Proximal Gastric Resection Research Articles

RISK FACTORS FOR ESOPHAGOGASTRIC ANASTOMOSIS FAILURE DEPENDING ON TYPE OF ESOPHAGEAL PLASTY

Aim. The aim of the study was to improve the results of treatment of esophageal anastomosis failure in esophagoplasty. Materials and methods. During 20 years, 262 esophageal resections with different variants of plasty for cancer and benign esophageal diseases were fulfilled. Anastomosis failure was developing in 65 % of cases (24,8 %). Results. More frequently anastomosis failure was developing after the posteromediastinal esophagogastroplasty - in 43 patients (38,4 %). Following the proximal gastric resections with esophageal resection from laparotomy approach, complications were diagnosed 11 patients (24,3 %), gastrectomy with esophageal resection - in 6 persons (16,2 %). Anastomosis failure occurred after Lewis surgeries - in 5 cases (7,7 %). Twenty three (35,4 %) patients underwent the repeated surgeries. Thirty one patients died (11,4 %). Death caused by purulent complications following anastomosis failure was registered in 58,1 % of patients. Surgical circular stapling instruments CDH and CEEA used for the formation of anastomosis permitted to reduce its failure rate from 34,1 to 15,4 %, and experience of esophageal surgery - to decrease lethality from 19,1 to 6,8 % for 20 years. Conclusions. Esophageal anastomosis failure more often occurs after the posteromediastinal esophagogastroplasty, rarely - after Lewis surgery that is connected with peculiar features of transplant blood supply. Machine suture raises reliability of anastomosis.

ENDOSCOPIC VACUUM THERAPY IN THE TREATMENT OF ANASTOMOTIC INCOMPETENCE IN THE UPPER DIGESTIVE TRACT: THE FIRST EXPERIENCE AND A REVIEW OF THE LITERATURE

Surgery for the upper digestive tract is justly a high-risk one and is absolutely associated with the development of severe, life-threatening complications, particularly incompetent digestive anastomoses, which in turn lead to pyoseptic complications. After extensive surgical interventions into the esophagus and stomach, the mortality rates from anastomotic incompetence are as high as 60%. There is a steady decline in the number of complications due to the accumulation of experience and improvement of surgical techniques. Endoscopic techniques for the closure of perforation are priority since they result in lower mortality rates. The paper describes the experience in treating 6 patients (after laparoscopic proximal gastric resection (n = 4), gastrectomy (n = 1), and longitudinal gastric resection (n = 1)), by using a vacuum aspiration system, in the period from March to December 2015. It shows a procedure for installing the vacuum aspiration system and its mechanism of action, gives the obtained results of this procedure, and analyzes the experience of world literature.

Technique and Outcomes of Laparoscopic-combined Linear Stapler and Hand-sutured Side-to-Side Esophagojejunostomy With Roux-en-Y Reconstruction as a Treatment Modality in Patients Undergoing Proximal Gastrectomy for Benign and Malignant Disease of the Gastroesophageal Junction

