Incidence Of Early Gastric Cancer Research Articles

Advantages of Function-Preserving Gastrectomy for Older Patients With Upper-Third Early Gastric Cancer: Maintenance of Nutritional Status and Favorable Survival.

The incidence of early gastric cancer is increasing in older patients alongside life expectancy. For early gastric cancer of the upper third of the stomach, laparoscopic function-preserving gastrectomy (LFPG), including laparoscopic proximal gastrectomy (LPG) and laparoscopic subtotal gastrectomy (LSTG), is expected to be an alternative to laparoscopic total gastrectomy (LTG). However, whether LFPG has advantages over LTG in older patients remains unknown. We retrospectively analyzed data of consecutive patients aged ≥75 years who underwent LTG, LPG, or LSTG for cT1N0M0 gastric cancer between 2005 and 2019. Surgical and nutritional outcomes, including blood parameters, percentage body weight (%BW) and percentage skeletal muscle index (%SMI) were compared between LTG and LPG or LSTG. Survival outcomes were also compared between LTG and LFPG groups. A total of 111 patients who underwent LTG (n=39), LPG (n=48), and LSTG (n=24) were enrolled in this study. To match the surgical indications, LTG was further categorized into "LTG for LPG" (LTG-P) and "LTG for LSTG" (LTG-S). No significant differences were identified in the incidence of postoperative complications among the procedures. Postoperative nutritional parameters, %BW and %SMI were better after LPG and LSTG than after LTG-P and LTG-S, respectively. The survival outcomes of LFPG were better than those of LTG. LFPG is safe for older patients and has advantages over LTG in terms of postoperative nutritional parameters, body weight, skeletal muscle-sparing, and survival. Therefore, LFPG for upper early gastric cancer should be considered in older patients.

Long-term outcomes after endoscopic resection for late-elderly patients with early gastric cancer

With the population aging, the incidence of early gastric cancer (EGC) is increasing. We aimed to clarify the indications for endoscopic resection (ER) in late-elderly patients with EGC in terms of life expectancy. Patients aged≥75 years who underwent ER for EGC at our institution from January 2007 to December 2012 were enrolled. Clinical data, including Eastern Cooperative Oncology Group performance status (ECOG-PS), Charlson comorbidity index, and Prognostic Nutritional Index (PNI), were collected at the time of ER. Overall survival (OS) was the main outcome measure. Four hundred consecutive patients were enrolled. Mean patient age was 79.3 years (range, 75-93). The 5-year follow-up rate was 89.0% (median follow-up period, 5.6 years). Five-year OS was 80.8% (95% confidence interval [CI], 76.4-84.4), and 5-year net survival standardized for age, sex, and calendar year was 1.09 (95% CI, 1.03-1.15). With a multivariate analysis, ECOG-PS 2 to 4 (hazard ratio, 8.84; 95% CI, 3.07-25.4), PNI<49.1 (hazard ratio, 2.49; 95% CI, 1.53-4.06), and eCura C-2 (hazard ratio, 1.79; 95% CI, 1.11-2.88) were independent prognostic factors. When none of these factors was met, the 5-year OS rate was 90.4% (95% CI, 84.0-94.3). ER for EGC in late-elderly patients may improve life expectancy. ER is recommended in patients with a good ECOG-PS and PNI and in whom ER is expected to be non-eCura C-2.

Effect of non-curative endoscopic submucosal dissection on short-term outcomes of subsequent surgery for early gastric cancer

BackgroundWith growing incidence of early gastric cancer (EGC), endoscopic submucosal dissection (ESD) is widely performed as a standard treatment for mucosal cancer. Due to the increasing application of ESD, the number of non-curative resection after ESD is also growing, leading to escalating number of patients who require additional gastrectomy with lymph node dissection after non-curative ESD. However, effects of ESD prior to surgery on technical difficulties during operation for EGC remain unclear. Therefore, this study aimed to determine the effect of non-curative ESD on short-term surgical outcomes in patients who underwent additional surgical treatment using propensity score matching method. MethodsTo evaluate the effect of ESD on short-term surgical outcomes in patients who underwent additional surgical treatment after a non-curative ESD procedure, patients were divided into two groups: (1) those who underwent additional gastrectomy after non-curative resection of ESD [ESD + Surgery (ES) Group], and (2) those who underwent gastrectomy as the initial treatment [Surgery Only (SO) Group]. To minimize differences in baseline demographic features that could potentially be associated with short-term outcomes, propensity-scored matching analysis was performed. ResultsAfter propensity-scored matching (1:1 matching), 140 patients altogether were selected and analyzed in this study. Complications were experienced by 18 (25.7%) patients in the ES group and 13 (18.6%) patients in the SO group, showing no significant (p < 0.416) difference between the two groups. ConclusionsAdditional surgery after non-curative ESD can be safely applied, even within one month after ESD in terms of short-term complications.

