Comparison of survival of surgical resection and conservative treatment in patients with gastric cancer aged 80 years or older: a single-center experience

PURPOSE: With the increase in the average life expectancy, the elderly population continues to increase rapidly. However, no consensus has been reached on the feasibility for surgical resection due to the high morbidity and mortality rate after surgical treatment in elderly patients caused by aging and underlying diseases. METHODS: This study was performed with patients aged 80 years and older. The subjects were classified into 2 groups as follows: the surgical resection group consisting of 61 patients, and the conservative treatment group consisting of 39 patients suitable for curative resection. RESULTS: Mean age and clinical stages in the conservative treatment group were higher than those in the surgical resection group. There was no significant difference in sex, location of the lesion, histological type, or underlying disease. The mean survival time of surgical resection group and conservative treatment group was respectively 52.1 ± 2.66 months and 37.1 ± 5.08 months (P < 0.05) for clinical stage 1 disease, 41.7 ± 5.16 months and 22.4 ± 6.07 months (P = 0.004) for stage 2 disease, and 31.7 ± 9.37 months and 10.6 ± 1.80 months (P = 0.049) for stage 3 disease. However, as for the extent of lymph node resection for the different stages, we observed no significant difference between the 2 groups. CONCLUSION: Surgical resection in all clinical stages, except stage 4, showed a higher survival rate than conservative treatment. To minimize postoperative surgery complications, limited lymph node dissection should also be considered.

Surgical Treatment for Patients Who Underwent Endoscopic Mucosal Resection (EMR)/Endoscopic Submucosal Dissection (ESD) of Early Gastric Cancer (EGC)

PURPOSE: To evaluate the necessity for additional surgical treatment after Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD), we analyzed the pathologic results of patients who underwent surgical treatment. METHODS: 140 consecutive patients underwent additional surgical treatment after EMR/ESD with en bloc resection between April 2005 and November 2009 at ASAN Medical Center. Additional surgical treatments were undergone for following conditions such as incomplete dissection (involvement of margin), undifferentiated-type histology (> or =2 cm) and submucosal cancer. RESULTS: One patient with deep margin involvement displayed advanced gastric cancer after gastrectomy. Three of 74 patients with clear resection margin were confirmed to have residual cancer at ESD site and 2 of 3 patients displayed advanced gastric cancer after surgery. In univariate analysis for metastasis of lymph node, deep submucosal invasion (over sm2 or 500microm) and the presence of lymphovascular invasion showed significant differences for lymph node metastasis. Especially, lymphovascular invasion was an important predictive factor for lymph node metastasis in multivariate analysis. In analysis for residual cancer, lateral margin involvement and large tumor (>3 cm) were risk factors. And, only lateral margin involvement showed significant risk in multivariate analysis. CONCLUSION: Although EMR/ESD were fully accomplished for resection margin, gastrectomy and lymph node dissection were positively necessary for patients with deepsubmucosal invasion (over sm2 or 500microm) and the presence of lymphovascular invasion to eliminate the possibility of residual cancer or more advanced gastric cancer or metastatic lymph nodes.

Utility of Surgical Resection in the Management of Metachronous Krukenberg's Tumors of Gastric Origin

PURPOSE: The aim of this study was to determine the prognostic factors and the significance of metastatectomy for Krukenberg's tumors of gastric origin. MATERIALS AND METHODS: Among the patient who underwent gastric surgery from 1992 through 2005, 90 female patients with Krukenberg's tumors of gastric origin were identified. We retrospectively reviewed the clinicopathologic characteristics, prognostic factors, and treatments for primary gastric cancer. We also investigated the prognostic risk factors for the onset of metachronous Krukenberg's tumors and the survival time of patients who underwent an operation for metachronous Krukenberg's tumors. RESULTS: The presence of a synchronous Krukenberg's tumor (mean survival time=17.6 months, P<0.01), peritoneal seeding (14.5 months, P<0.01), and non-curative resection (15.1 months, P<0.01), were statistically significant prognostic factors for survival time in female patients with gastric cancer. The stage of primary gastric cancer (P=0.049) and lymph node metastasis (P=0.011) were statistically significant risk factors for recurrence time of a metachronous Krukenberg's tumor. In the metachronous Krukenberg's tumor group (n=53), the mean survival time of the metastatectomy group (n=46, 43.2 months, P=0.012) was longer than that in the chemotherapy or conservative treatment groups (n=7 and 24 months, respectively). Metastatectomy, presense or abscence of residual tumor and extent of residual tumor were significant prognostic factors for survival time in female patients with metachronous Krukenberg's tumor of gastric origin. CONCLUSIONS: A close observation and evaluation with ultrasound or computed tomography is necessary in female patients with advanced gastric cancer to detect a metachronous Krukenberg's tumor as soon as possible. The surgeon must operate more aggressively in patients with metachronous Krukenberg's tumors.

