Risk factors for metachronous gastric cancer in the remnant stomach after early cancer surgery

Characteristics of Metachronous Remnant Gastric Cancer After Proximal Gastrectomy: A Retrospective Analysis

PURPOSE

Despite annual endoscopy, patients with metachronous remnant gastric cancer (MRGC) following proximal gastrectomy (PG) are at times ineligible for endoscopic resection (ER). This study aimed to clarify the clinical risk factors for ER inapplicability.

MATERIALS AND METHODS

We reviewed the records of 203 patients who underwent PG for cT1 gastric cancer between 2006 and 2015. The remnant stomach was categorized as a pseudofornix, corpus, or antrum.

RESULTS

Thirty-two MRGCs were identified in the 29 patients. Twenty MRGCs were classified as ER (ER group, 62.5%), whereas 12 were not (non-ER group, 37.5%). MRGCs were located in the pseudo-fornix in 1, corpus in 5, and antrum in 14 in the ER group, and in the pseudo-fornix in 6, corpus in 4, and antrum in 2 in the non-ER group (P=0.019). Multivariate analysis revealed that the pseudo-fornix was an independent risk factor for non-ER (P=0.014). In the non-ER group, MRGCs at the pseudo-fornix (n=6) had more frequent undifferentiated-type histology (4/6 vs. 0/6), deeper (≥pT1b2; 6/6 vs. 2/6) and nodal metastasis (3/6 vs. 0/6) than non-pseudo-fornix lesions (n=6). We examined the visibility of the region developing MRGC on an annual follow-up endoscopy one year before MRGC detection. In seven lesions at the pseudofornix, visibility was only secured in two (28.6%) because of food residues. Of the 25 lesions in the non-pseudo-fornix, visibility was secured in 21 lesions (84%; P=0.010).

CONCLUSIONS

Endoscopic visibility increases the chances of ER applicability. Special preparation is required to ensure the complete clearance of food residues in the pseudo-fornix.

Incidence and risk of remnant gastric cancer after gastrectomy for gastric cancer: a population-based study from the SEER database

BACKGROUND

Gastric cancer (GC) constitutes a major global health problem, of which remnant gastric cancer (RGC) occurs less frequently. The rate of RGCs after gastrectomy for GC is increasing recently due to improved survival and screening, however, their incidence and risk have not been reported in the U.S.

POPULATION

The objective of this study was to evaluate the incidence and elevated risk of RGC after GC gastrectomy in this population, and to identify the risk factors.

METHODS

Patients underwent gastrectomy for first primary GC in 2000-2015 and those who developed RGC were identified from Surveillance, Epidemiology and End Results (SEER) database. Fine-Gray regression was used to estimate the cumulative incidence and to identify risk factors. Standardized incidence ratios (SIRs) were calculated by Poisson regression to compare the risk with the general population.

RESULTS

Among 21,566 patients included in the cohort, 227 developed RGC. The 20-year cumulative incidence of RGC was 1.88%. Multivariate analysis revealed that older age, invasion depth, male sex, marital status, and lower income are independent risk factors for RGC development. SIR was 7.70 overall and > 4.5 in each stratum.

CONCLUSIONS

Cumulative incidence and risk for RGCs increased continuously in patients underwent GC gastrectomy. Close and lifelong endoscopy surveillance should be recommended for patients who received GC gastrectomy, especially those with high-risk factors.

Metachronous lesions after gastric endoscopic submucosal dissection: first assessment of the FAMISH prediction score

BACKGROUND

Surveillance after gastric endoscopic submucosal dissection (ESD) is recommended for all patients owing to the persistent risk of metachronous gastric lesions (MGLs). We developed and validated a prediction score to estimate MGL risk after ESD for early neoplastic gastric lesions, to define an individualized and cost-saving approach.

METHODS

Clinical predictors and a risk score were derived from meta-analysis data. A retrospective, single-center, cohort study including patients with ≥ 3 years of standardized surveillance after ESD was conducted for score validation. Predictive accuracy of the score by the area under the receiver operating characteristic curve (AUC) was assessed and cumulative probabilities of MGL were estimated.

RESULTS

The risk score (0-9 points) included six clinical predictors (scored 0-3): positive family history of gastric cancer, older age, male sex, corpus intestinal metaplasia, synchronous gastric lesions, and persistent Helicobacter pylori infection (FAMISH). The study population included 263 patients. The MGL rate was 16 %. The score diagnostic accuracy for predicting MGL at 3 years' follow-up, measured by the AUC, was 0.704 (95 %CI 0.603-0.806). At 3 years and a cutoff < 2, the score achieved maximal sensitivity and negative predictive value; 15 % of patients could be assigned to a low-risk group, in which the progression to MGL was significantly lower than for the high-risk group (P = 0.04).

CONCLUSION

The FAMISH score might be a useful tool to accurately identify patients with low-to-intermediate risk for MGL at 3 years of follow-up who could have surveillance intervals extended to reduce the burden of care.

Incidence of Metachronous Remnant Gastric Cancer after Proximal Gastrectomy with the Double-flap Technique (rD-FLAP-rGC Study): A Multicenter, Retrospective Study

BACKGROUND

Although proximal gastrectomy (PG) with the double-flap technique (DFT) is a function-preserving surgery that prevents esophagogastric reflux, there is a risk of developing metachronous remnant gastric cancer (MRGC). Moreover, details of MRGC and appropriate postoperative follow-up after PG with DFT are unclear.

METHODS

We reviewed the medical records of 471 patients who underwent PG with DFT for cancer in a preceding, multicenter, retrospective study (rD-FLAP Study). We investigated the incidence of MRGC, frequency of follow-up endoscopy, and eradication of Helicobacter pylori (H. pylori) infection.

RESULTS

MRGC was diagnosed in 42 (8.9%) of the 471 patients, and 56 lesions of MRGC were observed. The cumulative 5- and 10-year incidence rates were 5.7 and 11.4%, respectively. There was no clinicopathological difference at the time of primary PG between patients with and without MRGC. Curative resection for MRGC was performed for 49 (88%) lesions. All patients with a 1-year, follow-up, endoscopy interval were diagnosed with early-stage MRGC, and none of them died due to MRGC. Overall and disease-specific survival rates did not significantly differ between patients with and without MRGC. The incidence rate of MRGC in the eradicated group after PG was 10.8% and that in the uneradicated group was 19.6%, which was significantly higher than that in patients without H. pylori infection at primary PG (7.6%) (p = 0.049).

CONCLUSIONS

The incidence rate of MRGC after PG with DFT was 8.9%. Early detection of MRGC with annual endoscopy provides survival benefits. Eradicating H. pylori infection can reduce the incidence of MRGC.

Risk assessment of metachronous gastric cancer development using OLGA and OLGIM systems after endoscopic submucosal dissection for early gastric cancer: a long-term follow-up study

BACKGROUND

Metachronous gastric cancer (MGC) may develop in patients undergoing curative endoscopic submucosal dissection for early gastric cancer. As gastritis and intestinal metaplasia are notable precursors to gastric cancer, we assessed MGC risk using the Operative Link on Gastritis Assessment (OLGA) and Operative Link on Gastric Intestinal Metaplasia assessment (OLGIM) systems.

METHODS

This retrospective cohort study classified the OLGA and OLGIM stages for 916 patients who had undergone endoscopic submucosal dissection for early gastric cancer between 2005 and 2015. MGC development was followed up until 2020 and risk factors were evaluated using the Cox proportional hazards regression analysis.

RESULTS

During a median follow-up of 94 months, MGC developed in 120 subjects. OLGA stages II ~ IV were significantly associated with increased MGC risk (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.05-3.19; HR 2.31, 95% CI 1.22-4.38; HR 2.36, 95% CI 1.16-4.78) in multivariable analysis, even after adjusting for the well-known positive predictor of Helicobacter pylori eradication. OLGIM stages II ~ IV also showed significant association (HR 2.86, 95% CI 1.29-6.54; HR 2.94, 95% CI 1.34-6.95; HR 3.64, 95% CI 1.60-8.29). 5-year cumulative incidence increased with each stage. Helicobacter pylori-eradicated patients with OLGIM stages 0 ~ II had significantly less MGC than non-eradicated patients (4.5% vs 11.8%, p = 0.022), which was not observed with OLGIM stages III ~ IV.

CONCLUSIONS

High OLGA and OLGIM stages are independent risk factors for metachronous gastric cancer, with the OLGIM staging system being a better predictor. Patients with OLGIM stages 0 ~ II are a subgroup that may benefit more from Helicobacter pylori eradication.

Endoscopic submucosal dissection for lesions involving the anastomosis after upper gastrointestinal surgery

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging due to severe fibrosis, deformity, staples, and limited space for procedure. We aimed to characterize the clinicopathological characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the upper gastrointestinal tract.

METHODS

We retrospectively investigated 43 patients with lesions involving the anastomoses of the upper GI tract who underwent ESD from April 2007 to February 2021. We collected clinicopathological characteristics, procedure‑related parameters and outcomes, and follow‑up data and analyzed the impact of anastomotic involvement.

