With the increasing incidence of upper gastric cancer and early gastric cancer, surgeons have gradually paid attention to the selection of appropriate digestive tract reconstruction methods. At present, the safety of surgery is no longer the main aim pursued by surgeons, and the focus of surgery has gradually changed to postoperative quality of life. Surgical procedures for upper gastric cancer include total gastrectomy (TG) and proximal gastrectomy (PG). Roux-en-Y anastomosis is recommended for digestive tract reconstruction after TG. The classic method of digestive tract reconstruction after PG is distal residual stomach and esophageal anastomosis. However, to prevent esophageal reflux caused by PG, a lot of explorations have been carried out over the years, including tubular gastroesophageal anastomosis, double-flap technique (Kamikawa anastomosis), interposition jejunum, double-tract reconstruction and so on. But the appropriate method of digestive tract reconstruction for upper gastric cancer is still controversial. In this paper, based on literatures and our clinical experience, the selection, surgical difficulties and techniques of digestive tract reconstruction after PG are discussed.
Anastomosis, Roux-en-Y/methods* ; Anastomosis, Surgical/methods* ; Gastrectomy/methods* ; Gastric Stump/surgery* ; Humans ; Quality of Life ; Retrospective Studies ; Stomach Neoplasms/surgery* ; Treatment Outcome

After gastrojejunostomy, a small space can occur between the jejunum at the anastomosis site, the transverse mesocolon, and retroperitoneum, which may cause an intestinal hernia. This report presents a rare case of intestinal ischemic necrosis caused by retroanastomotic hernia after subtotal gastrectomy. A 56-year-old male was admitted to Kangwon National University Hospital with melena, abdominal pain, and nausea. His only relevant medical history was gastrectomy due to stomach cancer. Endoscopic findings revealed subtotal gastrectomy with Billroth-II reconstruction and a bluish edematous mucosal change with necrotic tissue in afferent and efferent loops including the anastomosis site. Abdominopelvic CT showed strangulation of proximal small bowel loops due to mesenteric torsion and thickening of the wall of the gastric remnant. Emergency laparotomy was performed. Surgical findings revealed the internal hernia through the defect behind the anastomosis site with strangulation of the jejunum between 20 cm below the Treitz ligament and the proximal ileum. Roux-en-Y anastomosis was performed, and he was discharged without complication. Retroanastomotic hernia, also called Petersen's space hernia, is a rare complication after gastric surgery, cannot be easily recognized, and leads to strangulation.
Abdominal Pain ; Anastomosis, Roux-en-Y ; Emergencies ; Gangwon-do ; Gastrectomy ; Gastric Bypass ; Gastric Stump ; Hernia ; Humans ; Ileum ; Ischemia ; Jejunum ; Laparotomy ; Ligaments ; Male ; Melena ; Mesocolon ; Middle Aged ; Nausea ; Necrosis ; Stomach Neoplasms

The most important advantages of laparoscopic gastrectomy are the minimal invasiveness, including less postoperative pain, shorter recovery, and minimal complications. A laparoscopic distal gastrectomy is accepted widely as a standard treatment for gastric cancer. On the other hand, a laparoscopic total gastrectomy has not been popularized as a distal gastrectomy because of the complexity of a lymph node dissection and the diversity of reconstruction. In terms of laparoscopic surgery for a remnant gastrectomy, there are three key points, which are critical for safe operation: adequate lymph node dissection, meticulous adhesiolysis, and reconstruction. After radical surgery for gastric cancer, the intra-abdominal condition is greatly changed. In addition, the lymphatic anatomy around the stomach is broken and surgeons should be aware of a newly developed lymphatic system to perform adequate node dissection. An esophago-jejunal reconstruction is at risk of leakage. Until evidence that is more concrete can be obtained, experienced surgeons should consider the laparoscopic approach.
Gastrectomy ; Gastric Stump ; Hand ; Laparoscopy ; Lymph Node Excision ; Lymphatic System ; Pain, Postoperative ; Stomach ; Stomach Neoplasms ; Surgeons

