Characteristics of Metachronous Remnant Gastric Cancer After Proximal Gastrectomy: A Retrospective Analysis.

PURPOSE: Despite annual endoscopy, patients with metachronous remnant gastric cancer (MRGC) following proximal gastrectomy (PG) are at times ineligible for endoscopic resection (ER). This study aimed to clarify the clinical risk factors for ER inapplicability. MATERIALS AND METHODS: We reviewed the records of 203 patients who underwent PG for cT1 gastric cancer between 2006 and 2015. The remnant stomach was categorized as a pseudofornix, corpus, or antrum. RESULTS: Thirty-two MRGCs were identified in the 29 patients. Twenty MRGCs were classified as ER (ER group, 62.5%), whereas 12 were not (non-ER group, 37.5%). MRGCs were located in the pseudo-fornix in 1, corpus in 5, and antrum in 14 in the ER group, and in the pseudo-fornix in 6, corpus in 4, and antrum in 2 in the non-ER group (P=0.019). Multivariate analysis revealed that the pseudo-fornix was an independent risk factor for non-ER (P=0.014). In the non-ER group, MRGCs at the pseudo-fornix (n=6) had more frequent undifferentiated-type histology (4/6 vs. 0/6), deeper (≥pT1b2; 6/6 vs. 2/6) and nodal metastasis (3/6 vs. 0/6) than non-pseudo-fornix lesions (n=6). We examined the visibility of the region developing MRGC on an annual follow-up endoscopy one year before MRGC detection. In seven lesions at the pseudofornix, visibility was only secured in two (28.6%) because of food residues. Of the 25 lesions in the non-pseudo-fornix, visibility was secured in 21 lesions (84%; P=0.010). CONCLUSIONS: Endoscopic visibility increases the chances of ER applicability. Special preparation is required to ensure the complete clearance of food residues in the pseudo-fornix.

Key nodal stations for predicting splenic hilar nodal metastasis in upper advanced gastric cancer without invasion of the greater curvature.

Background: Standard surgery for upper advanced gastric cancer without invasion of the greater curvature (UGC-GC) is spleen-preserving D2 total gastrectomy without dissection of the splenic-hilar nodes (#10). However, some patients with nodal metastasis to #10 survive more than 5 years due to nodal dissection of #10. If nodal metastasis to #10 is predictable based on the positivity of other nodes dissected by the current standard surgery without #10 nodal dissection, physicians may be able to consider #10 dissection. Methods: This study retrospectively reviewed data from the National Cancer Center Hospital in Japan between 2000 and 2012. We selected cases that met the following criteria: (1) D2 or more total gastrectomy with splenectomy, (2) UGC-GC, and (3) histological type is gastric adenocarcinoma. We performed univariate and multivariate analyses concerning lymph node stations associated with #10 metastasis. Results: A total of 366 patients were examined. A multivariate analysis revealed that #10 metastasis was associated with positivity of the nodes along the short gastric arteries (#4sa) and distal nodes along the splenic artery (#11d) (#4sa: p = 0.003, #11d: p = 0.016). When either key node was positive, the metastatic rate of #10 was 24.4%, and the therapeutic value index was 13.3. Conclusions: #4sa and #11d were key lymph nodes predicting #10 nodal metastasis in UGC-GC. When these key nodes are positive on computed tomography before surgery or according to a rapid pathological examination during surgery, dissection of #10 should be considered even if upper advanced tumors are not invading the greater curvature.

Impact of D2 Total Gastrectomy Including Splenectomy for Scirrhous Gastric Cancer in the Era of Effective Adjuvant Chemotherapy.

BACKGROUND: Total gastrectomy with D2 dissection including splenectomy (TGS) is usually selected for locally resectable scirrhous gastric cancer (SGC), which was established in the era of surgery alone. However, it remains unclear whether TGS for SGC is justified in the era of effective adjuvant chemotherapy. METHODS: This study included 112 SGC patients, consisting of 60 cases treated between January 2000 and December 2006 (Former group), and 52 cases treated between January 2007 and December 2016 (Latter group). We collected clinicopathological data and then examined the survival and the therapeutic value indexes. RESULTS: The background characteristics were well-balanced, except for sex and physical status. The Latter group might be characterized by frequent female (P = 0.037) and poorer physical status (P = 0.048). Adjuvant chemotherapy was administered to 86.5% of the Latter group and was 11.7% of the Former group (P < 0.001). The 5-year-overall survival rate of the Latter group was 58.7% (95% confidence interval: 43.5-71.1), seems better than that of the Former group (44.5%; 95% confidence interval 31.7-56.6) (hazard ratio = 0.758, P = 0.291). Improvement of the index from the Former group was observed in the Latter group at almost all stations. The ratio of the index between two groups was 1.42 at the D1 station and 1.67 at the D2 station. Index of splenic hilar node ranked similarly high in both groups. CONCLUSION: The therapeutic value index was improved in almost all nodal stations by S-1 adjuvant chemotherapy, especially in D2 nodes. TGS would be more important for locally resectable SGC in the era of effective adjuvant chemotherapy.

