Postgastrectomy Patients Research Articles

ALTERATIONS IN COAGULATION AND FIBRINOLYSIS DURING SEPSIS

Circulating levels of thrombin-antithrombin III complex (TAT) and plasmin-alpha 2 plasmin inhibitor complex (PIC) in 49 septic patients (23 patients with organ dysfunction (OD), 26 without OD) and 11 postgastrectomy patients were measured to determine the significance of the coagulation-fibrinolytic systems in the development of OD. Tissue plasminogen activator (t-PA), plasminogen activator inhibitor 1 (PAI-1), and thrombomodulin were also measured. The mean level of TAT on the day when OD occurred was significantly higher compared with the maximum level of TAT in septic patients without OD (P < .01) or postoperative patients (P < .01). There was no difference in PIC levels between the three groups. The TAT/PIC ratio was significantly higher in septic patients with OD compared with the other groups (P < .001). Septic patients with OD showed higher levels of PAI-1 (P < .001) but not of t-PA. Thrombomodulin levels were significantly higher in the septic patients with OD compared with the others (P < .001). We conclude that suppression of the fibrinolytic system contributes to the imbalance between coagulation and fibrinolysis, and that this hypercoagulable millieu on the endothelial surface leads to the onset of OD.

Gastric DNA content in postgastrectomy patients. Relationship to mucosal dysplasia.

Gastric mucosal cellular DNA content was assessed in patients who had undergone gastric surgery for peptic ulcer disease more than 20 years previously, with the aim of examining the relationship between abnormal DNA content and gastric mucosal dysplasia, as well as determining the effect of different types of surgery on DNA content. Sixty-five subjects underwent upper gastrointestinal endoscopy. In each, six biopsies were taken from the stoma or antrum and graded for severity of dysplasia. Cellular DNA was quantified using a microprocessor-controlled image analysis system with a fast densitometer card on Feulgen-stained slides. DNA histograms were evaluated using the 2c deviation index (2cDI) for proliferative activity and the 4c exceeding rate (4cER) and the 5c exceeding rate (5cER) as indices of malignant potential. In subjects with Billroth II operations, all the above DNA criteria were higher than in Billroth I (P < 0.05), vagotomy and pyloroplasty (P < 0.001), and controls (P < 0.0001). DNA values increased as dysplasia progressed in severity (2cDI, Rs = 0.67; 4cER, Rs = 0.61; 5cER, Rs = 0.72; respectively, P < 0.0001). Among subjects with no dysplasia, more aneuploid cells were found in the Billroth II group, (p < 0.005) compared with the other types of operation. Cellular DNA content is abnormal at an early stage in dysplasia and may even predate it. Increasing values of abnormal DNA content are related to the severity of dysplasia. DNA analysis may be a useful additional tool in surveillance programs to select high-risk patients for screening.

Gastric DNA content in postgastrectomy patients: Relationship to mucosal dysplasia

Gastric DNA content in postgastrectomy patients: Relationship to mucosal dysplasia

Chronological changes in bone mineral content following gastrectomy.

Recent advances in the modalities of quantitatively assessing bone mineral content have resulted in an increasing awareness of metabolic bone disease as a late complication following gastrectomy. In this study, 98 postgastrectomy patients were examined by quantitative computed tomography (QCT). The bone mineral density index (BMDI), defined as 100 x (measured bone mineral density divided by that of age- and sex-matched controls), was used to evaluate the actual effect of gastrectomy on bone disorders. The BMDI values following gastrectomy were 80.4 +/- 27.3, with no significant difference between men and women, or between total and distal gastrectomy. Moreover, no significant differences were observed between the BMDI values within 6 months, being 92.6 +/- 37.3, and those 6 months to 1 year post gastrectomy, being 79.6 +/- 31.2; however, a significant and sharp decrease to 70.5 +/- 36.0 was evident after 1-2 years. The regression coefficient of the BMDI measured within 2 years postoperatively was lower than that measured after 2 years. These findings suggest that the influence of gastrectomy on bone metabolism is induced within 2 years, after which the bone mineral content decreases in accordance with physiological nature. Thus, we conclude that the treatment for bone disease resulting from gastrectomy would only be effective if initiated within a short period after surgery.

