Carcinogenesis after remote peptic ulcer surgery: the long-term prognosis of partial gastrectomy

[Emergency laparoscopy in the treatment of perforated gastroduodenal ulcers]

OBJECTIVE

To compare the results of endoscopic and open treatment of perforated gastroduodenal ulcers.

MATERIAL AND METHODS

There were 445 patients with perforated gastroduodenal ulcers between 2013 and 2021. Endoscopic suturing of perforation was performed in 172 patients (38.7%), 273 ones underwent open surgery.

RESULTS

Among 172 patients scheduled for endoscopy, 160 (93.6%) ones underwent laparoscopic suturing of perforation. Morbidity rate was 5.0% (n=8), postoperative mortality rate - 1.3% (n=2). Comparison of the outcomes after laparoscopic suturing of ulcers in 160 patients and open surgery in 134 patients showed that laparoscopy was followed by 2.5 times lower incidence of complications and 3 times lower postoperative mortality.

CONCLUSION

Diagnostic laparoscopy is advisable in patients with perforated ulcers and no contraindications. In most cases, surgery can be successfully and effectively completed without conversion to laparotomy. Endoscopic closure of ulcerative defect is preferable since this procedure has certain advantages over traditional intervention, contributes to significant reduction in morbidity, mortality and hospital-stay.

Prediction of onset of remnant gastric cancer by promoter DNA methylation of CDO1/HOPX/Reprimo/E-cadherin

Background

Early detection of remnant gastric cancer (RGC) is required to reduce the risk of death, but long-term endoscopic surveillance is difficult after gastrectomy. In this study, data for the methylation status of 4 methylation genes (CDO1, HOPX, Reprimo, and E-cadherin) to predict the onset of RGC are presented.

Results

The 4 genes showed hypermethylation in RGC tumors in contrast to the corresponding non-cancerous mucosa tissues. The methylation level in the non-cancerous mucosa tissues of the initial surgery was obviously high in initial malignant disease for CDO1 (P = 0.0001), while in initial benign one for E-cadherin (P = 0.003). Promoter DNA methylation status in the remnant non-cancerous mucosa tissues together with the basic clinical data in turn predicted either initial malignant disease or initial benign disease with a high AUC score of 0.94, suggesting that methylation events are differentially recognized between the initial malignant and benign disease. We then finally confirmed that 4 genes hypermethylation of the non-cancerous tissues by biopsy prior to onset of RGC could predict terms until RGC occurred (P < 0.0001).

Methods

A total of 58 RGC patients were used to establish the model. The 4 genes promoter methylation were analyzed for DNA obtained from the patient's specimens using quantitative methylation specific polymerase chain reaction.

Conclusions

This risk model would help provide guidance for endoscopic surveillance plan of RGC after gastrectomy.

Training in early gastric cancer diagnosis improves the detection rate of early gastric cancer: an observational study in China

Few studies have analyzed the training of endoscopists in the diagnosis of early gastric cancer (EGC). This study assessed whether specific training of endoscopists improves the detection rate of EGC. The rates of detection of EGC by endoscopists at the Digestive Endoscopy Center of the Affiliated Nanfang Hospital of China Southern Medical University between January 2013 and May 2014 were retrospectively analyzed. Because some endoscopists received training in the diagnosis of EGC, beginning in September 2013, the study was divided into 3 time periods: January to September 2013 (period 1), September 2013 to January 2014 (period 2), and January to May 2014 (period 3). The rates of EGC detection during these 3 periods were analyzed. From January 2013 to May 2014, a total of 25,314 gastroscopy examinations were performed at our center, with 48 of these examinations (0.2%) detecting EGCs, accounting for 12.1% (48/396) of the total number of gastric cancers detected. The EGC detection rates by trained endoscopists during periods 1, 2, and 3 were 0.3%, 0.6%, and 1.5%, respectively, accounting for 22.0%, 39.0%, and 60.0%, respectively, of the gastric cancers detected during these time periods. In comparison, the EGC detection rates by untrained endoscopists during periods 1, 2, and 3 were 0.05%, 0.08%, and 0.10%, respectively, accounting for 3.1%, 6.0%, and 5.7%, respectively, of the gastric cancers detected during these times. After training, the detection rate by some trained endoscopists markedly increased from 0.2% during period 1 to 2.3% during period 3. Further, the use of magnifying endoscopy with narrow-band imaging (M-NBI) (odds ratio = 3.1, 95% confidence interval 2.4-4.1, P < 0.001) contributed to the diagnosis of EGC. In conclusion, specific training could improve the endoscopic detection rate of EGC. M-NBI contributed to the diagnosis of EGC.

