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

BACKGROUND/AIMS: We evaluated the efficacy of the following three surgical options in gastrectomy for early gastric cancer; 1) reduction of the extent of gastrectomy, 2) preservation of the vagal nerve, and 3) preservation of the pylorus. METHODOLOGY: The postoperative physical conditions of patients who had undergone 6 kinds of operating methods incorporating elements 1), 2) and 3) were compared. The efficacy of elements 1) and 3) was evaluated by comparison among a 2/3 proximal gastrectomy group (2/3-PG group, n = 5), 4/5 proximal gastrectomy group (4/5-PG group, n = 7), and total gastrectomy group (TG group, n = 12). The efficacy of elements 1), 2) and 3) was also evaluated by comparison among a pylorus-preserving gastrectomy (PPG) group with preservation of the vagal nerve (PPGV group, n = 15), 2/3 distal gastrectomy group with preservation of the vagal nerve (2/3-DGV group, n = 12), and 4/5 distal gastrectomy group without preservation of the vagal nerve (4/5-DG group, n = 15). RESULTS: Body weight loss and the incidence of abdominal symptoms and anemia in the 2/3-PG group, PPGV or 2/3-DGV group were less frequent than in the TG group or 4/5-DG group. The increases in acetaminophen concentration in the 2/3-PG group, PPGV or 2/3-DGV groups, and the changes in blood sugar and insulin levels in the 2/3-PG or PPGV group were modest, while hypergastrinemia in the 2/3-PG group was remarkable. The insulinogenic index was high in the 2/3-DGV group, and the plasma cholecystokinin changes and contraction pattern of the gallbladder resembled their preoperative pattern in the PPGV and 2/3-DGV groups. These results indicated that the patients in the 2/3-PG group owed their benefits to elements 1) and 3), the 2/3-DGV group to elements 1) and 2), and the PPGV group to elements 1), 2) and 3). CONCLUSIONS: Three surgical options in gastrectomy procedures for early gastric cancer, 1) reduction of the extent of gastrectomy, 2) preservation of the vagal nerve, and 3) preservation of the pylorus, were individually confirmed to have benefits for better postoperative quality of life.

Preoperative simulation of vascular anatomy by three-dimensional computed tomography imaging in laparoscopic gastric cancer surgery.

BACKGROUND: Treatment of early gastric cancer may be an ideal application for laparoscopic surgery. But laparoscopic surgery has various limitations derived from the lack of tactile feedback and a two-dimensional display of the operative field. So, laparoscopic surgery is technically challenging and requires a more detailed understanding of local anatomy than conventional open surgery does. The purpose of this study was to evaluate the value of three-dimensional computed tomography imaging in the preoperative simulation of laparoscopic gastric cancer surgery. STUDY DESIGN: Multidetector-row helical CT was performed preoperatively in 49 patients who underwent laparoscopic gastric cancer surgery. Scanning was initiated approximately 20 seconds after an intravenous injection of 100 mL of contrast material at 5 mL/second. Three-dimensional CT images were reconstructed using the volume-rendering technique. RESULTS: 3D-CT imaging depicted the stomach, arterial, and venous anatomy and was able to identify important vascular variants. Preoperative information concerning the right gastric artery led us to the site of its branching and facilitated dissection of suprapyloric lymph nodes. The left gastric artery furnishing the aberrant left hepatic artery was successfully revealed and this information enabled us to avoid accidental hemorrhage and ischemic liver damage. Preoperative confirmation of the drainage routes of the left gastric vein was also useful in accomplishing secure lymphadenectomy. CONCLUSIONS: 3D-CT imaging provides a vascular "road map," which is critical for surgical guidance, and prevents the risks involved in surgery. Preoperative 3D-CT imaging may be an informative device to overcome the disadvantages of laparoscopic gastric cancer surgery.

[Clinical application of three-dimensional imaging with multislice CT for laparoscopic colorectal surgery].

