Long-term survival after gastrectomy for advanced bleeding or perforated gastric carcinoma

OBJECTIVE: To find out whether massive bleeding or free perforation of advanced gastric carcinoma affect long term survival after gastrectomy. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Teaching hospital, Hong Kong. INTERVENTIONS: Gastrectomy. MAIN OUTCOME MEASURES: Long term survival. RESULTS: Data of 50 patients with gastric carcinoma that had penetrated the serosa (pT3) and who were operated on between 1985 and 1990 were analysed. A total of 17 patients with tumour free perforation and 10 with massive bleeding underwent emergency gastrectomy, and 23 patients with comparable uncomplicated tumours had elective gastrectomy. Twelve variables that could have influenced survival including malignant perforation, bleeding, or the absence of complications were analysed using the Cox's proportional hazards model. Survival was influenced only by proliferative cell nuclear antigen (PCNA) index and not by perforation, bleeding, or the uncomplicated nature of the tumour. CONCLUSIONS: These findings suggest that perforation or bleeding from advanced gastric carcinomas do not significantly affect long term survival after gastrectomy.     

Surgery for gastric remnant carcinoma following Billroth II gastrectomy

Between January 1983 and December 1995, 31 patients with gastric remnant carcinoma were operated on 6-45 years after a Billroth II resection for peptic ulcer disease. Total gastrectomy with Roux-en-Y reconstruction was performed in all cases. In 16 patients (52%) extended resection with removal of one or more adjacent organs was necessary for oncological reasons. In this elderly population with a high incidence of pre-operative risk factors (55%), most tumours were classified as stage III or IV (45%). Although total gastrectomy should be the surgical option of first choice for gastric remnant carcinoma, it resulted in high levels of post-operative mortality and morbidity (13% and 35%, respectively), especially in patients with stage III and IV tumours who underwent resection of an adjacent organ. Despite extended surgery, if necessary, the recurrence rate after 'curative' surgery is high (8/20 patients) and the cumulative disease-free 5-year survival rate was 48%. Detection of the tumour at an earlier stage not only limits the extent of resection and lowers the complication rate, but also improves survival.     

Residual gastric mucosa after gastrectomy: development of precancerous lesions

The gastric remnant can be regarded as a model to investigate the events of gastric carcinogenesis of intestinal type. Histologic changes precursor of the malignancy develop in higher incidence in the postoperative stomachs than in non-resected ones. 316 patients hemi-gastrectomized for peptic ulcer were assessed by an endoscopic-histologic study to provide further informations on the sequential chain of histologic lesions that precede the development of cancer. The anastomosis was by far the commonest diseased area at endoscopy, particularly in the patients with a Billroth II resection (p < 0.0004). The 10% of the 233 patients biopsied evidenced a normal gastric mucosa, in the others Superficial Gastritis 74%, Chronic Atrophic Gastritis 36%, Cystic Dilatation 52%, Foveolar Hyperplasia 29%, Intestinal Metaplasia 39%, moderate-severe Dysplasia 6% as single abnormality or variously associated were observed. The stoma was the most damaged area at histology. The occurrence of the DC, the FI and the IM at the anastomotic site was significative (p values between 0.02 and 0.001). The earliest postoperative histologic lesion was the CAG, evidenced, in mean 13 years after operation, the latest the DC observed in mean 18 years after surgery (p < 0.004). The IM, the IF, the CD, and the dysplasia in association with the CAG were observed at postoperative intervals shorter when non-associated with CAG (respective p value: NS, < 0.03, < 0.0002, NS). The probability of transition from an histologic lesions to a more advanced one in our patients was similar to that of a non resected population at medium--high risk of gastric cancer.     

