Culture-based bacterial evaluation of the appendix lumen and antibiotic susceptibility of acute appendicitis in Japan: A single-center retrospective analysis.

The question of whether to perform an appendectomy or conservative treatment for acute appendicitis can differ depending on the facility or surgeon, but antibiotic treatment is administered regardless of whether an appendectomy or conservative treatment is selected. We investigated the contemporary bacteriology for acute appendicitis and evaluated the antibiotic sensitivity of the bacteria that are currently associated with appendicitis. We retrospectively analyzed the bacterial culture results and antibiotic susceptibility of 141 patients who underwent appendicitis surgery, including the identification and antimicrobial susceptibility of the cultured bacteria within the excised appendices. Bacterial cultures were positive in 131 cases (92.9%). The most commonly isolated bacteria were Escherichia coli (90 isolates, 66.7%), followed by Enterococcus species (n = 19, 14.5%), Pseudomonas aeruginosa (n = 18, 13.7%), Streptococcus species (n = 15, 11.5%), and Klebsiella species (n = 8, 6.1%). Eight strains (8.8%) of E coli were extended-spectrum ß-lactamase producers, and ten strains (11.1%) were fluoroquinolone-resistant. Tazobactam/piperacillin and meropenem inhibited the growth of 100% of the major identified bacteria. The patients with appendicoliths had a significantly higher bacterial culture rate. Enterococcus species were frequently isolated from the patients with complicated appendicitis. For the antibiotic treatment of appendicitis, it is essential to understand the patient's microbiological profile and antibiotic susceptibilities. Research from Asian countries such as Japan can enhance our knowledge of regional antibiotic resistance patterns and inform effective treatment strategies.

Three Curative Pancreatectomies for the Metachronous Appearance of Pancreatic Invasive Ductal Adenocarcinoma.

We report a rare case of a patient who underwent 3 successful curative operations for the metachronous appearance of pancreatic cancer. In July 2007, a 54-year-old woman underwent pylorus-preserving pancreaticoduodenectomy. In March 2010, a tumor measuring 9 mm in diameter was detected in the tail of the pancreas on computed tomography (CT) and magnetic resonance imaging. The pancreas tail was subsequently resected while preserving the pancreatic body. In February 2011, CT revealed a cystic tumor measuring 2.5 cm in diameter in the remnant pancreatic body without any metastasis; therefore, total resection of the residual pancreas was performed in April 2011. The first resected tumor was histopathologically diagnosed as undifferentiated adenocarcinoma with osteoclast-like giant cells. Additionally, the third resected tumor had similar undifferentiated components. Contrarily, the second resected tumor was diagnosed as a well-differentiated tubular adenocarcinoma. We consider that the tumor from the third operation was an intra-pancreatic metastasis of the primary cancer and that the tumor from the second operation was the second primary cancer. The patient responded well with good control of surgical diabetes for 92 months since the last pancreatectomy. This case suggested that aggressive repeated resection for recurrent pancreatic invasive ductal adenocarcinoma is beneficial in limited cases.

Pylorus-preserving pancreatoduodenectomy for pancreatic head cancer after surgery for esophageal cancer with gastric tube reconstruction in a long-term survivor: A case report.

INTRODUCTION: To maintain the blood circulation of the gastric tube in pylorus-preserving pancreatoduodenectomy (PPPD) for periampullary cancer after esophagectomy for esophageal cancer, it is necessary to preserve the gastroduodenal artery and its branch, the right gastroepiploic artery, which are usually resected for more convenient, complete, and effective lymph node dissection. Here we report the case of a patient with a postoperative survival period of more than 5 years. PRESENTATION OF CASE: A 79-year-old man, who underwent subtotal esophagectomy and gastric tube reconstruction 11 years ago, was diagnosed with pancreatic head cancer during routine examination 5 years after the esophageal surgery. After placement of a coronary artery stent for an arterial branch stenosis incidentally found during preoperative screening electrocardiogram, he underwent pancreatic surgery. As the tumor did not extend to the anterior surface of the pancreas and as there were no swollen lymph nodes in the area, the gastroduodenal artery, the gastroepiploic artery and vein could be preserved. Elective PPPD was conducted without incident, and good preoperative gastric tube circulation was maintained postoperatively. Reconstruction was performed according to the modified Child procedure with duct-to-mucosa stentless pancreaticojejunostomy. The postoperative course was uneventful and though it took the patient a long time to overcome the physical decline, he remains alive with no recurrent disease over 5 years post-operation. CONCLUSION: Although PPPD may be performed after esophagectomy with gastric tube reconstruction, it is still unclear how the risk of recurrence is affected. Therefore, the indications of this procedure should always be carefully considered.