RESULTS

The median duration from previous upper GI surgery was 60 months and the median procedure duration was 30 min. The rate of en bloc resection and en bloc with R0 resection was 90.7% and 81.4%, respectively. Two patients (4.7%) experienced major adverse events, including delayed bleeding and febrile episode. During a median follow-up of 80 months, 3 patients had local recurrence and 4 patients had metastases. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 89.6% and 95.1%, respectively. Compared with the unilaterally involving group, the straddling anastomosis group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and en bloc with R0 resection, and shorter DFS and OS (all P < 0.05). However, rates of adverse events did not differ significantly between the two groups.

CONCLUSIONS

The short‑ and long-term outcomes of ESD for upper GI anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for anastomotic lesions.

Long-term nutritional status after total gastrectomy was comparable to proximal gastrectomy but with much less reflux esophagitis and anastomotic stenosis

AIM

To compare the long-term nutritional status, reflux esophagitis and anastomotic stenosis, between total gastrectomy (TG) and proximal gastrectomy (PG).

METHODS

Patients who underwent PG or TG in this single institution between January 2014 and December 2016 were included in this study. The inclusion and exclusion criteria were defined. One-to-one propensity score matching (PSM) by the demographic and pathological characteristics was performed to compare the long-term outcomes between the two groups. The primary endpoint was long-term nutritional status, and the second endpoints were reflux esophagitis and anastomotic stenosis. Long-term nutritional status was valued by percentage of body mass index (%BMI), body weight, and blood test including total protein, prealbumin, hemoglobin and total leukocytes.

RESULTS

Totally 460 patients received PG or TG in our institution for the treatment between January 2014 and December 2016 and according to the inclusion and exclusion criteria 226 cases were included in this study finally. There was no significant difference as to nutritional status in the end of first 5 years after PG or TG. While reflux esophagitis and anastomotic stenosis were significantly higher in the PG group than in the TG group (54.4% versus 26.8%, p < 0.001; 14.9% versus 4.5%, p=0.015; respectively). Overall survival rates were similar between the two groups after PSM (5-year survival rates: 65.4% versus 61.5% in the PG and TG groups, respectively; p = 0.54). The rate of carcinoma of remnant stomach after PG was 3.5% in this group of patients.

CONCLUSIONS

TG should be more aggressively recommended for the similar nutritional status, significantly lower reflux esophagitis and anastomotic stenosis, and free of carcinoma of remnant stomach compared with PG.

Risk factors for gastric metachronous lesions after endoscopic or surgical resection: a systematic review and meta-analysis

INTRODUCTION : Metachronous gastric lesions (MGL) are a significant concern after both endoscopic and surgical resection for early gastric cancer. Identification of risk factors for MGL could help to individualize surveillance schedules and potentially reduce the burden of care, but data are inconclusive. We aimed to identify risk factors for MGL and compare the incidence after endoscopic resection (ER) and subtotal gastrectomy. METHODS : We conducted a systematic review by searching PubMed, ISI, and Scopus, and performed meta-analysis. RESULTS : 52 studies were included. Pooled cumulative MGL incidence after ER was 9.3 % (95 % confidence interval [CI] 7.7 % to 11.0 %), significantly higher than after subtotal gastrectomy (1.2 %, 95 %CI 0.5 % to 2.2 %). After adjusting for mean follow-up, predicted MGL at 5 years was 9.5 % after ER and 0.7 % after subtotal gastrectomy. Older age (mean difference 1.08 years, 95 %CI 0.21 to 1.96), male sex (odds ratio [OR] 1.43, 95 %CI 1.22 to 1.66), family history of gastric cancer (OR 1.88, 95 %CI 1.03 to 3.41), synchronous lesions (OR 1.72, 95 %CI 1.30 to 2.28), severe gastric mucosal atrophy (OR 2.77, 95 %CI 1.22 to 6.29), intestinal metaplasia in corpus (OR 3.15, 95 %CI 1.67 to 5.96), persistent Helicobacter pylori infection (OR 2.08, 95 %CI 1.60 to 2.72), and lower pepsinogen I/II ratio (mean difference -0.54, 95 %CI -0.86 to -0.22) were significantly associated with MGL after ER. Index lesion characteristics were not significantly associated with MGL. ER treatment was possible in 83.2 % of 914 MGLs (95 %CI 72.2 to 91.9 %). CONCLUSION : Follow-up schedules should be different after ER and subtotal gastrectomy, and individualized further based on diverse risk factors.

Detection of secondary upper gastrointestinal tract cancer during follow-up esophagogastroduodenoscopy after gastrectomy for gastric cancer

Aim

Esophagogastroduodenoscopy (EGD) may contribute to early detection of secondary cancer in the upper gastrointestinal tract although the clinical relevance of follow-up after gastrectomy remains unclear. This study aimed to elucidate the effectiveness of follow-up EGD by investigating the incidence of secondary cancer in any part of the upper gastrointestinal tract.

Methods

Data from 1438 patients who underwent curative partial gastrectomy for primary gastric cancer between 2008 and 2014 and follow-up EGD at least once during a 5-year follow-up period were retrospectively reviewed. Incidence rates of remnant gastric cancer, laryngeal cancer, and esophageal cancer detected after follow-up EGD were determined, and risk factors for secondary cancers were examined. The characteristics of clinicopathological diagnoses of secondary cancers were reviewed and compared according to the frequency of follow-up EGD.

Results

The average annual frequency of EGD was 0.7, while the 5-year cumulative incidence rates of remnant gastric cancer and secondary laryngeal and esophageal cancers were 2.9% and 1.3%, respectively. Risk factors for remnant gastric cancer included heavy smoking, proximal gastrectomy, and tumor size ≥ 30 mm. All secondary cancers were resectable upon diagnosis, with endoscopically resectable cancer accounting for 81.0% of cases. Our results found a significantly higher proportion of endoscopically resectable cancers during regular follow-up than during infrequent follow-up.

Conclusions

Follow-up EGD can be a useful modality for detecting secondary upper gastrointestinal tract cancer, likely leading to curative treatment for secondary cancer. Focusing on patients presenting with risk factors may increase the value of follow-up EGD after gastrectomy.

Clinicopathological Features of Remnant Gastric Cancer After Gastrectomy

BACKGROUND

Remnant gastric cancer (RGC) encompasses all cancers arising from the remnant stomach. Various studies have reported on RGC and its prognosis, but no consensus on its surgical treatment and postoperative management has been reached. Moreover, the correlation between the clinicopathological characteristics and long-term outcomes of RGC remains unclear. This study investigated the clinicopathological factors associated with the long-term survival of RGC patients.

METHODS

The medical records (March 1993-September 2020) of 104 RGC patients from Tokyo Medical University Hospital database were analyzed. Of these 104 patients, the medical records of 63 patients who underwent surgical curative resection were analyzed using R. Kaplan-Meier plots of cumulative incidence of RGC were made. Differences in survival rates were compared using the log-rank test. Prognostic factors were analyzed using multivariate Cox regression analysis (P < .05).

RESULTS

Of the 104 RGC patients, 63 underwent total remnant stomach excision. The median time from the first surgery to the total excision was 10 years. The 5-year survival rate of the 63 RGC patients was .55 ((95% CI); .417-.671). The clinicopathological factors that were significantly associated with the long-term outcome of the RGC patients were tumor diameter (≥3.5 cm), presence or absence of combined resection of multiple organs, tumor invasion (deeper than T2), TNM stage, and postoperative morbidity. The multivariate Cox regression analysis showed that tumor invasion depth was the only independent prognostic factor for RGC patients [HR (95% CI): 5.49 (2.629-11.5), P ≤ .005].

CONCLUSIONS

Among prognostic factors, tumor invasion depth was the only independent factor affecting RGC's long-term outcome.

Comparative molecular subtypes of index and metachronous gastric adenocarcinomas: a study of 42 Korean patients

To date, there have been no studies comparing the molecular subtypes of Index gastric cancers (IGCs) and metachronous gastric cancers (MGCs). We evaluated a cohort of 42 patients with 43 IGCs and 45 MGCs. Molecular subtyping was performed by immunohistochemistry of mismatch repair (MMR) proteins, E-cadherin, p53, and Epstein-Barr virus- (EBV-) in situ hybridization (ISH). Gastric adenocarcinomas were classified into 5 subtypes: EBV-associated, MMR deficient (MMRD), E-cadherin aberrant, p53-aberrant [p53(+)], and p53 non-aberrant [p53(neg)]. All IGCs had been successfully treated by either surgery (19%) or endoscopic resection (81%). The mean interval between IGCs and MGCs was 85 months. Among the IGCs, EBV-associated, MMRD, E-cadherin-aberrant, p53(+), and p53(neg) molecular subtypes represented 2 (5%), 4 (9%), 2 (5%), 21 (49%), and 14 (32%) of the cases, respectively. Two cases had concomitant p53(+) and aberrant E-cadherin molecular subtypes. Among metachronous cancers, EBV-associated, MMRD, E-cadherin-aberrant, p53(+), and p53(neg) molecular subtypes represented 3 (7%), 11 (24%), 0 (0%), 22 (49%), and 9 (20%) cases. Concomitant p53(+) was observed in 1 EBV-associated and 2 MMRD MGCs. Although, there was no significant difference in the frequency of most molecular subtypes in IGCs and MGCs, the number of MMRD gastric cancers more than doubled in the MGC group. Half of the MGCs had a divergent molecular subtype compared to that of the IGCs. Notably, the interval between the development of IGCs and MGCs was significantly longer in patients with divergent molecular subtypes (P = 0.010). All 4 patients with MMRD IGC developed MMRD MGCs. Although the concept of mucosal field cancerization may explain the matching molecular subtypes in early-developing MGCs, the presence of divergent subtypes in late-occurring MGCs suggests a shift in the carcinogenic mechanism affecting the residual mucosa possibly related to Helicobacter pylori eradication.

