Treatment of primary multiple early gastric cancer: from the viewpoint of clinicopathologic features.

The treatment of multiple early gastric cancer was investigated through the clinicopathologic assessment of 61 cases of primary multiple early gastric cancer (82 accessory lesions) treated by surgical resection over a 15-year period. These cases accounted for 11.7% of all cases of early gastric cancer resected during the same period. The 61 patients included 48 men (mean age 64 years) and 13 women (61 years). Of the 82 accessory lesions, 41 (50%) were located in the same region as the main lesion. The most frequent combination of macroscopic types of the main lesion and the accessory lesion was depressed type/depressed type (28 cases). The main lesion was of the well differentiated type in 39 (64%) of the 61 cases; the accessory lesion was also well differentiated in 37 of the 39 cases. Of the 82 accessory lesions, 29 (35%) had been overlooked preoperatively; most of them were located in the middle third of the stomach and included 17 depressed and 10 flat lesions, most of which measured no more than 1 cm. Cases of multiple early gastric cancer are characterized by the predominance of male patients of advanced age (> 60 years), a combination of the same macroscopic type of the main and accessory lesions, and well differentiated carcinoma. Lymph node metastasis and vascular invasion are equally or less frequent than in cases of solitary early gastric cancer. The postoperative crude survival rate in patients with multiple gastric cancer is similar to that in those with solitary gastric cancer. Therefore we believe that multiple early gastric cancer does not require extended operative procedures. Endoscopic treatment may be indicated if each lesion fits the criteria for treatment and careful follow-up is ensured.

Technical devices in jejunal pouch reconstruction following total gastrectomy, including postoperative results.

BACKGROUND/AIMS: Either straight Roux-en-Y anastomosis or jejunal interposition used to be adopted following total gastrectomy. However, dissatisfaction with regard to postoperative quality of life has prompted the development of new techniques. The purpose of this study is to describe and assess the authors' technical devices in jejunal pouch (J-pouch) reconstruction following total gastrectomy and the results of these operations. PATIENTS AND METHODS: A prospective study of 17 patients with malignant gastric disease (nine with J-pouch interposition, eight with J-pouch Roux-en-Y reconstruction) was performed. To facilitate the side-to-side anastomosis of the jejunal loop, the authors used an autosuture instrument. The anastomosis was then checked for hemostasis using a vaginoscope. RESULTS: An Endo GIA with a 60-mm long white cartridge (closed height of staples, 1.0 mm) is the instrument of choice to create the J-pouch. This autosuture instrument fires triple staggered staple lines, which minimizes bleeding from the anastomosed site and reduces operative time. No anastomotic leaks were associated with the autosuture instrument. The vaginoscope facilitates a direct observation of the staple lines internally and if necessary, enables secure hemostasis with sutures. Bowel motility was satisfactory for both surgical procedures, as measured by the percentage of radiopaque markers which were expelled from the pouch. There were no serious complications, and all patients have currently survived, a maximum of 5 years and 6 months after surgery, except for one patient who died from recurrent disease. CONCLUSION: The authors' procedures for J-pouch reconstruction are advantageous due to a favorable postoperative quality of life, with low complication rates.

Proximal gastrectomy and jejunal pouch interposition for the treatment of early cancer in the upper third of the stomach: surgical techniques and evaluation of postoperative function.

BACKGROUND: Limited surgery for the treatment of early gastric cancer located in the upper third of the stomach should be based on a well-balanced reduction in the extent of lymph node dissection and gastric resection while assuring a favorable quality of life and prognosis after operation. METHODS: We have used interposition of a double jejunal pouch between the esophagus and the remnant stomach after performing proximal gastrectomy. To assure anastomosis and hemostasis during this operation, we currently use a surgical stapler with a vaginoscope and our new edge clamps. This method has been used in 12 patients to date. RESULTS: On histopathologic examination the 12 cases comprised 11 early cancers (seven mucosal and four submucosal cancers) and one subserosal cancer. There was no evidence of lymph node metastasis of postoperative complications such as anastomotic leakages or hemorrhage, demonstrating the low-risk nature of this procedure. CONCLUSIONS: The evaluation of postoperative quality of life, in terms of clinical signs and symptoms and dietary status, yielded favorable results. Thus our method has the important advantage of allowing good organ preservation.

