Adenocarcinoma of the gastric cardia

Benefit of a clipping device in use in intestinal bleeding and intestinal leakage

BACKGROUND

The over-the-scope clip (OTSC) system was first used to close the access route in natural orifice transluminal endoscopic surgery and is increasingly used for other indications.

OBJECTIVE

We analyzed the use of the OTSC in intestinal bleeding and in closure of GI tract leaks.

DESIGN

Analysis of a consecutive series of patients.

SETTING

University hospital.

PATIENTS

Nineteen patients (group A: closure of GI leak site, n = 12; group B: complex GI bleeding, n = 7) were retrospectively enrolled in this study. We analyzed outcome and follow-up (6-68 weeks; group A: mean 37 weeks, standard deviation 24) in terms of treatment success (closure of the GI tract leak/durable hemostasis).

INTERVENTION

Endoscopic application of OTSCs.

MAIN OUTCOME MEASUREMENTS

Resolution of leaks, closure of fistula (group A), or stopping bleeding (group B).

RESULTS

In group A, durable closure was achieved in 8 of 12 patients. Sealing a postoperative/postinterventional leak was successful in 6 patients and failed in 3. A gastrocutaneous fistula was primarily closed successfully in 2 patients, but recurred in 1 of these patients. A gastric wall dehiscence in necrotizing pancreatitis was successfully closed in another patient. Group B patients had previous endoscopic treatment failure in 4 of 7 patients (through-the-scope clips, injection of Suprarenin or fibrin glue, others) and were deemed not treatable by through-the-scope clips in 3 of 7 patients. The primary success rate was 100% (7 of 7 patients); durable hemostasis was achieved in 4 of 7 patients, whereas surgery or angiography was necessary in the remaining patients.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

Leaks and fistulae are reliably closed with OTSCs in tissue flexible enough to be sucked into the attached cap (eg, in lesions caused <1 week before). GI bleeding may be stopped by OTSCs with reliable transient hemostasis, but durable hemostasis is less frequent.

Distinct recurrence pattern and outcome of adenocarcinoma of the gastric cardia in comparison with carcinoma of other regions of the stomach

BACKGROUND

Carcinoma arising in the cardioesophageal junction is a distinct clinical entity compared with tumors located in other regions of the stomach. The prognosis for adenocarcinoma of the upper stomach is considered to be relatively poorer than carcinomas of the more distal stomach. We have therefore investigated patients with carcinoma of the gastric cardia in order to evaluate the underlying cause of this poor prognosis.

MATERIALS AND METHODS

Clinicopathologic features and postoperative prognosis of 101 patients with carcinoma of the cardia were evaluated and compared with findings on 1884 patients with tumors in other regions of the stomach.

RESULTS

Tumors of the cardia had a mean size of 6.8 cm, which was significantly larger than the mean size of 5.9 cm for tumors found in the middle- and lower third of the stomach. The incidence of serosal invasion, lymph node metastasis, and lymphatic and blood vessel invasion was higher in association with adenocarcinoma of the cardia than with adenocarcinoma in remaining parts of the stomach. In the analysis of patients who had undergone curative resection, the 5-year survival rates were 61.6, 79.1, and 82.6% in patients with carcinoma of the cardia, upper one-third, and remaining middle- and lower one-third of the stomach, respectively, and the differences were statistically significant. Multivariate analysis indicated that adenocarcinoma of the gastric cardia is an independent prognostic factor. With regard to the site of recurrence, both lymph node and hematogenous recurrence were observed more frequently in the cardia than in the remaining parts of the stomach.

CONCLUSIONS

Our data indicate that the prognosis of patients with adenocarcinoma of the gastric cardia is extremely poor. To improve their prognosis, new treatments in addition to gastrectomy with extensive lymph node dissection are needed.

Comparison of results of surgery in the upper third and more distal stomach

The results of surgery for gastric cancer in the upper third of the stomach and the more distal region were compared to explain the comparatively poor outcomes in the former. Characteristics and therapeutic results of 1245 patients who underwent curative gastrectomy (244 with tumors in the upper third of the stomach and 1001 with more distal cancers) were compared. Survival was significantly lower in patients with cancer of the upper third of the stomach than in patients with more distal cancers. There was a significant difference between the two groups in the survival of patients with advanced gastric cancer, particularly in those with pN1. Among patients with tumors deeper than T2 and pN1, survival was significantly reduced in those aged <or=75 years with tumors in the upper third of the stomach that were macroscopically ill defined, histologically undifferentiated, and showed venous invasion. Hematogenous recurrence was more frequent in patients with tumors deeper than T2 and pN1 in the upper third of the stomach. Tumors in the upper third of the stomach and venous invasion independently predicted hematogenous recurrence. Treatments for T2 or deeper and pN1 tumors in the upper third of the stomach, particularly for hematogenous metastasis, require further investigation.

Randomized clinical trial on the combination of preoperative irradiation and surgery in the treatment of adenocarcinoma of gastric cardia (AGC)--report on 370 patients

PURPOSE

An attempt was made to define the role of radiotherapy before operation for AGC.

METHODS AND MATERIALS

From January 1978 to May 1989, a prospective randomized trial on preoperative radiotherapy (R+S) vs. surgery alone (S) for AGC was carried out in 370 patients. Patients were randomized into a combined group (R+S, 171 patients) or a surgery alone group (S, 199 patients) by the envelope method. 8-MV photon or telecobalt was used for the preoperative radiation therapy, using anterior-posterior opposing parallel fields to deliver 40 Gy to the cardia, lower segment of the esophagus, fundus, lesser curvature, and hepatogastric ligament. Surgery was performed after 2 to 4 weeks rest.

RESULTS

The 5- and 10-year survival rates of the R+S Group and the S Alone Group were 30.10% and 19.75%, 20.26% and 13.30%, respectively. The survival curves of these two groups diverged right from the beginning after the operation over the ninth year. Statistics by Kaplan-Meier log rank test proves that the difference is significant (chi2 = 6.74, p = 0.0094). The immediate results were: resection rate 89.5% and 79.4% (p < 0.01); pathologic stage after resection T2 12.9% and 4.5% (p < 0.01), T4 40.3% and 51.3% (p < 0.05), lymph node metastasis rates 64.3% and 84.9% (p < 0.001); operative mortality rates 0.6% and 2.5%; intrathoracic leak rates 1.8% and 4.0%, respectively. The causes of failure were: local uncontrol and recurrence 38.6% vs. 51.7% (p < 0.025), regional lymph node metastasis 38.6% vs. 54.6% (p < 0.005), distant metastasis 24.3% vs. 24.7%.

CONCLUSION

Preoperative radiation therapy is able to improve the results of surgery for adenocarcinoma of the gastric cardia.