Circular stapler and hand-sutured esophagojejunostomy has been the most popular technique utilized in patients undergoing proximal gastrectomy through Roux-en-Y reconstruction for disease processes of the gastroesophageal junction. In recent years, with the advent of laparoscopic bariatric surgical techniques and refined linear stapler cutters, surgeons have developed the linear stapler side-to-side technique as a valid option. The aim of this study is to describe our technique and review the outcomes using the Roux-en-Y reconstruction with linear staplers after laparoscopic proximal gastrectomy for malignant and benign disease. After Internal Review Board approval and with adherence to the Health Insurance Portability and Accountability Act guidelines, a retrospective review of a prospectively collected database was conducted. A total of 14 patients underwent proximal laparoscopic gastric resection at our institution during a 3-year period from January 2008 to January 2011. Sex, body mass index, prior surgeries, complications of the prior surgery, intraoperative complications, pathologic findings, postoperative complications, hospital stay, and outpatient follow-up were measured in the preoperative and postoperative period. Our patient population consisted of 9 women and 5 men, with a mean age and body mass index of 45.42 years and 35.64 kg/m, respectively. Indications for proximal gastrectomy was in 4 patients a leak at the angle of His secondary to sleeve gastrectomy for morbid obesity, 1 patient was a stricture after a vertical banded gastroplasty, 1 patient a revision of a eroded gastric band, 1 patient a revision of a eroded mesh secondary to a hiatal hernia repair, 1 patient a conversion of a failed Nissen, 3 patients had a total gastrectomy due to a stage 2 gastric cancer, and 1 patient a gastrointestinal stromal tumor. There were no intraoperative complications. All the procedures were completed laparoscopically. The mean operative time was 137.16 minutes. The mean hospital stay was 7.6 days. One patient had a postoperative stricture at the esophagojejunal anastomosis that required multiple dilatations. All patients with gastric cancer are free of tumor recurrence. The use of a laparoscopic proximal gastrectomy with Roux-en-Y reconstruction through combined side-to-side linear stapler and hand-sewn esophagojejunal anastomosis seems to be a feasible and safe approach.

PWE-167 Anvil suture pull-through technique for laparoscopic circular stapled oesophagojejunostomy: technical report and outcomes

IntroductionThe development of laparoscopic gastrectomy has lead to the need for intracorporeal stapled oesophagojejunostomy. Described techniques include overlap with a linear stapler1 and oral insertion of the anvil of a...

Esophageal Avulsion Following Removal of a Partially Covered Esophageal Stent: Lessons Learned 10 Years Later

S esophageal stents are used for benign and malignant diseases, though no self-expandable metal stent (SEMS) is ood and Drug Administration (FDA)-approved for benign disease. ully covered SEMS and self-expandable plastic stents (SEPS) are emovable due to lack of tissue embedment.1 We describe a patient in whom a partially covered SEMS was placed for benign disease prior to the commercial availability of fully covered SEMS and SEPS. Subsequent removal was complicated by stent avulsion. A 60-year-old man underwent distal esophagectomy with proximal gastric resection of a T3N0M0 adenocarcinoma in early 2001. Two months after surgery, he developed an esophagogastric anastomotic stricture and tracheoesophageal fistula with severe aspiration pneumonia. Neither fully covered SEMS nor SEPS were commercially available then. A 23-mm diameter, partially covered SEMS (Ultraflex; Boston Scientific, Natick, MA) was placed across the esophagogastric anastomosis. He clinically improved with normal swallowing. Serial bronchoscopic examinations were performed (Figure A) until the stula could no longer be identified 6 months later. Endoscopic stent emoval was performed by grasping the proximal portion of the stent ith a rat-toothed forceps and was withdrawn, but the esophagus was till attached (Figure B). Pathology revealed squamous mucosa with ubmucosal fibrosis. The patient was emergently intubated, transerred to intensive care, and upper endoscopy showed completely enuded esophageal mucosa, but no perforation or disruption of the nastomosis was seen. Bronchoscopy showed a 1-mm tracheoesophgeal fistula. Repeat esophagoscopy and bronchoscopy 4 days later howed a hypopharyngeal tear at the upper esophageal sphincter. ollow-up examinations showed healing of the tear and fistula but he patient subsequently developed a refractory proximal cervical sophageal stricture necessitating hypopharyngeal colonic interposiion. Unfortunately, the patient developed chronic aspiration and ied of pneumonia 8.5 years after initial SEMS placement and withut recurrent adenocarcinoma. SEMS and SEPS were developed for palliation of malignant esophgeal disease. Over time they have been used for benign diseases. emoval of partially covered SEMS is feasible despite the fact that the ncovered portion becomes embedded into the esophageal wall. In ases where the distal end of a partially covered SEMS remains in the tomach embedding generally occurs only on the esophageal side. fter this present case and before SEPS and fully covered SEMS were ntroduced, we would remove partially covered SEMS using the inersion technique as described by Low and Kozarek.2 Nevertheless, there have been complications similar to this case.3,4 More recently, removal of partially covered SEMS using a stent-in-stent technique has been described.5 Using this method a fully covered SEMS or SEPS is placed inside the partially covered SEMS to induce tissue necrosis between the esophageal lumen and the embedded stent in order to bring the uncovered portion of the SEMS to the luminal surface. Both stents are then removed during the endoscopic session 7 to 14 days later (Supplementary Video 1). We continue to use partially covered SEMS in patients with benign esophageal disease who have experienced repeated SEMS and/or SEPS migration and have not resolved their underlying disease process with removal of the partially covered SEMS using the stent-in-stent technique as described. To date we have removed 5 partially covered SEMS using this method without technical difficulty or adverse event.