Recent updates and current issues of sentinel node navigation surgery for early gastric cancer.

With the increase in the incidence of early gastric cancer (EGC), several endoscopic and laparoscopic approaches, such as endoscopic submucosal dissection and function-preserving gastrectomy, have been accepted as standard treatments. Sentinel node navigation surgery (SNNS) is an ideal surgical option for preservation of most parts of the stomach and consequent maintenance of normal gastric function to improve quality of life in patients with EGC. Although many previous studies and clinical trials have demonstrated the safety and feasibility of the sentinel node concept in gastric cancer, the clinical application of SNNS is debatable. Several issues regarding technical standardization and oncological safety need to be resolved. Recently several studies to resolve these problems are being actively performed, and SNNS might be an important surgical option in the treatment of gastric cancer in the future.

Clinicopathologic characteristics of early gastric cancer according to specific intragastric location

BackgroundAlthough the incidence of early gastric cancer (EGC) continues to rise, there have been few studies on the intra-gastric distribution and locational characteristics of EGCs. In addition, there has been no attempt to visualize the intra-gastric distribution of EGCs using a merged tumor map.MethodsWe investigated the anatomic distribution of 644 cases of EGCs and analyzed the correlation between clinicopathologic findings and location by dividing areas of the stomach vertically and transversely. Merged tumor maps were generated using 310 surgically resected cases.ResultsEarly gastric cancer was most commonly located in the antrum (57.5%) along the lesser curvature (37.8%). The intra-gastric distributions were similar in the merged tumor maps. Vertically, cancers of the middle third were associated with younger patient age, larger tumor size, and more frequent poorly differentiated (PD) or signet ring cell histology than cancers in other sites. Submucosal invasion was most frequently observed in the upper third. When divided transversely, tumors in the anterior or posterior wall showed more frequent PD or signet ring cell histology than those along the lesser or greater curvatures.ConclusionsEGC is the most prevalent in the antrum along the lesser curvature and has characteristic locational features, including histologic type, invasion depth, patient age, and tumor size. These results will improve the endoscopic detection rate of EGC and help to determine endoscopic resectability.

Function-preserving gastrectomy for early gastric cancer based on Japanese researches

In the past, people only focused on surgical resection of gastric cancer to obtain satisfactory therapeutic effect, while the concept of function-preserving in gastric cancer surgery has not been emphasized. Gastric function-preserving surgery was originally performed by Japanese doctor Maki for surgical treatment of gastroduodenal ulcer. With the definition of early gastric cancer being accepted, the pylorus-preserving gastrectomy can be used continuously in the treatment of gastric cancer. Because of high incidence of early gastric cancer in Japan, a variety of application and research about function-preserving gastrectomy in other areas for treatment of early gastric cancer, such as proximal gastrectomy and jejunal interposition, segmental gastrectomy, gastric local resection and laparoscopic and endoscopic cooperative surgery (LECS) at the same time, and regional or sentinel lymph node dissection were performed for the purpose of radical cure. Function-preserving gastrectomy for the treatment of early gastric cancer should include four important factors: (1) decrease of the scope of gastrectomy; (2)retaining pylorus; (3)retaining vagus nerve; (4)regional or sentinel lymph node dissection. The technique of sentinel lymph node can reduce the extent of gastric resection, avoid distal gastrectomy or total gastrectomy, and make gastric resection more suitable for laparoscopic partial gastrectomy, segmental resection, pylorus-preserving gastrectomy and proximal gastrectomy. Function-preserving gastrectomy has the advantage of improving the quality of life and has great potential in the treatment of early gastric cancer. However, the various treatment methods including LECS need strict technical standardization for confirmation of oncology safety. We need careful design, prospective multicenter randomized controlled trials to provide theoretical and technical support.

