Norio Shiraishi

A Multicenter Study on Oncologic Outcome of Laparoscopic Gastrectomy for Early Cancer in Japan

Background:Laparoscopic surgery for gastric cancer is technically feasible, but it is not widely accepted because it has not been evaluated from the standpoint of oncologic outcome. We conducted a retrospective, multicenter study of a large series of patients in Japan to evaluate the short- and long-term outcomes of laparoscopic gastrectomy for early gastric cancer (EGC). Methods:The study group comprised 1294 patients who underwent laparoscopic gastrectomy during the period April 1994 through December 2003 in 16 participating surgical units (Japanese Laparoscopic Surgery Study Group). The short- and long-term outcomes of these patients were examined. Results:Distal gastrectomy was performed in 1185 patients (91.5%), proximal gastrectomy in 54 (4.2%), and total gastrectomy in 55 (4.3%); all were performed laparoscopically. The morbidity and mortality rates associated with these operations were 14.8% and 0%, respectively. Histologically, 1212 patients (93.7%) had stage IA disease, 75 (5.8%) had stage IB disease, and 7 (0.5%) had stage II disease (the UICC staging). Cancer recurred in only 6 (0.6%) of 1294 patients treated curatively (median follow-up, 36 months; range, 13–113 months). The 5-year disease-free survival rate was 99.8% for stage IA disease, 98.7% for stage IB disease, and 85.7% for stage II disease. Conclusions:Although our findings may be considered preliminary, our data indicate that laparoscopic surgery for EGC yields good short- and long-term oncologic outcomes.

Quality of life after laparoscopy-assisted Billroth I gastrectomy.

OBJECTIVE To evaluate the quality of life of patients who had undergone laparoscopy-assisted Billroth I gastrectomy (LAG) for cure of cancer. SUMMARY BACKGROUND DATA In 1994, the authors reported the first case of LAG for early gastric cancer, and this approach quickly has been adopted by Japanese surgeons. However, little is known about the subjective clinical results of this less invasive surgery. METHODS Quality of life was estimated using the 24-item questionnaire with a scoring system of 1, 2, and 3 and was compared between 41 consecutive patients with LAG and 35 with conventional open gastrectomy. All patients underwent Billroth I gastrectomy for early gastric cancer from January 1993 to July 1997 and were alive without recurrence. RESULTS Patients who had undergone LAG were taking a normal diet (100%) with >66% of volume at each meal (90%), showed no decreased performance status (90%), and were satisfied with their surgical results (88%). Patients with LAG, when compared with open gastrectomy, showed significantly better results with regard to weight loss, difficulty in swallowing, heartburn and belch, early dumping syndrome, and total score. LAG was better accepted by the patients. CONCLUSIONS Quality of life after Billroth I gastrectomy was significantly better in patients in whom a laparoscopic technique was used than in those who underwent a conventional method. LAG is less invasive and better accepted by patients and is the procedure of choice for the treatment of early gastric cancer.

Rate of detection of lymph node metastasis is correlated with the depth of submucosal invasion in early stage gastric carcinoma

Gastric carcinoma invading the submucosa is often accompanied by lymph node metastasis. However, the relation between the depth of submucosal invasion and the status of metastasis has not been investigated. The objective of this study was to clarify the relation between lymph node status and the histologic features of gastric carcinoma invading the submucosa.

Laparoscopic gastrectomy with lymph node dissection for gastric cancer

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric cancer, and it has been performed worldwide, especially in Japan and Korea. We reviewed the English-language literature to clarify the current status of and problems associated with laparoscopic gastrectomy with lymph node dissection as treatment for gastric cancer. In Japan, early-stage gastric cancer (T1/T2, N0) is considered the only indication for laparoscopic gastrectomy. As yet, there is little high-level evidence based on long-term outcome supporting laparoscopic gastrectomy for cancer, but reports have provided level 3 evidence that the procedure is technically safe, and that it yields better short-term outcomes than open surgery; that is, recovery is faster, hospital stay is shorter, there is less pain, and cosmesis is better. However, investigation into the oncological outcome of laparoscopic gastrectomy as treatment for cancer is lacking. To establish laparoscopic surgery as a standard treatment for gastric cancer, multicenter randomized controlled trials to compare the short- and long-term outcomes of laparoscopic surgery versus open surgery are necessary.

Pattern of lymph node micrometastasis and prognosis of patients with colorectal cancer.

