Gastric carcinoma

Abdominal drainage versus no drainage post-gastrectomy for gastric cancer

BACKGROUND

Gastrectomy remains the primary therapeutic method for resectable gastric cancer. Thought of as an important measure to reduce post-operative complications and mortality, abdominal drainage has been used widely after gastrectomy for gastric cancer in previous decades. The benefits of abdominal drainage have been questioned by researchers in recent years.

OBJECTIVES

The objectives of this review were to assess the benefits and harms of routine abdominal drainage post-gastrectomy for gastric cancer.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases (UGPD) Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2014, Issue 11); MEDLINE (via PubMed) (1950 to November 2014); EMBASE (1980 to November 2014); and the Chinese National Knowledge Infrastructure (CNKI) Database (1979 to November 2014).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing an abdominal drain versus no drain in patients who had undergone gastrectomy (not considering the scale of gastrectomy and the extent of lymphadenectomy); irrespective of language, publication status, and the type of drain. We excluded RCTs comparing one drain with another.

DATA COLLECTION AND ANALYSIS

We adhered to the standard methodological procedures of The Cochrane Collaboration. From each included trial, we extracted the data on the methodological quality and characteristics of the participants, mortality (30-day mortality), re-operations, post-operative complications (pneumonia, wound infection, intra-abdominal abscess, anastomotic leak, drain-related complications), operation time, length of post-operative hospital stay, and initiation of a soft diet. For dichotomous data, we calculated the risk ratio (RR) and 95% confidence interval (CI). For continuous data, we calculated mean difference (MD) and 95% CI. We tested heterogeneity using the Chi(2) test. We used a fixed-effect model for data analysis with RevMan software, but we used a random-effects model if the P value of the Chi(2) test was less than 0.1.

MAIN RESULTS

We included four RCTs involving 438 patients (220 patients in the drain group and 218 in the no-drain group). There was no evidence of a difference between the two groups in mortality (RR 1.73, 95% CI 0.38 to 7.84); re-operations (RR 2.49, 95% CI 0.71 to 8.74); post-operative complications (pneumonia: RR 1.18, 95% CI 0.55 to 2.54; wound infection: RR 1.23, 95% CI 0.47 to 3.23; intra-abdominal abscess: RR 1.27, 95% CI 0.29 to 5.51; anastomotic leak: RR 0.93, 95% CI 0.06 to 14.47); or initiation of soft diet (MD 0.15 days, 95% CI -0.07 to 0.37). However, the addition of a drain prolonged the operation time (MD 9.07 min, 95% CI 2.56 to 15.57) and post-operative hospital stay (MD 0.69 day, 95% CI 0.18 to 1.21) and led to drain-related complications. Additionally, we should note that 30-day mortality and re-operations are very rare events and, as a result, very large numbers of patients would be required to make any sensible conclusions about whether the two groups were similar. The overall quality of the evidence according to the GRADE approach was 'very low' for mortality and re-operations, and 'low' for post-operative complications, operation time, and post-operative length of stay.

AUTHORS' CONCLUSIONS

We found no convincing evidence to support routine drain use after gastrectomy for gastric cancer.

Abdominal drainage versus no drainage post gastrectomy for gastric cancer

BACKGROUND

Gastrectomy remains the primary therapeutic method for resectable gastric cancer. Thought of as an important measure to reduce post-operative complications and mortality, abdominal drainage was used widely after gastrectomy for gastric cancer in previous decades. The benefits of abdominal drainage have been questioned by researchers in recent years.

OBJECTIVES

The objectives of this review were to access the benefits and harms of routine abdominal drainage post gastrectomy for gastric cancer.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Central/CCTR) in The Cochrane Library (2010, Issue 10), including the Specialised Registers of the Cochrane Upper Gastrointestinal and Pancreatic Diseases (UGPD) Group; MEDLINE (via Pubmed, 1950 to October, 2010); EMBASE (1980 to October, 2010); and the Chinese National Knowledge Infrastructure (CNKI) Database (1979 to October, 2010).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing abdominal drain versus no drain in patients who had undergone gastrectomy (not considering the scale of gastrectomy and the extent of lymphadenectomy; irrespective of language, publication status, and the type of drain). We excluded RCTs comparing one drain with another.