Double-blind placebo controlled cross-over trial of cisapride in postgastrectomy patients with duodenogastric reflux (DGR)

• Double-Blind Placebo Controlled Cross-Over Trial of Cisapride in Postgastrectomy Patients with Duodenogastric Reflux (DGR). M. Vaezi*, R. Sears*, J. Richter #. *U Ala, B'ham;#Cleveland Clin. Excessive DGR is responsible for upper GI symptoms in about 15% of partial gastrectomy patients. Medical treatment has been disappointing, necessi tat ing surgical interventions in many patients. Using ambulatory esophageal bilirubin monitoring (Bilitec 2000), we evaluated the efficacy of cisapride in improving DGR and pat ient-symptoms. METHODS: Ten chronically symptomatic partial gastrectomy VA patients (5 BI, 5 BII) (8M, x age 57) with DGR by Bilitec, without acid reflux, randomized to either placebo or cisapride (20 mg qid) in double-blinded crossover study. Using Bilitec and standard 2200 calorie, liquid diet, DGR evaluated at baseline and after 1 month on each therapy. Daily diary of severity/frequency of upper GI symptoms recorded and mean monthly scores determined. At end of each treatment month , overal l global a s se s smen t made of s y m p t o m improvements. RESULTS: x&+SE. Wilcoxon, Fisher's tests; * p 0.14 Baseline Placebo Cisapride Total 26.2-+3.6 17.5+_2.1 11.2-+3.7 Upright 26.4+4.1 12.8-+3.5 7.1-+2.9 Supine 21.0+3.6 25.7+5.6 11.9-+3.8 Compared to placebo, cisapride significantly decreased DGR by 45% in upright and 54% in supine positions. There was no order effect. Overall symptoms improved in 70% of patients on cisapride compared to 10%'on placebo tp 7 and bili abs. > 0.14. RESULTS: x-+SE;ANOVA;*p 7 7.2-+1.8 6.1-+1.8 6 .0-+1.7 5.7-+1.6 4.6-+1.5 bili>.14 0.7-+0.2 11.1-+5.0 20.1-+8.4 25.9-+5.9* 48.0-+4.8*# B_~dmM) 0.03-+0.0 0.09-+0.03* 0.16-+0.05 0.24-+0.07_.* 0.50+-0,10# % Time pH 0.14 and gastric BA only discriminated complicated Barrett's from other patient groups. Linear regression found significant correlation (R=0.7, p 0.14 (R=0.3, p>.05), while correlation remained strong for % time pH 7 did not differentiate patients. CONCLUSIONS: 1) pH < 4 is a better predictor of GERD severity. 2) Bile reflux shows parallel increase over GERD spectrum, but only discriminates complicated Barrett's patients from other GERD patient groups. 3) Our study supports the 1 ° role of acid in GERD, but suggests a possible synergistic role for bile acids in complicated Barrett's patients.

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.

A CASE OF LENNERT'S LYMPHOMA ASSOCIATED WITH GASTRIC CANCER

A case of Lennert's lymphoma in a postgastrectomy patient under strict observation for gastric cancer is descrived with a review of the literature. A 67-year-old man was admitted to the hospital because of a walnut-sized mass in the left axilla. The mass was relatively hard, painless, and poor in movability. It has a smooth surface. We suspeced lymph node metastasis of the gastric cancer or malignant lymphoma. Biopsy cytology was performed, but no definite diagnosis was made. A resection of the left axillar tumor was performed. Histological diagnosis was made as of Lennert's lymphoma. Anticancer chemetherapy was added following the surgical treatment, and he has been disease-free. The relationship between gastric cancer and Lennert's lymphoma is still obscure. No additional case report has been seen in the literature as far as we could review. This case is extremely rare.

