Comparative analysis of station-specific lymph node yield in laparoscopic and open distal gastrectomy for early gastric cancer.

BACKGROUND: Randomized trials and cohort studies show that laparoscopic distal gastrectomy (LDG) achieves similar oncological results to open distal gastrectomy (ODG). However, studies have consistently demonstrated lower lymph node yield (LNY) for laparoscopic lymphadenectomy. Analysis of station-specific LNY may be useful in evaluating the reasons behind this difference. OBJECTIVES: Comparison of station-specific LNY, surgical, and oncological outcomes between LDG and ODG for early gastric cancer. METHODS: Patients who underwent R0 distal gastrectomy with histologically confirmed early gastric cancer were eligible for the study. All consecutive cases of LDG since the beginning of our experience with laparoscopic gastrectomy and synchronous cases of ODG with R0 resection were included in the study. Demographic, operative, histopathologic, and follow-up data were recorded in all patients. RESULTS: A total of 259 cases of LDG and 95 cases of ODG were performed between 2000 and 2009. Patients undergoing LDG had longer operations but less bleeding (P<0.05). Postoperative complications were similar in both groups. The preoperatively planned extent of lymphadenectomy was D1 (stations 1, 3, 4sb, 4d, 5, 6, and 7), D1+ (D1with stations 8a and 9), or D2 (D1+ with stations 11p and 12a). During surgery, dissection of stations 3, 4d, 5, 6, and 7 was performed in all cases of LDG and ODG. Dissection of stations 1, 4sb, 8a, 9, 11p, and 12a was performed more frequently during ODG than during LDG. Consequently, the total LNY was 26.71 and 31.43 for LDG and ODG, respectively. Station-specific LNY was significantly lower for LDG than for ODG in the common hepatic artery nodes only (P<0.05). The mean follow-up was 43.6 months. Lymph node metastases, metastatic-to-resected lymph node ratio, recurrence, and cancer-related deaths were similar for LDG and ODG. CONCLUSIONS: LDG was associated with less extensive lymph node dissection compared with ODG. Station-specific LNY was similar in all nodal stations except for the common hepatic artery nodes. In our experience, laparoscopic sub-D2 lymphadenectomy was adequate in the context of early gastric cancer and represents the future of gastric cancer resection in Japan.

Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction: evolution in a totally intracorporeal technique.

INTRODUCTION: Laparoscopic gastrectomy is gaining popularity. Increasingly, Roux-en-Y reconstruction after distal gastrectomy is preferred because of reduced reflux and associated symptoms. Therefore, efficient and reliable techniques for intracorporeal Roux-en-Y reconstruction are in demand. AIMS: To determine the surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction in the treatment of gastric cancer. PATIENTS AND METHODS: Laparoscopic gastrectomy is indicated for gastric cancer up to stage T1N1. Our technique for laparoscopic Roux-en-Y reconstruction incorporates intracorporeal-stapled gastrojejunostomy with extracorporeal hand-sewn jejunojejunostomy, or more recently, totally intracorporeal reconstruction. RESULTS: From 2003 to 2009, 82 patients underwent laparoscopic distal gastrectomy with Roux-en-Y reconstruction. The mean age of the patients was 64.6 years (range, 39 to 83 y) and the male:female ratio was 2.4:1. Most patients (85%) had stage I disease. The mean operation time was 354 minutes (SD 82.7). The conversion rate was 0%. The mean lymph node yield was 27.2 nodes (SD 12.4). Eleven patients had totally intracorporeal reconstruction. Overall, anastomotic leakage of the gastrojejunostomy occurred in 2 patients (2.4%) both requiring reoperation. There were 2 cases (2.4%) of duodenal stump leakage, which were treated conservatively. Postoperative stasis was encountered in 2 patients (2.4%). The mean follow-up was 21 months (range, 5 to 50 mo). None of the patients developed reflux symptoms or endoscopic evidence of reflux during follow-up. Recurrence occurred in 1 patient who was the only patient with metastasis to the third tier of lymph nodes. CONCLUSIONS: Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction were acceptable in the context of early gastric cancer. Totally intracorporeal reconstruction was technically feasible, safe, and associated with no obvious drawbacks.

Proteomics-based identification of a tumor-associated antigen and its corresponding autoantibody in gastric cancer.

Identification of novel tumor-related antigens and autoantibodies will lead to early diagnosis of cancer and the development of more effective immunotherapies. The purpose of this study was to identify novel tumor antigens from the gastric cancer cell lines MkN-1, MkN-45 and KATOIII, and their related autoantibodies in sera of patients with gastric cancer using a proteomics-based approach. Proteins from the gastric cancer cell lines (MkN-1, MkN-45 and KATOIII) were separated by two-dimensional polyacrylamide gel electrophoresis, followed by Western blotting and antibody reaction with sera from patients with gastric cancer, healthy individuals and patients with other cancers. Positive spots were excised from Coomassie blue stained gels and analyzed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF/TOF MS). Sera from patients with gastric cancer yielded multiple spots, one of which was identified as the 78 kDa glucose-regulated protein (GRP78) by MALDI-TOF/TOF MS. Western blots against recombinant GRP78 showed reactivity in sera from 17/60 (28.3%) patients with gastric cancer and 0/20 (0.0%) of healthy individuals. Autoantibodies against GRP78 were found in 4/15 (26.7%) and 3/15 (20.0%) patients with esophageal and colon cancer, respectively. We identified for the first time an autoantibody against GRP78 in gastric cancer patients. The proteomic approach implemented in this study offers a powerful tool for identifying novel serum markers that may display clinical usefulness in cancer.

