Development and Validation of a Symptom-Focused Quality of Life Questionnaire (KOQUSS-40) for Gastric Cancer Patients after Gastrectomy / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer. Materials and Methods Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity. @*Results@#The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8. Conclusion The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

Development and Validation of a Symptom-Focused Quality of Life Questionnaire (KOQUSS-40) for Gastric Cancer Patients after Gastrectomy / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer. Materials and Methods Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity. @*Results@#The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8. Conclusion The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

The pattern of postoperative quality of life following minimally invasive gastrectomy for gastric cancer: a prospective cohort from Korean multicenter robotic gastrectomy trial

Purpose@#Quality of life (QOL) has become important in the trend of emphasizing patient satisfaction. This study aimed to evaluate the QOL in patients who underwent laparoscopic or robotic gastrectomy for gastric cancer. @*Methods@#A prospective trial was performed involving patients who underwent laparoscopic or robotic gastrectomy for primary gastric cancer at 11 hospitals in Korea. Within this comparative trial, QOL, postoperative pain, and long-term complications were exanimated. The quality-of-life questionnaire (QLQ)-C30 and QLQ-STO22 developed by the European Organization for Research and Treatment of Cancer were used for the QOL survey. We compared the data after dividing it into several types of characteristics as follows; device (robotic or laparoscopic), operation type, pathological stage, and sex.Biased components were extracted by logistic regression analysis. Propensity score matching was applied to the data set with the biased components. @*Results@#In total, 434 patients (211 for laparoscopic surgery and 223 for robotic surgery) were enrolled, out of which 321 patients who responded to both preoperative and postoperative surveys were selected for analysis. Robotic gastrectomy was not different from laparoscopic gastrectomy with respect to postoperative QOL. Distal gastrectomy showed better scores than total gastrectomy in terms of role functioning, social functioning, fatigue, nausea/vomiting, pain, dyspnea, constipation, financial difficulties, dysphagia, eating restrictions, anxiety, taste, and body image. Male patients showed better scores on the 19 scales compared to female patients. @*Conclusion@#Robotic and laparoscopic approaches for gastric cancer surgery did not differ from each other with respect to QOL. Distal gastrectomy resulted in better QOL than total gastrectomy.

Surgical outcomes and prognostic factors of gastric cancer surgery in octogenarians

PURPOSE: As the Korean population ages, an increasing number of elderly patients with gastric cancer are undergoing surgical resection. The aim of this study was to analyze the surgical outcomes and prognostic factors after gastric cancer surgery for patients 80 years of age or older.METHODS: We analyzed the medical records of 720 patients with gastric cancer who underwent gastrectomy from March 2010 to December 2014 retrospectively. Patients were divided into two groups: octogenarians (age ≥80 years, n=46) and non-octogenarians (age <80 years, n=674). We evaluated clinicopathologic data including postoperative morbidity, mortality, and 5-year survival rate.RESULTS: The rate of curative resection was not different between the two groups. The American Society of Anesthesiology score was significantly higher in the octogenarians (P<0.05). Octogenarians exhibited poorer performance scale scores, higher comorbidities, and more advanced TNM stages than non-octogenarians. There was no difference in surgical resection margins between the two groups. In addition, octogenarians suffered from more postoperative morbidity and mortality than non-octogenarians. In the analysis of risk factors of survival after gastrectomy for octogenarians, advanced TNM stage and dose of transfusion were independent risk factors. Overall survival was significantly lower in octogenarians than non-octogenarians. There was no difference in the disease-specific survival for each stage of cancer after adjustment for tumor stage.CONCLUSION: Octogenarians had more preoperative risk factors and postoperative morbidity and mortality, but cancer-specific survival was comparable with non-octogenarians. Careful preoperative evaluation, thorough resection, and attentive postoperative care can improve the overall survival of octogenarians with gastric cancer.

