Results of surgical treatment of gastric cancer

BACKGROUND/AIM

The extent of gastric resection and the role of lymphadenectomy in the treatment of gastric cancer are controversial.

METHODS

This study evaluates the results of radical gastric resection (D2 lymphadenectomy) in 375 patients with a gastric carcinoma operated according to a prospective protocol.

RESULTS

Total gastrectomy was performed in 196 and a subtotal gastrectomy in 179 patients, with an operative mortality of 3.5 and 2.8%. The presence of lymph node metastasis was related to the depth of the tumor in the gastric wall. The cumulative 5-year survival was dependent on the depth of tumoral invasion in the gastric wall and also on the presence of lymphatic metastasis. Curative resection had a significantly better 5-year survival (72%) than noncurative resection (26%).

CONCLUSION

Although it is difficult to prove the benefits of extended lymphadenectomy in the surgical treatment of gastric carcinoma, the results of these series seem to support its usefulness.

[Non Hodgkin lymphoma of the stomach: evaluation of surgical treatment in 24 patients]

This is a retrospective review of 24 patients with Non Hodgkin Lymphoma of the stomach operated between 1959 and 1991. The diagnosis was reached with a radiological study in 12 of 15 (80%) patients and with endoscopy in 11 of 16 (69%) of patients. Eleven of 14 (78%) preoperative biopsies available at the moment of the revision were positive for non Hodgkin Lymphoma. Clinical staging was performed using Ann Arbor Classification and the histological type was defined according to the Working Formulation. Diffuse large cell lymphoma (intermediate grade) was the most frequent histological subtype. Eleven patients were in clinical stage I, 10 patients in stage II and 3 in stage IV. Eight total gastrectomies and 16 subtotal gastrectomies were performed. Twenty one percent of patients had a postoperative complication and operative mortality was 12%. Stage I patients were treated exclusively with surgery and no recurrences were observed. Stage II patients received adjuvant chemotherapy, the tumor recurred in three and two died due to disease progression. Five years disease free survival was 64%. It is concluded that surgical treatment achieves a good disease control in stage I patients but must be complemented with chemotherapy in stage II tumors.

[Pyogenic liver abscess. Experience with 50 cases]

During the last years the diagnosis and treatment of pyogenic liver abscess has changed substantially. The aim of this work is to report a retrospective analysis of 50 patients aged 24 to 87 years old, that presented with a pyogenic liver abscess and were treated in the last 13 years. The sensitivity for diagnosis of ultrasound examination, CAT scan and angiography was 68, 89 and 75% respectively. The origin of the abscess was detected at the biliary tree in 46% and remained unknown in 38%. Thirty one patients were operated, 13 were subjected to percutaneous drainage and 5 were treated only with antimicrobials. Forty percent of patients had a septic complication and 4 (8%) died. Mean hospital stay was 31 days for operated patients and 21 for the rest. The abscess recurred in seven patients and two of these had a gallbladder carcinoma. It is concluded that percutaneous drainage is an alternative to surgical treatment that must be accompanied by a careful diagnostic workup.

[Choledochocele. Report of a case and review of the literature]

We report a 29 years old man with a choledochocele or type III choledochal cyst, an extremely rare condition. This was found during a cholecystectomy using a transcystic intra operative cholangiogram. A transduodenal sphincteroplasty was performed. The cyst diameter was 1.5 cm approximately and two 1-2 mm stones were extracted from its lumen. The chemical composition of these was different from those located in the gallbladder. The postoperative period was uneventful and the patient remains asymptomatic.

[Gastrointestinal bleeding of unknown origin. Experience in 31 cases]

Thirty one patients with GI bleeding of obscure origin, defined as those with normal upper endoscopy and colonoscopy, were studied to know the yield of different diagnostic procedures. Seventeen patients consulted for hematochezia and bleeding less than 10 days of evolution in 71%. Small bowel X ray examination was performed in 14 cases with a diagnostic effectiveness (number of diagnosis/number or examination) of 14%, angiography was performed in 12 cases with an effectiveness 33%, radiolabeled erythrocyte scanning in 12 cases with an effectiveness of 75%, scintigraphy with pertechnetate in 6 cases with an effectiveness of 17% and intraoperatory endoscopy in 2 cases with an effectiveness of 50%. A definitive diagnosis was reached in 8 patients during the first admission and in 6 during the second admission. The principal etiologies were small bowel tumors in 3 cases, cecal ulcers in 2 and ileal diverticula in 2. Ten subjects were subjected to surgical and 2 to endoscopic treatment. Five patients with recurrent bleeding remain without diagnosis. It is concluded that radiolabeled erythrocyte scanning and angiography are effective examinations that should follow upper and lower endoscopies in the diagnosis of a concealed GI bleeding. When a diagnosis is not reached in the first admission, patients should be following with repeated diagnostic procedures.