Reconstruction of the esophagojejunostomy by double stapling method using EEA™ OrVil™ in laparoscopic total gastrectomy and proximal gastrectomy

Here we report the method of anastomosis based on double stapling technique (hereinafter, DST) using a trans-oral anvil delivery system (EEATM OrVilTM) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection.As a basic technique, laparoscopic total gastrectomy employed Roux-en-Y reconstruction, laparoscopic proximal gastrectomy employed double tract reconstruction, and end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum.We used EEATM OrVilTM as a device that permitted mechanical purse-string suture similarly to conventional EEA, and endo-Surgitie.After the gastric lymph node dissection, the esophagus was cut off using an automated stapler. EEATM OrVilTM was orally and slowly inserted from the valve tip, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. Yarn was cut to disconnect the anvil from a tube and the anvil head was retained in the esophagus.The end-Surgitie was inserted at the right subcostal margin, and after the looped-shaped thread was wrapped around the esophageal stump opening, assisting Maryland forceps inserted at the left subcostal and left abdomen were used to grasp the left and right esophageal stump. The surgeon inserted anvil grasping forceps into the right abdomen, and after grasping the esophagus with the forceps, tightened the end Surgitie, thereby completing the purse-string suture on the esophageal stump.The main unit of the automated stapler was inserted from the cut-off stump of the lifted jejunum, and a trocar was made to pass through. To prevent dropout of the small intestines from the automated stapler, the automated stapler and the lifted jejunum were fastened with silk thread, the abdomen was again inflated, and the lifted jejunum was led into the abdominal cavity.When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, DST-based anastomosis was completed with no dog-ear.The method may facilitate safe laparoscopic anastomosis between the esophagus and reconstructed intestine. This is also considered to serve as a useful anastomosis technique for upper levels of the esophagus in laparotomy.

Adenocarcinoma of the esophagogastric junction: Neoadjuvant radiochemotherapy and radical surgery

