Choice of digestive tract reconstruction in upper gastric cancer / 中华胃肠外科杂志

With the increasing incidence of upper gastric cancer and early gastric cancer, surgeons have gradually paid attention to the selection of appropriate digestive tract reconstruction methods. At present, the safety of surgery is no longer the main aim pursued by surgeons, and the focus of surgery has gradually changed to postoperative quality of life. Surgical procedures for upper gastric cancer include total gastrectomy (TG) and proximal gastrectomy (PG). Roux-en-Y anastomosis is recommended for digestive tract reconstruction after TG. The classic method of digestive tract reconstruction after PG is distal residual stomach and esophageal anastomosis. However, to prevent esophageal reflux caused by PG, a lot of explorations have been carried out over the years, including tubular gastroesophageal anastomosis, double-flap technique (Kamikawa anastomosis), interposition jejunum, double-tract reconstruction and so on. But the appropriate method of digestive tract reconstruction for upper gastric cancer is still controversial. In this paper, based on literatures and our clinical experience, the selection, surgical difficulties and techniques of digestive tract reconstruction after PG are discussed.

Apendicitis del muñón: reporte de un caso y revisión de la literatura / Stump appendicitis: case report and literature review

La apendicitis del muñón es una rara entidad, de la cual se desconoce su incidencia, con alrededor de 100 casos reportados en la literatura médica. Requiere un alto grado de sospecha clínica para su correcta identificación. El tratamiento recomendado es quirúrgico. Se presenta el caso de un paciente de 26 años, con antecedente de apendicectomía hace 17 años, con cuadro de dolor abdominal en fosa iliaca derecha y signos apendiculares positivos en el examen físico. La Tomografía Axial Computarizada demostró una colección con gas y fecalitos en su interior, localizada en fosa iliaca derecha, planteándose un diagnóstico de apendicitis del muñón. Se realizó una laparotomía exploratoria, evidenciándose un muñón apendicular perforado en su tercio proximal, por lo que se completó la apendicectomía del muñón. El informe histopatológico reportó un muñón apendicular con infiltrado mono y polimorfo nuclear, que compromete el espesor de la pared. El paciente fue dado de alta con evolución dentro de parámetros esperados y fue remitido a control y seguimiento por Consulta Externa.

Stump appendicitis is a rare entity, of which its incidence is unknown, with about 100 cases reported in the medical literature, which requires a high degree of clinical suspicion for proper identification. The recommended treatment is surgical. The case of a 26-year-old patient with an appendectomy antecedent 17 years ago, with abdominal pain in right lower quadrant and positive appendicular signs on the physical exam is presented. Computerized Axial Tomography demonstrated a collection of gas and fecalites inside, located in right lower quadrant, considering a diagnosis of stump appendicitis. An exploratory laparotomy was performed, with an appendicular stump perforated in its proximal third, and the stump appendectomy was completed. The histopathological report reported an appendicular stump with mono and polymorph nuclear infiltrate, which compromises the thickness of the wall. The patient is discharged with evolution within expected parameters and is referred to control and follow-up by External Consultation.

Surgical results of remnant gastric cancer treatment / Resultados cirúrgicos do tratamento dos tumores do coto gástrico

ABSTRACT Background: remnant gastric cancer (RGC) develops five years or later after previous resection for benign or malignant lesion. The treatment is performed through completion total gastrectomy (CTG) with radical lymphadenectomy. Some reports consider this procedure may be associated with higher rates of morbidity and mortality. Objective: to evaluate surgical results and survival after CTG in patients with RGC. Methods: 54 patients who underwent CTG between 2009 and 2019 were included in the study. As a comparison group 215 patients with primary gastric cancer (PGC) who underwent total gastrectomy (TG) in the same period were selected. Results: among the initial characteristics, age (68.0 vs. 60.5; p<0.001), hemoglobin values (10.9 vs. 12.3; p<0.001) and body mass index (22.5 vs. 24.6; p=0.005) were different between the RGC and PGC groups, respectively. The most frequent postoperative complications were related to pulmonary complications, infection and fistula in both groups. There was a higher incidence of esophagojejunal fistula in the CTG group (14.8% vs 6.5%, p=0.055). Perioperative mortality was higher in RGC patients (9.3% vs. 5.1%), but without significance (p=0.329). Hospital length of stay, postoperative complications graded by the Clavien-Dindo classification, mortality at 30 and 90 days were not different between groups. There was no significant difference in disease-free and overall survival between RGC and PGC groups. Conclusion: despite previous reports, surgical results and survival were similar between groups. Higher risk of esophagojejunal fistula must be considered.