Why is there a change in patterns of GE cancer?

Recent decades have seen a worrying trend in incidence rates of distal oesophageal and proximal gastric cancers. Fuelled by radical changes in lifestyle, diet, physical activity and environmental exposures, as well as an ageing population and host genetic predisposition, the incidence of oesophageal adenocarcinoma (OAC) is on the rise in Western populations. While overall incidence of gastric cancers is declining, the ageing of society means that an increase in absolute numbers is expected over coming years. Both cancers tend to present at an advanced stage, hence prognosis remains poor despite increasingly effective screening and treatment strategies. The development of gastric and oesophageal malignancies is influenced by myriad factors, not least geographical, racial and socioeconomic differences in addition to lifestyle choices. The multidimensional nature of these risk factors requires a holistic understanding of their net influence in the development of malignancy. This review explores the evidence base for established and putative risk factors in the development of gastric and oesophageal cancers. It is hoped that with a clear understanding of important risk factors, a multidisciplinary approach including effective primary prevention, regular screening of high-risk groups and continued research into the molecular biology of gastrointestinal carcinogenesis may facilitate a reduction in incidence rates, as well as early detection and optimal management of upper gastrointestinal malignancies.

Gastrectomy and risk of pancreatic cancer: systematic review and meta-analysis of observational studies

PURPOSE

To investigate the association between gastrectomy and risk of pancreatic cancer (PaC).

METHODS

We identified eligible studies in Medline and EMBASE up to 11 February 2012 and the reference lists of original studies and review articles on this topic. Summary relative risks with their 95 % confidence intervals were calculated with a random-effects model. Between-study heterogeneity was assessed using Cochran Q and I (2) statistics.

RESULTS

Fifteen studies (11 case-control studies and 4 cohort studies) met eligibility criteria. The current data suggest that gastrectomy is associated with a 54 % excess risk of PaC (SRRs = 1.54; 95 % CI, 1.25-1.90; test for heterogeneity Q = 17.94, p < 0.001, I (2) = 22 %). There was no publication bias in the present meta-analysis.

CONCLUSION

A significant increased risk of PaC exists in patients who have undergone gastrectomy, particularly those receiving Billroth II resection with a long postoperative interval.

Increased mortality in prostate carcinoma and smoking-related disease after parietal cell vagotomy: a long-term follow-up study

OBJECTIVE

There is an increased risk of gastrointestinal carcinoma and smoking-related diseases after partial gastrectomy for peptic ulcer disease. The purpose of this study was to evaluate long-term cancer incidence and mortality after parietal cell vagotomy (PCV), a surgical method with a low rate of side effects, but creating hypochlorhydria in the stomach mimicking long-term treatment with antisecretory drugs.

MATERIAL AND METHODS

Data on 383 ulcer patients operated on with PCV during 1971-80 at Lund University Hospital were compared with the national registers for cause of death and cancer incidence for selected diagnoses. Median follow-up was 28 years and 31 years, respectively. Standardized mortality ratios (SMRs) and standardized incidence ratios (SIRs) were calculated.

