Subtotal Gastrectomy For Gastric Cancer Research Articles

Subtotal gastrectomy for gastric cancer

Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and "disease-tailored" surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.

The foregut theory as a possible mechanism of action for the remission of type 2 diabetes in low body mass index patients undergoing subtotal gastrectomy for gastric cancer

BackgroundThe question of whether pure metabolic surgery could be used in nonobese patients with type 2 diabetes has been considered. The objective of this study was to assess the comparative effects of the Billroth I (BI) and Billroth II (BII) reconstruction methods on remission of type 2 diabetes in nonobese patients undergoing subtotal gastrectomy for cancer. MethodsThe charts of 404 patients who underwent radical subtotal gastrectomy for cancer between January 2008 and December 2010 were retrospectively reviewed. From these patients, 49 with type 2 diabetes were included in this study. Diabetes remission rates, the percentage change in fasting plasma glucose levels, glycated hemoglobin levels, body mass index, and fasting total cholesterol levels at 2 years were observed. Outcomes were compared using propensity scores and inverse probability-weighting adjustment that reduced treatment-selection bias. Covariate-adjusted logistic regression models were assessed. ResultsThe 2-year diabetes remission rate for the 23 patients who underwent BI reconstruction was 39.1%, compared with 50.0% for the 26 patients who underwent BII reconstruction. At 2 years, the BII group showed lower glycated hemoglobin levels (BI, 6.4%; BII, 6.1%; P = .003) and had greater percent reductions in their average glycated hemoglobin levels from baseline (BI,−11.6%; BII,−14.5%; P = .043). BII reconstruction was significantly associated with an increased diabetes remission rate (odds ratio, 3.22; 95% confidence interval, 1.05–9.83) in covariate-adjusted logistic regression analysis. ConclusionsThese propensity score-adjusted analyses of patients who had undergone subtotal gastrectomy indicated that BII reconstruction was associated with increased diabetes remission compared with BI reconstruction during the 2-year follow-up period. This study suggests the possibility of employing the surgical duodenal switch for the treatment of nonobese type 2 diabetes patients.

Commentary:H. pylorieradication therapy after subtotal gastrectomy for gastric cancer - can the qualitative be quantified?

Commentary:<i>H. pylori</i>eradication therapy after subtotal gastrectomy for gastric cancer - can the qualitative be quantified?

Commentary:H. pylorieradication therapy after subtotal gastrectomy for gastric cancer - can the qualitative be quantified? Authors' reply

We appreciate Dr Genta for his valuable comments1 and agree with his perspective on our analysis.2 The updated Sydney system recommends that glandular atrophy and intestinal metaplasia be graded as absent, mild, moderate or marked.3 Such grading in this updated system is not a continuous scale, but an ordinal scale. Thus, the data evaluated in the updated Sydney system might not be suitable for comparing means and variances (standard deviations or standard errors of the mean) after conversion into numerical values. Several studies, however, have used means and variances to present changes both before and after Helicobacter pylori eradication.4-7 In our study, we similarly analysed our data using numerical analysis. However, to overcome the limitations of the numerical values, we incorporated Figure 3 into our paper, which provides a graphical representation of the distribution of the changes in gastritis severity both before and after H. pylori eradication.2 We also evaluated our data using a mixed-effects ordinal logistic regression model, which was suggested by Ohkusa et al.5 The results showed significant decreases in both glandular atrophy and intestinal metaplasia scores of the lesser curvature of the corpus in H. pylori-negative patients compared with those in H. pylori-positive patients, after considering H. pylori status over time (data not shown). Updated Sydney system grading was founded on a relatively objective visual analogue scale, using a graphic model and reducing textual explanation. However, as Dr Genta suggests, grading of such observations is still subject to significant inter- and intra-observer variabilities, particularly for atrophy.8, 9 Despite these limitations, this system is currently the mostly widely accepted and used grading system for gastritis. One specialised pathologist's examination could handle inter-observer variations, but is still subject to intra-observer variabilities. We believe that this dilemma might be resolved in part by a double-blind, randomised trial design. The authors’ declarations of personal and financial interests are unchanged from those in the original article.2

