Gastric cancer with positive peritoneal cytology is a hotspot in the study of gastric cancer, and its prognosis is poor. Intraperitoneal free cancer cells may be associated with cancer cells migration, invasion and metastasis. Tumor T stage, peritoneal metastasis, lymph node metastasis, low histological differentiation, linitis plastica, adenocarcinoma of esophagogastric junction, and operation are the clinicopathological risk factors of gastric cancer with positive peritoneal cytology. Currently, the acquisition of free cancer cells is mainly through diagnostic laparoscopy combined with peritoneal lavage, and cytopathological examination is gold standard for diagnosis. Its treatment strategies are not in consensus, including preoperative chemotherapy combined with radical resection, postoperative chemotherapy and peritoneal local treatment, which can prolong the survival of patients. At present, postoperative chemotherapy is often used in China, and the best treatment strategies remain to be further studied.
China ; Gastrectomy ; Humans ; Neoplasm Staging ; Peritoneal Lavage ; Peritoneal Neoplasms/diagnosis* ; Prognosis ; Retrospective Studies ; Stomach Neoplasms/surgery*

Tumor deposit (TD) is a common histopathological finding in gastric cancer. With the improved ability of lymphadenectomy and pathological examination, the positive rate and harvested number of TD are also increasing. The role of TD in staging and prognosis prediction for gastric cancer patients is getting more attention. However, due to the lack of standardization and unification, the denomination, definition and diagnostic criteria are still controversial. The previous studies on the definition and diagnostic criteria of TD were reviewed to standardize the items and improve the awareness. TD is an independent prognostic factor in gastric cancer. Each TD should be counted separately as a lymph node in the final pN determination according to TNM staging system of the Union for International Cancer Control (UICC) or American Joint Committee on Cancer(AJCC) or Japanese classification of gastric carcinoma. But this rule is just an experience-based practice, without support from high-level evidence. Several studies have tried to incorporate TD into TNM staging system to improve the accuracy and discriminative ability. With the wide use of the 8th TNM staging system, how to incorporate TD into the new staging system in an easy and reasonable way still needs more investigations.
Humans ; Lymph Node Excision ; Lymph Nodes ; pathology ; surgery ; Neoplasm Staging ; methods ; Prognosis ; Stomach Neoplasms ; diagnosis ; pathology ; therapy

Acute perforated gastric cancer (GC) is defined as an acute perforation of primary GC. It is a rare surgical acute abdominal disease that is mainly caused by advanced GC. The onset of acute perforation of GC is related to the depth of invasion. Preoperative diagnosis is very difficult for GC with acute perforation. The main method to confirm malignant perforation is intraoperative frozen section, which also is the primary clinical standard at present. The primary treatment for GC with acute perforation is surgical intervention, which is associated with high morbidity and mortality. Therefore, we should first consider short-term safety and choose the surgical approach based on the patient's condition, tumor stage and surgeon's experience. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) can provide a comprehensive assessment for patient's condition and surgical risk. Secondly, long-term survival should be considered and R0 resection is the most important. When R0 resection can not be achieved in the initial treatment phase, palliative gastrectomy should be avoided. A simple perforation repair can provide an opportunity for two-stage laparoscopic surgery, but the timing of the second stage operation is controversial. We advocate that advanced GC with acute perforation undergoing initial perforation repair can receive subsequent neoadjuvant therapy. A second stage surgery should depend on the response to therapy. Cases of acute perforation of gastric cancer are few. At present, high-level evidence is absent for surgical treatment at home and abroad, and there is no guideline or consensus for diagnosis and treatment. Therefore, it is necessary to explore and establish a comprehensive process of diagnosis and surgical treatment for acute perforated GC, which may be very helpful for first-line surgeons and can also improve the short-term outcomes and long-term survival for GC with acute perforation.
Gastrectomy ; Humans ; Laparoscopy ; Stomach Neoplasms ; diagnosis ; surgery