RESULTS

An increased incidence of cancer in the respiratory organs (SIR 1.97, 95% CI: 1.08-3.31) and prostate carcinoma (SIR 1.85, 95% CI: 1.22-2.69) was found, and among men also an increased mortality in prostate carcinoma (SMR 3.85, 95% CI: 1.41-8.38) and chronic respiratory disease (SMR 2.76, 95% CI: 1.01-6.02). Overall mortality was similar to that of the background population and no increased risk of gastrointestinal malignancies was observed.

CONCLUSIONS

Patients with peptic ulcer operated on with PCV have a long-term increased risk of smoking-related diseases, but PCV does not seem to increase the risk of gastrointestinal carcinoma. An increased risk of, and mortality in prostate carcinoma was found, a cancer previously not found to be related to smoking. This might be the result of surgery-induced hypochlorhydria, which warrants further investigation in patients on long-term proton-pump inhibitors.

Gastric stromal tumors in Carney triad are different clinically, pathologically, and behaviorally from sporadic gastric gastrointestinal stromal tumors: findings in 104 cases

Carney triad, as originally described in 1977, was the association of 3 tumors: gastric epithelioid leiomyosarcoma [later renamed gastrointestinal stromal tumor (GIST)], extra-adrenal paraganglioma, and pulmonary chondroma. The disorder affected mostly young women and was not familial. We studied the clinical and pathologic features of the gastric neoplasm in 104 patients with the syndrome. Most (88%) were young women (mean age, 22 y), and the usual presentation was gastric bleeding. The tumors, commonly antral-based (61%), were multifocal, and ranged from 0.2 to 18.0 cm in dimension. Most (86%) featured round and polygonal (epithelioid) cells. Metastasis occurred in 49 patients (47%): to gastric lymph nodes (29%), liver (25%), and peritoneum (13%). Immunopositivity was detected in the tumors tested as follows: KIT, 100%; CD34, 75%; PKCtheta, 21%; PDGFRA, 90%; and smooth muscle actin, 6%. Fourteen patients (13%) died of metastatic GIST at a mean age of 45 years (range, 30 to 69 y). Estimated 10 and 40-year survivals were 100% and 73%, respectively. Median survival time was 26.5 years (range, 16 to 60 y). There was no correlation between the National Institutes of Health tumor risk classification and the tumor behavior. Compared with sporadic gastric GISTs, the gastric stromal tumor in Carney triad showed distinctive features: female predilection, young patient age, epithelioid cell predominance, multifocality, frequent lymph node metastasis, serial tumor occurrence, and unpredictable behavior. Thus, the Carney triad gastric stromal tumor is different clinically, pathologically, and behaviorally from sporadic gastric GIST.

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

Although Helicobacter pylori (H. pylori) seropositivity is linked to an excess risk of pancreatic cancer, the biologic mechanism is unknown. Gastric ulcer is primarily associated with corpus colonization of H. pylori, atrophic gastritis and formation of N-nitrosamines. Duodenal ulcer is a marker of antral colonization, hyperacidity and uninhibited secretin release. We estimated relative risks for pancreatic cancer among patients with gastric or duodenal ulcer, based on a register-based retrospective cohort study with 88,338 patients hospitalized for gastric ulcer and 70,516 patients for duodenal ulcer recorded in the Swedish Inpatient Register between 1965 and 2003. Following operation, the 14,887 patients who underwent gastric resection and 8,205 with vagotomy were analyzed separately. Multiple record-linkages allowed complete follow-up and identification of all incident cases of pancreatic cancer until December 31, 2003. Standardized incidence ratios (SIRs) estimated relative risks. During years 3-38 of follow-up, we observed a 20% excess risk (95% confidence interval [CI] 10-40%) for pancreatic cancer among unoperated gastric ulcer patients. The excess increased to 50% (95% CI 10-110%) 15 years after first hospitalization (p for trend = 0.03). SIR was 2.1 (95% CI 1.4-3.1) 20 years after gastric resection. Unoperated duodenal ulcer was not associated with pancreatic cancer risk, nor was vagotomy. Our results lend indirect support to the nitrosamine hypothesis, but not to the hyperacidity hypothesis in the etiology of pancreatic cancer.