The Incidence and Risk Factors for Metachronous Gastric Cancer in the Remnant Stomach after Gastric Cancer Surgery

Background/Aims

Less invasive surgical treatment is performed in East Asia to preserve postoperative digestive function and reduce complications such as postgastrectomy syndromes, but there is an issue of metachronous gastric cancer (GC) in the remaining stomach. This study aimed to analyze the incidence of metachronous GC and its risk factors in patients who had undergone partial gastrectomy.

Methods

A total of 3,045 GC patients who had undergone curative gastric partial resection at Seoul National University Bundang Hospital were enrolled and analyzed retrospectively for risk factors, including age, sex, smoking, alcohol, Helicobacterpylori status, family history of GC, histological type, and surgical method.

Results

Metachronous GC in the remaining stomach occurred in 35 of the 3,045 patients (1.1%) 23 in the distal gastrectomy group (18 with Billroth-I anastomosis, five with Billroth-II anastomosis), seven in the proximal gastrectomy (PG) group, and five in the pylorus-preserving gastrectomy (PPG) group. Univariate and multivariate Cox regression analyses showed that age ≥60 years (p=0.005) and surgical method used (PG or PPG, p<0.001) were related risk factors for metachronous GC, while male sex and intestinal type histology were potential risk factors.

Conclusions

Metachronous GC was shown to be related to older age and the surgical method used (PG or PPG). Regular and careful follow-up with endoscopy should be performed in the case of gastric partial resection, especially in patients with male sex and intestinal type histology as well as those aged ≥60 years undergoing the PG or PPG surgical method.

Sporadic foveolar-type gastric adenoma with a raspberry-like appearance in Helicobacter pylori-naïve patients

Sporadic foveolar-type gastric adenoma (FGA) has been described as an extremely rare polyp that is whitish and flatly elevated. However, we recently found that sporadic FGA with a raspberry-like appearance (FGA-RA) is not rare in Helicobacter pylori (H. pylori)-naïve gastric mucosa. We endoscopically or surgically treated 647 patients with gastric epithelial neoplasms in the last 5 years, with 7.7% (50/647) being H. pylori-naïve. Among these, 43 FGA-RAs were diagnosed based on histologic and endoscopic features in 34 patients, who were all enrolled in this retrospective study. All lesions were observed by white-light endoscopy (WLE) and narrow-band imaging with magnification endoscopy (NBIME). We subsequently analyzed their endoscopic and microscopic features and patient characteristics. The patients were 22 males and 12 females aged 57±23 years (mean±2SD). WLE showed raspberry-like small polyps mimicking gastric hyperplastic polyps in the oxyntic gastric compartment (body/fundus). Multiple growths were confirmed in 20.6% (7/34) of the patients. NBIME revealed irregularly shaped papillary/gyrus-like microstructures with abnormal capillaries. Histologically, all lesions were intraepithelial neoplasms, and most of lesions (62.8%, 27/43) exhibited low-grade dysplasia. Immunohistochemically, neoplastic cells featured strong and diffuse MUC5AC expression, negative or very low MUC6 expression, and negative MUC2/CD10 expression. They also showed Ki-67 hyperexpression with a mean labeling index of 59.4±48.7%. The coexistence of fundic gland polyps in the background mucosa was significantly higher in multiple FGA-RA cases than in solitary cases (100% vs. 55.5%, P< 0.05). FGA-RA is a newly suggested histologic variant of sporadic FGA whose occurrence is not rare in daily endoscopic practice.

The risk scoring system for assessing the technical difficulty of endoscopic submucosal dissection in cases of remnant gastric cancer after distal gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for remnant gastric cancer (RGC) after distal gastrectomy (DG) is considered technically challenging due to the narrow working space, and severe fibrosis and staples from the previous surgery. Technical difficulties of ESD for RGC after DG have not been thoroughly investigated. This study aimed to develop and validate a risk-scoring system for assessing the technical difficulty of ESD for RGC after DG in a large multicenter cohort.

METHODS

We investigated patients who underwent ESD for RGC after DG in 10 institutions between April 2008 and March 2018. A difficult case was defined as ESD lasting ≥ 120 min, involving piecemeal resection, or the occurrence of perforation during the procedure. A risk-scoring system for the technical difficulty of the procedure was developed based on multiple logistic regression analyses, and its performance was internally validated using bootstrapping.

RESULTS

A total of 197 consecutive patients with 201 lesions were analyzed. There were 90 and 111 difficult and non-difficult cases, respectively. The scoring model consisted of four independent risk factors and points of risk scores were assigned for each as follows: tumor size > 20 mm: 2 points; anastomosis site: 2 points; suture line: 1 point; and non-expert endoscopist: 2 points. The C-statistics of the scoring system for technical difficulty was 0.72.

CONCLUSIONS

We developed a validated risk-scoring model for predicting the technical difficulty of ESD for RGC after DG that can contribute to its safer and more reliable performance.

Surveillance Endoscopy Guidelines for Postgastrectomy Patients Based on Risk of Developing Remnant Gastric Cancer

BACKGROUND

Remnant gastric cancer (RGC) has a major impact on the long-term survival of postgastrectomy patients. In this study, we established surveillance endoscopy guidelines for postgastrectomy patients based on the risk of RGC.

PATIENTS AND METHODS

A total of 6365 patients who underwent gastrectomy at Seoul St. Mary's Hospital from September 2005 to June 2018 were retrospectively reviewed; 85 patients were identified as having RGC. We divided the RGC patients into subgroups according to the interval between primary and secondary gastrectomy.

RESULTS

The curative resection rate was significantly lower in patients with an interval of ≤ 5 years versus > 5 years (p = 0.017). RGC developed more frequently after Billroth II reconstruction, and at the anastomotic site, in patients with a > 10- versus ≤ 10-year interval (p = 0.006 and p = 0.014, respectively). Similar results were observed based on the 15-year interval cutoff (p = 0.001 and 0.018, respectively). The 5-year overall survival rate of patients with a ≤ 5-year interval was significantly lower than that of patients with a > 5-year interval (60.0% versus 85.7%, p = 0.015), while overall survival did not differ between the ≤ 10- and > 10-year, or ≤ 15- and 15-year interval groups. RGC incidence showed a decrease after around 20 years postoperatively.

CONCLUSIONS

Thorough endoscopic examination should be conducted for up to 5 years postgastrectomy. Routine annual endoscopic follow-up should be performed for up to 20 years after the primary operation for gastric cancer, to allow for early detection of RGC.

Clinicopathologic Characteristics of Patients with Gastric Superficial Neoplasia and Risk Factors for Multiple Lesions after Endoscopic Submucosal Dissection in a Western Country

Background

Endoscopic submucosal dissection (ESD) is a treatment for early gastric neoplasms that preserves the stomach. However, the risk of multiple lesions persists.

Objectives

To assess clinicopathologic characteristics of patients with early gastric neoplasms in a Western country and evaluate risk factors for multiple gastric lesions, synchronous, or metachronous.

Methods

A retrospective cohort of 230 consecutive patients who underwent ESD for primary neoplasms from 2012 to 2017 (median follow-up: 33 months) was assessed to determine the clinicopathologic characteristics and risk factors for multiple lesions.

Results

The mean age was 68 years, and 53.9% were male. Current/former smoking status was present in 40.4%, and 29.5% had family history of gastric cancer. A third of the patients had only focal gastric atrophy/metaplasia (operative link on gastritis assessment/operative link on gastric intestinal metaplasia assessment [OLGA/OLGIM] I/II; endoscopic grading of gastric intestinal metaplasia [EGGIM] 1-4). Synchronous and me-tachronous lesions occurred in 14.3 and 8.6% of patients, respectively. There was a trend for higher risk of multiple lesions in smokers and patients with extensive metaplasia (EGGIM >4), but only older age was an independent risk factor (OR 3.30; 95% CI 1.05-10.34). Age >60 years (OR 10.10, 95% CI 1.40-88.04), current/former smoking status (OR 3.64, 95% CI 1.07-12.40), and OLGIM III/IV (OR 3.07, 95% CI 1.01-9.36) were independent risk factors for synchronous lesions. No risk factors for metachronous lesions were found.