The Chinese Consensus on Endoscopic Diagnosis and Management of Gastrointestinal Submucosal Tumors is the first guideline in the area of gastrointestinal submucosal tumors(SMT) in China. SMTs of the Gastrointestinal tract are bulge lesions that originate from muscularis mucosa, submucosa, or muscularis propria. Endoscopic treatment of SMT is an effective way to improve the quality of life for patients, to reduce the burden on patients' families and the society, and to save national medical resources. For these reasons, this consensus has proposed the indications for endoscopic resection, on the basis of current status of diagnosis and treatment for SMT in China, and in combination with domestic and foreign literature and experts' experience:(1)For tumors with malignant potential suspected by preoperative examination or pathologically confirmed through biopsy, endoscopic resection should be considered when technically possible; (2) Endoscopic resection is indicated for SMT with symptoms (e.g. hemorrhage and obstruction); (3) For benign tumors suspected by preoperative examinations or confirmed by pathological examination, endoscopic resection could be considered when patients cannot attend regular follow-up, tumors grow rapidly in a short period or patients have a strong willing for endoscopic treatment. After endoscopic resection for SMT, different treatment algorithms should be recommended according to pathological types:(1)For benign lesions, such as lipoma and leiomyoma, postoperative routine treatment and follow-up are recommended;(2)For SMT without malignant potential, such as well-differentiated rectal neruoendocrine tumors (NET) that are < 1 cm, survival rate after complete resection is approximately 98.9%-100% and the recurrence rate is extremely low. Therefore, routine follow-up is recommended when the margin were confirmed negative pathologically; (3)Low-malignant-potential SMT, such as low-risk GIST, should be assessed by endoscopic ultrasonography or imaging every 6-12 months, and then managed according to clinical instructions; (4)Medium/high-malignant-potential SMT, such as type 3 and type 4 gastric NET, colorectal NET that are >2 cm, and medium/high-risk GISTs, additional treatment is required according to the guidelines for each specific disease. This expert consensus aims to provide an endoscopic SMT diagnosis and treatment standard,which fits our current national status, to domestic hospitals at all levels.
China ; Consensus ; Gastric Mucosa ; Gastrointestinal Stromal Tumors ; diagnosis ; surgery ; Humans ; Neoplasm Recurrence, Local ; Quality of Life ; Stomach Neoplasms ; diagnosis ; surgery ; Treatment Outcome

OBJECTIVETo evaluate the clinical significance of No.12 lymph node dissection for advanced gastric cancer with D2 lymphadenectomy.

METHODSClinicopathologic data and No.12 lymph node dissection of 256 advanced gastric cancer patients undergoing radical operation in our department between January 2005 and December 2010 were retrospectively summarized and the influence factors of metastasis in No.12 lymph nodes were analyzed.

RESULTSOf 256 patients, 179 were male and 77 were female with the average age of 59.2 years. Tumor located in the upper of stomach in 24 cases, middle of stomach in 41 cases, lower of stomach in 174 cases, multi-focus or diffuse distribution of stomach in 17 cases. Tumor diameter was <3 cm in 39 cases, 3 to 5 cm in 100 cases, >5 cm in 117 cases. Serum carcinoembryonic antigen (CEA) level increased in 61 cases, serum carbohydrate antigens (CA)72-4 increased in 56 cases and CA19-9 increased in 61 cases. The number of No.12 lymph nodes resected from all the patients was 1 152, and the average number was 4.5±1.9. The metastasis rate of No.12 lymph nodes was 9.4%(24/256) after hematoxylin eosin staining (positive group). All the patients received effective follow-up to December 2015, and the average follow-up time was 101.2 months. The median survival time of positive No.12 group (24 cases) was 29.8 months and of negative No.12 group (232 cases) was 78.2 months, whose difference was statistically significant (χ=21.715, P=0.000). Univariate analysis found that No.12 lymph node metastasis was not associated with age, gender, tumor differentiation (all P>0.05), but was associated with tumor location, tumor diameter, invasive depth (all P<0.05), and was closely associated with Borrmann type, outside metastatic lymph nodes of No.12 and high levels of serum CEA, CA72-4 and CA19-9 (all P=0.000). Multivariate regression analysis found that tumor location (RR=2.452, 95%CI:1.537 to 3.267, P=0.000), Borrmann type (RR=1.864, 95%CI:1.121 to 3.099, P=0.016) and number of outside metastatic lymph nodes of No.12 (RR=2.979, 95%CI: 2.463 to 3.603, P=0.000) were the independent risk factors of the No.12 metastasis (P<0.05).

CONCLUSIONSMetastasis in No.12 lymph nodes indicates poorer prognosis. The No.12 lymph nodes of advanced gastric cancer patients with curative resection, especially those with the tumor located in the lower part, Borrmann type IIII(, outside metastatic lymph nodes of No.12, should be regularly cleaned.

Antigens, Tumor-Associated, Carbohydrate ; blood ; CA-19-9 Antigen ; blood ; Carcinoembryonic Antigen ; blood ; Female ; Follow-Up Studies ; Humans ; Lymph Node Excision ; methods ; Lymph Nodes ; pathology ; surgery ; Lymphatic Metastasis ; diagnosis ; pathology ; physiopathology ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Grading ; statistics & numerical data ; Neoplasm Invasiveness ; Neoplasm Staging ; statistics & numerical data ; Prognosis ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; blood ; mortality ; pathology ; Survival Rate

OBJECTIVETo explore the risk factors and prognosis of No.8p lymph node metastasis in cases with advanced gastric cancer.

