Additional laparoscopic gastrectomy after noncurative endoscopic submucosal dissection for early gastric cancer: A single-center experience

BACKGROUND The necessity of additional gastrectomy for early gastric cancer (EGC) patients who do not meet curative criteria after endoscopic submucosal dissection (ESD) is controversial. AIM To examine the clinicopathologic characteristics of patients who underwent additional laparoscopic gastrectomy after ESD and to determine the appropriate strategy for treating those after noncurative ESD. METHODS We retrospectively studied 45 patients with EGC who underwent additional laparoscopic gastrectomy after noncurative ESD from January 2013 to January 2019 at the Cancer Hospital of the Chinese Academy of Medical Sciences. We analyzed the patients’ clinicopathological data and identified the predictors of residual cancer (RC) and lymph node metastasis (LNM). RESULTS Surgical specimens showed RC in ten (22.2%) patients and LNM in five (11.1%).Multivariate analysis revealed that positive horizontal margin [odds ratio (OR)=13.393, 95% confidence interval (CI): 1.435-125, P=0.023] and neural invasion (OR=14.714, 95%CI: 1.087-199, P=0.043) were independent risk factors for RC. Undifferentiated type was an independent risk factor for LNM (OR=12.000, 95%CI: 1.197-120, P=0.035). Tumors in all patients with LNM showed submucosal invasion more than 500 μm. Postoperative complications after additional laparoscopic gastrectomy occurred in five (11.1%) patients, and no deaths occurred among patients with complications. CONCLUSION Gastrectomy is necessary not only for patients who have a positive margin after ESD, but also for cases with neural invasion, undifferentiated type, and submucosal invasion more than 500 μm. Laparoscopic gastrectomy is a safe, minimally invasive, and feasible procedure for additional surgery after noncurative ESD. However, further studies are needed to apply these results to clinical practice.

Survival outcomes and prognostic indicators for gastric cancer patients with positive peritoneal wash cytology but no peritoneal metastasis after radical gastrectomy

BACKGROUND Positive peritoneal wash cytology with no peritoneal metastasis(CY1P0)is a special type of distant gastric cancer metastasis,which describes a patient with positive peritoneal lavage cytology,but no definitive peritoneal metastasis,and there are no widely accepted treatment guidelines.We enrolled 48 primary CY1P0 gastric cancer patients treated by radical gastrectomy in this study.Our study illustrated the efficacy of radical gastrectomy for CY1P0 gastric cancer patients,and suggested that the pathological N factor and vascular invasion were significant independent risk factors for overall survival(OS).AIM To assess the survival of CY1P0 gastric cancer patient post-radical gastrectomy,and to identify factors associated with long-term prognosis.METHODS Our study included 48 patients with primary CY1P0 gastric cancer who had radical gastrectomies at the Cancer Hospital,Chinese Academy of Medical Sciences,Beijing,China between 2013 and 2018.R0 resection was achieved in all 48 patients.Twelve patients received neoadjuvant chemotherapy.Thirty patients received adjuvant chemotherapy and four received adjuvant chemoradiotherapy.OS statistics were available for 48 patients.Follow-up continued through March 2020.Univariate and multivariate analyses were performed using a Cox proportional hazards model to identify prognostic factors.RESULTS Median OS was 22.0 mo(95%confidence interval:13.366-30.634 mo)post-surgery.Univariate analyses demonstrated that tumor site(P=0.021),pathological N factor(P=0.001),pathological T factor(P=0.028),vascular invasion(P=0.046),and the level of CA199 prior to initiating therapy(P=0.002)were significant risk factors for OS.Multivariate analyses demonstrated that pathological N factor(P=0.001)and vascular invasion(P=0.031)were significant independent risk factors for OS.CONCLUSION This study suggested that radical gastrectomy may be efficient for CY1P0 gastric cancer patient post-radical gastrectomy and the pathological N factor and vascular invasion are significant independent risk factors for OS.

Surgical resection of gastric stump cancer following proximal gastrectomy for adenocarcinoma of the esophagogastric junction

BACKGROUND Proximal gastrectomy(PG) is performed widely as a function-preserving operation for early gastric cancer located in the upper third of the stomach and is an important function-preserving approach for esophagogastric junction(EGJ)adenocarcinoma. The incidence of gastric stump cancer(GSC) after PG is increasing. However, little is known about the GSC following PG because very few studies have been conducted on the disease.AIM To clarify clinicopathologic features, perioperative complications, and long-term survival rates after the resection of GSC following PG.METHODS Data for patients with GSC following PG for adenocarcinoma of the EGJ diagnosed between January 1998 and December 2016 were retrospectively reviewed. Multivariate analysis was performed to identify factors associated with overall survival(OS). GSC was defined in accordance with the Japanese Gastric Cancer Association.RESULTS A total of 35 patients were identified. The median interval between the initial PGand resection of GSC was 4.9(range 0.7-12) years. In 21 of the 35 patients, the tumor was located in a nonanastomotic site of the gastric stump. Total gastrectomy was performed in 27 patients; the other 8 underwent partial gastrectomy. Postoperative complications occurred in 6 patients(17.1%). The tumor stage according to the depth of tumor invasion was T1 in 6 patients, T2 in3 patients, T3 in 9 patients, and T4 in 17 patients. Lymph node metastasis was observed in 18 patients. Calculated 1-, 3-, and 5-year OS rates were 86.5%, 62.3%,and 54.2%, respectively. Multivariate analysis showed advanced T stage to be associated with OS.CONCLUSION This study reveals the characteristics of GSC following PG for adenocarcinoma of the EGJ and suggests that a surgical approach can lead to a satisfactory outcome.