Efficacy of Self-Expandable Metallic Stent Inserted for Refractory Hemorrhage of Duodenal Cancer.

Because of advances in the technology of gastrointestinal endoscopy and improvements in the quality of stents, it has become routine to place a stent as palliative therapy for malignant gastrointestinal obstruction. On the other hand, stent placement for malignant gastrointestinal hemorrhage has scarcely been reported, although it may be performed for hemorrhage of the esophageal varicose vein. We recently experienced a patient with refractory hemorrhage from an unresectable duodenal cancer who underwent placement of a self-expandable metallic stent (SEMS) and thereafter had no recurrence of the hemorrhage. A 46-year-old man underwent laparotomy to radically resect a cancer in the third portion of the duodenum, which invaded widely to the superior mesenteric vein and its branches and was considered unresectable. After stomach-partitioning gastrojejunostomy was performed, chemotherapy was initiated according to the regimen of chemotherapy of far advanced gastric cancer. One year and 4 months after induction of chemotherapy, gastrointestinal hemorrhage occurred. Upper gastrointestinal endoscopy revealed the hemorrhage oozing from the duodenal cancer, and endoscopic hemostasis, such as injection of hypertonic saline epinephrine and argon plasma coagulation, was unsuccessful. Twenty days after emergence of the hemorrhage, an endoscopic covered SEMS was placed with confirmation by fluoroscopy. Immediately after placement of the stent, the tarry stool stopped and the anemia ceased to progress. The recurrence of the hemorrhage has not been confirmed without migration of the stent. SEMS is an effective hemostatic procedure for malignant refractory hemorrhage.

An FDG-PET/CT-positive lesion mimicking local recurrence of colon cancer 5 years after radical colectomy.

BACKGROUND: Radical resection of colorectal cancer yields satisfactory results. Even if the cancer recurs, long-term survival is expected through further surgical resection of the recurrent disease. For early detection of recurrent lesions, we routinely perform periodic blood tests and imaging studies, in which 18F-fluorodeoxyglucose-glucose positron emission tomography (FDG-PET) plays an important role, for lesion differentiation. We encountered a case of a benign lesion, which had been clinically diagnosed as recurrence of resected colon cancer by FDG-PET/computed tomography (CT). CASE REPORT: A 69-year-old woman underwent radical resection of stage II sigmoid colon cancer. Five years after the operation, local recurrence was suspected on the basis of follow-up CT examination findings. Since the standardized uptake value (SUV) on FDG-PET/CT was 13.3, we diagnosed the lesion as a postoperative local recurrence and performed surgical resection of the lesion. The lesion was conclusively diagnosed as benign fatty tissue, including a fibrovascular component, by histopathological examination. CONCLUSIONS: FDG-PET is a very useful technique for differentiating benign from malignant disease. In colorectal cancer, FDG-PET not only enables the differentiation of malignancy in the primary tumor, but also the confirmation of metastasis and postoperative recurrence. However, even if the SUV is high, as in the presented case, the lesion may eventually be diagnosed as benign. Therefore, further advances in the PET technique are expected along with the development of more useful modalities.

Technical procedures causing biliary complications after hepaticojejunostomy in pancreaticoduodenectomy.

BACKGROUND: Although pancreaticoduodenectomy has been established as a standard operation for pancreatobiliary diseases, postoperative biliary complications still exist and impair patient quality of life. METHODS: We enrolled 67 patients who underwent pancreaticoduodenectomy. Patients were divided into 2 chronological groups representing different surgical procedures: group A (G-A) included patients treated between 2003 and 2006 and group B (G-B) included patients treated later. We compared surgical procedures and postoperative biliary complications between the groups. RESULTS: The number of stitches at hepaticojejunostomy was 33.2 ± 8.4 in G-A and 14.0 ± 2.3 in G-B. A biliary drainage stent was placed in 31 of 32 cases in G-A and in none of the 35 cases in G-B. For each surgical procedure, there was a significant difference between the groups. Bile leakage occurred in 9.4% of G-A patients and 2.9% of G-B patients. The serum alkaline phosphatase level was significantly higher in G-A than in G-B. Moreover, the number of patients hospitalized for cholangitis was significantly greater in G-A than in G-B. CONCLUSION: Among procedure-related factors pertaining to hepaticojejunostomy in pancreaticoduodenectomy, the number of anastomotic stitches and the placement of a biliary drainage stent were confirmed to affect the development of an anastomotic stricture.