Totally Laparoscopic Distal Gastrectomy with ROUX-EN-Y Reconstruction for Treatment of Duodenal Ulcer Obstruction

Because of advancement of medical treatment, surgical management of gastric or duodenal ulcer was indicated for treatment of perforation, massive hemorrhage and obstruction. The distal gastrectomy including ulcer was known as principle method of duodenal ulcer obstruction, but actually many surgeons have performed only bypass surgery for the difficulty of formation of duodenal stump. In our case, 61-year-old male with repetitive duodenal ulcer obstruction transferred with obstruction due to deformities and inflammations of duodenal ulcer. We had performed totally laparoscopic distal gastrectomy with ROUX-EN-Y reconstruction using the clear visibility of laparoscopy and fine dissections of harmonic scalpel. The patient started soft diet on postoperative day 5 and discharged on postoperative day 8. He returned to work after discharging immediately.

The Impact of Preoperative Chemotherapy on the Surgical Management of Unresectable Gastric Cancer

PURPOSE: There have been reported that preoperative chemotherapy for treating noncurative gastric cancer could increase the R0 resection rate by downstaging the gastric cancer. Yet there have been only rare reports about the effect of preoperative chemotherapy on performing surgery for noncurative gastric cancer. Our study was designed to analyze our experiences with these effects. MATERIALS AND METHODS: We retrospectively analyzed 46 patients who had undergone gastrectomy after chemotherapy between December 2001 and January 2009. The patients' preoperative condition, the operative findings and the postoperative clinical coursed were analyzed. RESULTS: Preoperative chemotherapy was performed for a mean of 4.4 cycles. Four patients showed a level of ANC below 1,500 (micron/L) and above a 10 percentile weight loss, respectively. For an operation, we found fibrosis or fixation between the tumor and the adjacent organs in 29 patients, and 4 of the 13 patients who underwent resection with another organ were documented to have invasion by tumor. Forty one patients underwent curative resection. Ten patients developed postoperative complications. There was no mortality at postoperative 60 days. CONCLUSION: We assumed that preoperative chemotherapy had little effect on the patient preoperatively, and it had some effect on down-staging pathologically. Preoperative chemotherapy didn't increase the postoperative complication rate.

Following of the Omentum Preserving Gastrectomy for Advanced Gastric Cancer without Serosa Exposure

PURPOSE: The generally accepted standard surgery for advanced gastric cancer is gastrectomy with D2 dissection accompanied by omentectomy. Theoretically, advanced gastric cancer without serosa exposure cannot disseminate metastasis to the omentum. However, the significance of routine omentectomy in survival remains unproved. METHODS: From January 2000 to December 2002, 174 patients, who diagnosed T2 gastric adenocarcinoma pathologically, underwent curative gastrectomy by one operator. 52 patients underwent omentum-preserving gastrectomy and 122 patients underwent gastrectomy with resection of omentum. We compared clinicopathologic characteristics, recurrence patterns, recurrence rate and survival rates between the two groups. RESULTS: Five-year survival rate was 82.9% in the omentum-preserving group and 85.2% in the omentectomy group (P=0.729). Moreover, there was no significant difference in recurrence rate between the two groups (P=0.298). In the omentum-preserving group, 3 peritoneal (25%), 4 local (33.3%), 4 hematogenous (33.3%), 1 distant lymph node (8.3%) recurrences were shown. However, in the omentectomy group, 7 peritoneal (35%), 6 local (30%), 6 hematogenous (30%), 1 distant lymph node (5%) recurrences were shown (P=0.935). CONCLUSION: These results suggest that the omentum-preserving gastrectomy may be applicable to advanced gastric cancer without serosa exposure, and that it is not necessary to perform uniform omentectomy for all advanced gastric cancer.

