Two cases of gastric involvement of esophageal cancer: intramural metastasis and intramural lymph node metastasis

Cases of esophageal cancer with intramural metastasis to the stomach and esophageal cancer with metastasis to an intramural lymph node of the stomach are herein reported. The former patient was a 52 year-old male. Squamous cell carcinoma (SCC) of the lower esophagus with an intramural metastasis located at the gastric cardia and a small leiomyoma at the fornix were resected. The latter patient was a 70 year-old female. SCC of the lower esophagus and an intramural lymph node metastasis located at the anterior wall of the gastric cardia were resected. The patient died nevertheless of multiple liver metastases. These gastric involvements were detectable by endoscopy before surgery. The clinicopathological features of these esophageal cancers were characterized; the sites were the lower part of the esophagus, and extreme lymphatic and vascular invasions were shown histologically. The gastric tumors were located in the upper third of the stomach, and the findings revealed submucosal tumors. It is therefore important to discriminate other gastric tumors, and to resect them simultaneously with esophageal cancer when a gastric tube has been used for reconstruction after esophagectomy.     

Curative laparoscopic surgery for early gastric cancer: five years experience

Sixty-one patients who were diagnosed with mucosal gastric cancer have been successfully treated with two laparoscopic techniques at our institute from March 1992 to March 1997. One is laparoscopic wedge resection of the stomach using a lesion-lifting method for lesions of the anterior wall, the lesser curvature, and the greater curvature of the stomach. The other is laparoscopic intragastric mucosal resection for lesions of the posterior wall of the stomach and near the cardia or the pylorus. Indications are as follows: (1) preoperatively diagnosed mucosal cancer; (2) <25 mm diameter elevated lesions; and (3) <15 mm diameter depressed lesions without ulcer formation. Patients were discharged in 4 to 8 days uneventfully. There was no major complication or mortality. The resected specimens had sufficient surgical margins horizontally (16 +/- 5 and 8 +/- 4 mm, respectively) and vertically. In one patient histologic examination revealed slight tumor infiltration into the submucosal layer with lymphatic invasion. He underwent gastrectomy with lymph node dissection 1 month after surgery. Otherwise, histologic examination revealed curative surgery. All patients in the series have survived during the 4- to 65-month follow-up period. There have been two recurrences in the series, both of which were found near the staple line 2 years after the initial surgery and were still mucosal lesions. They were successfully treated by open gastrectomy and laser irradiation. A separate early gastric cancer was found 2 years after the initial surgery in one patient, who then underwent curative open gastrectomy. In conclusion, if the patients are selected properly, these laparoscopic procedures are curative, minimally invasive treatment for early gastric cancer.     

Gastric emptying after gastric interposition for esophageal carcinoma: comparison between the anterior and posterior mediastinal approaches

BACKGROUND/AIMS: Close observation and evaluation of the function of the transposed stomach after esophagectomy is essential. The present study uses the sulfamethizole capsule meal test to evaluate differences in gastric emptying between the anterior and posterior mediastinal approaches in patients undergoing esophagectomy. METHODOLOGY: Thirty-eight patients who underwent the esophagectomy and esophagogastrostomy for esophageal cancer were randomly divided into 2 groups: Group 1: anterior mediastinal approach, and Group 2: posterior mediastinal approach. Gastric emptying was studied using the sulfamethizole capsule meal test. Patients received sulfamethizole food capsules, 65 g of bread, and 150 ml of water. Plasma sulfamethizole levels were determined by high performance liquid chromatography (HPLC). RESULTS: Gastric emptying in both groups was significantly accelerated compared to healthy volunteers. Gastric emptying did not differ significantly between groups 1 and 2. CONCLUSIONS: The present data show that the sulfamethizole capsule meal test is an effective means of evaluating the emptying of the transposed stomach. Furthermore, when the stomach is used as an esophageal substitute following esophagectomy, gastric emptying does not differ according to the access route.     

