Laparoscopic surgery for early gastric cancer--its advantages and pitfalls]

We have successfully established two different laparoscopic procedures for early gastric cancer since March 1992, which are laparoscopic wedge resection of the stomach using a lesion-lifting method and laparoscopic intragastric mucosal resection. The indication is as follows; (A) mucosal cancer, (B) < 25 mm, if the lesion is elevated type, (C) < 15 mm and Ul (-), if the lesion is depressive type. The advantages of these methods are; 1) minimally invasiveness, 2) sufficient surgical margin, 3) feasibility of detailed histology, 4) feasivility of perigastric lymph node dissection. In contrast, there are several problems to be solved, which are; 1) preoperative diagnostic accuracy of the depth of cancer invasion, 2) possibility of reoperation because of sm invasion or lymphatic or venous invasion in final histology, 3) possibility of postoperative stenosis after laparoscopic intragastric mucosal resection for the lesion near the cardia, 4) incidence of metachronous multiple gastric cancer. In conclusion, if the indication is properly selected, these laparoscopic procedures are curative and minimally invasive treatment for early gastric cancer.     

Laparoscopic surgery for early gastric cancer--its advantage and pitfall

We have successfully treated 50 patients with early gastric cancer by using two different laparoscopic procedures since March 1992. which are laparoscopic wedge resection of the stomach using a lesion-lifting method (n = 33) and laparoscopic intragastric mucosal resection (n = 17). The indication is as follows; (A) mucosal cancer, (B) < 25 mm, if the lesion is protruded type, (C) < 15 mm and Ul(-), if the lesion is depressive type. The advantages of these methods are; 1) minimally invasiveness. 2) sufficient surgical margin, 3) feasibility of detailed histology, 4) feasibility of perigastric lymph node dissection. In contrast, there are several problems to be solved, which are; 1) preoperative diagnostic accuracy of the depth of cancer invasion, 2) possibility of reoperation because of sm invasion or lymphatic or venous invasion in final histology, 3) possibility of postoperative stenosis after laparoscopic intragastric mucosal resection for the lesion near the cardia, 4) incidence of metachronous multiple gastric cancer.     

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.     

Clinicopathologic features of submucosal carcinoma of the stomach

A retrospective study of 155 patients with submucosal gastric carcinoma compared the clinicopathologic features with mucosal and muscularis proprial gastric carcinoma. Fifty-seven percent of the patients presented with gastrointestinal symptoms, whereas 36.1% had been detected by mass screening. The incidence of curative resection, lymph node metastasis, and complications were 96.1, 20.6, and 14.8%, respectively. Two patients died of sepsis and pulmonary infarction 30 days post-operatively. Five patients died of recurrent gastric cancer 1-5 years postresection. The overall 5-year survival rate was 90.2%. Recurrence patterns, histologic type, lymph node metastasis, lymphatic and venous infiltration, and growth pattern were similar to those of muscularis proprial carcinoma rather than mucosal carcinoma. Therefore, curative gastrectomy with extended lymphadenectomy (D2) may be feasible for submucosal carcinoma of the stomach.     

Early gastric cancer in the remnant stomach

BACKGROUND/AIMS: Early gastric cancer in the remnant stomach is rare. Periodical endoscopic examinations are mandatory for patients with partial gastrectomy for a good prognosis. Our goal is to improve the surgical management of gastric cancer in the remnant stomach. We have retrospectively investigated a total of 15 rare cases of early gastric cancer after partial gastrectomy. METHODOLOGY: From 1976 to 1994, a total of 2,102 cases of gastric cancer were resected in our Department. Among these resected cases, 845 cases were histologically diagnosed as having early gastric cancer of the stomach. Of these, 15 patients had previously undergone a partial gastric resection. The time interval between the initial partial gastrectomy and the second resection of the remnant stomach, was more than 10 years for 8 patients (Group 1) and less than 10 years for 7 patients (Group 2). Here we investigate these rare cases of remnant early gastric cancer. RESULTS: The incidence of early gastric cancer in the remnant stomach was 1.8% (15/845). The cancer location in the remnant stomach was around the stoma and suture line in 75% of Group 1 and in 28.6% of Group 2. The incidence rate of mucosal cancer (m-cancer) was 87.5% for Group 1, and 14.3% for Group 2. Total gastrectomy was selected for 37.5% of Group 1, and for 100% of Group 2. No lymph node metastasis was discovered in both groups. The postoperative mortality was zero in both groups. One patient from Group 2, later died of liver metastasis 2 years after the second total gastrectomy, while the other 9 patients continued to live for more than 5 years with no gastric cancer recurrence to date. CONCLUSIONS: The outcome for patients with gastric cancer in the remnant stomach is generally considered poor. However, the outcome of early gastric cancer in the remnant stomach was good without major postoperative complications. Therefore, to improve surgical management of remnant-stump gastric cancer, early diagnosis is most important, using periodic endoscopic follow-up examinations, especially around the stoma. When mucosal cancer around the stoma is diagnosed, subtotal gastrectomy can be selected even in gastrectomized patient for a good prognosis.     