Robot-Assisted Versus Laparoscopy-Assisted Proximal Gastrectomy for Early Gastric Cancer in the Upper Location: Comparison of Oncological Outcomes, Surgical Stress, and Nutritional Status.

Background:An increasing amount of attention has been paid to minimally invasive function-preserving gastrectomy, with an increase in incidence of early gastric cancer in the upper stomach. This study aimed to compare oncological outcomes, surgical stress, and nutritional status between robot-assisted proximal gastrectomy (RAPG) and laparoscopy-assisted proximal gastrectomy (LAPG).Methods:Eighty-nine patients were enrolled in this retrospective study between November 2011 and December 2013. Among them, 27 patients underwent RAPG and 62 underwent LAPG. Perioperative parameters, surgical stress, nutritional status, disease-free survival, and overall survival were compared between the 2 groups.Results:Sex, age, and comorbidity were similar in the RAPG and LAPG groups. There were also similar perioperative outcomes regarding operation time, complications, and length of hospital stay between the groups. The reflux esophagitis rates following RAPG and LAPG were 18.5% and 14.5%, respectively (P = .842). However, patients in the RAPG group had less blood loss (P = .024), more harvested lymph nodes (P = .021), and higher costs than those in the LAPG group (P < .001). With regard to surgical stress, no significant differences were observed in C-reactive protein concentrations and white blood cell count on postoperative days 1, 3, and 7 between the groups (Ps > .05). There appeared to be higher hemoglobin levels at 6 months (P = .053) and a higher body mass index at 12 months (P = .056) postoperatively in patients in the RAPG group compared with those in the LAPG group, but this difference was not significant. Similar disease-free survival and overall survival rates were observed between the groups.Conclusions:RAPG could be an alternative to LAPG for patients with early gastric cancer in the upper stomach with comparable oncological safety and nutritional status. Further well-designed, prospective, large-scale studies are needed to validate these results.

Minimally invasive surgery in gastric cancer

Gastric cancer surgery with curative intent comprises subtotal or total gastrectomy with radical lymph node dissection. Recently, as the incidence of early gastric cancer (EGC) is increasing, minimally invasive surgery can be applied to gastric cancer treatment. Minimally invasive gastric surgery has four aspects such as minimally invasive access, modified function-preserving gastrectomy, limited lymphadenectomy, and no reconstruction. Laparoscopic gastrectomy became popular for EGC and its indication is being expanded to advanced gastric cancer. Reduced or single port gastrectomy can be performed for selective EGC. For middle or upper EGC, laparoscopic pylorus-preserving gastrectomy or proximal gastrectomy is applicable as function-preserving gastrectomy. D1+ node dissection is enough for EGC without lymph node metastasis and sentinel node biopsy will be helpful for avoiding unnecessary lymph node dissection in EGC patients.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea.

Laparoscopic gastrectomy for gastric cancer has rapidly gained popularity as a result of the increased incidence of early gastric cancer in Korea. Although laparoscopic gastrectomy has been considered as an investigational treatment because of the lack of solid evidence of efficacy and safety, it is increasingly regarded as a standard treatment for early gastric cancer. Moreover, solid evidence is anticipated from two studies in Korea, KLASS 01 and KLASS 02, the latter of which examines the suitability of laparoscopic gastrectomy for advanced gastric cancer. The use of cutting-edge techniques for laparoscopic gastrectomy enables surgeons to deliver various treatment options that offer the best possible quality of life after gastrectomy. In this review, we summarize the current status of clinical trials on laparoscopic gastrectomy in Korea and examine future perspectives regarding laparoscopic gastrectomy for the treatment of gastric cancer.