[Colorectal cancer. Study of survival and surgical results]

The aim of this study was to assess the progress in the surgical treatment of colorectal carcinoma in a 15 years period at the Catholic University Clinical Hospital. The medical records of 397 patients were retrospectively analyzed. Two hundred eighty four patients (164 male) aged 24 to 90 years old, subjected to elective and curative interventions, were selected for the study and separated in two groups: 132 subjects operated between 1975 and 1984 (group A) and 152 operated between 1985 and 1989 (group B). Group B patients were older (66.7 vs 61.3 years old), had a higher proportion of Dukes A tumors (11 vs 18%) and a lower proportion of lesions localized in the rectum (37 vs 49%). Rectal operations had higher morbidity than colonic interventions (35 vs 17.5%). Operative mortality was 0.7% in group A and 0.6% in group B. Ninety one percent of patients had a mean follow up of 38 months. Five years actuarial survival was 52% in group A and 69% in group B and 58, 74 and 46% for tumors Dukes A, B and C respectively.

Metaplasia and precursor lesions of gallbladder carcinoma. Frequency, distribution, and probability of detection in routine histologic samples

BACKGROUND

Gallbladder diseases, especially cholelithiasis, are extremely frequent in Chile, and an increasing frequency of gallbladder carcinoma has been observed during the last decades. Hyperplastic and atypical epithelial lesions of gallbladder epithelium have been considered potential precursors of invasive carcinoma. The current study was designed to study the frequency, distribution, extension, and probability of routine detection of potentially preneoplastic changes of gallbladder epithelium.

METHODS

Epithelial changes were histologically studied by mapping gallbladders obtained at elective cholecystectomy for lithiasis in 162 Chilean patients.

RESULTS

Antral-type metaplasia was found in 95.1% of the cases, intestinal metaplasia in 58.1%, hyperplasia in 46.9%, dysplasia in 16%, and carcinoma in situ in 2.5%. A significant association of intestinal metaplasia with hyperplasia, intestinal metaplasia with dysplasia, and hyperplasia with dysplasia was found. Hyperplasia and dysplasia were also present in four cases with carcinoma in situ. Mean extension of the lesions (percentages of the sections in which the change was observed) was antral-type metaplasia (62.7%), intestinal metaplasia (25.3%), hyperplasia (24.1%), dysplasia (15.5%), and carcinoma in situ (9.7%). Antral-type and intestinal metaplasia were more extensive and more severe in patients older than 50 years of age. Hyperplasia was more extensive in cases in which it was associated with dysplasia and carcinoma in situ.

CONCLUSIONS

The extension of metaplasia seems to depend in part on the age of the patients. The association of intestinal metaplasia with hyperplasia and dysplasia agrees with the findings of other authors that relate metaplasia to gallbladder cancer. The epithelial lesions are focal or partially confluent, thus a single random histologic section will detect less than one third of the hyperplasias, dysplasias, and carcinomas in situ.

[Pregnancy and portal hypertension]

The course of pregnancy in three patients with portal hypertension is described. The cause of portal hypertension was cirrhosis in one and portal vein obstruction in two (one of these had previous shunt surgery). The patient with cirrhosis had an episode of encephalopathy at week 27, the rest of the patients had an uneventful pregnancy. All three had preterm vaginal deliveries at week 33, 31 and 37 of pregnancy. The clinical features of pregnancy in women with portal hypertension was reviewed in the literature. There is agreement that the risk of preterm delivery increases and pregnancy does not influence maternal prognosis. Vaginal delivery can be anticipated in most women and cesarean section is reserved for obstetric indications. Pregnancy in these women should be managed in tertiary care centers with close collaboration between perinatologists, internists and surgeons.

[Vascular compression syndrome of the duodenum. Report of 2 cases]

Two young female patients with the syndrome of vascular compression of the duodenum are reported. Both patients presented with a history of vomiting and weight loss. Barium examination of the gastrointestinal tract showed in both cases, marked stomach distention and obstruction of the third portion of the duodenum. In one patient, abdominal CT scan discarded other causes of extrinsic compression. Both patients were operated. The simpler and safer surgical procedure is the section of the Treitz ligament and duodenal liberation, which can be used in the majority of patients.