Pathological appearance of the stomach after endoscopic mucosal resection for early gastric cancer

BACKGROUND: The pathological findings of the resected stomach after endoscopic mucosal resection (EMR) for early gastric cancer were reviewed. EMR was indicated when a lesion consisting of well or moderately differentiated adenocarcinoma had a diameter of less than 2 cm. METHODS: Of 39 patients with early gastric cancer were treated with EMR between 1990 and 1995, 11 required additional surgery. RESULTS: Malignant tissue in the gastric wall was completely removed in four patients, while cancer cells remained in the mucosa adjacent to the scar in five and infiltrated into the submucosa in two. Most of these residual cancers were characterized by a lesion with a diameter exceeding 15 mm and by the location in the body or cardia of the stomach. Lymph node metastases were observed in one patient whose carcinoma invaded the deeper submucosal layer. Assessment of the depth of entire invasion from the endoscopically-resected specimen was correct for six of 11 patients. CONCLUSION: Gastric carcinomas to be resected by EMR should be smaller, especially if located in the body or cardia. Accurate diagnosis of the width and depth of invasion is indispensable before proceeding to EMR. Surgery may be the treatment of choice when there is submucosal invasion.     

Effects of visnagin on cyclic nucleotide phosphodiesterases and their role in its inhibitory effects on vascular smooth muscle contraction

Several reports have been published which describe the technique of using an Endo GIA to resect submucosal tumors on the anterior wall of the stomach. Lesions on the posterior wall, however, especially near the esophagocardiac junction (ECJ), are difficult to resect using these reported techniques. This is because the surgeon must divide the omentum and enter the omental bursa in order to use a similar extraluminal technique. Furthermore, special care must be taken to ensure that resections do not involve the ECJ and narrow the esophagus. In order to overcome these difficulties, we have proposed a new technique for the laparoscopic excision of a submucosal tumor located on the posterior wall of the gastric fundus. The principle of this procedure involves the intraluminal resection of the submucosal tumor, including the surrounding stomach wall, using the Endo GIA. This technique is safe, simple, and effective. We believe that we are the first to address the excision of a submucosal lesion by resecting the full thickness of the posterior gastric wall lesion intraluminally.     

Aminoalkanolic derivatives of xanthone with potential antiepileptic activity

BACKGROUND AND OBJECTIVES: Since 1993, we have performed preoperative embolization therapy (PET) in an attempt to augment the blood flow of the gastric tube and prevent anastomotic leakage after esophageal resection. The clinical effects and complications associated with PET are reported. METHODS: The femoral artery was punctured and the left gastric artery, right gastric artery, and splenic artery underwent embolization, leaving the right gastroepiploic artery as the only patent feeding artery for the stomach. PET was performed in 54 patients, and data concerning blood flow of the stomach before and after the construction of the gastric tube were available in 51 patients. Of the 25 patients who were operated in the same period without undergoing PET, similar data were available in 20 patients. RESULTS: In the group of patients who underwent PET, the blood flow of the gastric tube after its construction was 67% of the value measured at the upper part of the stomach just after opening the abdominal cavity. For those who were not pretreated by PET, it declined to 33%. CONCLUSIONS: PET for esophageal cancer is a safe procedure that contributes to the decrease in the frequency of anastomotic dehiscence after esophageal operation, owing to the augmented tissue blood flow of the upper portion of the stomach following the construction of gastric tubes.     

Extrathoracic esophagectomy in the treatment of esophageal cancer

Extrathoracic esophagectomy has the potential of improving the results of resectional therapy for carcinoma of the esophagus by eliminating the need for thoracotomy and decreasing postoperative pulmonary complications. This report compares the operative and functional results of blunt extrathoracic esophagectomy and substernal reversed gastric tube reconstruction in patients with esophageal cancer to results in 10 consecutive nonrandomized control patients treated by standard esophagogastrectomy. Extrathoracic esophagectomy was associated with greater pulmonary dysfunction than standard esophagogastrectomy. While there was no significant difference in survival in the two groups, three patients in the standard esophagogastrectomy group (mean survival 9.0 months) and none in the extrathoracic esophagectomy group (mean survival 7.4 months) developed anastomotic recurrence. Extrathoracic esophagectomy evidently does not afford patients with esophageal carcinoma better palliation than standard esophagogastrectomy.     

