Shinichi Sakuramoto

Laparoscopic versus open distal gastrectomy for early gastric cancer in Japan: long-term clinical outcomes of a randomized clinical trial

PurposeWe report the long-term clinical outcomes of a randomized clinical trial comparing laparoscopy-assisted distal gastrectomy (LADG) with open DG (ODG).MethodsBetween 2005 and 2008, 63 patients with clinical T1 (cT1) gastric cancer were randomly assigned to undergo either LADG or ODG. Long-term clinical outcomes included prospective questionnaire-based symptoms and survival.ResultsBased on the responses to the prospective questionnaires, patients who underwent LADG reported greater satisfaction and were more likely to favor the procedure than those who underwent ODG. The most notable difference in symptoms was related to wound pain and diarrhea. After ODG, wound pain reduced in intensity but persisted throughout the follow-up. Surprisingly, diarrhea was more frequent after LADG than after ODG, possibly due to overeating, because symptoms elicited by overeating, such as vomiting after a meal or heartburn, were also more frequent after LADG. In terms of long-term survival, there were no cases of recurrence in either group.ConclusionsLADG was associated with less wound pain during long-term follow-up after surgery, whereas symptoms related to overeating were common. Based on our findings and the patients’ reported satisfaction, we recommend LADG for cT1 gastric cancer as an effective procedure with excellent long-term survival.

Increased neutrophil-to-lymphocyte ratio is a novel marker for nutrition, inflammation and chemotherapy outcome in patients with locally advanced and metastatic esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is one of the most common types of cancer, and its progression is strongly influenced by the presence of inflammation. Recently, there has been growing interest in the host inflammatory response, and increasing evidence has indicated that the neutrophil-to-lymphocyte ratio (NLR), a useful marker of systemic inflammation, may be an effective prognostic indicator in various types of malignant diseases. In the present study, 260 patients with ESCC were enrolled, including 110 who received chemoradiation therapy (CRT) involving irradiation and chemotherapy of 5-fluorouracil and cisplatin, and 150 received chemotherapy using 5-fluorouracil and cisplatin (FP). The patients of each group were both divided into two groups according to their NLR: High NLR (NLR>3.0) and low NLR (NLR≤3.0). Serum levels of prealbumin and retinol binding protein, which are nutritional parameters, were both significantly inversely correlated with NLR in patients treated with CRT, and patients treated with FP. Levels of CRP, a marker of inflammation, were significantly correlated with NLR, and stimulation indices, markers of immune reactions, were inversely correlated with NLR in both of CRT patients and FP patients. In patients treated with CRT, a partial response was significantly higher in patients with a low NLR and with progressive disease compared to those with a high NLR. In patients treated with FP, a partial response was also significantly higher in patients with a low NLR and with progressive disease compared to those with a high NLR. The overall survival of patients with CRT and FP were both significantly worse in patients with a high NLR than in those with a low NLR. NLR may serve as a useful marker of the tumor response, immune suppression, malnutrition and prognosis upon CRT or FP in patients with locally advanced or metastatic ESCC.

Postoperative quality of life after laparoscopy-assisted pylorus-preserving gastrectomy compared With laparoscopy-assisted distal gastrectomy: A cross-sectional postal questionnaire survey

BACKGROUND Little is known about postgastrectomy syndrome and quality of life (QOL after laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG). The aim of this study was to assess postgastrectomy syndrome and QOL after LAPPG as compared with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGBI). METHODS Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaires were sent by mail to 167 patients. To balance the characteristics of the groups, propensity score matching was performed. RESULTS Of the 167 patients sent questionnaires, 112 (67%) responded, including 47 who underwent LAPPG and 65 who underwent LADGBI. After propensity score matching, the LAPPG group scored significantly better on the diarrhea and dumping subscales. Multiple regression analysis showed that female sex and LADGBI were independent factors predicting dumping. Evaluation of outcome measures for singular symptom showed that the LAPPG group scored significantly worse on the acid regurgitation subscale, but significantly better on the lower abdominal pain and early dumping abdominal subscales. CONCLUSION LAPPG is superior to LADGBI for ameliorating postgastrectomy syndrome and maintaining QOL. LAPPG is recommended for patients with cT1N0 middle third gastric cancer.

Impact of insulin-like growth factor-1 receptor and amphiregulin expression on survival in patients with stage II/III gastric cancer enrolled in the Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer.

BackgroundExploratory biomarker analysis was conducted to identify factors related to the outcomes of patients with stage II/III gastric cancer using data from the Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer, which was a randomized controlled study comparing the administration of an orally active combination of tegafur, gimeracil, and oteracil with surgery alone.MethodsFormalin-fixed paraffin-embedded surgical specimens from 829 patients were retrospectively examined, and 63 genes were analyzed by quantitative real-time RT-PCR after TaqMan assay-based pre-amplification. Gene expression was normalized to the geometric mean of GAPDH, ACTB, and RPLP0 as reference genes, and categorized into low and high values based on the median. The impact of gene expression on survival was analyzed using 5-year survival data. The Benjamini and Hochberg procedure was used to control the false discovery rate.ResultsIGF1R and AREG were most strongly correlated with overall survival, which was significantly worse in high IGF1R patients than low IGF1R patients, but better in high AREG patients than low AREG patients. The hazard ratio for death in the analysis of overall survival (S-1 vs. surgery alone) was reduced in the high IGF1R group compared with the low IGF1R group and in the low AREG group compared with the high AREG group. There were no significant interaction effects.ConclusionIGF1R gene expression was associated with poor outcomes after curative resection of stage II/III gastric cancer, whereas AREG gene expression was associated with good outcomes. No significant interaction effect on survival was evident between S-1 treatment and gene expression.

