Recurrence of gastric cancer in the jejunal pouch after completion gastrectomy

Intragastric free cancer cells may be attached to automatic staplers during anastomosis in patients with gastric cancer

BACKGROUND

Automatic staplers are often used to reconstruct the digestive tract during surgeries for gastric cancer. Intragastric free cancer cells adhering to automatic staplers may come in contact with the laparoscopic port area and progress to port site recurrence. This study aimed to investigate the presence/absence of cancer cells adhering to automatic staplers during gastric cancer surgery using cytological examinations. We further determined the positive predictive clinicopathological factors and clinical implications of free cancer cells attached to automatic staplers.

METHODS

This study included 101 patients who underwent distal gastrectomy for gastric cancer. Automatic staplers used for anastomosis in gastric cancer surgeries were shaken in 150 ml of saline solution to collect the attached cells. Papanicolaou stains were performed. We tested the correlation between cancer-cell positivity and clinicopathological factors to identify risk factors arising from the presence of attached cancer cells to the staplers.

RESULTS

Based on the cytology, cancer cells were detected in 7 of 101 (6.9%) stapler washing fluid samples. Univariate analysis revealed that circular staplers, type 1 tumors, and positive lymph nodes were significantly associated with higher detection of free cancer cells adhering to staplers. No significant differences in other factors were detected. Of the seven cases with positive cytology, one developed anastomotic recurrence.

CONCLUSIONS

Exfoliated cancer cells adhered to the automatic staplers used for anastomoses in 6.9% of the staplers used for distal gastrectomies in patients with gastric cancer. Staplers used for gastric cancer surgeries should be handled carefully.

Recurrence of gastric cancer caused by implantation of tumor cells after curative endoscopic submucosal dissection

A 93-year-old female underwent curative endoscopic submucosal dissection (ESD) for intramucosal gastric cancer (70 mm in diameter) in the antrum. The lesion showed an irregularly villous structure covered with mucus. En bloc resection was performed. The large resected specimen induced a longitudinal laceration on the right wall of the esophagogastric junction (EGJ) during retrieval. Unavoidably, we segmented the specimen in the stomach to facilitate retrieval. Histopathological evaluation of the specimen revealed well-to-moderately differentiated tubular and papillary adenocarcinoma. A new elevated lesion (15 mm in diameter) was found at the gastric side of the EGJ laceration scar 6 months after the first ESD, necessitating a second resection with ESD. Endoscopic, histopathological, and immunohistochemical features of the new lesion resembled those of the antral lesion. We assessed the new lesion as a recurrence of cancer caused by implantation of tumor cells in the mucosal laceration after ESD.We experienced recurrence caused by implantation of tumor cells in a mucosal laceration after curative gastric ESD. Endoscopist should be aware of the risk of implantation after gastric ESD.

Recurrence of Gastric Cancer in the Jejunum Close to the Anastomotic Site after Total Gastrectomy

A 61-year-old man underwent total gastrectomy with esophago-jejunostomy for Borrmann type I gastric cancer. Postoperative intra-abdominal abscess made the patient unable to receive adjuvant chemotherapy. Only 23 weeks after operation, the patient developed melena and anemia, leading to the diagnosis of recurrence in the jejunum close to the anastomotic site. The patient received salvage resection of the recurrence. Pathological study showed that the tumor was composed of atypical cells similar to those of the primary gastric cancer. Normal jejunal mucosa was observed between the esophagus and the recurrent tumor. We judged that exfoliation of the gastric cancer cells caused the recurrence due to both the very short disease-free interval and pathological findings. Surgeons should pay attention to this type of recurrence especially for Borrmann type I gastric cancer. In addition to the adjuvant chemotherapy, gastric irrigation using distilled water during the operation seems to be a feasible measure to prevent this type of recurrence.

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer

BACKGROUND

Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.

METHODS

We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.

RESULTS

Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.