AbstractBackground: Studies of lymph node micrometastases in patients with colorectal cancer have ignored the prognostic significance of the number and level of lymph node micrometastases. The aim of this study was to clarify the prognostic significance of the status of lymph node micrometastases in histologically node-negative colorectal cancer. Methods: We used immunohistochemistry with anti-cytokeratin antibody CAM5.2 to examine 1013 lymph nodes in 42 patients (12 recurrent and 30 nonrecurrent) with histologically determined Dukes’ B colorectal cancer. Five serial 6-μm sections were used for immunohistochemical staining. The frequency, tumor cell pattern, and number and level of lymph node micrometastases were compared between the recurrent and nonrecurrent groups. Results: Micrometastasis was confirmed in 16% (59/373) of lymph nodes in the recurrent group and 12% (77/640) of lymph nodes in the nonrecurrent group, and the frequency of lymph node micrometastases was 92% (11/12) in the recurrent group and 70% (21/30) in the nonrecurrent group. The tumor cell pattern in the metastatic lymph nodes was similar in the recurrent and nonrecurrent groups. Micrometastasis in four or more lymph nodes occurred more frequently in the recurrent group than in the nonrecurrent group (58% vs. 20%, P < .05), and micrometastasis to N2 or higher nodes occurred more frequently in the recurrent group than in the nonrecurrent group (92% vs. 47%, P < .01). Conclusions: The number and level of positive micrometastatic lymph nodes was significantly correlated with postoperative recurrence of histologically determined Dukes’ B colorectal cancer. This parameter is a useful prognostic indicator in histologically node-negative colorectal cancer and is helpful in planning adjuvant chemotherapy.

AFP-Producing Gastric Carcinoma: Multivariate Analysis of Prognostic Factors in 270 Patients

Serum α-fetoprotein (AFP) is sometimes high in patients with primary gastric carcinoma, and there is no comprehensive study on the clinicopathologic characteristics and prognostic factors of AFP-producing gastric carcinoma (AGC). To clarify the variables associated with the survival after gastrectomy for AGC, we reviewed the data of patients with AGC and examined the independent prognostic factors. We studied 270 cases of AGC reported in the Japanese literature from June 1982 to March 2001, together with 1 patient of our own experience. The clinicopathologic findings, including serum AFP level, operative curability, and stage of the disease were examined, and factors associated with survival were determined by multivariate analysis. There were 15 stage I tumors (6%), 50 stage II tumors (19%), 51 stage III tumors (20%), and 145 stage IV tumors (55%). The tumors were characterized by frequent serosal invasion (75%), lymph node metastasis (83%), liver metastasis (33%), stage III or IV disease (75%), and noncurative operation (48%). The survival was influenced by the serum AFP level, tumor size, serosal invasion, lymph node metastasis, and liver metastasis, but the independent prognostic factors were operative curability (curative vs. noncurative) and stage of the disease (I, II vs. III, IV). Although the 5-year survival rate and median survival period in all patients were 22% and 14 months, respectively, those in patients with curative gastrectomy were 42% and 29 months, respectively. The results indicate that operative curability and stage of the disease are factors associated with the survival of patients with AGC. Although tumors are often advanced and complicated with liver metastases, long-term survival can be achieved when patients with stage I or II tumor undergo curative gastrectomy.

Current status of laparoscopic gastrectomy for cancer in Japan

Because of the increased incidence of early gastric cancer in Japan, minimally invasive laparoscopic approaches to gastric malignancies have been under development since 1991. Laparoscopic local resection of the stomach, i.e., laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR), is used to treat mucosal cancer without lymph node metastasis. Laparoscopy-assisted distal gastrectomy (LADG) is used to treat early gastric cancer with risk factors for regional lymph node metastasis. A survey conducted by the Japan Society for Endoscopic Surgery showed that 1428 LWRs, 260 IGMRs, and 2600 LADGs were performed between 1991 and 2001 in departments of endoscopic surgery in Japan. Laparoscopic gastrectomy for gastric cancer is still under development in Japan. According to short-term results reported by a small group of surgeons, laparoscopic approaches to gastric cancer provide for minimal invasion, early recovery, and decreased morbidity and mortality. If the advantages can be confirmed in one or more multicenter randomized control studies of the long-term outcome of patients undergoing laparoscopic gastrectomy for gastric cancer, the procedure should come into wide acceptance and use.