Laparoscopic Assisted Total Gastrectomy (LATG) with Extracorporeal Anastomosis and using Circular Stapler for Middle or Upper Early Gastric Carcinoma: Reviews of Single Surgeon's Experience of 48 Consecutive Patients

PURPOSE: Many recent studies have reported on the feasibility and usefulness of laparoscopy assisted distal gastrectomy (LADG) for treating early gastric cancer. On the other hand, there has been few reports about laparoscopy assisted total gastrectomy (LATG) because upper located gastric cancer is relatively rare and the surgical technique is more difficult than that for LADG, We now present our procedure and results of performingLATG for the gastric cancer located in the upper or middle portion of the stomach. MATERIALS AND METHODS: From Jan 2005 to Sep 2007, 96 patients underwent LATG by four surgeons at the Asan Medical Center, Seoul, Korea. Among them, 48 consecutive patients who were operated on by asingle surgeon were analyzed with respect to the clinicopathological features, the surgical results and the postoperative courses with using the prospectively collected laparoscopy surgery data. RESULTS: There was no conversion to open surgery during LATG. For all the reconstructions, Roux-en Y esophago- jejunostomy and D1+beta lymphadenectomy were the standard procedures. The mean operation time was 212+/-67 minutes. The mean total number of retrieved lymph nodes was 28.9+/-10.54 (range: 12~64) and all the patients had a clear proximal resection margin in their final pathologic reports. The mean time to passing gas, first oral feeding and discharge from the hospital was 2.98, 3.67 and 7.08 days, respectively. There were 5 surgical complications and 2 non-surgical complications for 5 (10.4%) patients, and there was no mortality. None of the patients needed operation because of complications and they recovered with conservative treatments. The mean operation time remained constant after 20 cases and so a learning curve was present. The morbidity rate was not different between the two periods, but the postoperative course was significantly better after the learning curve. Analysis of the factors contributing to the postoperative morbidity, with using logistic regression analysis, showed that the BMI is the only contributing factor forpostoperative complications (P=0.029, HR=2.513, 95% CI=1.097-5.755). Conclusions: LATG with regional lymph node dissection for upper and middle early gastric cancer is considered to be a safe, feasible method that showed an excellent postoperative course and acceptable morbidity. BMI should be considered in the patient selection at the beginning period because of the impact of the BMI on the postoperative morbidity.

The Learning Curve of Laparoscopy-assisted Distal Gastrectomy (LADG) for Cancer

PURPOSE: Laparoscopic surgery for gastric cancer was introduced in the past decade because it was considered less invasive than open surgery, and this results in less postoperative pain, faster recovery and an improved quality of life. Several studies have demonstrated the safety and feasibility of this procedure. We examined the outcome of performing laparoscopic surgery for gastric cancer over the last two year. MATERIALS AND METHODS: From April 2004 to December 2006, 329 patients with gastric adenocarcinoma underwent a laparoscopy-assisted distal gastrectomy with lymph node dissection. The data was retrospectively reviewed in terms of the clinicopathologic findings, the perioperative outcomes and the complications. RESULTS: The total patient group was comprised 196 men (59.6%) and 133 women (40.4%). The mean BMI was 23.6 and the mean tumor size was 2.7 cm. The mean number of harvested lymph node was 22.7, and this was 18.6 before 30 cases and 23.1 after 30 cases, and the difference was significant (P=0.02). The mean operation time was 180.9 min, and this was than 287.9 min before 30 cases and 170.2 min after 30 cases. After 30 cases, there was a significant improvement of the operation time (P<0.01). The mean incision length after 30 cases was shorter than that before 30 cases (P<0.01). Postoperative complications occurred in 24 (7.3%) of 329 patients and there was no conversion to open surgery. CONCLUSION: Even though the LADG was accompanied by a difficult learning curve, we successfully performed 329 LADG procedures over the past 2 years and we believe that LADG is a safe, feasible operation for treating most early gastric cancers (EGC).