Early diagnosis of early gastric cancer

The prognosis of gastric cancer is closely related to the stage of disease at diagnosis. Early gastric cancer, whereby disease is limited to mucosa and submucosa, confers a survival rate of greater than 90% in 5 years in many centres. Gastric cancer is still a major cause of cancer mortality worldwide. In high incidence areas such as Japan, screening of asymptomatic population has been advocated. However, in Western countries, mass screening is not cost-effective. Hence, strategy has been directed to screen symptomatic individuals who are at higher risk of gastric cancer. Most patients with early gastric cancer present with symptoms indistinguishable from benign peptic ulcer disease. Screening for this group of patients improves detection rate of early gastric cancer and therefore its prognosis. Endoscopy for surveillance of premalignant lesions has been explored with this objective in mind. Serology testing for biomarkers such as pepsinogen, anti-Helicobacter pylori antibody and gastrin has been studied as an alternative to endoscopy. There is compelling evidence for the role of H. pylori in the initiation of Correa's cascade (stepwise progression from chronic active gastritis, atrophic gastritis, intestinal metaplasia, dysplasia and finally adenocarcinoma). Regression of premalignant lesions has been demonstrated with H. pylori eradication. However, it is not known whether this might effectively prevent gastric cancer in either low or high-risk population.

Acute upper gastrointestinal bleeding in operated stomach: Outcome of 105 cases

AIM: To compare the causes and clinical outcome of patients with acute upper gastrointestinal bleeding (AUGB) and a history of gastric surgery to those with AUGB but without a history of gastric surgery in the past.

METHODS: The causes and clinical outcome were compared between 105 patients with AUGB and a history of gastric surgery, and 608 patients with AUGB but without a history of gastric surgery.

RESULTS: Patients who underwent gastric surgery in the past were older (mean age: 68.1±11.7 years vs 62.8±17.8 years, P = 0.001), and the most common cause of bleeding was marginal ulcer in 63 patients (60%). No identifiable source of bleeding could be found in 22 patients (20.9%) compared to 42/608 (6.9%) in patients without a history of gastric surgery (P = 0.003). Endoscopic hemostasis was permanently successful in 26 out of 35 patients (74.3%) with peptic ulcers and active bleeding or non-bleeding visible vessel. Nine patients (8.6%) were operated due to continuing or recurrent bleeding, compared to 23/608 (3.8%) in the group of patients without gastric surgery in the past (P = 0.028). Especially in peptic ulcer bleeding patients, emergency surgery was more common in the group of patients with gastric surgery in the past [9/73 (12.3%) vs 19/360 (5.3%), P = 0.025]. Moreover surgically treated patients in the past required more blood transfusion (3.3±4.0 vs 1.5±1.7, P = 0.0001) and longer hospitalization time (8.6±4.0 vs 6.9±4.9 d, P = 0.001) than patients without a history of gastric surgery. Mortality was not different between the two groups [4/105 (3.8%) vs 19/608 (3.1%)].

CONCLUSION: Upper gastrointestinal bleeding seems to be more severe in surgically treated patients than in non-operated patients.

Association of laryngeal cancer with previous gastric resection

OBJECTIVE

To investigate the association between gastric surgery and cancer of the larynx.

SUMMARY BACKGROUND DATA

Biliary reflux is frequent after gastric surgery and may reach the proximal segment of the esophagus and the larynx. It is possible that duodenal content (consisting in bile acids, trypsin), together with pepsin and acid residues when gastric resection is partial, may cause harmful action on the multistratified epithelium of the larynx.

