Gastric stump carcinoma after partial gastrectomy for benign gastric lesion: what is feasible as standard surgical treatment?

Clinicopathological Features of Remnant Gastric Cancer (RGC): Detection of RGC after Five Years of Follow-Up Was Associated with a Poor Prognosis

The purpose of this study was to evaluate the clinicopathological features and prognosis of patients who underwent surgery for remnant gastric cancer (RGC) during/after the regular five-year follow-up period after initial distal gastrectomy for gastric cancer that is recommended by the Japanese gastric cancer treatment guidelines. Between January 2007 and December 2017, 40 patients underwent surgery for RGC after distal gastrectomy. Twenty-eight of the 40 patients underwent initial gastrectomy for cancer. We divided the 28 patients into two groups: patients who were diagnosed with RGC during/after the five-year follow-up period after initial gastrectomy, and analyzed their retrospectively collected data. Among the 28 patients, 15 patients were diagnosed with RGC within five years and 13 patients were diagnosed with RGC after five years. There were significant differences in the reconstruction of the initial operation, curative resection, pathological depth of the tumor, and pathological stage of the two groups. Multivariate analyses revealed that the interval between initial gastrectomy and RGC and the pathological TNM stage were significant risk factors for shorter cancer-specific survival. Kaplan-Meier analyses demonstrated that patients with RGC after the five-year follow-up period had a significantly worse prognosis in terms of cancer-specific survival than those who developed RGC within five years. This study suggested surveillance by using the annual endoscopy might be necessary beyond the initial five-year period for patients who underwent gastrectomy for gastric cancer.

Gastric remnant cancer patients had a better prognosis than upper-third gastric cancer patients in a case-control study after surgical treatment

Background

The aim was to compare the clinicopathological features and prognostic outcomes of gastric remnant carcinoma patients with those of patients with upper-third gastric cancer.

Methods

Clinical data extracted from 112 gastric remnant carcinomas and 367 upper-third gastric cancer patients were analyzed to explore the clinicopathologic differences between two groups. After radical resection, prognostic difference between them was evaluated through a 1:2 matched case-control study.

Results

The pattern of gastric remnant carcinomas showed a male predominance. Undifferentiated type histology, depth at T4 stage and distant metastases were more frequent in gastric remnant carcinomas than in upper-third gastric cancers (P <0.05). The radical resectability of gastric remnant carcinomas was lower and the multi-visceral resectabilitiy was relatively higher than the other group (P = 0.00). Gastric remnant carcinomas trended to have a higher incidence of metastases to either mesojejunum or lower mediastinal lymph nodes than upper-third gastric cancers, but patient survival was not significantly different. In the case-control study, gastric remnant carcinomas had a better prognosis than upper-third gastric cancers after radical resection when the clinicopathologic features and surgical treatment were matched.

Conclusions

Although there was no significant prognostic distinction between gastric remnant carcinomas and upper-third gastric cancer, after radical surgical treatment, patients with the former had an even better prognosis.

Effects of initial disease status on lymph flow following gastrectomy in cases of carcinoma in the remnant stomach

PURPOSE

In cases of carcinoma in the remnant stomach (CRS), the lymphatic flow may be altered by the initial surgery. In this study of CRS after gastrectomy, we investigated how the regions of lymph node metastasis and changes in lymphatic flow depend on initial disease status.

METHOD

The study included 76 patients with CRS who underwent gastrectomy between September 2002 and November 2014. We analyzed and compared the clinicopathological factors and survival periods between patients after distal gastrectomy for malignant disease (group M, 33 patients) and patients after distal gastrectomy for benign disease (group B, 43 patients).

RESULTS

The depth of tumor invasion was more advanced in group B (T1/T2/T3/T4: group M 18/1/7/7, group B 8/11/8/16; P = 0.002). However, the degree of lymph node metastasis did not differ significantly between the two groups. The incidence of lymph node metastasis was high at stations 2 (19 %), 4sa (17 %), 10 (25 %), 11p (19 %), and 11d (27 %) in group M and 1 (14 %), 3 (23 %), and 4sb (15 %), and the mesojejunal lymph node (21 %) in group B. Lymph node dissection was highly beneficial at station 3, station 7, and the mesojejunum in both groups, but not at stations 10 or 11d.

CONCLUSION

As compared with group B, group M showed higher incidences of lymph node metastasis in the greater curvature, splenic hilum, and lymph nodes along the splenic artery, suggesting the predominance of lymphatic flows from the greater curvature to the splenic hilum and from the remnant stomach to the splenic artery.