Clinical significance of skip lymph node metastasis in gastric cancer patients

PurposeGiven the recent increase in the incidence of early gastric cancer, there is greater interest in identifying a minimally invasive therapy. The purpose of this study was to analyze the patterns of lymph node metastasis in patients with gastric cancer and to elucidate the clinical significance of skip metastasis. MethodsWe retrospectively analyzed patterns of lymph node metastasis (LNM) and clinicopathologic factors related to skip metastasis. ResultsAmong 2963 patients with gastric cancer, 997 patients (33.6%) were detected as having LNM, and 27 patients (2.7%) with skip metastasis were detected among 997 patients with LNM. Skip metastasis were detected more frequently in the elderly. Compared with the N1 group, the skip metastasis group showed lower frequency of vascular invasion, and compared with the stepwise N2 group, the skip metastasis group showed smaller tumor size and a significantly higher incidence of negative lymphatic, vascular, and perineural invasion. ConclusionsCurrently there is no way to predict N2 station LNM including skip metastasis, D2 LN dissection for gastric cancer is thought to be the appropriate treatment, even during early stage disease. Minimally invasive therapy should be performed cautiously in consideration of possible skip metastasis.

Factors that affect surgery after endoscopic resection of early gastric cancer patients

Purpose: The increase in the incidence of early gastric cancer (EGC) cases has led to an increase in endoscopic resections, thereby resulting in an increasing number of endoscopic resection failure cases. The purpose of this study was to identify indicators for endoscopic resection, such as depth of invasion and tumor differentiation. Methods: This study included 273 patients who underwent endoscopic resection for EGC at Hallym University Sacred Heart Hospital from January 2006 to May 2013. Of these resection cases, 41 were also surgical treatment cases. The endoscopic findings and lesion characteristics were analyzed, retrospectively using medical records. Results: The results suggested that when the location of tumor was in the middle third of the stomach (P=0.002), the patient was younger (P=0.057), there was a higher likelihood of surgical treatment after endoscopic resection. Conclusion: To determine the indicators for endoscopic resection, it is essential to consider tumor location as well as tumor size, tumor differentiation and depth of invasion, which are considered important factors. If the lesion was located in the upper and middle third of the stomach, sufficient explanation and consent was required.

A Case of Early Gastric Cancer with Solitary Metastasis to the Pleura

The incidence of early gastric cancer (EGC) has increased to >50% in Korea owing to a higher detection rate caused by rapid advances in diagnostic instrumentation. EGC with distant metastasis has been rarely reported. Here, we report the case of a 76-year-old woman in whom general EGC was initially diagnosed by endoscopy and endoscopic ultrasonography. She subsequently underwent endoscopic submucosal dissection (ESD). Histological examination of the ESD specimen revealed that neoplastic cells were located predominantly in the submucosal layer and submucosal lymphatic channels. Metastatic cancer cells were also found in the pleural effusion. After conducting all analyses, including immunohistochemical staining, we concluded that the patient had primary EGC with pleural metastasis.

Clinicopathological Characteristics and Survival Difference Between Gastric Stump Carcinoma and Primary Upper Third Gastric Cancer

BackgroundThe increased incidence of early gastric cancer in several Asian countries has been associated with an increase in gastric stump carcinoma (GSC) following gastric cancer surgery. The clinicopathological characteristics of GSC remain unclear because of the limited number of patients with GSC. MethodsThe clinicopathological characteristics, including the 5-year survival rate of patients with GSC following distal gastrectomy (167 patients), were compared with those of patients with primary upper third gastric cancer (PGC; 755 patients). The clinicopathological characteristics of patients with GSC were also compared between those who had initial surgery for gastric cancer (GSC-M group, 78 patients) and for benign lesions (GSC-B group, 89 patients). ResultsThe GSC-B group has a greater male/female ratio (13.8 vs. 3.1) and a longer interval between initial gastrectomy and surgery for GSC (31.0 vs. 9.4 years) than the GSC-M group. The 5-year survival rate was not significantly different between the GSC-B group (49.0 %) and the GSC-M group (59.3 %, P = 0.359). A comparison between the GSC group and the PGC group revealed a poorer 5-year survival rate for the GSC group (53.6 %) than the PGC group (78.3 %, P < 0.001), and the same trend was observed even after stratification by the pathological stage. ConclusionsStump carcinoma arises earlier following gastrectomy for malignant disease than for benign disease. The prognosis was poor in patients with GSC compared to those with PGC. Early detection of GSC is necessary and an appropriate follow-up program should be established.