RESUMO Antecedentes: o câncer do coto ou remanescente gástrico (CRG) se desenvolve cinco anos ou mais após a ressecção gástrica por lesão benigna ou maligna. O tratamento é realizado através da gastrectomia total complementar (GTC) com linfadenectomia. Alguns relatos consideram que esse procedimento pode estar associado a maiores taxas de morbimortalidade. Objetivo: avaliar os resultados cirúrgicos e a sobrevida após GTC em pacientes com CRG. Métodos: 54 pacientes submetidos a GTC entre 2009 e 2019 foram incluídos no estudo. Como grupo de comparação, foram selecionados 215 pacientes com câncer gástrico primário (CGP) submetidos à gastrectomia total (GT) no mesmo período. Resultados: dentre as características iniciais, a idade média (68,0 vs. 60,5; p <0,001), os valores de hemoglobina (10,9 vs. 12,3; p <0,001) e o índice de massa corporal (22,5 vs. 24,6; p = 0,005) diferiram entre os grupos CRG e CGP, respectivamente. As complicações pós-operatórias mais frequentes foram pulmonares, infecciosas e fístulas nos dois grupos. Houve maior incidência de fístula esofagojejunal no grupo GTC (14,8% vs 6,5%, p = 0,055). A mortalidade perioperatória foi maior nos pacientes com CRG (9,3% vs. 5,1%), mas sem significância (p = 0,329). O tempo de internação hospitalar, complicações pós-operatórias (Clavien-Dindo), mortalidade aos 30 e 90 dias não foram diferentes entre os grupos. Não houve diferença significativa na sobrevida livre de doença e global entre os grupos CRG e CGP. Conclusão: apesar dos relatos anteriores, os resultados cirúrgicos e a sobrevida foram semelhantes entre os grupos. Maior risco de fístula esofagojejunal dever ser considerado.

Is Laparoscopic Approach Also Safe for the Treatment of Remnant Gastric Cancer?

The most important advantages of laparoscopic gastrectomy are the minimal invasiveness, including less postoperative pain, shorter recovery, and minimal complications. A laparoscopic distal gastrectomy is accepted widely as a standard treatment for gastric cancer. On the other hand, a laparoscopic total gastrectomy has not been popularized as a distal gastrectomy because of the complexity of a lymph node dissection and the diversity of reconstruction. In terms of laparoscopic surgery for a remnant gastrectomy, there are three key points, which are critical for safe operation: adequate lymph node dissection, meticulous adhesiolysis, and reconstruction. After radical surgery for gastric cancer, the intra-abdominal condition is greatly changed. In addition, the lymphatic anatomy around the stomach is broken and surgeons should be aware of a newly developed lymphatic system to perform adequate node dissection. An esophago-jejunal reconstruction is at risk of leakage. Until evidence that is more concrete can be obtained, experienced surgeons should consider the laparoscopic approach.

Ischemic Necrosis Caused by Retroanastomotic Hernia after Subtotal Gastrectomy / 대한소화기학회지

After gastrojejunostomy, a small space can occur between the jejunum at the anastomosis site, the transverse mesocolon, and retroperitoneum, which may cause an intestinal hernia. This report presents a rare case of intestinal ischemic necrosis caused by retroanastomotic hernia after subtotal gastrectomy. A 56-year-old male was admitted to Kangwon National University Hospital with melena, abdominal pain, and nausea. His only relevant medical history was gastrectomy due to stomach cancer. Endoscopic findings revealed subtotal gastrectomy with Billroth-II reconstruction and a bluish edematous mucosal change with necrotic tissue in afferent and efferent loops including the anastomosis site. Abdominopelvic CT showed strangulation of proximal small bowel loops due to mesenteric torsion and thickening of the wall of the gastric remnant. Emergency laparotomy was performed. Surgical findings revealed the internal hernia through the defect behind the anastomosis site with strangulation of the jejunum between 20 cm below the Treitz ligament and the proximal ileum. Roux-en-Y anastomosis was performed, and he was discharged without complication. Retroanastomotic hernia, also called Petersen's space hernia, is a rare complication after gastric surgery, cannot be easily recognized, and leads to strangulation.

Long-Term Nutritional Outcomes of Near-Total Gastrectomy in Gastric Cancer Treatment: a Comparison with Total Gastrectomy Using Propensity Score Matching Analysis

PURPOSE: This study sought to examine whether near total gastrectomy (nTG) confers a long-term nutritional benefit when compared with total gastrectomy (TG) for the treatment of gastric cancer. MATERIALS AND METHODS: Patients who underwent nTG or TG for gastric cancer were included (n=570). Using the 1:2 matched propensity score, 25 patients from the nTG group and 50 patients from the TG group were compared retrospectively for oncologic outcomes, including long-term survival and nutritional status. RESULTS: The length of the proximal resection margin, number of retrieved lymph nodes and tumor nodes, metastasis stage, short-term postoperative outcomes, and long-term survival were not significantly different between the groups. The body mass index values, and serum total protein and hemoglobin levels of the patients decreased significantly until postoperative 6 months, and then recovered slightly over time (P < 0.05); however, there was no difference in the levels between the groups. The prognostic nutritional index values and serum albumin levels decreased significantly until postoperative 6 months and then recovered (P < 0.05); the levels decreased more in the nTG group than in the TG group (P < 0.05). The mean corpuscular volumes and serum transferrin levels increased significantly until postoperative 1 year and then recovered slightly over time (P < 0.05); however, there was no difference between the groups. Serum vitamin B12, iron, and ferritin levels of the patients did not change significantly over time, and no difference existed between the groups. CONCLUSIONS: A small remnant stomach after nTG conferred no significant nutritional benefits over TG.

