Partial Gastrectomy For Benign Disease Research Articles

S3736 Adenocarcinoma of the Gastric Stump After Billroth II

Introduction: Patients with a prior partial gastrectomy for benign diseases, such as Peptic Ulcer Disease (PUD), are at an increased risk of developing Gastric remnant Carcinomas which generally arise near the anastomotic site. Advancing therapeutics have reduced the prevalence of peptic ulcer gastrectomy, though it may still be indicated in certain instances including; bleeding, perforation, malignancy, and gastric outlet obstruction. Despite decreased gastrectomies performed, the long interval between surgery and the development of cancer has caused the incidence to remain stagnant. Case Description/Methods: A 90-year-old male with a history of PUD status post-Billroth II 57 years prior presented to the hospital with hematemesis. He was admitted to the ICU for hemorrhagic shock and treated with packed red blood cells, IV Pantoprazole, and taken for endoscopy. Unfortunately, the stomach and the middle two-thirds of the esophagus were filled with clotted blood. After more than an hour of irrigation and clot removal, the source of hemorrhage was not found due to the excessive blood. The patient was kept nothing by mouth, given IV erythromycin, and taken for a repeat endoscopy. Again, after copious irrigation and clot removal, a source could not be found. The treatment continued and again endoscopy was performed. During this evaluation, the tissue of the anastomotic region of the stomach was noted to have granularity, friability, erythema, and ulcers. Biopsies were taken, which demonstrated adenocarcinoma of the stomach. The patient decided not to undergo further treatment and was discharged home with hospice care. (Figure) Discussion: Remnant gastric stump cancer after resection of benign disease is a well-recognized complication and is defined as malignancy occurring five or more years after gastrectomy. The incidence is between 0.5-1% and typically increases 30 years after the initial gastrectomy. The underlying pathogenesis is thought to be secondary to reflux of biliary contents retrograde into the stomach, causing gastritis, leading to intestinal metaplasia, and the development of adenocarcinoma. Despite the risk, partial gastrectomy continues to be performed for PUD complications after conservative management has failed. While this process takes many years, it should be strongly considered in younger patients when considering partial gastrectomy. Cases such as this may highlight a need for further research and the development of screening guidelines for earlier detection of gastric remnant carcinoma.Figure 1.: Ulcers, granularity, friability, erythema, and congestion in the gastric antrum.

Outcomes after completion total gastrectomy for gastric remnant cancer: experience from a Canadian tertiary centre

There is controversy about the safety and outcomes of completion total gastrectomy (CTG) for gastric adenocarcinoma. We compared a cohort of patients who underwent CTG for gastric remnant cancer (GRC) after partial gastrectomy for benign disease with patients who underwent primary total gastrectomy (PTG) for sporadic gastric cancer. We retrospectively reviewed a single-institution, prospectively maintained clinical database of patients who had undergone gastrectomy from 2005 to 2016 for demographic, surgical, clinical and tumour pathology data, as well as postoperative, pathologic and oncologic outcomes including complications, length of stay, disease-free survival and overall survival. We used the χ2 and Wilcoxon rank-sum tests to compare groups and performed the Mantel-Cox log-rank test for Kaplan-Meier survival estimates. We compared the CTG group to all patients in the PTG group and to a 5:1 propensity-matched PTG cohort. We analyzed data for 64 patients (9 CTG, 55 PTG). The groups were equivalent at baseline and had similar operative, perioperative treatment and pathologic characteristics. After propensity matching, the reoperation rate for complications was higher after CTG than PTG (22% v. 0%, p = 0.03), but there was no significant difference in the overall complication rate or length of stay. At 5 years, there was no difference in disease-free survival (28% v. 58%, p = 0.4) or overall survival (33% v. 44%, p = 0.7). Our findings suggest that CTG for gastric adenocarcinoma can be undertaken safely a priori with no additional risk of recurrence or death compared to PTG for sporadic gastric cancer.

Atypical anastomotic malignancies of small bowel after subtotal gastrectomy with Billorth II gastroenterostomy for peptic ulcer: Report of three cases and review of the literature.