Multiple early gastric stump carcinomas after gastrectomy for peptic ulcer

The remnant stomach after partial gastrectomy is considered to have a predilection for the development of primary gastric carcinoma. However, early gastric stump carcinomas are uncommon because the diagnosis of gastric stump carcinoma is more difficult than that of carcinoma in the intact stomach. Triple early gastric stump carcinomas, as in the present case, are exceedingly rare and may provide some clues for further investigation of carcinogenesis in the gastric stump. We studied about the histological appearance, genetic alterations (P-53 gene, c-erbB-2 gene and K-ras gene), and expression of tumor-associated antigens (carcinoembryonic antigen, carbohydrate antigen 19-9, and sialyl-Tn) in this rare case. The three carcinomas differed from each other histologically. With respect to genetic alterations, c-erbB-2 was amplified in one lesion, but no mutations of K-ras and P-53 gene were detected. The three carcinomas also differed from each other on the expression of tumor-associated antigens. In noncancerous mucosal epithelium at the anastomosis showing hyperplasia and cystic formation of glandular epithelial cells, no genetic alterations were detected, but sialyl-Tn and carbohydrate antigen 19-9 were expressed. These results suggest that there may be different processes of carcinogenesis of the three carcinomas even though they occurred under identical environmental conditions to those that have increased cancer risk.     

Physiologic effects of cisapride on gastric emptying after pylorus-preserving gastrectomy for early gastric cancer

Pylorus-preserving gastrectomy (PPG) has been considered reasonable reduction surgery. However, even patients in whom more than 1 year passed after surgery frequently have a feeling of gastric fullness after meals and long-term retention of foods in the residual stomach. To treat this syndrome, cisapride has been administered. We studied the emptying time of a semisolid diet (radioisotope method using 99mTc-tin colloid-labeled rice gruel) and the emptying time of a fluid diet (acetaminophen method with orange juice) before and after oral administration of cisapride (15 mg/day for 1 month) in 14 patients (10 men, 4 women; 32-70 years old, average 60.6 years) who underwent PPG (Billroth I procedure, D2 lymph node dissection, curability A) for treatment of early gastric cancer. Ten healthy volunteers without gastrointestinal symptoms and digestive diseases (7 men, 3 women; 28-61 years old, average 49.8 years) were enrolled as controls. The results showed obviously delayed emptying time of the semisolid diet before administration of cisapride in patients with PPG compared with that of the control group, whereas the emptying curves for the fluid diet showed an almost normal pattern. One month after the start of cisapride administration the emptying time of the semisolid diet was improved, and the emptying curves were close to the patterns in the control group. Emptying of the fluid diet was slightly accelerated compared with that before administration of cisapride, and the emptying curves showed almost the same pattern as in the control group. A postgastrectomy symptom, "gastric fullness," after PPG was alleviated by cisapride. These results showed that cisapride improved delayed emptying of a semisolid diet after PPG and prevented the feeling of gastric fullness after meals due to retention in the residual stomach.     

Nutritional status of gastric cancer patients after total gastrectomy

A number of causes of malnutrition after total gastrectomy have been proposed. The purpose of this study was to assess nutritional status and to determine the cause of malnutrition after total gastrectomy. We studied 20 gastric cancer patients who had undergone total gastrectomy and immunochemotherapy and 6 normal controls. Nutritional status was assessed by dietary history, anthropometric methods, and serologic measurements. Malabsorption tests included the fecal fat excretion test, D-xylose absorption test, glucose tolerance test, vitamin B12 absorption test using dual isotopes, bacterial culture of jejunal aspirates, and jejunal biopsy. Weight loss was compared to the preoperative status in all patients (average 15%: 59.0 +/- 9.9 vs. 50.2 +/- 7.8 kg, preoperatively vs. postoperatively). Average daily calorie intake was 1586.2 kcal, which is lower than the normal intake of Korean adults (1838 kcal). Malnutrition of skeletal and visceral protein was not found. There was, however, severe fat malnutrition and a deficit of body fat. Postoperatively the body mass index was considerably lower than that preoperatively (22.2 +/- 0.4 vs. 18.9 +/- 0.4 kg/m2; preoperatively vs. postoperatively). With malabsorption tests, the daily excreted amount of fecal fat was 28.6 +/- 3.4 g (mean +/- SD) in patients and 6.9 +/- 0.2 g in controls. There was no significant malabsorption of carbohydrates. In 64.3% (9/14) of patients, vitamin B12 absorption was abnormal; and the serum concentration of vitamin B12, which was significantly related to malabsorption of this vitamin, was lower than normal in 73.7% (14/19). Bacterial overgrowth was not found, and there were no abnormal histologic findings in the jejunal mucosa. These results suggest that poor oral intake and fat malabsorption following total gastrectomy cause malnutrition and that fat malabsorption may be related to relative pancreatic insufficiency.     