CLINICOPATHOLOGICAL EVALUATION OF CANCER OF THE REMNANT STOMACH

To clarify the pathogenesis of cancer of the remnant stomach, we clinicopathologically evaluated 16 patients more than 10 years postgastrectomy. Four had undergone gastrectomy for gastric cancer (group A) and 12 for peptic ulcer (group B). Patients in group B were older than in group A. Billroth-I method was used in 13 cases and Billroth-II method in 3 cases. Billroth-II method was not used in group A. The interval after gastrecotmy was 12.3±3.9 years in group A and 25.3±7.6 years in group B (p<0.001). Resectability was 100% in group A and 50% in group B. Nine patients located in the surgical stump and 7 at other sites. Early gastric cancer was found in 5 cases and advanced cancer in 11 cases. Invasive advanced cases, such as type 3 or 4, accounted for 58.3% in group B. Nine cases (56.3%) were curable and curability in group B was less than in group A. Undifferentiated adenocarcinoma was found in 12 cases (75.%) and it accounted for 83.3% in group B. Histological stage III and IV lesions accounted for 58.3% of the cases in group B. Five-year survival rates after operation were 75.0% in group A and 31.4% in group B. The survival rates for the early cases or for the curative cases were better in both group than for the advanced cases or for the noncurative cases. Appropriate follow up enabled early detection for cancer of the remnant stomach and improved results of therapy in postgastrectomy patients regardless of whether the reason for the gastrectomy was cancer or peptic ulcer.

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.

Clinical and radionuclide evaluation of bile diversion by Braun enteroenterostomy: prevention and treatment of alkaline reflux gastritis. An alternative to Roux-en-Y diversion.

OBJECTIVE AND SUMMARY BACKGROUND: Symptomatic, medically resistant postgastrectomy patients with alkaline reflux gastritis (ARG) have increased enterogastric reflux (EGR) documented by quantitative radionuclide biliary scanning. Even asymptomatic patients after gastrectomy have increased EGR compared with nonoperated control patients. Roux-en-Y biliary diversion, although successfully treats the clinical syndrome of ARG, has a high incidence of early and late postoperative severe gastroparesis, Roux limb retention (the Roux syndrome), or both, which often requires further remedial surgery. As an alternative to Roux-en-Y diversion, this review evaluates the efficacy of the Braun enteroenterostomy (BEE) in diverting bile away from the stomach in patients having gastric operations. Based on previous pilot studies, the BEE is positioned 30 cm from the gastroenterostomy. Thirty patients had the following operations and were evaluated: standard pancreatoduodenectomy (8), vagotomy and Billroth II (BII) gastrectomy (6), BII gastrectomy only (10), and palliative gastroenterostomy to an intact stomach (6). All anastomoses were antecolic BII with a long afferent limb and a 30-cm BEE. Four symptomatic patients with medically intractable ARG and chronic gastroparesis had subtotal BII gastric resection with BEE rather than Roux-en-Y diversion. Eight control symptomatic patients and six asymptomatic patients with previous BII gastrectomy and no BEE were evaluated. Radionuclide biliary scanning was performed within 30 days in all patients and at 4 to 6 months in 14 patients. Bile reflux was expressed as an EGR index (%). After operation, 18 of 34 patients (53%) had no demonstrable EGR while in the fasting state for as long as 90 minutes. The range of demonstrable bile reflux (EGR) in the remaining 16 patients was from 2% to 17% (mean, 4.5%). Enterogastric reflux in the 14 control patients (with no BEE) ranged from 5% to 82% (mean, 42%). The four patients with ARG and chronic gastroparesis treated by subtotal gastrectomy and BEE had postoperative EGR of 0%, 2%, 2%, and 4%, respectively. They are asymptomatic with no evidence of bile reflux gastritis. In the 14 patients who had late evaluation, EGR ranged from 0% to 16% (mean, 5.5%). No patient had signs or symptoms of ARG after operation. Braun enteroenterostomy successfully diverts a substantial amount of bile from the stomach. The ARG syndrome might be prevented by performing BEE during gastric resection or bypass in a variety of operations. Conversion to a BII with BEE may be an alternative to Roux-en-Y diversion in treating medically resistant ARG and subsequent may avoid the Roux syndrome.

The value of sham-feeding tests in patients with postgastrectomy syndromes.