Gastric stump cancer (GSC) is a carcinoma arising from the remnant stomach following gastric surgery for benign or malignant disease, and is more common in men. The risk of morbidity has an obvious time dependence. GSC incidence is likely to rise with lengthening of the initial operation interval. The GSC time interval after malignant disease is significantly shorter than that of benign disease. GSC etiologies mainly include duodenogastric reflux and denervation of the gastric mucosa resulting in the change of the gastric environment after gastrectomy and the Helicobacter pylori infection. Due to atypical clinical symptoms, GSC is always identified at an advanced stage and the long-term survival rate is low. An optimal endoscopic surveillance system is essential to improve early detection rates. Treatments in GSC and primary gastric cancer are the same and include resection of the lesion and radical lymph node dissection. R0 resection is an important prognostic factor. Here we review previous reports with respect to epidemiological characteristics, etiology, clinical symptoms, treatment, and prognosis of GSC.
Gastrectomy ; Gastric Stump ; pathology ; surgery ; Helicobacter Infections ; complications ; Humans ; Lymph Node Excision ; Male ; Stomach Neoplasms ; surgery

OBJECTIVETo study the clinicopathological features and prognosis of gastric stump cancer (GSC) following subtotal gastrectomy for gastric cancer, to compare the clinicopathologic differences between narrow GSC and generalized GSC, and to compare the prognosis between GSC and primary proximal gastric cancer (PPGC) after radical resection.

METHODSLiteratures of GSC-associated clinical study were searched by computer from the Cochrane Library, Medline, PubMed, CNKI, Wanfang and VIP databases, and the retrieval period was from the establishment of database to December 31, 2017.

INCLUSION CRITERIA(1) GSC was defined as a carcinoma arising in the gastric remnant after radical gastrectomy for gastric cancer, and confirmed by the pathological or histological examination, the elapsed time from the initial operation was not considered in the definition. (2) Retrospective or prospective clinical cohort study. (3) Study included at least one of below items: gender, anastomotic type in gastric cancer surgery, the interval between the initial surgery and diagnosis of GSC, the location, treatment, pathological differentiation, pathologic stage, lymph node metastasis rate and prognosis of GSC. (4) When similar studies were reported by the same institution or author, either the better quality study or the newest publication was chosen.

EXCLUSION CRITERIA(1) Abstracts, reviews, case reports, meeting record, editorials and repeated research. (2) Studies including patients with initial non-gastric cancer. In this study, gastric stump cancer(GSC) after gastric cancer was divided into two groups: the incidence without limit interval time (generalized GSC group) and above 10 years (narrow GSC group). Selective trials were Meta-analyzed by the Stata13.0 software and statistical analysis was performed using SPSS 21.0 software.

RESULTSA total of 27 literatures were finally enrolled, which comprised 1463 GSC patients, including 1146 males and 317 females. The generalized group and narrow GSC group had 921 and 542 patients respectively. The generalized GSC group and the narrow GSC group did not significantly differ in terms of previous reconstruction mode, types of differentiation, pathologic T staging, postoperative pathology tumor-node-metastases staging, and distant metastasis rate (χ=2.341, 0.926, 0.350, 0.965, 2.311 respectively, all P>0.05). As compared to generalized GSC group, narrow GSC group had higher ratio of male patients (82.8% vs. 75.7%, χ=9.909, P=0.002), more lesions locating in anastomotic stoma (37.8% vs. 26.1%, χ=18.091, P=0.000), higher ratio of patients undergoing radical resection (84.2% vs. 70.3%, χ=11.738, P=0.001), higher positive rate of postoperative lymph node (45.8% vs. 34.5%, χ=6.319, P=0.012), and larger size of tumor [(5.9±2.2) cm vs. (4.5±1.9) cm, t=9.151, P=0.000]. The overall 5-year survival rate and postoperative pathology stage III(-IIII( survival ratio in narrow GSC group were higher compared to general GSC group (42.7% vs. 30.6% and 27.5% vs. 18.1%, respectively), which were significantly different (χ=10.938, P=0.000; χ=4.128, P=0.042), while the postoperative pathology stage I(-II( survival ratio was not significantly different between two groups (67.3% vs. 67.0% respectively, χ=0.015, P=0.92). There was no significant difference in the 5-year survival rate between GSC with radical resection and PPGC(RR=1.04, 95%CI:0.79-1.36, P=0.805) and the 5-year survival rate of same postoperative pathology stage was not significantly different between two groups (I(-II( stage: RR=1.08, 95%CI:0.93-1.26, P=0.328; III(-IIII( stage: RR=0.59, 95%CI:0.33-1.04, P=0.111).