Twenty-Four Hour pH Study and Manometry in Gastric Esophageal Substitutes in Children / 대한소아소화기영양학회지

PURPOSE: Studies on the physiology of the transposed stomach as an esophageal substitute in the form of a gastric pull-up or a gastric tube in children are limited. We conducted a study of motility and the pH of gastric esophageal substitutes using manometry and 24-hour pH measurements in 10 such patients. METHODS: Manometry and 24 hour pH studies were performed on 10 children aged 24 to 55 months who had undergone gastric esophageal replacement. RESULTS: Six gastric tubes (4, isoperistaltic; 2, reverse gastric tubes) and 4 gastric pull-ups were studied. Two gastric tubes and 4 gastric pull-ups were transhiatal. Four gastric tubes were retrosternal. The mean of the lowest pH at the midpoint of the substitute was 4.0 (range, 2.8–5.0) and in the stomach remaining below the diaphragm was 3.3 (range, 1.9–4.2). In both types of substitute, the difference between the peak and the nadir pH recorded in the intra-thoracic and the sub-diaphragmatic portion of the stomach was statistically significant (p < 0.05), with the pH in the portion below the diaphragm being lower. The lowest pH values in the substitute and in the remnant stomach were noted mainly in the evening hours whereas the highest pH was noted mainly in the morning hours. All the cases showed a simultaneous rise in the intra-cavitatory pressure along the substitute while swallowing. CONCLUSION: The study suggested a normal gastric circadian rhythm in the gastric esophageal substitute. Mass contractions occurred in response to swallowing. The substitute may be able to effectively clear contents.

De la nécessité de surveiller nos patients aux antécedents de gastrectomie partielle: à propos d'un cas d'adenocarcinome du moignon gastrique

Les gastrectomies partielles pour lésions bénignes peuvent se compliquer, plusieurs années après l'intervention, d'un cancer sur la portion restante de l'estomac. Nous rapportons ici un cas clinique d'adénocarcinome sur moignon de gastrectomie d'emblée métastatique chez un adulte jeune ayant eu une gastrectomie 23 ans auparavant et sans aucun suivi endoscopique. Le patient est décédé après une survie de 4 mois. Cette observation nous rappelle la nécessité d'un suivi endoscopique de nos patients ayant un passé de gastrectomie partielle

Interpretation on Chinese surgeons' consensus opinion for the definition of gastric stump cancer (version 2018) / 中华胃肠外科杂志

Gastric stump cancer(GSC) is defined as newly developed remnant stomach cancer following gastrectomy. This definition initially referred to carcinoma detected in the remnant stomach more than 5 years after the primary surgery for a benign disease. Subsequently, this timeframe was extended to 10 years after the primary surgery for a malignant disease. Recently, the concept of "carcinoma in the remnant stomach(CRS)" proposed by the Japanese Gastric Cancer Association was introduced in China. The new definition encompasses all carcinomas arising in the remnant stomach following gastrectomy, irrespective of the histology of the primary lesion, extent of resection, or reconstruction method. It includes all carcinoma types that have developed in the remnant stomach, such as newly developed cancer, recurrent cancer, remaining cancer, and multiple cancers. Considering the current diagnosis and treatment status of gastric cancer in China, if CRS is to be used as a direct equivalent to GSC in clinical practice, confusion may arise concerning disease identification and diagnosis. Following several discussion rounds, a meta-analysis of the literatures at home and abroad, and a multicenter national retrospective study with a large sample population, the "Chinese surgeons' consensus opinion for the definition of gastric stump cancer (version 2018)" was completed. By reviewing the detailed evidence-based medicine supporting the consensus document, this paper aims to assist clinical diagnosis and enhance future academic exchange.

Prognostic and influential factors of gastric stump cancer / 中华胃肠外科杂志

Gastric stump cancer was first defined as cancer occurring in the remnant stomach 5 years or later following distal subtotal gastrectomy of a benign stomach tumor. This definition was expanded to include malignant gastric cancer recurrence following distal gastrectomy and heterochronous gastric adenocarcinoma. Evidence regarding whether patients with gastric stump cancer had the same prognosis as those with primary gastric cancer has been inconsistent. Nonetheless, considering the notable differences regarding risk factors, treatment strategies, and lymph node metastasis status, gastric stump cancer should be differentiated from primary stomach cancer. Overall, the prognosis of gastric stump cancer is influenced by clinicopathological characteristics such as primary tumor features, location of gastric stump cancer, histological type, invasion depth, lymph node metastasis, and distant metastasis, as well as treatment factors such as treatment strategy, dissection range, and lymph node resection range. In previous studies on gastric stump cancer, the sample size was limited, and future studies with larger sample size are needed to further validate the prognostic factors of gastric stump cancer.

Epidemiological characteristics and inducing factors of gastric stump cancer / 中华胃肠外科杂志

Gastric stump cancer was initially defined as a carcinoma of the stomach occurring more than 5 years after surgery for gastric or duodenal benign disease. In recent years, as the number of total gastrectomy for benign disease has gradually decreased and the gastric cancer detection and operation rate have annually increased, residual recurrence of primary gastric cancer more than 10 years after gastric cancer surgery has also been considered as gastric stump cancer. The incidence of gastric stump cancer is increasing annually. The epidemiological characteristics of this form of cancer are also developing, and they show a higher incidence in males compared to females. The incidence has been affected following digestive tract reconstruction, and the risk increases in patients who undergo Billroth II( reconstruction. The interval of onset is related to the benign and malignant condition of primary disease, and the incidence increases after 10 years of early gastric cancer surgery. Lymph node metastasis pattern in gastric stump cancer is different from that in primary gastric cancer as the primary operation may destroy normal lymph flow. Many factors are known to cause gastric stump cancer, mainly duodenal gastric reflux, Helicobacter pylori infection, and gastric mucosal barrier dysfunction; however, the mechanism is not clear. It is expected to reduce the incidence of gastric stump cancer by taking precautionary measures against different inducements, which also has some guiding significance for the treatment and prognosis of gastric cancer.