Long-term survival after sequential chemotherapy and surgery for advanced gastric cancer.

INTRODUCTION: We experienced a case with long relapse-free survival after successful treatment of chemotherapy and surgery to advanced gastric cancer. PRESENTATION OF CASE: A 56-year-old man was examined because of rapid weight loss and was diagnosed as having far-advanced gastric cancer with portal vein tumor thrombus (PVTT) and liver, lymph node and peritoneal metastases. Immediately after beginning chemotherapy, gastric obstruction due to gastric cancer was discovered. Therefore gastrojejunostomy, a bypass operation, was performed, and this was followed by the first course chemotherapy with S-1 and cisplatin. After 4 courses of this regimen were completed, PVTT and the peritoneal metastasis could no longer be confirmed, and new lesion had not appeared; therefore, the patient underwent a radical operation with distal gastrectomy, lymph node dissection and partial hepatectomy. After the operation, he received second-line chemotherapy with S-1 and paclitaxel for 1 year. He has been in good health without any signs of recurrence for 3 years and 8 months after the radical operation. DISCUSSION AND CONCLUSION: Although complete recovery from far-advanced gastric cancer is rarely expected, this case demonstrates that long-term survival is achievable with carefully considered treatment plans.

Immunohistochemically detected expression of p27(Kip1) and Skp2 predicts survival in patients with intrahepatic cholangiocarcinomas.

In intrahepatic cholangiocarcinomas (ICCs), the prognostic significance of p27(Kip1), a cyclin-dependent kinase inhibitor, remains controversial, and there have been no studies of degradation pathway associated proteins, S-phase kinase-interacting protein (Skp2), and Jun activation domain-binding protein-1 (Jab1). In the present study of 74 patients with ICC-mass forming type (ICC-MF) undergoing radical surgery, we determined immunohistochemical expression of p27(Kip1), Skp2, and Jab1 and examined relationships with clinicopathologic findings and patient survival. On the basis of the average of labeling indices, we set cutoff values to define high and low expressors and divided the cases into two groups. A statistically significant correlation was found between low p27(Kip1) expression and lymph node metastasis (P = .009). Patient survival in the low p27(Kip1) expression group (n = 25) was also significantly worse than that in the high p27(Kip1) expression group (n = 49, P = .0007). A significant inverse correlation was found between p27(Kip1) and Skp2 expression (P = .016). High Skp2 expression (n = 36) was significantly associated with poor prognosis (P = .0046). High Jab1 expression was observed in 32 cases, but there was no statistically significant relationship with clinicopathologic findings or patient survival. The multivariate analysis revealed that low p27(Kip1) and high Skp2 expression are independent and significant factors of poor prognosis. The results suggest that low p27(Kip1) and high Skp2 expression are associated with aggressive tumor behavior, and these cell-cycle regulators are useful markers to predict outcome of patients with ICC-MF.

Colo-colic intussusception associated with Henoch-Schönlein purpura in adults.

Henoch-Schönlein purpura (HSP) is often seen in childhood and is a self-limiting illness, and complication with intussusception is rare in adults. The case is reported of a 74-year-old man who was diagnosed with intussusception with HSP by ultrasonography on day of admission. Conservative therapy was started. However, his abdominal symptoms worsened, so he underwent laparotomy 3 days after admission. Histological study of the resected specimens demonstrated necrosis in the intussuscepted colon induced by HSP vasculitis. Bowel necrosis with intussusception in adult HSP is rare and might easily be overlooked. Thus special attention should be paid to gastrointestinal manifestations and, in an abdominal emergency, timely surgical intervention is life-saving.

[TS-1 therapy via intestinal catheter used for tube feeding in a patient with gastric cancer after total gastrectomy].