Free and total bupivacaine plasma concentrations after continuous epidural anaesthesia in infants and children

OBJECTIVES: The aim of this study was to elucidate the prevalence of Helicobacter pylori and its distribution in order to clarify the frequency of H. pylori infection and the most appropriate site of endoscopic biopsy for studies of H. pylori infection associated with different gastric diseases. DESIGNS AND METHODS: Swiss role mucosal strips from 275 resected stomachs, which included the greater curvature, anterior wall and lesser curvature of the antrum, incisura and corpus, were stained with haematoxylin-eosin and H. pylori antibody. RESULTS: The prevalence of H. pylori infection was 97% in duodenal ulcers, 98% in gastric ulcers, 98% in intestinal-type carcinomas and 99% in diffuse-type carcinomas. H. pylori was present at a rate of 100% in any site in cases of duodenal ulcer, but was diffusely distributed in the antrum and patchily distributed in the corpus. The detection rate of H. pylori was 50-100% in gastric ulcers, 30-100% in intestinal-type adenocarcinomas and 63-100% in diffuse-type adenocarcinomas depending on the site of the stomach examined. CONCLUSIONS: The prevalence of H. pylori infection was very high in peptic ulcers of the duodenum and stomach and gastric carcinomas of Japanese patients. Biopsy specimens for evaluation of H. pylori infection should be taken routinely from both the greater curvature of the antrum and corpus. Immunohistochemical staining should be used to assay for H. pylori when few organisms are present or eradication therapy has been used.     

Topical clonidine for orofacial pain: a pilot study

BACKGROUND: To preserve postoperative digestive function in patients with esophageal carcinoma, jejunal or colonic segments on long vascular pedicles are transplanted and anastomosed between the esophagus and residual stomach. A postoperative survey showed pedicled jejunum transplantation to be superior in terms of digestive and absorptive functions, intraesophageal pressure, pH, and the quality of life of long-term postoperative survivors. Anastomotic leakage and necrosis of the pedicled intestinal graft are occasional complications; circulatory disorders of the pedicled intestine are a probable cause of both complications. STUDY DESIGN: To simulate pedicled jejunum transplantation, we prepared pedicled colonic segments from dogs and measured blood flow volume at the cut end of the oral side of the colonic segments using the hydrogen clearance method and at the nutrient vascular pedicle with an electromagnetic blood flowmeter. RESULTS: Resection of excess colon increased blood flow volume per unit weight of the colonic segment. CONCLUSIONS: It is essential to resect excess intestine and keep only the minimum length of pedicled intestinal graft needed for reconstruction of the esophagus.     

Indications, new surgical technique and results of colon interposition or bypass in esophageal surgery

Over a 5-year period, 29 patients with esophageal disease underwent colon interposition or bypass. The indication was cure of cancer in 11 patients, who underwent earlier a gastric resection. Other indications was benign stricture in 7 patients, bypass for unrespectable cancer in 6, having a caustic injury in 3 and after an esophageal perforation in 2. In 14 patients the left colon, in 15 the right colon was used. The colon was transected without dividing the mesentery other than just along its mesenteric border. This preserves additional blood supply from the marginal artery, also improves the function of the graft in transporting food. Anastomosis leakage occurred in 4 cases (13.7%). Graft necrosis occurred in 2 of 29 patients, one of whom alter underwent a successful second reconstruction. The 30 day operative mortality rate was 13.7%. A colon interposition provides good quality of deglution, and is the organ of choice for patients who require an esophageal substitute and are potential candidates for long survival, or when the stomach is unsuited for replacement or bypass.     