CONCLUSIONSThere are some different clinicopathological features between the generalized and the narrow GSC after gastric cancer surgery. The prognosis of GSC after radical resection is similar to primary proximal gastric cancer.

Female ; Gastrectomy ; Gastric Stump ; pathology ; surgery ; Humans ; Male ; Neoplasm Staging ; Prognosis ; Prospective Studies ; Retrospective Studies ; Stomach Neoplasms ; surgery ; Survival Rate

OBJECTIVETo explore the surgical techniques and feasibility of robotic surgery for carcinoma in the remnant stomach(CRS).

METHODSClinicopathological data of 20 CRS patients undergoing robotic surgery at the Minimally Invasive Center for Gastrointestinal Surgery, Army Medical University Southwest Hospital from November 2012 to October 2017 were retrospectively collected. The surgical methods, procedures, main difficulties, and key techniques were analyzed, and the clinical efficacy was evaluated.

RESULTSAmong 20 CRS patients, 14 were male and 6 were female with mean age of 59.9 years and mean BMI of 19.7 kg/m. For the primary diseases, 17 patients underwent laparotomy, 3 underwent laparoscopic radical resection of gastric cancer; 18 cases received distal subtotal gastrectomy plus Billroth II( anastomosis, 2 received distal subtotal gastrectomy plus Billroth I( anastomosis. CRS located in anastomotic stoma in 15 cases and in the gastric fundus and cardiac part in 5 cases. Preoperative staging revealed 2 cases of T2NxM0, 1 of T3NxM0, 2 of TxNxM0 and 15 of T4aNxM0. Sixteen patients received robotic surgery with Roux-en-Y reconstruction successfully, and 4 patients were converted to laparotomy for palliative total gastrectomy, including 1 case with diaphragm invasion, 1 case with transverse colon invasion, and 2 cases with tight adhesions. The mean surgery time was (255±35) minutes, mean blood loss was (230±50) ml, mean number of dissected lymph nodes was 19.5±3.0, mean recovery time to gastrointestinal function was (2.3±1.0) days, mean time to feeding was (2.3±1.0) days, and mean time to ambulatory activity was (2.5±0.5) days. Pathological examinations revealed 12 patients with poorly differentiated adenocarcinoma, 6 patients with moderately differentiated adenocarcinoma, and 2 patients with mucinous adenocarcinoma. Postoperative pTNM staging was identified as follows: stage I(B for 1 patient, stage II(A for 2 patients, stage II(B for 5 patients, stage III(A for 5 patients, stage III(B for 4 patients, and stage III(C for 3 patients. One patient died 2 weeks after operation due to multiple organ failure. One patient received another hemostasis operation due to hemorrhage of splenic artery and recovered postoperatively. Two patients experienced anastomotic leakage, 1 patient developed duodenal stump fistula and 1 patient experienced incision site infection postoperatively, and all of them recovered after conservative treatment. During 5-60 months follow-up, 10 cases died and 10 cases survived, including 1 case for 6 years.

CONCLUSIONSRobotic surgery for CRS is feasible with satisfactory short-term efficacy. However, the long-term efficacy requires further study.

Female ; Gastrectomy ; Gastric Stump ; surgery ; Humans ; Laparoscopy ; Male ; Middle Aged ; Retrospective Studies ; Robotic Surgical Procedures ; Stomach Neoplasms ; surgery

OBJECTIVETo explore the risk factors and establish an effective model to predict lymph node metastasis (LNM) for remnant gastric cancer (RGC).

METHODSClinicopathological characteristics of 91 RGC patients undergoing radical gastrectomy at Sun Yat-sen University Cancer Center from January 2000 to December 2017 were retrospectively analyzed. RGC was defined as cancer detected in the remnant stomach >5 years for primary benign diseases or >10 years for malignant diseases following distal gastrectomy. Risk factors of LNM in RGC were identified using logistic regression (P<0.1). Covariates were then scored according to the β regression coefficient in the multivariate analysis, and a score model was established, in which higher score indicated higher risk of LNM. Finally, receiver operating characteristic(ROC) curve was used to evaluate the diagnostic efficacy of risk factors and the score model.