The patient was a 76-year-old man having gastric cancer with peritoneal dissemination. He underwent total gastrectomy for resection of the primary tumor and improvement of the oral intake. He developed ileus and peritonitis after the surgery, which necessitated two additional operations. An intestinal stoma was thus therefore created using a catheter for tube feeding, and tube feeding was initiated after the surgery. Nutrients, as well as TS-1 (taken out of the capsule; 80 mg/day) were administered via the catheter for tube feeding. This therapy was followed by a reduction in tumor marker levels and improvement of the patient's performance status (PS), after which the patient could be discharged. He stayed at home for about 8 months, with a much-improved quality of life during this period. We concluded that the TS-1 therapy via the catheter used for alimentation was effective for the treatment of cancer in this patient. We report our experience with this case, in which tube feeding became necessary after total gastrectomy, but administration of TS-1 via the same catheter used for alimentation improved the patient's PS and made it possible for him to receive chemotherapy at home.

[A case of multiple pulmonary metastases from rectal cancer effectively treated by TS-1 and low-dose CDDP therapy].

We report a patient with multiple pulmonary metastases from rectal cancer effectively treated with TS-1 and low-dose CDDP combination chemotherapy. The patient was a 61-year-old man with rectal cancer and multiple pulmonary metastases. He had undergone abdominoperineal excision of the rectum at another hospital before this hospitalization. After the operation, we treated the patient by the combination chemotherapy of TS-1 and low-dose CDDP during his hospital stay and in the outpatient clinic after hospital discharge. After the chemotherapy was started, tumor markers decreased, and finally were in the normal range. The pulmonary metastatic lesions were remarkably reduced on CT, and the effect of this therapy was PR. No severe side effect was observed throughout the treatment. This combination chemotherapy is considered to be an effective therapy for colorectal cancer with good QOL.

Evaluation of liver function for hepatic resection for hepatocellular carcinoma in the liver with damaged parenchyma.

BACKGROUND: Liver functional parameters, including the Child-Pugh score and indocyanine green clearance (ICG), and volumetric parameters influencing postoperative liver function were evaluated with the aim of obtaining standardardized criteria for selecting patients for, and deciding the extent of, hepatectomy for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The study population consisted of 120 patients with HCC undergoing hepatic resection excluding those with more than 3000 ml of intraoperative bleeding. Patients were classified as grades A, B, or C on the basis of, respectively, a Child-Pugh score of 5 or 6, 7-9, or >or=10 and were assigned to group D (postoperative liver dysfunction) or group N (no complication). Postoperative complications included massive ascites, pleural effusion, or hyperbilirubinemia. For each grade, the standardized estimated liver remnant ratio (STELR) was determined as the ratio of the liver remnant volume (estimated by computerized tomography) to the standardized total liver volume (STLV), estimated from the body surface area using the equation: liver volume [cm(3)] = 706 x body surface area [m(2)] + 2.4. The ICG retention rate at 15 min after injection (ICGR15) was then plotted against the STELR for each grade and a demarcation line separating patients in groups N and D was determined statistically by discriminant analysis. RESULTS: For grade A patients, the equation of the demarcation line was ICGR15 = 27.5 x STELR + 1.9 (Wilks' Lambda: 0.667, P < 0.001), indicating that, for safe hepatic resection in patients with an ICGR15 of 10%, the STELR should be greater than 0.29. In contrast, for grade B patients, the equation was ICGR15 = 72 x STELR - 22.1 (0.589, P < 0.001), indicating that, in patients with a 10% ICGR15, the STELR should be greater than 0.44, a larger value than in grade A patients. The number of grade C patients was too small for analysis. CONCLUSIONS: By combining the Child-Pugh score, ICG clearance, and liver volumetric parameters, criteria for the selection of patients for hepatic resection for HCC were established.

Dihydropyrimidine dehydrogenase (DPD) activity in gastric cancer tissue and effect of DPD inhibitory fluoropyrimidines.