AIMTo present patients who developed small-bowel malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy for ulcer, to review relevant literature, and to attempt to interpret the reasons those cancers developed to these postsurgical non-gastric sights.METHODSFor the current retrospective study and review of literature, the surgical and histopathological records dated from January 1, 1993 to December 31, 2017 of our department were examined, searching for patients who have undergone surgical treatment of small-bowel malignancy to identify those who have undergone subtotal gastrectomy for benign peptic ulcer. A systematic literature search was also conducted using PubMed, EMBASE, and Cochrane Library to identify similar cases.RESULTSWe identified three patients who had developed small-intestine malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy with Billroth II gastroenterostomy for benign peptic ulcer-two patients with adenocarcinoma originated in the Braun anastomosis and one patient with lymphoma of the efferent loop. All three patients were submitted to surgical resection of the tumor with Roux-en-Y reconstruction of the digestive tract. In the literature review, we only found one case of primary small-intestinal cancer that originated in the efferent loop after Billroth II gastrectomy because of duodenal ulcer but none reporting Braun anastomosis adenocarcinoma following partial gastrectomy for benign disease. We also did not find any case of efferent loop lymphoma following gastrectomy.CONCLUSIONAnastomotic gastric cancer following distal gastrectomy for peptic ulcer is a well-established clinical entity. However, malignancies of the afferent or efferent loop of the gastrointestinal anastomosis are extremely uncommon. The substantial diversion of the potent carcinogenic pancreaticobiliary secretions through the Braun anastomosis and the stomach hypochlorhydria, allowing the formation of carcinogenic factors from food, are the two most prominent pathogenetic mechanisms for those tumors.

Gastric Stump Cancer After Distal Gastrectomy for Benign Disease: Clinicopathological Features and Surgical Outcomes

The purpose of the present study was to analyze clinicopathologic features and long-term prognosis of gastric stump cancer (GSC) arising in the remnant stomach 5years or later after partial gastrectomy for benign disease. We reviewed the results of 176 patients resected with curative intent for GSC at 8 Italian centers belonging to the Italian Research Group for Gastric Cancer (GIRCG). The median (range) follow-up time for surviving patients was 71.2 (6-207)months. One hundred forty-six patients were men, the mean age at the time of diagnosis was 69.2years, and the great majority (167 cases) underwent Billroth II reconstruction. R0 resection was achieved in 158 (90%) patients, and in 94 (53%) lymph node dissection was ≥D2. Postoperative mortality and complication rates were 6.2 and 43.2%, respectively. T1 tumor was diagnosed in 45 (25%) cases. Lymph node metastases were evident in 86 patients (49%). Thirteen patients had involvement of the jejunal mesentery nodes (pJN+); five cases were T2-T3 and eight cases were T4. Overall 5-year survival rate was 53.1%. Five-year survival rates were 68.1, 37.8, and 33.1% for pT1, pT2-3, and pT4 tumors, respectively (P=0.001). Five-year survival rate was 56.5% for node-negative tumors (pN0), 32.3% for tumors with nodal metastases without involvement of jejunal mesentery nodes (pN+), and 17.1% for tumors with involvement of jejunal mesentery nodes (pJN+) (P=0.002). Our study suggests that an aggressive surgical approach can achieve a satisfactory outcome in GSC.

Current State of Gastric Stump Carcinoma in Japan: Based on the Results of a Nationwide Survey

BackgroundCarcinoma of the gastric remnant after partial gastrectomy for benign disease or cancer is unusual but an important cancer model. The Japanese Society for the Study of Postoperative Morbidity after Gastrectomy (JSSPMG) performed a nationwide questionnaire survey to understand the current state of gastric stump carcinoma in Japan.MethodsIn the questionnaire survey of November 2008, gastric stump carcinoma was defined as an adenocarcinoma of the stomach occurring 10 years or more after Billroth I or Billroth II gastrectomy for benign condition or cancer disease. The survey was conducted at the request of reports on five or more patients with gastric stump carcinoma for each institution. Items for the survey included gender, age, methods of reconstruction in an original gastrectomy, original diseases, time interval between original gastrectomy and first detection of stump carcinomas, locations of stump carcinomas, tumor histology, tumor depth, and extent of lymph node metastasis. The questionnaire was sent to 163 surgical institutions in the JSSPMG.ResultsNinety-five institutions (58.3%) responded to the survey, and the data of 887 patients satisfied the required conditions for the survey. A total of 887 patients were composed of 368 patients who received Billroth I distal gastrectomy and 519 who received Billroth II. The Billroth II group has a significantly higher number of original benign lesions than the Billroth I group (P < 0.001). This study confirmed the following issues: (1) The remnant stomach after gastrectomy for cancer disease had a higher prevalence to develop stump carcinomas occurring in a shorter time interval since original gastrectomy; (2) Patients with Billroth II gastrectomy had stump carcinomas most frequently in the anastomotic area, but not in the non-stump area as in Billroth I gastrectomy; (3) Tumor histology of 72.4% of 304 stump carcinomas at an early stage was intestinal type adenocarcinoma, i.e., well or moderately differentiated adenocarcinoma, whereas it decreased to 42.2% at the locally advanced stage of 521 stump carcinomas (P = 0.0015), suggesting that stump carcinoma mostly may develop from intestinal type and change to diffuse type during the evolution to advanced stage cancers.ConclusionsThis large series of surveys suggest that there are two distinct biological plausibilities in the development of gastric stump carcinoma: (1) it develops in a shorter time interval of 10 years or less since the original gastrectomy, may come from a higher risk of gastric mucosa after gastrectomy for cancer diseases that highly predisposes to cancer, and (2) it develops during a longer time interval of 20 years or more, may come from gastrectomy-relating mechanisms after gastrectomy for original benign diseases.