Advertent problems about gastric stump cancer surgery / 中华胃肠外科杂志

Due to different disease background of gastric stump cancer(GSC) patients (benign or malignant lesion, reconstruction of digestive tract, etc.), the GSC surgical procedure and the difficulty of lymphadenectomy are also different. The extent of radical lymphadenectomy for gastric stump cancer should extend beyond D2 lymphadenectomy, according to the different backgrounds of initial disease, reconstructions, and tumor location. A lymphadenectomy should include the lymph nodes in anterior (No.17) and posterior (No.13) surface of the pancreatic head, along the superior mesenteric vein (No.14v), jejunal mesenteric lymph nodes, the splenic hilum (No.10), infra-diaphragm (No.19), esophageal hiatus of the diaphragm(No.20), para-esophageal nodes in the lower thorax (No.110) and supra-diaphragm (No.111). To achieve R0 resection, combined adjacent organ (transverse colon and spleen) resection is necessary in some cases. The indication for endoscopic submucosal dissection of early remnant gastric cancer is similar to primary early gastric cancer in selected patients. The advantages of laparoscopic and robot-assisted surgery for early remnant gastric cancer need to be confirmed through multicenter studies. Compared with primary proximal gastric cancer, remnant gastric cancer showed an equivalent survival rate. Roux-en-Y is the first choice for digestive tract reconstruction.

Comparison of clinicopathological features and prognosis analysis between gastric stump cancer and recurrence of gastric cancer after radical gastrectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate and compare the clinicopathological characteristics of gastric stump cancer(GSC) and the recurrent of gastric cancer (RGC) following radical gastrectomy, and to evaluate survival prognosis.</p><p><b>METHODS</b>A retrospective cohort study was performed on clinicopathological and survival data of patients with GSC (n=31) and with RGC (n=105) following radical gastrectomy at the Chinese People's Liberation Army General Hospital between January 1992 and August 2017. GSC was defined as cancer occured in remnant stomach ≥10 years after radical gastrectomy, while RGC was defined as <10 years. Patients of both groups received radical resection or palliative operation with tumor resection and had complete clinicopathological data regarding the first operation and gastric stump operation. T-test was used to compare quantitative data between the two groups, and Pearson χ test was used to compare qualitative data between the two groups. Kaplan-Meier method was applied to draw survival curves and log-rank test to assess survival differences.</p><p><b>RESULTS</b>Of the 136 enrolled patients, 113 were male and 23 were female. In the first operation, compared with RGC group, in GSC group, the Borrmann type and histological differentiation were more better [Borrmann I(: 11/31 (35.5%) vs. 5/105 (4.8%), χ=23.003, P=0.001; the high differentiation: 15/31 (48.4%) vs. 1/105 (1.0%), χ=57.137, P=0.001]; the tumor diameter was smaller [<4 cm: 28/31(90.3%) vs. 56/105(53.3%), χ=14.045, P=0.001]; the pT stage [pT1: 12/31 (38.7%) vs. 3/105 (2.9%), χ=50.373, P=0.001], pN stage [pN0: 28/31 (90.3%) vs. 19/105 (18.1%), χ=55.722, P=0.001] and pTNM staging [I(: 26/31 (83.9%) vs. 11/105 (10.5%), χ=66.688, P=0.001] were earlier. Most of the GSC occurred at non-anastomotic sites, while the recurrence mostly occurred at anastomotic sites [51.6%(16/31) vs. 61.9%(65/105), χ=7.520, P=0.023]. Compared with RGC group, GSC group had better histological differentiation [high differentiation: 5/31 (16.1%) vs. 2/105(1.9%), χ=10.029, P=0.007]. There was more histological type change between the first and the second operation in GSC group than that in RGC group[48.4%(15/31) vs. 26.7%(28/105), χ=5.222, P=0.022]. The overall survival time of GSC group was significantly longer than that of RGC group [mean: (161.0±18.6) months vs. (50.8±27.6) months, respectively, Log-rank: 76.818, P=0.001]. The survival time after the second surgery of GSC group was longer than that of RGC group [mean: (30.7±18.4) months vs. (20.5±15.0) months, P=0.003]. In the subgroup analysis of all the 136 patients according to histological type change between the two surgeries (unchanged 93 patients, changed 43 patients), compared with unchanged group, the overall survival time of changed group was longer [mean: (99.6±56.5) months vs. (72.1±58.1) months, P=0.008].</p><p><b>CONCLUSIONS</b>GSC patients have better histological differentiation and earlier clinical stage of primary gastric cancer, and longer survival time compared with RGC patients. The histological type change between two operations may be used as a new factor to define GSC.</p>

