Morphology of the murine peritoneum after pneumoperitoneum vs laparotomy.

BACKGROUND: Although there have been studies of the effects of pneumoperitoneum on the peritoneal cavity, we still do not know whether the morphologic changes to the peritoneum are different for pneumoperitoneum vs laparotomy. Using scanning electron microscopy, we examined the murine peritoneum after pneumoperitoneum vs laparotomy and compared the changes. METHODS: Forty-five mice were anesthetized with diethyl ether and divided into seven groups. Pneumoperitoneum was established at 5 mmHg for 30 min with carbon dioxide (CO(2)) (n = 9), helium (n = 9), and air (n = 9). One group underwent laparotomy for 30 min (n = 9), and a control group underwent anesthesia only (n = 3). CO(2) pneumoperitoneum was further established at 10 mmHg for 30 min (n = 3) and at 5 mmHg for 60 min (n = 3). After the procedures, the peritoneum was resected from the mesenterium of the small intestine in each animal and examined by scanning electron microscope for morphologic changes of the mesothelial cells. RESULTS: Bulging up of the mesothelial cells was evident immediately after pneumoperitoneum, whereas detachment of the mesothelial cells was present immediately after laparotomy. Bulging up of the mesothelial cells was reduced at 24 h after CO(2) pneumoperitoneum and fully resolved at 72 h in all pneumoperitoneum groups, whereas the mesothelial cells remained detached at 72 h in the laparotomy group. Intercellular clefts were found immediately after helium pneumoperitoneum and were present at 24 h and 72 h after helium pneumoperitoneum, but they were not seen after air pneumoperitoneum and were only evident after CO(2) pneumoperitoneum at 10 mmHg. Depression of the mesothelial cell surface was observed when pneumoperitoneum lasted 60 min. CONCLUSION: Morphologic peritoneal alterations after pneumoperitoneum differed from those after laparotomy and were influenced by the type of gas, amount of pressure, and duration of insufflation. These peritoneal changes after pneumoperitoneum may be associated with a specific intraperitoneal tumor spread after laparoscopic cancer surgery.

Increased expression of P-cadherin mRNA in the mouse peritoneum after carbon dioxide insufflation.

BACKGROUND: Although systemic responses to carbon dioxide (CO(2)) pneumoperitoneum have been studied, there have been few reports of local responses within the peritoneum. We investigated the expression of mRNA for adhesion molecules involved in cell-cell interactions, including ICAM-1, VCAM-1, CD44, E-cadherin, P-cadherin, and N-cadherin, after the induction of a CO(2) pneumoperitoneum in mice. METHODS: Mice were treated with CO(2) pneumoperitoneum (4-6 mmHg for 30 min) and then killed after 24 h, 48 h, and 72 h. The peritoneum of the abdominal wall was resected, and total RNA was extracted by the acid guanidinium thiocyanate-phenol-chloroform extraction procedure, cDNA were synthesized by reverse transcription. Expression of the mRNA for each gene was normalized to that of b-actin for semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: The expression of P-cadherin mRNA was significantly increased at 48 h (p = 0.007) and returned to the control level by 72 h after CO(2) pneumoperitoneum. The expression of CD44 increased gradually, reaching a peak at 48 h and returning to the control value by 72 h after CO(2) pneumoperitoneum. Expression of ICAM-1 mRNA was not changed significantly after the application of CO(2). CONCLUSION: The expression of P-cadherin mRNA in the peritoneum can be induced to repair injuries to mesothelial cells caused by CO(2) pneumoperitoneum.

Hyaluronic acid secretion during carbon dioxide pneumoperitoneum and its association with port-site metastasis in a murine model.