Preoperative embolization of gastric arteries for esophageal cancer

BACKGROUND: We developed a novel treatment of preoperative embolization therapy in an attempt to prevent anastomotic leakage after esophageal resection. We report the results of this new treatment. METHODS: Preoperative embolization therapy (PET) was performed in 24 cases of esophageal carcinoma. The femoral artery was punctured, and celiac angiography was performed. The left gastric artery and splenic artery underwent embolization. The right gastric artery then underwent embolization at a site beyond the second or third branch to the gastric wall. With a laser flow meter the stomach tissue blood flow was measured before and after construction of the gastric tube, and the change in blood flow was compared. RESULTS: The average decrease in gastric blood flow was 23% in patients with PET and 65% in patients without PET. Twenty-one (88%) of 24 cases maintained more than 50% tissue blood flow in patients with PET and in 1 (8%) of 12 in patients without PET (p < 0.001 by t test). No serious complications occurred. CONCLUSIONS: Preoperative embolization therapy is a safe and uncomplicated technique, and tissue blood flow in the stomach was better preserved. This new technique is expected to reduce the frequency of anastomotic leakage after esophageal operation.     

A case of advanced gastric cancer resembling submucosal tumor of the stomach

We report a case of primary gastric carcinoma with a macroscopic appearance indistinguishable from that of a submucosal tumor. A 48-year-old man visited our hospital with a chief complaint of epigastric discomfort. Endoscopic examination revealed a protruding lesion with a well defined margin on the anterior wall of the gastric antrum. Most of the tumor surface was covered with apparently normal gastric mucosa and a shallow recess with mild erosion was observed on the top. Abdominal ultrasonography showed a hypoechoic lesion with an irregular margin under the gastric mucosa. Laboratory examination revealed an elevated CA19-9 level of 106.9 U/ml. In spite of repeated bouling biopsies, no histological diagnosis could be obtained before surgery. However, gastrectomy with regional lymph node dissection was performed because of the high likelihood of gastric cancer, in view of the markedly elevated CA19-9 level and irregular tumor margin demonstrated by abdominal ultrasonography. The tumor was diagnosed histologically as papillo-tubular adenocarcinoma invasive to the serosa with marked vessel infiltration. No metastasis was found in the regional lymph nodes. Gastric cancer resembling submucosal tumor is rare and often difficult to diagnose. Careful estimation of the possibility of gastric cancer and the informed consent of the patient are critically important, in cases of suspected primary gastric cancer resembling submucosal tumor, in order to decide the form of treatment.     

The clinical prognosis of the complication of peptic ulcer by acute hemorrhage

Clinical parameters have been studied in 45 peptic ulcer patients without and 47 ones with acute hemorrhage. Factors of acute hemorrhage risk in ulcer patients have been specified (old age, long history of the disease, previous hemorrhages, duodenal ulcer localization at the back and upper walls and gastric ulcer localization at the middle and upper thirds of the lesser curvature of the stomach, size of ulcer, penetration). Combined existence of the factors is conducive to acute hemorrhage.     

Laparoscopic anterior gastroplasty. A preliminary report of a new technique

BACKGROUND: The treatment of the morbidly obese patient is difficult because compliance with dietary regimens is poor. As a result, most weight reduction programs fail very quickly. Surgical treatment, on the other hand, provides a reliable method for sustained weight reduction. The most frequently performed procedure has been the vertical banded gastroplasty. Adaptation of the standard open procedure to laparoscopic techniques has been technically difficult and imprecise. We have developed, in the laboratory, an anterior wall banded gastroplasty that can be performed precisely and reproducibly using laparoscopic techniques. METHODS: Five Yorkshire pigs were used in attempt to laparoscopically perform the standard vertical banded gastroplasty. The procedure was difficult and was associated with a risk of staple line leak and with bleeding along the lesser curvature of the stomach. Furthermore, a reproducible pouch of proper dimension could not be created reliably. Fifteen animals were then used to develop a new technique using a small gastric pouch based on the anterior gastric wall. RESULTS: A reproducible pouch, 4 cm in length, was created over an 18-Fr nasogastric tube. A standard polyproylene band of 5.2 cm in length was utilized at the gastric pouch outlet. CONCLUSIONS: This operation can be reproduced accurately and has not demonstrated any leaks on postmortem examination.     