Pathological staging criteria for carcinoma in the remnant stomach: an exploratory study / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the prognostic value of the tumor-ratio-metastasis (TRM) staging system for carcinoma in the remnant stomach(CRS).</p><p><b>METHODS</b>Clinicopathological data of 91 CRS patients who underwent surgery at Peking University People's Hospital between March 1992 and December 2017 were retrospectively analyzed. According to the ratio of metastatic lymph node to dissected lymph node, the R staging was obtained, and the pN staging was replaced by the R staging to create the TRM staging. To compare the predictive accuracy of TRM and tumor-node-metastasis (TNM, UICC version 7), the R staging and pN staging were included in the prognostic factor analysis model, and the survival curve, c-index, and 95% confidence interval (CI) of the TRM staging and TNM staging system were compared. A higher c-index value means higher prediction accuracy.</p><p><b>RESULTS</b>Of 91 CRS patients, 77 were male and 14 were female with the mean onset age of (65.2±10.4) years. The mean interval from the first operation to CRS onset was 156(6-600) months. The primary diseases of 49(53.8%) cases were benign and of 42(46.2%) cases were malignant. The median number of retrieved lymph node (RLN) was 8 (0-38), and 64 patients (70.3%) had an RLN ≤15. Lymph node metastasis occurred in 50 patients (54.9%). pN staging result was as follows: 41 cases in N0 stage, 14 in N1 stage, 19 in N2 stage, and 17 in N3 stage. R staging result was as follows: 41 cases in R0 stage, 4 in R1 stage, 19 in R2 stage, and 27 in R3 stage. TNM staging result was as follows: 13 cases in stage I(, 25 in stage II(, 10 in stage III(a, 23 in stage III(b, and 6 in stage III(c. TRM staging result was as follows: 13 cases in stage I(, 24 in stage II(, and 4 in stage III(a, 18 in stage III(b, and 18 in stage III(c. Univariate analysis showed that tumor diameter ≥7 cm (HR=2.696, 95%CI: 1.307-5.563, P=0.007), T3-4 stage (HR=4.350, 95%CI: 1.949-9.707, P=0.000), N2-3 stage (HR=1.883, 95%CI: 1.167-3.038, P=0.009), R2-3 stage (HR=1.642, 95%CI: 1.026-2.628, P=0.039), TNM III(-IIII( stage (HR=2.448, 95%CI:1.490-4.021, P=0.000), and TRM III(-IIII( stage (HR=2.504, 95%CI:1.515-4.137, P=0.000) were related to prognosis. Tumor diameter, pT staging, and pN staging were included in the Cox multivariate analysis, and the result showed that pT staging (HR=5.507, 95%CI:2.254-13.454, P=0.000) and pN staging (HR=1.698, 95%CI: 1.022-2.789, P=0.041) were independent risk factors for overall survival of CRS in this group. While R staging replaced pN staging and was included in the Cox multivariate analysis together with tumor diameter and pT staging, the result showed that R staging was not an independent risk factor for CRS in this group (HR=1.622, 95%CI: 0.866-2.329, P=0.164). Survival curve revealed pN and TNM staging systems provided better stratified curves according to each staging than R and TRM staging systems. The overall survival c-index of TNM and TRM staging systems was 0.813(95%CI: 0.732-0.826) and 0.809(95%CI: 0.741-0.847) respectively, and no significant difference in predictive accuracy was found (P=0.693). In 42 patients with primary malignance, the overall survival c-index of TNM and TRM staging systems was 0.774(95%CI: 0.589-0.901) and 0.761(95%CI: 0.596-0.912) respectively, and there was no significant difference in predictive accuracy as well (P=0.881).</p><p><b>CONCLUSION</b>TRM staging is not superior to TNM staging (7th UICC) in evaluating the resected samples of CRS.</p>

Clinicopathological characteristics and prognostic factor analysis of carcinoma in remnant stomach cancer at Peking University Cancer Hospital / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the interval time to canceration, clinicopathological characteristics and prognostic factors of carcinoma in remnant stomach (CRS) in patients with primary benign diseases or primary malignant tumors.</p><p><b>METHODS</b>Based on the criteria of the definition of CRS proposed by Japanese Gastric Cancer Association in 2017, a retrospective analysis was conducted on clinicopathological characteristics of patients diagnosed with CRS at Peking University Cancer Hospital from March 1992 to March 2017. Between patients with primary benign diseases (CBS-B group) and primary malignant tumors (CBS-M group), continuous variables were compared using the Student's t-test or the Mann-Whitney U test; categorical variables were compared using the chi-square test or Fisher's exact test. Spearmen-Rho was used to examine correlation. Survival was estimated and compared using Kaplan-Meier methods. Cox proportional hazards regression was applied to identify independent prognostic factors. Area under ROC curve(AUC) was used to evaluate and compare prediction accuracy.</p><p><b>RESULTS</b>A total of 89 patients were included in the study with a male: female ratio of 5.4 to 1.0. The male: female ratio in CRS-B (n=46) and CRS-M (n=43) group was 14.3 to 1.0 and 2.9 to 1.0 respectively with significant difference (χ=6.091, P=0.019). The interval time to canceration in CRS-B and CRS-M group was 342(36-576) months and 47(12-360) months respectively with significant difference (t=8.887, P=0.000). The interval time to canceration was correlated with the first operative procedure in CRS-B group (r=0.398, P=0.006), while interval time to canceration was correlated with the age at the first operation in CRS-M group (r=0.337, P=0.027). After differentiating the pathological findings of the first operative sample and the second operative sample, 27 patients presented recurrence and 15 patients had new cancer, and the corresponding interval time to canceration was 46(12-132) months and 60(12-360) months respectively with significant difference (t=5.652, P=0.023). In CRS-B group, location of stump carcinoma in gastric intestinal anastomosis, gastric anastomosis, and non-anastomosis area was found in 60.9%(28/46), 23.9%(11/46) and 15.2%(7/46) respectively, and the corresponding percentage in CRS-M group was 39.5%(17/43), 16.3%(7/43) and 44.2%(19/43) respectively without significant difference (χ=4.726, P=0.096). Among 77 patients with radical gastrectomy, the overall surgical complication rate was 20.8%(16/77), including 8 cases of infection and 7 cases of respiratory system diseases. The 3-year survival rate was 78.4% and 62.6% in CRS-B and CRS-M group respectively with significant difference (χ=3.969, P=0.046), indicating better prognosis of CRS-B patients. The AUC for the lymph nodes ratio and N staging was 0.725 and 0.639 respectively. Multivariate analysis showed the pathological T staging was an independent risk factor of prognosis (HR=1.192, 95%CI:1.032-1.376, P=0.017).</p><p><b>CONCLUSIONS</b>Men have more CRS than women. The interval time to canceration is correlated to the first operative procedure for CRS-B patients, while it is correlated to the age at the first operation for CRS-M patients. The major location of CRS is in the gastrointestinal anastomosis for CRS-B patients and in non-anastomosis area for CRS-M patients. Main postoperative complications include respiratory and infectious complications. Pathological T staging is an independent prognostic risk factor for CRS patients.</p>