To retrospectively evaluate treatment results and toxicity following a combined approach consisting of neoadjuvant radiochemotherapy and radical surgery in advanced adenocarcinoma of the esophagus and gastroesophageal junction. Between 2005 and 2009, a total of 41 consecutive patients with newly diagnosed nonmetastatic adeno-carcinoma of the esophagus and the esophagogastric junction were evaluated, of whom 23 received neoadjuvant radiochemo-therapy (RCT). A total dose of 50.4 Gy with 2 cycles of simultaneous cisplatin/5-fluorouracil (FU) or Taxol/FU-chemotherapy were applied. A radical transthoracic subtotal esophageal and proximal gastric resection through a right thoracoabdominal laparotomy with intrathoracic anastomosis was performed 6-8 weeks following RCT. This was combined with a two-field lymphadenectomy of mediastinal and abdominal lymph nodes. Standard histopathological evaluation included the application of regression grading according to Werner and Höfler. Toxicity was recorded on the basis of CTC criteria; survival curves were calculated according to Kaplan-Meier. V10, V15, and V20 data were correlated with pulmonary toxicity. Overall survival for all 23 patients was 61% at 3 years. Of the original 23 patients, 18 (78%) patients proceeded to radical surgery. Reasons for no surgery included advanced age of 79, 82, and 86 years (n = 3), severe comorbidity (n = 1), and progression during radiochemotherapy (n = 1). Surgical morbidity (grade 3-4) and mortality rates were 35% and 6%, respectively. Resurgery was necessary in 3 cases (18%). Clear resection margins were achieved in 17 of 18 patients (94%). Twelve of 18 (67%) patients initially diagnosed with T3 tumors and 3 of 3 patients with T4 tumors experienced downstaging. The ypN0 rate was 12 of 18 patients (67%). Out of a total of 18 patients, regression grading revealed < 10% viable cells in 8 (44%) including 3 cases (17%) with complete regression, 10-50% viable cells in 9 (50%) and > 50% viable cells in 1 patient. During the postoperative course or thereafter, 8 of 23 (35%) patients experienced pulmonary complications including pneumonia and/or pneumonitis. V10 > 20% (p = 0.019), V15 > 13% (p = 0.008), and V20 > 10% (p = 0.008) were associated with a significant increase in the rate of pulmonary toxic effects. Neoadjuvant radiochemotherapy in patients with advanced adenocarcinoma of the esophagogastric junction followed by thoracoabdominal surgery is a feasible concept. Significant tumor regression in 44% of the patients and an ypN0 rate in 67% of the patients may favor this approach due to its high efficacy. However, to avoid toxic pulmonary effects constraints for low-dose radiation volume parameters need specific attention.

Reconstruction of the Gastrointestinal Tract byHemi-DoubleStapling Method for the Esophagus andJejunum Using EEA OrVil in Laparoscopic Total Gastrectomy and Proximal Gastrectomy

We report the method of anastomosis based on a hemi-double stapling technique (hereinafter, HDST) using a trans-oral anvil delivery system (EEA OrVil) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection. As a basic technique, end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum. After the gastric lymph node dissection, the esophagus was cut off obliquely to the long axis using an automated stapler. EEA OrVil was orally, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, HDST-based anastomosis was completed. The method may safe laparoscopic anastomosis between the esophagus and reconstructed intestine.

Clinicopathologic features, diagnosis and treatment of 38 neuroendocrine carcinoma in the digestive system

To investigate the clinicopathologic features, diagnosis and treatment of neuroendocrine carcinoma (NEC) in the digestive system. Thirty-eight patients with NEC from Jan 1985 to Mar 2008 were analyzed retrospectively and the related literatures were reviewed. There were 29 males and 9 females. Common symptoms were melena or hematochezia (n=21, 55%), abdominal pain (n=19, 50%), abdominal mass (n=15, 39%), constipation (n=14, 37%), rectal mass (n=12, 32%), abdominal distention (n=11,29%) and diarrhea (n=7,18%). All the patients received surgical treatment including 1 esophagectomy, 5 radical total gastrectomies, 1 palliation proximal gastric resection, 2 local gastric resections, 6 pancreaticoduodenectomies, 1 distal pancreatectomies, 3 partial small intestine resections, 7 radical right hemicolectomies, 5 Dixon operations, 3 Miles operations, and 4 local resections of rectal tumor. Thirty-six patients received follow-up. The follow-up time ranged from 3 months to 144 months (median, 70 months). The 1-, 3- and 5-year survival rates were 94.7%, 86.8%, and 57.9% respectively. The median survival time was 62 months. The survival time of the patients with carcinoma infiltration exceeding bowel muscularis propria was (36+/-5) months, significantly shorter than that of patients without carcinoma infiltration exceeding the bowel muscularis propria [(73+/-5) months, P<0.05]. The survival time of the patients with positive lymph node metastasis was (34+/-7) months, significantly shorter than that of patients with negative lymph node metastasis [(74+/-5) months, P<0.05]. Clinical symptoms, signs of neuroendocrine carcinoma in the digestive system are nonspecific. The correct diagnosis should depend on histopathologic examination. Systematic treatments including radical resection of NEC are the preferable treatment.