The Impact of Obesity on Operative Results and Postoperative Courses in Laparoscopic-assisted Distal Gastrectomy (LADG)

PURPOSE: Despite known advantages of laparoscopy-assisted distal gastrectomy (LADG) over open surgery, including less blood loss, less pain, faster recovery, and shorter hospital stays, many surgeons still hesitate to perform LADG in overweight patients due to concerns about increased perioperative morbidity. We investigated whether surgical outcomes in LADG differ in overweight patients and normal patients, as well as the influence of surgical experience. METHODS: Between April 2004 and December 2006, 331 consecutive patients underwent LADG for preoperatively diagnosed early gastric cancer. Using the definition of overweight by western criteria, patients were classified into a low (n = 187, BMI 25 kg/m(2)) group. We retrospectively analyzed surgical outcomes, including operation time, retrieved lymph nodes, hospital courses, and postoperative complications. RESULTS: The only differences in overweight and normal patients were longer operation time, incision length, and fewer retrieved lymph nodes. As our surgical team accumulated experience (after 250 cases in our study), there were no differences at all between the two groups. CONCLUSION: Technical difficulty in overweight patients could hamper some surgical outcomes but didn't worsen the post- operative courses or complications. Moreover, those difficulties can be overcome as the surgical team accumulates experience.

Preoperative Chemotherapy for Highly Advanced Gastric Cancer

PURPOSE: The prognosis of advanced gastric cancer is still dismal despite of aggressive surgical treatment. Many investigational approaches such as the use of adjuvant chemotherapy and neoadjuvant chemotherapy with or without radiation therapy have been widely attempted for highly advanced gastric cancer. There are, however, few studies about the use of these types of treatment in Korea. METHODS: Between 2001 and 2004, 38 patients with highly advanced gastric cancer underwent preoperative chemotherapy using the DXP (Docetaxel, Xeloda, and Cisplatin) regimen before surgery. An retrospective analysis including clinicopathological features, recurrence, and survival was performed using patient medical records. RESULTS: Twenty-five patients had locally advanced gastric cancer without a distant metastasis, and 13 patients had a distant metastasis or peritoneal metastasis. Patients received the chemotherapy regimen an average of 4.2 times. A partial response and stable disease were found in 28 (73.7%) and 10 (26.3%) patients, respectively, according to the RECIST criteria. Twenty- one (84%) of 25 patients without a distant metastasis had a curative resection compared to 6 (46.2%) of 13 patients with a distant metastasis (P=0.024). Four patients (10.5%) had complications with 1 postoperative death. The overall 5 year survival rate was 34% and the median survival duration was 22 months (49%, 34 months for the locally advanced group vs. 0%, 10 months for the distant metastasis group; P<0.001). The only predictor of prognosis of patients as determined by multivariate analysis was the pathological TNM stage. CONCLUSION: Preoperative chemotherapy can be safely performed without increased postoperative morbidity and mortality. To define the actual benefits for patient survival after pre-operative chemotherapy, a large scale randomized prospective control study should be performed.