Does remnant gastric cancer really differ from primary gastric cancer? A systematic review of the literature by the Task Force of Japanese Gastric Cancer Association

Remnant gastric cancer, most frequently defined as cancer detected in the remnant stomach after distal gastrectomy for benign disease and those cases after surgery of gastric cancer at least 5 years after the primary surgery, is often reported as a tumor with poor prognosis. The Task Force of Japanese Gastric Cancer Association for Research Promotion evaluated the clinical impact of remnant gastric cancer by systematically reviewing publications focusing on molecular carcinogenesis, lymph node status, patient survival, and surgical complications. A systematic literature search was performed using PubMed/MEDLINE with the keywords "remnant," "stomach," and "cancer," revealing 1154 relevant reports published up to the end of December 2014. The mean interval between the initial surgery and the diagnosis of remnant gastric cancer ranged from 10 to 30 years. The incidence of lymph node metastases at the splenic hilum for remnant gastric cancer is not significantly higher than that for primary proximal gastric cancer. Lymph node involvement in the jejunal mesentery is a phenomenon peculiar to remnant gastric cancer after Billroth II reconstruction. Prognosis and postoperative morbidity and mortality rates seem to be comparable to those for primary proximal gastric cancer. The crude 5-year mortality for remnant gastric cancer was 1.08 times higher than that for primary proximal gastric cancer, but this difference was not statistically significant. In conclusion, although no prospective cohort study has yet evaluated the clinical significance of remnant gastric cancer, our literature review suggests that remnant gastric cancer does not adversely affect patient prognosis and postoperative course.

Gastric remnant cancer: A distinct entity or simply another proximal gastric cancer?

BACKGROUND

The purpose of this study was to compare outcomes following resection of gastric remnant (GRC) and conventional gastric cancer.

METHODS

Patients who underwent resection for gastric cancer in 8 academic institutions from 2000-2012 were evaluated to compare morbidity, mortality, and survival based on history of prior gastrectomy.

RESULTS

Of the 979 patients who underwent gastrectomy with curative-intent during the 12-year study period, 55 patients (5.8%) presented with GRC and 924 patients (94.4%) presented with conventional gastric cancer. Patients with GRC were slightly older (median 69 vs. 66 years). GRC was associated with higher rates of complication (56% vs. 41%, P = 0.028), longer operative times (301 vs. 237 min, P < 0.001), higher intraoperative blood loss (300 vs. 200 ml, P = 0.012), and greater need for blood transfusion (43% vs. 23%, P = 0.001). There were no significant differences in 30-day (3.6% vs. 4%) or 90-day mortality (9% vs. 8%) between the two groups. Overall survival rates were similar between GRC and conventional gastric cancer (5-year 20.3% vs. 38.6%, P = 0.446). Multivariate analysis revealed that history of gastrectomy was not predictive of survival while established predictors (older age, advanced T-stage, nodal involvement, blood transfusion, multivisceral resection, and any complication) were associated with poor survival.

CONCLUSIONS

Despite higher morbidity, prognosis after resection of gastric remnant cancer is similar to conventional gastric cancer.

Surgical Resection of Remnant Gastric Cancer Following Distal Gastrectomy: A Retrospective Clinicopathological Study

BACKGROUND

Remnant gastric cancer (RGC) is one of the less prevalent gastric cancers. The purpose of this study was to explore the clinicopathological characteristics and results of the operation of RGC following distal gastrectomy. In particular, we examined factors related to prognosis.

METHODS

Between January 1970 and December 2012, 122 patients with RGC following distal gastrectomy underwent further surgery and were analyzed retrospectively.

RESULTS

Initial gastric diseases included benign (49 patients, 40.2 %) and malignant diseases (73 patients, 59.8 %). Reconstructions by initial surgery included Billroth I (80 patients, 65.6 %) and Billroth II (42 patients, 34.4 %). Tumors were located at anastomotic (44 patients, 36.1 %) and nonanastomotic sites (78 patients, 63.9 %). There were 59 patients (48.4 %) classified with pathological (p) stage I, 19 as p stage II (15.6 %), 22 as p stage III (18.0 %), and 22 (18.0 %) as p stage IV. A total of 100 patients (82.0 %) underwent curative resection, and 22 underwent noncurative resection. The number of cases of postoperative morbidity, 90-day mortality, and adjuvant chemotherapy were 23 (18.9 %), 3 (2.5 %), and 20 (16.4 %), respectively. Univariate and multivariate analyses were performed to identify the prognostic factors of RGC. Multivariate analysis revealed historical periods, pathological venous invasion, curative resection, and postoperative morbidity to be independent prognostic factors.