RESULTSAmong the 91 RGC patients, 84 were male and 7 were female with the age ranging from 47 to 82 years (63.7±8.5) years. Mean harvested lymph node (LN) was 16.0±11.8, including ≥15 LNs in 42(46.2%) patients and <15 LNs in 49(53.8%) patients. Forty-six (50.5%) patients were identified as LNM. Univariate analysis showed that tumor size ≥4 cm (χ=8.106, P=0.004), Borrmann III(-IIII( gross type (χ=6.129, P=0.013), increased CEA level (χ=4.041, P=0.044) and T3-4 stage (χ=17.321, P=0.000) were associated with LNM in RGC. In Logistic multivariate analysis, tumor size ≥4 cm (OR: 2.362, 95%CI: 0.829-6.730, P=0.100, β regression coefficient: 0.859) and T3-4 stage (OR: 7.914, 95%CI: 1.956-32.017, P=0.004, β regression coefficient: 2.069) remained as the independent risk factors for LNM, and were scored as 1 and 2 point in the final prediction model. In the final score model, LNM of patients with 0, 1, 2, 3 point were 11.1%(2/18), 1/5, 51.6%(16/31) and 73.0%(27/37), respectively. The AUC of the prediction model was 0.756 (P=0.000).

CONCLUSIONSIncreased CEA level, tumor size ≥4 cm, Borrmann III(-IIII( gross type, and deeper T stage are associated with LNM in RGC. Moreover, the score model combining with tumor size and T stage can effectively predict the LNM in RGC.

Aged ; Aged, 80 and over ; Factor Analysis, Statistical ; Female ; Gastrectomy ; Gastric Stump ; pathology ; Humans ; Lymph Node Excision ; Lymph Nodes ; Lymphatic Metastasis ; Male ; Middle Aged ; Prognosis ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; pathology ; surgery

OBJECTIVETo evaluate the clinicopathological features and prognostic factors of carcinoma in the remnant stomach (CRS).

METHODSClinicopathological data of 217 consecutive CRS patients from January 2000 to March 2017 at Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University were retrospectively analyzed. CRS was defined as the primary cancer arising from the remnant stomach following gastrectomy, regardless of the initial disease or operation, and at no special time interval. The clinicopathological features and treatment were compared between CRS after benign disease operation (CRS-B) group and CRS after gastric cancer operation (CRS-C) group, and factors influencing prognosis were analyzed using Cox regression model analysis.

RESULTSOf 217 patients, 189 were male and 28 were female with mean age of (60.9±11.2) years. The interval between the first and the second operations was (18.3±15.1) years. The CRS-B group comprised 108 patients and the CRS-C group comprised 109 patients. Compared to CRS-C group, CRS=B group had higher ratio of male [92.6% (100/108) vs. 81.7% (89/109), χ=5.779, P=0.016], longer interval [30(25-40) years vs. 4(1.5-8.0) years, Z=-1.685, P=0.000], longer tumor diameter [(5.9±3.2) cm vs. (3.9±2.4) cm, t=3.390, P=0.000] and later tumor stage [patients in stage I(, II(, III(, and IIII(: 6 (8.0%), 14 (18.7%), 41 (54.7%), and 14 (18.7%) vs. 16 (25.4%), 14 (22.2%), 21(33.3%), and 12(19.0%), respectively, Z=-2.018, P=0.044]. A total of 138 patients underwent surgery, including 118(85.5%) patients of curative resection and 20(14.5%) patients of palliative resection. The other 79 patients did not receive surgery due to extensive metastasis or miscellaneous reasons. Among 138 patients receiving surgery, 3 patients underwent endoscopic resection, 6 patients underwent minimally invasive surgery (laparoscopy or robot), and 129 patients underwent laparotomy. Forty-eight patients underwent surgery involving combined resection. The median postoperative hospital stay was 10(8-14) days. The incidence of postoperative complication was 23.2%(32/138). A total of 91 patients were followed up for 7-120 months, including 51 patients in CRS-B group and 40 in CRS-C group. The overall 1-, 3-, and 5-year survival rates of the 75 patients receiving curative resection were 80.7%, 55.1%, and 41.6%, respectively. The overall 1-, 3-, and 5-year survival rates were 73.5%, 48.3%, and 29.0% respectively in CRS-B group and 83.1%, 51.2%, and 32.5% respectively in CRS-C group. There was no significant difference between two groups (P=0.527). Multivariate analysis showed that age (RR=1.879, 95%CI: 1.015-3.479, P=0.045), radical procedure (RR=2.956, 95%CI: 1.421-6.150, P=0.004) and TNM stage (RR=1.570, 95%CI: 1.047-2.354, P=0.029) were independent prognostic factors for CRS.