Sa1677 The Significance of Immunohistochemical Staining of EGC Following ESD, With a Focus on Invasion Depth and Lymphovascular Invasion

With the increase in incidence of early gastric cancer (EGC), endoscopic resection is now considered standard treatment for EGC in Korea and Japan. Therefore, precise assessment of the risk of lymph node metastasis in specimens has become essential. Many studies have reported various predictive factors for lymph node metastasis (LNM) in EGC. Among these factors, lymphovascular invasion (LVI) was consistently correlated with LMN in many studies. The aim of this study was to evaluate the relationship between the depth of invasion and the presence of lymphovascular invasion in patients who underwent ESD for EGC, using immunohistochemical staining (IHCS).

Surgical outcomes for gastric cancer of a single institute in southeast China

Background In recent years, with social and economic development and lifestyle changes, the incidence of gastric cancer as well as the surgical results and prognoses of patients with gastric cancer have changed significantly in southeast China. Methods A total of 1,451 patients were divided into 2 groups according to admission time periods. Trends in clinicopathologic characteristics and operative outcomes of these patients were analyzed retrospectively. Results The numbers of old and young patients were significantly increased in period 2 compared with period 1. Tumors located in the proximal stomach increased from 20.26% to 36.83%. The incidence of early gastric cancer was significantly increased from period 1 to period 2. Lymph node metastasis was seen more prevalently in period 2 than in period 1. The rate of operation-related major complications decreased from 5.23% to 1.43%. Operative mortality was .49% in period 1 and .24% in period 2. The 5-year survival rate increased from 38.40% to 53.99%. Conclusions Early diagnosis, standardized surgical treatment including pertinent lymph node dissection, and better perioperative care notably improve the outcomes of patients with gastric cancer.

Lymphovascular invasion is an important predictor of lymph node metastasis in endoscopically resected early gastric cancers

With an increased incidence of early gastric cancer (EGC) and advances in endoscopic technologies, endoscopic resection (ER) has become an important treatment modality for EGC. Therefore, precise assessment of the risk of lymph node (LN) metastasis in ER specimens has become essential. The widely accepted criteria for ER have been mostly obtained from surgical data. This study was performed to evaluate the adequacy of these criteria and re-evaluate the predictive power of the criteria for LN metastasis. We evaluated a series of pathologic factors in ER specimens from 79 gastric cancer patients treated with endoscopic mucosal resection (7) or endoscopic submucosal dissection (72) and underwent subsequent surgical resection due to the potential risk of LN metastasis. Of the 79 patients, 10 patients (12.7%) exhibited regional LN metastasis. Univariate analysis revealed that the presence of lymphovascular invasion (LVI) was significantly associated with LN metastasis (26/69, 37.7 vs. 9/10, 90%, P = 0.004). The number of LVI was significantly higher in the LN metastasis group (1.1 ± 2.3 vs. 7.7 ± 8.4, P<0.001). By multivariate analysis, the presence of LVI (odds ratio, 21.41; P = 0.010) and undifferentiated histology (odds ratio, 11.15; P = 0.016) were significantly correlated with LN metastasis. The presence of LVI, undifferentiated histology and the numbers of LVI were important risk factors for LN metastasis. Among these factors, the presence of LVI was the most important risk factor for LN metastasis in endoscopically resected early gastric cancer.