Endoscope-assisted laparoscopic resection of the gastric wall

The early gastric carcinomas measuring 10-25 mm in diameter, macroscopically I-II/C types and benign gastric tumours are relegated to laparoscopic wedge resection of the stomach. Authors report on the use of a new endoscopic assisted--"double-lifting"--laparoscopic resection of the gastric wall, in the course of removal of an early stage gastric carcinoma (13 mm in diameter, macroscopically II/C type) and a gastric lipoma (21 mm in diameter). The advantage of this method: the affected gastric wall could be removed safely far from the lesion and all layers of the gastric wall are available for histological examination.     

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.     

Gastric carcinoma resected 95 months after being diagnosed: report of a case

It is usually assumed that patients with gastric carcinoma will almost certainly die within 5 years if they do not receive treatment. We report herein a rare case of curative gastrectomy being performed 95 months after gastric carcinoma was diagnosed. A 37-year-old Japanese man had an upper gastrointestinal endoscopy with biopsy which revealed moderately differentiated adenocarcinoma of the stomach. This was diagnosed as type IIc early gastric carcinoma with ulceration but he refused surgery. At 45 years of age, 95 months later, he presented to our hospital with melena, at which time lesions in an identical location had enlarged to Borrmann type 3 advanced gastric carcinoma. Thus, a total gastrectomy with regional lymph node dissection was performed. Although there was no liver or peritoneal metastasis, the regional lymph nodes were involved; however, the patient recovered well and is still alive without any further recurrence roughly 4 years postoperatively. The natural history of gastric carcinoma and the malignant cycle are discussed following the presentation of this case.     

Cervical spinal cord compression caused by ossification of the posterior vertebral ligament. Apropos of a case

In eight Japanese patients, three different laparoscopic procedures were used to excise an early gastric carcinoma; partial resection in four, intragastric resection of the gastric mucosa in two, and laparoscopic-assisted distal partial gastrectomy with the abdominal wall-elevating method in two patients. Histological examinations revealed that the lesions were completely resected, and there was no evidence of lymphatic metastasis. The operation time ranged from 2 to 4 h. These forms of laparoscopic gastric surgery for patients with early gastric carcinomas may be useful from the standpoint of minimal access, rapid recovery, less pain, and good cosmesis.     

D2 receptor binding in dopa-responsive dystonia

OBJECTIVES: Synchronous gastric tumors (including benign and secondary tumors) associated with esophageal cancer present diagnostic and therapeutic issues. We investigated this synchronous association, and retrospectively determined the frequency of the gastric tumors and the clinical characteristics. METHODS: In a series of 208 patients with esophageal cancer, we investigated the synchronous gastric tumors, as well as the frequency of association, clinicopathological characteristics, diagnosis, treatment, and the clinical outcome after surgery. RESULTS: Twenty-eight gastric tumors were found in 24 patients. Adenocarcinoma was most frequent. Most of these tumors were located at the upper or middle third of the stomach. Eight gastric tumors in six patients could not be detected preoperatively. Six of these tumors including a gastric remnant cancer were detected in the resected stomach, and two leiomyomas were detected during the operation. In one patient in which an endoscope could not pass through the esophagus, a leiomyoma was detected in the resected stomach. For the gastric cancers, total gastrectomy or proximal gastrectomy with lymph node dissections was performed. For the benign tumors, partial resection of the stomach was performed, and endoscopic resection was performed preoperatively for an adenoma. In both the postoperative hospital mortality rate and the survival rate after surgery, there were no significant differences between the patients with and without gastric tumors. CONCLUSIONS: Synchronous gastric tumors associated with esophageal cancer are not rare. When an endoscope cannot pass through the esophagus before surgery, other techniques must be performed to explore the stomach. For these patients, surgical treatment should be adapted positively.     