METHODSClinicopathological and follow-up data of 790 cases with advanced gastric cancer undergoing gastrectomy (including No.8p lymphadenectomy) from October 2003 to October 2013 in Fujian Provincial Tumor Hospital were analyzed retrospectively. Patients receiving neoadjuvant chemotherapy were excluded. Associations of No.8p lymph node metastasis with clinicopathological characteristics and metastasis in other regional lymph node were analyzed. Prognostic difference between positive No.8p group and negative No.8p group was examined.

RESULTSPositive No.8p lymph node was found in 93 cases (11.8%) among 790 cases with advanced gastric cancer. Univariate analysis showed that gender [male 9.8%(56/572) vs. female 17.0%(37/218), P=0.005], preoperative CEA level [<5 μg/L 28.0%(61/218) vs. ≥5 μg/L 5.6%(32/572), P=0.005], tumor size[diameter <5 cm 3.8%(13/346) vs. ≥5 cm 18.0%(80/445), P=0.000], tumor location [gastric fundus and cardiac 10.7% (26/244) vs. gastric body 13.5% (30/222) vs. gastric antrum 10.1% (31/308) vs. total gastric 37.5%(6/16), P=0.007], Borrmann staging [type II( 1.9%(4/211) vs. type III( 11.6% (54/464) vs. type IIII( 30.4%(35/115), P=0.000], tumor differentiation [high 0/8 vs. moderate 6.7%(25/372) vs. low 16.6%(68/410), P=0.000], T staging [T2 2.4%(4/170) vs. T3 13.1%(35/267) vs. T4 15.3%(54/353), P=0.000], N staging [N0 0 (0/227) vs. N1 2.2%(5/223) vs. N2 15.2%(26/171) vs. N3 36.7%(62/169), P=0.000] were closely associated with the No.8p lymph node metastasis. Multivariate analysis that revealed gender (OR=1.762, 95%CI: 1.020-3.043), tumor size (OR=1.107, 95%CI: 1.020-1.203), N staging (OR=4.093, 95%CI: 2.929-5.718), tumor differentiation (OR=1.782, 95%CI:1.042-3.049), and metastasis in No.8a(OR=5.370, 95%CI: 3.425-8.419), No.3(OR=1.127, 95%CI:1.053-1.206), No.6(OR=1.221,95%CI: 1.028-1.450), No.7(OR=2.149, 95%CI: 1.711-2.699), No,11p(OR=2.085, 95%CI: 1.453-2.994), No.14v(OR=2.604, 95%CI: 1.038-6.532) group lymph nodes were the independent risk factors of No.8p lymph node metastasis. One-year, 3-year and 5-year survival rates in positive No.8p group were 85.7%, 47.5% and 22.6%, and those in negative No.8p group were 96.2%, 82.5% and 70.3% respectively, whose differences were significant (χ=109.767, P<0.05).

CONCLUSIONSMetastasis in Np.8p lymph nodes is an important factor affecting the prognosis of patients with advanced gastric cancer. In patients with female gender, tumor diameter ≥5 cm, preoperative late N staging, low tumor differentiation or metastasis in No.8a, No.3, No.6, No.7, No.11p, No.14v group lymph nodes, thorough clean rance of No.8p group lymph node should be considered.

Carcinoembryonic Antigen ; blood ; Female ; Gastrectomy ; Humans ; Lymph Node Excision ; methods ; Lymph Nodes ; physiopathology ; surgery ; Lymphatic Metastasis ; diagnosis ; pathology ; physiopathology ; Male ; Multivariate Analysis ; Neoplasm Grading ; statistics & numerical data ; Neoplasm Staging ; statistics & numerical data ; Prognosis ; Retrospective Studies ; Risk Factors ; Sex Factors ; Stomach Neoplasms ; diagnosis ; mortality ; surgery ; Survival Rate

OBJECTIVETo investigate the prognostic factors of patients with lymph node-negative metastasis gastric cancer (pN0).

METHODSClinicopathological data of patients with pN0 gastric cancer who underwent radical operation at the Department of Surgical Oncology, The First Hospital of China Medical University from May 1980 to August 2012 were collected and analyzed retrospectively.