DATA COLLECTION AND ANALYSIS

From each trial, we extracted the data on the methodological quality and characteristics of the included studies, mortality (30-day mortality), re-operations, post-operative complications (pneumonia, wound infection, intra-abdominal abscess, anastomotic leak, drain-related complications), operation time, length of post-operative hospital stay and initiation of soft diet. For dichotomous data, we calculated the risk ratio (RR) and 95% confidence intervals (CI). For continuous data, we calculated mean differences (MD) and 95% CI. We tested heterogeneity using the Chi(2) test. We used a fixed-effect model for data analysis with RevMan software but we used a random-effects model if the P value of the Chi(2) test was less than 0.1.

MAIN RESULTS

We included four RCTs involving 438 patients (220 patients in the drain group and 218 in the no-drain group).There was no evidence of a difference between the two groups in mortality (RR 1.73, 95% CI 0.38 to 7.84); re-operations (RR 2.49, 95% CI 0.71 to 8.74); post-operative complications (pneumonia: RR 1.18, 95% CI 0.55 to 2.54; wound infection: RR 1.23, 95% CI 0.47 to 3.23; intra-abdominal abscess: RR 1.27, 95% CI 0.29 to 5.51; anastomotic leak: RR 0.93, 95% CI 0.06 to 14.47); and initiation of soft diet (MD 0.15 day, 95% CI -0.07 to 0.37). However, the addition of a drain prolonged the operation time (MD 9.07 min, 95% CI 2.56 to 15.57) and post-operative hospital stay (MD 0.69 day, 95% CI 0.18 to 1.21) and lead to drain-related complications. Additionally, we should note that 30-day mortality and re-operations are very rare events and, as a result, very large numbers of patients would be required to make any sensible conclusions about whether the two groups were similar. The overall quality of the evidence according to the GRADE approach was "Very Low" for mortality and re-operations, and "Low" for post-operative complications, operation time, and post-operative length of stay.

AUTHORS' CONCLUSIONS

We found no convincing evidence to support routine drain use after gastrectomy for gastric cancer.

Extensive analysis of D7S486 in primary gastric cancer supports TESTIN as a candidate tumor suppressor gene

BACKGROUND

High frequency of loss of heterozygosity (LOH) was found at D7S486 in primary gastric cancer (GC). And we found a high frequency of LOH region on 7q31 in primary GC from China, and identified D7S486 to be the most frequent LOH locus. This study was aimed to determine what genes were affected by the LOH and served as tumor suppressor genes (TSGs) in this region. Here, a high-throughput single nucleotide polymorphisms (SNPs) microarray fabricated in-house was used to analyze the LOH status around D7S486 on 7q31 in 75 patients with primary GC. Western blot, immunohistochemistry, and RT-PCR were used to assess the protein and mRNA expression of TESTIN (TES) in 50 and 140 primary GC samples, respectively. MTS assay was used to investigate the effect of TES overexpression on the proliferation of GC cell lines. Mutation and methylation analysis were performed to explore possible mechanisms of TES inactivation in GC.

RESULTS

LOH analysis discovered five candidate genes (ST7, FOXP2, MDFIC, TES and CAV1) whose frequencies of LOH were higher than 30%. However, only TES showed the potential to be a TSG associated with GC. Among 140 pairs of GC samples, decreased TES mRNA level was found in 96 (68.6%) tumor tissues when compared with matched non-tumor tissues (p < 0.001). Also, reduced TES protein level was detected in 36 (72.0%) of all 50 tumor tissues by Western blot (p = 0.001). In addition, immunohistochemical staining result was in agreement with that of RT-PCR and Western blot. Down regulation of TES was shown to be correlated with tumor differentiation (p = 0.035) and prognosis (p = 0.035, log-rank test). Its overexpression inhibited the growth of three GC cell lines. Hypermethylation of TES promoter was a frequent event in primary GC and GC cell lines. However, no specific gene mutation was observed in the coding region of the TES gene.

