Clinical outcome of high segmental gastrectomy for early gastric cancer in the upper third of the stomach

Sentinel Node Navigation Surgery for Early Gastric Cancer: A Narrative Review

Early gastric cancer (EGC) refers to malignant tumor lesions that are limited to the mucosa and submucosa layers, regardless of the presence of lymph node metastasis. Typically, EGC has a low rate of perigastric lymph node metastasis, and long-term survival outcomes are good after radical surgical treatment. The primary objective of surgical treatment for EGC is to achieve functional preservation while ensuring a radical cure. Sentinel node navigation surgery (SNNS) is a surgical technique used in the treatment of EGC. This approach achieves functional preservation by limiting lymph node dissection and performing restrictive gastrectomy guided by intraoperative negative sentinel node (SN) biopsy. Despite the apparent improvement in the detection rate of SN with the emergence of various tracing dyes and laparoscopic fluorescence systems, the oncological safety of SNNS remains a controversial research topic. SNNS, as a true form of stomach preservation surgery that enhances the quality of life, has become a topic of interest in the EGC field. In recent years, scholars from Japan and South Korea have conducted extensive research on the feasibility and safety of SNNS in the treatment of EGC. This article aims to provide reference choices for surgeons treating EGC by reviewing relevant research on SNNS for EGC in recent years.

Cardia function-preserving surgery and anti-reflux anastomotic method after proximal gastrectomy for gastric cancer: Current status and future perspectives

The incidence and mortality of gastric cancer ranked 5th and 3rd worldwide, respectively, in 2018, and the incidence of gastroesophageal junction adenocarcinoma increased over the past 40 years. Radical resection and lymph node dissection is the preferred treatment for gastric cancer. Proximal gastrectomy or total gastrectomy is usually performed for gastroesophageal junction adenocarcinoma and upper gastric cancer. Owing to the resection of the cardia structures, the incidence of reflux esophagitis increases significantly after proximal gastrectomy and total gastrectomy, resulting in poor postoperative quality of life. To reduce the incidence of reflux esophagitis and improve patients' postoperative quality of life, various methods to preserve the function of the cardia or to perform anti-reflux reconstruction have emerged. In this manuscript, we systematically introduced the advantages and problems of various anti-reflux anastomotic method after proximal gastrectomy, and cardia-preserving gastrectomy including endoscopic resection (ER), local gastrectomy by gastroscopy combined with laparoscopy, segmental gastrectomy, subtotal gastrectomy, and cardia-preserving radical gastrectomy. Cardia-preserving radical gastrectomy has the advantage of more thorough lymph node dissection and wider indications than those for subtotal gastrectomy. However, the clinical efficacy of cardia-preserving radical gastrectomy requires verification in prospective and controlled clinical trials. Cardia-preserving radical gastrectomy is a promising approach as one of the more reasonable anti-reflux surgeries.

Mapping Lymph Node during Indocyanine Green Fluorescence-Imaging Guided Gastric Oncologic Surgery: Current Applications and Future Directions

Huge strides have been made in the navigation of gastric cancer surgery thanks to the improvement of intraoperative techniques. For now, the use of indocyanine green (ICG) enhanced fluorescence imaging has received promising results in detecting sentinel lymph nodes (SLNs) and tracing lymphatic drainages, which make it applicable for limited and precise lymphadenectomy. Nevertheless, issues of the lack of specificity and unpredictable false-negative lymph nodes were encountered in gastric oncologic surgery practice using ICG-enhanced fluorescence imaging (ICG-FI), which restrict its application. Here, we reviewed the current application of ICG-FI and assessed potential approaches to improving ICG-FI.

Scoring Model Based on Nodal Metastasis Prediction Suggesting an Alternative Treatment to Total Gastrectomy in Proximal Early Gastric Cancer

Purpose

Total gastrectomy (TG) with lymph node (LN) dissection is recommended for early gastric cancer (EGC) but is not indicated for endoscopic resection (ER). We aimed to identify patients who could avoid TG by establishing a scoring system for predicting lymph node metastasis (LNM) in proximal EGCs.

