Management Of Early Gastric Cancer Research Articles

Recent advances in sentinel node navigation for gastric cancer: A paradigm shift of surgical management

The sentinel node (SN) is defined as the first draining node from the primary lesion and it has proven to be a good indicator of the metastatic status of regional lymph nodes in solid tumors. In the past 5 years, the validity of SN concept for gastric cancer has been demonstrated by a number of single institutional studies. Using a dual tracer method as the optimal procedure, the radio-guided method allows us to confirm the complete harvest of SNs by gamma probing, while the dye procedure enables us to perform real time observation of the lymphatic vessels. From previous reports, clinically staged T1N0 gastric cancer seems to be a good entity on which to try to change the therapeutic approach based on SN biopsy. At present, two large scale prospective multicenter trials are on-going in Japan. To overcome some remaining issues, such as limited sensitivity of intra-operative diagnosis of metastasis, and technical difficulty in laparoscopic SN detection, further technical and instrumental developments will be required. During this transitional phase, focused lymph node dissection targeted to sentinel lymphatic basins and modified resection of the stomach is an acceptable approach. Although there are several remaining issues, SN navigation should provide a paradigm shift for the surgical management of early gastric cancer in near future.

Minimally invasive surgery for gastric cancer — toward a confluence of two major streams: a review

The minimalization of therapeutic invasiveness in order to preserve quality of life (QOL) is a major topic in the management of early gastric cancer. After laparoscopic surgery for gastric cancer was introduced by Kitano et al. in 1991, an enthusiasm to develop laparoscopic procedures has grown steadily. In the initial phase, early gastric cancer limited to the mucosal layer with no risk of lymph node metastasis was treated by laparoscopic wedge resection or intragastric mucosal resection. Since technical and instrumental advances in endoscopic treatment were achieved by gastroenterologists, these cases can be managed by intraluminal endoscopic approaches. The attention of surgeons then shifted to more radical procedures such as laparoscopic gastrectomy with lymph node dissection, which is comparable to open surgery and can be indicated even in advanced cancer. Although this paradigm shift has already been realized in the field of colorectal surgery, we must pay attention to the particular biological nature of gastric cancer in terms of the potential of peritoneal dissemination. While early-phase recovery after surgery has been improved by laparoscopic surgery, preservation of late-phase QOL by function-preserving surgery is also essential in this regard; therefore, the sentinel node (SN) concept has been a much-discussed topic in gastric cancer surgery to approach this aspect. Recently, the validity of the SN concept has been demonstrated by a number of single institutional studies, and prospective multicenter trials are currently ongoing. Theoretically, various types of function-preserving surgery could be applied in cases of early gastric cancer with negative SNs as less invasive surgery to improve long-term QOL. Although we still have to solve several remaining issues in the treatment of gastric cancers, a confluence of these two major streams, laparoscopic surgery and sentinel node navigation surgery, would enable us to apply a novel individualized minimally invasive approach, both in terms of degree of incisional access and extent of function preservation.

A prospective randomized study comparing open vs laparoscopy-assisted distal gastrectomy in early gastric cancer: early results

We conducted a prospective randomized trial to compare laparoscopy-assisted distal gastrectomy (LADG) including lymphadenectomy with open distal gastrectomy for the management of early gastric cancer (EGC). Forty-seven patients who had been diagnosed endoscopically with EGC were included in a study that ran from November 2001 to August 2003. With the aid of random number table, 23 patients were assigned to the open group (group O) and 24 patients were assigned to the LADG group (group L). Estimated blood loss and transfusion amounts were similar in the two groups. The mean postoperative hospital stay and the duration of analgesic administration were shorter for group L but not significantly so. The mean number of harvested lymph nodes was 38.1 in the O group and 31.8 in the L group (p = 0.098). Postoperative pulmonary complications occurred more frequently in the O group (p = 0.043). At a median follow-up of 14 months, there has been no recurrence of disease in either group. In terms of resulting in fewer pulmonary complications while maintaining the curability of EGC, LADG has a clear advantage over its open counterpart.

Appropriate gastric resection with lymph node dissection for early gastric cancer.

The extent of lymphadenectomy (limited vs. extended) and that of gastric resection (partial vs. total) remain controversial issues in the management of early gastric cancer (EGC). A multicentric study was performed to elucidate the appropriate gastric resection with lymph node dissection for early gastric cancer. From 1979 to 1988, 332 patients with EGC underwent surgery in 23 French centers. Clinicopathological data, the extent of resection, and the number of lymph nodes retrieved were reviewed retrospectively and screened for prognostic effect. The mean follow-up for the 332 EGC patients was 80 months. Postoperative mortality was correlated to age (odds ratio [OR], 1.1) and extent of gastric resection (OR,10.3). Examination of survival data (excluding postoperative deaths) with univariate analysis and the Cox proportional hazards model showed that the independent factors for excellent prognosis included no lymphatic involvement (P =.005), 10 or more lymph nodes retrieved (P =.003), site of the tumor in the lower third of the stomach (P =.01), and mucosal lesions (P =.04). The extent of resection did not influence long-term survival. Our results suggest that because of the associated good prognosis, the appropriate surgical treatment for EGC is partial gastrectomy with lymphadenectomy retrieving 10 or more lymph nodes.