Comment. Sensory testing of the hands in leprosy

Early gastric cancer is now treated successfully by endoscopic mucosal resection (EMR). This technique, however, is not indicated when the tumoral lesion is located near the esophagogastric (EG)-junction, on the lesser curvature, or in the upper body or near the pylorus ring, and not indicated when the tumor size is greater than 20 mm. For these cases, we have developed what we term, "transgastrostomal endoscopic surgery" (TGES), using a Buess-type scope system. The aim of this study was to evaluate the efficacy of this technique in the treatment of those gastric cancers that could not be treated by EMR. In 4 patients selected for TGES, a Buess-type tube (external diameter: 40 mm) was inserted into the stomach through a temporary gastrostoma, and the whole operation was performed through the Buess-tube, using a video-camera for visualization. Using electrocautery scissors and forceps, complete resection of each lesion was performed, and the wound was closed by sutures. The average operation duration was 195 (130-240) minutes and the average blood loss was 59 (30-100) ml. The average size and margin of the resected specimens were 48 (30-59) and 13 (5-23) mm respectively. TGES is a substitutive, minimally invasive surgery to treat an early gastric cancer for which EMR would be difficult. This technique appeared to be simpler and easier than that of laparoscopic resection especially for a lesion on the posterior side of the stomach.     

Catastrophic complications of the cervical esophagogastric anastomosis

Recent enthusiasm for the cervical esophagogastric anastomosis has arisen because of its perceived low morbidity. Although catastrophic complications of a cervical esophagogastric anastomosis are unusual, they can and do occur, and prevention is possible if the potential for them is recognized. Among 856 patients undergoing a cervical esophagogastric anastomosis after transhiatal esophagectomy, catastrophic cervical infectious complications occurred in 11 patients (1.3%): vertebral body osteomyelitis (1), epidural abscess with neurologic impairment (2), pulmonary microabscesses from internal jugular vein abscess (1), tracheoesophagogastric anastomotic fistula (1), and major dehiscence necessitating anastomotic takedown (6). These complications became manifest from 5 to 85 days after the esophageal resection and reconstruction (mean 19 days). Leakage from a gastric suspension stitch placed in the anterior spinal ligament over the vertebral bodies resulted in a posterior gastric leak and either osteomyelitis or an epidural abscess in three patients, none of whom had evidence of extravasation on the routine barium swallow 10 days after operation. Cervical exploration for a presumed anastomotic leak led to the unexpected discovery of an abscess formed by the stomach and the adjacent wall of the internal jugular vein, which was ligated and resected. One patient without symptoms who was discharged from the hospital with a contained anastomotic leak on the postoperative barium swallow was readmitted 7 days later with a cervical tracheoesophagogastric anastomotic fistula of which he ultimately died. In 6 patients (7% of those who had anastomotic leaks) there was sufficient gastric ischemia or necrosis, or both, to necessitate takedown of the anastomosis and intrathoracic stomach, cervical esophagostomy, and insertion of a feeding tube. As a result of this experience, it is recommended that cervical gastric suspension sutures either be omitted entirely or placed in the fascia over the longus colli muscles anterior to the spine, but not directly into the prevertebral fascia overlying the vertebral bodies or cervical disks. All but minute cervical anastomotic leaks, even if apparently contained, are best drained rather than treated expectantly. Patients who remain febrile and ill after bedside drainage of a cervical esophagogastric anastomosis leak should undergo cervical reexploration in the operating room; major gastric ischemia or necrosis, or both, may warrant takedown of the anastomosis and intrathoracic stomach.     