CONCLUSIONSAs compared to the CRS-C group, the CRS-B group has higher percentage of male, longer interval, larger tumor diameter and later TNM stage. Radical resection indicates better prognosis.

Aged ; Female ; Gastrectomy ; Gastric Stump ; pathology ; surgery ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Neoplasm Staging ; Prognosis ; Retrospective Studies ; Stomach Neoplasms ; pathology ; surgery ; Survival Rate

OBJECTIVETo compare clinicopathological features and prognosis between patients with carcinoma in the remnant stomach (CRS) and with gastric cancer, and to investigate the prognostic factors in CRS patients.

METHODSA retrospective cohort study was performed on clinicopathological data of 96 CRS patients (CRS group) and selected 440 patients with gastric cancer (GC group) treated at Harbin Medical University Cancer Hospital from January 1977 to December 2017.

INCLUSION CRITERIA(1) undergoing gastrectomy; (2) diagnosed with CRS or gastric cancer through electronic gastroscopies and pathology; (3) without preoperative neoadjuvant radiotherapy or chemotherapy; (4) complete clinicopathological and follow-up data. The patients who died of other reasons or were lost during follow-up were excluded. Chi-square test and independent samples t-test were used to determine differences in clinicopathological factors between two groups. Survival analysis was conducted using the Kaplan-Meier method, and Log-rank test was used to compare survival difference between two groups. The prognosis of CRS patients was analyzed using Cox proportional hazards regression model.

RESULTSAs compared to GC group, CRS group had a higher proportion of female [30.2%(29/96) vs. 13.2%(58/ 440), χ=14.095, P=0.000], younger age [(56.4±10.1) years vs. (60.0±9.9) years, t=2.838, P=0.005], more distant metastasis and local organ infiltration [25.0%(24/96) vs. 16.1%(71/440), χ=4.246, P=0.039; 64.6% (62/96) vs. 24.5% (108/440), χ=58.331, P=0.000], lower prognostic nutritional index [(48.0±6.7) vs. (50.4±6.9), t=3.093, P=0.002], lower serum hemoglobin level [(115.0±24.7) g/L vs. (127.9±24.6) g/L, t=4.634, P=0.000], lower serum albumin level [(40.0±4.9) g/L vs. (41.2±5.0) g/L, t=2.038, P=0.042], and earlier occurrence of symptoms [(1.9±1.4) months vs. (3.7±3.2) months, t=5.431, P=0.000]. However, there were no statistically significant differences in TNM staging, postoperative hospital stay, and total hospitalization days between the two groups (all P>0.05). During follow-up, 24(25.0%) patients developed recurrence or distant metastasis and 68 (70.8%) patients died of tumor progression in CRS group, while 71(16.1%) patients developed recurrence or distant metastasis and 378(85.9%) patients died of tumor progression in GC group. The 5-year survival rate of CRS patients was 23.4%, which was higher than 15.0% of gastric cancer patients (P=0.032). Univariate analysis showed that the CRS patients with radical operation (P=0.000), earlier TNM stage (P=0.000), non-distant metastasis (P=0.022), serum hemoglobin level >130 g/L(P=0.013), and serum album level >40 g/L (P=0.042) had better prognosis. Multivariate analysis, enrolling above 5 factors, showed that TNM staging (HR=2.363, 95%CI: 1.478-3.776, P=0.000) and serum hemoglobin level >130 g/L(HR=0.449, 95%CI: 0.244-0.827, P=0.010) were independent factors influencing prognosis of CRS patients.