BACKGROUND: Dihydropyrimidine dehydrogenase (DPD) is an enzyme that catabolizes 5-fluorouracil (5-FU). The effect of DPD inhibitory fluoropyrimidines (DIF) is presumably related to DPD activity. We studied the efficacy of DIF (tegafur + uracil UFT], tegafur + gimeracil + osteracil [S-1 (TS-1)]) relative to DPD activity, with other fluoropyrimidines as controls. METHODS: The efficacy of DIF relative to DPD activity was evaluated in 58 gastric cancer patients who received postoperative administration of fluoropyrimidines, consisting of DIF in 42 patients (UFT in 23; S-1 in 19) and non-DIF in 16 patients. RESULTS: In patients with low DPD activity (under 40 U/mg protein), curative potential tended to be lower for DIF than for non-DIF, but the survival rate was the same for both. In patients with high DPD activity (40 U/mg protein or more), such a tendency was not detected. In a comparison between those treated with UFT and those treated with S-1, prognosis was better in the latter group, in spite of their predominance of lower curative potentials of B or C. In 27 patients with measurable lesions, a partial response (PR) or higher response occurred in 33% (5/15) of those with low DPD activity, and in 17% (2/12) of those with high DPD activity. In the patients with low DPD activity, non-DIF induced no change (NC) in 17% (16), and progressive disease (PD) in the rest. UFF induced PD in all 5 patients, while S-1 induced a response rate of 44% (7/16), with NC in 25% (4/16). In the patients with high DPD activity, on the other hand, non-DIF (n = 3) and UFT (n = 3) induced PD in all the patients, while S-1 induced PR in 33% (2/6) and NC or a higher response in 67% (4/6). CONCLUSION: It is recommended to use S-1 rather than UFF in patients with high DPD activity. Measurement of DPD was useful in drug selection.

Significance of reduction surgery in multidisciplinary treatment of advanced hepatocellular carcinoma with multiple intrahepatic lesions.

BACKGROUND AND OBJECTIVES: By comparing the survival rates of patients treated with or without surgery, the significance of, and the indication for, reduction surgery in the multidisciplinary treatment of patients with HCC with multiple intrahepatic lesions were examined. METHODS: In patients with HCC with multiple intrahepatic lesions, cumulative survival rates were determined and compared for 28 patients (group S) who underwent reductive hepatic resection and 43 (group N) who were treated nonsurgically by transcatheter arterial infusion chemotherapy (TAI), transcatheter arterial chemoembolization (TACE), or percutaneous transhepatic ethanol injection therapy. In group S, 20 patients had adjuvant therapy, consisting of ethanol injection therapy or microwave coagulonecrotic therapy for the remaining satellite lesions during hepatectomy, and all patients in this group underwent TAI or TACE postoperatively. The influence of surgery on patient survival was examined by multiple regression analysis using the Cox's hazard model; then, for each prognostic factor, survival rates were obtained and compared between the groups. RESULTS: In group S, the 1-, 3-, and 5-year cumulative survival rates were 58.2%, 27.1%, and 21.7%, whereas the corresponding values in group N were 34.3%, 4.7%, and 4.7%, the difference being statistically significant (P = 0.0239). In group S, the 1-, 3-, and 5-year cumulative survival rates for patients without intraoperative adjuvant therapy were 25%, 0%, and 0%, whereas those for patients with intraoperative adjuvant therapy were 72.7%, 41.3%, and 33.0% (P = 0.001). Multiple regression analysis showed that hepatic resection, the Child-Pugh score, and the size of the main tumor affected survival independently. Univariate analysis of differences in the cumulative survival rates between the groups as a function of prognostic factor showed that group S had statistically significant better survival rates than group N in those subgroups of patients who were <60 years old, with HBV infection, with a Child-Pugh score of 5 or 6, with a main tumor of <5-cm diameter, with <5 tumors, or without portal thrombi. CONCLUSIONS: When combined with intraoperative adjuvant therapy for remaining satellite tumors, reduction surgery provided survival benefit for patients with HCC with multiple intrahepatic lesions in those groups of patients selected by criteria determined in this study.

Lymphocytic infiltration surrounding liver metastases from colorectal cancer.

BACKGROUND AND OBJECTIVES: Tumor infiltrating lymphocytes (TILs) have been recognized as a tumor-host reaction in various primary neoplasms. Although several studies reported TILs surrounding metastatic liver tumors, to the authors' knowledge few evaluations of the clinical significance of such features in patients with colorectal liver metastases have been carried out. METHODS: Forty-one patients who underwent initial hepatic resection for liver metastases from colorectal cancer were studied. Lymphocytic infiltration surrounding metastatic liver tumor was graded as weak or dense according to the mean number of TILs from 10 high-power microscopic fields (< or =50 or >50/HPF). RESULTS: Dense lymphocytic infiltration between the metastatic tumor and hepatic parenchyma was seen in 18 of 41 patients (44%). Histologically, tumor invasion of the portal vein was rare in patients with dense TILs (12%) compared with patients with weak TILs (36%). Patients with dense TILs survived longer than patients with weak TILs after hepatic resection (P = 0.013). Multivariate analysis using the Cox proportional hazard model identified this pathological variable as a significant independent prognostic factor after hepatic resection. CONCLUSIONS: The extent of lymphocytic infiltration between the metastatic nodule and hepatic parenchyma may reflect host defensive activity in the liver and is closely related to prognosis in patients who underwent hepatic resection for liver metastases from colorectal cancer.