METHODS

A retrospective case-control study on subjects admitted between January 1987 and May 2002 in the same hospital in Rome was carried out. The study included 828 consecutive patients with laryngeal cancer (cases) and 825 controls with acute myocardial infarction. Controls were randomly sampled out of a total of 10,000 and matched with cases for age, sex, and year of admission. Logistic regression models were used to assess the role of gastric resection in determining laryngeal cancer risk while controlling for potential confounding factors.

RESULTS

Previous gastrectomy was reported by 8.1% of cases and 1.8% of the controls (P < 0.0001). A 4-fold association emerged between gastric surgery and laryngeal cancer risk (adjusted OR = 4.3, 95% CI: 2.4-7.9). The risk appeared strongly increased 20 years after surgery (OR = 14.8, 95% CI: 3.4-64.6). Heavy alcohol drinking (OR = 2.5, 95% CI: 1.8-3.5), smoking (OR = 4.7, 95% CI: 3.3-6.7), and blue-collar occupation (OR = 4.6, 95% CI: 3.2-6.7) were all independently associated with the risk of laryngeal cancer.

CONCLUSIONS

Previous gastric surgery is associated with an increased risk of laryngeal cancer. A periodic laryngeal examination should be considered in long-term follow-up of patients with gastric resection.

Cancer in the gastric remnant after gastric bypass: a case report

Gastric cancer in the gastric stump after a Bilroth II subtotal gastrectomy is a well-recognized entity. However, gastric cancer in the bypassed gastric remnant after a gastric bypass operation for morbid obesity has not been well described, and only 2 such cases have been reported in the English literature. This case report presents a patient who developed gastric cancer in the defunctionalized, bypassed stomach 22 years after undergoing an open gastric bypass with a Roux-en-Y gastro-jejunostomy for morbid obesity. The problems of monitoring the defunctionalized bypassed stomach after gastric stapling and gastro-jejunostomy are discussed.

Role of therapy or monitoring in preventing progression to gastric cancer

It is generally accepted that intestinal-type gastric adenocarcinoma arises through a multistep process originating with chronic gastritis, progressing through stages of atrophy, intestinal metaplasia, and dysplasia and finally invasive carcinoma. This sequential process, known as the "Correa cascade" is in many instances initiated by Helicobacter pylori infection and perpetuated by a number of environmental and host factors. Given that the development of carcinoma can be the end point of this sequential process, there is great interest in determining which if any of these steps may be reversible. Clinical studies have shown that the eradication of H. pylori can lead to resolution of chronic gastritis, and a few studies have suggested some improvement in gastric atrophy. Intestinal metaplasia, however, does not appear to be as reversible. Nevertheless, results of several intriguing studies of high-risk populations support the notion that eradication of H. pylori may decrease or delay progression to gastric carcinoma despite the inability to reverse all mucosal damage. The applicability of these findings to low-risk countries such as the United States and the United Kingdom remain uncertain. Currently, in the United States, there is no widely accepted screening program for H. pylori infection in asymptomatic individuals, and consensus regarding surveillance for gastric intestinal metaplasia or dysplasia is lacking. The purpose of this report is to evaluate the available data regarding the epidemiology of H. pylori and associated carcinoma, discuss relevant human and animal data that address eradication strategies in the prevention of gastric carcinoma, and finally discuss current recommendations regarding screening programs aimed at high-risk populations.

Mucosal changes in the gastric remnant: long-term effects of bile reflux diversion and Helicobacter pylori infection

OBJECTIVE

Bile reflux is thought to be responsible for reflux gastritis and stump carcinoma occurring after partial gastrectomy for peptic ulcer. Gastritis and gastric carcinoma are also correlated with Helicobacter pylori. The aim of this study was to investigate whether diversion of enteric reflux and the presence of H. pylori infection alter long-term histological developments in the gastric remnant.