Conclusions

Surveillance limited to patients with advanced stages of gastritis may miss some primary superficial neoplasms. Although older age increases the risk of multiple lesions, no risk factors were found for metachronous lesions. Therefore, endoscopic surveillance after ESD should be done equally in all patients.

Surgical resection of gastric stump cancer following proximal gastrectomy for adenocarcinoma of the esophagogastric junction

BACKGROUND

Proximal gastrectomy (PG) is performed widely as a function-preserving operation for early gastric cancer located in the upper third of the stomach and is an important function-preserving approach for esophagogastric junction (EGJ) adenocarcinoma. The incidence of gastric stump cancer (GSC) after PG is increasing. However, little is known about the GSC following PG because very few studies have been conducted on the disease.

AIM

To clarify clinicopathologic features, perioperative complications, and long-term survival rates after the resection of GSC following PG.

METHODS

Data for patients with GSC following PG for adenocarcinoma of the EGJ diagnosed between January 1998 and December 2016 were retrospectively reviewed. Multivariate analysis was performed to identify factors associated with overall survival (OS). GSC was defined in accordance with the Japanese Gastric Cancer Association.

RESULTS

A total of 35 patients were identified. The median interval between the initial PG and resection of GSC was 4.9 (range 0.7-12) years. In 21 of the 35 patients, the tumor was located in a nonanastomotic site of the gastric stump. Total gastrectomy was performed in 27 patients; the other 8 underwent partial gastrectomy. Postoperative complications occurred in 6 patients (17.1%). The tumor stage according to the depth of tumor invasion was T1 in 6 patients, T2 in 3 patients, T3 in 9 patients, and T4 in 17 patients. Lymph node metastasis was observed in 18 patients. Calculated 1-, 3-, and 5-year OS rates were 86.5%, 62.3%, and 54.2%, respectively. Multivariate analysis showed advanced T stage to be associated with OS.

CONCLUSION

This study reveals the characteristics of GSC following PG for adenocarcinoma of the EGJ and suggests that a surgical approach can lead to a satisfactory outcome.

Long-term outcome following sentinel node navigation surgery for cT1 gastric cancer

Sentinel node navigation surgery (SNNS) has become a standard procedure for early-stage melanoma and breast cancer. However, very few studies have evaluated the long-term clinical outcomes following SNNS for gastric cancer. The present study analyzed 51 patients with cT1 gastric cancer who underwent SNNS at our hospital. Sentinel nodes (SNs) were identified using the dual tracer method. Patients underwent limited gastrectomy with SN station dissection when the SNs were reported as pathologically negative during surgery. When SNs were pathologically positive, standard gastrectomy with D2 lymphadenectomy was performed. Out of the 51 cases, 42 cases (82%) were pathologically diagnosed as SN-negative using a frozen section. The surgical procedures included segmental gastrectomy (n=33) and local resection (n=9). A total of 9 patients (18%) had lymph node metastasis in SNs. The mean observation period was 3,125±167 days, and the 5-year overall survival rate was 98%. There was no recurrence, and body weight loss was minimal following the SNNS. Remnant gastric cancer developed in 4 (8%) of the 50 patients except total gastrectomy. Thus, SNNS was a useful procedure for cT1 gastric cancer from the long-term clinical outcomes, though metachronous gastric cancer should paid further attention to.

The Feasibility of Laparoscopic Gastrectomy for Remnant Gastric Cancer

We compared laparoscopic gastrectomy for remnant gastric cancer (LRG) with open gastrectomy for remnant gastric cancer (ORG) to assess the safety and invasive nature of LRG. This study was a retrospective study. The study population consisted of 27 consecutive patients who underwent gastrectomy for remnant gastric cancer. Of these, 15 underwent ORG between January 2003 and April 2007, and 12 underwent LRG between May 2007 and January 2013. The operation time was not significantly different between the 2 groups. However, blood loss was significantly less in the LRG group than in the ORG group. No intraoperative blood transfusion was required. There was no significant difference in morbidity rate between the LRG (1/12, 8.3%) and ORG (4/15, 26.7%) groups, and no patients died in either group. Body temperature on postoperative day (POD) 7 (P = 0.034); systolic blood pressure on PODs 6 (P = 0.042) and 7 (P = 0.035); and heart rate on POD 7 (P = 0.049) were significantly lower in the LRG group than in the ORG group. No significant differences were observed in white blood cell count, or C-reactive protein and serum albumin levels between the groups. Serum total protein levels were significantly higher on POD 1 (P = 0.020), and the number of lymphocytes was significantly higher on POD 7 in the LRG group than in the ORG group (P = 0.036). Pain scores on POD 7 were significantly lower in the LRG group than in the ORG group (P = 0.033). LRG is a technically feasible and safe procedure.

Carcinoma in the Remnant Stomach During Long-Term Follow-up After Distal Gastrectomy for Gastric Cancer: Analysis of Cumulative Incidence and Associated Risk Factors

BACKGROUND

The number of patients with remnant gastric cancer following resection of gastric cancer may increase. The aims of this study were to investigate the development of remnant gastric cancer after distal gastrectomy for gastric cancer and to examine its cumulative incidence, clinicopathological characteristics, and risk factors.

METHODS

We examined 437 patients with relapse-free survival for 5 years or more after distal gastrectomy with Billroth I reconstruction for gastric cancer performed between 1985 and 2005.

RESULTS

A total of 17 patients suffered from remnant gastric cancer. The cumulative incidence was 3.7% at 10 years and 5.4% at 20 years. The median time until development of remnant gastric cancer was 79 months (range 30-209 months). The presence of synchronous multiple gastric cancers was a significant independent risk factor for remnant gastric cancer (hazard ratio 4.036; 95% confidence interval 1.478-11.02; P = 0.006). Of the 17 patients, the 13 whose remnant gastric cancer was detected via regular endoscopy showed better prognoses than the patients detected by other means (P < 0.001).

CONCLUSION

The cumulative incidence of remnant gastric cancer was 5.4% at 20 years. In particular, patients who had multiple gastric cancers at initial gastrectomy were at higher risk for remnant gastric cancer. Therefore, long-term endoscopic surveillance is important.

Incidence and treatment of metachronous gastric cancer after proximal gastrectomy

BACKGROUND AND PURPOSE

Proximal gastrectomy (PG) is a widely accepted function-preserving surgical procedure; however, the incidence and treatment of metachronous gastric cancer (MGC) after PG have been the subject of a number of reports.

METHODS

We collected data from 1576 consecutive patients who underwent gastrectomy for gastric cancer between January, 2003 and December, 2010, and analyzed the outcomes of 671 patients treated with PG or distal gastrectomy (DG) for cT1N0 disease. We also discuss the treatments for MGC.

RESULTS

MGC was diagnosed within a median follow-up of 52.8 months after PG and DG in six (6.6%) and nine (1.8%) patients, respectively. The cumulative prevalence of MGC after PG was significantly higher than that after DG; P = 0.005. Univariate and multivariate analysis revealed male sex and PG as significant risk factors for MGC (P = 0.014 and P = 0.026, respectively). Five of the six patients who underwent PG were treated by endoscopic submucosal dissection.

CONCLUSIONS

The incidence of MGC after PG was significantly higher than that after DG. However, most of the MGCs that developed after PG could be treated by endoscopic submucosal dissection.

Risk factors for metachronous gastric carcinoma development after endoscopic resection of gastric dysplasia: Retrospective, single-center study

AIM

To determine the gastric adenocarcinoma (GAC) occurrence rate and related factors, we evaluated the follow-up results of patients confirmed to have gastric dysplasia after endoscopic resection (ER).

METHODS

We retrospectively analyzed the medical records, endoscopic examination records, endoscopic procedure records, and histological records of 667 cases from 641 patients who were followed-up for at least 12 mo, from among 1273 patients who were conformed to have gastric dysplasia after Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of gastric mucosal lesions between January 2007 and August 2013 at the Chungnam National University Hospital.

RESULTS

The mean follow-up period was 33.8 mo, and the median follow-up period was 29 mo (range: 12-87). During the follow-up period, the occurrence of metachronous GAC was 4.0% (27/667). The mean and median interval periods between the occurrence of metachronous GAC and endoscopic treatment of gastric dysplasia were 36.3 and 34 mo, respectively (range: 16-71). The factors related to metachronous GAC occurrence after ER for gastric dysplasia were male sex (5.3% vs 1.0%), open-type atrophic gastritis (9.5% vs 3.4%), intestinal metaplasia (6.8% vs 2.4%), and high-grade dysplasia (HGD; 8.4% vs 3.2%). Among them, male sex [OR: 5.05 (1.18-21.68), P = 0.029], intestinal metaplasia [OR: 2.78 (1.24-6.23), P = 0.013], and HGD [OR: 2.70 (1.16-6.26), P = 0.021] were independent related factors in multivariate analysis. Furthermore, 24 of 27 GAC cases (88.9%) occurred at sites other than the previous resection sites, and 3 (11.1%) occurred at the same site as the previous resection site.