2014–2017 Nationwide Bariatric and Metabolic Surgery Report in Korea

PURPOSE: The information committee of the Korean Society for Metabolic and Bariatric Surgery (KSMBS) performed the nationwide survey of bariatric and metabolic operations to report IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders) worldwide survey annually. This study aimed to report the trends of bariatric and metabolic surgery in Korea in 2014–2017. MATERIALS AND METHODS: We analyzed the accumulated nationwide survey data conducted for annual ISFO survey from 2014 to 2017. Trends such as the number of operations by hospital type and the number of operations by surgical method were analyzed. RESULTS: The number of operations has decreased sharply in 2015 comparing to 2014 (913⇒550). The number of operations performed in private hospitals dropped sharply from 529 to 250, 198, and 103 cases. The number of revisional surgeries increased to 223 in 2015. The primary surgery number fell from 757 in 2014 to 327 in 2015. In primary surgery, sleeve gastrectomy was gradually increased from 2014 to 143 (18.9%), 105 (32.1%), 167 (47.2%) and 200 (56.3%) and became the most frequently performed surgery. On the other hand, the incidence of adjustable gastric band decreased gradually from 439 (58.0%) to 117 (35.8%), 112 (31.6%) and 59 (16.6%). CONCLUSION: The overall number of obesity metabolic operations has decreased since 2014, especially the number of adjustable gastric band, and the number of operations in private hospitals declined sharply. On the other hand, the number of operations in university hospitals did not change much, and the number of sleeve gastrectomy increased.

Epidemiologic Study of Human Epidermal Growth Factor Receptor 2 Expression in Advanced/Metastatic Gastric Cancer: an Assessment of Human Epidermal Growth Factor Receptor 2 Status in Tumor Tissue Samples of Gastric and Gastro-Esophageal Junction Cancer

PURPOSE: The Trastuzumab for gastric cancer (GC) trial identified human epidermal growth factor receptor 2 (HER2) as a predictor of successful treatment with trastuzumab (HER2 receptor targeting agent) among patients with advanced/metastatic GC. To date, the prevalence of HER2 overexpression in the Korean population is unknown. The present study aimed to assess the incidence of HER2 positivity among GC and gastroesophageal (GE) junction cancer samples and the relationship between HER2 overexpression and clinicopathological characteristics in Korean patients. MATERIALS AND METHODS: Tumor samples collected from 1,695 patients with histologically proven GC or GE junction enrolled at 14 different hospitals in Korea were examined. After gathering clinicopathological data of all patients, HER2 status was assessed by immunohistochemistry (IHC) at each hospital, and IHC 2+ cases were subjected to silver-enhanced in situ hybridization at 3 central laboratories. RESULTS: A total of 182 specimens tested positive for HER2, whereas 1,505 tested negative. Therefore, the overall HER2-positive rate in this study was 10.8% (95% confidence interval: 9.3%–12.3%). The HER2-positive rate was higher among intestinal-type cases (17.6%) than among other types, and was higher among patients older than 70 years and 50 years of age, compared to other age groups. CONCLUSIONS: Our evaluation of the HER2 positivity rate (10.8%) among Korean patients with GC and GE junction indicated the necessity of epidemiological data when conducting studies related to HER2 expression in GC and GE junction.

The Short-term Outcome and Safety of Laparoscopic Colorectal Cancer Resection in Very Elderly Patients / 대한소화기학회지

BACKGROUND/AIMS: Due to the recent increase in elderly population, laparoscopic surgery is more frequently performed in the elderly. This study aimed to compare the short-term outcomes of laparoscopic colorectal cancer surgery between the very elderly group (VEG), categorized as those with age over 80 years and the elderly group (EG), categorized as those with age 65 to 79 years. METHODS: We retrospectively compared 48 very elderly patients with 96 elderly patients (1:2 matched) who underwent laparoscopic resection for colorectal cancers at our institution between March 2010 and December 2014. The clinicopathologic parameters, surgical characteristics and short term outcomes were compared. RESULTS: There was no statistically significant difference in clinicopathologic characteristics between VEG and EG. Postoperative pain score (7 points vs. 6 points, p=0.264), time to first flatus (3 days vs. 3 days, p=0.335), hospital stay (15 days vs. 16.5 days, p=0.361), complication rates (47.9% vs. 26.0%, p=0.147) and major complication rate (25% vs. 20.8%, p=0.681) were not statistically different between the two groups. Before surgery, VEG had higher rate of neurologic underlying disease, such as dementia or cerebrovascular disease, than EG (25.0% vs. 7.3%, p=0.007). CONCLUSIONS: There was no significant difference in the clinicopathologic characteristics, short-term outcomes, and complication rates for laparoscopic colorectal resection between VEG and EG, except delirium. Age over 80 years may be relevant for the application of laparoscopic colorectal cancer resection.