Laparoscopy-assisted Billroth-I gastrectomy (LADG) for cancer: our 10 years' experience.

To evaluate laparoscopy-assisted Billroth-I gastrectomy (LADG), we examined the outcome of its use over the last 10 years. From December 1991 to December 2001, 116 patients with early gastric cancer underwent LADG in the surgical department of Oita Medical University and Koga hospital by the same surgical staffs. An operation record and clinical sheets were reviewed to obtain the operative findings, clinical course, and pathologic findings of resected specimens to evaluate the usefulness of LADG in the management of early gastric cancer. In all LADG procedures, regional lymph nodes dissection (D1+&agr;) was successfully performed using laparoscopy. The mean operative duration and blood loss were 234 minutes and 139 mL, respectively. There were only four major complications, including pneumonia, leakage of anastomosis, pancreatic injury, and anastomotic stenosis, but all these cases were successfully treated conservatively. The mean length of postoperative stay was 16.3 ± 2.5 days. All patients except one, who died not of cancer but of cerebral bleeding, were alive without recurrence or port-site metastasis during mean follow-up period of 45 months. We successfully performed 116 LADG procedures over 10 years. This procedure is recommended for the treatment of patients with early gastric cancer because of the associated good prognosis and several benefits, including less invasiveness and early recovery.

Modern Treatment of Early Gastric Cancer: Review of the Japanese Experience

Background: Recently, detections of early gastric cancer (EGC) have been increasing, and the treatment strategies for gastric cancer have been changing. To demonstrate recent clinical experience of EGC in Japan and to assess modern strategies for the treatment of EGC, we investigated the English-language literature of the past 10 years through computer searches. Methods: This article intends to provide gastric surgeons with recent Japanese experience of the treatment for EGC. In a search for modern treatments of EGC, we selected 100 papers published in well-known medical journals, and focused on the following items of EGC: (1) prognostic factors, (2) endoscopic treatment, (3) surgical procedures, and (4) Japanese guidelines. Results: The most important factor influencing the survival of patients with EGC is the status of lymph node metastasis. The incidence of lymph node metastasis is 1–3% for mucosal cancers and 11–20% for submucosal cancers. Endoscopic mucosal resection (EMR) is a technique for the treatment of EGC, and the recent indication includes the tumors confined to the mucosa up to 3 cm in size or those invading the superficial submucosa. Surgical procedures include conventional Billroth I gastrectomy, limited resections, and laparoscopic surgery. Laparoscopic wedge resection using the lesion-lifting method and laparoscopy-assisted distal gastrectomy provide less pain, faster recovery and shorter hospital stay. Guidelines for the treatment of gastric cancer proposed by the Japanese Gastric Cancer Association show that patients with mucosal cancer can be managed by EMR or distal gastrectomy, whereas patients with submucosal cancer are candidates for distal gastrectomy with lymph node dissection. Conclusion: Although the prognosis of patients with EGC depends on the presence or absence of lymph node metastasis, most are successfully treated by modern endoscopic or surgical techniques. Laparoscopic surgery and limited resections will contribute to the better quality of life of patients with EGC.

Prognostic effect of lymph node micrometastasis in patients with histologically node-negative gastric cancer

BackgroundThere is no consensus as to the impact of lymph node micrometastasis on survival of patients with gastric cancer. The aim of this study was to clarify the prognostic significance of lymph node micrometastasis in patients with histologically node-negative gastric cancerMethodsLymph nodes (n=2039) from 64 patients with histologically node-negative gastric cancer (T2, T3) were evaluated for micrometastasis. Three serial 5-μm sections of the resected lymph nodes were prepared for immunohistochemical staining with the anti-cytokeratin antibody CAM 5.2.ResultsMicrometastasis was found in 73 of 2039 nodes (4%) and 20 of 64 patients (32%). The 5-year survival rate was significantly lower for patients with lymph node micrometastasis than for those without lymph node micrometastasis (66% vs. 95%,P<.01). The 5-year survival rate was significantly lower when there were four or more positive micrometastatic nodes (94% vs. 29%,P <.01) and when there were extragastric micrometastatic nodes (89% vs. 53%,P<.01).ConclusionsLymph node micrometastasis was associated with poor outcome in patients with histologically node-negative gastric cancer. The number and the level of lymph node micrometastases are useful prognostic markers for deciding treatment strategies for additional therapy and follow-up.