Quality of life of patients with gastric adenocarcinoma after curative gastrectomy

Quality of life (QOL) was evaluated in 162 patients having radical gastrectomy for cancer. The results showed that more than half of the patients had a good appetite; they consumed a normal diet and a normal volume of food. Approximately 60% of the patients had weight loss of more than 5 kg. Patients who underwent a total gastrectomy had poor tolerance of normal food and frequent eating and body weight loss versus those who had a subtotal gastrectomy. Patients who underwent Billroth II reconstruction after a distal subtotal gastrectomy lost more body weight than those with a Billroth I anastomosis. The extent of lymphadenectomy did not influence the QOL. Patients under 65 years of age had a better QOL. Nearly all patients had normal work and daily living activities. Some patients appeared to lack energy or had a period of anxiety or depression. These data indicate that radical gastrectomy can be performed with an acceptable QOL for a potentially curable gastric carcinoma.     

Disseminated carcinomatosis of the bone marrow occurring 11 years after subtotal gastrectomy for gastric cancer]

A 44-year-old man was admitted to our hospital because of purpura, increased serum alkaline phosphatase, and thrombocytopenia. He had undergone subtotal gastrectomy for gastric cancer 11 years earlier. A biopsy specimen of the bone marrow revealed metastatic mucin-forming, moderately differentiated adenocarcinoma. Because the primary tumor was not detected in any other organ, the gastric cancer the patient was treated for 11 years earlier was suspected as the primary tumor. Microangiopathic hemolytic anemia and disseminated intravascular coagulation developed during the clinical course, and the patient deteriorated despite treatment with anticoagulants. Finally, he died of pulmonary carcinomatous lymphangitis. Autopsy revealed a small number of adenocarcinomatous cells in the lymphoduct of the remaining stomach in spite of its mucosa being intact. We concluded that the bone marrow was infiltrated by cancer cells which originated in the stomach 11 years before. It is unclear why adenocarcinoma cells remained dormant for as long as 11 years in the gastric lymphoduct and bone marrow.     

The role of microsatellite instability in gastric carcinoma

Hernia repair may involve the use of an implant to augment or replace autologous tissue, but the best material for use in this application has not been established. We developed a dog model to evaluate the mechanical strength of fascial defects repaired using carbon fibers, compared with the strength of similar defects repaired using polypropylene mesh (Marlex). Unrepaired defects were included as an additional control. Bilateral defects (1 cm square) were made in the fascia of the back, and the ultimate mechanical strength and stiffness at the repair sites were measured 3-12 months after operation. Defects repaired with carbon fibers were significantly stronger 12 months after operation compared with defects repaired with polypropylene mesh and compared with unrepaired defects. It is concluded that carbon fibers are biocompatible and significantly increase mechanical strength at the repair site. A randomized clinical trial involving patients undergoing hernia repair seems justified to determine whether carbon fibers are superior to standard therapy.     

Food intake and the menstrual cycle: a retrospective analysis, with implications for appetite research

The biological regulation of appetite is currently an important topic in nutrition, since hyperphagia has been implicated as the prime cause of obesity. Cyclical fluctuations in food intake occur in women across the menstrual cycle, with a periovulatory nadir and a peak in the luteal phase. These alterations in food intake, in response to ovarian steroid hormone changes may be more than 2.5 MJ/day, with the mean reported changes shown in 19 separate studies of 1.0 MJ/day. Hormonal induced fluctuations in food intake could, therefore, contribute to energy imbalance and consequent weight gain. Further, in nutrition studies involving women subjects where the menstrual cycle phase is not controlled, hormonally induced changes in food selection and intake may mask the often considerably smaller changes in response to experimental variables in appetite research.     