Synchronous triple primary cancers occurring in the stomach, kidney, and thyroid

We report an unusual case of synchronous triple primary cancer of the stomach, kidney, and thyroid in a 50-year-old male patient. Initial esophagogastroduodenoscopy with biopsy for the medical check-up revealed poorly differentiated adenocarcinoma. We performed an abdominal/pelvic computed tomography scan for staging and incidentally found a 1.7-cm exophytic hypervascular mass in the left kidney. Thyroid ultrasonography showed suspicious malignant nodules suspicious with multiple lymph nodes (LNs) metastasis in the right side of the neck. Subsequent fine needle aspiration biopsy of a nodule and a LN was performed. Cytologic report revealed papillary thyroid carcinoma with lateral LNs metastasis. Our integrate oncology team performed radical subtotal gastrectomy, partial nephrectomy, and total thyroidectomy with modified radical neck dissection. The postoperative pathologic finding was well-differentiated gastric adenocarcinoma (T1N0M0; stage 1A), renal cell carcinoma (T1aN0M0; stage 1), and papillary thyroid carcinoma (T4bN1bM0; stage 4B). He received postoperative a radio-active iodine ablation and is doing well with no recurrence.

Metachronous Liver Metastasis Resulting from Early Gastric Carcinoma after Subtotal Gastrectomy Following Endoscopic Resection: A Case Report

Hepatic metastasis of early gastric cancer (EGC) following subtotal gastrectomy with lymphadenectomy is rare. We report the case of a 61-year-old male patient who was diagnosed with EGC that was initially treated using endoscopic submucosal dissection (ESD) and subsequently underwent laparoscopic subtotal gastrectomy. Histopathological examination of the patient's ESD specimen showed a moderately differentiated tubular adenocarcinoma invading the submucosa without lymphatic invasion. The deep margin of the specimen was positive for adenocarcinoma, and he subsequently underwent laparoscopic distal gastrectomy. The patient developed liver metastasis 15 months after the operation and then underwent liver resection. Histology of the resected specimen confirmed the diagnosis of two foci of metastatic adenocarcinoma originating from stomach cancer. Immunohistochemical analysis of the specimen demonstrated overexpression of human epidermal growth factor receptor 2. The patient was treated with trastuzumab in combination with chemotherapy consisting of capecitabine and cisplatin. Twenty-four months after the operation, the patient remained free of recurrence.

Two Cases of Advanced Gastric Carcinoma Mimicking a Malignant Gastrointestinal Stromal Tumor

Gastric cancer that mimics a submucosal tumor is rare. This rarity and the normal mucosa covering the protuberant tumor make it difficult to diagnosis with endoscopy. We report two cases of advanced gastric cancer that mimicked malignant gastrointestinal stromal tumors preoperatively. In both cases, the possibility of cancer was not completely ruled out. In the first case, a large tumor was suspected to be cancerous during surgery. Therefore, total gastrectomy with lymph node dissection was performed. In the second case, the first gross endoscopic finding was of a Borrmann type II advanced gastric cancer-like protruding mass with two ulcerous lesions invading the anterior wall of the body. Therefore, subtotal gastrectomy with lymph node dissection was performed. Consequently, delayed treatment of cancer was avoided in both cases. If differential diagnosis between malignant gastrointestinal stromal tumor and cancer is uncertain, a surgical approach should be carefully considered due to the possible risk of adenocarcinoma.

Factors Related to Morbidity in Elderly Gastric Cancer Patients Undergoing Gastrectomies