Acceleration of sarcopenia in elderly patients who develop asymptomatic pneumonia shadow within one year after surgery for early gastric cancer.

BACKGROUND: Although early gastric cancer is curable with local treatment, the overall survival in elderly patients did not reach 80% at five years after surgery. The major cause of death in elderly patients with early gastric cancer is not cancer itself but is related to postoperative sarcopenia. Elderly patients frequently develop postoperative asymptomatic pneumonia shadow, which is associated with a poor prognosis. However, why asymptomatic pneumonia shadow worsens the prognosis remains unclear. We investigated whether sarcopenia is accelerated in patients who developed asymptomatic pneumonia shadow. METHODS: We retrospectively examined patients of > 75 years of age who underwent R0 gastrectomy for gastric cancer and were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. The diagnosis of asymptomatic pneumonia shadow was defined by diagnostic findings of pneumonia (consolidation type, reticular type, and nodular type) which were newly observed on chest computed tomography performed one year after surgery in comparison to preoperative computed tomography. Postoperative muscle loss was assessed by a computed tomography-based analysis using the L3 skeletal muscle index before and two years after surgery and the rate of decrease was calculated. Patients were classified into two groups according to the rate of decrease (cut-off value: 10%). RESULTS: Of the 3412 patients who underwent gastrectomy in our hospital during the study period, 142 were included in this study. Asymptomatic pneumonia shadow was found in 26 patients (18%). Patients who developed asymptomatic pneumonia shadow showed a significantly greater loss of muscle volume in comparison to patients who did not develop asymptomatic pneumonia shadow. In the multivariate analysis, total gastrectomy and asymptomatic pneumonia shadow were the independent risk factors for severe muscle loss. However, there was no significant difference in prognosis between the two groups. CONCLUSIONS: Sarcopenia was accelerated in elderly patients who developed asymptomatic pneumonia shadow after surgery for early gastric cancer. However, the poor prognosis in these patients may not be related to accelerated sarcopenia.

Possible candidates for splenic hilar nodal dissection among patients with upper advanced gastric cancer without invasion of the greater curvature.

BACKGROUND: Spleen preserving D2 total gastrectomy without dissection of the splenic hilar nodes (#10) is a standard operation for upper advanced gastric cancer without invasion of the greater curvature (UGC-wGC). However, some patients with #10 metastasis have survived after splenectomy with dissection of #10. This study explored possible candidates for dissection of #10 among patients with UGC-wGC by examining the metastatic rate and the therapeutic index. METHODS: This study retrospectively reviewed data of patients treated in National Cancer Center Hospital (Japan) between 2000 and 2012. We applied the following inclusion criteria: (1) ≥ D2 total gastrectomy with splenectomy, (2) UGC-wGC, and (3) gastric adenocarcinoma histology. Univariate and multivariate analyses were performed to identify risk factors for #10 metastasis. RESULTS: A total of 366 patients were examined; #10 metastasis was observed in 4.4% (16/366). The multivariate analysis revealed that location (posterior vs. others, P = 0.025) and histology (undifferentiated vs. differentiated, P = 0.048) were significant factors for #10 metastasis among sex, age, tumor size, dominant circumferential location, macroscopic type, depth of invasion, and histology. The incidence of #10 metastasis was 14.9% (7/47) for tumors located on the posterior wall with undifferentiated type histology. The 5-year overall survival rate of these patients was 42.9%, and the therapeutic index was 6.38, which was the second highest value among the second-tier nodal stations. CONCLUSION: Even for upper advanced gastric cancer without invasion of the greater curvature, dissection of #10 could be justified for tumors located on the posterior wall with undifferentiated type histology.

[Gentle Method to Elevate Left Liver Lobe in Robot Assisted Gastrectomy].

Robot-assisted gastrectomy with the Davinci XiTM has been performed in our department since August 2019. This technique requires elevation of the left liver lobe. In order to prevent perioperative liver injury and expansion of postoperative subcutaneous emphysema, we use a silicone disc(HAKKO MEDICAL Co., Ltd.)and thread to elevate the liver. After docking the Davinci system, we move the needle as follows:(ⅰ). left side peritoneum near the left triangular ligament, (ⅱ). silicone rubber(, ⅲ). center of crus(, ⅳ). silicone rubber(, ⅴ). hepatic cirrus, and(ⅵ). right side peritoneum. Both ends of the thread are guided out of the abdominal cavity from both hepatic circumflex by end-close, forming a V-shape with the center of crus at the bottom, which provides a stable and effective view of the liver. Fifty-three cases were performed after introduction of this elevation technique. Median AST and ALT on postoperative day 1 were 37(14-1,556)IU/L and 30(10- 1,676)IU/L, respectively, although small subcutaneous emphysema confined to the anterior chest and upper abdominal wall was observed in 2 patients(3.8%). No cases of extensive subcutaneous emphysema involving the neck or extremities were observed. This elevation technique protects the liver and may reduce the incidence of postoperative subcutaneous emphysema.