INCLUSION CRITERIA(1) Patients were diagnosed as gastric adenocarcinoma; (2) Postoperative pathology confirmed T1a to 4bN0M0 gastric cancer; (3) Total number of harvested lymph node was more than 15. The patients, who died within 1 month after the operation, died of other diseases, had remnant gastric cancer, or had incomplete follow-up data, were excluded. Univariate analysis was used to analyze the clinical factors that may influence the prognosis of patients with stage pN0 gastric cancer, then, those significant variables were entered into the Cox's proportional hazards regression model for multivariate analysis to obtain the independent prognostic factors for patients with pN0 gastric cancer finally. Furthermore, the prognosis of patients with pN0 advanced gastric cancer (invasive depth ≥ T2) were analyzed using the same method.

RESULTSA total of 610 patients with pN0 gastric cancer were enrolled in the study, including 441 males and 169 females with age ranging from 19 to 83 (mean 56.4±11.0) years, D1 lymph node dissection in 45 cases, D2 lymph node dissection in 543 cases, D3 lymph node dissection in 22 cases, and 384 cases of advanced gastric cancer. The overall followed-up was 1 to 372 (median 32) months. Ninety cases (14.8%) were dead during the follow-up. The median survival was 277.7(95%CI: 257.6 to 297.8) months, and the 1-, 3-, 5-year survival rates were 96.5%, 87%, 83.2%. Univariate analysis showed that tumor diameter, depth of invasion, gross type, lymph node dissection and lymph vessel cancer embolus were related to the prognosis (all P<0.05). The 5-year survival rate of patients with tumor diameter >4 cm was significantly lower than those with tumor diameter ≤4 cm (75.6% vs. 87.8%, P=0.000). The 5-year survival rates of T1a, T1b, T2, T3 and T4 were 98.4%, 92.8%, 84.2%, 61.0% and 31.4% respectively, and the difference was statistically significant (P=0.000). In gross type, 5-year survival rate of early gastric cancer was 96.0%, and of Borrmann I( to IIII( type gastric cancer was 100%, 83.4%, 73.7% and 68.9% respectively, whose difference was statistically significant(P=0.000). The 5-year survival rates in patients undergoing lymph node dissection D1, D2 and D3 were 100%, 83.3% and 58.7%, and the difference was significant (P=0.005). The 5-year survival rate of patients with positive lymphatic cancer embolus was lower than those with negative ones (69.4% vs. 86.9%, P=0.000). Multivariate analysis showed that the gross type [Borrmann II(/early gastric cancer: HR(95% CI)=15.129(3.284 to 69.699), Borrmann III(/early gastric cancer: HR(95% CI)=14.613 (3.292 to 64.875), Borrmann IIII(/early gastric cancer: HR (95% CI)=15.430 (2.778 to 85.718),Borrmann IIIII(/early gastric cancer: HR(95%CI)=12.604 (1.055 to 150.642), P=0.025] and the positive lymphatic cancer embolus [HR(95% CI)=3.241 (2.056 to 5.108), P=0.000] were the independent prognostic factors of patients with pN0 gastric cancer. For pN0 patients with advanced gastric cancer, multivariate analysis showed that the depth of invasion [stage T3/stage T2: HR(95%CI)=1.520 (0.888 to 2.601), stage T4/stage T2: HR(95%CI)=2.235(1.227 to 4.070); P=0.031] and the positive lymphatic cancer embolus [HR(95%CI)=3.065 (1.930 to 4.868); P=0.000] were the independent risk factors influencing the prognosis.

CONCLUSIONSPositive lymphatic cancer embolus and worse gross pattern indicate poorer prognosis of patients with pN0 gastric cancer, which may be used as effective markers in evaluating the prognosis. As for pN0 advanced gastric cancer, invasion depth and positive lymphatic cancer embolus can play a more important role in the prediction.

Adenocarcinoma ; classification ; diagnosis ; mortality ; Adult ; Aged ; Aged, 80 and over ; China ; Female ; Humans ; Lymph Node Excision ; statistics & numerical data ; Lymph Nodes ; pathology ; surgery ; Lymphatic Metastasis ; physiopathology ; Lymphatic Vessels ; pathology ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Invasiveness ; pathology ; physiopathology ; Neoplasm Staging ; statistics & numerical data ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; classification ; diagnosis ; mortality ; Survival Rate