BACKGROUND: The mechanism of port-site metastasis after laparoscopic cancer surgery is unclear. This study aimed to determine whether carbon dioxide (CO2) pneumoperitoneum caused an increase in hyaluronic acid, which is secreted from mesothelial cells of the peritoneal cavity, and to assess the risk for port-site metastasis using a murine pneumoperitoneal model. METHODS: Sandwich-binding protein assay was used to measure the concentration of hyaluronic acid in the peritoneal cavity at 6, 12, 18, 24, 48, and 72 h after CO2 pneumoperitoneum or laparotomy for 30 min. The concentrations of hyaluronic acid during pneumoperitoneum were compared among different gases (CO2, helium, air), intervals (5, 30, 60 min), and pressures (0-2, 4-6, 8-10 mmHg). To investigate the effects of exogenous hyaluronic acid, the development of port-site metastasis was examined using mouse adenocarcinoma cell-line colon 26 cells. RESULTS: The intraperitoneal concentration of hyaluronic acid after CO2 pneumoperitoneum had increased already at 6 h, had reached the maximum level at 24 h, and had begun to decrease at 72 h. The concentration of hyaluronic acid at 24 h and 48 h in the CO2 pneumoperitoneum group was higher than that in the laparotomy group. This increase in hyaluronic acid also was found during helium and air pneumoperitoneum, and the concentration of hyaluronic acid in the peritoneal cavity was at its maximum when CO2 pneumoperitoneum lasted 30 min at 4 to 6 mmHg. The frequency of port-site metastasis was the highest when hyaluronic acid was injected during CO2 pneumoperitoneum (100%). CONCLUSIONS: In a murine model, the intraperitoneal concentration of hyaluronic acid was significantly increased after CO2 pneumoperitoneum, and the increase was more evident than that after laparotomy. Increased hyaluronic acid during pneumoperitoneum may be associated with port-site metastasis after laparoscopic cancer surgery.

Effect of laparotomy and laparoscopy on the establishment of lung metastasis in a murine model.

BACKGROUND: Laparoscopic surgery is now applied to patients with gastrointestinal cancer. In animal studies, extraperitoneal tumor growth has been significantly less after laparoscopy than after laparotomy, but whether hematogenous metastasis occurs less frequently after laparoscopy is unknown. The aim of this study was to compare the frequency and growth of lung metastasis and serum levels of IL-6 and tumor necrosis factor-alpha (TNF-alpha) in mice treated by laparotomy and in mice treated by laparoscopy. METHODS: We used 182 male BALB/c mice. Colon 26 cancer cells (5 x 10(4)) were injected into the tail vein, and the mice were assigned to a laparotomy group (3-cm laparotomy), a laparoscopy group (carbon dioxide pneumoperitoneum at 6 to 8 mm Hg for 30 minutes), or a control group. Lung weight, number of lung metastases, and serum levels of IL-6 and TNF-alpha were measured and compared among the 3 groups. RESULTS: The lung weight and number of metastases on the lung surface and cut section in the laparotomy group (0.44+/-0.21 g, 55.7+/-46.7, 23.0+/-19.0) were significantly larger than those in the laparoscopy group (0.32+/-0.15 g, 29.9+/- 25.5, 13.1+/-9.9) or the control group (0.28+/-0.13, 29.3+/-26.2, 11.1+/-11.1). Three hours after the procedures, the serum level of IL-6 was significantly higher in the laparotomy group (1353 +/- 790 pg/mL) than in the laparoscopy group (671+/-353 pg/mL) or the control group (333+/-341 pg/mL). The lung weight, number of lung metastases, and levels of IL-6 and TNF-alpha were not different between the laparoscopy and control groups. CONCLUSIONS: Our results indicate that, although laparotomy accelerates tumor metastasis to the lung in this murine model, laparoscopy does not increase the frequency and growth of lung metastasis. The laparoscopic approach may suppress hematogenous metastasis to the lung because of decreased surgical stress and reduced cytokine response.

Most important lymph node information in gastric cancer: multivariate prognostic study.