Surgical treatment for abdominal actinomycosis: A report of two cases.

Since actinomycosis sometimes causes an abdominal tumor which mimics malignancy, treatment strategy varies from case to case. We herein report two cases which were treated with a combination of antibiotics and surgical intervention. Both patients presented with an intra-abdominal tumor lesion mimicking malignant disease after an appendectomy for acute appendicitis. Case 1 received surgical extirpation of the abdominal tumor in the liver and kidney twice since the clinical diagnosis of actinomycosis was not made. In contrast, case 2 was successfully treated by a combination of antibiotics and laparoscopic surgery following the experience of case 1. When a high probability diagnosis can be made, a laparoscopic approach is a useful and effective option to treat this condition.

Intracorporeal stapled anastomosis following laparoscopic segmental gastrectomy for gastric cancer: technical report and surgical outcomes.

BACKGROUND: Limited gastrectomy for early gastric body cancers can offer a better functional outcome by preserving more remnant stomach. Intracorporeal stapled techniques result in cosmesis and avoid awkward anastomosis through a minilaparotomy. METHODS: Laparoscopic segmental gastrectomy is indicated for early gastric cancers of the body of the stomach with no evidence of lymph node involvement. Laparoscopic pylorus-preserving gastrectomy is a specific type of segmental resection for lower-body lesions with dissection of lymph nodes in station 6. Intracorporeal gastrogastric anastomosis is performed by the delta-shaped technique using linear staplers. RESULTS: Since January 2008 we have performed 12 laparoscopic pylorus-preserving gastrectomies and 13 laparoscopic segmental gastrectomies. All procedures were completed by laparoscopy. One patient with minor anastomotic leakage was managed conservatively. Bleeding from the anastomosis was not encountered in any of the patients. One patient developed narrowing at the anastomotic site and was treated successfully by balloon dilatation. There was no stasis encountered in any of the patients. CONCLUSIONS: Laparoscopic segmental gastrectomy with acceptable surgical outcomes is technically feasible. Although the impact of such resections on oncological outcomes remains to be further evaluated, laparoscopic segmental gastrectomy represents a minimally invasive limited resection that maximizes the potential for a better quality of life following gastric cancer surgery.

[Efficacy of S-1 combined with weekly Paclitaxel for gastric cancer with cancerous ascites].

We used combination therapy of S-1 and Paclitaxel to treat gastric cancer complicated by carcinomatous ascites and assessed the clinical results. The subjects were 8 patients who were gastric-cancer-ascites-positive, and they were treated by biweekly administration of S-1 orally, continuously for 2 weeks, and Paclitaxel on day 1 and day 8 of S-1 administration. The results showed disappearance of the ascites on diagnostic images in 37.5% (3/8) and PR in 50% (4/8) in terms of the main gastric cancer focus. An average 15 courses were conducted, and the overall adverse event rate was 87.5% (7/8). Hematologic toxicity occurred in 75.0% (6/8), and it was G3 or 4 in 37.5% (3/8). Non-hematological toxicity was confirmed in 75.0% (6/8), but none of it was G3 or 4. Although they were historical controls, we assessed the results of treatment in a conventional treatment group (control group; n=24) and the S-1 and Paclitaxel group (S-1+Paclitaxel group; n=8) by comparing the survival rates. MST in the S-1 and Paclitaxel group was 413 days, and the longest survival time was 1,148 days. The 1-year survival rate was 62.5%, and the 2-year survival rate was 37.5%. The survival rate in the S-1+Paclitaxel group was better than in the control group (p<0.001). We have reported this study because S-1+Paclitaxel therapy appears to be an important method of treating gastric cancer complicated by carcinomatous ascites.

[A case of paclitaxel-resistant cancerous ascites secondary to gastric carcinoma responding well to TS-1 therapy].

Paclitaxel was used as the first-line drug for treatment of a case with peritoneal recurrence of gastric cancer, accompanied by cancerous ascites. Because paclitaxel was ineffective, TS-1 was used as the second-line drug, resulting in disappearance of cancerous ascites on diagnostic imaging. This case was an 81-year-old male patient. In February 2004, he underwent resection of the pyloric side of the stomach (D 2) based on a diagnosis of advanced gastric cancer. CT scans, conducted in February 2005, revealed ascites, and a diagnosis of cancerous peritonitis was made on the basis of subsequent cyto-diagnostic findings. He was later hospitalized because of anorexia and difficulty with oral ingestion, and received paclitaxel therapy (60 mg/m(2)). Abdominal CT scans in May of the same year showed the disappearance of ascites. Thereafter, he was managed as an outpatient. In June of the same year, relapse of ascites was detected by CT scans, and exacerbation of ascites was seen in August. In October, paclitaxel was switched to TS-1 (80 mg/m(2)). CT scans, obtained at the end of two cycles of TS-1 therapy, revealed complete disappearance of ascites. This therapy was administered for 4 cycles in total. CT scans, performed at the end of each cycle of TS-1 therapy, confirmed the absence of ascites. At present (July 2006), the patient is managed on an outpatient basis. Our experience with this case suggests that if paclitaxel therapy fails to exert satisfactory efficacy, switching to second-line TS-1 therapy is a promising means of treating gastric cancer complicated by cancerous peritonitis.