The value of gastric secretory testing in surgical practice has been questioned. Sham feeding (SF) is a test of gastric secretion that determines the status of gastric vagal innervation or incomplete vagotomy. Our purpose was to show that the results of SF tests affect operative strategy and/or clinical management. The medical records of 30 consecutive patients studied with SF in our laboratory were reviewed to determine if patient management was affected by the results of SF. All 30 patients had prior vagotomies. Sham feeding was performed in patients (1) before planned reoperation for postgastrectomy syndromes (n = 17), (2) with peptic ulcerations/pain of unclear etiology (n = 8), or (3) postoperatively in those who were at high risk for recurrent ulcer (n = 5). Sham feeding indicated complete vagotomy in 16 patients and incomplete vagotomy in 14 patients. In 17 patients studied before planned reoperation, operative strategy was affected by results of SF in 15 cases; five patients had revagotomies performed at reoperation, 11 did not, and one patient had her operation canceled. In patients with atypical postoperative ulcers/pain, management was changed in only two of eight patients. In the high-risk patients studied postoperatively, management was affected in four of five patients. (1) We believe that our results justify the performance of SF before any reoperation on the stomach, since an operative plan was nearly always affected. (2) In patients with atypical peptic complaints after gastric surgery, SF usually (80%) confirmed acid hypersecretion, thereby affecting management less often. (3) Although unproved, we believe SF results can guide the use of "prophylactic" H2-blockers in treating selected high-risk postgastrectomy patients.

Changes in gastric mucosal ornithine decarboxylase and tyrosine phosphorylation of proteins in postgastrectomy patients.

There is evidence to suggest that partial gastrectomy is associated with an increased risk of developing gastric carcinoma in humans. Since ornithine decarboxylase (ODC) and tyrosine phosphorylation of proteins are involved in the regulation of cell proliferation, the present study was undertaken to examine the time-dependent changes of these variables in the postgastrectomy stomach. Thirty-seven postgastrectomy patients (Billroth I (BI), n = 7, and Billroth II (BII), n = 30) underwent gastroscopy. For comparison, five patients with intact stomachs (three healthy and two postvagotomy and pyloroplasty) were also studied. Gastric mucosal biopsy specimens were obtained within 5 cm of the anastomosis and analyzed for ODC activity. In addition, tyrosine phosphorylation of membrane proteins was also determined in representative samples of BII patients. Gastric mucosal ODC activity was significantly higher in BII patients in whom gastrectomy had been performed > 15 years earlier compared with those in whom it had been performed < 15 years earlier (p < 0.001) or controls (p = 0.004). Although the mean ODC activity was higher in BII than in BI patients, the difference was not significant (p = 0.103). Isolated patients with high ODC activity demonstrated increased phosphorylation of tyrosine membrane proteins with M(r) of 55-60.

OSTEOMALACIA COMPLICATING IN THE EARLY COURSE AFTER GASTRECTOMY-REPORT OF A CASE-

This paper presents a case of osteomalacia developed about one year after gastrectomy. A 62-year-old man was seen at the hospital because of back pain. There was a history of undergoing distal partial gastrectomy with combined resection of the pancreas head and duodenum one year before. On examination, hypocalcemia and high blood level of ALP were revealed. Bone mineral density of the lumbal spine was in a low level (0.636g/cm2) measured by DEXA (Dual energy X-ray absorptiometry). Iliac bone biopsy was performed after tetracycline labelling. Osteomalacia was diagnosed because of increasing osteoid surface, osteoid thickness and delayed mineralization time by using histomorphometric analysis. The active vitamin D was used on the patient. Ionized Ca and clinical symptoms were improved after the treatment. The patient was diagnosed as postgastrectomy osteomalacia. It is supposed that the early development of osteomalacia may be due to Ca and vitamin D malabsorption, resulting from gastrectomy with combined resection of the pancreas head and duodenum, which were severer than usual postgastrectomy patients.