CONCLUSIONS

The prognosis of patients with RGC can be improved by aggressively performing curative resection without causing complications.

Risk factors for complications during surgical treatment of remnant gastric cancer

BACKGROUND

Surgical treatment for remnant gastric cancer is related to high mortality and morbidity. The aim of this study was to identify risk factors that predispose to postoperative complications after gastrectomy for remnant gastric cancer.

METHODS

A total of 210 patients who underwent a gastrectomy for remnant gastric cancer between January 1998 and December 2012 were retrospectively analyzed. Surgical complications were reviewed and graded using the Clavien-Dindo classification. Univariate and multivariate analysis was performed to identify the risk factors for development of complications.

RESULTS

The incidence of postoperative complications was 46% (96/210), and major complications occurred in 14% (30/210). The operation-related mortality rate was 1.0%. Multivariate analysis revealed that only a BMI ≥25 (P = 0.001) and blood transfusion (P < 0.001) were significant independent risk factors for major complication. Indication for the initial gastrectomy and previous anastomosis type were not related to the development of surgical complications.

CONCLUSIONS

Although surgery for remnant gastric cancer is a complex procedure because of the previous operation, factors related to the previous operation do not affect the development of postoperative complications.

Clinicopathological characteristics and survival difference between gastric stump carcinoma and primary upper third gastric cancer

BACKGROUND

The increased incidence of early gastric cancer in several Asian countries has been associated with an increase in gastric stump carcinoma (GSC) following gastric cancer surgery. The clinicopathological characteristics of GSC remain unclear because of the limited number of patients with GSC.

METHODS

The clinicopathological characteristics, including the 5-year survival rate of patients with GSC following distal gastrectomy (167 patients), were compared with those of patients with primary upper third gastric cancer (PGC; 755 patients). The clinicopathological characteristics of patients with GSC were also compared between those who had initial surgery for gastric cancer (GSC-M group, 78 patients) and for benign lesions (GSC-B group, 89 patients).

RESULTS

The GSC-B group has a greater male/female ratio (13.8 vs. 3.1) and a longer interval between initial gastrectomy and surgery for GSC (31.0 vs. 9.4 years) than the GSC-M group. The 5-year survival rate was not significantly different between the GSC-B group (49.0 %) and the GSC-M group (59.3 %, P = 0.359). A comparison between the GSC group and the PGC group revealed a poorer 5-year survival rate for the GSC group (53.6 %) than the PGC group (78.3 %, P < 0.001), and the same trend was observed even after stratification by the pathological stage.

CONCLUSIONS

Stump carcinoma arises earlier following gastrectomy for malignant disease than for benign disease. The prognosis was poor in patients with GSC compared to those with PGC. Early detection of GSC is necessary and an appropriate follow-up program should be established.

Progression of remnant gastric cancer is associated with duration of follow-up following distal gastrectomy

AIM

To re-evaluate the recent clinicopathological features of remnant gastric cancer (RGC) and to develop desirable surveillance programs.

METHODS

Between 1997 and 2008, 1149 patients underwent gastrectomy for gastric cancer at the Department of Digestive Surgery, Kyoto Prefectural University of Medicine, Japan. Of these, 33 patients underwent gastrectomy with lymphadenectomy for RGC. Regarding the initial gastric disease, there were 19 patients with benign disease and 14 patients with gastric cancer. The hospital records of these patients were reviewed retrospectively.

RESULTS

Concerning the initial gastric disease, the RGC group following gastric cancer had a shorter interval [P < 0.05; gastric cancer vs benign disease: 12 (2-22) vs 30 (4-51) years] and were more frequently reconstructed by Billroth-I procedure than those following benign lesions (P < 0.001). Regarding reconstruction, RGC following Billroth-II reconstruction showed a longer interval between surgical procedures [P < 0.001; Billroth-II vs Billroth-I: 32 (5-51) vs 12 (2-36) years] and tumors were more frequently associated with benign disease (P < 0.001) than those following Billroth-I reconstruction. In tumor location of RGC, after Billroth-I reconstruction, RGC occurred more frequently near the suture line and remnant gastric wall. After Billroth-II reconstruction, RGC occurred more frequently at the anastomotic site. The duration of follow-up was significantly associated with the stage of RGC (P < 0.05). Patients diagnosed with early stage RGC such as stage I-II tended to have been followed up almost every second year.