Application of preoperative portal vein embolization before major hepatic resection in patients with normal or abnormal liver parenchyma.

BACKGROUND: Clinical parameters influencing the effect of preoperative portal vein embolization (PVE) in hypertrophying the nonembolized lobe of patients with either normal or abnormal liver parenchyma and its effect upon portal pressure were examined to identify the patient population for whom this approach is most suited. METHODS: The study population included 43 patients undergoing major hepatectomy after PVE. Patients were divided into 2 groups according to their liver parenchyma: 17 patients with normal liver parenchyma (N group) and 26 patients with damaged liver parenchyma due to viral hepatitis (D group). We calculated the correlation between volumetric increases in the nonembolized (left) lobe after PVE (hypertrophic ratio = post-PVE left lobe volume/pre-PVE left lobe volume) using computed tomography volumetry before and 2 weeks after PVE. Clinical parameters also were examined to identify those parameters modifying the hypertrophic ratio in each group, and changes in portal pressure by PVE and the subsequent hepatectomy were recorded. Finally, by comparing patients with or without postoperative liver failure after hepatectomy, the influence of the hypertrophic ratio and portal pressure on the outcome of subsequent hepatectomy was examined. RESULTS: The hypertrophic ratio was 1.34 +/- 0.23 in the N group, and 1.25 +/- 0.21 in the D group. This difference was not significant. Multiple regression analysis revealed that the parenchymal volumetric rate of the right lobe (PVR) in the D group and both PVR and prothrombin time in the N group were independent parameters predicting the hypertrophic ratio. The portal pressure increased immediately after PVE and was similar in both groups to levels after hepatectomy. Six patients in the D group experienced postoperative liver dysfunction. In 5 of these 6 patients, the hypertrophic ratio was below 1.2, and the portal pressure was higher than that in patients without liver dysfunction. CONCLUSIONS: PVE induces hypertrophy of the nonembolized lobe of both abnormal and normal liver parenchyma, and the effect was predictable. Postoperative liver failure appeared to be more severe in patients having a lower hypertrophic ratio and higher portal pressure in abnormal liver parenchyma, however. PVE also may have diagnostic use in predicting portal pressure after hepatectomy, which may be associated with surgical outcome.

Hepatic resection for metastatic tumors from gastric cancer.

OBJECTIVE: To assess the surgical results and clinicopathologic features of hepatic metastases from gastric adenocarcinoma to identify patients with a better probability of survival. SUMMARY BACKGROUND DATA: Many studies have reported the benefit of hepatic resection for metastatic tumors from colorectal cancer. However, indications for a surgical approach for gastric adenocarcinoma involving the liver have not been clearly defined. METHODS: Ninety (11%) of 807 patients with primary gastric cancer were diagnosed with synchronous (n = 78) or metachronous (n = 12) hepatic metastases. Of these, 19 underwent 20 resections intended to cure the metastatic lesion in the liver. The clinicopathologic features of the hepatic metastases in, and the surgical results for, the 19 patients were analyzed. RESULTS: The actuarial 1-year, 3-year, and 5-year survival rates after hepatic resection were, respectively, 77%, 34%, and 34%, and three patients survived for more than 5 years after surgery. Solitary and metachronous metastases were significant determinants for a favorable prognosis after hepatic resection. Pathologically, a fibrous pseudocapsule between the tumor and surrounding hepatic parenchyma was found in 13 of the 19 patients (68%). The presence of a peritumoral fibrous pseudocapsule and a well-differentiated histologic type of metastatic nodule were significant prognostic factors. Factors associated with the primary lesion were not significant prognostic determinants in patients who underwent curative resection of the primary cancer. CONCLUSIONS: Solitary and metachronous metastases from gastric cancer should be treated by a surgical approach and confer a better prognosis. A new prognostic factor, the presence of a pseudocapsule, may be helpful in defining indications for postoperative adjuvant treatment.