CONCLUSIONS

Collectively, all results support the role of TES as a TSG in gastric carcinogenesis and that TES is inactivated primarily by LOH and CpG island methylation.

Vitamin D stimulates apoptosis in gastric cancer cells in synergy with trichostatin A /sodium butyrate-induced and 5-aza-2'-deoxycytidine-induced PTEN upregulation

Previous studies have shown an anticancer effect of vitamin D, but the mechanisms underlying this action have not been fully explored. Here we show that 1,25-dihydroxyvitamin D3 (VD3, the active form of vitamin D) significantly promoted apoptosis in the undifferentiated gastric cancer cell line HGC-27, and this was accompanied by a concurrent increase in phosphatase and tensin homolog deleted on chromosome 10 (PTEN) expression on VD3 treatment. In contrast, knockdown of PTEN expression by stable transfection of PTEN small interfering RNA greatly decreased the apoptosis rate. We further demonstrated that VD3 induced PTEN expression through vitamin D receptor. In addition, our evidence showed that vitamin D receptor, Egr-1 and p300 induced PTEN expression in a synergistic fashion. Furthermore, we found that the histone deacetylase inhibitors trichostatin A and sodium butyrate and the methylation inhibitor 5-aza-2'-deoxycytidine played important roles in vitamin D-induced apoptosis through PTEN upregulation. The data presented in this article suggest potential benefits of vitamin D in gastric cancer therapies in association with the use of trichostatin A/sodium butyrate and 5-aza-2'-deoxycytidine.

Effects of Wei Chang An on expression of multiple genes in human gastric cancer grafted onto nude mice

AIM: To investigate the expression of multiple genes in Chinese jianpi herbal recipe Wei Chang An (WCA) in human gastric cancer cell line SGC-7901.

METHODS: A human gastric adenocarcinoma cell line SGC-7901 grafted onto nude mice was used as the animal model. The mice were randomly divided into 3 groups, one control and the two representing experimental conditions. Animals in the two experimental groups received either WCA over a 34-d period or 5-fluorouracil (5-FU) over 6-d period starting at 8th d after grafting. Control animals received saline on an identical schedule. Animals were killed 41 d after being grafted. The expression profiles in paired WCA treated gastric cancer samples and the N.S. control samples were studied by using a cDNA array representing 14 181 cDNA clusters. The alterations in gene expression levels were confirmed by Real-time Quantitative polymerase chain reaction (qPCR).

RESULTS: When compared with controls, the average tumor inhibitory rate in WCA group was 44.32% ± 5.67% and 5-FU 47.04% ± 11.33% (P < 0.01, respectively). The average labeling index (LI) for PCNA in WCA group and 5-FU group was significantly decreased compared with the control group. Apoptotic index (AI) was significantly increased to 9.72% ± 4.51% using the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate fluorescence nick end labeling (TUNEL) method in WCA group compared with the controls 2.45% ± 1.37%. 5-FU group was also found to have a significantly increased AI compared with the controls. The expression of cleaved Caspase-3 in WCA group and 5-FU group was significantly increased compared with the control group respectively. There were 45 different expressed sequence tags (ESTs) among the control sample pool and WCA sample pool. There were 24 ESTs up-regulated in WCA samples and 21 ESTs down-regulated. By using qPCR, the expression level of Stat3, rap2 interacting protein x (RIPX), regulator of differentiation 1 (ROD1) and Bcl-2 was lower in WCA group than that in control group respectively. By using SP immunohistochemical method the expression of Phospho-Stat3 (Tyr705) and Bcl-2 in WCA group and 5-FU group was significantly decreased compared with the control group respectively.

CONCLUSION: WCA could inhibit gastric cancer cell SGC-7901 growth in vivo. WCA could induce gastric cancer cell apoptosis and suppress proliferation. Its mechanisms might be involved in the down-regulation of Stat3, RIPX, ROD1 and Bcl-2 gene.

Challenges in the treatment of gastrointestinal tumours

In the last 20 years there have been many breakthroughs in the treatment of gastrointestinal tumours. In this review we have considered the three most important subgroups of gastrointestinal tumours (colorectal, gastric and pancreatic cancer), focusing on the state-of-the-art treatments.