PURPOSE: The prevalence of gastric cancer in the elderly is increasing. The purpose of this study was to clarify factors related to morbidity following gastric cancer surgery in elderly patients. MATERIALS AND METHODS: For this study, data from 411 patients who underwent curative gastrectomies with lymph node dissections between March 2010 and January 2013 were retrospectively studied using a prospectively designed database. Patients were divided into 2 groups ( or =70 years). For each group, perioperative factors were analyzed to determine if they were associated with postoperative morbidity and mortality. RESULTS: Comorbidities were more prevalent in the elderly group (> or =70 years). Intraoperative and postoperative transfusions were also more frequently required in the elderly group. There was no significant difference in the number of retrieved lymph nodes between the 2 groups (44.3 vs. 46.6 nodes). In a comparison of the elderly versus non-elderly groups, the postoperative morbidity rates were 22.7% versus 8.9% (P<0.001) and the postoperative mortality rates were 4.2% versus 0% (P=0.002), respectively. Of the possible non-surgical complications, pulmonary problems were predominately found in the elderly group (P<0.001). Surgical complications were evenly distributed between the 2 groups (P=0.463). Postoperative morbidity was significantly associated with older age and postoperative transfusion. Multivariate analysis showed that higher body mass index (BMI) and postoperative transfusion were important factors associated with postoperative complications in the elderly group. CONCLUSIONS: Pulmonary complications were frequently problematic in elderly patients. Higher BMI and postoperative transfusion were significant risk factors for postoperative complications in elderly patients with gastric cancer.

Comparison of the Risk Factors for Arterial Stiffness between Extremity Muscular and Abdominal Elastic Arteries

PURPOSE: Muscular artery differs from elastic artery in physical properties and constituents of the arterial wall. To investigate the difference between muscular and elastic arteries, we measured the pulse wave velocities (PWVs) in lower extremity muscular arteries (femoral ankle PWV, faPWV) and abdominal elastic arteries (brachial femoral PWV, bfPWV), and searched for the relationships between the PWVs of muscular, elastic arteries and the risk factors of arteriosclerosis. METHODS: 184 normal volunteers were enrolled in the study. Among them, the ratios of male/female, smoker/non-smoker, and hypertension/normal were 81/103, 66/118, and 63/121, respectively. Using volume plethysmography, faPWV and bfPWV were measured. The risk factors of arteriosclerosis in this study were age, gender, smoking, hypertension, body mass index, low density lipoprotein, high density lipoprotein, triglyceride, hemoglobin A1C, and white blood cell. RESULTS: The PWVs of lower extremity muscular arteries (faPWVs) were significantly faster than those of abdominal elastic arteries (bfPWVs) (right, P<0.001; left, P<0.001) Multiple regression analysis revealed that the independent risk factors of the PWV were age (right, P<0.001; left, P<0.001) and gender (right, P=0.008; left, p=0.014) in abdominal elastic arteries. However, in lower extremity muscular arteries, hypertension (right, P<0.001; left, P<0.001) as well as age (right, P<0.001; left, P<0.001) and gender (right, P=0.009; left, P=0.001) were other significant independent risk factors. CONCLUSION: The PWVs of lower extremity muscular arteries were significantly faster than those of abdominal elastic arteries. The significance of hypertension in faPWV suggests that hypertension is an important risk factor in inducing arterial stiffness, especially in lower extremity muscular arteries.

The Schedule Dependency for Induction of Thymidine Phosphorylase Activity and the Enhancement of Capecitabine Efficacy by Docetaxel on the SNU-484 Gastric Cancer Cell Line That was Injected into Xenografted Nude Mice

PURPOSE: Docetaxel (Taxotere(R)) and capecitabine are used in combination to treat advanced gastric cancer. Thymidine phosphorylase (TP) is an essential enzyme for the activation of capecitabine in tumors. This study sought to identify the best combination therapy with capecitabine and using two different schedules for docetaxel, a TP up-regulator, to enhance capecitabine's efficacy. METHODS: The human gastric cancer cell line SNU-484 was cultured and docetaxel (2 microgram/ml) was added to the 24-well plates that contained 5 x 10(5) cells/well. The total RNA was isolated and RT-PCR was done to identify the TP expression. Four- or five-week-old BALB/c-nu/nu mice were subcutaneously inoculated with the SNU-484 cells. The nude mice were divided into two groups and they were given capecitabine 539 mg/m2 p.o. from days 1 to 14: Group 1 was given docetaxel 15 mg/m2 i.v. on day 1; Group 2 was given docetaxel 7.5mg/m2 on days 1 and 8. Tumor tissues were excised on days 1, 8 and 15 to measure the TP and bcl-2 levels. RESULTS: TP was expressed 2 hours after docetaxel administration. Group 2 had a higher TP concentration in the tumor tissues and a better antitumor effect than did Group 1. There was no difference in the bcl-2 concentration in the two groups. CONCLUSION: These results suggest that docetaxel stimulates the TP expression in tumor tissues and it enhances the antitumor activity of capecitabine. A weekly docetaxel injection with capecitabine administration can be used to treat gastric cancer more effectively than when docetaxel is injected once per cycle. Capecitabine had no bcl-2 suppressive effect in this study.

