (80 mg/m2/day) twice daily for 21 consecutive days, and cisplatin (60 mg/m2) was infused over 2 hours on day 8 with hydration. This schedule was repeated every 5 weeks. After each cycle, the clinical response evaluation was performed with endoscopy, barium meal, and spiral CT scan. Surgery was carried out about 3 weeks after chemotherapy. RESULTS: All patients were responders (100%) after one or two cycles. However, there was no patient with either complete response, or down-staging. Toxicities, according to the WHO criteria, were very mild and none required treatment. Postoperatively one patient died of aspiration pneumonia unrelated to the chemotherapy. The others were discharged within 3 weeks after operation without complications. CONCLUSIONS: S-1 plus cisplatin seems safe and effective as neoadjuvant chemotherapy in advanced gastric cancer patients.

Cloning of a G-protein-coupled receptor that shows an activity to transform NIH3T3 cells and is expressed in gastric cancer cells.

The present study was directed towards the identification of novel factors involved in the transformation process leading to the formation of gastric cancer. A cDNA library from human gastric cancer cells was constructed using a retroviral vector. Functional cloning was performed by screening for transformation activity in transduced NIH3T3 cells. Six cDNA clones were isolated, including one encoding the elongation factor 1alpha subunit, which was already known to play a role in tumorigenesis. One cDNA (clone 56.2), which was repeatedly isolated during the course of screening, encoded a protein identical to a G-protein-coupled receptor protein, GPR35. In addition, another cDNA clone (72.3) was found to be an alternatively spliced product of the GPR35 gene, whereby 31 amino acids were added to the N-terminus of GPR35. Hence, the proteins encoded by clones 56.2 and 72.3 were designated GPR35a and GPR35b, respectively. RT-PCR experiments revealed that GPR35 gene expression is low or absent in surrounding non-cancerous regions, while both mRNAs were present in all of the gastric cancers examined. The level of 72.3-encoded mRNA was consistently significantly higher than that of 56.2 encoded mRNA. An expression pattern similar to that observed in gastric cancers was detected in normal intestinal mucosa. Based on the apparent transformation activities of the two GPR35 clones in NIH3T3 cells, and the marked up-regulation of their expression levels in cancer tissues, it is speculated that these two novel isoforms of GPR35 are involved in the course of gastric cancer formation.

Trends in long-term survival following surgery for gastric cancer: a single institution experience.

We reviewed cases at our institution in an attempt to identify temporal trends in survival of patients with operable gastric cancer. We analyzed data on 1632 patients who received a diagnosis of gastric adenocarcinoma between 1975 and 1995 and who underwent surgery at our institution. The time trends were examined by comparing three time periods (1975-1984, 1985-1989 and 1990-1995). Over time there was an improvement in the R0 resection rate: the rate significantly increased from 65% to 83%. Short-term outcomes following surgery have improved, with 30-day mortality dropping from 3.5% to 1%. The overall survival curve continuously improved with time. The five-year survival rates improved from 43% to 61%. The increased use of extended lymph node dissection with careful examination for metastases allowed for more accurate TNM staging. The incidence of peritoneal failure remains high, with peritoneal recurrence observed in 49% of the patients who underwent R0 resection between 1985 and 1995 and who experienced recurrences. Our results demonstrated that current efforts to improve gastric cancer management are finally meeting with noticeable success. However, advanced-stage cancer remains a medical problem. Multimodal treatment of advanced disease will be an important theme in coming years.

Prepubertal resveratrol exposure accelerates N-methyl-N-nitrosourea-induced mammary carcinoma in female Sprague-Dawley rats.

The major object of this study was to characterize the effect of prepubertal trans-3,4',5-trihydroxystilbene (resveratrol) exposure on N-methyl-N-nitrosourea (MNU)-induced mammary carcinogenesis in female Sprague-Dawley rats. Prepubertal rats (15 to 19 days of age) were treated daily with either 10 or 100 mg/kg resveratrol for 5 days, and were compared with resveratrol-untreated animals (30 rats in each group). Six rats in each group were autopsied at 49 days of age, and their growth was evaluated. All remaining rats were given 50 mg/kg MNU, followed by monitoring for occurrence of mammary carcinoma. A dose of 100 mg/kg (but not 10 mg/kg) resveratrol significantly increased incidence of rat with mammary carcinomas > or =1 cm and multiplicity (all histologically detected mammary carcinomas per rat), but did not affect latency, compared with untreated controls. Resveratrol did not affect body weight increase, but 100 mg/kg resveratrol caused slightly earlier vaginal opening. Although all rats cycled, resveratrol-treated animals exhibited significantly increased irregularity of estrous cycle, spending more time in the estrus phase. Thus, short resveratrol treatment of prepubertal female rats affected endocrine function, and accelerated development of MNU-induced mammary carcinomas.