Risk factors analysis of postsurgical gastroparesis syndrome and its impact on the survival of gastric cancer after subtotal gastrectomy

To investigate the risk factors of postsurgical gastroparesis syndrome (PGS) after subtotal gastrectomy in gastric cancer and the impact of PGS on prognosis. Clinical data of 422 patients who underwent subtotal gastrectomy for gastric cancer in the Central Hospital of Huzhou Sity from January 2004 to May 2010 were analyzed retrospectively. Risk factors of PGS were indentified and the recurrence-free survival was compared between the patients with and without PGS. PGS occurred in 42 patients (9.5%). Univariate analysis showed that: age over 65, combination of anxiety disorder, low-albuminemia in perioperative period, pyloric obstruction in preoperative period, high serume glucose level (≥ 11.2 mmol/L) in postoperative period, Billroth II (gastroenterostomy, operation time over 4 hours, using patient-controlled analgesia, or intravenous fluid over 3500 ml/d (all P<0.05) were prone to develop PGS. These might be potential clinical risk factors associated to PGS. Correlation analysis showed the number of clinical risk factors was positively correlated with the incidence of PGS (r=0.967, P<0.05). A total of 215 cases (50.9%) were followed up for 3-60 months. The mean recurrence-free survival time of patients with PGS was 26.1 months, which was shorter than that of those without PGS (33.4 months, P=0.029). Gastric cancer patients with the clinical risk factors mentioned above are prone to develop PGS after subtotal gastrectomy. PGS is associated with poor prognosis.

Pancreatoduodenectomy in Patients with Periampullary Cancer after Radical Subtotal Gastrectomy for Gastric Cancer

Pancreatoduodenectomy in Patients with Periampullary Cancer after Radical Subtotal Gastrectomy for Gastric Cancer

A Case of Hepatic Metastasis of Gastric Hepatoid Adenocarcinoma Mistaken for Primary Hepatocellular Carcinoma

Gastric hepatoid adenocarcinoma is a special type of gastric carcinoma, which produces AFP. We report a case of an metastatic gastric hepatoid adenocarcinoma mistaken for primary hepatocellular carcinoma (HCC). A 72 year-old woman was transferred to our hospital for treatment of the hepatic mass. She underwent subtotal gastrectomy for gastric cancer 2 years ago. A year ago, she was diagnosed with hepatic mass and treated with transhepatic chemoembolization under the suspicion of primary HCC in other hospital. The hepatic mass looked like primary HCC on CT, and serum AFP was elevated to 18,735 IU/mL. We did the transhepatic mass biopsy and compared it to the histology of the previous gastric cancer. The results of immunohistochemical staining between them was coincident, and so it was diagnosed as a hepatic metastasis of gastric hepatoid adenocarcinoma.

Quality of life beyond the early postoperative period after laparoscopy-assisted distal gastrectomy: the level of patient expectation as the essence of quality of life

The aim of this study was to compare the quality of life after the early postoperative period and before reaching 5 years postoperatively between patients who underwent laparoscopy-assisted distal gastrectomy (Group A) and patients who underwent open distal subtotal gastrectomy (Group B). The Korean versions of the European Organization for Research and Treatment (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and a gastric cancer-specific module, the EORTC QLQ-STO22, were used to assess the quality of life of 80 patients who underwent laparoscopy-assisted distal gastrectomy or open distal subtotal gastrectomy for gastric cancer. The postoperative period ranged between 6 months and 5 years. The global health status/quality of life scores of Groups A and B were 56.0 ± 19.0 and 57.4 ± 18.2, respectively (p = 0.729). Group A experienced worse quality of life in role functioning (p = 0.026), cognitive functioning (p = 0.034), fatigue (p = 0.039), eating restrictions (p = 0.009), and anxiety (p = 0.033). Group A showed a trend to experience worse quality of life in physical functioning, emotional functioning, social functioning, insomnia, and body image, albeit without statistical significance. After the early postoperative period and before achieving long-term survival, patients who underwent laparoscopy-assisted distal gastrectomy appeared to experience lower quality of life compared to patients who underwent open distal subtotal gastrectomy. This finding may be associated with the patients' erroneously high expectations of laparoscopy-assisted distal gastrectomy.