Risk Factors for Residual Tumors in Surgery Following Neoadjuvant Chemotherapy for Thoracic Esophageal Cancer

Abstract Background: Neoadjuvant chemotherapy (NAC) followed by esophagectomy is considered the standard treatment for resectable advanced esophageal squamous cell carcinoma in Japan. The purpose of this study was to identify the risk factors for residual tumors in surgery following NAC. Patients and Method: We reviewed the medical records of patients in our institution selected by using the following criteria: (1) pathologically confirmed squamous cell carcinoma or adenosquamous carcinoma before treatment; (2) cT1-3; and (3) receipt of thoracotomy with the intention of curative resection after NAC composed of 5-fluorouracil plus cisplatin between 2007 and 2010. The patients were divided into the complete resection group (R0 group) and the macroscopic or microscopic residual tumor group (R(+) group). Results: Eighty-eight patients were eligible (R0, 70 patients; R1, 9 patients; R2, 7 patients; and not resected, 2 patients). There were more cT3 cancers and clinical node-positive diseases in the R(+) group ...

Prognosis of Stage IIB early gastric cancer has a unique and dismal property putatively requiring post operative adjuvant chemothrapy

Abstract Background Pathological T1 (pT1) gastric cancer showed excellent prognosis, however lymph node metastasis sometimes reflects patients with dismal prognosis. In this study, we investigated prognosis of pT1 gastric cancer with lymph node metastasis to identify prognostic factors. Patients and Methods Among 1,442 gastric cancer patients between 2002 and 2010, 73 (5%) of pT1 with lymph node metastasis were identified. Univariate prognostic factors were applied to multivariate Cox proportional hazards model. Results (1) Among the 1,442 patients, pT1 was composed of 333 patients with pT1a and 423 patients with pT1b, which included 9 (2.7%) and 64 cases (15.1%) with lymph node metastasis, respectively. (2) Ten (13.7%) patients of the 73 patients with lymph node metastasis showed tumor relapse.　　Univariate negative prognostic factors were tumor size (p=0.03), intraoperative bleeding (p=0.03), and perioperative transfusion (POT)(p=0.001), as well as 14th JGCA Stage (p<0.0001), and multivariate analysis id...

Laparoscopic Versus Open Distal Gastrectomy With D2 Lymph Node Dissection for cT2 Gastric Cancer: A Retrospective Cohort Study of Short- and Long-Term Outcomes

The purpose of this study was to determine whether laparoscopy-assisted distal gastrectomy (LDG) with D2 lymphadenectomy could be a standard treatment for cT2N0-1 gastric cancer. There have been fe...

Esophageal bypass in two patients with a complete response after definitive chemoradiotherapy for thoracic esophageal cancer

Abstract Esophageal bypass is a palliative operation for patients with unresectable esophageal cancer and impaired oral intake. This method is recently used to treat complications such as stenosis associated with esophageal cancer or esophagorespiratory fistula after chemoradiotherapy (CRT). However, its outcome has not been evaluated. We describe the effectiveness of esophageal bypass after CRT in two patients with a complete response (CR) but marked deterioration of quality of life due to esophageal stenosis after definitive CRT. The first patient had metastases in the right recurrent nerve lymph nodes and refused to undergo radical resection. The second patient had unresectable esophageal cancer due to invasion into the right subclavian artery. Both patients responded to esophageal bypass with good oral intake and without relapse. These two cases demonstrate that esophageal bypass can be a good, low-invasive surgical option for patients with CR but with esophageal stenosis after definitive CRT.

A Case of Usefulness of Laparoscopic Surgery for Reflux Esophagitis with Esophageal Stenosis

症例は64歳の男性で, 5年前より胸焼けを, 2か月前より食物のつかえ感と頻回の嘔吐を認め来院した. 上部消化管内視鏡検査にて逆流性食道炎 (Los Angeles分類; 以下, LA: Grade D) を認め, 食道胃接合部には食道炎によるpin hole状の瘢痕性狭窄を伴っていた. 初期治療としてプロトンポンプ阻害薬 (proton pump inhibitor; 以下, PPI) の投薬を開始したが症状は改善しなかった. 次に, バルーンにて計7回の拡張術を施行したが, 拡張後早期の再狭窄を繰り返した. 24時間食道pHモニタリングでは食道内酸逆流時間は6.8%であり, 食道内圧検査では食道体部に運動機能障害を認めた. 以上より, 逆流性食道炎による食道狭窄と診断し, 内科的治療に抵抗性であったため腹腔鏡下Toupet噴門形成術を施行した. 術後つかえ感は消失し, 内視鏡では粘膜障害と食道狭窄が消失した. pHモニタリングでも酸逆流時間は0.3%と正常化した.