A Case of Gastric Adenocarcinoma Presenting as Meningeal Carcinomatosis

Leptomeningeal carcinomatosis occurs in approximately 5% of patients with cancer. The most common cancers involving the leptomeninges are breast, lung cancer and melanoma. However, gastric adenocarcinoma has been rarely reported with leptomeningeal carcinomatosis. The presenting manifestations are usually headache, visual disturbances and seizures. We report a case of leptomeningeal metastasis that presented as a gastric cancer. A 49-year-old woman was admitted to our hospital with the symptoms of headache and melena for 10 days. The endoscopy showed a thickening of the folds of the stomach compatible with the diagnosis of a Borrman type IV gastric cancer. The biopsy revealed a signet ring cell carcinoma. The MRI of brain showed no abnormal findings; however, the patient complained of an intractable persistent headache, nausea and vomiting on admission day 6. The cytology examination of the cerebrospinal fluid supported the diagnosis of metastatic signet ring cell carcinoma.

Gastrointestinal Anisakiasis

We report a case of gastrointestinal anisakiasis which was misinterpreted as a gastrointestinal stromal tumor until an operation and pathological report. A 44-year-old female was diagnosed as having a gastrointestinal stromal tumor on esophagogastroduodenoscopy during a routine medical examination. The esophagogastroduodenoscopy revealed a 1 cm sized submucosal tumor at the gastric mid-body. Endoscopic ultrasonography showed a low echoic tumor, with an irregular margin, in the submucosal layer. The patient underwent a wedge resection of the gastric lesion. A histological examination revealed chronic granulomatous inflammation, with abscess formation and a parasitic organism, morphologically consistent with anisakiasis.

A Case of Eosinophilic Gastritis Mimicking Borrmann Type-4 Advanced Gastric Cancer

Eosinophilic gastroenteritis is a rare clinicopathologic entity of unknown etiology with a variety of digestive symptoms. The pathogenesis is poorly understood. Diagnostic criteria include demonstration of eosinophilic infiltration of the affected bowel wall, lack of evidence of extraintestinal disease, and exclusion of various disorders that could mimic similar conditions. The disease might involve any area of the gastrointestinal tract from the esophagus to the rectum, but the stomach and the proximal small bowel are most commonly affected. The clinical features depend on which layer and site are involved. We report the case of a 59-year-old male patient with a 3-week history of post-prandial vomiting with malnutrition and weight loss. An abdominopelvic CT showed a gastric outlet obstruction with diffuse wall thickening, as with linitis plastica. Three gastrofiberscopic biopsies showed chronic gastritis. We carried out a radical total gastrectomy with D2 lymph node dissection. The pathologic report revealed a mural type eosinophilic gastritis with a marked hypertrophic scar formation at the proper muscle layer. We report this case with a brief review of the literature.

A Case of Locally Recurrent Gastric Cancer at Kim's Tie Site of the Jejunum after a Total Gastrectomy

Despite improvements in the surgical treatment of gastric adenocarcinomas, the recurrence rates remain high in patients with advanced-stage disease. Most of the recurrence occurs within 3 years of the surgical resection, and nearly 90% of the patients with recurrence die within 2 years of the diagnosis of recurrence. A recent study analyzed recurrence patterns for patients who had undergone a potentially curative gastrectomy. For those patients, 33% of the recurrences involved locoregional sites, 44% the peritoneum, and 38% distant sites. A 51-year-old female patient was diagnosed with stomach cancer and underwent a total gastrectomy with D2 lymph node dissection during Oct. 1999. The pathologic report indicated a T3N1M0 tumor. We performed immunochemotherapy for 2 years with regular follow up. A gastrofiberscopic examination done during Sep. 2004, cancer recurrence was found at the *Kim's tie site of the jejunual loop. We did an abdominal exploration and a segmental resection of cancer site with pathologically negative resection margins. After the operation, we started secondary chemotherapy with TS-1.