Muscular composition of the gastric groove in the golden hamster

The golden hamster possesses a forestomach and a glandular stomach. The gastric groove connects the cardia to the glandular stomach and is situated on the lesser curvature of the stomach. The constitution of the muscle fibers in the gastric groove was investigated. The gastric groove consisted of two lips and a groove floor. The muscle coat of the lips was composed of a mixture of smooth and striated muscle fibers. The smooth muscle fibers were components of the cardiac muscle loop. The striated muscle fibers were extensions from the esophageal inner circular muscle layer, and invaded about half the length of the lips. The muscle coat of the groove floor consisted of an inner circular muscle layer made up of smooth muscle fibers, and the outer longitudinal muscle layer of the striated muscle fibers extended from the esophageal outer longitudinal muscle layer. The present study revealed that the muscle coat of the gastric groove in the golden hamster was composed of smooth and striated muscle fibers, and that these striated muscle fibers were extensions of the esophageal muscle coat.     

Atraumatic gastric transposition after transhiatal esophagectomy

Transhiatal esophagectomy using the stomach for esophageal replacement requires that the gastric "neoesophagus" be transferred from the peritoneal cavity through the posterior mediastinum into the neck under blind conditions. This process is associated with stretching, tearing, and hematoma formation in the most critical portion of the gastric tube, that to be used for the anastomosis. A technique is described for this procedure that is simple to perform and, most importantly, completely atraumatic to the gastric conduit.     

Ulcer location in the stomach and pylorantral hypertrophy: problem of correlation of the ulcer location and wall hypertrophy in ulcus ventriculi

Relationship between gastric ulcer (n = 100) site and antropyloric wall hypertrophy was examined in a prospective study. Irrespective of ulcer multiplicity most ulcers were found to be located at the lesser curvature and at the posterior wall (p less than 0,001); men had significantly more ulcers at the posterior wall than females (p less than 0, 001). Single ulcers and those connected with pyloric stenosis were more distant to the pylorus than multiple ulcers (p less than 0,001). Ulcer location did not relate to hypertrophy of the pyloric channel wall. Observed differences between single and multiple ulcers were limited to wall parts only: the musculature of high located single ulcers was significantly less hypertrophied 2,5 cm orally of the pylorus (p less than 0,02) and that of high multiple ulcers was more hypertrophied at the pylorus (p less than 0,02) than in the other parts. These findings suggest that ulcer variations do not influence the diffuse antropyloric disease in gastric ulcer patients and suggest that the generalized antral changes are prior to gastric ulcer occurance.     

Enhanced motility of the vagotomized canine stomach by electrical stimulation

Functional impairment of the vagotomized stomach used as a substitute oesophagus seriously deteriorates the quality of life of patients following oesophageal cancer surgery. We speculated that if the enteric neurons of the reconstructed gastric tube survived functionally, the motility of the gastric tube could be facilitated and the recovery process after operation would improve as a consequence. In the present study we investigated whether direct electrical stimulation was effective for facilitating the motility of the canine vagotomized stomach. Dogs underwent truncal vagotomy by transabdominal approach and, in some cases, arteries to the upper stomach and the oesophagus were also ligated and resected to resemble the blood supply and surgical invasion of the reconstructed gastric tube. Electrical stimulation, a few minutes of positive rectangular current pulses, amplitude 20 V (or 15 mA), duration 0.5 ms and frequency between 0.2 and 7 Hz, was delivered on the greater curvature of the mid corpus. Changes in mechanical contractions were recorded using strain gauge force transducers. Electrical stimulation successfully enhanced the mechanical force of the phasic ring contractions of the vagotomized stomach in a frequency dependent manner. Aboral propagation and periodicity of the contractions, impaired by surgical procedures, were restored during stimulation. These excitatory effects were inhibited by atropine, hexamethonium and tetrodotoxin, suggesting that electrical stimulation acts on intramural cholinergic nerves that have survived functionally. These results suggest that electrical stimulation could be an effective method for improving the motility of the vagotomized stomach.