CONCLUSION

Meticulous follow-up examination and early detection of RGC might lead to a better prognosis. Based on the initial gastric disease and the procedure of reconstruction, an appropriate follow-up interval and programs might enable early detection of RGC.

Differences of the lymphatic distribution and surgical outcomes between remnant gastric cancers and primary proximal gastric cancers

BACKGROUND

Although remnant gastric cancer (RGC) following distal gastrectomy is located in the proximal stomach, little is known about the differences of the lymphatic distribution and surgical outcomes between RGC and primary proximal gastric cancer (PGC).

METHODS

Between 1997 and 2008, 1,149 patients underwent gastrectomy for gastric cancer. Of these, 33 (2.9%) RGC patients and 207 (18.5%) PGC patients were treated at our department. We reviewed their hospital records retrospectively.

RESULTS

Compared with the PGC patients, those with RGC had a slightly higher age at onset (p=0.09), higher incidence of undifferentiated cancer (p=0.06), higher incidence of vascular invasion (p=0.09), and higher incidence of T4 (p=0.07). Gastrectomy for RGC involved greater blood loss (p<0.005), longer surgical duration (p=0.01), combined resection, and high incidence of complications. However, the survival rate for RGC patients was similar to that for PGC patients (p=0.67). 2) Patients with RGC had a different pattern of lymph node metastasis compared with that in PGC. Particularly in advanced RGC with pT2-T4 tumors, RGC frequently demonstrated jejunal mesentery lymph node metastases (RGC vs. PGC, 35% vs. 0%) and splenic hilar lymph node metastases (RGC vs. PGC, 17% vs. 10%). The jejunal mesentery lymph node metastases were detected only following Billroth II reconstruction (Billroth I vs. Billroth II, 0% vs. 67%).

CONCLUSION

Although the clinical behaviors of the two gastric cancers were different, the survival rates were similar. The pattern of metastasis indicates that the jejunal mesentery and splenic hilar lymph nodes should be specifically targeted for en bloc resection during complete gastrectomy in RGC.

Gastric remnant cancer: an old problem with novel concerns

BACKGROUND AND AIMS

The patients with cancers in the remnant stomachs after previous partial resections for benign diseases constitute a peculiar subset of the patients with gastric cancer. They are generally at advanced stages on admissions due to disregarding the symptoms related to cancer.

PATIENTS AND METHODS

Twenty six patients with cancer arising from the remnant stomach were analyzed. Clinicopathologic features such as age, gender, time interval between the initial operation and diagnosis of gastric remnant cancer, preoperative symptoms, surgical management, and tumor characteristics like size, location, histopathology, depth of invasion, lymph node involvement, presence of distant metastasis, and stages were documented.

RESULTS

None of the cancers were diagnosed by routine surveillance and all the patients were symptomatic at the time of diagnosis. Twenty five patients were qualified for surgery. The resectability rate was 61% (n = 16). The ability to perform a curative resection and tumor location at the anastomotic site were determined as the factors significantly influencing survival (p < 0.05).

CONCLUSION

Curative resection has to be the goal of surgical management in patients with gastric remnant cancer. Concerning clinician should be sceptical about a newly developing cancer in order to detect it in an early stage and enhance resectability.

Clinicopathological features and surgical outcomes of patients with remnant gastric cancer after a distal gastrectomy

BACKGROUND

The incidence of gastric cancer in the remnant stomach after distal gastrectomy is increasing. The aim of this study was to evaluate the clinicopathological features and surgical outcomes of remnant gastric cancer (RGC).

METHODS

We reviewed the medical records of 58 patients who underwent laparotomy for RGC at Seoul National University Hospital between 2000 and 2005.

RESULTS

The mean interval between the first and second operations was 12.5 years, and the rate of RGC diagnosis by tests included the follow-up program was 41.4%. The 45 RGCs occurring after distal gastrectomy for initial gastric cancer had a shorter interval and were more frequently located at the non-anastomotic site than those following benign lesions (P <0.001 and P = 0.010). Of all patients, 41 (70.7%) underwent, and the overall 3-year survival rate was 62.4%. An early stage of the initial gastric cancer, no symptoms at diagnosis, curative resection, tumor size smaller than 6 cm, and an early TNM stage of the RGC were associated with longer survival; the initial gastric disease, the interval and the location of RGC were not.