Materials and Methods

Between January 2003 and December 2017, a total of 1,025 proximal EGC patients who underwent TG with LN dissection were enrolled. Patients who met the absolute ER criteria based on pathological examination were excluded. The pathological risk factors for LNM were determined using univariate and multivariate logistic regression analyses. A scoring system for predicting LNM was developed and applied to the validation group.

Results

Of the 1,025 cases, 100 (9.8%) showed positive LNM. Multivariate analysis confirmed the following independent risk factors for LNM: tumor size >2 cm, submucosal invasion, lymphovascular invasion (LVI), and perineural invasion (PNI). A scoring system was created using the four aforementioned variables, and the areas under the receiver operating characteristic curves in both the training (0.85) and validation (0.84) groups indicated excellent discrimination. The probability of LNM in mucosal cancers without LVI or PNI, regardless of size, was <2.9%.

Conclusions

Our scoring system involving four variables can predict the probability of LNM in proximal EGC and might be helpful in determining additional treatment plans after ER, functioning as a good indicator of the adequacy of treatments other than TG in high surgical risk patients.

Assessment of Lymph Node Metastasis in Patients With Gastric Cancer to Identify Those Suitable for Middle Segmental Gastrectomy

IMPORTANCE

Segmental gastrectomy, a type of function-preserving surgery, is not broadly studied but can improve postoperative function and quality of life among patients with gastric cancer (GC).

OBJECTIVE

To establish an indication for middle segmental gastrectomy (MSG) as a treatment for middle-body (MB) and high-body (HB) GC.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed patients with GC undergoing surgery between January 2000 and December 2015 in the National Cancer Center, Goyang, Korea, a high-volume cancer center with a structured database and accurate long-term follow-up. Inclusion criteria were age 18 to 85 year, histologically proven adenocarcinoma located in the HB or MB, cT1 to cT3 category cancers, curative resection with negative margins performed, and follow-up for at least 3 years. Exclusion criteria were Borrmann type 4 GC, T4 category cancer, neoadjuvant chemotherapy, and a history of other cancers. Data analysis was performed from December 2018 to May 2020.

EXPOSURES

Total or subtotal gastrectomy and LN dissection.

MAIN OUTCOME AND MEASURES

The primary outcome was the rate of metastasis at LN stations 2, 4sa, 5, 6, and 11d, which cannot be dissected during MSG.

RESULTS

Among 9952 patients who underwent surgery for GC, 8219 underwent either laparoscopic or open total or subtotal gastrectomy. Seven hundred seventy-three patients (mean [SD] age, 56.21 [12.16] years; 464 men [60.0%]) had GC in the MB or HB of the stomach. Among the 701 patients included in the final analysis after exclusion of the cN2/N3 carcinomas, the mean (SD) age was 56.35 (12.24) years, and 418 (59.6%) were men. The incidence of LN metastasis was 0% at station 5 for cT1-3N0/1M0 cancers, station 4sa for cT1-2N0/1M0 cancers, station 2 for cT1N0/1M0 cancers, station 6 for cT1N1M0 cancers, station 11d for cT1N1M0-cT2N0/1M0 cancers, and station 12a for cT1N0/1M0-T2N1M0 cancers, regardless of size and differentiation. The rates of LN metastasis for cT1N0M0 cancers were 0.3% (1 of 396 LNs) at station 6 and 0.8% (1 of 129 LNs) at station 11d. Tumors 4 cm or smaller were associated with a lower risk of LN metastasis compared with tumors 4.1 cm or larger (odds ratio, 2.10; 95% CI, 1.20-3.67; P = .009), and well-differentiated tumors were associated with lower risk of LN metastasis compared with poorly differentiated tumors (odds ratio, 2.88; 95% CI, 1.45-5.73; P = .002).

CONCLUSIONS AND RELEVANCE

These findings suggest that MSG with dissection of stations 1, 3, 4sb, 4d, 7, 8a, 9, 11p, and 12a could be done for HB and MB cT1N0/1M0 gastric cancers 4 cm or smaller and well-differentiated cT2N0/1M0 cancers.

