Postoperative evaluation of pylorus-preserving gastrectomy for early gastric cancer.

BACKGROUND/AIMS: There have been many reports proposing some advantages of pylorus-preserving gastrectomy for gastric ulcer compared to the conventional distal gastrectomy. However, it is not clear whether similar results will be obtained from the patients with early gastric cancer. METHODOLOGY: Of 50 patients with early gastric cancer, 25 underwent pylorus-preserving gastrectomy under strict criteria and the other 25 underwent distal gastrectomy with Billroth I anastomosis by the same surgeon. The subjects were then interviewed and examined periodically to assess symptoms, food intake, body weight and serum nutritional parameters. Endoscopy and a radioisotope gastric emptying test was performed 1 year after the operation. RESULTS: Many of the patients with pylorus-preserving gastrectomy complained of gastric fullness after meals, resulting in poor food intake; a significant between-group difference was found up to 1 year after the operation. A low incidence of reflux gastritis and slow gastric emptying were confirmed in the patients after pylorus-preserving gastrectomy. CONCLUSIONS: Pylorus-preserving gastrectomy has advantages over distal gastrectomy in terms of the avoidance of dumping syndrome and protection against duodeno-gastric reflux. However, more time was necessary for improved gastric fullness or food intake. Pylorus-preserving gastrectomy should be applied in younger patients with early gastric cancer expecting long survival.

Congenital hemangiopericytoma: report of a case.

We report a case of congenital hemangiopericytoma arising in the lower right leg of a 4-day-old male neonate. Despite the generally good prognosis associated with this neoplasm, a complete surgical excision has so far been recommended to avoid recurrences, because no definite criteria for determining whether or not the tumor will regress spontaneously have been established to date.

Incidence and prognosis of para-aortic lymph node metastasis in gastric cancer.

BACKGROUND/AIMS: We investigated the frequency of para-aortic lymph node involvement and evaluated the effects on survival of dissection of these lymph nodes in patients with N4 node metastasis. METHODOLOGY: One hundred and forty nine gastric cancer patients with N4 node dissection were analyzed. Total gastrectomy with splenectomy or pancreatosplenectomy was performed in 99, distal gastrectomy 48, pancreaticoduodenectomy 3, and proximal gastrectomy with splenectomy 2. RESULTS: N4 nodal involvement was found in about 30-40% of operable patients with Borrmann's type 3 or 4 tumor, with tumor >8 cm in size, with tumor throughout the entire or in the upper third of the stomach, with tumor invasion to the serosa or adjacent structures, with N2 or N3 regional lymph node metastasis, and with undifferentiated histological type. The survival was quite poor. However, in patients without N3 nodal involvement or intraperitoneal free cancer cells, the survival after resection of tumor with N4 nodal involvement was relatively favorable. CONCLUSIONS: The resection of these involved lymph nodes can be expected to be beneficial in patients without extensive serosal invasion and without extensive lymph nodal involvement such as N3 nodes. Patients with tumor in the upper third of the stomach are appropriate candidates for N4 node dissection.

[Jejunal pouch and interposition reconstruction after a total gastrectomy for cancer].

The authors modified the operative procedures used in pouch and interposition (PI) reconstruction in an attempt to improve the surgical results after a total gastrectomy, because a randomized controlled trial had revealed that the clinical assessment of PI was quite poor, even though it is a physiological route. In most of the treated patients, the gastric emptying test revealed delayed emptying, and an X-ray video film showed folding and twisting of the jejunal conduit between the pouch and duodenum, which disturbed the transmission of the nutrition. Modified PI (m-PI) was performed by decreasing the length of the jejunal conduit and widening the jejunal pedicle to preserve the blood and nerve supply. The m-PI group showed a lower incidence of symptoms, a greater food intake, and a greater weight recovery than the PI group. The gastric emptying test also revealed an acceptable degree of emptying. We conclude that the m-PI reconstruction is more useful for improving the postoperative quality of life than the previously used method of PI reconstruction.

Emptying of the jejunal pouch as a gastric substitute after total gastrectomy for cancer.

BACKGROUND/AIMS: The reservoir and transit capacity of the post-gastrectomy jejunal pouch was evaluated, using a radioisotopic method, to examine the relationship of the gastric emptying to postprandial symptoms and to the food intake status. METHODOLOGY: Thirty-seven patients who had undergone total gastrectomy for cancer (Roux-Y reconstruction, 8; Hunt- Lawrence pouch and Roux-Y, 15; pouch interposition, 5; modified pouch interposition, 9) were retrospectively studied. Based on the percent retention in the gastric substitute, the emptying curves were classed as showing delayed, intermediate, and rapid emptying types. RESULTS: All of the patients with pouch reconstruction showed either delayed or intermediate emptying. High frequency of the sensation of epigastric fullness, nausea, or vomiting was demonstrated in the patients with delayed emptying (p < 0.01). The patients with delayed emptying showed poor food intake compared to those with intermediate emptying (p < 0.05). Given the X-ray video film and endoscopic findings, the delayed emptying was thought to be due to poor drainage of the efferent loop resulting from the post-operative adhesions. CONCLUSIONS: The present study revealed that delayed emptying is associated with postprandial symptoms and with poor food intake. The examination of gastric emptying is useful in evaluating or predicting the postoperative status.

Jejunal pouch and interposition reconstruction after total gastrectomy for cancer.

