J Gastrointest Surg DOI 10.1007/s11605-014-2576-3

ORIGINAL ARTICLE

Subtotal Gastrectomy with Limited Lymph Node Dissection is a Feasible Treatment Option for Patients with Early Gastric Stump Cancer Tomoyuki Irino & Naoki Hiki & Souya Nunobe & Manabu Ohashi & Shinya Tanimura & Takeshi Sano & Toshiharu Yamaguchi

Received: 17 March 2014 / Accepted: 9 June 2014 # 2014 The Society for Surgery of the Alimentary Tract

Abstract The de facto standard treatment for early gastric stump cancer (GSC) has been total gastrectomy combined with radical lymph node dissection. However, some patients could benefit if partial resection of the gastric stump is feasible. We investigated the feasibility of subtotal gastrectomy for early GSC as less invasive surgery. Subtotal gastrectomy was defined as a segmental resection of the gastric remnant including the anastomosis with limited lymph node dissection. A total of 66 patients with early GSC were enrolled and 24 patients (36.4 %) underwent subtotal gastrectomy (SG group). Clinicopathological characteristics were analyzed along with those of the other 42 patients (63.6 %) who underwent total gastrectomy (TG group). There were no significant differences between the two groups in the number of lymph nodes harvested (p=0.880). Lymph node involvement was detected in 2 patients (8.3 %) in SG group and 5 patients (11.9 %) in TG group (p=1.000). The previous disease (benign or malignant) and surgery (Billroth I or II) did not affect the rate of nodal involvement. The 5-year overall survival rate of SG group (94.7 %) was acceptable. Subtotal gastrectomy of the gastric remnant could be a feasible treatment option for patients with early gastric stump cancer when indicated. Keywords Early gastric cancer . Gastric stump cancer . Subtotal gastrectomy . Total gastrectomy

Introduction Gastric stump cancer (GSC) is defined as all carcinomas arising in the gastric remnant following a gastrectomy regardless of the histology of the previous lesion (benign or malignant), its risk of recurrence, the extent of initial resection, or methods of reconstruction.1 Although a standard treatment for GSC has not been proposed in any guidelines because of a lack of evidence, the de facto standard treatment for GSC has been total gastrectomy combined with a radical lymph node T. Irino : N. Hiki (*) : S. Nunobe : M. Ohashi : S. Tanimura : T. Sano : T. Yamaguchi Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku 135-8550, Tokyo, Japan e-mail: [email protected]

dissection; a survey conducted in Japan revealed that approximately 90 % of patients with resectable GSC underwent total gastrectomy.2 Some patients with early GSC underwent partial gastrectomy as a less-invasive surgery, which is based solely on an assumption that early GSC might have a low incidence of lymph node involvement. Although no report has validated the assumption, we also have performed subtotal gastrectomy of the gastric remnant with a limited lymph node dissection on patients with early GSC in whom the cancer was located at the distal side or the anastomotic site of the gastric remnant because we believe that patients with the small gastric stump could live better in terms of quality of life (QOL) than those without the whole stomach. We conducted a retrospective study using patients who underwent surgery for early GSC in our institution and investigated clinicopathological factors along with prognosis to clarify whether the subtotal gastrectomy of the gastric remnant for early GSC was feasible.

J Gastrointest Surg

Patients and Methods Study Patient This is a retrospective study using data collected in a single hospital, and we reviewed medical records and collected clinicopathological and follow-up data. We performed surgery for 4,809 patients with gastric cancer between January 2002 and March 2012. Of these, a total of 138 patients (2.9 %) were identified who underwent surgery for GSC in our hospital, and 68 (49.3 %) out of 138 patients had early GSC pathologically diagnosed as having invasion into mucosa or submucosa irrespective of lymph node involvement. Since all patients had undergone pathologically curative surgery, no definite or conclusive recurrence was included in the analysis. Among the 68 patients, total gastrectomy with a radical lymph node dissection, subtotal gastrectomy with limited lymph node dissection, and partial resection without lymph node dissection were performed on 42 patients (61.8 %), 24 patients (35.3 %), and 2 patients (2.9 %), respectively. Finally, the 66 patients (97.1 %) who underwent total gastrectomy or subtotal gastrectomy were analyzed.

nodes along the short gastric artery and at the left side of the cardia), and around the spleen (hialar lymph nodes) in order to keep enough blood supply to the gastric remnant after subtotal gastrectomy. During surgery, we usually confirm whether no lymph node was involved by a frozen section of harvested lymph nodes. Data Collection The pathological stage was recorded in accordance with the 7th edition TNM classification by Union for International Cancer Control. Histologic types were classified into two categories: differentiated and undifferentiated. The former included papillary, well-differentiated, and moderately differentiated adenocarcinoma, and the latter included poorly differentiated adenocarcinoma and signet-ring cell carcinoma. The tumor location was concisely divided into three groups: cardia, body, and anastomosis. The “cardia” and “anastomosis” cancers comprised tumors located within 2 cm from the cardia and anastomosis, respectively. In cases where multifocal lesions were identified in the gastric remnant, the largest or the deepest tumor, which seemed to have the greatest impact on prognosis, was considered for analysis.

Primary Indication for Subtotal Gastrectomy Statistical Analysis The procedure for tumor in the gastric stump was decided based primarily on the location of tumor. The indications for subtotal gastrectomy were basically as follows: clinically early GSC, no obvious lymph node swelling on computedtomography images, and tumor located at anastomotic site or adjacent to anastomosis (approximately within 2 cm from the anastomosis). However, the gastric stump was greatly affected by the primary disease and procedure, thus different patients had different capacities and anatomy of the gastric stump. For that reason, the final decision was made on a case-by-case basis. Since the patients were analyzed historically, all patients with GSC until April 2002 underwent total gastrectomy when the first subtotal gastrectomy with limited lymph node dissection was performed. Surgical Procedure We defined the procedure of subtotal gastrectomy as a segmental resection of the gastric remnant including the anastomosis with limited lymph node dissection. Although the remaining lymph nodes varied among patients, depending on the histology of the previous lesion and the methods of reconstruction, we usually harvested lymph nodes along the lesser curvature, around the anastomosis, the left gastric artery, the splenic artery, the celiac axis, and the superior margin of the pancreas. Lymph nodes in the jejunal mesentery, where relevant, were also removed. On the other hand, we did not remove lymph nodes along the greater curvature (lymph

Statistical analyses were performed with R version 2.15.0. The Chi-square test, Fisher’s exact probability test, and Student’s t test were used to compare two groups, and p value less than 0.05 was considered as significant. The cumulative 5year survival rate was calculated by Kaplan–Meier method with 95 % confidence intervals and survival curves were compared using log–rank test.

Results As above, 66 patients with early GSC were included in the analysis. The mean age was 70.6 years ranging from 47 to 86 years, and 55 patients (83.3 %) were male and 11 (16.7 %) were female. Mean follow-up months in all patients were 34 months. The patient clinicopathological characteristics were shown in Table 1. There were no significant differences in patient background between the two groups including age, gender, follow-up period, and histologic type. Because of the nature of the study, patients in SG group had a tumor located in the anastomotic site or around while patients in TG group tended to have a tumor located in the body of the gastric stump or near cardia (p

Subtotal gastrectomy with limited lymph node dissection is a feasible treatment option for patients with early gastric stump cancer.

The de facto standard treatment for early gastric stump cancer (GSC) has been total gastrectomy combined with radical lymph node dissection. However, ...
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