METHODS

Twenty-nine patients partially gastrectomized for peptic ulcer were reoperated on with re-resection and a Roux-en-Y reconstruction because of reflux gastritis (12 patients) or severe dysplasia/early gastric cancer (17 patients). The resected specimens and subsequent biopsies from the new anastomotic region taken at endoscopies 5-17 years after reoperation were evaluated regarding the presence of H. pylori, the grade of active and non-active chronic gastritis, and the premalignant changes--atrophy, intestinal metaplasia and dysplasia.

RESULTS

A progression of active chronic gastritis, atrophy, intestinal metaplasia and dysplasia was seen after re-resection and Roux-en-Y reconstruction. Non-active chronic gastritis remained unchanged. The development was, in general, independent of H. pylori infection.

CONCLUSIONS

Enteric reflux may perhaps induce a histological transformation of the gastric mucosa that cannot be reversed, even if the reflux is diverted. In our study, H. pylori infection had no impact on the histological development. Factors other than enteric reflux and H. pylori infection might also be of importance.

Gastric cancer epidemiology and risk factors

We performed a detailed analysis of the epidemiology of gastric carcinoma, based upon a review of the literature in English. The analysis reveals many puzzling features. There has been a steady fall in the incidence of gastric carcinoma in most societies studied, but a more recent steady rise in the incidence of adenocarcinoma of the cardia and lower esophagus, largely confined to White males. Although the evidence for a major role for Helicobacter pylori (H. pylori) in the etiology of gastric corpus cancer is compelling; in Western society, it probably accounts for fewer than half the cases. The relative roles of dietary constituents such as salt and nitrites and the phenotyping of H. pylori in causation and the beneficial effects of a high fruit and vegetable diet and an affluent lifestyle, for all of which there is some evidence, are yet to be quantified.

Malignant neoplasms after radiation therapy for peptic ulcer

Most information on radiation-related cancer risk comes from the Life Span Study (LSS) of the Japanese atomic bomb survivors. Stomach cancer mortality rates are much higher in Japan than in the U.S., making the applicability of LSS findings to the U.S. population uncertain. A unique cohort of U.S. patients who were irradiated for peptic ulcer to control gastric secretion provides a different perspective on risk. Cancer mortality data were analyzed and relative risks estimated for 3719 subjects treated by radiotherapy (mean stomach dose 14.8 Gy) and/or by surgery and medication during the period 1936-1965 and followed through 1997 (average 25 years). Compared to the U.S. rates, stomach cancer mortality was significantly increased for irradiated and nonirradiated patients (observed/expected = 3.20 and 1.52, respectively). We observed strong evidence of exposure-related excess mortality from cancer of the stomach (RR 2.6, 95% CI 1.3, 5.1), pancreas (RR 2.7, 95% CI 1.5, 5.1), and lung (RR 1.5, 95% CI 1.1, 2.1), with commensurate radiation dose responses in analyses that included nonexposed patients. However, the dose responses for these cancers were not significant when restricted to exposed patients. Our excess relative risk per gray estimate of 0.20 at doses <or=10 Gy (95% CI 0, 0.73) is consistent with the estimate of 0.24 (95% CI 0.10, 0.40) obtained from the LSS study with the linear model.

Outcomes of endoscopy in patients with iron deficiency anemia after Billroth II partial gastrectomy

GOALS

To determine the frequency of gastrointestinal lesions detected by upper endoscopy and colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery.

STUDY

The authors reviewed the medical records of 116 consecutive patients with a Billroth II partial gastrectomy and 232 age- and gender-matched controls without gastric surgery who were referred for endoscopy to evaluate iron deficiency anemia over a 5-year period.

