Kyong-Choun Chi

Unresectable gastric cancer with gastric outlet obstruction and distant metastasis responding to intraperitoneal and folfox chemotherapy after palliative laparoscopic gastrojejunostomy: report of a case

BackgroundGastric outlet obstruction (GOO) caused by unresectable gastric cancer is a challenging aspect of patient care. There have been no reports involving patients with obstructing gastric cancer and several incurable factors curatively treated by multimodal treatments.Case presentationWe report a case of 55-year-old man who was diagnosed with a poorly differentiated adenocarcinoma in the pre-pyloric antrum with GOO by gastroscopy. An abdominal computed tomography (CT) scan revealed thickening of the gastric wall and adjacent fat infiltration, and a large amount of food in the stomach suggesting a passage disturbance, enlarged lymph nodes along the common hepatic and left gastric arteries, and multiple hepatic metastases. The serum carcinoembryonic antigen (CEA) level was 343 ng/ml and the carbohydrate antigen (CA) 19-9 level was within normal limits. The patient underwent a laparoscopic gastrojejunostomy for palliation of the GOO. On the 3rd and 12th days after surgery, he received intraperitoneal chemotherapy with 40 mg of docetaxel and 150 mg of carboplatin. Simultaneously, combined chemotherapy with 85 mg/m2 of oxaliplatin for the 1st day and 600 mg/m2 of 5-FU for 2 days (FOLFOX regimen) was administered from the 8th post-operative day. After completion of nine courses of FOLFOX, the patient achieved a complete response (CR) with complete disappearance of the primary tumor and the metastatic foci. He underwent a radical subtotal gastrectomy with D3 lymph node dissection 4 months after the initial palliative surgery. The pathologic results revealed no residual primary tumor and no lymph node metastasis in 43 dissected lymph nodes. He has maintained a CR for 18 months since the last operation.ConclusionCombination chemotherapy with systemic and intraperitoneal chemotherapy following laparoscopic bypass surgery showed marked efficacy in the treatment for unresectable advanced gastric cancer with GOO.

A multi-center, open-label, randomized phase III trial of first-line chemotherapy with capecitabine monotherapy versus capecitabine plus oxaliplatin in elderly patients with advanced gastric cancer

OBJECTIVES More than half of cases of gastric cancer (GC) are diagnosed in elderly patients (≥70years). While doublet combination with fluoropyrimidines and platinum is currently considered standard first-line chemotherapy in advanced GC, the main goal of chemotherapy remains palliation. MATERIALS AND METHODS In a multi-center phase III trial, patients with chemotherapy-naïve, metastatic GC, aged 70years or older were randomized 1:1 to receive X monotherapy (capecitabine 1000mg/m2 bid po on days one to fourteen) or XELOX (X plus oxaliplatin 110mg/m2 iv on D1). Treatment was repeated every 21days until disease progression, unacceptable toxicity, or withdrawal. Primary endpoint was overall survival (OS). RESULTS In total, 50 patients with a median age of 77 (range, 70 to 84) were enrolled (X, n=26; XELOX, n=24). No treatment-related serious adverse events or unexpected toxicities were observed. The most frequently observed toxicities were nausea and hand-foot syndrome, with fatigue and peripheral neuropathy more common in XELOX than in X patients. Median OS was 11.1months for XELOX arm and 6.3months for X arm (HR 0.58, 95% CI 0.30-1.12, P=0.108). Although the difference was not significant, on the basis of evidence of superiority of XELOX seen in the first interim analysis, an independent data monitoring committee recommended early stopping of the trial. PFS was significantly longer (HR 0.32, 95% CI 0.17-0.61, P<0.001) with XELOX (7.1months) than with X (2.6months). CONCLUSION Platinum-based combination chemotherapy was associated with survival benefit, as compared with X monotherapy in elderly patients with GC.

Preoperative Body Mass Index May Determine the Prognosis of Advanced Gastric Cancer

ABSTRACT Radical gastrectomy followed by adjuvant chemotherapy for advanced gastric cancer causes serious nutritional impairment. Our study evaluated the clinical impact of body mass index (BMI) on the long-term outcomes of advanced gastric cancer (stage II and III). We analyzed 211 cases of stage II and III gastric cancer between January 2005 and December 2010 at Chung-Ang University Hospital, Seoul, Korea. Patients were divided into four groups according to BMI: underweight, normal, overweight, and obese. In addition, we divided patients into two groups: BMI-High (BMI ≥ 23 kg/m2) vs. BMI-Low (BMI < 23 kg/m2). We assessed age, sex, tumor location, lymph node (LN) involvement, operation method, initial cancer stage, recurrence, and survival between the two groups. There was significant difference in overall survival (OS) between the underweight group and the other groups (P = 0.005). The survival of the BMI-High group was better than that of the BMI-Low group. The rate of cancer-related death in the BMI-High group was significantly lower than that in the BMI-Low group (cancer-related death: BMI-Low 27% vs. BMI-High 12.6%, P = 0.022). Our findings suggest that preoperative BMI may have an influence on the long-term outcomes of advanced gastric cancer after radical surgery and chemotherapy.