Comparison of clinicopathological features and prognosis analysis between carcinoma in the remnant stomach and gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare clinicopathological features and prognosis between patients with carcinoma in the remnant stomach (CRS) and with gastric cancer, and to investigate the prognostic factors in CRS patients.</p><p><b>METHODS</b>A retrospective cohort study was performed on clinicopathological data of 96 CRS patients (CRS group) and selected 440 patients with gastric cancer (GC group) treated at Harbin Medical University Cancer Hospital from January 1977 to December 2017.</p><p><b>INCLUSION CRITERIA</b>(1) undergoing gastrectomy; (2) diagnosed with CRS or gastric cancer through electronic gastroscopies and pathology; (3) without preoperative neoadjuvant radiotherapy or chemotherapy; (4) complete clinicopathological and follow-up data. The patients who died of other reasons or were lost during follow-up were excluded. Chi-square test and independent samples t-test were used to determine differences in clinicopathological factors between two groups. Survival analysis was conducted using the Kaplan-Meier method, and Log-rank test was used to compare survival difference between two groups. The prognosis of CRS patients was analyzed using Cox proportional hazards regression model.</p><p><b>RESULTS</b>As compared to GC group, CRS group had a higher proportion of female [30.2%(29/96) vs. 13.2%(58/ 440), χ=14.095, P=0.000], younger age [(56.4±10.1) years vs. (60.0±9.9) years, t=2.838, P=0.005], more distant metastasis and local organ infiltration [25.0%(24/96) vs. 16.1%(71/440), χ=4.246, P=0.039; 64.6% (62/96) vs. 24.5% (108/440), χ=58.331, P=0.000], lower prognostic nutritional index [(48.0±6.7) vs. (50.4±6.9), t=3.093, P=0.002], lower serum hemoglobin level [(115.0±24.7) g/L vs. (127.9±24.6) g/L, t=4.634, P=0.000], lower serum albumin level [(40.0±4.9) g/L vs. (41.2±5.0) g/L, t=2.038, P=0.042], and earlier occurrence of symptoms [(1.9±1.4) months vs. (3.7±3.2) months, t=5.431, P=0.000]. However, there were no statistically significant differences in TNM staging, postoperative hospital stay, and total hospitalization days between the two groups (all P>0.05). During follow-up, 24(25.0%) patients developed recurrence or distant metastasis and 68 (70.8%) patients died of tumor progression in CRS group, while 71(16.1%) patients developed recurrence or distant metastasis and 378(85.9%) patients died of tumor progression in GC group. The 5-year survival rate of CRS patients was 23.4%, which was higher than 15.0% of gastric cancer patients (P=0.032). Univariate analysis showed that the CRS patients with radical operation (P=0.000), earlier TNM stage (P=0.000), non-distant metastasis (P=0.022), serum hemoglobin level >130 g/L(P=0.013), and serum album level >40 g/L (P=0.042) had better prognosis. Multivariate analysis, enrolling above 5 factors, showed that TNM staging (HR=2.363, 95%CI: 1.478-3.776, P=0.000) and serum hemoglobin level >130 g/L(HR=0.449, 95%CI: 0.244-0.827, P=0.010) were independent factors influencing prognosis of CRS patients.</p><p><b>CONCLUSIONS</b>Although CRS patients have better prognosis than gastric cancer patients, but local organ invasion and distant metastasis occurs more readily. TNM staging and serum hemoglobin level are independent prognostic factors for CRS patients.</p>