RESULTS

Clinically important lesions were detected in 22.4% of the patients with gastric surgery and in 59.5% of those with intact stomachs (p < 0.001). In the gastric surgery group, clinically important lesions were found more often in the upper gastrointestinal tract than in the colon (19.0% vs. 3.4%, p < 0.001). In the nonsurgical group, the diagnostic yields of upper endoscopy and colonoscopy were not significantly different (38.4% vs. 32.8%, p = 0.24). Synchronous lesions in the upper and lower gastrointestinal tract were significantly less common in the group of patients with gastric surgery compared with those without gastric surgery (0.0% vs. 11.6%, p < 0.001). Small bowel biopsies and small bowel follow-through did not identify any additional lesions. In the gastric surgery group, multivariate analysis identified abdominal symptoms (OR = 11.2, 95% CI 3.2-39.2, p < 0.001), a positive result on fecal occult blood testing (OR = 6.4, 95% CI 2.0-20.3, p = 0.002), and Billroth II surgery at least 10 years before evaluation (OR = 5.4, 95% CI 1.7-16.7, p = 0.004) as independent predictors of identifying a clinically important lesion by endoscopy.

CONCLUSIONS

Upper endoscopy had a significantly higher diagnostic yield than colonoscopy in patients who developed iron deficiency anemia after Billroth II surgery. Prospective studies are necessary to determine the role and cost-effectiveness of colonoscopy in the evaluation of iron deficiency anemia in this patient population.

Carcinogenic potential of duodenal reflux juice from patients with long-standing postgastrectomy

AIM: To determine whether study on the carcinogenic potential of reflux juice from patients with remote gastrectomy could clarify the inherent relationship between duodenal reflux and gastric stump cancer.

METHODS: A total of 37 reflux juice samples (13 Billroth I, 24 Billroth II) were employed in the present study. A two-stage transformation assay using BALB/c 3T3 cells was carried out to test the initiating or promoting activity of these samples.

RESULTS: Two of 18 (11.1%) reflux samples exerted initiating activities, whereas 9/19 (47.4%) samples enhanced the MNNG-initiating cell transformation, suggesting the duodenal reflux juice might more frequently possess the tumor-promoter activity (P = 0.029). In addition, there was no difference in initiating activities of the samples irrespective of surgical procedures (P = 0.488), while Billroth II samples exhibited stronger tumor-promoter activity than Billroth I samples (P = 0.027). Furthermore, the promoter activities were well correlated with the histological changes of the stomas (r_s = 0.625, P = 0.004), but neither their cytotoxicities nor initiating activities had this correlation (Probabilities were 0.523 and 0.085, respectively).

CONCLUSION: The duodenal reflux juice from patients with remote postgastrectomy did have carcinogenic potential, and suggested that tumor-promoting activity should principally account for the high incidence of gastric cancer in gastrectomy patients. In contrast, it is difficult to explain the high stump-cancer incidence with the "N-nitroso compounds" theory-a popular theory for the intact stomach carcinogenesis, and it seemed to be justified to focus chemoprevention of this cancer on the tumor-promoting potential of reflux juice.

Surgical pathophysiology and disease management during the centuries

During the centuries the pathophysiological concept of illness underwent drastic changes, depending on medical discoveries and religious belief. There is evidences of surgical practice in Mesopotamia, Egypt, and Greece 2000 years B.C., but we have to wait the Roman Empire with Celso, Galeno, and most of all Asclepiade and Temisone to appreciate the endeavor to rationally understand diseases as an alteration among different body constituents and not only as divine will. During the Middle Ages, when medicine was disputed by clergy, Ugo and Teodorico Borgognone perceived by intuition the problem of sepsis in patient recovery. This problem was cleared up six centuries later by Semmelweis with his antisepsis. Discoveries of blood circulation, hemostasis, anesthesia, and antisepsis in the 17th and 19th centuries permitted better disease management and have promoted, since the 1950s, pathophysiology as an autonomous discipline. Now pathophysiological mechanisms are used for comprehension of several diseases, such as gallstone formation, peptic ulcers, cranial trauma, cardiovascular abnormalities, and many others, to suggest to us which are the better surgical or clinical trials to realize, while observing caution about their limits and consequences. By a multidisciplinary approach involving surgeons, physiologists, biologists, and physicians, we are able to facilitate patient recovery and to perform modern, scientific, high-quality disease management.