Comparative Analysis of Laparoscopy-assisted Gastrectomy versus Open Gastrectomy

PURPOSE: There has been increased the number of early gastric cancer and laparoscopy-assisted gastrectomy (LAG), due to early detection through mass screening program. We started the LAG in April 2004 and performed 119 cases of gastric cancer in 2005, so we report a surgical outcome compared with that of open gastrectomy (OG). MATERIALS AND METHODS: 119 patients underwent LAG in 2005, and for open group, 126 patiens of early gastric cancer were selected sequentially from January 2005 to March 2005. We compared clinicopathologic characteristics, postoperative courses and complications between two groups. RESULTS: There was no significant difference between age, a length of hospital stay, distal resection margin and a number of retrived lymph nodes. The operation time was longer in LAG group (239.2 vs 123.3 mins, P < 0.001) and a diet progression was faster in LAG group (first flatus: 3.05 vs 3.70 days, SOW: 2.86 vs 3.22 days, liquid diet: 3.87 vs 4.19 days ,soft diet: 4.84 vs 5.26 days, P < 0.001). But there was no difference statistically in postoperative discharge date (7.73 vs 8.25 days, P=0.229). The additional requirement of analgesic injection was less frequent in LAG group (2.97 vs 4.92 times, P < 0.001). The harvested lymph nodes were similar in both groups (23.9 vs 23.1, P=0.563). A complication rate was lower in LAG group (4.9% vs 9.5%), but there was no statistical significance (P=0.179). There was no mortality in both groups and no conversion to open gastrectomy in the LAG group. CONCLUSION: LAG can be performed safely and accepted in view of curative procedure in treatment of early gastric cancer. But we need the follow up of long-term period to evaluate the survival rate and recurrence, and a prospective randomized controlled study should be done to establish that LAG will be a standard operation for early gastric cancer.

Correlation of the Body Mass Index with the Rates of Postoperative Wound Complications in Gastric Cancer Patients

PURPOSE: We assumed that an obese patient has a high rate of postoperative wounds, but there is no objective data showing the relationship between the body mass index (BMI) and the rate of postoperative wounds in Korea. We describe the relationship of BMI and rates of postoperative wound complications. MATERIALS AND METHODS: From September 2005 to February 2006, 772 patients undergoing elective gastrectomy surgery due to gastric cancer were enrolled in a retrospective study to measure postoperative wound complications. A preoperative history, physical examination and daily progress notes were reviewed retrospectively from the medical records. Postoperative wound complications were detected from the elective medical record and from a doctor in charge statement. RESULTS: The total number of patients was 772, the mean age of the patients was 57+/-11.2 years and the sex ratio (male/female) was 1.82:1. Postoperative wound complication rates were different among the BMI groups (BMI25 kg/m2), and patients with a BMI>25 kg/m2 that underwent gastrectomy had a significantly higher wound complication rate (4.6%) than underweight and normal weight patients (0.9% and 1.6%, respectively) (P=0.038). CONCLUSION: Overall, there was a statistical correlation between BMI and the postoperative wound complication rate. Overweight (BMI>25 kg/m2) patients that underwent gastrectomy had a higher wound complication rate than normal body weight (BMI< or =25 kg/m2) patients. Further studies will be required with a larger population and prospectively designed study considering other factors that affect the wound complication rate.

Morbidity of Laparoscopic Assisted Gastrectomy for Early Gastric Cancer

PURPOSE: Recently, the use of laparoscopic assisted gastrectomy for early gastric cancer has been on the increase and the procedure has been quickly adopted by clincians. However, there are few reports regarding the safety and risk of this type of surgery. The aim of this study is to evaluate the morbidity and to verify the safety of laparoscopic assisted gastrectomy for early gastric cancer. MATERIALS AND METHODS: A total of 376 patients that had undergone laparoscopic assisted gastrectomy for early gastric cancer between April 2004 and December 2006 were reviewed retrospectively. The clinicopathological characteristics, operative complications, and factors related to complications were evaluated. RESULTS: The overall operative morbidity and mortality rates were 10.6% and 0%, intraoperative morbidity was 1.1% (4 of 376 patients) and post operative morbidity was 9.6% (36 of 376 patients). Most complications required no surgery except for an intestinal obstruction in two cases. Multivariate analysis of risk factors related to operative morbidity determined that age was an independent factor associated with morbidity (P=0.021). CONCLUSION: The complication rate of laparoscopic assisted gastrectomy is low and most complications can be managed by conservative methods rather than with surgery. There were no specific predicting factors for complications except old age. Laparoscopy is a technically feasible and acceptable surgical modality for early gastric cancer.