Endoscopic treatment of early oesophageal or gastric cancer.

BACKGROUND AND AIMS: Endoscopic treatment has become increasingly popular in recent years as an alternative to surgical treatment with the hope of offering superior quality of life (QOL) for the patient. The results of endoscopic treatment of mucosal lesions of mostly early oesophageal or gastric cancer performed in 145 patients (155 lesions) over the past eight years were reviewed from the standpoint of QOL. RESULTS: In 56 patients who underwent radical resection of the oesophageal mucosa, no serious complications and symptoms occurred, with epithelialisation completed within about a month. Patients also showed good results regarding dietary intake and performance status (PS), and all are currently alive without any sign of recurrence. One time fractionated endoscopic resection was carried out in about 40% of the 57 patients who underwent gastric mucosal resection. In these 57 patients, an artificial ulcer measuring 3 cm or more was formed, resulting in a favourable outcome after healing. An overwhelming proportion of these subjects had no symptoms and good PS after the treatment. CONCLUSIONS: The introduction of this method, endoscopic mucosal resection using a cap fitted panendoscope, is expected to permit additional indications for endoscopic treatment. Endoscopic Nd-YAG laser irradiation was applied mainly to early gastric cancer lesions (32 patients), usually for relative indications for endoscopic treatment. This procedure is safe and advantageous in that it requires no hospitalisation, permits fractionated irradiation, and secures good QOL.

A new method of endoscopic mucosal resection of neoplastic lesions in the stomach: its technical features and results.

BACKGROUND/AIMS: In gastric cancer, endoscopic treatment can be expected to provide an absolute cure only if the lesion is mucosal and not accompanied by metastatic lymph nodes. To further evaluate such possibly curable lesions, we retrospectively reviewed 208 cases of early gastric cancer surgically resected over the past 20 years. METHODOLOGY: Our new method of endoscopic mucosal resection using a cap-fitted panendoscope, which is called EMRC, has been employed in the treatment of 73 gastric neoplastic lesions. RESULTS: It was found that curable lesions would, as the primary condition, be histologically well-differentiated carcinomas and measure 2 cm or less of the elevated type and less than 1 cm of the depressed type. The lesions were consequently identified as 49 early cancers (46 mucosal, 3 submucosal), 23 adenomas and 1 carcinoid. Although resection was completed in a single session of EMRC treatment in all cases, approximately 40% of them required fractionated resection, leaving an ulcer measuring 3 cm or more in approximately 30%. Bleeding or muscle resection occurred in 7 patients, in whom conservative treatment was effective. No recurrence has been found in any of the 73 lesions, demonstrating a favorable outcome. CONCLUSIONS: This method is advantageous in that it is simple and relatively easily applied at almost any location within the stomach. In addition, the size of the specimen obtained by en bloc resection is approximately 2 cm. The method is thus fairly likely to come into widespread use.

Monocyte function associated with intermittent lentinan therapy after resection of gastric cancer.

The effect of lentinan administration on monocyte function in the peripheral blood were examined in 33 patients who underwent resection of gastric cancer. As parameters of monocyte function, IL-1 production, C3b receptor, Fc gamma receptor and monocyte ratio were determined every 4 weeks for a maximum of 24 weeks. Among patients who were taking combined therapy with lentinan, an increase in IL-1 beta production of more than 50% was found 8 weeks (2 months) after the initiation of therapy in 8 of 12 patients given 2 mg at 2-week intervals, and in 11 of 16 patients given the same dose at 4-week intervals. This increase was particularly clear in stage II or more advanced cases. There were no significant changes in the other parameters studied. It has been considered that lentinen is effective when administered once a week. The results of the present study, however, suggest that lentinan given every 4 weeks also stimulates monocyte function enough to maintain immunological activity.

[Clinical evaluation of anticancer effect of methionine-depleting total parenteral nutrition with 5-fluorouracil and/or mitomycin C].