[Budd-Chiari syndrome. Report of 2 surgical cases]

Two female patients with Budd-Chiari syndrome and suffering of Polycythemia Vera are reported. Both patients were operated performing a central spleno renal shunt with preservation of the spleen and ligation of the splenic artery. The patients are well 6 and 24 months after the operation respectively. The principal features and therapeutic alternatives of this condition are reviewed briefly.

Axonal sprouting induced in the sciatic nerve by the amyloid precursor protein (APP) and other antiproteases

Protease inhibition is the mechanism by which some trophic factors promote the extension of neurites. In the rat sciatic nerve, we assessed the ability to induce sprouts of the APP isoform that embodies the Kunitz antiprotease domain and other antiproteases. With the electron microscope, axonal sprouts were found when antiproteases were supplied but not after administration of inactive substances. We conclude that axons have a drive to sprout which can be released by the unbalance of an extracellular protease-antiprotease system. We propose that this system is involved in the pathogenesis of Alzheimer's disease.

[Treatment of non-variceal upper digestive hemorrhage with endoscopic thermocoagulation]

Over a year period, 60 of 172 patients presenting with upper gastrointestinal bleeding were treated by endoscopic thermocoagulation. Entry criteria included active bleeding (pulsatile or oozing), a visible vessel, sentinel clot or the presence of a pigmented protuberance at the ulcer crater. Hemostatic therapy was performed using the heat probe. The physical status and risk of the patients was estimated according to the ASA classification. Hemostasis was obtained in 17 of 21 patients with pulsatile bleeding (81%), 30 of 30 patients with oozing (100%) and 18 of 18 patients with a visible vessel or a pigmented protuberance in the lesion (100%). Three patients, older than 70 years of age, died. All had pulsatile bleeding from a deep ulcer located at the posterior-inferior wall of the duodenal bulb. They were classified as ASA III (n = 1) or IV (n = 2) with significant concomitant illness. These results suggest that endoscopic thermocoagulation is an effective treatment of active upper gastrointestinal bleeding, especially useful in a group of high risk patients.

[Acute severe pancreatitis. Analysis of mortality and morbidity]

Sixty-three patients with severe acute pancreatitis have been studied. Pancreatitis was associated with biliary tract disease in 23 patients (36.5%) and with alcoholism in 21 (33.3%). It occurred post-operatively in 9, and was associated with other conditions in 10. We evaluated the Ranson prognostic signs (RPS) with the appearance of complications. 36 patients (57.2%) had 3-4 RPS, 9 (30.2%) had 5-6 RPS and 8 (12.6%) had 7 or more RPS. Diagnostic laparotomy was performed in 11 patients (17.5%). 55 patients were operated one or more times due to failure of medical treatment and/or local and septic complications. The most frequent complications were pancreatic abscess (60.3%), sepsis (58.7%) and pulmonary insufficiency (52.4%). Renal failure occurred in 26 patients and 9 required dialysis. Of the patients with renal failure, 84.6% (22/26) had 4 or more RPS; 78.4% (29/37) of those with sepsis and 71.6% (27/38) of those with pancreatic abscess also had 4 or more RPS. The mean duration of hospitalization of survivors was 58 +/- 30 days. Overall mortality was 28.6%. We conclude that RPS are helpful to predict complications in patients with severe pancreatitis.

[Regeneration of gastric mucosa after endoscopic biopsy]

Eleven gastric mucosal defects produced by endoscopic biopsy in non-tumoral areas were histologically studied in gastrectomy specimens. The biopsies had been performed from one up to seven days before the operation. The base of each defect was formed by submucosa infiltrated by erythrocytes, fibrin and neutrophils, which were later replaced by small blood vessels, fibroblasts and collagen fibrils. The mucosa of the margins bowed down towards the base of the defect. This marginal mucosa showed dedifferentiation of the glandular epithelial cells, increased mitotic index and some cystic glandular structures lined by basophilic cells. The defect was progressively covered by a layer of flattened or cuboidal cells in which no mitoses were observed; their cytoplasm contained mucosubstances similar to those of the superficial epithelium of the remaining mucosa, either foveolar- or intestinal metaplastic-type. From this layer, simple gland-like invaginations to the underlying connective tissue were observed. The findings are consistent with the regenerative events described in experimental gastric ulcers in animals. The method employed may be useful to study specific aspects on the regeneration of the human gastric mucosa.