Comparison of Reconstruction Methods after Distal Gastrectomy for Gastric Carcinoma in Terms of the Long Term Physiologic Function and Nutritional Status; Billroth I Gastroduodenostomy versus Roux-en Y Gastrojejunostomy

PURPOSE: The only curative treatment for gastric carcinoma is surgery and it is still under debate which reconstruction method is better after performing gastrectomy for gastric carcinoma. The typical reconstruction methods after distal gastrectomy are Billroth I, Billroth II and Roux-en Y reconstruction. Yet it is difficult to compare these methods and not so much is known about which reconstruction is better in terms of the physiologic and nutritional function. With this background, we compared two reconstruction methods after distal gastrectomy (Billroth I versus Roux-en Y reconstruction) in terms of the long term physiologic function and nutritional status to create a reference for selecting reconstruction methods after distal gastrectomy. MATERIALS AND METHODS: Between 1999 and 2002, 663 patients who underwent distal gastrectomy for early gastric carcinoma filled out questionnaires every six months after operation, and these questionnaires evaluated the physiologic function. To evaluate their nutritional status, blood tests were performed every six months to check their albumin, protein and hemoglobin levels, and we checked the body weight every 6 months as well. RESULTS: The total score of the 15 questions on the questionnaire concerned with the physiologic function showed no difference between the two groups at every evaluation time, and both groups showed very low total scores, indicating tolerable physiologic function after operation. When comparing each question between two the groups, only symptoms of regurgitation and food passage showed a difference between the two groups, showing that the Roux-en Y group had better function in terms of these two symptoms. The Billroth I group showed a better nutrition status, indicating that the level of albumin, protein and hemoglobin were higher in the Billroth I group, with statistical significance. Body weight loss was severe in the Roux-en Y group. CONCLUSION: The physiologic function is slightly better in the Roux-en Y group in terms of some symptoms such as regurgitation and food passage. However, the nutritional status is better in the Billroth I group. In conclusion, because we cannot definitely ascertain which reconstruction is better when we consider both the physiologic and nutritional functions, it is reasonable that surgeon should choose reconstruction methods according to their experience and preference.

Neoadjuvant Imatinib in Locally Advanced Gastrointestinal Stromal Tumors of the Stomach: Report of Three Cases / Journal of the Korean Cancer Association, 대한암학회지

Neoadjuvant imatinib therapy used to treat locally advanced or metastatic gastrointestinal stromal tumors (GI ST) remains under active investigation. We studied three cases of locally advanced gastric GISTs treated with imatinib on a neoadjuvant basis, followed by a complete surgical resection. Three patients were diagnosed with locally advanced unresectable GIST of the stomach and were started on imatinib 400 mg/day. After the imatinib treatment, partial responses were achieved in all patients and the tumors were considered resectable. Surgical resection was done after 7, 11, and 8 months of imatinib therapy, respectively. In one case, a metastatic liver lesion was detected during the imatinib treatment using computed tomography scans, so the imatinib therapy was maintained for 11 months postoperatively. In the other two patients without distant metastasis, imatinib treatment was not restarted after surgery. Mutational analysis revealed a mutation in exon 11 of the c-kit gene in two patients, and wild-type c-kit and PDGFRA in one patient. During pathology review of all three cases, we noted several features common to imatinib treatment. There was no evidence of tumor recurrence in all three patients at respective follow-up visits of 22, 15, and 7 months. These results suggest that the neoadjuvant imatinib therapy is a potentially curative approach for selected patients with locally advanced GIST.