BACKGROUND: In gastric cancer, the level and number of lymph node metastases is useful for predicting survival, and there are several staging systems for lymph node metastasis. The aim of this study was to compare the several lymph node classifications and to clarify the most important lymph node information associated with prognosis using multivariate analysis. METHODS: A total of 106 patients with histologically node-positive gastric cancer treated by radical gastrectomy and extended lymph node dissection (D2, D3) were studied. The level of lymph node metastasis was categorized simply as Level I nodes (perigastric, No.1-6), Level II nodes (intermediate, No.7-9), and Level III nodes (distant, No.10-16), irrespective of the tumor location. The Level II nodes included lymph nodes along the left gastric artery, common hepatic artery, and celiac trunk. RESULTS: Overall 5-year survival rate was 51%. Univariate analysis showed that 5-year survival rate was significantly influenced by the level of positive nodes (P < .01), total number of positive nodes (P < .01), number of positive Level I nodes (P < .01), and number of positive Level II nodes (P < .01), in addition to the tumor location (P < .05), tumor size (P < .05), gross type (P < .01), and depth of wall invasion (P < .01). Of these, independent prognostic factors associated with 5-year survival rate were the number of positive Level II nodes (0-1 vs. > or =2) (62% vs. 19%, P < .01) and the depth of wall invasion (within vs. beyond muscularis) (79% vs. 43%, P < .01). CONCLUSIONS: Among several staging systems for lymph node metastases, the number of positive Level II nodes provided the most powerful prognostic information in patients with node-positive gastric cancer. When there were two or more metastases in the Level II nodes, prognosis was poor even after D2 or D3 gastrectomy.

Cloning, overexpression and mutagenesis of cDNA encoding dihydrolipoamide succinyltransferase component of the porcine 2-oxoglutarate dehydrogenase complex.

Dihydrolipoamide succinyltransferase (E2o) is the structural and catalytic core of the 2-oxoglutarate dehydrogenase (OGDH) complex. The cDNA encoding porcine E2o (PE2o) has been cloned. The PE2o cDNA spans 2547 bases encoding a presequence (68 amino-acid residues) and a mature protein (387 residues, Mr = 41 534). Recombinant porcine E2o (rPE2o) (residues 1-387), C- and N-terminal truncated PE2os, and site-directed mutant PE2os were overexpressed in Escherichia coli via the expression vector pET-11d and purified. The succinyltransferase activity of the rPE2o was about 2.2-fold higher than that of the native PE2o. Electron micrographs of the rPE2o negatively stained showed a cube-like structure very similar to that of the native PE2o. Deletion of five amino-acid residues from the C-terminus resulted in a complete loss of both enzymatic activity and formation of the cube-like structure, but the deletion of only the last two residues had no effect on either function, suggesting the important roles of the C-terminal leucine triplet (Leu383-384-385). Substitution of Ser306 with Ala, and Asp362 with Asn, Glu or Ala in the putative active site, and Leu383-384-385 with Ala or Asp abolished both functions. Substitution of His358 with Cys resulted in an 8.5-fold reduction in kcat, with little change in Km values for dihydrolipoamide and succinyl-CoA. However, self-assembly was not affected. These data indicate that Ser306, Asp362 and the Leu383-384-385 triplet are important residues in both the self-assembly and catalytic mechanism of PE2o.

Rate of detection of lymph node metastasis is correlated with the depth of submucosal invasion in early stage gastric carcinoma.