Laparoscopic reversal of Hartmann's procedure.

Reversal of Hartmanns procedure is a major surgical procedure associated with significant morbidity and mortality. Because of the difficulty of the procedure, laparoscopic reversal of Hartmanns procedure is not well established. We describe our experience with this laparoscopic procedure to assess its difficulty and safety. Five patients (4 men and 1 woman) underwent laparoscopic reversal of Hartmanns procedure (LRHP). The initial surgeries were performed to manage obstructive colorectal cancer for 4 patients, and rectovesical fistula for one patient. The procedure was laparoscopically completed for 4 patients. Conversion to open laparotomy was required for one patient, secondary to massive adhesion in lower abdomen. Transient ileostomies were made in 2 cases. Operative time ranged from 240 to 545 minutes. There was no operative mortality. LRHP can be performed safely by an experienced surgeon. However, it is still technically challenging and time consuming.

Smaller-Diameter Circular Stapler Has an Advantage in Billroth I Stapled Anastomosis After Laparoscopy-Assisted Distal Gastrectomy

INTRODUCTION Billroth I gastroduodenostomy using a circular stapler is the most preferred reconstruction method after laparoscopy-assisted distal gastrectomy (LADG). The optimal stapler size for this procedure has not yet been proposed. METHODS Sixty-five patients who underwent LADG and stapled anastomosis with a 25-mm stapler (25-mm group) and a 29-mm stapler (29-mm group) were enrolled in this study. Clinical data and gastroscopic findings at 6 and 12 months after surgery were retrospectively reviewed. RESULTS Postoperative complications and postprandial symptoms were similar in both groups. Gastroscopically, food materials remained more frequently in the remnant stomach in the 25-mm group than in the 29-mm group at 6 months after surgery (P=.041). Gastritis and bile reflux were observed more frequently in the 29-mm group than in the 25-mm group (P=.012 and P=.015, respectively). All these differences in the gastroscopic findings between the two groups decreased at 12 months after surgery except for reflux esophagitis, which was observed more frequently in the 29-mm group (P=.002). The length of the incision was smaller in the 25-mm group than in the 29-mm group (4.39 cm versus 4.95 cm, P=.009). CONCLUSION A small-diameter stapler is a risk factor for gastric stasis in the early postoperative period, whereas a large-diameter stapler is a risk factor for gastritis and bile reflux in the early postoperative period and for esophagitis in the late postoperative period. Thus, a small-diameter circular stapler has more advantages over a large-diameter circular stapler. It also enables a reliable anastomosis through a smaller incision and easy handling of the stapler during anastomosis.

Interstitial lung disease caused by TS-1: a case of long-term drug retention as a fatal adverse reaction

TS-1 is an oral anti-cancer agent for gastric cancer with a high response rate and low toxicity. We report a case of long-term drug retention of TS-1 causing interstitial lung disease (ILD) as a fatal adverse reaction. A 65-year-old woman underwent a total gastrectomy with pathologic confirmation of gastric adenocarcinoma. She received 6 cycles of TS-1 and low-dose cisplatin for post-operative adjuvant chemotherapy followed by single-agent maintenance therapy with TS-1. After 8 months, the patient complained of a productive cough with sputum and mild dyspnea. A pulmonary evaluation revealed diffuse ILD in the lung fields, bilaterally. In spite of discontinuing chemotherapy and the administration of corticosteroids, the pulmonary symptoms did not improve, and the patient died of pulmonary failure. TS-1-induced ILD can be caused by long-term drug retention that alters the lung parenchyma irreversibly, the outcome of which can be life-threatening. Pulmonary evaluation for early detection of disease is recommended.

Postoperative Complications of Laparoscopy-assisted Gastrectomy in Early Gastric Cancer: The Importance of Precise Preoperative Staging