Indikationen und Ergebnisse der palliativen Magenresektion beim fortgeschrittenen Magenkarzinom

BACKGROUND: Gastric carcinoma is often diagnosed at UICC stage 3 b or 4. R0 resection can be achieved only in very few such cases. Even for these patients the 5-year survival rate is less than 5 %. Surgical palliation is traditionally reserved for the treatment of severe tumour complications not responding to other forms of treatment. PATIENTS AND METHODS: We report on 21 patients who underwent palliative resection for gastric carcinoma at our institution between 2004 and 2007. Ten of these were assigned to palliative surgical treatment pre-operatively while this choice was made for 11 patients on the grounds of the intra-operative findings. We performed 17 gastrectomies, 3 proximal gastric resections and one distal gastric resection. RESULTS: It has been shown that the patients have an improved overall survival time as compared to patients who received non-surgical treatment. The perioperative risk was reasonable when patients were carefully selected. Median survival for resected patients was 16 months. 80 % of patients were alive after 6 months and approximately 60 % of patients were alive after 12 months. The perioperative mortality was 0 % with a mean hospital stay of 12 days. All patients were discharged home with proper bowel passage and analgesia as individually required. CONCLUSIONS: We are convinced that palliative gastric resection provides a pronounced survival benefit over any other palliative treatment options. Patients also have an improved quality of life.

Indikationen und Ergebnisse der palliativen Magenresektion beim fortgeschrittenen Magenkarzinom

Gastric carcinoma is often diagnosed at UICC stage 3 b or 4. R0 resection can be achieved only in very few such cases. Even for these patients the 5-year survival rate is less than 5 %. Surgical palliation is traditionally reserved for the treatment of severe tumour complications not responding to other forms of treatment. We report on 21 patients who underwent palliative resection for gastric carcinoma at our institution between 2004 and 2007. Ten of these were assigned to palliative surgical treatment pre-operatively while this choice was made for 11 patients on the grounds of the intra-operative findings. We performed 17 gastrectomies, 3 proximal gastric resections and one distal gastric resection. It has been shown that the patients have an improved overall survival time as compared to patients who received non-surgical treatment. The perioperative risk was reasonable when patients were carefully selected. Median survival for resected patients was 16 months. 80 % of patients were alive after 6 months and approximately 60 % of patients were alive after 12 months. The perioperative mortality was 0 % with a mean hospital stay of 12 days. All patients were discharged home with proper bowel passage and analgesia as individually required. We are convinced that palliative gastric resection provides a pronounced survival benefit over any other palliative treatment options. Patients also have an improved quality of life.

Clinical Importance of the Resection Margin Distance in Gastric Cancer Patients

Purpose: The way in which the resection margin distance for gastric cancer patients who undergo a gastric resection influences the recurrence rate, aspects of recurrence, and the prognosis according to the characteristic of the tumor is not known. We aim to find a standard for tailor-made treatment after selecting patients in this point of view who need a more sufficient resection margin. Materials and Methods: A retrospective study was done on 1,472 patients who underwent a gastrectomy due to gastric cancer at our hospital from 1992 to 2005. The median follow-up period was 37 months. Results: There were no significant differences in the recurrence rate, the aspects of recurrence, and the 5-year survival rate between early gastric cancer (EGC) patients with a resection margin distance of less than 2 cm compared with EGC patients with a resection margin distance of greater than 2 cm. However, significant differences in the survival rate were found in advanced gastric cancer (AGC) patients when the patients were classified into groups with resection margin distances less than or greater than 3 cm (P=0.02). Significant differences were noted especially in cases of diffuse histologic-type tumors located in the lower third of the stomach and in cases with Borrmann type-3 and -4 tumors. Conclusion: The distance between the tumor resection margin and the proximal gastric resection margin has no significant influence on the survival rate in EGC patients if the resection margin is negative. However, to improve a patient's survival rate, it is important to guarantee a resection margin of more than 3 cm in AGC patients, especially when the tumor is a diffuse histologic type located in the lower third of the stomach or a Borrmann type 3 and 4.