BACKGROUND: Gastric carcinoma invading the submucosa is often accompanied by lymph node metastasis. However, the relation between the depth of submucosal invasion and the status of metastasis has not been investigated. The objective of this study was to clarify the relation between lymph node status and the histologic features of gastric carcinoma invading the submucosa. METHODS: The histopathology of 118 patients who underwent gastrectomy and lymph node dissection for gastric carcinoma invading the submucosa was examined. These pT1 tumors with invasion of the submucosa were confirmed by histologic examination of the resected specimens. Tumor size, depth of submucosal invasion, histologic type, and macroscopic type were investigated in association with presence or absence of and anatomic level of lymph node metastasis. RESULTS: Among the 118 patients, 16 (14%) had lymph node metastasis, and the status of metastasis significantly correlated with tumor size and depth of submucosal invasion. The frequency of metastasis to perigastric lymph nodes and extragastric lymph nodes was 0% and 0% for < or =1-cm tumors, 5% and 1% for 1- to 4-cm tumors, and 46% and 15% for >4-cm tumors, respectively. There was no lymph from a node metastasis in tumors with less than 300 microm of submucosal invasion. The frequency of lymph node metastasis for tumors with 300-1000 microm and >1000 microm of submucosal invasion were 19% and 14%, respectively. CONCLUSIONS: Tumor size and depth of submucosal invasion serve as simple and useful indicators of lymph node metastasis in early stage gastric carcinoma. Optimal lymph node dissection levels are as follows: 1) local resection (D0) for lesions < or =1 cm, 2) limited lymph node dissection (D1) for 1- to 4-cm lesions, and 3) radical lymph node dissection (D2) for lesions >4 cm. When submucosal invasion of a locally resected tumor is more than 300 microm, additional gastrectomy and lymph node dissection are necessary.

Laparoscopic-assisted proximal gastrectomy for early gastric carcinomas.

Laparoscopic-assisted proximal gastrectomy was performed in two Japanese patients with early gastric carcinomas located in the gastric cardia. The lower esophagus and upper stomach was divided under the pneumoperitoneum and resected via a minilaparotomy through an incision, 5 cm long, made in the epigastric area. The distal esophagus was anastomosed to a gastric tube made by resecting the lesser curvature of the stomach with a linear auto-stapler. Both patients recovered quickly without any postoperative complications, such as esophagitis, developing during follow-up periods of 3 and 6 months, respectively. Thus, we conclude that laparoscopic-assisted proximal gastrectomy and reconstruction with a gastric tube may be an effective method of treatment for patients with early gastric carcinomas located in the upper stomach in this era of minimally invasive surgery.

Clinicopathologic study of gastric cancer based on Dukes' classification.

Dukes' classification is a useful staging system in patients with colorectal cancer. The aim of this study was to present clinicopathologic characteristics and survival of patients with gastric cancer based on Dukes' classification. A total of 273 patients with gastric cancer curatively treated by radical gastrectomy and lymph node dissection (D2, D3) were studied. With the modified Dukes' classification, A includes tumors limited to the mucosa, submucosa, or muscularis propria; B includes tumors extending into the subserosa or serosa; Ca includes tumors with one to six positive lymph nodes; and Cb includes tumors with seven or more positive lymph nodes. Dukes' classification modified by the number of positive lymph nodes well correlated with the tumor size (p < 0.01), depth of wall invasion (p < 0.01), level of lymph node metastasis (p < 0.01), and degree of lymphatic permeation (p < 0.01) and venous permeation (p< 0.01). The 5-year survival rate was significantly different among Dukes' A (98%), Dukes' B (90%), Dukes' Ca (75%), and Dukes' Cb (44%) cases. The results indicate that Dukes' classification modified by the number of positive lymph nodes (Dukes' A, B, Ca, an Cb) significantly correlates with tumor progression and patient survival; and it may be a simple and useful staging system for gastric cancer.

Quality of life after laparoscopy-assisted Billroth I gastrectomy.