[The medical treatment of intestinal obstruction due to adhesions and adherences]

Adhesions are the most common cause of intestinal obstruction. Medical treatment for those patients with no signs of vascular involvement has been successful in many cases. We reviewed the clinical records of 87 patients with intestinal obstruction due to adhesions, having a total of 122 episodes. Satisfactory follow up was obtained in 76% of patients for a mean of 29.6 months. 47% of episodes resolved without need for surgical intervention. Volume entrapment during the first hours was correlated with need for surgical treatment (p < 0.01). Recurrences were not different between medical and surgical patients (p = 0.28). Thus, medical treatment of this type of intestinal obstruction may be attempted in most patients, not only those who are poor surgical risks.

[Duodenal obstruction caused by cholelithiasis (Bouverets' syndrome): a clinical case]

A 55 year old man presented with vomiting, abdominal pain, diarrhea, jaundice and choluria. An obstruction of the gastric outlet by a large gallstone located at the duodenum was demonstrated by radiologic, ultrasonographic and endoscopic examinations. The stone could not be removed through endoscopy and the patient was successfully operated on. A review of published reports is included.

[Gastric cancer: surgical results and survival]

From 1975 to 1984, 292 patients with gastric cancer were treated according to a prospective and standardized surgical protocol. This series included 195 men and 97 women, with an average age of 62.5 +/- 11 years (SD). In 20 patients (6.8%) surgery was not performed and 99 were considered unresectable at laparotomy. Gastric resection was performed in 173 (63.3%) (distal subtotal gastrectomy in 94 and total gastrectomy in 79). Operative mortality for subtotal gastrectomy was 3.1% and 6.3% for total gastrectomy. Early gastric cancer was found in 21 patients (none presented lymph node metastases). The cancer invaded the muscular layer in 18 (31% with lymph node metastases) and reached beyond the muscular layer in 134 patients (60.8% with lymph node metastases). The five year actuarial survival was 0% in patients who did not undergo gastric resection, 35.5% for those patients with tumor invading the serosal layer or beyond who were resected, 56.5% for those with invasion up to the muscular layer and 91.8% for patients with early gastric cancer. For those patients who underwent a curative resection, actuarial five year survival was 81%.

[Splenic abscess]

Splenic abscess is an uncommon condition associated with a high mortality. In most cases an hematogenous focus can be identified. Early diagnosis is essential for recovery. CT scan and ultrasound tomography are the best diagnostic tools. The latter was used to establish the diagnosis in 2 patients who were successfully treated by surgery.

[Value of preoperative colonoscopy in colon-rectal neoplasms]

The surgical approach to treat colo-rectal carcinoma is usually based on the findings of barium enema. In 102 patients we reviewed the yield of pre-operative colonoscopy. Barium enema revealed the cancer in 76 of 84 patients (91%), whereas colonoscopy did so in 96 of 102 subjects (94%). In addition, 5 associated cancerous lesions were demonstrated by colonoscopy and none by barium enema. Associated benign lesions were seen in 14 patients. In 5 patients the surgical plan based on the barium enema was modified by the findings at colonoscopy. Eight false negatives to barium enema were correctly diagnosed by colonoscopy. We conclude that colonoscopy yields valuable information, beyond that of barium enema, in patients with colo-rectal cancer.

[Colorectal cancer: follow-up after curative resection]

From Jan 1978 to Dec 1984, 128 patients had a curative resection of colorectal carcinoma. A program for early detection and surgical correction of recurrences was initiated in 88 patients with a mean age of 61 years (range 24 to 85). Seventy two patients complied with the program involving clinical examination, chest X-ray, alkaline phosphatase and CEA determinations and endoscopy at 6 month intervals. Mean follow up was 36 months (range 6 to 60). A total of 28 recurrences (32%) were detected: 4 local, 17 distant and 7 local and distant. Recurrences occurred in 46% of grade C, 19% of grade B and 0% of grade A lesions. Sixty eight% of recurrences were detected within 12 months and 93% within 36 months after surgery. Recurrences were detected by clinical examination in 71% of cases. CEA determination was sensitive (81% and specific (92%) for detection of recurrences in the remaining patients. Four patients (14%) were reoperated on with a survival of 3 to 26 months, all dying from disseminated disease. We conclude that this program did not help to improve the 5 year survival rate of colorectal carcinoma submitted to curative resection. CEA determination may be indicated at 2 month intervals during the period of increased recurrence risk.