Current status of proximal gastrectomy for gastric and esophagogastric junctional cancer: A review

Proximal gastrectomy (PG) is one of the function-preserving surgical methods for the treatment of upper gastric cancer. Favorable postoperative results have been reported in comparison with total gastrectomy. However, because there are challenges, such as postoperative reflux esophagitis, anastomotic stenosis, and residual food, appropriate selection of a reconstruction method is crucial. Some methods include esophagogastric anastomosis, including simple esophagogastrostomy, tube-like stomach esophagogastrostomy, side overlap with fundoplication by Yamashita, and double-flap technique, and reconstruction using the small intestine, including double-tract methods, jejunal interposition, and jejunal pouch interposition. However, standard reconstruction methods are yet to be established. PG has also been employed in early gastric cancer of the upper third of the stomach, and indications have also been extended to esophagogastric junction cancer, which has shown an increase in recent years. Although many retrospective studies have revealed the functional benefits or oncological safety of PG, the characteristics of each surgical procedure should be understood so that an appropriate reconstruction method, with a reflux prevention mechanism and minimal postoperative injury, can be selected.

Reconstruction methods after radical proximal gastrectomy: A systematic review

BACKGROUND

The incidence of tumors located in the upper third of the stomach is increasing, and the use of radical proximal gastrectomy is becoming prevalent. After a proximal gastrectomy, various reconstructions are performed, but surgical outcomes are controversial. This study was performed to review clinical outcomes of reconstructions after proximal gastrectomy.

METHODS

Inclusion criteria focused on postoperative complications of patients who underwent a proximal gastrectomy for gastric cancer. Exclusion criteria were case reports; targeted data not investigated; a duplicate study reported in a larger cohort; esophageal sphincter preservation surgery; near-total gastrectomy; recurrence of tumor; and combined organ resection.

RESULTS

In total, 22 retrospective and 2 prospective studies were included. The studies investigated surgical outcomes of esophagogastrostomy (n = 10), jejunal interposition (n = 12), jejunal pouch interposition (n = 7), double tract jejunal interposition (n = 1), and tube-like stomach esophagogastrostomy (n = 5). Pooled incidences of reflux esophagitis or reflux symptoms for these procedures were 28.6%, 4.5%, 12.9%, 4.7%, and 10.7%, respectively. Incidences of postoperative complications were 9.5%, 18.1%, 7.0%, 11.6%, and 9.3%, respectively.

CONCLUSIONS

Despite increasing operation complexity, which perhaps increased the risk of other postoperative complications, currently used reconstructions present excellent anti-reflux efficacy. However, the optimal reconstruction method remains to be determined.

功能保留手术在早期胃癌治疗中的作用

随着人们健康意识的增加和胃镜等医疗诊断技术的不断进步, 早期胃癌的诊断率逐年上升. 早期胃癌的功能保留胃切除术是在根治原发病灶, 行标准淋巴结清扫前提下, 限制胃切除范围, 同时保留幽门及迷走神经功能, 以达到改善患者术后生活质量的目的, 其手术方式包括: 保留幽门的胃切除术, 近端胃切除术, 胃节段切除以及局部切除. 此外, 内镜下黏膜切除术和黏膜剥离也被认为属于功能保留胃切除术范畴. 对于大部分早期胃癌患者, 根治性手术具有良好的治疗效果, 其5年生存率在90%以上. 因此, 在达到手术根治目的的前提下, 保留部分胃的解剖和生理功能, 提高患者术后的生活质量, 对早期胃癌患者具有重要的意义.