OBJECTIVE: To evaluate the quality of life of patients who had undergone laparoscopy-assisted Billroth I gastrectomy (LAG) for cure of cancer. SUMMARY BACKGROUND DATA: In 1994, the authors reported the first case of LAG for early gastric cancer, and this approach quickly has been adopted by Japanese surgeons. However, little is known about the subjective clinical results of this less invasive surgery. METHODS: Quality of life was estimated using the 24-item questionnaire with a scoring system of 1, 2, and 3 and was compared between 41 consecutive patients with LAG and 35 with conventional open gastrectomy. All patients underwent Billroth I gastrectomy for early gastric cancer from January 1993 to July 1997 and were alive without recurrence. RESULTS: Patients who had undergone LAG were taking a normal diet (100%) with >66% of volume at each meal (90%), showed no decreased performance status (90%), and were satisfied with their surgical results (88%). Patients with LAG, when compared with open gastrectomy, showed significantly better results with regard to weight loss, difficulty in swallowing, heartburn and belch, early dumping syndrome, and total score. LAG was better accepted by the patients. CONCLUSIONS: Quality of life after Billroth I gastrectomy was significantly better in patients in whom a laparoscopic technique was used than in those who underwent a conventional method. LAG is less invasive and better accepted by patients and is the procedure of choice for the treatment of early gastric cancer.

Convenient murine pneumoperitoneal model for the study of laparoscopic cancer surgery.

To investigate the effects of laparoscopic surgery on the progression of cancers, it is necessary to establish a reliable and economical animal model. We describe a convenient murine pneumoperitoneal model for the study of laparoscopic cancer surgery. Under anesthesia using diethyl ether, peritoneal cavity was insufflated with gas through an intravenous catheter placed in the left lower quadrant. Syringe pump was used for continuous gas insufflation, and intraperitoneal pressure was measured. Intraperitoneal pressure increased and reached 10 cm H2O when 15 mL of CO2 gas was injected, but fell to 1 cm H2O 5 min after stopping the injection. When the continuous flow was adjusted by syringe pump between 20 and 160 mL/hour, intraperitoneal pressure was easily maintained at 8 cm H2O for >60 min. We believe that this murine model for pneumoperitoneum may be useful for the study of laparoscopic cancer surgery.

Perigastric lymph node status as a prognostic indicator in patients with gastric cancer.

BACKGROUND: The extent of lymph node dissection and histological examination of dissected lymph nodes varies among countries, which leads to the erroneous nodal stage and different surgical results in gastric cancer (stage migration, 'Will Rogers effect'). The aim of this study was to clarify the prognostic significance of the number of positive perigastric lymph nodes, which could be evaluated simply after D1 gastrectomy. METHODS: A consecutive series of 106 patients with histologically node-positive gastric cancer treated by radical gastrectomy and lymph node dissection (D2 or D3) was studied. The number of metastatic perigastric nodes (level I, nos 1-6) was examined, and its influence on the survival of patients was analysed. RESULTS: The overall 5-year survival rate was 50.9 per cent; the 5-year survival rate was significantly decreased when positive perigastric nodes exceeded six (62 per cent for one to six nodes versus 23 per cent for seven or more nodes, P< 0.001). Tumours having one to six positive perigastric nodes compared with those having seven or more positive perigastric nodes were more likely to have a size less than 4 cm (29 per cent versus one of 30, P< 0.001), grossly localized type (45 per cent versus seven of 30, P=0.042), absence of serosal invasion (32 per cent versus none of 30, P=0.002) and metastasis limited to the perigastric lymph nodes (70 per cent versus seven of 30, P < 0.001). CONCLUSION: The results indicate that the number of positive perigastric nodes correlates with tumour progression and patient survival. This parameter is a simple and useful prognostic indicator for node-positive gastric cancer, and is available not only for D2 and D3 gastrectomy but also for D1 gastrectomy.

[Effects of polychlorinated biphenyls on regenerating myelin of peripheral nerve in rats].

The effects of polychlorinated biphenyls (PCB) on regenerating myelin of the peripheral nerves were investigated in rats. The sciatic nerves were crushed at the mid-thigh level on the last of 32 days of oral administration of PCB. The sciatic nerves were biopsied from the crushed regions at 4, 8 and 12 weeks after crushing. The nerves were fixed in 2.5% glutaraldehyde buffered with 0.1 M sodium cacodylate and embedded in epon 812. The ultrathin sections were analysed by JEOL JEM-1210 with EDAXDX-4. The chloride which was composed of PCB was increased in myeline on 4 weeks after crushing. Freeze fracture study of myelines of sciatic nerves on 8 and 12 weeks after crushing showed an increase of intramembranous particle on 12 weeks and an increase of caveolae on 8 weeks. These results suggest that PCB may affect the plasmamembrane of shwann cell and induce the disturbance of myeline.