CONCLUSIONSAlthough CRS patients have better prognosis than gastric cancer patients, but local organ invasion and distant metastasis occurs more readily. TNM staging and serum hemoglobin level are independent prognostic factors for CRS patients.

Aged ; Female ; Gastrectomy ; Gastric Stump ; pathology ; surgery ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Recurrence, Local ; Neoplasm Staging ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Stomach Neoplasms ; pathology ; surgery

OBJECTIVETo investigate the interval time to canceration, clinicopathological characteristics and prognostic factors of carcinoma in remnant stomach (CRS) in patients with primary benign diseases or primary malignant tumors.

METHODSBased on the criteria of the definition of CRS proposed by Japanese Gastric Cancer Association in 2017, a retrospective analysis was conducted on clinicopathological characteristics of patients diagnosed with CRS at Peking University Cancer Hospital from March 1992 to March 2017. Between patients with primary benign diseases (CBS-B group) and primary malignant tumors (CBS-M group), continuous variables were compared using the Student's t-test or the Mann-Whitney U test; categorical variables were compared using the chi-square test or Fisher's exact test. Spearmen-Rho was used to examine correlation. Survival was estimated and compared using Kaplan-Meier methods. Cox proportional hazards regression was applied to identify independent prognostic factors. Area under ROC curve(AUC) was used to evaluate and compare prediction accuracy.

RESULTSA total of 89 patients were included in the study with a male: female ratio of 5.4 to 1.0. The male: female ratio in CRS-B (n=46) and CRS-M (n=43) group was 14.3 to 1.0 and 2.9 to 1.0 respectively with significant difference (χ=6.091, P=0.019). The interval time to canceration in CRS-B and CRS-M group was 342(36-576) months and 47(12-360) months respectively with significant difference (t=8.887, P=0.000). The interval time to canceration was correlated with the first operative procedure in CRS-B group (r=0.398, P=0.006), while interval time to canceration was correlated with the age at the first operation in CRS-M group (r=0.337, P=0.027). After differentiating the pathological findings of the first operative sample and the second operative sample, 27 patients presented recurrence and 15 patients had new cancer, and the corresponding interval time to canceration was 46(12-132) months and 60(12-360) months respectively with significant difference (t=5.652, P=0.023). In CRS-B group, location of stump carcinoma in gastric intestinal anastomosis, gastric anastomosis, and non-anastomosis area was found in 60.9%(28/46), 23.9%(11/46) and 15.2%(7/46) respectively, and the corresponding percentage in CRS-M group was 39.5%(17/43), 16.3%(7/43) and 44.2%(19/43) respectively without significant difference (χ=4.726, P=0.096). Among 77 patients with radical gastrectomy, the overall surgical complication rate was 20.8%(16/77), including 8 cases of infection and 7 cases of respiratory system diseases. The 3-year survival rate was 78.4% and 62.6% in CRS-B and CRS-M group respectively with significant difference (χ=3.969, P=0.046), indicating better prognosis of CRS-B patients. The AUC for the lymph nodes ratio and N staging was 0.725 and 0.639 respectively. Multivariate analysis showed the pathological T staging was an independent risk factor of prognosis (HR=1.192, 95%CI:1.032-1.376, P=0.017).

CONCLUSIONSMen have more CRS than women. The interval time to canceration is correlated to the first operative procedure for CRS-B patients, while it is correlated to the age at the first operation for CRS-M patients. The major location of CRS is in the gastrointestinal anastomosis for CRS-B patients and in non-anastomosis area for CRS-M patients. Main postoperative complications include respiratory and infectious complications. Pathological T staging is an independent prognostic risk factor for CRS patients.

Cancer Care Facilities ; Factor Analysis, Statistical ; Female ; Gastrectomy ; Gastric Stump ; pathology ; surgery ; Humans ; Lymphatic Metastasis ; Male ; Neoplasm Recurrence, Local ; Neoplasm Staging ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Stomach Neoplasms ; surgery ; Survival Rate ; Universities