Laparoscopic sentinel node navigation surgery for early gastric cancer

Currently, the most accurate method for identifying lymph node metastasis is intraoperative diagnosis by sentinel node (SN) biopsy. Based on the SNNS study-a recent large-scale, nationwide, multicenter prospective study-the SN concept seems to be scientifically valid in patients with early gastric cancer. SN biopsy is a multistep technique consisted of six essential elements: indication, the selection of a tracer, a proper tracer injection method, the objective detection of SNs, a reliable biopsy technique, and the precise detection of nodal metastasis. For SN biopsy of gastric cancer, these elements have been validated as follows: the indication should be limited to clinical T1 less than 4 cm in diameter; combination mapping with radioactive colloid and blue dye is used as the standard; and endoscopic submucosal injection is the standard tracer injection. Detection of SNs and a reliable biopsy technique are enabled by adaptation of lymphatic basin dissection, a proper biopsy technique for gastric cancer. Lymphatic basin dissection is a selective lymphadenectomy procedure for dissecting basins en bloc, collecting lymph nodes and lymphatic vessels stained with dye. Lymphatic basin dissection is superior to the ordinary pick-up method, not only for minimizing the rate of missed SNs, but also in terms of oncological safety as it complements an intraoperative frozen section diagnosis by serving as a backup dissection. Moreover, indocyanine green (ICG) fluorescence mapping has been developed in recent years. ICG fluorescence mapping is superior because of its high sensitivity and signal stability. Moreover, it is feasible for both open and laparoscopic gastrectomy in treating early gastric cancer. SN biopsy has brought dramatic changes to laparoscopic surgery for early gastric cancer. With laparoscopic SN biopsy using ICG fluorescence navigation, laparoscopic surgery for early gastric cancer has changed from the uniform standard gastrectomy with D1+ into a tailor-made function-preserving surgical procedure, such as local resection with lymphatic basin dissection.

Function-preserving gastrectomy for gastric cancer in Japan

Surgery used to be the only therapy for gastric cancer, and since its ability to cure gastric cancer was the focus of attention, less attention was paid to function-preserving surgery in gastric cancer, though it was studied for gastroduodenal ulcer. Maki et al developed pylorus-preserving gastrectomy for gastric ulcer in 1967. At the same time, the definition of early gastric cancer (EGC) was being considered, histopathological investigations of EGC were carried out, and the validity of modified surgery was sustained. After the development of H2-blockers, the number of operations for gastroduodenal ulcers decreased, and the number of EGC patients increased simultaneously. As a result, the indications for pylorus-preserving gastrectomy for EGC in the middle third of the stomach extended, and various alterations were added. Since then, many kinds of function-preserving gastrectomies have been performed and studied in other fields of gastric cancer, and proximal gastrectomy, jejunal pouch interposition, segmental gastrectomy, and local resection have been performed. On the other hand, from the overall perspective, it can be said that endoscopic resection, which was launched at almost the same time, is the ultimate function-preserving surgery under the current circumstances. The current function-preserving gastrectomies that are often performed and studied are pylorus-preserving gastrectomy and proximal gastrectomy. The reasons for this are that these procedures that can be performed with systemic lymph node dissection, and they include three important elements: (1) reduction of the extent of gastrectomy; (2) preservation of the pylorus; and (3) preservation of the vagal nerve. In addition, these operations are more likely to be performed with a laparoscopic approach as minimally invasive surgery. Of the above-mentioned three elements, reduction of the extent of gastrectomy is the most important in our view. Therefore, we should try to reduce the extent of gastrectomy if curability of the gastric cancer can still be achieved. However, if we preserve a wider residual stomach in function-preserving gastrectomy, we should pay attention to the development of metachronous gastric cancer.

Surgical techniques to prevent reflux esophagitis in proximal gastrectomy reconstructed by esophagogastrostomy with preservation of the lower esophageal sphincter, pyloric and celiac branches of the vagal nerve, and reconstruction of the new His angle for early proximal gastric cancer

PURPOSE

This article describes the surgical techniques to prevent reflux esophagitis (RE) after proximal gastrectomy reconstructed by esophagogastrostomy (PGE) preservation of the lower esophageal sphincter (LES) and both pyloric and celiac branches of the vagal nerve (PCVN), and reconstruction of the new His angle (HA) for early proximal gastric cancer (PGC).

METHODS

Twenty patients after PGE were divided into 2 groups (group A: 10 patients without preserved LES and PCVN for advanced PGC; group B: 10 patients with preserved LES and PCNV and the addition of a new HA for early PGC). A postoperative interview on gastroesophageal reflux disease (GERD) and satisfaction with this procedure and the collection of endoscopic findings for RE and stasis of the remnant stomach (SRS) were conducted 1 year after PGE in groups A and B.