Proximal gastric resection in the treatment of bleeding gastro-oesophageal varices in patients with portal hypertension due to extrahepatic obstruction.

Abstract Proximal gastric resection is, in our opinion, the operation of choice in the treatment of recurrent haemorrhage in three groups of patients with extrahepatic portal obstruction leading to portal hypertension:— In children who are too small for splenorenal or mesocaval anastomosis, when the haemorrhage can no longer be controlled by periodic injection of the varices through an oesophagoscope.In patients of any age with no suitable radicle of the portal venous tree available for portal systemic anastomosis.In patients who have had splenectomy alone or with gastric transection, or who have had previous shunt operations which have failed to control haemorrhage. It is the only operation short of total gastrectomy in which the varix-bearing area of the stomach is removed. Twenty-eight patients have had this operation at St. Bartholomew's Hospital in the 16-year period 1949-65. The total and late mortality (4 patients) is 14 per cent during a mean follow-up period of 10 years. Only I patient could remotely be considered as an operative death (3.5 per cent). There was no recurrence of haemorrhage in 53 per cent. Three patients (10.5 per cent) had severe haemorrhage from recurrent varices. Two of these died and are included in the mortality figures. The operative procedure is described.

Gastric Carcinoids

To analyze tumor biology and the outcome of differentiated treatment in relation to tumor subtype in patients with gastric carcinoid. Gastric carcinoids may be subdivided into ECL cell carcinoids (type 1 associated with atrophic gastritis, type 2 associated with gastrinoma, type 3 without predisposing conditions) and miscellaneous types (type 4). The biologic behavior and prognosis vary considerably in relation to type. A total of 65 patients from 24 hospitals (51 type 1, 1 type 2, 4 type 3, and 9 type 4) were included. Management recommendations were issued for newly diagnosed cases, that is, endoscopic or surgical treatment of type 1 and 2 carcinoids (including antrectomy to abolish hypergastrinemia) and radical resection for type 3 and 4 carcinoids. Infiltration beyond the submucosa occurred in 9 of 51 type 1, 4 of 4 type 3, and 7 of 9 type 4 carcinoids. Metastases occurred in 4 of 51 type 1 (3 regional lymph nodes, 1 liver), the single type 2 (regional lymph nodes), 3 of 4 type 3 (all liver), and 7 of 9 type 4 carcinoids (all liver). Of the patients with type 1 carcinoid, 3 had no specific treatment, 40 were treated with endoscopic or surgical excision (in 10 cases combined with antrectomy), 7 underwent total gastrectomy, and 1 underwent proximal gastric resection. Radical tumor removal was not possible in 2 of 4 patients with type 3 and 7 of 9 patients with type 4 carcinoid. Five- and 10-year crude survival rates were 96.1% and 73.9% for type 1 (not different from the general population), but only 33.3% and 22.2% for type 4 carcinoids. Subtyping of gastric carcinoids is helpful in the prediction of malignant potential and long-term survival and is a guide to management. Long-term survival did not differ from that of the general population regarding type 1 carcinoids but was poor regarding type 4 carcinoids.

Surgical treatment of esophageal carcinoma complicated by fistulas.