Prognostic Impact of Long-term Postoperative Pneumonia in Elderly Patients with Early Gastric Cancer.

Background: Elderly patients with stage I gastric cancer, a disease that is curable by surgery, easily develop long-term postoperative pneumonia (LTPP) within two years after surgery despite showing no active symptoms. The present study assessed whether or not LTPP determines the later prognosis among elderly patients. Methods: We retrospectively examined patients >75 years old who underwent R0 gastrectomy for gastric cancer and were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. LTPP was evaluated by chest computed tomography every year until two years after surgery. Results: Of the 3412 patients who underwent gastrectomy in our hospital during this period, 159 were included in this study. The elderly patients who developed LTPP had a worse prognosis than those who did not. Furthermore, their comorbidities and LTPP were significant independent risk factors for a poor prognosis. Patients who developed LTPP had a significantly higher risk of dying due to respiratory disease or cardiovascular disease than those without pneumonia. Conclusions: LTPP was significantly related to a poor survival and death from respiratory disease. To improve the prognosis, not only nutritional support but also exercise and rehabilitation program may be required for patients who develop LTPP within two years after surgery.

Long-term postoperative pneumonia in elderly patients with early gastric cancer.

BACKGROUND: Pneumonia is a major cause of death in the elderly population. Considering body weight loss, muscle loss, and reflux after gastrectomy, elderly patients are considered to be at very high risk for pneumonia, which could decrease overall survival because early gastric cancer is mostly curable only by surgery. We aimed to clarify the incidence of pneumonia in the long-term period after gastrectomy in elderly patients who were diagnosed with early gastric cancer and its risk factors. METHODS: We retrospectively examined patients of > 75 years of age who underwent R0 gastrectomy for gastric cancer and who were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. Long-term postoperative pneumonia was diagnosed by chest computed tomography every year until 2 years after surgery. The presence of preoperative sarcopenia was assessed using preoperative L3 skeletal muscle index. RESULTS: 167 patients were included in this study. Long-term postoperative pneumonia was observed in 44 (26%) patients. Of the 44 people diagnosed with long-term postoperative pneumonia, 33 were diagnosed in the 1st year and 11 in the 2nd year. 117 patients (70%) were diagnosed with sarcopenia which was significantly frequently found in the patients who developed long-term postoperative pneumonia (91%) than those without (63%). Preoperative sarcopenia was the only independent risk factor in multivariate analysis. Type of gastrectomy was not a significant risk factor. CONCLUSIONS: Long-term postoperative pneumonia was frequently observed in the elderly patients. Preoperative sarcopenia was associated with long-term postoperative pneumonia in elderly patients who underwent curative surgery for gastric cancer. After gastrectomy, long-term special care would be required for elderly patients, especially with sarcopenia.

Optimal surgery and lymph node metastasis of duodenal bulbar neuroendocrine neoplasms.

BACKGROUND: There is no consensus on the extent of nodal dissection for duodenal bulbar NENs (neuroendocrine neoplasms). MATERIALS AND METHODS: We constructed and analyzed a combined dataset consisting of the patients who received surgery in our hospital and the patients from the literature based on a systematic review. The incidence, risk factors and location of nodal metastases were examined. RESULTS: Fifty-nine cases including 11 cases managed at our hospital and 48 cases identified from the literature search were examined. Nodal metastasis was observed in 24 patients (40.7%). The 5-year overall survival rate was 100%, regardless of nodal metastasis. Risk factors for lymph node metastasis were tumor size ≥15 mm and muscularis propria or deeper invasion. Stomach-related lymph node metastasis was found in >20% of patients who were positive for at least one risk factor and 15.4% when patients were negative for both risk factors, while pancreas-related lymph node metastasis was observed in 45.5% of patients who were positive for both risk factors, 7.7% who were only positive for one risk factor, and 0% who were negative for both risk factors. CONCLUSIONS: Tumor size and depth of invasion would determine whether the optimal surgery for duodenal bulbar NENs is distal gastrectomy or pancreatico-duodenectomy.

Primary malignant melanoma of the esophagus successfully treated with nivolumab: a case report.