Purpose: Although laparoscopy-assisted gastrectomy (LAG) has become a popular treatment option for early gastric cancer, information about postoperative complications is limited in the literature and their risk factors vary among investigators. We analyzed the complications and their risk factors of LAG. Methods: We performed LAGs in 92 gastric cancer patients from July 2006 to December 2009. LAG indication was gastric cancer preoperatively diagnosed as cT1N0. Clinical and operative data and perioperative complications were retrospectively reviewed. According to the surgical experience, cases were divided into early (1∼40) and late (41∼92) groups because operative times stabilized after the 40th case. Results: There were no open conversion or mortality cases. Complications occurred in 11 patients. Two of them were non-surgical complications: postoperative delirium and cerebral infarction. Surgical complications were ischemic necrosis of transverse colon, duodenal stump leakage, anastomotic bleeding, leakage and stenosis. Univariate analysis proved that lymph node metastasis, and comorbidities were related to complication rate (P=0.000, P=0.032). Multivariate analysis proved that lymph node metastasis was the most important risk factor of complication (P=0.001). Surgical experience was not related to complication rate (12.5% in early period and 11.5% in late period, P=1.000). Conclusion: Complication rate of LAG was acceptable (11.9%). According to this study, unexpected lymph node metastasis is thought to be the most important risk factor for complications of LAG. Therefore, it is possible to accomplish lower complication rates in this procedure with careful patient selection through accurate preoperative evaluation. (J Korean Surg Soc 2010;79:340-348)

Antireflux surgery is equally beneficial in nonerosive and erosive gastroesophageal reflux disease

Purpose Although nonerosive and erosive gastroesophageal reflux disease (GERD) have similar symptom severity, nonerosive reflux disease (NERD) is considered a milder type of GERD and gastroenterologists have hesitated to refer these patients for antireflux surgery. The aim of this study was to compare surgical outcomes of antireflux surgery between patients with NERD and erosive reflux disease (ERD). Methods Seventy patients met the inclusion criteria of this study among a total of 117 patients who underwent antireflux surgery from November 2012 to October 2017. According to preoperative endoscopy, patients were classified into NERD group (minimal changes or no esophagitis) and ERD group. Clinical characteristics and surgical outcomes were compared between NERD and ERD. Results There were 26 patients in NERD group and 44 patients in ERD group. The male:female ratio was higher in the ERD group than in the NERD group (P = 0.044). Preoperative symptoms, response to acid suppressive medication, acid exposure on pH monitoring study, and esophageal manometry results were similar in the 2 groups. Reflux on barium esophagography was more frequently observed in ERD (77.3%) than in NERD (50.0%, P = 0.019). At 6 months after surgery, complete resolution and partial improvement of GERD symptoms were similar in the 2 groups (80.8% and 15.4%, respectively, in NERD vs. 88.6% and 2.3%, respectively, in ERD; P = 0.363). Conclusion Laparoscopic Nissen fundoplication is equally beneficial to patients with NERD and ERD. Antireflux surgery should not be avoided for GERD patients without mucosal breaks on endoscopy as the evidence of erosive esophagitis.

Laparoscopic Gastrectomy Performed by an Expert in Open Gastrectomy

Purpose Senior surgeons prefer open gastrectomy (OG), while young surgeons prefer laparoscopic gastrectomy (LG). The purpose of this study was to evaluate the surgical outcomes of LG performed by a senior surgeon who was an expert in OG during his learning period, by comparing them with LGs performed by a young surgeon. Materials and Methods A senior surgeon performed 50 curative gastrectomies with laparoscopy (LG-S group) from March 2015 to August 2016. A young surgeons initial 50 LGs comprised the LG-Y group. Clinicopathological characteristics and surgical outcomes were compared between the LG-S and LG-Y groups. Results D2 lymphadenectomy was more frequently performed in the LG-S group than in the LG-Y group (P=0.029). The operation time and number of retrieved lymph nodes did not significantly differ between the 2 surgeons (P=0.258 and P=0.410, respectively). Postoperative hospital stay and postoperative complication rate were similar between 2 groups (P=0.234 and P=1.000, respectively). Similarly, significant decreases in operation time with increasing case numbers were observed for both surgeons, whereas the number of retrieved lymph nodes increased significantly in the LG-Y group but not in the LG-S group. Conclusions The LG outcomes when performed by the senior surgeon were comparable to those when performed by the young surgeon, despite performing more extended lymphadenectomies. Senior surgeons who are experts in OG should not refrain from performing LG.

Prediction of the long-term outcomes associated with body mass index and advanced gastric cancer.

82 Background: Radical gastrectomy followed by adjuvant chemotherapy for advanced gastric cancer brings about serious nutritional impairment. Recent studies have shown an association between body mass index (BMI) and perioperative outcomes of gastric cancer. However, little is known about the association between BMI and long-term outcomes of advanced gastric cancer. Our study evaluated the clinical impact of BMI on the long-term outcomes of gastric cancer staged at II and III, treated by radical gastrectomy followed by adjuvant chemotherapy. Methods: We analysed a total of 211 cases of advanced gastric cancer stage II and III between January 2005 and December 2010 at Chung-Ang University Hospital. The patients were divided into 4 groups according to BMI; underweight, normal, overweight, and obese. In addition, they were divided into two groups (BMI-High vs BMI-Low). We assessed age, sex, tumor location, lymph node involvement, operation method, initial cancer stage, recurrence, and survival (overall survi...