Proximal gastric cancer: advances of laparoscopic surgery

Although the overall incidence of gastric cancer is decreasing, gastric cancer still remains the fourth most common cancer worldwide. The decrease in the incidence rate varies considerably depending on the geographical area. For example, gastric cancer is continuously the most common cancer type in Asian countries such as Japan, Korea, and China, with a slow and slight drop in the prevalence of the disease in these countries. There has been a greater decrease in the incidence curve over the last few decades in the USA and northwest Europe, but the prevalence of proximal and gastroesophageal junction cancer in these areas is increasing. Therefore, there is interest in how to manage patients with upper-third stomach cancer to improve oncological and quality-of-life (QOL) outcomes not only in the Eastern but also in the Western world. The Aihara et al. [1] report in the September issue of Surgical Endoscopy provides useful information for the laparoscopic surgical treatment of patients with proximal gastric cancer. The authors describe a technique of laparoscopy-assisted proximal gastrectomy (LAPG) and gastric tube reconstruction using a miniloop retractor (MLR). The feasibility and safety of this technique was evaluated in 44 patients with early-stage upper gastric carcinoma. Five surgical ports were inserted into the abdomen and the stomach was lifted to the abdominal wall side with a MLR. Reconstruction with a gastric tube (20 cm long, 3 cm wide) using a circular stapler was performed through a small incision, through which the specimen was removed. The mean operating time was 202 min. There were no serious complications no deaths, and no conversions to open surgery. The authors concluded that this technique of LAPG and gastric tube reconstruction using MLR is feasible and safe for the treatment of proximal early gastric cancer. The data provided by Aihara et al. [1] support the safety of their technique, which is technically more complicated than laparoscopy-assisted distal gastrectomy (LADG). The incidence of early gastric cancer (EGC) in Japan and Korea is high and approximately 50% of cases are diagnosed at this early stage through established nationwide endoscopic screening. These high EGC rates have led to the development and validation of minimally invasive approaches, including endoscopic submucosal dissection (ESD) and laparoscopic surgery in these countries. Criteria for clinical decision-making on ESD, laparoscopic gastrectomy, or open surgery have been defined by Japanese scientific associations. There is now an explosion in laparoscopic surgery for the treatment of gastric cancer in Asian countries and also an increase in the use of this minimally invasive approach in some specialized centers in the West [2]. Based on strong evidence of the superiority of laparoscopic versus open surgery with respect to quality of life for colorectal cancer patients [3] and accumulating evidence, although still incomplete, for early gastric cancer patients [4–6], the technique of laparoscopic gastrectomy has evolved rapidly. Now, the evolution includes totally intracorporeal laparoscopic distal, proximal, or total gastrectomy with standardized extended D2 lymphadenectomy, and indications for its use have been expanded to include patients with advanced resectable stage II and stage III disease [2]. Survival benefits of D2 surgery [7] are now being confirmed by the long-term 15 year survival results of a Dutch trial [8]. This assessment of D2 surgery gains in open surgery makes this standardized lymphadenectomy an C. Batsis (&) Department of Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, TK, Greece e-mail: chbatsis@hotmail.com

Early gastric cancer: The importance of early diagnosis on prognosis of gastric carcinoma.

29 Background: The aim of this study was to evaluate the characteristics of early gastric cancer (EGC) in comparison to advanced tumors and its role in patient's prognosis. Methods: This study was related to 1,272 patients admitted with gastric or gastroesophageal junction carcinoma in our department, between January 1988 and December 2008. During this period the incidence of EGC was 12.68% (3.62% T0, 42.75% T1a and 53.62% T1b). Several clinical, pathological and staging parameters were evaluated according to classification in EGC and advanced tumors. Results: Significant differences were observed in location (p&lt;0.001); type of resection surgery (p&lt;0.001) and of lymphadenectomy (p=0.008 for Siewert and p&lt;0.001 for Japanese classifications) with less radical surgery in EGC patients. This type of tumors presented characteristics associated with a better prognosis in the following pathological parameters: tumor dimensions (p&lt;0.001), macroscopic form (p&lt;0.001), Ming's classification (p&lt;0.001), venous invasion (p&lt;0.001) and lymphatic permeation (p&lt;0.001). The 5-year survival rate of this series was 33.7%. There were significant differences in survival curves according to classification in EGC and advanced tumors (73% at 5 years and 26% at 5 years, respectively). Cox-regression analysis identified age, T and lymph node ratio as independent prognostic factors. There was no significant differences in age (cut-off 45 years), but there was significant differences in lymph node metastasis (p&lt;0.001). In 23.87% of EGC there was lymph node involvement, with significant differences (p=0.002) according to the depth wall invasion [T0 (100% N0), T1a (91.5% N0, 8.5% N1), T1b (60.8% N0, 21.6% N1, 13.5% N2, 4.1% N3a)]. Conclusions: The EGC percentage in our series was lower in comparison with other countries with high incidence of gastric cancer. The prognosis of the patients with gastric carcinoma continues to be gloomy mainly due to the late diagnosis and, given that the surgical treatment doesn't seem plausible of achieving a margin of significant additional progression, the need for an early diagnosis emerges if an improvement in patient survival is desired. No significant financial relationships to disclose.