Progression and prognosis of gastric stump cancer

The incidence of gastric stump cancer (GSC) is increasing. The aim of this study is to determine the clinicopathologic feature and the differences of surgical outcome between GSC after partial gastrectomy for benign diseases (GSC-B) and GSC after partial gastrectomy for malignant tumors (GSC-M). Medical records of 42 patients with GSC-B and 47 patients with GSC-M who underwent surgical treatment were studied and analyzed retrospectively. Clinicopathologic parameters, the 5-year survival rate after operation and prognostic factors, were analyzed retrospectively. GSC was frequently detected in anastomotic site. Poorly differentiated cancer was common. No difference was found between patients with GSC-B and patients with GSC-M in terms of histologic type, tumor location, and distribution of tumor stage. GSC-B patients had a higher incidence in No. 7, 8, 9 lymph nodes than GSC-M patients. In contrast, the patients with GSC-M had higher incidence of metastasis to jejunal mesentery lymph nodes and No. 10, 11 lymph nodes. The overall 5-year survival rates were 38.1% for GSC-B and 10.4% for GSC-M, with significant difference (P < 0.05). GSC has a particular pattern in lymph node metastasis and organs invasion. Surgical resection is considered an effective therapeutic strategy for GSC.

Metastatic Gastric Remnant Cancer Occuring Six Years after Partial Gastrectomy for Gastric Ulcer

To describe an early development of metastatic gastric cancer following a partial gastrectomy for a benign condition A case report Gastric stump cancer is known to occur following partial gastrectomy for benign diseases. However, the risk is believed to increase four to fivefold, 20 to 25 years after gastrectomy. We report a 41-year-old man with history of tobacco and alcohol abuse who presented with abdominal pain and constipation. He underwent partial gastrectomy six years previously for gastric ulcer. There was no evidence of malignancy in the surgical specimen and sampled lymph nodes at that time. He was admitted for acute pancreatitis. CT abdomen revealed multiple liver lesions, and biopsy revealed poorly differentiated metastatic adenocarcinoma. EGD revealed mild esophagitis, and duodenal erosion but colonoscopy was normal. CEA and B-HCG were elevated, but AFP was normal. The patient's condition deteriorated and he died before palliative chemotherapy could be started for cancer of unknown primary. At autopsy, there was no gross stomach lesion, but the histopathology at the anastomotic site revealed adenocarcinoma with signet ring features. We reviewed the literature to highlight the need for identification of patients at risk of developing gastric stump cancer especially as it is now being described even in patients who underwent gastric bypass surgery for obesity, a population that continues to increase. More studies are needed to better define any predisposition to cancer following gastric surgery

Laparoscopic gastric resections.

The impressive breakthrough in laparoscopic surgery has pushed surgeons to perform gastric resection through such an approach. Laparoscopy reduces the surgical stress and the postoperative pain and has a positive impact on the rehabilitation time, the hospital stay, and return to work and social activities. Laparoscopic partial gastrectomy for benign diseases and for palliation has been accepted as an effective surgical option: they are reproducible operations performed worldwide at a more and more rapid pace. Laparoscopic gastric resections and laparoscopically assisted gastric resections for malignancy deserve a word of caution. Nevertheless, the investigators report their series of laparoscopic subtotal and distal gastrectomies for cancer with medium and long-term results comparable with those of open surgery. Furthermore, new and less invasive surgical options have been recently introduced. Full and partial thickness local resections may be accomplished through intragastric procedures, for treatment of small benign tumors and early stage gastric cancer.

Laparoscopic Gastric Resections

The impressive breakthrough in laparoscopic surgery has pushed surgeons to perform gastric resection through such an approach. Laparoscopy reduces the surgical stress and the postoperative pain and has a positive impact on the rehabilitation time, the hospital stay, and return to work and social activities. Laparoscopic partial gastrectomy for benign diseases and for palliation has been accepted as an effective surgical option: they are reproducible operations performed worldwide at a more and more rapid pace. Laparoscopic gastric resections and laparoscopically assisted gastric resections for malignancy deserve a word of caution. Nevertheless, the investigators report their series of laparoscopic subtotal and distal gastrectomies for cancer with medium and long-term results comparable with those of open surgery. Furthermore, new and less invasive surgical options have been recently introduced. Full and partial thickness local resections may be accomplished through intragastric procedures, for treatment of small benign tumors and early stage gastric cancer.

