Role of New Anatomy, Biliopancreatic Reflux, and Helicobacter Pylori Status in Postgastrectomy Stump Cancer.

Luigi Basso,Luca Esposito,Paolo Izzo,Enrico Fiori,Andrea Giuliani,Luciano Izzo,Giuseppe Cavallaro,Andrea Polistena,Maria Vittoria Carati,Daniele Biacchi,Alessandro Micarelli,Antonietta Lamazza,Mariarita Tarallo,Gaetano Gallo

doi:10.3390/jcm11061498

Abstract

Distal gastrectomy for benign gastroduodenal peptic disease has become rare, but it still represents a widely adopted procedure for advanced and, in some countries, even for early distal gastric cancer. Survival rates following surgery for gastric malignancy are constantly improving, hence the residual mucosa of the gastric stump is exposed for a prolonged period to biliopancreatic reflux and, possibly, to Helicobacter pylori (HP) infection. Biliopancreatic reflux and HP infection are considered responsible for gastritis and metachronous carcinoma in the gastric stump after oncologic surgery. For gastrectomy patients, in addition to eradication treatment for cases that are already HP positive, endoscopic surveillance should also be recommended, for prompt surveillance and detection in the residual mucosa of any metaplastic-atrophic-dysplastic features following surgery.

Highlights

In 1881, the Viennese surgeon Theodor Billroth and his colleagues, following previous experimental studies, successfully performed the first distal gastrectomy on a 43-year-old patient with cancer of the pylorus
Regardless of the adopted technique of reconstruction, the location of gastric stump cancer” (GSC) was often not at the anastomosis but at a site between the lesser curve and the posterior wall of the stump, corresponding to the location of the primary carcinoma of the proximal third of the stomach (PUGC) [18]. These findings suggest that pre-existing atrophic-metaplastic alterations of the mucosa, rather than biliopancreatic reflux, are the most likely cause of GSC [12]
Our research group has shown that in 151 partial-gastrectomy peptic ulcer patients, after a mean interval of 25 years from surgery, there was a 10-fold increase in the prevalence of normal mucosa in Helicobacter pylori (HP)-negative (22.0%) vs. HP-positive (2.4%) patients, and the prevalence of intestinal metaplasia was four times higher in HP-positive than in HP-negative patients (19.6% vs 4.6%) [83]. In another endoscopic study assessing 187 peptic ulcer hemi-gastrectomy patients or distal gastric cancer patients, we observed that chronic atrophic gastritis, intestinal metaplasia, and dysplasia are more common in the HPpositive group [84]

Summary

Introduction

In 1881, the Viennese surgeon Theodor Billroth and his colleagues, following previous experimental studies, successfully performed the first distal gastrectomy on a 43-year-old patient with cancer of the pylorus. Surgical reconstruction of the continuity between the residual stomach and the duodenum (gastroduodenostomy) was called “Billroth 1” (B1); three years later, Billroth experimented another technique involving anastomosis of the residual stomach to one of the first loops of the jejunum (gastrojejunostomy, Billroth 2 or B2) [1]. Both procedures were not widely adopted until the end of the 19th century: while Billroth never published his own results, these were released by one of his scholars, Wolfler, who is considered the inventor of the gastrojejunostomy antecolic technique [2]. The following is still meant to be an exhaustive and informative, albeit non-systematic, review, certainly not covering every aspect, yet still important for definition of the problem and for stressing the role of HP and of the new local environment toward the development of further malignancy, which is of potentially tremendous beneficial clinical impact

Gastric Stump Cancer after Partial Gastrectomy

Gastric Stump Cancer

HP Infection and Metachronous Carcinoma following Endoscopic Resection of EGC

Findings

Conclusions