Clinicopathological characteristics and prognosis analysis of 217 patients with carcinoma in the remnant stomach / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the clinicopathological features and prognostic factors of carcinoma in the remnant stomach (CRS).</p><p><b>METHODS</b>Clinicopathological data of 217 consecutive CRS patients from January 2000 to March 2017 at Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University were retrospectively analyzed. CRS was defined as the primary cancer arising from the remnant stomach following gastrectomy, regardless of the initial disease or operation, and at no special time interval. The clinicopathological features and treatment were compared between CRS after benign disease operation (CRS-B) group and CRS after gastric cancer operation (CRS-C) group, and factors influencing prognosis were analyzed using Cox regression model analysis.</p><p><b>RESULTS</b>Of 217 patients, 189 were male and 28 were female with mean age of (60.9±11.2) years. The interval between the first and the second operations was (18.3±15.1) years. The CRS-B group comprised 108 patients and the CRS-C group comprised 109 patients. Compared to CRS-C group, CRS=B group had higher ratio of male [92.6% (100/108) vs. 81.7% (89/109), χ=5.779, P=0.016], longer interval [30(25-40) years vs. 4(1.5-8.0) years, Z=-1.685, P=0.000], longer tumor diameter [(5.9±3.2) cm vs. (3.9±2.4) cm, t=3.390, P=0.000] and later tumor stage [patients in stage I(, II(, III(, and IIII(: 6 (8.0%), 14 (18.7%), 41 (54.7%), and 14 (18.7%) vs. 16 (25.4%), 14 (22.2%), 21(33.3%), and 12(19.0%), respectively, Z=-2.018, P=0.044]. A total of 138 patients underwent surgery, including 118(85.5%) patients of curative resection and 20(14.5%) patients of palliative resection. The other 79 patients did not receive surgery due to extensive metastasis or miscellaneous reasons. Among 138 patients receiving surgery, 3 patients underwent endoscopic resection, 6 patients underwent minimally invasive surgery (laparoscopy or robot), and 129 patients underwent laparotomy. Forty-eight patients underwent surgery involving combined resection. The median postoperative hospital stay was 10(8-14) days. The incidence of postoperative complication was 23.2%(32/138). A total of 91 patients were followed up for 7-120 months, including 51 patients in CRS-B group and 40 in CRS-C group. The overall 1-, 3-, and 5-year survival rates of the 75 patients receiving curative resection were 80.7%, 55.1%, and 41.6%, respectively. The overall 1-, 3-, and 5-year survival rates were 73.5%, 48.3%, and 29.0% respectively in CRS-B group and 83.1%, 51.2%, and 32.5% respectively in CRS-C group. There was no significant difference between two groups (P=0.527). Multivariate analysis showed that age (RR=1.879, 95%CI: 1.015-3.479, P=0.045), radical procedure (RR=2.956, 95%CI: 1.421-6.150, P=0.004) and TNM stage (RR=1.570, 95%CI: 1.047-2.354, P=0.029) were independent prognostic factors for CRS.</p><p><b>CONCLUSIONS</b>As compared to the CRS-C group, the CRS-B group has higher percentage of male, longer interval, larger tumor diameter and later TNM stage. Radical resection indicates better prognosis.</p>

Risk factor analysis and prediction model establishment of lymph node metastasis in remnant gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the risk factors and establish an effective model to predict lymph node metastasis (LNM) for remnant gastric cancer (RGC).</p><p><b>METHODS</b>Clinicopathological characteristics of 91 RGC patients undergoing radical gastrectomy at Sun Yat-sen University Cancer Center from January 2000 to December 2017 were retrospectively analyzed. RGC was defined as cancer detected in the remnant stomach >5 years for primary benign diseases or >10 years for malignant diseases following distal gastrectomy. Risk factors of LNM in RGC were identified using logistic regression (P<0.1). Covariates were then scored according to the β regression coefficient in the multivariate analysis, and a score model was established, in which higher score indicated higher risk of LNM. Finally, receiver operating characteristic(ROC) curve was used to evaluate the diagnostic efficacy of risk factors and the score model.</p><p><b>RESULTS</b>Among the 91 RGC patients, 84 were male and 7 were female with the age ranging from 47 to 82 years (63.7±8.5) years. Mean harvested lymph node (LN) was 16.0±11.8, including ≥15 LNs in 42(46.2%) patients and <15 LNs in 49(53.8%) patients. Forty-six (50.5%) patients were identified as LNM. Univariate analysis showed that tumor size ≥4 cm (χ=8.106, P=0.004), Borrmann III(-IIII( gross type (χ=6.129, P=0.013), increased CEA level (χ=4.041, P=0.044) and T3-4 stage (χ=17.321, P=0.000) were associated with LNM in RGC. In Logistic multivariate analysis, tumor size ≥4 cm (OR: 2.362, 95%CI: 0.829-6.730, P=0.100, β regression coefficient: 0.859) and T3-4 stage (OR: 7.914, 95%CI: 1.956-32.017, P=0.004, β regression coefficient: 2.069) remained as the independent risk factors for LNM, and were scored as 1 and 2 point in the final prediction model. In the final score model, LNM of patients with 0, 1, 2, 3 point were 11.1%(2/18), 1/5, 51.6%(16/31) and 73.0%(27/37), respectively. The AUC of the prediction model was 0.756 (P=0.000).</p><p><b>CONCLUSIONS</b>Increased CEA level, tumor size ≥4 cm, Borrmann III(-IIII( gross type, and deeper T stage are associated with LNM in RGC. Moreover, the score model combining with tumor size and T stage can effectively predict the LNM in RGC.</p>