CONCLUSION

Male sex, intestinal metaplasia, and HGD were significantly related to the occurrence of metachronous GAC after ER of gastric dysplasia, and most GACs occurred at sites other than the previous resection sites.

Comparative study between endoscopic submucosal dissection and surgery in patients with early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is accepted as a standard treatment in patients with early gastric cancer (EGC) who have a negligible risk of lymph node metastasis. The aim of this study was to compare the short-term and long-term outcomes between ESD and surgery in patients with EGC that fulfilled the expanded indication of ESD on their final pathologic report.

METHODS

We reviewed the clinical data of patients who underwent gastric ESD and surgery between January 2007 and December 2012. Patients with pathologically confirmed EGC that fulfilled the expanded indication of ESD on their final pathologic report were analyzed.

RESULTS

Among 2023 patients, 817 (40.4%) underwent ESD and 1206 (59.6%) underwent surgery. The proportion of cases meeting the absolute indication was significantly higher in the ESD group than in the surgery group (66.0 vs. 26.2%). Lesions on the middle third, >3 cm in size, flat or depressed, and of undifferentiated histology were significantly more common in the surgery group than in the ESD group. The ESD group showed lower acute complication rates [8.1% (66 of 817) vs. 18.1% (218 of 1206), P ≤ 0.001] and procedure-related mortality [0 vs. 0.3% (4 of 1206), P = 0.153] than the surgical group. The annual incidence of recurrent gastric cancer was 2.18% in the ESD group and 0.19% in the surgery group. The 5-year overall and disease-specific survival rates were not significantly different between the ESD group and the surgery group (overall survival: 96.4 vs. 97.2%, P = 0.423; disease-specific survival: 99.6 vs. 99.2%, P = 0.203).

CONCLUSIONS

Although EGC lesions had poorer features in the surgery group than in the ESD group, ESD was comparable to surgery for EGCs that fulfilled the expanded indication of ESD, with lower rates of acute complication and comparable overall survival.

Predictive risk factors associated with synchronous multiple early gastric cancer

The aim of this study was to elucidate the predictive risk factors of synchronous multiple early gastric cancer regardless of the treatment modality.Patients who underwent early gastric cancer treatment between July 2005 and June 2015 were retrospectively reviewed. In total, 1529 patients who were treated for early gastric cancer were included. We analyzed the patient's data to find predictive factors of synchronous multiple early gastric cancer compared to solitary early gastric cancer. Further analysis was performed to verify the difference between endoscopic and surgical treatment groups.Among the 1529 patients, synchronous multiple early gastric cancer was diagnosed in 68 (4.4%) patients. Significant differences in sex (P = .004), gross appearance (P = .038), depth of invasion (P = .007), and lymphovascular invasion (P = .039) were found between patients with solitary early gastric cancer and synchronous multiple early gastric cancer by univariate analysis. In multivariate analysis, male sex (odds ratio, 2.475; P = .011) and submucosal invasion (odds ratio, 1.850; P = .033) were independent predictive risk factors of synchronous multiple early gastric cancer. In addition, in multivariate analysis, significant differences in age, tumor size, longitudinal location, depth of invasion, and histology were found between patients groups depending on the mode of treatment.Male sex and submucosal invasion were predictive risk factors of synchronous multiple early gastric cancer. Patients with these factors should undergo more meticulous endoscopic surveillance.

Endoscopic Submucosal Dissection of Gastric Epithelial Neoplasms after Partial Gastrectomy: A Single-Center Experience

Aims

To investigate the feasibility and safety of endoscopic submucosal dissection (ESD) of gastric epithelial neoplasms in the remnant stomach (GEN-RS) after various types of partial gastrectomy.

Methods

This study included 29 patients (31 lesions) who underwent ESD for GEN-RS between March 2006 and August 2016. Clinicopathologic data were retrieved retrospectively to assess the therapeutic ESD outcomes, including en bloc and complete resection rates and procedure-related adverse events.

Results

The en bloc, complete, and curative resection rates were 90%, 77%, and 71%, respectively. The types of previous gastrectomy, tumor size, macroscopic type, and tumor histology were not associated with incomplete resection. Only tumors involving the suture lines from the prior partial gastrectomy were significantly associated with incomplete resection. The procedure-related bleeding and perforation rates were 6% and 3%, respectively; none of the adverse events required surgical intervention. During a median follow-up period of 25 months (range, 6–58 months), there was no recurrence in any case.

Conclusions

ESD is a safe and feasible treatment for GEN-RS regardless of the previous gastrectomy type. However, the complete resection rate decreases for lesions involving the suture lines.

Differences in Prevalence of Lymphovascular Invasion among Early Gastric Cancers between Korea and Japan

BACKGROUND/AIMS

The presence of invasion is a diagnostic criterion of early gastric cancer (EGC) in Korea, whereas diagnosis in Japan is based on enlarged nuclei and prominent nucleoli. Moreover, the depth of invasion is the location of cancer cell infiltration in Korea, whereas it is the location of lymphovascular invasion (LVI) or cancer cell infiltration in Japan. We evaluated the characteristics of EGC with LVI to uncover the effects of different diagnostic criteria.

METHODS

Consecutive T1-stage EGC patients who underwent complete resection were included after endoscopic or surgical resection. The presence of LVI was evaluated.

RESULTS

LVI was present in 112 of 1,089 T1-stage EGC patients. LVI was associated with depth of invasion (p<0.001) and age (p=0.017). The prevalence of LVI in mucosal cancer was significantly higher in Korea (p<0.001), whereas that of submucosal cancer was higher in Japan (p=0.024). For mucosal EGC types, LVI was positively correlated with diagnostic criteria applied in Korea (p=0.017). For submucosal EGC types, LVI was positively correlated with Japanese criteria (p=0.001) and old age (p=0.045).

CONCLUSIONS

The higher prevalence of LVI for mucosal EGC in Korea and for submucosal EGC in Japan indicates that different diagnostic criteria should be considered when reading publications from other countries.

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.

Clinical outcomes of gastric polyps and neoplasms in patients with familial adenomatous polyposis

Background and study aims Familial adenomatous polyposis (FAP) is an autosomal dominant syndrome caused by a germline mutation in the adenomatous polyposis coli (APC) gene, characterized by the presence of more than 100 adenomatous polyps in the colorectum. The upper gastrointestinal tract is an extracolonic site for malignancy in patients with FAP. The frequency of death in Japanese patients with FAP because of gastric cancer is 2.8 % and that because of colon cancer is 60.6 %. Few studies have reported upper gastrointestinal diseases in patients with FAP. In the present study, we investigated the clinical outcomes of patients with FAP diagnosed with gastric neoplasms. Patients and methods We enrolled 80 patients with FAP who underwent esophagogastroduodenoscopy from October 1997 to December 2011. We investigated patient characteristics, endoscopic findings of gastric lesions, treatment outcomes, and long-term courses. Results Fundic gland polyposis was observed in 51 patients (64 %) and gastric neoplasms in 22 patients (28 %), including 20 with non-invasive and 2 with invasive neoplasm. Of the 26 neoplasms, 11 were treated by endoscopic resection (ER) and 4 by surgical resection. Metachronous gastric neoplasms were observed in 7 patients (15 lesions) and treated by ER, except for in 1 patient. No patients died of gastric lesions during a median follow-up period of 6.5 years (range, 0 - 14). Conclusion Because gastric lesions including gastric cancers in patients with FAP did not cause any deaths, they can be considered to have favorable prognoses. Early detection of gastric neoplasms through an appropriate follow-up interval may have contributed to these good outcomes.

Surveillance for Gastric Cancer

This article discusses the current National Comprehensive Cancer Network guidelines and other available Western and Eastern guidelines for the surveillance of gastric cancer following surgical resection. It reviews the literature assessing the utility of intensive surveillance strategies for gastric cancer, which fails to show an improvement in survival. The unique issues relating to follow-up of early gastric cancer and after endoscopic resection of early gastric cancer are discussed. This article also reviews the available modalities for follow-up. In addition, it briefly discusses the advancements in treatment of recurrent and metastatic disease and the implications for gastric cancer survival and surveillance strategies.

Incidence and impact of scheduled endoscopic surveillance on recurrence after curative endoscopic resection for early gastric cancer

BACKGROUND AND AIMS

The aim of this study was to identify the incidence of recurrent lesions after endoscopic submucosal dissection (ESD) and to determine whether scheduled endoscopic surveillance might control their development and treatment.

METHODS

We reviewed the clinical data of patients who underwent gastric ESD between March 2007 and April 2014.