Abdominal wall lifting with spinal anesthesia vs pneumoperitoneum with general anesthesia for laparoscopic herniorrhaphy.

BACKGROUND: Laparoscopic herniorrhaphy has generally been very successful since any postoperative inguinal pain or tension is considerably less troublesome than after other open methods. The conventional laparoscopic approach in the treatment of inguinal hernia involves the use of pneumoperitoneum and general anesthesia. Nevertheless, some complications can be encountered and the procedure is costly. We, therefore, examined the possibility of using a more practical and cost efficient method. MATERIALS AND METHODS: Based on our findings, we propose the use of a Kirschner lifting wire as a means of separating the abdominal wall during laparoscopic herniorrhaphy. Two Kirschner wires are introduced through the subcutaneous tissue, between the umbilicus and inguinal ligament, and parallel to the inguinal ligament. Furthermore, we recommend the use of spinal anesthesia as a means by which the problems associated with general anesthesia and the potential cardiopulmonary complications of carbon dioxide insufflation, are circumvented. Fifteen cases of inguinal hernia have been treated with this new method and compared to the more conventional procedure of pneumoperitoneum under general anesthesia. RESULTS: Visibility of the operative field when used in the inguinal region was not limited at all, and Kirschner wire is considerably less expensive. The postoperative course for the patients who were operated by the new method was uneventful. CONCLUSIONS: Our results indicate that this new method can be useful for the treatment of inguinal hernia.

Laparoscopic intervention to relieve small bowel obstruction following laparoscopic herniorrhaphy.

In this report, we present two cases of small bowel obstruction after laparoscopic herniorrhaphy (LH). One case involved incarceration of the small intestine into the port site, resulting in obstruction in an 80-year-old man on the third day after LH. The other case involved a 78-year-old man with bilateral inguinal hernia and a recurrent type on one side. In this case, a small bowel obstruction occurred due to intestinal herniation through the repaired peritoneum in the pelvic floor. In both cases, the location of the obstruction was diagnosed by means of a computed tomography scan. Subsequently, the trocar incision was extended to relieve obstruction with laparotomy in the first case, and the herniated intestinal loop was extracted followed by reclosure of the defective peritoneum under laparoscopic intervention in the second case. After the second operation, the clinical course of each patient was uneventful, and they were discharged from hospital at 10 days after the second surgery. In conclusion, (a) although patients can greatly benefit from LH, it must be kept in mind that problems can occur and (b) laparoscopic surgery to relieve small bowel obstruction following LH is the preferred procedure.

Evaluation of the cell kinetics of MNNG-treated rat gastric mucosa based on AgNOR and ODC activity.

To investigate the process of carcinogenesis in gastric cancer, we studied the histological features and cell kinetics in the gastric mucosa of N-methyl-N'-nitro-N-nitrosoguanidine (MNNG)-treated rats. Samples of gastric mucosa from both MNNG-treated and control rats were histologically examined by staining with nucleolar argylophilic nonhistone (AgNOR) proteins, and their ornithine decarboxylase (ODC) activity was determined every 2 months for 10 months. In 40% of the MNNG-treated rats, atrophy of the gastric mucosa was observed after 2 months, followed by adenomatous proliferation. More AgNOR-positive granules were found in the pyloric glands than in the fundic glands, and the total number of positive granules increased over time. Cancerous and hyperplastic lesions preferentially developed in the pyloric glands and showed significantly more AgNOR-positive granules than the normal mucosa. After 6 months the ODC activity in the MNNG-treated rats was significantly higher than that in the control rats. These results thus suggest that the pyloric glands have a high growth activity, while in addition, adenomatous proliferation is a characteristic pathological feature of precancerous lesions in the stomach in MNNG-treated rats.