Handsewn Versus Stapled Gastroduodenostomy in Patients with Gastric Cancer: Long‐Term Follow‐up of a Randomized Clinical Trial

The role of circular staplers in gastroduodenostomy during subtotal gastrectomy for gastric cancer has not been defined clearly. A randomized clinical trial included patients with gastric cancer who underwent subtotal gastrectomy with either stapled (99 patients) or handsewn gastroduodenostomy (98 patients). The anastomosis time and postoperative outcomes in the two groups were compared. Performance of stapled gastroduodenostomy was significantly quicker than handsewn gastroduodenostomy. There were no significant differences between the groups in postoperative course, morbidity and mortality rates, survival rate, and recurrence pattern. Stapled gastroduodenostomy with a circular stapler can reduce the anastomosis time with relative safety.

Randomized controlled trial comparing Billroth-I and Roux-en-Y reconstruction in distal gastrectomy for gastric cancer.

65 Background: In distal subtotal gastrectomy for gastric cancer, Billroth-I (B-I) reconstruction has been performed predominantly in Japan, while increasing number of surgeons chose Roux-en-Y (R-Y) reconstruction recently. To evaluate the safety and superiority of R-Y we conducted a multi-institutional prospective randomized controlled trial. Methods: Gastric cancer patients who underwent distal gastrectomy were randomized to B-I or R-Y intraoperatively. The primary endpoint was the ratio of body weight loss 1 year after surgery, the secondary endpoints were the incidence of delayed gastric emptying (DGE) and postoperative morbidity. Results: Between Aug 2005 and Dec 2008, a total of 332 patients were enrolled and 163 patients were assigned to B-I and 169 patients to R- Y. The patient's characteristics were well balanced between the two groups. The operation time was significantly longer in R-Y than B-I (median 180 min in B-I vs 214 min in R-Y, p &lt; 0.0001). The postoperative morbidity was 14 patients (8.6%) in B-I and 23 (13.6%) in R-Y (p = 0.14), the incidence of DGE was 7 (4.3%) in B-I vs 16 (9.5%) in R-Y (p = 0.06), and the hospital stay after surgery was 14.1days in B-I vs 16.4 days in R-Y (p = 0.02). There was no hospital death in the two groups. The body weight loss at 1 year after surgery compared to preoperation was -5.4kg (-9.1%) in B-I vs -6.2kg (-9.8%) in R-Y (p = 0.11). Conclusions: The advantage of R- Y reconstruction compared to B-I was not proved in terms of postoperative morbidity either the body weight loss 1 year after surgery. No significant financial relationships to disclose.

Trans-vaginal specimen extraction following totally laparoscopic subtotal gastrectomy in early gastric cancer

Although natural orifice extraction is now widely performed, there have been no reports of this procedure following subtotal gastrectomy for gastric cancer. This report describes trans-vaginal specimen extraction in four patients with early gastric cancer. The clinical data of four patients with early gastric cancer were reviewed. Totally laparoscopic subtotal gastrectomy and D1 + β lymph node dissection was performed using five trocars and a conventional procedure. Posterior colpotomy was performed by an experienced gynecologist, who retrieved the specimens in a retrieval bag via the trans-vaginal route. The colpotomy site was repaired immediately following specimen removal. Reconstruction was performed using the intracorporeal Billroth II method and an endo-GIA 60. Totally laparoscopic subtotal gastrectomy and trans-vaginal specimen extraction was successfully accomplished in all patients without intraoperative complications. The present technique may be a safe and feasible operative procedure for some limited groups of elderly female patients with early gastric cancer.

Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery

An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro-esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery. A total of 26 individuals were studied: eight patients after open Roux-en-Y gastric bypass (RYGB) for morbid obesity, six patients after laparoscopic Nissen fundoplication for GERD, seven patients after open subtotal gastrectomy for gastric cancer and five NI. Patients underwent high resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES) and measure gastric pressure 1, 2, 3, 4 and 5 cm below the LBLES, immediately before swallow and after the end of the LES relaxation. A station pull-through pH monitoring was performed in all but NI, from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal. Our results show that: (i) proximal gastric pressures are lower after swallow compared with before swallow in NI; (ii) patients after gastric surgery tend to have higher gastric pressure before and lower after swallow compared with NI and (iii) patients after RYGB with PPGAP have an increased gastric pressure after swallows in the segment where the PPGAP is noticed. Gastric motility may play a role in the genesis of PPGAP in patients after RYGB. The contribution of gastric motility for the genesis of PPGAP is still elusive in other patients.

Authors' reply: Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly (Br J Surg 2009; 96: 1437–1442)

Authors' reply: Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly (<i>Br J Surg</i> 2009; 96: 1437–1442)

Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly (Br J Surg 2009; 96: 1437–1442)

Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly (<i>Br J Surg</i> 2009; 96: 1437–1442)

Two-stage treatment of an unusual haemobilia caused by intrahepatic pseudoaneurysm

A 84-year-old man with a surgical history of subtotal gastrectomy for gastric cancer was transferred to our department because of a disorder of consciousness. Septic shock due to obstructive suppurative cholangitis secondary to choledocholithiasis was diagnosed. Anemia was also present, and upper gastrointestinal tract endoscopy revealed blood emerging from the Papilla of Vater. The cause of the anemia was identified as haemobilia. Angiography showed a small aneurysm over the artery on segment 3 (A3). The cause of the haemobilia was suspected to be the bleeding into the biliary tree from this aneurysm. Because the patient's general condition was poor, minimally invasive therapy was needed. Transcatheter arterial embolization (TAE) was selected initally. Later, lateral sectionectomy was performed in order to remove the aneurysm on A3. No surgical complication occurred and, after surgery, no haemobilia was identified. In conclusion, a two-stage treatment, namely, surgery following TAE, is recommended for patients in a physically poor condition who have haemobilia due to intrahepatic aneurysm.

Quality of Life of Long-Term Survivors after a Distal Subtotal Gastrectomy

The aim of this study was to investigate the impact of a distal subtotal gastrectomy on the quality of life (QoL). The QoL data of 126 patients were obtained on their 5th annual follow-up visit after a curative distal subtotal gastrectomy for gastric cancer (Group A). The QoL data of 130 age- and gender-adjusted healthy population were obtained from the individuals who visited the health screening center for a medical check-up (Group B). There were 42 women and 84 men in the study group and their mean age was 56.0±11.1 years. QoL was assessed using the Korean versions of the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire Core 30 (QLQ-C30) and QLQ-STO22. The EORTC QLQ-C30 global health status and QoL scores of Group A and Group B were 63.9±22.7 and 61.3±22.1, respectively (p=0.361). Group A revealed a better score for emotional functioning (84.1±16.1 and 75.2±21.4, respectively; p<0.001), cognitive functioning (82.0±16.4 and 75.0±21.4, respectively; p=0.004) and fatigue (27.7±20.8 and 33.8±23.2, respectively; p=0.028). However, Group A revealed a worse score for nausea and vomiting (14.8±20.0 and 10.2±16.0, respectively; p=0.042), financial difficulties (14.8±22.9 and 7.1±16.1, respectively; p=0.002), reflux (16.7±17.7 and 10.1±17.0, respectively; p=0.003), eating restrictions (13.6±15.2 and 6.6±10.2, respectively; p<0.001) and body image (23.3±25.4 and 16.2±24.6, respectively; p=0.023). The QoL of long-term survivors after a distal subtotal gastrectomy is still influenced by the surgery itself even though they are considered to be free of disease.

Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly

The aim of this study was to assess the safety and short-term value of laparoscopic gastrectomy in the elderly with gastric cancer compared with a younger cohort. Data on all patients with gastric cancer undergoing laparoscopic gastrectomy at ten institutions in Korea between May 1998 and December 2005 were collected. Patients under the age of 45 years and those undergoing total gastrectomy, proximal gastrectomy and pylorus-preserving gastrectomy were excluded. An analysis of clinicopathological data for patients aged 45-69 years (average-age group) and those aged 70 years or more (elderly group) was undertaken. Co-morbidity was more common and postoperative hospital stay was longer in elderly patients. Pre-existing pulmonary and cardiovascular disease in the elderly contributed to respiratory dysfunction and intraperitoneal complications respectively. Tumour size and location, stage, methods of reconstruction and the number of combined operations were similar in the two groups. There were no significant differences in postoperative morbidity or mortality. Although elderly patients had greater co-morbidity, laparoscopic gastrectomy was a safe treatment for gastric cancer in this age group.

Analysis of Fat Digestive and Absorptive Function after Subtotal Gastrectomy by a 13C-Labeled Mixed Triglyceride Breath Test

Background/Aim: In the choice of reconstructions, digestive and absorptive disturbances, resulting in weight loss after subtotal gastrectomy, remain a problem. The aim of this study was to compare fat absorptive function after Billroth I (B-I) and Roux-en-Y (RY) reconstructions after subtotal gastrectomy for gastric cancer. Methods: A ¹³C-labeled mixed triglyceride breath test was performed in 31 patients after subtotal gastrectomy and in 15 healthy volunteers to assess fat digestive and absorptive function. Seventeen B-I reconstructions and 14 RY reconstructions were performed after subtotal gastrectomy. Fat digestive and absorptive function was determined by percent ¹³CO₂ cumulative dose at 7 h. Relationship between fat absorptive function and perioperative factors were analyzed. Results: Gender distribution, mean age, pathological staging, level of lymph node dissection, preservative procedure of the vagus nerve and mean follow-up period in the two surgical groups did not differ significantly. Only the type of reconstruction (p = 0.024) was associated with differences in fat digestive and absorptive function by univariate analysis: B-I reconstruction was superior to RY reconstruction. Conclusions: Fat digestive and absorptive function after B-I reconstruction was superior to that after RY reconstruction, probably because the B-I reconstruction was the procedure that permitted food passage through the duodenum.

Análisis de calidad de vida en pacientes gastrectomizados por cáncer gástrico

Gastric cancer is the first cause of death by cancer in Chile. Quality of Life is a multidimensional construct that explores functionality and well-being, including physiological, psychological and social aspects.To assess Quality of Life of patients operated for gastric cancer.The European Organization Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30), translated into Spanish, was applied to 33 patients, aged 42 to 82 years (25 males), subjected to curative total or subtotal gastrectomy for gastric cancer, between January 2004 and December 2006.The average lapse from the moment of the surgical intervention to the interview, was 52.2 weeks. Fifty five percent perceived their Quality of Life in the "good" category. Male patients and those with less than 6 months of surgery, obtained better scores in psychological aspects of quality of life.A high percentage of patients operated for gastric cancer qualified their quality of life as good in spite of the severity of the underlying disease and invasiveness of the intervention. This is probably explained by the importance of psychological factors that influence quality of life.

Quality of life of patients operated for gastric cancer

Gastric cancer is the first cause of death by cancer in Chile. Quality of Life is a multidimensional construct that explores functionality and well-being, including physiological, psychological and social aspects. To assess Quality of Life of patients operated for gastric cancer. The European Organization Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30), translated into Spanish, was applied to 33 patients, aged 42 to 82 years (25 males), subjected to curative total or subtotal gastrectomy for gastric cancer, between January 2004 and December 2006. The average lapse from the moment of the surgical intervention to the interview, was 52.2 weeks. Fifty five percent perceived their Quality of Life in the "good" category. Male patients and those with less than 6 months of surgery, obtained better scores in psychological aspects of quality of life. A high percentage of patients operated for gastric cancer qualified their quality of life as good in spite of the severity of the underlying disease and invasiveness of the intervention. This is probably explained by the importance of psychological factors that influence quality of life.