RESULTS

A total of 1347 patients who underwent curative ESD for early gastric cancer that met the expanded indication for ESD were analyzed. Of these, recurrence at the previous ESD site occurred in 39 patients, whereas recurrence in the stomach at a site other than the ESD site occurred in 102 patients. Older age, intestinal metaplasia, flat or depressed lesions, and ESD criteria were associated with recurrence in the stomach in places other than the ESD site. The annual incidence was .84% for recurrence at the previous ESD site and 2.48% for recurrence in the stomach at other than the ESD site. In cases of local recurrence and metachronous lesions, there was a significant difference between the short- and long-surveillance interval group (≤12 months vs >12 months) in the proportions of recurrent adenocarcinoma (31.9% vs 60.9%, P = .021), additional gastrectomy (7.1% vs 46.2%, P = .033), and size (8.92 ± 4.17 mm vs 18.08 ± 10.47 mm, P = .010).

CONCLUSIONS

Scheduled endoscopy surveillance is necessary for detecting recurrent lesions. In addition, scheduled endoscopy surveillance might help to detect recurrent lesions at a stage early enough for a curative resection.

Comparing Laparoscopic to Endoscopic Resections for Early Gastric Cancer in a High Volume North American Center

Endoscopic submucosal dissection as an organ sparing option for early gastric cancer is becoming increasingly accepted as an alternative to laparoscopic gastrectomy. Given the very limited North American data, we sought to compare outcomes between endoscopic and laparoscopic resection of gastric malignant and premalignant tumors. Patients undergoing laparoscopic gastrectomy or endoscopic submucosal dissection from 2007 to 2014 for adenocarcinoma or dysplasia at the McGill University Health Center were identified from a prospectively collected database and dichotomized according to the surgical approach. Patient demographics, tumor characteristics, stage, oncologic outcome, length of stay, and postoperative complications were recorded. Of 155 patients with gastric cancer identified, 67 were treated by laparoscopic gastrectomy (n = 37) or endoscopic submucosal dissection (ESD) (n = 30). There were significantly more invasive lesions in the laparoscopic group and patients subject to ESD harbored more T1 lesions. No significant difference in the rate of R0 resection or overall complications was observed between the groups. Accordingly, length of stay was significantly shorter in the ESD group. There were no significant differences in terms of overall and disease-free survival. In selected patients, ESD is associated with improved short-term outcomes and provides an appropriate oncologic resection option in a North American patient cohort.

Second primary pancreatic ductal carcinoma in the remnant pancreas after pancreatectomy for pancreatic ductal carcinoma: High cumulative incidence rates at 5 years after pancreatectomy

OBJECTIVES

The aim of this study was to determine the incidence rate and clinical features of second primary pancreatic ductal carcinoma (SPPDC) in the remnant pancreas after pancreatectomy for pancreatic ductal carcinoma (PDC).

METHODS

Data of patients undergoing R0 resection for PDC at a single high-volume center were reviewed. SPPDC was defined as a tumor in the remnant pancreas after R0 resection for PDC, and SPPDC met at least one of the following conditions: 1) the time interval between initial pancreatectomy and development of a new tumor was 3 years or more; 2) the new tumor was not located in contact with the pancreatic stump. We investigated the clinical features and treatment outcomes of patients with SPPDC.

RESULTS

This study included 130 patients who underwent surgical resection for PDC between 2005 and 2014. Six (4.6%) patients developed SPPDC. The cumulative 3- and 5-year incidence rates were 3.1% and 17.7%, respectively. Four patients underwent remnant pancreatectomy for SPPDC. They were diagnosed with the disease in stage IIA or higher and developed recurrence within 6 months after remnant pancreatectomy. One patient received carbon ion radiotherapy and survived 45 months. One patient refused treatment and died 19 months after the diagnosis of SPPDC.

CONCLUSIONS

The incidence rate of SPPDC is not negligible, and the cumulative 5-year incidence rate of SPPDC is markedly high. Post-operative surveillance of the remnant pancreas is critical for the early detection of SPPDC, even in long-term survivors after PDC resection.

Sentinel Lymph Node Navigation Surgery for Early Gastric Cancer: Is It a Safe Procedure in Countries with Non-Endemic Gastric Cancer Levels? A Preliminary Experience

Purpose

Early diagnosis of gastric cancer is still the exception in Western countries. In the East, as in Japan and Korea, this disease is an endemic disorder. More conservative surgical procedures are frequently performed in early gastric cancer cases in these countries where sentinel lymph node navigation surgery is becoming a safe option for some patients. This study aims to evaluate preliminary outcomes of patients with early gastric cancer who underwent sentinel node navigation surgeries in Brazil, a country with non-endemic gastric cancer levels.

Materials and Methods

From September 2008 to March 2014, 14 out of 205 gastric cancer patients underwent sentinel lymph node navigation surgeries, which were performed using intraoperative, endoscopic, and peritumoral injection of patent blue dye.

Results

Antrectomies with Billroth I gastroduodenostomies were performed in seven patients with distal tumors. The other seven patients underwent wedge resections. Sentinel basin resections were performed in four patients, and lymphadenectomies were extended to stations 7, 8, and 9 in the other 10. Two patients received false-negative results from sentinel node biopsies, and one of those patients had micrometastasis. There was one postoperative death from liver failure in a cirrhotic patient. Another cirrhotic patient died after two years without recurrence of gastric cancer, also from liver failure. All other patients were followed-up for 13 to 79 months with no evidence of recurrence.

Conclusions

Sentinel lymph node navigation surgery appears to be a safe procedure in a country with non-endemic levels of gastric cancer.

Endoscopic Submucosal Dissection for Early Gastric Neoplasia Occurring in the Remnant Stomach after Distal Gastrectomy

Background/Aims:

Endoscopic submucosal dissection (ESD) for tumors occurring in the remnant stomach is technically difficult to perform because of limited working space and severe fibrosis and staples present around the suture line. We aimed to elucidate the feasibility and clinical outcomes of performing ESD for tumors in the remnant stomach.

Methods:

Between December 2007 and January 2013, 18 patients underwent ESD for tumors (six adenomas and 12 differentiated-type early gastric cancers [EGCs]) occurring in the remnant stomach after distal gastrectomy. Clinicopathologic features and clinical outcomes after ESD were retrospectively analyzed.

Results:

Two-thirds of the lesions were located on the body, and half were located on the suture line. En bloc resection, R0 resection, and en bloc with R0 resection rates were 88.9%, 100%, and 88.9%, respectively. Curative resection rate for EGC was 91.7%. Perforation occurred in one patient (5.6%) and was successfully managed by endoscopic closure with metallic clips and conservative management. There was no significant bleeding after ESD. During a median follow-up of 47.5 months, no local, metachronous, or extragastric recurrence was seen for either EGC or adenoma lesions.

Conclusions:

ESD is a feasible and effective treatment modality and can be considered a primary intervention for early gastric neoplasia occurring in the remnant stomach.

Prognostic factors and survival in patients with gastric stump cancer

AIM: To elucidate the clinicopathological characteristics and prognostic factors of gastric stump cancer (GSC).

METHODS: The clinical data for 92 patients with GSC were collected at Fudan University Shanghai Cancer Center. The prognostic factors were analyzed with Cox proportional hazard models.

RESULTS: GSC tended to occur within 25 years following the primary surgery, when the initial disease is benign, whereas it primarily occurred within the first 15 years post-operation for gastric cancer. Patients with regular follow-up after primary surgery had a better survival rate. The multivariate Cox regression analysis revealed that Borrmann type I/II (HR = 3.165, 95%CI: 1.055-9.500, P = 0.040) and radical resection (HR = 1.780, 95%CI: 1.061-2.987, P = 0.029) were independent prognostic factors for GSC. The overall 1-, 3-, and 5-year survival rates of the 92 patients were 78.3%, 45.6% and 27.6%, respectively. The 1-, 3-, and 5-year survival rates of those undergoing radical resection were 79.3%, 52.2%, and 37.8%, respectively. The 5-year survival rates for stages I, II, III, and IV were 85.7%, 47.4%, 16.0%, and 13.3%, respectively (P = 0.005).

CONCLUSION: The appearance of GSC occurs sooner in patients with primary malignant cancer than in patients with a primary benign disease. Therefore, close follow-up is necessary. The overall survival of patients with GSC is poor, and curative resection can improve their prognosis.

Increased incidence of secondary gastric neoplasia in patients with early gastric cancer and coexisting gastric neoplasia at the initial endoscopic evaluation

BACKGROUND AND AIMS

Multiple synchronous gastric cancers are found in up to 14% of affected patients. The aim of this study was to determine the incidence of secondary gastric neoplasia including missed synchronous gastric neoplasia in this patient group compared with that after a single cancer resection.

PATIENTS AND METHODS

Four hundred and forty patients who underwent endoscopic resection for early gastric cancer (EGC) were divided into two groups: those with or without synchronous gastric neoplasia at the initial assessment. Secondary gastric neoplasia was defined as missed synchronous gastric neoplasia or metachronous gastric neoplasia. We compared the clinicopathological characteristics and the incidence of secondary gastric neoplasia between the two groups.