Serum progesterone levels in patients with gastric adenocarcinoma before and after gastrectomy

We experienced a case of a hepatic subcapsular hematoma after extracorporeal shock wave lithotripsy (ESWL) for a right renal stone. To our knowledge this presentation is the second case in the Japanese literature. A 63-year-old female with a right renal stone received 2,800 shots of 14.0 kilo-volts shockwave with Sonolith 3,000. Preoperative examination of the blood disclosed no abnormalities in the coagulating system except slight reduction of platelet count and slight impairment of liver function. Postoperative routine ultrasound echograms revealed a hepatic subcapsular hematoma although she had no symptom. The size of the hematoma measured 11.0 x 5.0 cm in computed tomograms (CT). She was carefully observed without any treatments because the hematoma did not increase in size. CT scans 6 months after the ESWL treatment demonstrated neither hematoma nor masses in the liver. As a complication of ESWL for urolithiasis a hepatic subcapsular hematoma is very rare. We herein presented the case and discussed the complications of ESWL briefly in the literature.     

Measurement of pancreatic blood flow to prevent pancreatic juice leakage after pancreas-preserving total gastrectomy for gastric cancer

Disintegration apparatus according to P.Ph was adepted to measure the disintegration rate of tablets. The data obtained for 10 batches of aminophenazone tablets with different content of gelatine (2-20%) showed that there is a linear correlation between the area under non-disintegrated tablets mass curves (AUDC) and the area under release curves (AURC) described by equation: AUDC = bcr AURC - acr.     

Morbidity and mortality after D2 gastrectomy for gastric cancer: results of the Italian Gastric Cancer Study Group prospective multicenter surgical study

PURPOSE: To investigate whether pancreas preservation together with a strict quality-control system could ameliorate the outcome of D2 resections for gastric cancer in Western patients. PATIENTS AND METHODS: Italian patients with potentially curable proven adenocarcinoma of the stomach were registered from nine general and/or university hospitals in the area of Turin, Northern Italy. The study was performed according to the guidelines of the Japanese Research Society for Gastric Cancer (JRSGC). A strict quality-control system was guaranteed by a supervising surgeon of the reference center, who had stayed at the National Cancer Center Hospital, Tokyo, to learn the standard D2 gastrectomy. The standard procedure entailed removal of the level 1 and 2 lymph nodes. During total gastrectomy, the pancreas was preserved according to the Maruyama technique. RESULTS: Between May 1994 and December 1996, 191 eligible patients were entered onto the study. The mean number of lymph nodes removed was 39. The overall morbidity rate was 20.9%. Surgical complications were observed in 16.7% of patients. Reoperation was necessary in six patients and was always successful. The overall hospital mortality rate was 3.1%; it was higher after total gastrectomy (7.46%) than after distal gastrectomy (0.8%). The average length of hospital stay was 17 days. CONCLUSION: Given that postoperative morbidity and mortality rates are favorably comparable with those reported after the Western standard gastrectomy, the more extensive Japanese procedure with pancreas preservation can be regarded as a safe radical treatment of gastric cancer for selected Western patients treated in experienced centers.     

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.     

Positive association between dietary fat intake and risk of gastric stump carcinoma in rats

Effect of high- and low-fat diets on gastric stump carcinogenesis was experimentally investigated. A total of 130 Wistar male rats weighing 250-300 g received either sham operation or Billroth II partial gastrectomy, the resection of the distal two-thirds glandular stomach and reconstruction of gastro-jejunostomy. After surgery, each group of rats was switched from a standard diet (CRF-1) to a special diet containing either 15% soybean oil (high-fat) or 0.5% soybean (low-fat), fed ad libitum and tap water, and were killed 50 weeks after surgery. Gastric tumours were observed only in the animals that underwent gastrectomy while no tumours were detected in the animals following the sham operation. Tumours located invariably at the gastrojejunostoma, were carcinomas or adenomas in histology. Carcinomas developed in 12 of 29 gastrectomy animals (41%) fed the high-fat diet and 4 of 27 gastrectomy animals (15%) fed the low-fat diet. The difference was significant (P < 0.05). The incidence of adenoma was also significantly higher in the gastrectomy animals fed the high-fat diet (38%) than that in those fed the low-fat diet (15%) (P < 0.05). A daily faecal output of bile acids was significantly greater in the gastrectomy animals fed the high-fat diet (19.0 +/- 16.4 micromol/day) than that in those fed the low-fat diet (11.2 +/- 6.2 [micromol/day; P < 0.05). This study suggests that increased fat intake is associated with a high risk of gastric stump carcinoma.