CONCLUSION

Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

An autopsy case of primary jejunal pouch cancer which protruded from the abdominal wall 14 years after total gastrectomy for gastric cancer

Adenocarcinoma which develops in the jejunal pouch has rarely been reported, but most of such cases tend to be a recurrence of primary cancer due to the presence of residual or disseminated cancer cells. Primary jejunal pouch cancer is extremely rare. We experienced an autopsy case of primary jejunal pouch cancer which occurred 14 years after proximal gastrectomy for gastric cancer. A female in her late 60s was admitted because of hypoglycemia with liver dysfunction. She underwent total gastrectomy for fundic cancer and had been reconstructed by jejunal pouch interposition 14 years prior to this presentation. Hypoglycemia recovered by nutritional support. Computed tomography demonstrated severe fatty liver and liver biopsy proved non-alcoholic steatohepatitis, which was supposed to have been induced by malnutrition. Screening esophagogastroduodenoscopy (EGD) revealed no tumorous lesions in the jejunal pouch at this time. However, her anorexia gradually progressed and the symptom of bowel obstruction appeared. EGD performed 5 months after the previous EGD revealed adenocarcinoma which extended from the anastomosis of the interposed jejunum. Then liver metastasis developed and jejunal pouch cancer invaded the abdominal wall and protruded with ulcer formation. Finally, the patient died of malnutrition. An autopsy revealed adenocarcinoma which had developed in the interposed jejunal pouch and protruded through the abdominal wall accompanied with lung and liver metastasis. We herein describe this rare case of primary interposed jejunal pouch cancer and discuss our findings including a review of the pertinent literature.

Heterochronous Suture Line Recurrences in the Jejunal Pouch following Total Gastrectomy for Stage II Gastric Cancer: A Case Report and Literature Review

We report the case of a 65-year-old male who developed heterochronous local recurrences of gastric cancer in the jejunal pouch (J-pouch) four times after total gastrectomy. He underwent total gastrectomy, J-pouch, and Roux-en-Y reconstruction for stage II gastric cancer in 2005. Four local recurrences appeared on the esophago-jejunal anastomosis, the suture line within the pouch, the esophago-jejunal anastomosis, and the anastomosis between the jejunum and Y-loop, which were resected by partial excision or endoscopic submucosal dissection. Suture line recurrence of gastric cancer is rare. The common features for each recurrence included the surgically negative resection margins, observation of the same histopathological subtype, absence of remote metastasis or peritoneal seeding, and the recurrence on the anastomotic suture line, suggesting that the cause of recurrence was the implantation of exfoliated cancer cells probably in the suture line. However, there is no established procedure for preventing implantation recurrence currently, the effectiveness of lumen lavage is suggested.

Gastric washing by distilled water can reduce free gastric cancer cells exfoliated into the stomach lumen

PURPOSE

Intragastric free cancer cells in patients with gastric cancer have rarely been studied. The purpose of this study was to investigate the detection rate of intragastric free cancer cells in gastric washes using two types of solutions during endoscopic examination. We further clarified risk factors affecting the presence of exfoliated free cancer cells.

METHODS

A total of 175 patients with gastric cancer were enrolled. Lactated Ringer's solution (N = 89) or distilled water (DW; N = 86) via endoscopic working channel was sprayed onto the tumor surface, and the resultant fluid was collected for cytological examination. We compared the cancer-cell positivity rate between the two (Ringer and DW) groups. We also tested the correlation between cancer-cell positivity and clinicopathological factors in the Ringer group to identify risk factors for the presence of exfoliated cancer cells.

RESULTS

The cancer-cell positivity rate was significantly higher in the Ringer group than that in the DW group (58 vs 6%). Cytomorphology in the Ringer group was well maintained, but not in the DW group. The larger tumor size (≥ 20 mm) and positive lymphatic involvement were significant risk factors of exfoliated free cancer cells.

CONCLUSIONS

Cancer cells can be highly exfoliated from the tumor surface into the gastric lumen by endoscopic irrigation in large gastric cancer with lymphatic involvement. Gastric washing by DW can lead to cytoclasis of free cancer cells; therefore, it may minimize the possibility of cancer-cell seeding in procedures carrying potential risks of tumor-cell seeding upon transluminal communication, such as endoscopic full-thickness resection and laparoscopy-endoscopy cooperative surgery.