Distribution of acetylcholinesterase activity in the rat embryonic heart with reference to HNK-1 immunoreactivity in the conduction tissue.

Acetylcholinesterase (AChE) activity was topographically investigated in the presumptive cardiac conduction tissue regions visualized by HNK-1 immunoreactivity in rat embryos, and AChE-positive cells were examined with the electron microscope. On embryonic day (ED) 14.5, when HNK-1 was most intensely visualized, AChE activity could not be detected enzyme-histochemically in the conduction tissue regions, except in the ventricular trabeculae and part of the AV node. On ED 16.5, however, the AChE activity was clearly demonstrated in some parts of the developing conduction tissue. One exception was the AV node region, where an AChE-positive area was in close proximity to an area showing HNK-1 immunoreactivity but did not overlap. Furthermore, AChE activity was demonstrated predominantly in the ventricular trabeculae, including cardiac myocytes, but was rather weak in the atrium. With the electron microscope, AChE reaction products were observed predominantly intracellularly in both developing conduction tissue cells and developing ordinary myocytes, and no reactivity was found in neuronal components. From ED 18.5 until birth, both AChE activity and HNK-1 immunoreactivity faded away in the conduction tissue. Thus, transient AChE activity in the embryonic heart seems to be different from the developing adult form and may be related to a morphogenetic function in embryonic tissues, as proposed by other authors.

[Complete response in a case of unresectable gastric cancer treated by combined chemoimmunotherapy of MMC, 5-FU and OK-432].

A 68-year-old female patient with unresectable advanced gastric cancer was treated by combined administration of MMC (10 mg/month), 5-FU (200 mg/day) and OK-432 (5KE/2 weeks). Two months after starting the treatment, there was a diminution in the serum CEA level. Six months later, the CEA had decreased to the normal level, primary and metastatic sites completely disappeared and no cancer cell was confirmed by endoscopic biopsy. The patient has survived for 33 months of a state of complete response.

[Surgical treatment of gastric cancer with hepatic cirrhosis].

42 cases of gastric cancer associated with hepatic cirrhosis were reviewed retrospectively. These patients represented 2.8% of 1496 patients with gastric cancer who were treated over the 13 years period from 1980 to 1992. The male to female ratio was 3.7:1. On the basis of a detailed classification of the preoperative hepatic function into three risk groups, we have established a preoperative means of assessing surgical indication. Among the 42 patients, four patients were inoperable, and thirty-eight patients underwent gastric resection. One patient was died due to postoperative complication. In the preoperative assessment of operative risk, K-ICG was the most important factor.

Total gastrectomy for gastric cancer: 12-year data and review of the effect of performing lymphadenectomy.

A total of 1,272 patients with gastric cancer were admitted to our institute for surgery during 12 years (1975-1986). Of these, 1,059 (83.4%) underwent gastrectomy. Among these, 252 (23.8%) were total gastrectomy (TG), involving 160 (63.5%) cases of cancer mainly located in the upper third of the stomach, 81 (32.1%) in the middle third and 11 (4.4%) in the lower third. Radical TG was performed in 65.9% and palliative TG in 34.1%. Roux-en-Y reconstruction was selected in 80%, jejunal interposition in 17.6% and double tract in 2.4%. The survival rate was improved by introducing extended lymph node dissection, especially in the cases of stage III & IV cancer in which a combined pancreatico-splenectomy could lead to cure when associated with lymphadenectomy. In cases of a positive serosal exposure, the 5-year survival rate was increased by extended lymphadenectomy from 21% to 46% (p < 0.02). Anastomotic leakage occurred in 4.2%. The postoperative mortality rate was 1.6%, occurring in only 4 patients.