Application of robotic surgery to treat carcinoma in the remnant stomach / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the surgical techniques and feasibility of robotic surgery for carcinoma in the remnant stomach(CRS).</p><p><b>METHODS</b>Clinicopathological data of 20 CRS patients undergoing robotic surgery at the Minimally Invasive Center for Gastrointestinal Surgery, Army Medical University Southwest Hospital from November 2012 to October 2017 were retrospectively collected. The surgical methods, procedures, main difficulties, and key techniques were analyzed, and the clinical efficacy was evaluated.</p><p><b>RESULTS</b>Among 20 CRS patients, 14 were male and 6 were female with mean age of 59.9 years and mean BMI of 19.7 kg/m. For the primary diseases, 17 patients underwent laparotomy, 3 underwent laparoscopic radical resection of gastric cancer; 18 cases received distal subtotal gastrectomy plus Billroth II( anastomosis, 2 received distal subtotal gastrectomy plus Billroth I( anastomosis. CRS located in anastomotic stoma in 15 cases and in the gastric fundus and cardiac part in 5 cases. Preoperative staging revealed 2 cases of T2NxM0, 1 of T3NxM0, 2 of TxNxM0 and 15 of T4aNxM0. Sixteen patients received robotic surgery with Roux-en-Y reconstruction successfully, and 4 patients were converted to laparotomy for palliative total gastrectomy, including 1 case with diaphragm invasion, 1 case with transverse colon invasion, and 2 cases with tight adhesions. The mean surgery time was (255±35) minutes, mean blood loss was (230±50) ml, mean number of dissected lymph nodes was 19.5±3.0, mean recovery time to gastrointestinal function was (2.3±1.0) days, mean time to feeding was (2.3±1.0) days, and mean time to ambulatory activity was (2.5±0.5) days. Pathological examinations revealed 12 patients with poorly differentiated adenocarcinoma, 6 patients with moderately differentiated adenocarcinoma, and 2 patients with mucinous adenocarcinoma. Postoperative pTNM staging was identified as follows: stage I(B for 1 patient, stage II(A for 2 patients, stage II(B for 5 patients, stage III(A for 5 patients, stage III(B for 4 patients, and stage III(C for 3 patients. One patient died 2 weeks after operation due to multiple organ failure. One patient received another hemostasis operation due to hemorrhage of splenic artery and recovered postoperatively. Two patients experienced anastomotic leakage, 1 patient developed duodenal stump fistula and 1 patient experienced incision site infection postoperatively, and all of them recovered after conservative treatment. During 5-60 months follow-up, 10 cases died and 10 cases survived, including 1 case for 6 years.</p><p><b>CONCLUSIONS</b>Robotic surgery for CRS is feasible with satisfactory short-term efficacy. However, the long-term efficacy requires further study.</p>

Meta-analysis of gastric stump cancer after gastrectomy for gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To study the clinicopathological features and prognosis of gastric stump cancer (GSC) following subtotal gastrectomy for gastric cancer, to compare the clinicopathologic differences between narrow GSC and generalized GSC, and to compare the prognosis between GSC and primary proximal gastric cancer (PPGC) after radical resection.</p><p><b>METHODS</b>Literatures of GSC-associated clinical study were searched by computer from the Cochrane Library, Medline, PubMed, CNKI, Wanfang and VIP databases, and the retrieval period was from the establishment of database to December 31, 2017.</p><p><b>INCLUSION CRITERIA</b>(1) GSC was defined as a carcinoma arising in the gastric remnant after radical gastrectomy for gastric cancer, and confirmed by the pathological or histological examination, the elapsed time from the initial operation was not considered in the definition. (2) Retrospective or prospective clinical cohort study. (3) Study included at least one of below items: gender, anastomotic type in gastric cancer surgery, the interval between the initial surgery and diagnosis of GSC, the location, treatment, pathological differentiation, pathologic stage, lymph node metastasis rate and prognosis of GSC. (4) When similar studies were reported by the same institution or author, either the better quality study or the newest publication was chosen.</p><p><b>EXCLUSION CRITERIA</b>(1) Abstracts, reviews, case reports, meeting record, editorials and repeated research. (2) Studies including patients with initial non-gastric cancer. In this study, gastric stump cancer(GSC) after gastric cancer was divided into two groups: the incidence without limit interval time (generalized GSC group) and above 10 years (narrow GSC group). Selective trials were Meta-analyzed by the Stata13.0 software and statistical analysis was performed using SPSS 21.0 software.</p><p><b>RESULTS</b>A total of 27 literatures were finally enrolled, which comprised 1463 GSC patients, including 1146 males and 317 females. The generalized group and narrow GSC group had 921 and 542 patients respectively. The generalized GSC group and the narrow GSC group did not significantly differ in terms of previous reconstruction mode, types of differentiation, pathologic T staging, postoperative pathology tumor-node-metastases staging, and distant metastasis rate (χ=2.341, 0.926, 0.350, 0.965, 2.311 respectively, all P>0.05). As compared to generalized GSC group, narrow GSC group had higher ratio of male patients (82.8% vs. 75.7%, χ=9.909, P=0.002), more lesions locating in anastomotic stoma (37.8% vs. 26.1%, χ=18.091, P=0.000), higher ratio of patients undergoing radical resection (84.2% vs. 70.3%, χ=11.738, P=0.001), higher positive rate of postoperative lymph node (45.8% vs. 34.5%, χ=6.319, P=0.012), and larger size of tumor [(5.9±2.2) cm vs. (4.5±1.9) cm, t=9.151, P=0.000]. The overall 5-year survival rate and postoperative pathology stage III(-IIII( survival ratio in narrow GSC group were higher compared to general GSC group (42.7% vs. 30.6% and 27.5% vs. 18.1%, respectively), which were significantly different (χ=10.938, P=0.000; χ=4.128, P=0.042), while the postoperative pathology stage I(-II( survival ratio was not significantly different between two groups (67.3% vs. 67.0% respectively, χ=0.015, P=0.92). There was no significant difference in the 5-year survival rate between GSC with radical resection and PPGC(RR=1.04, 95%CI:0.79-1.36, P=0.805) and the 5-year survival rate of same postoperative pathology stage was not significantly different between two groups (I(-II( stage: RR=1.08, 95%CI:0.93-1.26, P=0.328; III(-IIII( stage: RR=0.59, 95%CI:0.33-1.04, P=0.111).</p><p><b>CONCLUSIONS</b>There are some different clinicopathological features between the generalized and the narrow GSC after gastric cancer surgery. The prognosis of GSC after radical resection is similar to primary proximal gastric cancer.</p>