Learning Curve of a Laparoscopy Assisted Distal Gastrectomy for a Surgeon Expert in Performing a Conventional Open Gastrectomy

PURPOSE: The laparoscopy assisted gastrectomy has been increasingly reported as the treatment of choice for early gastric cancer. However, expert surgeons, who have performed a conventional open gastrectomy for a long time, tend to have a negative attitude toward laparoscopic procedures. The aim of this study was to determine the learning curve of a laparoscopy assisted distal gastrectomy (LADG) for a surgeon expert in performing an open gastrectomy and to analyze the factors that have an effect on a LADG. MATERIALS AND METHODS: Between April 2005 and March 2006, 62 patients underwent a LADG with D1+beta lymph-node dissection. The 62 patients were divided into 10 sequential groups with 6 cases in each group (the last group was 8 cases), and the time required to reach the plateau of the learning curve was determined by examining the average operative times of these 10 groups. Other factors, such as sex, BMI, complications, transfusion requirements, the number of retrieved lymph nodes, and change of postoperative hemoglobin level, were also analyzed. RESULTS: With the 5th group (after 30 cases), the operative time reached a plateau (average: 170 min/operation). The differences between before the 30th case and after the 31st case with respect to changes in the postoperative hemoglobin level, the number of retrieved lymph nodes, the transfusion requirements, and the complications rate were not significant. CONCLUSION: According to an analysis of the operative time, experience with 30 LADGs in patients with early gastric cancer is the point at which the plateau of the learning curve (7 months) is reached. Abundant experience with a conventional open gastrectomy and a well-organized laparoscopic surgery team are important factors in overcoming the learning curve earlier.

Subjective and Functional Results after a Proximal Gastrectomy: Prospective Study for Comparison of Reconstruction Procedures

PURPOSE: A proximal gastrectomy is performed for gastric cancer in the upper part of the stomach to preserve the function of the stomach after surgery. An esophagogastrostomy is one of the common reconstruction methods for a proximal gastrectomy, but this method results in a high incidence of reflux esophagitis. This study was undertaken to compare subjective and functional results between esophagogastrostomy and jejunal interposition reconstructions. MATERIALS AND METHODS: From June 1998 to December 2002, proximal gastrectomies were perfomed in 33 patients with tumors in the upper third of the stomach; 8 had reconstruction using jejunal interposition between the esophagus and the remnant stomach (JI group) while 25 had reconstruction using esophagogastrostomy (EG group). The postroperative courses of the patients were reviewed in terms of symptoms, weight changes, and endoscopic findings. RESULTS: The mean age of the patients was 59 years; 26 were men and 7 were women. There were no significant differences in general complications, operating times, or histologic features between the two groups. Fifty-two percent (52%) of the EG group complained of dysphagia, and 16% them experienced heartburn and acid belching. Twelve percent (12%) of the JI group complained of dysphagia, but heartburn and acid belching did not occur. Incidences of reflux esphagitis (36%) and balloon dilatation for anastomotic stricture (16%) were more common in the EG group than in the JI group (0% and 12%). CONCLUSION: To prevent or minimize complications, such as reflux esophagitis and postoperative symptoms, a proximal gastrectomy with a jejunal interposition is an alternative method as an organ-preserving surgical strategy to improve quality of life for patients.

Indication of Dissection of the 14v Lymph Node in Advanced Distal Gastric Cancer

PURPOSE: According to the 2nd English Edition of the Japanese Gastric Cancer Association (JGCA) in 1998, in case of distal gastric cancer, the 14v (superior mesenteric vein) lymph node (LN) is included in the N2 group. However, in Korea, a modified radical gastrectomy is performed, and a 14v LN dissection is not done as a routine procedure. Thus, we investigated the rate of metastatic 14v LNs, evaluated the necessity of dissection of the 14v LN, and searched for indications of 14v LN dissection. MATERIALS AND METHODS: From April 2004 to August 2005, we enrolled the patients who were diagnosed as having advanced gastric cancer in the distal third portion of the stomach. We performed a distal gastrectomy with D2 lymph node dissection as defined in the 2nd English edition of the JGCA classification. We calculated the positive rate of metastatic LNs of each station and analyzed the relationship between the positive rates of No.6 LNs and 14v LNs. We also compared the positive 14v LN group with the negative 14v LN group. RESULTS: The total number of patients was 50, the mean age was 56 (range 30~80) years, and sex ratio (Male/Female) was 1.63 : 1. In 47 (94%) cases, distal a gastrectomy with gastroduodenostomy was done, and in the remaining 3 (6%) cases, a distal gastrectomy with gastrojejunostomy was done. The most frequently metastatic LNs were nos. 3 and 6 (54%). The metastatic rate of the 14v LN was 10%, which was similar to that of LN no. 9. In the comparison of the 14v positive group with the 14v negative group, there were significant differences in the numbers of metastatic LNs (mean 25.4 vs 4.91, P<0.001) and the numbers of metastatic no. 6 LNs, (mean 6.8 vs 1.42, P<0.001), and if no. 6 LNs were metastatic, the possibility of metastasis to the 14v LN was 19.2%. In the 14v positive group, all cases were more than stage 3 by the UICC 6th edition. CONCLUSION: In cases of advanced cancer with metastasis to the no. 6 LN, there was a good chance of metastasis to the 14v LN. Thus, in the operative field, if the tumor is advanced to more than stage 3 by the UICC classification and the no. 6 LN is metastatic, a 14v LN dissection is necessary. However, the usefulness of a 14v LN dissection should be evaluated prospectively through an analysis of tumor recurrence and long-term survival.