Endoscopy plays an important role in the diagnosis and treatment of postoperative complications of gastric cancer. Endoscopic intervention can avoid the second operation and has attracted wide attention. Early gastric anastomotic bleeding after gastrectomy is the most common. With the development of technology, emergency endoscopy and endoscopic hemostasis provide a new treatment approach. According to the specific circumstances, endoscopists can choose metal clamp to stop bleeding, electrocoagulation hemostasis, local injection of epinephrine or sclerotherapy agents, and spraying specific hemostatic agents. Anastomotic fistula is a serious postoperative complication. In addition to endoscopically placing the small intestine nutrition tube for early enteral nutrition support treatment, endoscopic treatment, including stent, metal clip, OTSC, and Over-stitch suture system, can be chosen to close fistula. For anastomotic obstruction or stricture, endoscopic balloon or probe expansion and stent placement can be chosen. For esophageal anastomotic intractable obstruction after gastroesophageal surgery, radial incision of obstruction by the hook knife or IT knife, a new method named ERI, is a good choice. Bile leakage caused by bile duct injury can be treated by placing the stent or nasal bile duct. In addition, endoscopic methods are widely used as follows: abdominal abscess can be treated by the direct intervention under endoscopy; adhesive ileus can be treated by placing the catheter under the guidance of endoscopy to attract pressure; alkaline reflux gastritis can be rapidly diagnosed by endoscopy; gastric outlet obstruction mainly caused by cancer recurrence can be relieved by metal stent placement and the combination of endoscopy and X-ray can increase success rate; pyloric dysfunction and spasm caused by the vagus nerve injury during proximal gastrectomy can be treated by endoscopic pyloromyotomy, a new method named G-POEM, and the short-term outcomes are significant. Endoscopic submucosal dissection (ESD) allows complete resection of residual gastric precancerous lesions, however it should be performed by the experienced endoscopists.
Anastomosis, Surgical ; adverse effects ; Bile Ducts ; injuries ; Constriction, Pathologic ; etiology ; therapy ; Digestive System Fistula ; etiology ; therapy ; Duodenogastric Reflux ; diagnostic imaging ; etiology ; Endoscopy, Gastrointestinal ; methods ; Enteral Nutrition ; instrumentation ; methods ; Female ; Gastrectomy ; adverse effects ; Gastric Outlet Obstruction ; surgery ; Gastritis ; diagnosis ; Gastrointestinal Hemorrhage ; etiology ; therapy ; Hemostasis, Endoscopic ; methods ; Hemostatics ; administration & dosage ; therapeutic use ; Humans ; Male ; Neoplasm Recurrence, Local ; surgery ; Postoperative Complications ; diagnosis ; therapy ; Precancerous Conditions ; surgery ; Pylorus ; innervation ; physiopathology ; surgery ; Stents ; Stomach Neoplasms ; complications ; surgery ; Treatment Outcome ; Vagus Nerve Injuries ; etiology ; surgery

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.
Anastomosis, Roux-en-Y ; adverse effects ; China ; Chylous Ascites ; etiology ; prevention & control ; therapy ; Duodenum ; blood supply ; surgery ; Gastrectomy ; adverse effects ; methods ; mortality ; Gastric Outlet Obstruction ; etiology ; prevention & control ; Gastric Stump ; surgery ; Hemostatic Techniques ; Hernia ; etiology ; prevention & control ; therapy ; High-Intensity Focused Ultrasound Ablation ; instrumentation ; Humans ; Jejunum ; blood supply ; surgery ; Lymph Node Excision ; adverse effects ; instrumentation ; Lymphatic System ; injuries ; Postoperative Complications ; classification ; diagnosis ; mortality ; prevention & control ; Prognosis ; Stomach ; surgery ; Stomach Neoplasms ; complications ; surgery ; Suture Techniques ; standards ; Thoracic Duct ; injuries ; Wound Closure Techniques ; standards

The anastomotic complications following radical gastrectomy mainly include anastomotic leakage, anastomotic hemorrhage, and anastomotic stricture. Theanastomotic complications are not rare and remain the most common complications resulting in the perioperativedeath of patients with gastric cancer. Standardized training could let surgeons fully realize that strict selection of operative indications, thorough preoperative assessment and preparation, and refined operation in surgery are the essential measures to prevent the anastomotic complications following radical gastrectomy. In addition, identifying these complications timely and taking effective measures promptly according to the clinical context are the keys to treating these complications, reducing the treatment cycle, and decreasing the mortality.
Anastomosis, Surgical ; adverse effects ; Anastomotic Leak ; prevention & control ; therapy ; Constriction, Pathologic ; prevention & control ; therapy ; Gastrectomy ; adverse effects ; methods ; Gastrointestinal Hemorrhage ; prevention & control ; therapy ; Humans ; Postoperative Complications ; diagnosis ; therapy ; Preoperative Care ; methods ; standards ; Risk Assessment ; methods ; standards ; Risk Factors ; Stomach Neoplasms ; complications ; mortality ; surgery