RESULTS

Synchronous gastric neoplasias were found in 34 patients (7.7%) at the initial endoscopic examination of EGC. Secondary gastric neoplasias were found in 67 of 440 patients (15.2%) during the follow-up period (median 24.0 months). The incidence of secondary gastric neoplasia and missed synchronous gastric neoplasia was higher in those patients with synchronous gastric neoplasia than in those with a solitary EGC at the initial treatment (P<0.01). Between the two groups, the risk of the secondary neoplasia was significantly higher within 1 year after endoscopic resection (P<0.01), but not after 1 year (P=0.20).

CONCLUSION

EGC with synchronous gastric neoplasia at the initial endoscopic examination was associated with an increased risk of secondary gastric neoplasia. These patients should be evaluated carefully with a shorter interval after the initial treatment.

Efficacy of endoscopic submucosal dissection for cancer of the operated stomach

PURPOSE

Cancer can develop in the operated stomach after partial gastrectomy and in the reconstructed gastric tube after surgery for esophageal cancer. It is considered that endoscopic therapy is more safe and suitable for the early gastric cancer developed in such stomach than operation. We investigated the efficacy of endoscopic submucosal dissection (ESD) for cancer of the operated stomach.

METHODS

Subjects were 669 gastric cancer patients who underwent ESD: 22 patients (23 lesions) had surgically altered gastric anatomy, whereas 647 patients (727 lesions) had normal gastric anatomy. In the altered gastric anatomy group, 13 patients, 6 patients, and 3 patients had previously undergone distal gastrectomy, gastric tube reconstruction, and proximal gastrectomy, respectively. Rates of complete en bloc resection and curative resection were compared between the two groups. Influence of an anastomotic site and/or a suture line on ESD outcomes was examined in the altered gastric anatomy group.

RESULTS

The rate of complete en bloc resection by ESD was 82.6% (19/23 lesions) in the altered gastric anatomy group and 92.3% (671/727 lesions) in the normal gastric anatomy group. The rate of curative resection and incident rates of complications were not significantly different between the groups. In the altered gastric anatomy group, the rate of complete en bloc resection was significantly lower when a lesion had spread across an anastomotic site and/or a suture line (P = 0.0372). Furthermore, duration of ESD was significantly longer (P = 0.0276), and resection efficiency was significantly lower (13 mm(2)/min, P = 0.0283), when treating lesions with an anastomotic site and/or a suture line than when treating isolated lesions.

CONCLUSIONS

Outcome of ESD for cancer of the operated stomach compares with that in normal stomach anatomy. Anastomotic site/suture line within a lesion influenced the ESD procedure.

Efficacy of endoscopic submucosal dissection for cancer of the operated stomach

PURPOSE

Cancer can develop in the operated stomach after partial gastrectomy and in the reconstructed gastric tube after surgery for esophageal cancer. It is considered that endoscopic therapy is more safe and suitable for the early gastric cancer developed in such stomach than operation. We investigated the efficacy of endoscopic submucosal dissection (ESD) for cancer of the operated stomach.

METHODS

Subjects were 669 gastric cancer patients who underwent ESD: 22 patients (23 lesions) had surgically altered gastric anatomy, whereas 647 patients (727 lesions) had normal gastric anatomy. In the altered gastric anatomy group, 13 patients, 6 patients, and 3 patients had previously undergone distal gastrectomy, gastric tube reconstruction, and proximal gastrectomy, respectively. Rates of complete en bloc resection and curative resection were compared between the two groups. Influence of an anastomotic site and/or a suture line on ESD outcomes was examined in the altered gastric anatomy group.

RESULTS

The rate of complete en bloc resection by ESD was 82.6% (19/23 lesions) in the altered gastric anatomy group and 92.3% (671/727 lesions) in the normal gastric anatomy group. The rate of curative resection and incident rates of complications were not significantly different between the groups. In the altered gastric anatomy group, the rate of complete en bloc resection was significantly lower when a lesion had spread across an anastomotic site and/or a suture line (P = 0.0372). Furthermore, duration of ESD was significantly longer (P = 0.0276), and resection efficiency was significantly lower (13 mm(2)/min, P = 0.0283), when treating lesions with an anastomotic site and/or a suture line than when treating isolated lesions.

CONCLUSIONS

Outcome of ESD for cancer of the operated stomach compares with that in normal stomach anatomy. Anastomotic site/suture line within a lesion influenced the ESD procedure.

Gastric stump carcinoma after distal subtotal gastrectomy for early gastric cancer: experience of 541 patients with long-term follow-up

BACKGROUND

Gastric stump carcinoma (GSC) has been studied after primary gastrectomy for benign disease but few studies have evaluated its correlation with gastric cancer.

PATIENTS

We assessed 541 patients submitted to subtotal gastrectomy for early gastric cancer at least 15 years ago.

RESULTS

GSC was diagnosed in 16 (2.9%) patients, giving a 4% cumulative risk of GSC 20 years after surgery. Diagnosis was made within 5 years of surgery in 10 patients and after 8 years in 6 cases. GSC occurred in 13/470 (2.8%) patients submitted to Billroth 2 reconstruction, 2/30 (6.7%) patients who underwent Billroth 1, and 1/41 (2.4%) patients after Roux-en-Y reconstruction. Significant risk factors observed for GSC were histologic type and sex. Other synchronous or metachronous extragastric tumors were registered in 56 (11.2%) patients.

CONCLUSIONS

The risk of GSC was low, even 20 years after subtotal gastrectomy for early gastric cancer. Lauren intestinal histotype and male sex were frequently associated with GSC. No correlation was observed between GSC and reconstruction technique or multifocality. Clinically speaking, GSC could be considered a subset of gastric cancer.

Management of Helicobacter pylori infection after gastric surgery

The Maastricht IV/Florence Consensus Report and the Second Asia-Pacific Consensus Guidelines strongly recommend eradication of Helicobacter pylori (H. pylori) in patients with previous gastric neoplasia who have undergone gastric surgery. However, the guidelines do not mention optimal timing, eradication regimens, diagnostic tools, and follow-up strategies for patients undergoing gastrectomy and do not indicate if eradication of H. pylori reduces the risk of marginal ulcer or stump cancer in the residual stomach after gastrectomy. The purpose of this review is to provide an update which may help physicians to properly manage H. pylori infection in patients who have undergone gastric surgery. This review focuses on (1) the microenvironment change in the stomach after gastrectomy; (2) the phenomenon of spontaneous clearance of H. pylori after gastrectomy; (3) the effects of H. pylori on gastric atrophy and intestinal metaplasia after gastrectomy; (4) incidence and clinical features of ulcers developing after gastrectomy; (5) does eradication of H. pylori reduce the risk of gastric stump cancer in the residual stomach? (6) does eradication of H. pylori reduce the risk of secondary metachronous gastric cancer in the residual stomach? and (7) optimal timing and regimens for H. pylori eradication, diagnostic tools and follow-up strategies for patients undergoing gastrectomy.

Characteristics of metachronous gastric tumors after endoscopic submucosal dissection for gastric intraepithelial neoplasms

Background. Recently, endoscopic submucosal dissection (ESD) has become a standard treatment method for early gastric cancer and concurrent stomach preservation. However, metachronous recurrences have become a major problem. We evaluated the incidence and clinicopathologic features of and examined the risk factors for metachronous gastric tumors. Methods. A total of 357 patients who underwent ESD for gastric tumors (245 early gastric cancers and 112 adenomas) and were followed up for more than 12 months without recurrence within the first 12 months were enrolled. We investigated the incidence and clinicopathologic features of metachronous tumors after ESD. We also analyzed the potential risk factors for metachronous tumors using the Kaplan-Meier method and Cox's proportional hazards model. Results. The annual incidence of metachronous tumors after ESD was 2.4%. The median period until discovery after initial ESD was 26.0 months, and the median observation period was 52.6 months. Male patients developed metachronous tumors more frequently (P = 0.04), and the hazard ratio of female to male patients was 0.36 (95% confidence interval: 0.11–0.89). Conclusions. Patients with a previous history of gastric tumors have a high risk of subsequent gastric tumor development and male patients should be carefully followed up after ESD for gastric tumor.

Incidence of metachronous gastric cancer in the remnant stomach after synchronous multiple cancer surgery

BACKGROUND

In the preoperative evaluation for gastric cancer, high-resolution endoscopic technologies allow us to detect small accessory lesions. However, it is not known if the gastric remnant after partial gastrectomy for synchronous multiple gastric cancers has a greater risk for metachronous cancer. The purpose of this study was to determine the incidence of metachronous cancer in this patient subset compared with that after solitary cancer surgery.

METHODS

Data on a consecutive series of 1,281 patients gastrectomized for early gastric cancer from 1991 to 2007 were analyzed retrospectively. The 715 gastric remnants after distal gastrectomy were periodically surveyed by endoscopic examination in Shikoku Cancer Center. Among those surveyed cases, 642 patients were pathologically diagnosed with solitary lesion (SO group) and 73 patients with synchronous multiple lesions (MU group) at the time of the initial surgery.