Neuroendocrine carcinoma of the gastric stump:A case report and literature review

We herein report a case of neuroendocrine carcinoma of the gastric stump found 47 years after Billroth II gastric resection for a benign gastric ulcer. A 74-yearold man was referred to another hospital with melena. Endoscopic examination revealed a localized ulcerative lesion at the gastrojejunal anastomosis. The diagnosis by endoscopic biopsy was neuroendocrine carcinoma. A total gastrectomy of the remnant stomach with D2 lymphadenectomy was performed at our hospital. The lesion invaded the subserosa, and metastasis was found in two of nine the lymph nodes retrieved. The lesion was positive for synaptophysin and chromogranin A, and the Ki-67 labeling index was 60%. The diagnosis of neuroendocrine carcinoma of the gastric stump was confirmed using World Health Organization 2010 criteria. Subsequently, the patient underwent one course of adjuvant chemotherapy with the etoposide plus cisplatin(EP) regimen; however, treatment was discontinued due to grade 3 myelosuppression. The patient showed lymph node metastasis in the region around the gastrojejunal anastomosis in the abdominal cavity 7 mo post-surgery. He then underwent radiotherapy and platinum-based combination chemotherapy; however, the disease progressed and liver recurrence was observed on follow-up computedtomography at 16 mo post-surgery. The patient then received chemotherapy with regimens used for the treatment of small cell lung cancer in first-and secondline settings. The patient died of disease progression 31 months after surgery.

胃癌腹腔冲洗细胞学阳性患者的治疗进展与争议

胃癌是我国发病率最高的恶性肿瘤之一,腹膜转移是胃癌常见的转移方式.腹腔冲洗细胞学阳性是一种特殊类型的胃癌远处转移,治疗原则尚无明确定论.目前进展期胃癌治疗的基础依然是根治性手术结合术后辅助化疗,转化治疗对腹腔冲洗细胞学阳性胃癌患者有十分重要的意义,腹腔冲洗液转阴后可以有效改善预后.腹腔热灌注化疗与术中腹腔灌洗治疗为此类患者的治疗提供了新思路,可以有效杀灭腹腔游离癌细胞.目前对腹腔冲洗细胞学阳性胃癌患者治疗原则的临床研究多数属于回顾性且样本量较小,我们建议对这些患者进行多学科MDT讨论,制定个体化的治疗方案,并且鼓励此类患者参加相关临床研究.

Treatment strategies for gastric cancer during the COVID-19 pandemic

The coronavirus disease 2019 pandemic has become a major global public health problem.Governments are taking the necessary steps to reduce the movement of people to contain the spread of the virus.However,these measures have caused considerable distress to patients with gastric cancer who are newly diagnosed or are undergoing treatment.In addition to the cancer,they must deal with longer waiting times for surgery and poor communication with doctors.Furthermore,gastric cancer patients generally have low immunity and a poor nutritional status,so they are a high-risk group for infection with the novel coronavirus.Therefore,it is necessary to formulate reasonable outpatient management strategies to reduce the adverse effects of the pandemic on their treatment.We summarize the management strategies for patients with gastric cancer during the pandemic.

Treatment of afferent loop syndrome using fluoroscopic-guided nasointestinal tube placement: Two case reports

BACKGROUND Afferent loop syndrome(ALS)is a rare mechanical complication that occurs after reconstruction of the stomach or esophagus to the jejunum,such as Billroth II gastrojejunostomy,Roux-en-Y gastrojejunostomy,or Roux-en-Y esophagojejunostomy.Traditionally,an operation is the first choice for benign causes.However,for patients in poor physical condition who experience ALS soon after R0 resection,the type of treatment remains controversial.Here,we present an efficient conservative method to treat ALS.CASE SUMMARY Case 1 was a 69-year-old male patient who underwent total gastrectomy with Roux-en-Y jejunojejunostomy.On postoperative day(POD)10 he developed symptoms of ALS that persisted and increased over 1 wk.Case 2 was a 59-yearold male patient who underwent distal gastrectomy with Billroth II gastrojejunostomy.On postoperative day POD 9 he developed symptoms of ALS that persisted for 2 wk.Both patients underwent fluoroscopic-guided nasointestinal tube placement with maintenance of continuous negative pressure suction.Approximately 20 d after the procedure,both patients had recovered well and were discharged from hospital after removal of the tube.At 3-mo follow-up,there were no signs of ALS in these two patients.CONCLUSION This is the first report of treating postoperative ALS by fluoroscopic-guided nasointestinal tube placement.Our cases demonstrate that this procedure is an effective and safe method to treat ALS that relieves patients’symptoms and avoids complications caused by other invasive procedures.

Protective effects of female reproductive factors on gastric signetring cell carcinoma

BACKGROUND The overall incidence of gastric cancer is higher in men than women worldwide.However,gastric signet-ring cell carcinoma(GSRC)is more frequently observed in younger female patients.AIM To analyze clinicopathological differences between sexes in GSRC,because of the limited evidence regarding association between sex-specific differences and survival.METHODS We reviewed medical records for 1431 patients who received treatment for GSRC at the Cancer Hospital,Chinese Academy of Medical Sciences between January 2011 and December 2018 and surveyed reproductive factors.Clinicopathological characteristics were compared between female and male patients.Cox multivariable model was used to compare the mortality risks of GSRC among men,menstrual women,and menopausal women.RESULTS Of 1431 patients,935 patients were male and 496 were female(181 menstrual and 315 menopausal).The 5-year overall survival in male,menstrual female and menopausal female groups was 65.6%,76.5% and 65%,respectively(P<0.01).Menstruation was found to be a protective factor(hazard ratio=0.58,95% confidence interval:0.42–0.82).CONCLUSION The mortality risk of GSRC in menstrual women was lower than that in men.This study identified the protective effects of female reproductive factors in GSRC.