Risk factors of esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer.

BACKGROUND/AIMS: The purpose of this study was to investigate the incidence of esophagojejunal anastomotic leakage (EJAL) after total gastrectomy. METHODOLOGY: Four hundred and four consecutive gastrectomy cases were reviewed to determine the incidence of esophagojejunal anastomotic leakage. RESULTS: EJAL developed in 33 patients (8.2%). The rate of leakage was found to be significantly related to the preoperative lymphocyte count and serum albumin level. Cases of para-aortic lymph node dissection (D4) had a significantly higher rate (16.1%) of EJAL than in conventional lymph node dissection (D2,3: 5.3%). The left upper abdominal evisceration group demonstrated a significantly higher EJAL rate (20.0%) than the cases without combined resection (4.8%). CONCLUSION: Aggressive surgery for advanced gastric cancer increases the risk of esophagojejunal anastomotic leakage. When aggressive surgery is necessary for curative purposes, meticulous preoperative, intraoperative and postoperative care are indispensable.

Surgery for gastric cancer in patients with cirrhosis.

To clarify the therapeutic strategies for gastric cancer surgery in the presence of cirrhosis, 39 patients with gastric cancer accompanied by liver cirrhosis were reviewed. Severe postoperative complications developed in 10 patients (25.6%), and there were 4 (10.3%) hospital deaths. 1 (2.6%) of which occurred within 1 month. Although extended lymph node dissection of D2 or more was adopted for low-risk patients, 3 of 19 patients who underwent such extensive operations, most of which involved complete lymph node dissection in the hepatoduodenal ligament, died. Conversely, only 1 of 20 patients who underwent limited lymph node dissection of D1 or less died. Postoperative massive ascites developed in 6 patients, 3 of whom died. The cumulative 5-year survival rate following curative resection was 63.7% for patients with early gastric cancer, and 13.9% for those with advanced gastric cancer. The most frequent cause of death was cirrhosis-related, such as hepatic failure or hepatoma. In conclusion, extensive lymph node dissection for patients with gastric cancer accompanied by cirrhosis carried a risk of postoperative fatal massive ascites as lymphorrhea. Thus, lymph node dissection in the hepatoduodenal ligament should be avoided, except in patients with evident metastases, and as a rule, aggressive surgery should not be performed in cirrhotic patients.

Distant lymph node metastasis of early gastric cancer.

Among 601 patients with early gastric cancer (EGC), the clinicopathological findings of 5 patients (invasion of the mucosal layer in 2 and of the submucosal layer in 3) with distant lymph node metastasis according to TNM classification (third- or fourth-tier lymph node metastasis according to the Japanese classification) were investigated. The proliferating-cell nuclear antigen (PCNA) expression of EGC was also examined immunohistologically. The sites of distant metastasis were the nodes at the root of the mesentery, in the hepatoduodenal ligament, and the paraaortic nodes. While the PCNA-positive rate of EGC with distant lymph node metastasis (35.4%) was significantly higher than that of EGC without lymph node metastasis (14.7% P = 0.01), it was similar to that of EGC with perigastric lymph node metastasis. The cumulative survival rate of the EGC patients with distant lymph node metastasis (5-year survival rate 20.0%) was significantly lower than that without lymph node metastasis (88.2%, P < 0.0001), first-tier lymph node metastasis (76.9%, P < 0.04), or second-tier lymph node metastasis (77.1%, P < 0.04). Thus, although the prognosis of EGC patients with distant lymph node metastasis was poor, a dissection of the distant lymph nodes should be performed when metastasis is suspected.

[Measurement of the plasma transforming growth factor-beta 1 (TGF-beta 1) level in patients of gastric carcinoma--compared with the serum IAP level and the lymphocyte subsets (CD3, CD4, CD8)].