The authors modified the operative procedures used in pouch and interposition (PI) reconstruction in an attempt to improve the surgical results after total gastrectomy, because a randomized controlled trial had revealed that the clinical assessment of PI was quite poor, even though it is a physiological route. In most of the treated patients, the gastric emptying test revealed delayed emptying, and an X-ray video film showed folding and twisting of the jejunal conduit between the pouch and duodenum, which disturbed the transmission of nutrition. Modified PI (m-PI) was performed by decreasing the length of the jejunal conduit and widening the mesenteric pedicle to preserve the blood and nerve supply. This procedure was retrospectively compared with the previously used PI reconstruction by evaluating the postprandial symptoms, food intake, body weight, serum nutritional parameters, and emptying time of the gastric substitute. The m-PI group (n = 6) showed a lower incidence of symptoms, a greater food intake, and a greater weight recovery than the PI group (n = 6). The gastric emptying test also revealed an acceptable degree of emptying. We thus conclude that the m-PI reconstruction is more useful for improving the postoperative quality of life than the previously used method of PI reconstruction.

Site of action of galanin in the cholinergic transmission of guinea pig small intestine.

The mode and site of action of galanin were examined in the guinea pig small intestine. Galanin (3 x 10(-9)-10(-7) M) inhibited the twitch contractions of longitudinally and circularly oriented muscle strips mediated by the stimulation of cholinergic neurons, but not the contractions mediated by direct stimulation of smooth muscle cells with carbachol. Galanin (3 x 10(-9)-10(-7) M) inhibited both the electrically stimulated and the tetrodotoxin-resistant high K+ (40 mM)-induced increase of [3H]acetylcholine outflow from the ileal strips preloaded with [3H]choline, in a concentration dependent fashion. The inhibitory effect of galanin was antagonized by galantide and produced self-desensitization. The spontaneous and stimulated outflow of [3H]noradrenaline and [3H]gamma-aminobutyric acid were not affected by galanin even at 10(-7) M. Thus, galanin inhibits the motility of guinea pig ileum by inhibition of acetylcholine release from the enteric cholinergic neurons. Galanin may act on the specific receptor located on soma-dendritic regions and nerve terminals of cholinergic neurons.

Jejunal pouch reconstruction after total gastrectomy for cancer. A randomized controlled trial.

OBJECTIVE: The authors determined the optimum reconstruction procedure after total gastrectomy in terms of the quality of life of the patients. SUMMARY BACKGROUND DATA: Gastric replacement with various enteric reservoirs has been used to improve the postprandial symptoms and nutrition of patients after total gastrectomy. However, the effect of each is uncertain because no prospective randomized studies have been conducted. METHODS: A randomized controlled trial was conducted to compare the usefulness of the three reconstruction procedures of simple Roux-en-Y (RY; N = 10), pouch and Roux-en-Y (PR; N = 10), and pouch and interposition (PI; N = 10). In each subject, the postprandial symptoms, food intake in a single meal, body weight, serum nutritional parameters, and emptying time of the gastric substitute were evaluated. RESULTS: The PR group showed significantly greater food intake in a single meal than the RY and PI groups, and greater weight recovery than the PI group. A gastric emptying test also revealed satisfactory retention capacity and emptying time of the gastric substitute in the PR group. CONCLUSIONS: Pouch and Roux-en-Y reconstruction is the most useful of the three procedures for improving the postoperative quality of life. In patients with pouch and interposition reconstruction, the clinical assessment was quite poor, even though it is a physiologic route.

Correlation of preoperative carcinoembryonic antigen levels and prognosis of gastric cancer patients.

BACKGROUND: The prognostic significance of preoperative serum carcinoembryonic antigen (CEA) determination in patients with gastric cancer has been controversial. METHODS: The correlation between preoperative serum CEA levels and clinicopathologic factors was evaluated in 865 patients with gastric cancer who underwent gastrectomy between 1980 and 1990. The authors also investigated whether preoperative CEA levels represented a prognostic parameter using Cox's proportional hazard model. RESULTS: Of the 865 patients, 249 (28.8%) were positive for CEA. The positivity rate was higher in the elderly, in male patients whose tumors were located in the lower third of the stomach, and in those with Borrmann types 2 and 3. It was also significantly correlated with tumor size, depth of invasion, lymph node metastasis, peritoneal and liver metastases, and cancer stage. The higher the serum CEA level, the more advanced the cancer stage, and the rate of curative resection also decreased as CEA levels were elevated. There was a significant difference between patients with CEA levels below 10 ng/ml and those with levels exceeding 10 ng/ml with regard to tumor progression and curability. Multivariate analysis showed a strong and highly significant association between preoperative serum CEA level and survival time. The prognosis was also significantly poorer when the CEA level was above 10 ng/ml, even in patients in the same stage (Stages 1, 2, and 3). CONCLUSIONS: Preoperative serum CEA determination in patients with gastric cancer valuable for predicting tumor progression and prognosis. Further, in patients in Stages 1, 2, and 3, CEA levels exceeding 10 ng/ml are clinically significant and provide more prognostic information than that obtained by conventional staging methods.

[Evaluation of surgical treatment of gastric cancer in the aged].

Patients with gastric cancer aged 70 years or over were divided into 3 age groups (70-74, 75-79, 80 years or over) and were compared with patients aged 60-69 years, (which is the age group with the highest incidence of stomach cancer) with regard to the incidence of postoperative complications. In addition, factors which might be associated with increased mortality were investigated. There were no significant differences with regard to the incidence of postoperative complications (16-21%) or the mortality rate (0-3%, within 30 days after surgery) between the various age groups. However, the incidence of those complications which later proved fatal was higher in those aged 75 years or over. Factors associated with the development of complications in each age group were the type of surgical technique used, the operation time, and the severity of hemorrhage during surgery. The prognosis for gastric resection was poor in patients aged 80 years or over. Our findings indicated that curative resections should be performed for gastric cancers in the elderly if the general physical condition of the patients permits. A more conservative approach is desirable when the general condition is not favorable.