Possible association between gastrectomy and subsequent development of esophageal cancer

Clinical features and treatment of patients with esophageal cancer and a history of gastrectomy: a multicenter, questionnaire survey in Kyushu, Japan

It is still controversial whether patients with a history of gastrectomy have high risk of esophageal carcinogenesis. On the other hand, the treatment strategy for esophageal cancer patients after gastrectomy is complicated. The association between histories of gastrectomy and esophageal carcinogenesis was retrospectively analyzed, and the treatment of esophageal cancer patients after gastrectomy was evaluated based on questionnaire data collected from multiple centers in Kyushu, Japan. The initial subject population comprised 205 esophageal cancer patients after gastrectomy. Among them, 108 patients underwent curative surgical treatment, and 70 patients underwent chemoradiation therapy (CRT). The time between gastrectomy and esophageal cancer development was longer in peptic ulcer patients (28.3 years) than in gastric cancer patients (9.6 years). There were no differences in the location of esophageal cancer according to the gastrectomy reconstruction method. There were no significant differences in the clinical background characteristics between patients with and without a history of gastrectomy. Among the 108 patients in the surgery group, the 5-year overall survival rates for stages I (n = 30), II (n = 18), and III (n = 60) were 68.2%, 62.9%, and 32.1%, respectively. In the CRT group, the 5-year overall survival rate of stage I (n = 29) was 82.6%, but there were no 5-year survivors in other stages. The 5-year overall survival rate of patients with CR (n = 33) or salvage surgery (n = 10) was 61.2% or 36%, respectively. For the treatment of gastrectomized esophageal cancer patients, surgery or CRT is recommended for stage I, and surgery with or without adjuvant therapy is the main central treatment in advanced stages, with surgery for stage II, neoadjuvant therapy + surgery for stage III, and CRT + salvage surgery for any stage, if the patient's condition permits.

Reconstruction after esophagectomy in patients with [partial] gastric resection. Case report and review of the literature of the use of remnant stomach

Background

Bowel reconstruction after subtotal esophagectomy represents a problem when a previous distal gastrectomy was performed: usually the colon or jejunum is used.

Methods

In a 10 year period 126 patients with primary esophageal cancer underwent esophageal resection in our Department. Surgical procedures were 57% two-phase subtotal oesophagectomy, 23% transhiatal, 9% stripping, 10 three-phase total esophagectomy and 2 endoscopic resections.

Results

In 112 patients alimentary tract reconstruction was achieved by means of esophago-gastric anastomosis. Reconstruction was performed using colon in 10 cases and jejunum in 2. We describe the technical aspects of esophagectomy and gastric reconstruction in a patient with previous antrectomy and Billroth II reconstruction. The procedure was performed via a combined laparotomy and thoracotomy with anastomosis at the level of the azygous vein using the remnant stomach.

Conclusion

Few technical reports have been reported in literature about the use of remnant stomach in reconstruction for subtotal esophagectomy subsequent to distal gastrectomy. Several hypotheses are made to explain the maintenance of the gastric vascular integrity as its intramural network without micro-vascular anastomosis.

Clinical outcome of esophageal cancer patients with history of gastrectomy

BACKGROUND

Surgery for thoracic esophageal cancer after gastrectomy involves a complicated reconstruction procedure. A surgeon's hesitation is further increased because the clinical outcome of surgical treatment of these patients has not been elucidated.

OBJECTIVES

Among 948 thoracic esophageal cancer patients who underwent curative operation, 72 (7.6%) had a history of gastrectomy. Their clinico-pathological features and survival (follow-up average 881 days) were compared with those without gastrectomy.