We evaluated the clinical significance of the plasma TGF-beta 1 by enzyme-linked immunosorbent assay (ELISA) in 40 patients with gastric carcinoma before operation who were hospitalized at our department between August 1992 and March 1993. Moreover, we examined the correlation of the immunosuppressive acidic protein (IAP) in the serum with the plasma TGF-beta 1 level. The lymphocyte subsets were analyzed with monoclonal antibodies (CD3, CD4, CD8) and compared with the plasma TGF-beta 1 level. Results 1) The plasma TGF-beta 1 was significantly high in patients with advanced stage of gastric carcinoma (with respect to the depth invasion) and poorly differentiated adenocarcinoma (histological type) (p < 0.01). When the carcinoma was macroscopically found to be advanced, TGF-beta 1 was higher in the invasive type than in the noninvasive type (p < 0.05). 2) We found a significant correlation between the plasma TGF-beta 1 and IAP in the serum (n = 25, r = 0.677, p < 0.01). 3) The lymphocyte fraction of CD3, CD4 was decreased in patients with a high level of TGF-beta 1, and was related with the plasma TGF-beta 1 level. Thus, TGF-beta 1 was presumed to be deeply associated with in the growth and progression of gastric carcinoma and related to systemic immunosuppressive reaction.

Significance of proliferating cell nuclear antigen (PCNA) expression in gastric cancer in relation to lymph node metastasis.

Proliferating cell nuclear antigen (PCNA) in gastric cancer was evaluated in relation to lymph node metastasis. A total of 125 gastric cancer patients who underwent gastrectomy were studied immunohistochemically. The PCNA-positive rate of the primary lesion with lymph node metastasis (47.6%) was significantly higher than those in those without metastasis (24.3%, P < 0.0001). The PCNA-positive rate of early gastric cancer was significantly higher in lesions with lymph node metastasis (36.9%) than in lesions without lymph node metastasis (14.7%). However, there was no significant difference between lesions with and without lymph node metastasis in advanced gastric cancer. In addition, the PCNA-positive rate in metastatic lesions (44.6%) was significantly higher than that in the primary lesion (40.0%, P = 0.001). It is concluded that gastric cancer with higher tumor growth activity has a higher rate of lymph node metastasis. Cancer cells in the metastatic foci of lymph node have a higher proliferating activity than that in the primary lesion.

Postoperative evaluation of pylorus-preserving gastrectomy for early gastric cancer.

Physical results after pylorus-preserving gastrectomy (PPG) with preservation of the vagus nerve were evaluated. The status of 15 patients with early gastric cancer after PPG was compared with that of 14 patients after distal gastrectomy (DG). The postoperative/preoperative body-weight ratio of the PPG group (0.99) was significantly greater than that of the DG group (0.92). Patients who had PPG had fewer postoperative abdominal symptoms than those who underwent DG. The gastric emptying pattern of patients who had a pylorus-preserving procedure was slower than that of those who had conventional gastrectomy, and more similar to the preoperative pattern. Contraction of the gallbladder after PPG was better than after DG. Gastroscopy revealed that the mucosa of the stomach remnant after PPG was less abnormal than after DG. In conclusion, PPG is a more physiological operation than conventional DG and should be applied in carefully selected cases of early gastric cancer.

[Detection of chromosomal aberration using fluorescence in situ hybridization on breast cancer].

The relationship between interphase cytogenetics and prognostic factors, especially the grade of nuclear atypism, nuclear DNA content, histological lymph node metastasis and clinical data was examined in 48 primary breast cancer specimens (touch preparation). Using fluorescence in situ hybridization (FISH) with a chromosome-specific DNA probe, the copy number of pericentrometric sequences on chromosome 17 was examined within the interphase nuclei in touch preparations from the tumor. The copy number of chromosome 17 was correlated with the increase in the grade of nuclear atypism, tumor size, histological lymph node metastasis and nuclear DNA content. In the diploid type of nuclear DNA content, the copy number of chromosome 17 was correlated with the increase in the grade of nuclear atypism and histological lymph node metastasis. In conclusion, the numerical chromosomal aberrations detected by FISH were found in the DNA diploid cases by FCM. The detection of numerical chromosomal aberrations by FISH provide important information about the prognostic factors.

Proximal subtotal gastrectomy for the treatment of carcinoma of the upper third of the stomach: its indications based on lymph node metastasis and perigastric lymphatic flow.