Radiographic diagnosis: arachnoid cyst in a dog

Lauren's intestinal type of gastric cancer was proposed to be dependent on long-term environmental factors and is always preceded by chronic premalignant change. A cohort study was performed and demonstrated an increased cancer risk of gastric remnant after gastric surgery for benign disease. It is generally believed that after gastrectomy the residual stomach has an environmental change and, thus, enters a neoplastic process. Based on the carcinogenic theory of intestinal-type tumour, it would be of interest to know whether the intestinal-type tumour is more common in gastric remnant cancer. Forty patients with gastric remnant cancer had gastrectomy in the Veterans General Hospital-Taipei. Another 683 patients with primary gastric carcinoma underwent resection and were used as controls. The clinical characteristics, tumour stage and intestinal-type tumour were analysed in gastric remnant cancer and were compared with the various portions of primary gastric carcinoma. Although the overall distribution of intestinal-type carcinoma in gastric remnant (45%) was no different to that of any other portion of stomach cancer, intestinal-type carcinoma was more common in the early stage of gastric remnant (73%) and distal stomach (73%), but not in the proximal stomach (50%), which was supposed to have the same characteristics as the gastric remnant because of identical anatomic location. More than expected, intestinal-type carcinoma in early gastric remnant cancer together with a long incubation interval between primary surgery and later tumour occurrence were compatible with the theory of carcinogenesis of intestinal-type carcinoma.     

Evaluation of acetic acid-induced gastric ulcers in dogs by endoscopic ultrasonography

To clarify the ability of endoscopic ultrasonography (EUS) to diagnose gastric ulcer, we induced gastric ulcer (19 open ulcers and 11 ulcer scars) by injecting acetic acid into the stomach via an endoscope in 15 dogs. The stomachs were resected and scanned by EUS in a water bath, and the findings were compared with the histologic observations. The ulcer depth was correctly diagnosed in 29 of 30 instances (96.7%). In active, open ulcers the width and depth of the ulcer crater and the thickness of the gastric wall around the crater measured in the photographs obtained by EUS corresponded with those observed in histologic photographs. In the ulcers disrupting the muscularis propria layer the distance between the disrupted muscularis propria layer in EUS also corresponded to the histologic observations. In all ulcer lesions the low-echoic area below the ulcer in EUS corresponded to the histologic area of granulation or fibrosis. However, it was difficult to distinguish granulation from fibrosis by EUS. EUS is thus considered useful for evaluating gastric ulcers quantitatively in the clinical setting.     

Food intake after gastrectomy for gastric carcinoma: the role of a gastric reservoir

Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.     

Admission-discharge policies for hysteroscopic surgery: a randomised comparison of day case with in-patient admission

Pernicious anemia is an autoimmune disease characterized by a gastric mucosal defect which results in an insufficiency of intrinsic factor to facilitate the absorption of the physiologic amount of cobalamin. Increased risk of cancers of the stomach has been reported for patients with pernicious anemia. We report here a case of a 65 year old woman who had been diagnosed as having pernicious anemia 16 months previously, was receiving monthly vitamin B12 injections, and developed early gastric cancer type IIa by routine follow-up gastroscopic examination. This patient underwent endoscopic mucosal resection for an early gastric cancer lesion with a free resection margin.     

Endoscopic mucosal resection for early gastric cancer

Endoscopic therapy of gastric cancer has been mainly performed to early cancer of nonresectable cases, for example patients having severe complications, high aged group and patients refusing the operation. Recently, endoscopic mucosal resection (EMR) made it possible to do radical resection for small gastric cancer of resectable cases. 112 patients of small cancers which diagnosed as a cancer limited to the mucosa were investigated. Indication to perform EMR instead of surgery were determined pathologically as follows, 1. depressed type of cancer not accompanying with converging folds measuring 1 cm or less in size, 2. elevated type of cancer measuring 2 cm or less in size, 3. differentiated type of carcinomas. According to those indications, 112 cases with 129 lesions of early gastric cancer were resected. The incision procedure consisted in EMR using two-channel fiberscope, a large chating forceps and a snare, the tissue being ablated with a high frequency electrical current. 2-6 ml of phisocal saline was locally infused at the submucosal level before resection to do it safely. Results: Relationship between the prognosis and the histological distance from the edge of the specimen to the margin of the cancer were discussed. All of 81 cases having the distance more than 2 mm, it's called 'complete radical resection', were not recurrent, on the other hand 4 of 24 cases having the distance less than 2 mm, called 'incomplete radical resection', were recurrent at the site of resection and 12 of 24 cases obviously cancer spread to the edge of the specimen, called 'non-radical resection', were recognized the recurrence. conclusion, 1) On endoscopical resection for small gastric cancer, the distance more than 2 mm between the edge of the specimen and the margin of the cancer was necessary to get a complete radical resection. 2) Technical and mechanical problems still remained at the case of the cancer located in the angular region and gastric body.     