A Case of Advanced Gastric Cancer with Virchow's Node and Lung Metastasis Successfully Resected after Combined Chemotherapy of Taxotere, CDDP, and 5-FU

We report a case of advanced gastric cancer with Virchow's node and lung metastasis that responded remarkably to preoperative chemotherapy. A 47-year-old female patient was diagnosed as having incurable advanced gastric cancer with Virchow's node and multiple lung metastasis. Preoperative chemotherapy with Taxotere, CDDP and 5FU was carried out. After four courses of the regimen, the Virchow's node and the lung metastasis had disappeared, and a marked reduction of the gastric lesion was observed on the CT scan. Consequently, the patient underwent a total gastrectomy with D2 lymph node dissection. On histopathological examination, cancer cells were found to have infiltrated up to the muscle layer of the gastric wall, and 42 out of 60 resected lymph nodes were found to be metastatic. The patient received another two courses of chemotherapy after the operation

Giant Gastrointestinal Stromal Tumor Accompanying Stomach Cancer

We report a case of giant malignant gastrointestinal stromal tumor (GIST) accompanying an advanced gastric adenocarcinoma. A 73-year-old male patient was admitted to our hospital due to epigastric discomfort. In gastrofiberscopic examination, a localized Borrmann III gastric cancer at the lower body and antrum was noted. In endoscopic ultrasonographic examination, T3 hyperechoic advanced gastric cancer lesion and a relatively well-marginated heterogenous hypoechoic huge mass with a size of 10 cm were noted. In abdomen CT findings, localized wall thickening in the gastric antrum and the anterior wall, and a 11-cm-sized large heterogeneously enhancing mass in gastric body, posterior wall were noted. We did a radical subtotal gastrectomy, including a huge mass, with D2 lymph node dissection. Pathologic findings revealed double primary gastric neoplasms (synchronous occurrence of an adenocarcinoma and a huge GIST). Although closely juxtaposed, these two tumors had not merged and were separated by the thin rim of the muscularis propria.

Anastomosis Site Stricture after Using Stapler Devices in a Total Gastrectomy

PUPOSE: Anastomosis site stricture is a common complication after a total gastrectomy. End-to-end anastomosis (EEA) stapler devices are preferred to a hand-sewn esophagojejunostomy these days. However, stapling devices have been reported not to reduce the incidence of esophagojejunostomy site stricture considerably. MATERIALS AND METHODS: From Sep. 1998 to Dec. 2000, at Korea Gastic Cancer Center, Seoul Paik Hospital, Inje University, we experienced 228 total gastrectomies in which EEA stapling devices had been used. We investigated the correlation of the stricture with the size of the EEA stapling device, the type of esophagojejunal reconstruction, reflux esophagitis, and duration of stricture development. RESULTS: Among the 228 cases, as far as the patient's age was concerned, the 7th decade was the most common 64 cases, followed by the 5th decades. The Male-to-female ratio was 2.3 : 1. A loop esophagojejunostomy was used in 223 cases, and the Roux-en-Y method was used in 5 cases. The 32 patients with anastomosis site stricture were patients with loop esophagojejunal anastomosis. Anastomosis site stricture occurred in 14% (32/228) of the total gastrectomy cases, in15.9% (11/69) of the total gastrectomies involving stapler devices with a 25-mm diameter, and in 13.2% (21/159) of the total gastrectomies involving staper devices with a 28-mm diameter. There was no correlation between the incidence of stricture and EEA- stapling device size (P>0.05). Reflux esophagitis occurred in 56 of the 228 cases, with 7 of those 56 cases (12.5%) and 25 of the remaining 172 cases (14.5%) having strictures. There was no considerable difference in the stricture incidence rate according to the presence of reflux esophagitis (P>0.05). The onset of stricture development, occurred within 6 months in 16 cases, including 4 cases of reflux esophagitis, between 7 and 18 months in 14 cases, including 3 cases of reflux eshophagitis, and after 19 months in 2 cases. CONCLUSION: An esophagojejunostomy site stricture after a total gastrectomy was not correlated with the esophagojejunal reconstruction type, the size of the stapling device, or the presence of reflux esophagitis. General anastomosis technical factors (e.g., adequate blood supply, tension-free manner, adequate hemostasis) may be more important to prevent anastomosis site stricture after an esophagojejunostomy during a total gastrectomy.