The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant esophageal fistulas is about 13%. The range of treatment modalities proposed by different authors varies from palliation to active and, if possible, radical surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas. Thirty-five patients (aged 28--67) with malignant esophageal fistulas of different localizations were operated over a period from 1990 to 2000. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and 11 cases, respectively. The malignant fistula with the mediastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, two, five, four and three cases, respectively. Subtotal esophagectomy and esophagogastroplasty were performed in 18 patients; subtotal esophagectomy with intrapleural coloesophagoplasty was performed in one case; proximal gastric and lower thoracic esophageal resection from the left-side abdominothoracic approach was performed in three cases. Esophagogastric bypass anastomoses were formed in ten patients. Gastrostomy was performed in three patients. The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resection, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3--31), the 2-year survival rate was 21% after combined esophagectomies. The goal of surgery for esophageal cancer with various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymphadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surgery or gastrostomy. We consider that en-bloc combined resection of esophageal cancer complicated by fistula can be done with a low mortality.

A new technique for esophagojejunostomy after total gastrectomy for gastric cancer

Background: The critical part of any operation involving a proximal gastric resection is the esophageal anastomosis. Leakage from this anastomosis is one of the main reasons for postoperative morbidity and death after gastrectomy. Application of the double-stapling technique affords many of the same advantages that it does for low rectal tumors, especially in obese patients with narrow costal margins. Methods: A new technique for esophagojejunostomy after total gastrectomy for gastric cancer is described. Results: This technique has been used in 3 patients. At a follow-up of 22 months, there have been no anastomotic leaks or evidence of clinical stenoses. Conclusion: This technique minimizes manipulation and dissection around the distal esophagus. Not only does this make the operation easier, but it also allows for a longer proximal resection margin. Possibly this will result in lower rates of esophageal breakdown.

Carcinoma of the gastric cardia: surgical practices and short-term operative results in a defined Swedish population.

Adenocarcinoma of the gastric cardia has one of the most rapidly increasing incidence rates of all tumors in Western countries. The aim of this population-based investigation was to study surgical practices and postoperative morbidity and mortality during routine hospital care. The study comprised 176 patients given a new diagnosis of adenocarcinoma of the gastric cardia from February 1, 1989 to the January 31, 1995 in five Swedish counties. The tumor was resectable in 100 (57%) patients (in 36% of the women and 64% of the men), but only 46% of all patients could be offered a potentially curative operation. A total gastrectomy was performed in 54 patients and a proximal gastric resection in 44. Postoperative complications occurred in 39%: in 20% of the patients under age 60 years and in 47% of those aged 60 and over (p = 0.006). Seventeen operated patients (13%) died before discharge. The hospital mortality increased from 3% among those < 60 years of age to 18% among those > 69 years (p = 0.041). Surgical treatment of carcinoma of the gastric cardia carries substantial morbidity and mortality. No important progress seems to have taken place since the 1960s.

Early gastric cancer: diagnosis, surgical treatment and follow-up of 45 cases.