Treatment Strategy of Gastric Cancer in Patients Older than 80 Years of Age

PURPOSE: The geriatric population will continue to increase in the coming decades, and the number of gastric cancer patients who are over 80 years of age is increasing. The aim of this study was to suggest optimal treatment in these patients on the basis of the cause of death. METHODS: Forty-four patients who underwent curative resection in the course of gastric cancer treatment and were over 80 years of age at Asan Medical Center between January 1990 and February 2002 were included in this study. The cause of death of those patients was retrospectively analyzed by checking medical record or calling to relatives. RESULTS: Average age of 41 patients was 81.41 years old and follow up duration was 49 months. Until February 2004, overall mortality was 23 patients (56%). The mortality from gastric cancer-related and from other disease was 12 patients (52%) & 11 patients (48%), respectively. The most common cause of death from other disease was senility. Median survival time of 11 patients from cancer none-related death was 57 months. Median survival time of 32 patients corresponding stage l & ll was 52.5 months. CONCLUSION: We, therefore, conclude that a standard gastrectomy is basically appropriate for patients older than 80 years of age, as long as they demonstrate a good risk.

Efficacy and Safety Study of Docetaxel as Salvage Chemotherapy in Metastatic Gastric Cancer Failing Fluoropyrimidine and Platinum Combination Chemotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Fluoropyrimidine (F) and platinum (P) combination chemotherapy has been widely used for the first line treatment of advanced gastric cancer (AGC). Docetaxel (D) has shown promising activity in this disease. The present study retrospectively investigated the efficacy of D monotherapy as salvage chemotherapy for AGC that is failing F and P combination chemotherapy. MATERIALS AND METHODS: A total of 34 patients, fitting the eligibility criteria, were included in this study. D was administered at a dose of 75 mg/m2 IV every 3 weeks, with dexamethasone prophylaxis. Twenty-nine patients had measurable lesions. The median treatment-free interval was 38.5 days, and 91.2% of patients had progressed within 4 months of withdrawal of the first line chemotherapy. RESULTS: A total of 133 cycles of D were administered, with a median of 3.5 (1~8) cycles. From an intention-to-treat analysis, 6 patients achieved partial responses (PR), with a response rate of 20.7% (95% CI, 6.0~35.4). The duration of objective PRs in these six were 2.3+, 2.5+, 2.9, 3.0+, 6.2 and 6.8 months, respectively. Six patients showed a stable disease, but 15 showed progression. The median time to progression was 4.2 months (95% CI, 2.8~5.5), with a median overall survival since the start of D monotherapy of 8.4 months (95% CI, 5.5~11.3). Grade 3/4 neutropenia and febrile neutropenia occurred in 12.9% of patients and 3.1% of cycles. The incidence of grade 3 or worse non-hematological toxicities were as follows; peripheral sensory neuropathy 9.7%, asthenia 3.2% and allergic reaction 2.7%. CONCLUSION: Docetaxel, 75 mg/m2, is active in AGC as second-line chemotherapy after failure of prior exposure to the F and P combination chemotherapy, with a favorable toxicity profile.