直径小于2厘米胃癌预制因素分析

Objective:The aim of our study was to identify clinicopathological characteristics as predictive factors for gastric cancer tumours of less than 2 cm in diameter. Methods: The clinicopathological features of 129 patients with gastric cancer tumour of less than 2 cm in diameter were reviewed retrospectively from hospital records between 1980 and 2000. The results of retrospective analysis of clinicopathological data of 58 patients with advanced cancer were compared with those of 71 patients with early cancer. Univariate and multivariate analyses of patients with gastric cancer tumours were performed to evaluate the prognostic significance of clinicopathological features. Results: Lymph-node metastasis was found more frequently in the advanced cancer group than in the early cancer group. In univariate analysis, unfavorable prognostic factors included deep cancer invasion. Using Cox's proportional hazard regression model, only depth of invasion emerged as an independent statistically significant prognostic parameter associated with long-term survival. Conclusion: Depth of invasion is an independent prognostic factor for gastric cancer tumours of less than 2 cm in diameter. Laparoscopic surgery should not be performed on tumours that are diagnosis in advanced stage and lymph-node involvement. We recommend laparoscopic surgery involving local resection of the stomach without lymphadenectomy for small, early gastric cancer tumours. However, the validity of this recommendation should be tested by a prospective randomized control trial in the future.     

T-cell response to HIV in natural infection: optimized culture conditions for detecting responses to gag peptides

We report a case of successful laparoscopic resection of a solitary schwannoma of the gastric fundus performed on emergency. The patient was a 52-year-old man who presented with an upper gastrointestinal hemorrhage. At admission, the endoscopy and hydro-CT scan showed a submucosal tumor, 2.5 cm in maximum diameter, with an area of central ulceration arising from the anterior wall of the gastric fundus. A wedge laparoscopic resection of the gastric wall was performed under endoscopic guidance. The defect in the anterior wall was repaired in part by linear stapler and in part using a continuous suture. The postoperative recovery was uneventful and the patient was discharged on the 4th postoperative day. Laparoscopic approach represents a safe and efficient approach for the treatment of benign tumors of the stomach, also on emergency basis.     

Surgical treatment of gastric adenocarcinoma: the role of lymph node dissection

In this retrospective study, 652 patients who had curative resections for gastric cancer from 1977 to 1991 were reviewed to evaluate improvements in gastric cancer surgery and the influence of the extent of lymphadenectomy on survival. The patients were grouped into three time periods: 1977 to 1981, 1982 to 1986 and 1987 to 1991. The percentage of patients with early gastric cancer increased from 17.7% during 1977 to 1981, to 24.3% during 1987 to 1991. The average number of dissected lymph nodes was 7.5 +/- 8.1 during 1977 to 1981 and 16.4 +/- 10.3 during 1987 to 1991, when more radical lymphadenectomy was adopted. Total gastrectomies increased from 10.9% to 25.9% in the same time periods while combined visceral resections increased from 26.7% to 38.1%. Operative mortality decreased from 5.0% to 1.7%. The overall 5-year survival rate increased from 34.8% to 59.4%. In subgroup analysis, significant improvement of the 5-year survival rate was noted in the following groups: patients with stage I, II and III tumors but not stage IV; both proximal and distally located tumors; tumors with or without lymph node metastases; T1 and T2 but not in T3 and T4 (cancer invasion beyond the serosa). The decreased surgical mortality in recent years suggests that curative resection with extensive lymph node dissection can now be safely performed. Radical gastrectomy with extended lymphadenectomy may be adopted in gastric cancer resection for better control of regional disease.     

Abdominal wall metastasis following surgical removal of colorectal carcinomas

Abdominal wall metastases after laparoscopic resection of colorectal cancer have been reported by various authors. It appeared that abdominal wall metastases occur more frequently after laparoscopic than after conventional, open resection of colorectal cancer. However, the frequency of abdominal wall metastases after laparoscopic surgery varies from only 0 to 1.9% in centres with sufficient relevant experience, whereas after conventional resections the frequency is 0.8-3.3%. A randomized clinical study comparing laparoscopic with conventional resection of colon cancer is necessary to assess the optimal surgical approach to colon cancer. Such a trial has been set up.     

Quality of nursing care--a midwife''s concern?

Early or superficial gastric cancer identifies a lesion that is confined to the mucosa or submucosa layer and that even in the presence of lymph nodes metastasis can be successfully treated with resection and lymph node dissection. In presence of cancer that invades the submucosa the incidence of N2 metastasis raises to 3-5%, and even though a D2 procedure is indicated as the postoperative mortality is similar to D1 procedure. Early gastric cancer of the mid portion of the stomach can be treated with a distal D2 pylorus preserving gastrectomy that has the advantage to reduce the incidence of dumping syndrome; this result can be achieved with a complete dissection of the infrapyloric nodes preservng part of the suprapyloric nodes to spare the right gastric artery. Endoscopic mucosal resection is another therapeutic option available in presence of a mucosal gastric cancer less than 2 cm, well differentiated without ulceration; among 50 cases treated so far, 32 cases were completed resected and they are free of disease up to now. The main risks of this procedure are hemorrhage (5%) and perforation (6.4%).