The 5-year survival rate of early gastric cancer (EGC) is 85%-100% after "curative" resection, as compared to 20%-30% in advanced gastric cancer (AGC). Because of this relatively high cure rate, the interest in the diagnosis and therapy of EGC has been steadily increasing. The present study, based on 45 EGCs, is aimed at a critical evaluation of the diagnostic procedures and surgical options. Forty-five patients with early gastric cancer (27 men and 18 women; median age, 62 years; range, 28-84) were diagnosed and operated on. They represented 22.5% of all patients with gastric cancer (200) treated in the period July 1987 to January 1998. Forty-one patients were from the northeastern part of Italy. The most frequent symptom was epigastric pain (84%). Barium upper gastrointestinal radiography findings were strongly suggestive of malignancy in 41 cases (91%). Preoperative histopathological diagnosis of adenocarcinoma was performed in 43 cases (95.5%). In two cases (4.5%) severe epithelial dysplasia (associated with ulcer) was the first diagnosis, but the final diagnosis on the basis of the resected specimens was a well differentiated adenocarcinoma. The primary surgical procedure included i) subtotal distal resection (37 cases) with Billroth 11 (33) and Billroth I (4) reconstructions; ii) total gastrectomy (3) for proximal neoplastic extension; iii) proximal gastric resection (2) for cardial cancer; iv) degastro-total gastrectomy (3) for cancer of the stump. Two patients, previously treated with conservative surgery, underwent degastro-total gastrectomy for neoplastic microfocal extension to the margin of resection and for early anastomotic recurrence, respectively. Mural infiltration was limited to the mucosa and submucosa in 27 and 18 cases, respectively. Lymph node metastases were found in three mucosal and five submucosal tumor cases, involving either the first or the second echelon. No operative deaths or postsurgical complications occurred in this series. In the follow-up period (median, 36 months; range, 3-120) four patients died due to other causes; one developed liver metastases, another developed oropharyngeal cancer and two died of biopsy-proven lung cancer without evidence of gastric cancer recurrence. The clinical presentation of EGC is aspecific. Preoperative endoscopy with biopsy remains the most sensitive diagnostic procedure. For treatment, subtotal distal gastric resection with lymphadenectomy is the "gold standard" but in some instances total gastrectomy may be indicated. Accurate pathological examination establishes the depth of infiltration, as well as the superficial extension of tumors and the lymph node status. Although the prognosis of EGC is favorable, a medium-term follow-up should be planned.

Barrett's cancer: indications, extent, and results of surgical resection.

In the Western world, the prevalence of Barrett's carcinoma, i.e., adenocarcinoma of the distal esophagus arising from specialized columnar epithelial metaplasia, has risen dramatically in the past two decades. High-grade dysplasia in the columnar epithelium has been identified as the precursor of malignant carcinoma. Whether an esophagectomy should be performed in patients with high-grade dysplasia remains controversial. Surgical resection is the mainstay of therapy in patients with invasive adenocarcinoma who are fit for surgery. Complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the distal esophagus. In patients with tumors located in the distal esophagus, this can be achieved by a radical transhiatal esophagectomy and proximal gastric resection with en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis. Early adenocarcinoma can be cured by this approach. The value of multimodality therapy in patients with advanced tumors needs to be confirmed in well-designed randomized prospective trials.

Survival benefit of extended D2 resection for proximal gastric cancer.

The long-term survival of patients with adenocarcinoma of the proximal stomach remains dismal. Despite its increasing frequency and poor prognosis, a general consensus has not been reached on the extent of surgical resection. The significance of extended lymph node dissection (D2 gastrectomy) for the surgical treatment of patients with proximal gastric cancer was evaluated. Sixty-two patients who underwent a potentially curative total or proximal gastric resection were retrospectively divided by extent of lymphadenectomy into two groups: the extended resection group (D2,D2.5) and limited resection group (D1,D1.5). Survival rates were estimated by the method of Kaplan and Meier [J Am Stat Assoc 53:457-486, 1958] and the differences compared by the log rank test. Multivariate analysis of prognostic parameters was performed using the Cox proportional hazard model. The median overall survival time for the extended resection group (D2,D2.5) was 34 months compared to 18 months for patients treated by a more limited resection (D1,D1.5). Patients treated with extended resection had an estimated 5-year overall survival rate of 37% compared to 21% for patients treated with limited resection. This difference was statistically significant with a P value of 0.04. The median disease-free interval for the extended resection group was 31 months compared to 17.6 months for patients in the limited resection group. The 5 year disease-free survival rate for both groups was 37% and 17%, respectively (P = 0.09). Extent of lymphadenectomy and stage of disease were found to be independent predictors of overall and cancer-free survival. Patients treated with an extended lymph node dissection (D2 gastrectomy) were more likely to survive 5 years, had longer disease-free intervals, and prolonged median survival times (particularly patients with T1-3,N0-1,M0 cancers) as compared to those patients treated with a more limited lymph node dissection (D1,D1.5). These differences reached or approached statistical significance.