THE INCIDENCE AND FACTOR OF GALLSTONE FORMATION AFTER GASTRECTOMY

To evaluate the incidence and period of gallstone formation after gastrectomy for a carcinoma, questionnaire survey has been conducted in 316 patients. Replies were obtained through 81% of the patients. Except for 48 unknown cases, 31 (15%) out of the 209 patients had gallstones. Additionally, 5 patients had gallbladder debris, 3 had cholesterol polyp, and one had acute cholecystitis. Overall 40 patients (19%) had some gallbladder disease. In 50 patients undergoing total gastrectomy, 13 (26%) had gallstones, and 17 (34%) had some gallbladder diseases. Gallstone was found within 5 years after gastrectomy in 14 cases, between 5 to 10 years in 12 cases, and after 10 years in 5 cases. In 26 cases (84%), gallstone was found within 10 years. Cholecystectomy was done in 13 patients, but 18 patients had no symptom and have been periodically checked at the outpatient clinic. In 13 cholecystectomised patients, 9 had black stone, and 2 had bilirubin stone. In the remaining 2 cases, nature of the stone was unclear. There was no cholesterol stone. In follow up of postgastrectomy patients with gastric cancer, special attention should be given to gallstone formation as well as recurrence. In such situation, the adequacy of prophylactic cholecystectomy would be a further problem to be solved.

Evaluation of endoscopy for early detection of gastric-stump cancer

The value of endoscopic surveillance of postgastrectomy patients for the early detection of gastric-stump cancer is controversial. Using data from an Amsterdam postgastrectomy cohort of 2633 patients, we have done a retrospective analysis of the effect on mortality from gastric cancer of endoscopic surveillance in these patients. Between 1976 and 1982, 504 symptom-free patients from the Amsterdam cohort participated in an endoscopic surveillance programme. All patients were followed up until 1988. Relative to the general Dutch population, risk of death from gastric cancer was less among patients who took part in surveillance than among those who did not participate. However, differences were small and similar differences existed for risk of death from lung and colorectal cancers, suggesting the presence of selection. Our study seems to confirm that large-scale surveillance of postgastrectomy patients is not justified.

Prospective comparison of Congo red and sham feeding testing to determine vagal innervation of the stomach

The purpose of this study was to validate Congo red (CR) testing as a means of determining the status of vagal innervation of the stomach after gastric surgery by comparing it with the sham feeding test (SF). Twenty-six patients with previous gastric operations were studied prospectively. The operations were vagotomy/antrectomy (n = 14), vagotomy/ antrectomy/Roux-en-Y anastomosis (n = 4), proximal gastric vagotomy (n = 3), vagotomy/pyloroplasty (n = 2), and antireflux (n = 3). In each case, the CR test was performed prior to the SF test so that the endoscopist was unbiased. The CR test solution was sprayed on the gastric mucosa through a wash catheter and immediately aspirated. A two-dimensional map of the endoscopist's conception of the red and black mucosa was drawn, and areas were calculated using a computerized scanner. The SF test was performed as described previously, with sham/peak ratios (sham feeding stimulated acid output [SAO]/peak acid output [PAO]) greater than 0.1 indicating a positive test, or incomplete vagotomy. The CR test was negative in 11 patients and positive in 15 patients. SF was negative in 16 patients (SAO/PAO of less than 0.1) and positive in 10 patients. The results correlated in 18 of 26 (69%) patients (p = not significant). Positive sham feeding tests and negative Congo red tests were more reliable, whereas negative sham feeding tests and positive Congo red tests were less reliable. Except patients with Roux-en-Y anastomosis, patients with negative or weakly positive CR tests did not have recurrent ulcers or other symptoms attributable to acid hypersecretion. The CR test was easier to perform and preferred by the patients. We conclude that both tests provide valuable clinical information and that both tests should be available in the evaluation of postgastrectomy patients.

Osteopenia and osteomalacia after gastrectomy: interrelations between biochemical markers of bone remodelling, vitamin D metabolites, and bone histomorphometry.

The prevalence of metabolic disease in a population of 68 postgastrectomy patients was assessed using histomorphometric evaluation of transiliac bone biopsy specimens after tetracycline double labelling. Trabecular bone volume was significantly lower in the postgastrectomy group (p less than 0.01): 62% of the patients had increased osteoid surface, 56% increased osteoid thickness, and 24% increased mineralisation lag time. Only 18%, however, fulfilled the diagnostic criteria for osteomalacia--increased osteoid thickness and increased mineralisation lag time. Postgastrectomy patients had reduced serum concentrations of calcium (p less than 0.01), phosphate (p less than 0.01), and 25-hydroxyvitamin D, while levels of alkaline phosphatase and 1,25 dihydroxyvitamin D were high (p less than 0.01). The severity of the mineralisation defect as reflected by mineralisation lag time was positively correlated to serum 25-hydroxyvitamin D, but unrelated to serum 1,25-dihydroxyvitamin D. Multiple linear regression analysis showed that serum 25-hydroxyvitamin D, age, and the duration of postoperative follow up were significant determinants of the mineralisation defect in a given patient. The limited value of serum markers in the diagnosis of osteomalacia was emphasised by the fact that six of the eight patients with osteomalacia had normal serum levels of calcium and alkaline phosphatase, and five of the eight had values for 25-hydroxyvitamin D in the normal range for healthy control subjects. The results clearly show the need for vitamin D supplementation and regular control after gastric resection.