INTRODUCTION: Primary malignant melanoma of the esophagus is a rare and aggressive disease that tends to have a poor response to chemotherapies. Previous studies have indicated that currently available treatment for primary malignant melanoma of the esophagus is insufficient. Here, we describe a case of recurrent primary malignant melanoma of the esophagus successfully treated with the immune checkpoint inhibitor nivolumab. CASE PRESENTATION: An 81-year-old Japanese female presented with a 3-month history of dysphagia. She was medicated for hypertension and sarcoidosis. The patient had no past history of cutaneous, ocular, or other-site melanomas. An esophagoscopy identified a 30-mm giant tumor in the lower esophagus, at a site 30 cm from the incisors. Enhanced computed tomography revealed wall thickening measuring 30 mm in size at the middle-third of the intrathoracic esophagus, with no significant lymph node infiltration or distant metastasis. Esophageal biopsy showed proliferation of large round tumor cells and melanophages. On the basis of these findings, the patient was diagnosed with esophageal malignant melanoma and underwent esophagectomy and lymph node dissection with gastric tube reconstruction. Although the pathological diagnosis was primary malignant melanoma of the esophagus, the patient presented with multiple lymph node and bone metastases 4 months after surgery. Subsequently, treatment with nivolumab 240 mg every 2 weeks was administered as the first-line treatment. Diffusion-weighted imaging with background body signal suppression following eight courses of nivolumab revealed that the multiple lymph node and bone metastases were markedly reduced. The patient received 30 courses of nivolumab and has maintained the partial response. No severe adverse events related to the immunotherapy were recorded. CONCLUSION: The current study suggests that nivolumab may be a viable option for patients with metastatic primary malignant melanoma of the esophagus. Additional evidence from future clinical trials and research is necessary to fully validate these findings.

Successful one-stage laparoscopic procedure for de Garengeot hernia: a totally extraperitoneal repair-first approach.

The de Garengeot hernia is a femoral hernia in which the appendix migrates into the hernia sac. It is usually diagnosed intraoperatively due to its rarity and lack of clinical presentation typical to acute appendicitis. Although most cases need emergency operation due to incarceration, no standard procedure exists. We report the case of a 49-year-old woman who was diagnosed with a de Garangeot hernia preoperatively by contrast-enhanced computed tomography. She underwent one-stage laparoscopic surgery via a totally extraperitoneal approach followed by laparoscopic appendectomy. She recovered uneventfully and was discharged on postoperative Day 3. Generally, hernioplasty and appendectomy are required for the de Garengeot hernia treatment. Avoiding a peritoneal incision around the herniation and performing a mesh repair prior to appendectomy is expected to carry a lower infectious risk than other laparoscopic procedures. With accurate diagnosis, this procedure could be a useful modality for de Garengeot hernia.

Laparoscopic transabdominal preperitoneal hernioplasty for recurrent obturator hernia: A case report.

Reports of recurrence after obturator hernia repair are few. We describe the case of an 89-year-old woman who presented to us with a thrice recurrent obturator hernia. She had undergone open non-mesh repair twice and then laparoscopic non-mesh repair. She was readmitted to our hospital 6 months after the laparoscopic repair. Manual reduction was successful, paving the way for elective transabdominal preperitoneal repair. During the endoscopic repair, surgical mesh was placed extraperitoneally over the hernia defect and then fixed to Cooper's ligament with absorbable tacks. The patient was discharged on postoperative day 2 without complications. In the 2 months that have passed since the surgery there has been no sign of recurrence, but the patient will be carefully followed up. Repair of a recurrent obturator hernia is technically challenging; however, the transabdominal preperitoneal approach seems to be reliable and safe.

Self-expanding metal stent restenosis in obstructive colon diverticulitis mimicking colon cancer: A case report.

INTRODUCTION: The self-expanding metal stent (SEMS) has been used in malignant colorectal obstruction as a bridge to surgery or for palliative treatment. We report a case of obstructive descending colon diverticulitis in-stent restenosis, which is difficult to distinguish from colon cancer. PRESENTATION OF CASE: A 48-year-old man presented with abdominal pain. Computed tomography demonstrated a segment of thickened wall in the descending colon with near-complete obstruction. Colonoscopy revealed stenosis over the entire circumference of the descending colon. Biopsy revealed no malignant findings. SEMS was inserted to improve bowel obstruction. However, bowel obstruction did not improve, and stent-in-stent insertion was performed. Because colon cancer could not be completely excluded, left hemicolectomy with lymph node dissection was performed. The pathological examination revealed colon diverticulitis and no malignant finding. DISCUSSION: Benign colorectal diseases can present with symptoms similar to those of obstructive colorectal cancer. As a result, it was benign colorectal stenosis, but it was thought that resection should be considered when the malignant lesion is suspected. The use of SEMS in benign colorectal disease has been reported a few. Reinsertion of the stent for restenosis, in bridge to surgery, was also considered useful from the viewpoint of avoiding emergent operation and reducing complications. CONCLUSION: For colon stenosis suspected of malignant disease, it was thought that resection by inserting SEMS should be taken into consideration even for benign disease as a result.