A phase II clinical trial to evaluate the effect of paclitaxel in patients with ascites caused by advanced or recurrent gastric carcinoma: a new concept of clinical benefit response for non-measurable type of gastric cancer.

A phase II clinical trial has started in the South West region of Japan to investigate the efficacy and safety of weekly paclitaxel chemotherapy for the treatment of patients with ascites-forming advanced gastric cancer. A novel trial design was created to assess more effectively prospective changes in symptomatology. The study design focuses on the typical features seen in patients with ascites-forming advanced gastric cancer, including girth of the abdomen and impaired performance status, which is evaluated in the endpoint of 'Clinical Benefit Response - Gastric Cancer'. The more traditional endpoints, objective tumor response and survival, are also included. As nearly 40% of patients with this disease are excluded from traditional phase II trials owing to the absence of 'measurable' disease, this study should more precisely illustrate the disease entity affecting patients with advanced gastric cancer.

Jejunal interposition helps prevent reflux gastritis.

BACKGROUND/AIMS: Jejunal interposition after distal gastrectomy is reported to prevent both duodenogastric reflux and rapid gastric emptying. However, comparing primary reconstruction with this procedure and Billroth-I in terms of clinical evaluation by the same surgeon is rare. In this study, the benefit of this procedure was retrospectively evaluated as compared to the Billroth-I method. METHODOLOGY: Of 30 patients with early gastric cancer located at the middle third of the stomach, 15 underwent distal gastrectomy with jejunal interposition and the other 15 underwent Billroth-I gastrectomy by the same surgeon. Isoperistaltic jejunal interposition measuring 10-12 cm was used. All the anastomoses without jejunojejunostomy were performed using auto-suture staplers. Assessment of postoperative symptoms and functions was performed one year after surgery. RESULTS: The mean operation time was significantly longer after jejunal interposition (p < 0.01). No serious complications occurred in either group, and the hospital stay after operation was also similar. There were no significant differences in terms of postoperative symptoms, food intake, and recovery of body weight. The incidence of bile regurgitation and reflux gastritis was very low or zero in the jejunal interposition group, which indicated differences (p < 0.05, p < 0.01, respectively). Reflux esophagitis was not found in jejunal interposition, but two patients after Billroth I showed grade B esophagitis. As regards gastric emptying, the retention capacity was very poor and there was no significant difference between the two groups. CONCLUSIONS: Jejunal interposition after distal gastrectomy was superior to the Billroth-I procedure in terms of reflux gastritis prevention. However, dumping syndrome and rapid gastric emptying were not prevented.

The superiority of ratio-based lymph node staging in gastric carcinoma.

BACKGROUND: The need for a precise lymph node staging without stage migration is of paramount importance when comparing and evaluating international treatment results. METHODS: We reviewed 1019 patients who underwent R0 resection at Kansai Medical University between 1980 and 1997. The patients were classified according to the 1997 International Union Against Cancer (UICC)/American Joint Committee on Cancer (AJCC) pN classification or the N staging depending on the ratio between the number of excised and the number of involved lymph nodes (pN1, < or = 25%; pN2, < or = 50%; pN3, >50%). RESULTS: Among the 1997 UICC/AJCC pN subgroups, prognosis worsened with an increase in lymph node ratio. In contrast, the ratio-based classification showed more homogenous survival according to the number of involved lymph nodes. Multiple stepwise regression analysis showed that the ratio-based classification was the most significant prognostic factor, whereas the 1997 UICC/AJCC classification was not found to be an independent predictor of survival. In addition, the ratio-based classification showed a superiority to the 1997 UICC/AJCC classification with respect to stage migration. CONCLUSIONS: Ratio-based lymph node staging is simple and gives more precise information for prognosis with fewer problems related to stage migration than the 1997 UICC/AJCC staging system.