Learning curve for laparoscopy‐assisted distal gastrectomy

Background: Laparoscopy‐assisted distal gastrectomy (LADG) has proved to be useful in the management of early gastric cancer. The aim of the present study was to examine the learning curve for LADG and clarify any technical problems.Methods: The study included 75 consecutive patients who underwent LADG between 1994 and 2002. All operations were performed by a single surgeon and with a surgical team who were skilled in laparoscopic procedures, but new to LADG. Patients were divided into three groups according to the surgeon's level of experience at the time of surgery: Group I (n = 25, surgeries performed between November 1994 and April 1997), Group 2 (n = 25, surgeries performed between May 1997 and January 2000), and Group 3 (n = 25, surgeries performed between February 2000 and August 2002). We considered Groups 1, 2 and 3 to reflect the surgeon's beginning, intermediate and advanced levels of experience, respectively. Operation time, blood loss and incidence of complications were analyzed and compared between groups.Results: Operation time and blood loss did not differ between Groups 1, 2 and 3 (operation time: 236 vs 258 vs 225 min; blood loss: 157 vs 198 vs 144 mg, respectively). Postoperative complications occurred in nine patients (12%); the incidence did not differ between groups. The most frequent complication was wound infection (4%), followed by anastomotic stenosis (3%). There were no intraoperative complications or conversions to open surgery.Conclusions: There is no learning curve for LADG, when it is performed by a skilled surgeon and surgical team. Proficiency in basic laparoscopic techniques and open gastric surgery is easily adapted to safe completion of LADG.

A Prospective Randomized Study Comparing Open Versus Laparoscopy-Assisted Distal Gastrectomy in Early Gastric Cancer

Background: We conducted a prospective randomized trial to compare laparoscopy-assisted distal gastrectomy (LADG) including lymphadenectomy with open distal gastrectomy for the management of early gastric cancer (EGC). Methods: Forty-seven patients who had been diagnosed endoscopically with EGC were included in a study that ran from November 2001 to August 2003. With the aid of random number table, 23 patients were assigned to the open group (group O) and 24 patients were assigned to the LADG group (group L). Results: Estimated blood loss and transfusion amounts were similar in the two groups. The mean postoperative hospital stay and the duration of analgesic administration were shorter for group L but not significantly so. The mean number of harvested lymph nodes was 38.1 in the O group and 31.8 in the L group (p = 0.098). Postoperative pulmonary complications occurred more frequently in the O group (p = 0.043). At a median follow-up of 14 months, there has been no recurrence of disease in either group. Conclusion: In terms of resulting in fewer pulmonary complications while maintaining the curability of EGC, LADG has a clear advantage over its open counterpart.

Endoscopic mucosal resection for early gastric cancer

See article on page 225 The paper by Ono and colleagues1 in this issue of Gut documents the remarkable results achieved at the Tokyo National Cancer Centre Hospital (NCCH) with...

The management of early gastric cancer

Early gastric cancer (EGC) was dened in 1962 as adenocarcinoma conned to the mucosa or submucosa irrespective of lymph node involvement [1]. Today it is well-accepted as a disease entity with a favorable prognosis after surgical treatment. Five-year survival rates over 90% have been reported from Western investigators [2] as well as Japanese surgeons. The majority of papers on EGC are from Japan where gastric cancer is the commonest malignancy. The nationwide screening system in the country [3,4] is usually referred to as a contributory factor to early detection of the disease. The clinicopathological features of the disease and their prognostic signicance have been meticulously investigated in Japan, in studies based on large numbers of cases, sometimes exceeding 1000 [5]. In the West, on the other hand, EGC remains a rare condition that a general surgeon might not encounter during his/her professional career. The number of EGC patients in the Western case series is usually small [2,6,7,8], though some recent European papers include more than a 100 patients [9,10,11]. All of these studies show a trend for EGC to increase as a proportion of all resected gastric cancers, probably because of improvement of diagnostic techniques. It should be noted that, as Everett and Axon concluded in their review [12], the clinicopathological features of the disease are remarkably similar between Japan and the West. Recent trends in the management of EGC show contrasts between Japan and the West. Despite the discouraging results of the D1/D2 trials in Britain [13] and the Netherlands [14], European surgeons have gradually been employing more aggressive surgery for curable gastric cancer [15,16]. On the other hand, Japanese

Radical lymphadenectomy in the management of early gastric cancer in western practice

Radical lymphadenectomy in the management of early gastric cancer in western practice

Experience with Laparoscopic Management of Early Gastric Cancer

Experience with Laparoscopic Management of Early Gastric Cancer