To clarify the indications for a proximal subtotal gastrectomy in the treatment of carcinoma in the upper third of the stomach based on lymph node metastases, 1055 patients in whom either a D2 or greater lymph node removal was performed were reviewed. In the patients in which the lesion was confined to the upper stomach and did not invade beyond the muscularis propria of the stomach wall, no metastases to either the lymph nodes above and below the pylorus or the lymph nodes along the greater curvature were observed. A lymphatic flow study revealed a minimal flow to these nodes from the upper stomach in patients without lymph node metastasis, but in cases with lymph node metastases the lymphatic flow changed. The indications for a proximal subtotal gastrectomy for a carcinoma of upper third of the stomach therefore must fulfill the following two conditions: (1) The deepest layer of cancerous invasion does not extend beyond the muscularis propria of the stomach wall, and (2) No macroscopic evidence of lymph node metastasis can be detected during surgery.

The significance of proliferating cell nuclear antigen (PCNA) expression in cancer of the ampulla of vater in terms of prognosis.

Seventeen patients with cancer of the ampulla of Vater were studied retrospectively using immunohistochemical staining with a monoclonal antibody to the proliferating cell nuclear antigen (PCNA). The relationships between the PCNA-positive rate, being the number of PCNA-positive cancer cells to total cancer cells, the clinicopathological findings, and the clinical course were evaluated. The PCNA-positive rate in patients with lymph node metastasis (47%) was significantly higher than that in patients without metastasis (29%), while that in patients with advanced cancer invading the pancreatic parenchyma (47%), was significantly higher than that in patients with early cancer without invasion of the sphincter of Oddi (32%). All of five patients with early cancer are still alive, whereas five with semi-advanced cancer invading the sphincter of Oddi but not the pancreatic parenchyma, and two with a PCNA-positive rate of over 40% died of recurrent cancer. Of seven patients with advanced cancer, only one with a low PCNA-positive rate of 23% is alive, but the other six with a PCNA-positive rate of over 40% all died. The results suggest that the PCNA-positive rate provides a prognostic index for cancer of the ampulla of Vater.

Prognostic value of the number of metastatic lymph nodes in gastric cancer with radical surgery.

To evaluate the effectiveness of extended lymph node dissection in gastric cancer, the relationship between the number of lymph nodes with metastasis and the long-term outcome was studied retrospectively in 761 patients who underwent curative resection with extensive lymph node dissection. The cumulative 5-year survival rate was 85.8% in patients without lymph node metastasis, 60.2% in those with 1-4 lymph nodes, 35.6% with 5-10 nodes, and 12.3% with 11 or more nodes involved. Concerning N2 or N3 patients in whom metastatic lymph nodes would have remained without extensive dissection, the 5-year survival rate was 70.5% in those with 1-4 lymph nodes involved and 44.0% with 5 or more lymph nodes involved when no serosal invasion was observed. It was 38.5% with 1-4 lymph nodes and 5% with 5 or more lymph nodes involved when serosal invasion was observed. These results suggest that extensive lymph node dissection is effective in gastric cancer patients without serosal invasion and, when only a few lymph nodes are involved, also in those with serosal invasion. However, it is not considered to be effective in patients with serosal invasion and metastasis to many lymph nodes. Combination therapies are thought to be required in such patients.

A case of neurofibroma located in the retroperitoneum involving the uncinate process of the pancreas.

A case of solitary neurofibroma in the retroperitoneum involving the uncinate process of the pancreas, which has been reported in only one case in Japan and less than 20 cases in the world literature, is described. A 57-year-old male complained of back pain and microhematuria. Plain and enhanced abdominal computed tomography (CT) indicated an 8 x 6 cm hypovascular tumor located in the uncinate process. We initially assumed it to be a cancer of the pancreas. His physical examination and blood chemistry result were normal. Various diagnostic imaging methods however, disclosed a rare type of tumor. The tumor was resected by pancreaticoduodenectomy and histological examination revealed it to be neurofibroma.