Multivariate Analysis of the Risk of Stomach Cancer after Ulcer Surgery in an Amsterdam Cohort of Postgastrectomy Patients

Although gastric cancer incidence is decreasing in the western world, it remains an important cause of death, and there has been debate about screening persons who have undergone gastrectomy for benign ulcers. The authors analyzed risk factors for stomach cancer mortality in an Amsterdam cohort of 2,633 postgastrectomy patients, followed from their initial surgery between 1931 and 1960 until 1975, with 99.7% complete follow-up. Increased stomach cancer mortality was observed in the study population (compared with the general Dutch population) among males 25 years or more after surgery (observed/expected, 5.0; 95% confidence interval (Cl) 2.8-8.3), and among females 15-24 years postoperatively (observed/expected, 3.5; 95% Cl 1.0-9.0). A multivariate Poisson regression analysis showed that after control for age at time of surgery and calendar year of operation, the most important risk factors were time since surgery (0-4 years, relative risk (RR) = 1.0; 5-14 years, RR = 4.1, 95% Cl 0.93-18.5; 15-24 years, RR = 9.4, 95% Cl 2.1-42.3; and 25-46 years, RR = 55.6, 95% Cl 11.7-265.4) and ulcer location (gastric versus duodenal ulcer, RR = 2.6, 95% Cl 1.4-4.8). Surveillance for postgastrectomy cancer could be considered 15-25 years after a patient undergoes surgery for gastric ulcer disease.

Long-term prognosis after partial gastrectomy for benign conditions: Survival and smoking-related death of 2633 Amsterdam postgastrectomy patients followed up since surgery between 1931 and 1960

Decreased life expectancy may occur after remote peptic ulcer surgery, but the cause of shortened survival is unclear. A 50-year follow-up study of an Amsterdam cohort of postgastrectomy patients who underwent ulcer surgery between 1931 and 1960 showed a statistically significant decrease in survival after a postoperative interval of 12 years or more compared with the general population. The shortened life expectancy mainly reflected decreased survival in men. In women, no significant difference in survival compared with the general population was observed. The excess mortality in men was predominantly due to a statistically significant increase in cancer-related deaths. Carcinoma of the lung accounted for the majority of excess mortality. No time relationship between lung cancer death and interval since surgery was observed. Thus, smoking, primarily in men who had undergone surgery for gastric ulcers, seems an important factor contributing to excess mortality and shortened life expectancy. Excess mortality due to tobacco use has also been observed in postmarketing surveillance of H2-receptor antagonists. Therefore, smoking cessation may provide the greatest improvement in the long-term prognosis of peptic ulcer patients, regardless of the treatment.

Geographical Variance in the Risk of Gastric Stump Cancer: No Increased Risk in Japan?

Geographical differences may exist in the risk of gastric stump cancer. Therefore, we performed meta‐analysis of literature reports in Japan (n=3), the USA (n=4), and Europe (n = 20) on the risk of postgastrectomy cancer. The weighted mean relative risk of stump cancer in Japan was 0.28, 95% confidence limits 0.21–0.38 as compared to 1.53, 95% confidence limits 0.98–2.41 in the USA and 1.66, 95% confidence limits 1.55–1.79 in Europe. Thus, the risk of gastric cancer in the postgastrectomy patient seems decreased in Japan and is significantly less than in the USA or Europe, where an increased risk exists. Since there is a high risk of gastric cancer of the intact stomach in Japan, the discovery of a low cancer risk in the gastric stump may provide evidence that these gastric cancers are two different entities.