RESULTS

In the follow-up period, 15 patients in the SO group and 3 patients in the MU group were diagnosed as having metachronous cancer in the gastric remnant. The cumulative 4-year incidence rate was 1.9 % in the SO group and 5.5 % in the MU group. The difference did not reach the significant level by the log-rank test.

CONCLUSIONS

The incidence of metachronous cancer is higher after multiple cancer surgery; however, the difference is not statistically significant.

Laparoscopic total gastrectomy for remnant gastric cancer: feasibility study

BACKGROUND

The benefits and feasibility of laparoscopic surgery for remnant gastric cancer are still unclear. The purpose of this study was to describe the detailed procedure and to evaluate the clinical short-term outcomes of laparoscopic total gastrectomy (LTG) compared with open total gastrectomy (OTG) for remnant gastric cancer (RGC).

METHODS

Of 1,247 consecutive patients who underwent gastrectomy for gastric cancer in our department at Kyushu University Hospital from January 1996 to May 2012, 22 patients who underwent successful curative resection of RGC with precise nodal dissection were enrolled in this study. Twelve patients underwent LTG and the remaining ten patients underwent OTG. We analyzed the clinical short-term outcomes of LTG and compared the results between LTG and OTG groups to evaluate the safety and feasibility of LTG.

RESULTS

Twelve patients with RGC successfully underwent LTG without open conversion and morbidity. The mean operation time of LTG, 362.3 ± 68.4 min, was significantly longer than that of OTG (p = 0.0176), but the mean blood loss of LTG, 65.8 ± 62 g, was smaller than that of OTG (p < 0.01). The mean postoperative times to resumption of water and food intake were significantly shorter in the LTG group than in the OTG group (p < 0.01). The overall 3-year survival rate was comparable between the LTG and OTG groups (77.8 vs. 100 %; p = 0.9406).

CONCLUSIONS

This study shows that LTG is a feasible and reliable procedure for the treatment of RGC in terms of short-term outcomes.

Randomised clinical trial: the effects of Helicobacter pylori eradication on glandular atrophy and intestinal metaplasia after subtotal gastrectomy for gastric cancer

BACKGROUND

Helicobacter pylori eradication is recommended for early gastric cancer (GC) patients after resection.

AIM

To evaluate whether H. pylori eradication improves glandular atrophy and intestinal metaplasia (IM) in GC patients undergoing subtotal gastrectomy.

METHODS

This randomised, double-blind trial was performed in tertiary care setting. Distal GC patients with H. pylori infection were randomised to receive proton pump inhibitor-based triple therapy or placebo. The histology was evaluated using the updated Sydney system before and at 36 months after surgery. The endpoints were the comparison of atrophy and IM score changes between the allocated groups and according to final H. pylori status.

RESULTS

Overall, 190 patients were randomised to the treatment and placebo groups. For lesser curvature of the corpus, mean atrophy and IM scores did not differ between the treatment and placebo groups. However, the H. pylori-eradicated patients had significantly lower mean scores than the H. pylori-persistent patients regarding atrophy (0.55 ± 0.95 vs. 1.05 ± 1.10 respectively; P = 0.0046) and IM (0.66 ± 0.99 vs. 1.05 ± 1.16 respectively; P = 0.0284). The percentage change from baseline was more marked in the H. pylori-negative than in the H. pylori-positive groups (-58.6% vs. -11.0% for atrophy and -60.5% vs. -35.6% for IM respectively). For greater curvature, mean atrophy score was lower in the H. pylori-negative group than in the H. pylori-positive group (0.14 ± 0.50 vs. 0.41 ± 0.75 respectively; P = 0.0281). The percentage change was -36.4% vs. 86.3%.

CONCLUSION

Helicobacter pylori eradication in GC patients is beneficial, as reflected by lower scores of atrophy and IM at 36 months after subtotal gastrectomy. (ClinicalTrials.gov number, NCT01002443).

Long-term outcome after proximal gastrectomy with jejunal interposition for gastric cancer compared with total gastrectomy

BACKGROUND

Proximal gastrectomy (PG) has been widely accepted as treatment for early gastric cancer located in the upper third of the stomach. Reconstruction by jejunal interposition has been known to reduce reflux esophagitis for PG patients. The aim of this study was to compare the long-term outcomes of patients who underwent PG with jejunal interposition with those treated by total gastrectomy (TG).

METHODS

Data on 102 cases of PG with jejunal interposition and 49 cases of TG with Roux-Y reconstruction for gastric cancer were analyzed retrospectively in terms of overall survival, weight maintenance, anemia and nutritional status, and endoscopic findings.

RESULTS

Median follow-up time was 59 months in the both groups. There was no significant difference in the overall 5-year survival rate between the PG group (94%) and the TG group (84%). The PG group showed significantly better body weight maintenance at the first year. The laboratory blood tests showed that the PG group had a significantly better red blood cell count and hemoglobin and hematocrit levels at the second and third year. However, postoperative endoscopic surveillance detected reflux esophagitis (3%), peptic ulcer (9%), and metachronous gastric cancer (5%) in the PG group.

CONCLUSIONS

Proximal gastrectomy maintains comparable oncological radicality to TG and is preferred over TG in terms of preventing postoperative anemia. However, periodic endoscopic follow-up is necessary to monitor the upper gastrointestinal tract.

A Caliber Persistent Artery (Dieulafoy's Lesion) which is Associated with an Early-Stage Gastric Stump Cancer Following a Distal Gastrectomy

A 75-years old man was hospitalized with symptoms which suggested gastric cancer. Thirty-eight years ago, he had undergone a Billroth-II gastric reconstruction for a peptic ulcer. At the present admission, he had presented with an eight-month history of recurrent haematemesis, epigastric pain, vomiting, and fatigue. The emergent endoscopy showed a type 0-IIc (superficial depressed) early gastric stump cancer in the anastomotic area and total removal of the gastric remnant and the jejunal segment was performed. The histological examination of the surgical specimen showed a gastric adenocarcinoma that invaded the mucosa and the submucosa, without lymph node metastases (pT1bN0 stage). Besides the tumour, enlarged vessels were observed in the submucosa and the muscularis propria, some of which were thrombotic. The surrounding normal gastric wall also presented submucosal oversized vascular spaces, some of which were protruding through the muscularis mucosae in the mucosal layer. Based on these characteristics and the recurrent haematemesis, a final diagnosis of early gastric stump carcinoma which was associated with Dieulafoy's lesion was made. This association has not yet been reported in the literature and it allowed us to diagnose the gastric stump cancer in a very early stage.

Follow-up: the evidence

There is currently no consensus on the best strategy for the follow-up of patients who have undergone surgical treatment with curative intent for gastric cancer. The wide variation in recommendations for surveillance among international experts and hospital schedules clearly reflects a lack of an established body of evidence on this subject. Consequently, most of the international guidelines aimed at early detection of disease recurrence gloss over details concerning the mode, duration, and intensity of surveillance since they cannot be based on an acceptable grade of recommendation. Very few report anything other than the detection of recurrences or death as the primary endpoints, and, given the poor survival of patients with recurrent gastric cancer, the prognostic effect of early detection seems doubtful. In recent years, an increasing focus on evidence-based medicine, which has coincided with a growing concern about costs and efficiency in medicine, has caused a reevaluation of most surveillance practices. In this paper, we review and discuss the current body of evidence and follow-up practices after curative resection of gastric cancer.

Clinical characteristics of gastric cancer in patients with familial adenomatous polyposis

Familial adenomatous polyposis is an autosomal dominant hereditary disease leading to the development of numerous colorectal polyps with malignant potential. Extra-colonic neoplasms are observed often in patients with familial adenomatous polyposis, but clinical characteristics of gastric cancer associated with familial adenomatous polyposis are not well understood. We studied the clinical characteristics of five Japanese patients who developed gastric cancer after undergoing colectomy for familial adenomatous polyposis. Gastric cancer was found on gastroduodenal endoscopy performed during postoperative follow-up in all five patients. Mean ages at the time of colectomy and at the time of diagnosis of gastric cancer were 39.2 and 58 years, respectively. Importantly, gastric fundic gland polyps were undetectable in these five patients. The mean duration between colectomy and diagnosis of gastric cancer was more than 20 years in three of five patients (mean: 19 years and 1 month). Cancers were multiple in three of five patients. Two patients developed metachronous gastric cancer in the gastric remnant. All five patients presented with well to moderately differentiated adenocarcinoma; four of the five patients were stage IA. Characteristics of the gastric cancer with familial adenomatous polyposis include a long duration between occurrence of gastric cancer and colectomy, metachronous cancers, multicentric lesions, and a high rate of well to moderately differentiated adenocarcinoma. Long-term and periodic gastroduodenal surveillance endoscopy is recommended for patients with FAP who underwent colectomy.