Methionine-depleting total parenteral nutrition (Met-deplete TPN), infusing AO-90 amino acid solution (lacking both L-methionine and L-cysteine) as a sole nitrogen source, showed synergistic effects with several antineoplastics including 5-fluorouracil (5-FU). In the recent multi-center, randomized, controlled study, advanced gastric cancer patients were randomly allocated to RT group and Control group. RT group received AO-90 amino acid solution, while Control group infused Amiparen (commercial methionine and cysteine containing amino acid solution) as protein source for 14 days' TPN with 5-FU and mitomycin C (MMC). The over all clinical response rate (PR+CR) in RT and Control groups were 26.3% and 8.1%, respectively, with significant statistical difference in both values at p = 0.015. Fourteen advanced gastric cancer patients allocated to RT and Control group randomly and received each amino acid as protein source for 7 days TPN with 5-FU administration. All cases were performed gastrectomy without waiting period, and resected material was examined the histological response. In the 7 cases of RT group, grade 2 was seen in 4 cases, grade 1-b in 1, grade 1-a in 1 and grade 0 in 1. In the 7 of Control, 3 cases were grade 1-a and the remaining 4 were grade 0. There were significant differences in both degree and incidence of the histological response at p = 0.016. A stage IV gastric cancer patient with marked liver metastasis received 2 times RT therapy with 5-FU and MMC for 14 days and undertaken gastrectomy after 22 day, waiting period. Resected gastric cancer showed grade 2 to 3 histological response, and the liver metastasis showed marked effect as PR to CR.

Synergistic effect of methionine-depleting total parenteral nutrition with 5-fluorouracil on human gastric cancer: a randomized, prospective clinical trial.

Methionine-depleting total parenteral nutrition (Met-depleting TPN), infusing AO-90 amino acid solution (lacking both L-methionine and L-cysteine) as a sole nitrogen source, showed synergistic effects with 5-fluorouracil (5-FU) in tumor-bearing rats and in clinical trials with gastrointestinal tract cancers. In this study, the effect of Met-depleting TPN with 5-FU upon thymidylate synthase (TS) activity was examined, and the histological effect of this treatment on human gastric cancer was evaluated. Fourteen preoperative advanced gastric cancer patients were divided randomly into two groups. Seven cases were given Met-depleting TPN for 7 days before surgery with continuous intravenous administration of 5-FU (500 mg/body per day; total 4.0 g/body) (AO-90 group). The other 7 received conventional L-methionine-containing TPN with 5-FU (control group). All patients underwent gastrectomy without complications due to these treatments. Resected materials were examined for TS kinetics, and the anti-cancer effect was also assessed histopathologically. The specimens in the AO-90 group showed marked degeneration of cancer, while almost no effect was seen in the control group. The free TS activity of carcinoma tissue in the AO-90 group was decreased and the TS inhibition rate was increased in comparison with the control group (P = 0.0165 and P = 0.0243, respectively). Met-depleting TPN appears to play a role as a biomodulator of 5-FU in human gastric cancer.

[Prognostic factors in gastric cancer with serosal invasion--importance of the extent of cancer infiltration in the subserosal layer].

The extent of cancer infiltration in the subserosal layer has been examined in 214 stomachs resected for cancer with a serosal invasion. The extent was 4 cm or less in 109 patients (Group A) and 5 cm or more in 105 patients (Group B). The resection was estimated as being non-curative in 26% of Group A and in 52% of Group B (p less than 0.001). Peritoneal dissemination was the outstanding non-curative factor in the latter. The five-year survival rate was 39% in Group A and 14% in Group B (p less than 0.001). The survival rate after the curative resection was 49% and 26%, respectively (p less than 0.01). In Group B, peritoneal dissemination was the main mode of recurrence after the curative resection.

Experience with the EEA stapler for esophagojejunostomy.

From January 1979 through December 1986, 239 patients underwent total gastrectomy for gastric cancer. In 94 patients esophagojejunostomy was performed with the EEA stapler and in 145 patients hand sutures were employed. Operating time (mean +/- SD) was 288 +/- 60 minutes in the stapled group and 306 +/- 75 minutes in the sutured group (p less than 0.05). The length of the resected esophagus (mean +/- SD) was 19 +/- 17 mm in the former and 14 +/- 14 mm in the latter (p less than 0.01). The rate of leakage was 7.4% in the former and 13.8% in the latter with no significant difference. Five patients (3.4%) died within 30 days after sutured anastomosis and in two of them death was caused by anastomotic leakage. There was no operative death in the stapled group. It seemed that the stapler was able to simplify and facilitate esophagojejunostomy after total gastrectomy and that anastomosis with the stapler was at least as reliable as that with hand sutures.