RESULTS

Esophagectomy for patients after gastrectomy was performed via right thoracotomy (66), left thoracotomy (4), and transhiatal resection (2), and reconstruction was done using the right-side colon (57) or jejunum (15). Compared to non-gastrectomized patients, gastrectomized patients were exposed to longer operation time (523 min vs. 460 min), but no significant difference was observed in operative mortality (4.2% vs. 2.5%) or blood loss (1,189 ml vs. 990 ml). Pathological examination showed no significant difference in depth of tumor invasion, lymph node metastasis, and TNM staging between gastrectomized and non-gastrectomized patients, while tumors were located at lower position in the gastrectomized patients (P = 0.046). The overall and cause-specific 5-year survival rates were 56% and 65% for gastrectomized esophageal cancer patients, which were significantly better than for non-gastrectomized patients (36% and 44%, P = 0.0235 and 0.024, respectively). Multivariate analysis showed gastrectomy as a marginally independent factor for a favorable prognosis (hazard ratio 1.832, P = 0.0324). With respect to tumor recurrence, hematogenic metastasis tended to be less frequent in gastrectomized patients than in non-gastrectomized patients. In gastrectomized patients, neither disease (peptic ulcer or gastric cancer) nor reconstruction (Billroth-I, Billroth-II, and Roux-Y) for gastrectomy affected the clinicopathological findings or post-operable survival.

CONCLUSIONS

Surgical treatment of esophageal cancer patients after gastrectomy was complicated but tolerable, and should be considered as a reliable therapeutic modality because of favorable patient prognosis.

Long-term effect on carcinoma of esophagus of distal subtotal gastrectomy

AIM: To investigate the surgical treatment and long-term survival for patients with carcinoma of esophagus after distal subtotal gastrectomy.

METHODS: Resections of the tumor through left thoracotomy were performed in 85 patients with esophageal carcinoma following distal subtotal gastrectomy. The procedure involved preserving the left short gastric artery and transporting the residual stomach, the spleen and tail of the pancreas into the left thoracic cavity, and using the residual stomach to reconstruct the alimentary tract.

RESULTS: The resectable rate was 91.8%, complication rate 10.3%, and no death occurred in the postoperative period. The 1-, 3-, 5-, and 10-year survival rates were 85.7%, 50.7%, 30.6% and 18.8%, respectively.

CONCLUSION: Surgical resection is the optimal management method for the patients with esophageal carcinoma after distal subtotal gastrectomy. The reconstruction of digestive tract using anastomosis of the esophagus and the residual stomach is not only simple but also can achieve a better curative effect, promoting the digestive function and improving the quality of life.

Effect of duodenal components of the refluxate on development of esophageal neoplasia in rats

When duodenal content is allowed to reflux into the esophagus of nitrosamine-treated rats, esophageal cancer is induced more rapidly and at higher frequency than after carcinogen treatment alone. The purpose of the present study was to identify the components of the duodenal content that are responsible for enhancing esophageal carcinogenesis. Eight-week-old Sprague-Dawley rats underwent one of four operations as follows: diversion of bile alone, pancreatic juice alone, both bile and pancreatic juice into the esophagus, or a control operation with no induced reflux. Two weeks after surgery, rats were treated with the esophageal carcinogen 2, 6-dimethylnitrosomorpholine (48 mg/kg [0.1 of LD50] intraperitoneally weekly for 20 weeks). The rats were killed at age 30 weeks. The esophagus was removed and full-length strips were examined under a microscope; separate segments were taken for flow cytometric evaluation. The prevalence of DNA aneuploidy and histologic esophageal papillomas or squamous cancer was increased in carcinogen-treated rats with pancreatic juice reflux (P <0.05 vs. control) and the combination of pancreatic and bile reflux (P <0.05 vs. control) but not in rats with bile reflux alone. We conclude that pancreatic juice is the most potent component of the duodenal refluxate in the promotion of esophageal carcinogenesis in rats.

Reflux of duodenal or gastro-duodenal contents induces esophageal carcinoma in rats