Laparoscopy-Assisted Distal Gastrectomy with Jejunal Pouch Interposition

The incidence of early gastric cancer (EGC) has been increasing in Asian countries as a result of the development of diagnostic modalities such as endoscopic examination and barium meal examination. Currently in Japan, patients with EGC account for more than half of all patients with gastric cancer. More than 90% of patients with EGC can be cured only by curative gastrectomy. Therefore, in the treatment of EGC, not only complete removal of cancer cells but also minimal invasiveness and improvement of patient quality of life (QOL) after surgery are essential. Distal gastrectomy (DG) with Billroth-I (B–I) reconstruction is the most popular surgical treatment for distal EGC in Japan. Recently, this operation has begun to be performed minimally invasively with laparoscopy-assisted techniques. However, many patients who have undergone open DG or laparoscopy-assisted DG (LADG) have experienced postgastrectomy syndrome, which involves efflux esophagitis, dumping syndrome, and loss of appetite. To prevent postgastrectomy syndrome after DG or LADG, several modified gastrectomy techniques have been developed: pylorus-preserving gastrectomy (PPG), vagal nerve-conserving gastrectomy, and gastrectomy with jejunal pouch interposition (JPI), among others. In this issue of the Annals, Junhyun et al. report the technical safety of LADG with JPI and the better long-term QOL experienced by patients undergoing this operation. The techniques of LADG with JPI, and especially the procedure for forming the jejunal pouch, are more complex than LADG with B–I reconstruction. In this procedure, creation of the jejunal pouch is performed under minilaparotomy in a manner similar to that under open surgery. Although autosuturing machines are used to simplify the techniques of jejunal pouch creation, there are several technical risks including ischemic change of the pouch, bleeding from the sutured edge, and ischemic change at the site of the pouch-duodenal anastomosis. To overcome these problems, several improved techniques have been devised: jejunal J-shaped pouch, short-length jejunal pouch, and use of a surgical stapler with a long slender shaft and three rows of staples (white cartridge). The study by Junhyun et al. evaluated the outcomes of LADG with a 10-cm Ushaped pouch made with a linear stapler with two rows of staples. Although the incidence of postoperative complications was not high, 2 of 25 patients had intra-abdominal bleeding. Thus, it is necessary to establish safe techniques for the performance of LADG with JPI. LADG with JPI was developed to provide patients with EGC advantages such as early recovery after surgery and improvement in postoperative QOL. In their article, Junhyun et al. report good QOL in patients who underwent LADG with JPI compared with those who underwent Billroth-II (B-II) reconstruction. Few reports address postoperative QOL after DG with JPI because of several problems related to research on patient QOL after gastrectomy. First, most important is determining what kind of postDG reconstruction method should be used as a control in the study of patient QOL. Patient QOL after gastrectomy primarily depends on the reconstruction method. Theoretically, dietary volume, systems to prevent efflux, and speed of digestion and movement of food into the duodenum may affect patient QOL. The aims of JPI are to increase dietary volume and decrease the symptoms of efflux. Junhyun et al. compared postoperative QOL after JPI reconstruction with that after B-II reconstruction. Although B-II reconstruction is the most popular method used in China and Korea, a comparison study between LADG with and without JPI should be performed to clarify the effect of JIP on postoperative QOL. A number of reconstruction Society of Surgical Oncology 2010

In vitro porcine training model for colonic endoscopic submucosal dissection: an inexpensive and safe way to acquire a complex endoscopic technique

Colonic endoscopic submucosal dissection (ESD) has developed in recent years to permit en bloc resection of larger colorectal lesions that cannot be done by standard polypectomy or mucosal resection techniques. Colonic ESD is technically demanding and has a steep learning curve. Adequate training is essential to make ESD a reliable treatment for colorectal neoplasms. We aim to share our early experience with an in vitro porcine training model for colonic ESD. Resected porcine distal colon was used to set up a training model for ESD, which was performed as in human using a standard endoscope and dissecting devices. Size of the lesions, operation time, en bloc resection rate, and perforation rate were recorded. Ten consecutive colonic ESD procedures were performed by a single endoscopist. Incomplete resection and perforation were encountered during the first two procedures. No perforation occurred in subsequent procedures and the operation time per task also decreased gradually. The setup cost for this model was only around US $30. The in vitro porcine model is easy and inexpensive to set up. Our initial experience showed that the model could simulate colonic ESD in human and technical proficiency improved by repetition. This simple setup may be a promising training model for endoscopists working in areas with a low incidence of early gastric cancer.