Evidence to support a unified pathogenesis of gastric stump cancer

Background Many studies indicate that remote partial gastrectomy for benign disease should be considered a premalignant condition. The reported overall risk of gastric stump cancer is approximately a 2-fold increase, but patients more than 20 to 25 years postoperatively may have a 4- to 5-fold increased risk, compared to the age- and sex-matched general population. Methods In a review the risks, the pathogenesis and the value of endoscopy to avoid gastric stump cancer are described. Results The duration of postoperative interval seems the most important risk factor. The first 10 years after initial surgery. gastric cancer risk may be reduced due to the removal of the most cancer prone distal part of the stomach, but thereafter there seems a rapid increase of the relative risk. The etiology and precise mechanism of carcinogenesis is unknown but the time relationship with the surgery suggests that alterations induced by the operation must be important. Premalignant and precursor lesions apparently occur more frequently in the gastric remnant after peptic ulcer surgery and endoscopic bioptic screening can detect early stump cancers at a curable stage. Conclusions Large scale screening programs of post-gastrectomy patients are nevertheless not recommended; the yield of early stomach carcinomas appears too low to justify surveillance. The individual postgastrectomy patient willing to undergo regular endoscopy may however benefit from such approach. In that event, multiple biopsies should be taken to assess the microscopic appearance of the mucosa. Especially dysplasia is considered as a dependable morphologic marker for the neoplastic potential of the gastric remnant and requires close follow-up.

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

Remote partial gastrectomy for benign disease is a premalignant condition. The overall risk of gastric stump cancer is approximately a twofold increase, but patients more than 20-25 years postoperatively may have a four- to fivefold increased risk, compared to the age- and sex-matched general population. The duration of postoperative interval is the most important risk factor. For the first 10 years after initial surgery, gastric cancer risk may be reduced due to the removal of the most cancer-prone distal part of the stomach, but thereafter there is a rapid increase of the relative risk. The etiology and precise mechanism of carcinogenesis is unknown, but the time relationship with surgery suggests that the anatomical alterations induced by the operation must be important. Hypochlorhydria, reflux, diminished gastrin production, bacterial proliferation, and nitrosation are the putative contributing factors. In addition, smoking appears to contribute to a generalized cancer mortality and decreased life expectancy after peptic ulcer surgery. Digestive tract cancers other than the gastric ones which show an increased risk after peptic ulcer surgery are pancreatic and biliary tract cancers. Premalignant and precursor lesions occur more frequently in the gastric remnant after peptic ulcer surgery and endoscopic bioptic screening can detect early stump cancers at a curable stage. Large-scale screening programs of post-gastrectomy patients are nevertheless not recommended, and surveillance appears not justified.

Epstein-Barr virus and gastric remnant cancer.

Carcinoma arising in the gastric remnant many years after partial gastrectomy for benign disease, referred to as gastric remnant cancer (GRC) is well known, and many causal explanations have been proposed. Elsewhere, Epstein-Barr virus (EBV) involvement has been demonstrated in a small but significant fraction of gastric cancers, and evidence has been presented suggesting that, in positive cases, EBV may have played a causal role. The present report is concerned with EBV involvement in GRC in particular. Paraffin sections from 48 cases of GRC were studied by EBER-1 in situ hybridization. Thirteen cases (27.1%) showed uniform hybridized signals restricted to the carcinoma cells in contrast to no hybridization in the normal mucosa, intestinal metaplasia, or hyperplastic epithelium. The prevalence of EBV involvement in GRC was significantly higher (P < 0.0001) than in gastric carcinomas from 1825 nonremnant cases; the difference remained highly significant even when the comparison was restricted to nonremnant cancers arising in the cardia and middle stomach, for which EBV-positive rates were highest. The EBV may play an important role in the carcinogenesis of GRC.

Early Detection of Gastric Remnant Carcinoma

Partial gastrectomy for benign ulcer disease has been associated with carcinoma in the gastric remnant. To detect formation of this cancer in patients having undergone this operation, we initiated a screening protocol using barium contrast studies, flexible gastroscopy, and biopsy. Patients were selected from a group of 233 patients who had undergone partial gastrectomy for benign disease between 1960 and 1975. In this group, operations for duodenal ulcer had been performed in 156 patients (83 Billroth I and 73 Billroth II reconstructions) and subtotal gastrectomy in 77 patients with gastric ulcer (17 Billroth I and 60 Billroth II reconstructions). From July 1980 to July 1985, 163 patients underwent gastroscopy and biopsy with a median postoperative interval of 14.6 years. Through screening, three resectable remnant carcinomas were found. We conclude that routine gastroscopy leads to earlier detection and a higher rate of resectability if gastric remnant carcinoma is found; yearly screening should be performed after a ten-year postresection interval; and gastroscopic biopsy is more accurate than upper gastrointestinal tract barium contrast studies and should be used preferentially to identify gastric remnant carcinoma.