CONCLUSION

The successful curative resection and an early stage of the RGC led to good outcomes. In considering the different latency periods of the two initial gastric diseases, appropriate follow-up programs should be developed.

Treatment and prognosis of gastric stump carcinoma in comparison with primary proximal gastric cancer

BACKGROUND

The intention of this study was to evaluate the outcome of patients with gastric stump cancer (GSC) in comparison with patients treated for primary proximal gastric cancer (PPGC).

METHODS

Nineteen patients with GSC undergoing surgery between January 1989 and August 2005 were compared with 194 PPGC patients treated during the same time period. Various factors such as epidemiologic data, type of treatment, and histopathologic data were evaluated in the analysis.

RESULTS

The overall 5-year disease-specific survival was 42% for resected GSC patients in comparison with 37% for resected PPGC patients. There was no statistically significant difference in the survival rate detected between these 2 groups. On multivariate analysis the infiltration of the gastrojejunal anastomosis by the carcinoma was shown to be a significant predictor for the outcome of patients with GSC.

CONCLUSIONS

In summary, no significant difference in the outcome between GSC and PPGC has been detected.

Cancer of the gastric stump following distal gastrectomy for cancer

BACKGROUND

Cancer of the gastric stump (CGS) after distal gastrectomy for cancer has not been characterized in a large study. The aim of this study was to investigate the clinicopathological features and outcome of CGS following distal gastrectomy for cancer.

METHODS

Patients with CGS following distal gastrectomy for gastric cancer diagnosed between 1970 and 2002 were reviewed retrospectively.

RESULTS

A total of 108 patients was identified. The median interval between the initial gastrectomy and resection for CGS was 7.5 (range 1-41) years. The depth of tumour invasion was T1 in 67 patients, T2 in 16, T3 in eight and T4 in 17 patients. Endoscopic mucosal resection was performed in 25 patients with T1 tumours. R0 resection was achieved in 103 patients. The overall 5-year survival rate was 53.1 per cent. The 5-year survival rates for patients with T1, T2, T3 and T4 disease were 76, 40, 13 and 9 per cent respectively.

CONCLUSION

The outcome for patients with non-early CGS was poor. Early detection of CGS is important following distal gastrectomy for gastric cancer and strict surveillance is recommended for at least 10 years after the initial gastrectomy.

Gastric stump carcinoma - epidemiology and current concepts in pathogenesis and treatment

AIM

The aim of this article is to review the aetiology, pathology and treatment of gastric stump carcinoma (GSC). GSC is an uncommon tumour; however, the incidence is not declining, so this tumour entity will be encountered in the years to come.

METHODS

The electronic literature search was performed in the MEDLINE database to identify relevant studies concerning epidemiology, prognosis, treatment, aetiology and pathology of GSC. The references reported in these studies were used to complete the literature search.

RESULTS

Patients subjected to distal gastric resection have a 4-7-fold increased risk of developing GSC, which is attributed mainly to gastroduodenal reflux. Denervation during partial gastrectomy may also contribute to the risk of developing GSC. Gastroduodenal ulcers were the main reason for partial gastrectomy. Both ulcer locations have an increased risk of developing GSC after 20 years. In GSC, Helicobacter pylori seems not to be an important risk factor, contrary to primary gastric cancer, because gastroduodenal reflux impairs the growth of Helicobacter pylori.

CONCLUSION

The treatment of choice for GSC should be the total removal of the gastric remnant including at least D2 lymphadenectomy. The pattern of lymph node metastases in GSC may differ from primary gastric cancer, as lymph node metastases have been reported in the jejunal mesentery and the lower mediastinum. Therefore, GSC may require a modified lymphadenectomy to include all important lymph node stations. After radical remnant gastrectomy, GSC has a prognosis not different from primary proximal gastric cancer.

[Adenocarcinoma of the gastric stump]

Cancer of the gastric stump is a classical late complication of gastrectomy for benign lesion. This tumor is defined by various criteria, including a minimal delay of 5 years since the initial gastrectomy and the benignity of the initial lesion. Early diagnosis is difficult since suggestive clinical signs are usually associated with advanced tumors. Prognosis is globally bad and theoretically justifies routine endoscopic screening. For tumors which can be radically resected, completion gastrectomy with lymphadenectomy is indicated and allows a 40% 5-year survival. In other cases, palliative treatment remains a major concern.