Clinical outcomes of recurrent gastric cancer detected by upper endoscopy after curative total gastrectomy

BACKGROUND/AIMS

Endoscopically detected tumor recurrence after curative total gastrectomy is very rare. We reviewed the clinicopathological and endoscopic findings together with the clinical outcomes of these patients.

METHODS

Seventeen patients with recurrent gastric cancer detected by upper gastrointestinal endoscopy who underwent curative total gastrectomy between January 1990 and May 2011 at the Asan Medical Center were analyzed retrospectively.

RESULTS

Of the 17 patients, 5 were resectable at the time of diagnosis of recurrence and 12 were unresectable. The median interval between total gastrectomy and diagnosis of recurrence was 20.2 months (interquartile range 12.4-42.1 months). The tumors were located in the anastomotic area in 8 patients, in the proximal part of the afferent or efferent loop in 7, and in the stump of the afferent loop in 2 patients. With regard to the endoscopic findings, a mass was found in 8 cases, an ulcer in 2, stricture in 4, and nodularities in 3. Operations were performed in 3 patients, chemotherapy in 10 (including 2 receiving adjuvant chemotherapy), and conservative management in 6. Fourteen patients died from progression of the disease and the median survival period from recurrence for all 17 patients was 5.3 months (interquartile range 1.2-7.7 months).

CONCLUSIONS

Local recurrence of gastric cancer detected by upper gastrointestinal endoscopy after curative total gastrectomy has a poor prognosis.

Reconstruction with Jejunal Pouch after Gastrectomy for Gastric Cancer

The construction of a gastric substitute pouch after gastrectomy for gastric cancer has been proposed to help ameliorate postprandial symptoms and nutritional performance. Adequate reconstruction after gastrectomy is an important issue, because postoperative patient quality of life (QOL) primarily depends on the reconstruction method. To this end, jejunal pouch (JP) reconstructions were developed to improve the patient's eating capacity and QOL by creating large reservoirs with improved reflux barriers to prevent esophagitis and residual gastritis. It is important that such reconstructions also preserve blood and extrinsic neural integrity for maintaining pouch function, because JP motility is associated directly with QOL. Some problems remain to be resolved with the JP reconstructions method including gastrointestinal motility, which plays a major role in food transfer, digestion, and absorption of nutrients. Further studies including basic research and larger prospective randomized control trials are also needed to obtain definitive results. With persistent innovations in surgical techniques, JP after gastrectomy could become a safe and preferable reconstructive modality to improve patient QOL after gastrectomy.

Recurrence of gastric cancer in the jejunal stump after radical total gastrectomy

This is a very rare case of the recurrence of gastric cancer in the jejunal stump after radical total gastrectomy with Roux-en-Y reconstruction. In January 2008, a 65-year-old man underwent radical total gastrectomy with Roux-en-Y reconstruction for stage IB gastric cancer of the upper body. At a follow-up in December 2011, the patient had a recurrence of gastric cancer on gastroduodenal fibroscopy. The gastroduodenal fibroscopic biopsy specimens show a well-differentiated tubular adenocarcinoma. Computed tomography showed no lymphadenopathy or hepatic metastases. At laparotomy, there was a tumor in the jejunal stump involving the pancreatic tail and spleen. Therefore, the patient underwent jejunal pouch resection, distal pancreatectomy and splenectomy. The patient was diagnosed with gastric cancer on histopathological examination.

Handsewn versus stapled gastroduodenostomy in patients with gastric cancer: long-term follow-up of a randomized clinical trial

BACKGROUND

The role of circular staplers in gastroduodenostomy during subtotal gastrectomy for gastric cancer has not been defined clearly.

METHODS

A randomized clinical trial included patients with gastric cancer who underwent subtotal gastrectomy with either stapled (99 patients) or handsewn gastroduodenostomy (98 patients). The anastomosis time and postoperative outcomes in the two groups were compared.

RESULTS

Performance of stapled gastroduodenostomy was significantly quicker than handsewn gastroduodenostomy. There were no significant differences between the groups in postoperative course, morbidity and mortality rates, survival rate, and recurrence pattern.

CONCLUSIONS

Stapled gastroduodenostomy with a circular stapler can reduce the anastomosis time with relative safety.