PURPOSE: Laparoscopic colorectal surgery, while minimally invasive, is a complicated technique. Therefore, prior to this surgery, it is important to determine the anatomical information of colorectal cancer. MATERIALS AND METHODS: Fifty-eight cases of patients with a confirmed diagnosis of colon cancer [caecal (n = 4), ascending colon (n = 6), transverse colon (n = 7), descending colon (n = 2), sigmoid colon (n = 22), and rectal (n = 17) cancer] were evaluated using multislice CT before laparoscopic surgery. CT examination was performed in an air-filled colorectum by colon fiberscopy. Contrast-enhanced images on multislice CT were obtained at arterial and venous phases. All images were reviewed on a workstation, and three-dimensional (3D) images of vessels, colorectum, cancer, and swollen lymph nodes were reconstructed by volume rendering and fused (integrated 3D imaging). We evaluated the usefulness of integrated 3D imaging with multislice CT for laparoscopic colorectal surgery. RESULTS: Integrated 3D imaging demonstrated clearly the distribution of arteries feeding the colorectal cancer and the anatomical location of colorectal cancer and arterial and venous systems. Moreover, measurement of the distance between the aortic bifurcation and the origin of the inferior mesenteric artery and that between the base of the inferior mesenteric artery and the origin of the left colic artery on integrated 3D imaging contributed to safe, prompt ligation of the vessels and excision of lymph nodes. CONCLUSION: Integrated 3D imaging with multislice CT was useful for simulation of laparoscopic colorectal surgery.

Clinical study to identify specific characteristics of cancer newly developed in the remnant stomach.

BACKGROUND: Cancer newly developed in the remnant stomach (CRS) after partial gastrectomy is worthy of attention not only because it is a typical model of carcinogenesis but also from the aspect of cancer diagnosis. METHODS: We treated 47 patients with CRS in the 20 years from 1979 to 1998. Clinicopathological variables, as well as long-term survival results after the second surgery, were reviewed to clarify whether there were any differences in the characteristics of this disease entity compared with the usual primary gastric cancer. RESULTS: The mean time interval between the initial surgery and surgery for CRS was 25.8 years for patients with CRS with previous benign gastric lesions, and 10.6 years for those with previous gastric cancer. CRS was frequently detected at an early stage in the patients with previous cancer, and in the patients who had undergone reconstruction by the Billroth I method (regardless of the primary nature of the disease). Cancers with a differentiated histology developed more frequently in the patients who had undergone the initial surgery for cancer disease. Long-term survival results after the second surgery clearly demonstrated that surgical treatment for CRS was as effective as that for primary cancer in the upper stomach (PUC). In addition, it was confirmed that new lymphatic drainage into the lower mediastinum or the jejunal mesentery had developed after the initial gastric surgery. CONCLUSION: The findings suggested that patients with CRS and those with PUC should be treated similarly, although the findings of a high incidence of lymph node metastasis to the lower mediastinum and/or to the jejunal mesentery in the CRS patients should be taken into consideration.

Expression of transforming growth factor beta (TGF-beta) may contribute, in part, to the variations in histogenesis and the prevalence of peritoneal dissemination in human gastric carcinoma.

BACKGROUND: Alterations in the activity of transforming growth factor beta (TGF-beta) in humans have been implicated in fibrosis, immunosuppression, development of cancer, and other disorders. Scirrhous gastric carcinoma is characterized by cancer cells that infiltrate rapidly in the stroma with extensive growth of fibroblasts and fibrous tissue. Hence, the majority of studies examining the role of TGF-beta in gastric carcinoma have focused on scirrhous carcinoma.METHODS: We undertook a retrospective immunohistochemical study of gastric carcinoma in order to characterize TGF-beta expression in malignant gastric lesions and to determine whether TGF-beta expression was related to disease progression.RESULTS: TGF-beta expression in scirrhous gastric carcinomas was significantly higher than that in nonscirrhous gastric carcinomas. In patients with advanced gastric carcinoma with surgically curative resection, TGF-beta expression was significantly higher in those patients who developed peritoneal recurrence after surgery than in those who did not develop such recurrence. Patients with TGF-beta expression-positive tumors had significantly poorer survival than did those with TGF-beta expression-negative tumors ( P = 0.017). In addition, multivariate Cox proportional hazard model analysis showed that TGF-beta immunohistochemical status was an independent prognostic factor ( P = 0.0031).CONCLUSION: These data suggest that TGF-beta may contribute, in part, to the variations in histogenesis and to the prevalence of peritoneal dissemination in gastric carcinoma.