RESULTS

The rates of proton pump inhibitor administration and the symptoms of GERD, RE and SRS in group A were significantly higher than those in group B (p = 0.0433, p = 0.0190, p = 0.0253, p = 0.0190, respectively). Seven out of 10 patients in group A voiced dissatisfaction. Patients in group B were significantly more satisfied with this procedure than those in group A (p = 0.0010).

CONCLUSION

This method is useful for preventing postoperative GERD including RE in early PGC patients.

Comparison of perioperative and long-term outcomes of total and proximal gastrectomy for early gastric cancer: a multi-institutional retrospective study

BACKGROUND

Various surgical procedures are used to treat early gastric cancers in the upper third of the stomach (U-EGCs). However, there is no general agreement regarding the optimal surgical procedure.

METHODS

The medical records of 203 patients with U-EGC were collected from 13 institutions. Surgical procedures were classified as Roux-en-Y esophagojejunostomy after total gastrectomy (TG-RY), esophagogastrostomy after proximal gastrectomy (PG-EG), or jejunal interposition after PG (PG-JI). Patient clinical characteristics and perioperative and long-term outcomes were compared among these three groups.

RESULTS

TG-RY, PG-EG, and PG-JI were performed in 122, 49, and 32 patients, respectively. Tumors were larger in TG-RY patients than in PG-EG and PG-JI patients, and undifferentiated-type gastric adenocarcinoma tended to be more frequent in TG-RY than in PG-EG. The operative time was shorter for PG-EG than for PG-JI and TG-RY. Hospital stay and early postoperative complications were not different for the three procedures. With respect to gastrectomy-associated symptoms, a "stuck feeling" and heartburn tended to be more frequent in PG-EG patients, while dumping syndrome and diarrhea were more frequent in TG-RY patients. Post-surgical weight loss was not different among the three groups, however, serum albumin and hemoglobin levels tended to be lower in TG-RY patients.

CONCLUSION

Three surgical procedures for U-EGC did not result in differences in weight loss, but PG-EG and PG-JI were better than TG-RY according to some nutritional markers. In U-EGC, where patients are expected to have long survival times, PG-EG and PG-JI should be used rather than TG-RY.

Limited subtotal gastrectomy for early remnant gastric cancer

BACKGROUND

Detection of early remnant gastric cancer (ERGC) is increasing as a result of the development of endoscopic technology and a surveillance program. The aim of this study was to evaluate the results of limited subtotal gastrectomy (SG) surgery for ERGC compared to total gastrectomy (TG).

METHODS

We retrospectively reviewed a database of 72 consecutive patients with remnant gastric cancer who underwent laparotomy at the National Cancer Center Hospital East between January 1993 and December 2008. Thirty-five patients with a preoperative diagnosis of ERGC underwent curative resection: 13 SG and 22 conventional TG. Patients and tumor characteristics, operative results, and postoperative assessments 1 year after surgery were compared between the two groups.

RESULTS

Operating time, blood transfusion, and hospital stay were similar in the two groups. In the SG group, blood loss and postoperative recovery of body weight tended to be better than in the TG group. There was no dumping syndrome in the SG group, while this occurred in three patients in the TG group. The levels of hemoglobin and total protein were higher 1 year after remnant gastrectomy in the SG group than in the TG group. No recurrence of gastric cancer was detected in the SG group during median follow-up of 99.2 months.

CONCLUSION

In comparison to TG, limited SG surgery for ERGC improved the postoperative course, with no recurrence of cancer. Therefore, SG is a safe and effective treatment for ERGC.

Tissue engineering of the stomach

Tissue engineering combines engineering principles with the biological sciences to create functional replacement tissues. The underlying principle of tissue engineering is that isolated cells combined with biomaterials can form new tissues and organs in vitro and in vivo. This review focuses on stomach tissue engineering, which is a promising approach to the treatment of gastric cancer, the fourth most common malignancy in the world and the second-leading cause of cancer mortality worldwide. Although gastrectomy is a reliable intervention to achieve complete removal of cancer lesions, the limited capacity for food intake after resection results in lower quality of life for patients. To address this issue, we have developed a tissue-engineered stomach to increase the capacity for food intake by creating a new food reservoir. We have transplanted this neo-stomach as a substitute for the original native stomach in a rat model and confirmed functional adaptation. Furthermore, we have demonstrated the feasibility of transplanting a tissue-engineered gastric wall patch in a rat model to alleviate the complications after resection of a large area of the gastric wall. Although progress has been achieved, significant challenges remain to bring this approach to clinical practice. Here, we summarize our work and present the state of the art in stomach tissue engineering.