Esophageal adenocarcinoma arises from Barrett's esophagus, which is induced by gastro-esophageal reflux. This refluxate often contains duodenal contents, whose backflow triggers gastric carcinoma, suggesting the hypothesis that refluxed duodenal contents cause esophageal carcinoma. This study examines the role of duodenal and gastric reflux in the absence of exogenous carcinogens in esophageal carcinogenesis. Wistar male rats, 120 in all, each weighing approximately 250 g, were used. Three experimental procedures were performed to produce gastro-duodeno-esophageal reflux, duodeno-esophageal reflux and gastro-esophageal reflux, for comparison with 2 control procedures, Roux-en-Y reconstruction and a sham operation. The animals were fed a standard diet and were examined 50 weeks after surgery. While no carcinoma was found among the 16 gastro-esophageal-reflux, 11 Roux-en-Y and 12 sham-operation animals, 10 of the 12 animals with gastro-duodeno-esophageal reflux (83%) and 10 of the 13 with duodeno-esophageal reflux (77%) developed esophageal carcinoma. The difference between groups was significant (p < 0.001). Two animals with gastro-duodeno-esophageal reflux had esophageal double and triple carcinomas respectively. Of the 23 carcinomas, 16 were adenocarcinoma, 4 adenosquamous carcinoma, and 3 squamous-cell carcinoma. Adenocarcinoma developed from the columnar-lined epithelium near the esophago-jejunostoma, while adenosquamous and squamous-cell carcinoma arose from the squamous esophagitis. These observations demonstrate that refluxed duodenal contents per so are responsible for esophageal carcinogenesis.

Reflux of duodenal or gastro-duodenal contents induces esophageal carcinoma in rats

Esophageal adenocarcinoma arises from Barrett's esophagus, which is induced by gastro-esophageal reflux. This refluxate often contains duodenal contents, whose backflow triggers gastric carcinoma, suggesting the hypothesis that refluxed duodenal contents cause esophageal carcinoma. This study examines the role of duodenal and gastric reflux in the absence of exogenous carcinogens in esophageal carcinogenesis. Wistar male rats, 120 in all, each weighing approximately 250 g, were used. Three experimental procedures were performed to produce gastro-duodeno-esophageal reflux, duodeno-esophageal reflux and gastro-esophageal reflux, for comparison with 2 control procedures, Roux-en-Y reconstruction and a sham operation. The animals were fed a standard diet and were examined 50 weeks after surgery. While no carcinoma was found among the 16 gastro-esophageal-reflux, 11 Roux-en-Y and 12 sham-operation animals, 10 of the 12 animals with gastro-duodeno-esophageal reflux (83%) and 10 of the 13 with duodeno-esophageal reflux (77%) developed esophageal carcinoma. The difference between groups was significant (p < 0.001). Two animals with gastro-duodeno-esophageal reflux had esophageal double and triple carcinomas respectively. Of the 23 carcinomas, 16 were adenocarcinoma, 4 adenosquamous carcinoma, and 3 squamous-cell carcinoma. Adenocarcinoma developed from the columnar-lined epithelium near the esophago-jejunostoma, while adenosquamous and squamous-cell carcinoma arose from the squamous esophagitis. These observations demonstrate that refluxed duodenal contents per so are responsible for esophageal carcinogenesis.

Induction of oesophageal and forestomach carcinomas in rats by reflux of duodenal contents

A study was designed to determine whether oesophageal carcinomas can be induced through reflux of duodenal contents. Male Wistar rats weighing 230-250 g were divided into three groups according to the surgical procedure performed: (1) the duodenal contents were directed into the forestomach through a stoma (duodeno-forestomach reflux); (2) the duodenal contents were regurgitated into the forestomach through the glandular stomach (duodeno-glandular-forestomach reflux); and (3) a sham operation was performed as a control. Animals were fed standard CRF-1 solid food and tap water that was not exposed to carcinogens and were sacrificed 50 weeks post-operatively. While no neoplasia was observed in any of the 32 control rats, 4/11 (36%) with duodeno-forestomach reflux and 3/18 (17%) animals with duodeno-glandular-forestomach reflux developed carcinomas in the lower oesophagus and forestomach. The incidence in each group was significantly higher than in the controls (P < 0.01 and P < 0.05 respectively). Six of the seven lesions consisted of squamous cell carcinomas, and one was a mucinous adenocarcinoma. Oesophageal columnar epithelial metaplasia was observed in two (18%) of the animals with duodeno-forestomach reflux. Carcinomas were always surrounded by chronic inflammatory changes, including regenerative thickening, basal cell hyperplasia and dysplasia. Additional well-differentiated adenocarcinomas were observed in the prepyloric antrum of 6/18 (33%) animals with duodeno-glandular-forestomach reflux. These findings indicate that chronic reflux of duodenal contents may cause oesophageal carcinoma.