Clinical Application of Modified Double Tracks Anastomosis in Proximal Gastrectomy

We compared the outcome of two surgical alimentary canal reconstruction methods after proximal gastrectomy. Three hundred ninety-six patients who underwent a radical proximal gastrectomy were randomized into two groups. Group A was treated with modified double tracks anastomosis, and Group B was treated with esophagus-remnant stomach direct anastomosis. Outcome measures were hematological indices, prognostic nutritional index (PNI), plasma hormone concentrations, and Visick index. The operative times in Groups A and B were 210 ± 53 and 150 ± 75 minutes and the hemorrhage volume was 173 ± 67 and 150 ± 75 mL, respectively. Six months after operation, values of hemoglobin concentration, body weights, and PNI indices were significantly increased in Group A compared with Group B. Levels of gastrin and somatostatin were obviously less than preoperative values and levels of cholecystokinin and motilin were significantly higher than preoperative values in both groups. All patients of Group A were classified into Visick index Grades I and II, whereas only 70.37 per cent of Group B belonged to Visick index Grades I and II postoperatively. The overall 3-year survival rate was not significantly different in both groups. Modified double tracks anastomosis as an alimentary canal reconstructive method for radical proximal gastrectomy showed better outcomes than esophagus-remnant stomach direct anastomosis.

Segmental gastrectomy with radical lymph node dissection for early gastric cancer

AIM: To describe a new surgical technique and evaluate the early results of segmental gastrectomy (SG) with modified D2 lymph node (LN) dissection for early gastric cancer (EGC).

METHODS: Fourteen patients with EGC underwent SG with modified D2 dissection from 2006 to 2008. Their operative results and postoperative courses were compared with those of 17 patients who had distal gastrectomy (DG) for EGC during the same period.

RESULTS: Operating time, blood loss, and hospital stay were similar between the 2 groups. Postoperative complications developed significantly more frequently in the DG group than in the SG group. Mean number of dissected LNs per each station in the SG group was comparable with that in the DG group. Postoperative recovery of body weight was significantly better in the SG group than in the DG group. The incidence of reflux esophagitis and gastritis after surgery was less frequent in the SG group than in the DG group.

CONCLUSION: SG with modified D2 LN dissection may be a new function-preserving gastrectomy that is feasible for treatment of EGC with possible LN involvement.

Intracorporeal stapled anastomosis following laparoscopic segmental gastrectomy for gastric cancer: technical report and surgical outcomes

BACKGROUND

Limited gastrectomy for early gastric body cancers can offer a better functional outcome by preserving more remnant stomach. Intracorporeal stapled techniques result in cosmesis and avoid awkward anastomosis through a minilaparotomy.

METHODS

Laparoscopic segmental gastrectomy is indicated for early gastric cancers of the body of the stomach with no evidence of lymph node involvement. Laparoscopic pylorus-preserving gastrectomy is a specific type of segmental resection for lower-body lesions with dissection of lymph nodes in station 6. Intracorporeal gastrogastric anastomosis is performed by the delta-shaped technique using linear staplers.

RESULTS

Since January 2008 we have performed 12 laparoscopic pylorus-preserving gastrectomies and 13 laparoscopic segmental gastrectomies. All procedures were completed by laparoscopy. One patient with minor anastomotic leakage was managed conservatively. Bleeding from the anastomosis was not encountered in any of the patients. One patient developed narrowing at the anastomotic site and was treated successfully by balloon dilatation. There was no stasis encountered in any of the patients.

CONCLUSIONS

Laparoscopic segmental gastrectomy with acceptable surgical outcomes is technically feasible. Although the impact of such resections on oncological outcomes remains to be further evaluated, laparoscopic segmental gastrectomy represents a minimally invasive limited resection that maximizes the potential for a better quality of life following gastric cancer surgery.