can we apply the same indications of esd for primary gastric cancer to remnant gastric cancer?
TRANSCRIPT
Can we apply the same indications of ESD for primary gastric cancer to rem-
nant gastric cancer?Saeed Alshomimi, Yoon Young Choi, In Gyu Kwon, Woo Jin Hyung,
Sung Hoon Noh
Department of Surgery, Yonsei University Health system
Cancer in the remnant stomach
1~7% of all gastric cancer
Risk of cancer : 4~7 fold after 20 yearsrisk increasing 28% by every 5 years
Introduction
Introduction
Partial Gastrectomy
↓ Blood supplyDenervation
Duodenal reflux
Hormonal change
Damage of gastric mucosa
Cell proliferation↑
↑ pHin stomach
Nitrate reducing bacteria↑
Nitrosamine↑
RGC
Introduction
Cancer in Remnant Stomach
Remnant Gastric Cancer (cancer after cancer)
Gastric Stump Cancer( Cancer after Benign )
1- Curative gastrectomy2- interval of 12 months3- pathologically confirmed adenocarcinoma in the remnant stomach
Incidence
Introduction
Treatment?
Complete resection of carcinoma with radical LN dissection
Difficult to do because of :postoperative adhesionanatomical deformation
Role of EMR & ESD for primary gastric cancer
Introduction
Role of EMR & ESD for RGC?
Has yet been decided because ofpossible effects of previous cancerlack of sufficient data
However, RGC will increaseearly detection would be possible
Need the indication of ESD for RGC
Introduction
Materials and Methods
105 patients underwent CTG for RGC(from January 1998 to December 2010)
Exclude gastric stump cancer (cancer after benign)
Adopting same indication of ESD for primary gastric cancer
CTG for RGC
( n = 105 )
Advanced
n= 64 (61%)
Early RGC
n=41 (39%)
Contraindications for ESD
N = 24
Expanded Indications
for ESD
N = 11
Absolute Indications
for ESD
N = 6
ESD for RGC
( n = 5 )
Results
T-stage Number of patients(LN+ patients/total pa-
tients)
LN (positive LN/retrieved LN)
Early RGC(n=41)
m 0/25 0/224sm 1*/16 1/120
Total 1/41 1/344
ResultsCTG for RGC
( n = 105 )
Early RGC
n=41 (39%)
ESD for RGC
( n = 5 )
Number of case
Age Sex T-stage Histologi-cal type
Presence of Ulcer
Size Location Lymph Nodepositive LN/retrieved LN
Duration of Follow up (months)
1 45 M m Diff - ≤20mm NAS 0/6 145
AI for ESD
2 71 M m Diff - ≤20mm NAS 0/11 79
3 66 M m Diff - ≤20mm Anastomotic site 0/19 81
4 73 M m Diff - ≤20mm Anastomotic site 0/13 24
5 76 M m Diff - ≤20mm Anastomotic site 0/8 30
6 66 M m Diff - ≤20mm NAS 0/1 24
7 70 M m Undiff - ≤20mm Anastomosis site 0/10 98*
EI for ESD
8 52 M m Undiff - ≤20mm NAS 0/0 73
9 40 M m Undiff - ≤20mm NAS 0/0 18
10 68 M m Diff - ≤30mm Anastomotic site 0/52 75
11 47 F m Undiff - ≤20mm NAS 0/2 18
12 74 M m Undiff - ≤20mm Anastomosis site 0/5 41
13 63 M m Undiff - ≤20mm Anastomosis site 0/11 35
14 33 F m Undiff - ≤20mm NAS 0/15 44
15 59 F m Undiff - ≤20mm NAS 0/8 24
16 43 F m Undiff - ≤20mm NAS 0/3 18
17 66 F Sm1 Diff ≤30mm NAS 0/1 30
Results
No metastatic
LN
CaseAge3 Sex
Reconstruction type
LN dissection Stage Interval to ESD(months) Location
Duration of Follow up (months)
1 75 M DG with BII D1 + T1N0 13 NAS 52
2 77 M DG with BII D1 + T1N0 87 NAS 211
3 64 M DG with BII D1 T1N0 32 NAS 352
4 55 M DG with BI D1 + T3N3 48 NAS 15
5 66 M DG with BI D1 T1N0 25 NAS 42
Results
Patients who underwent endoscopic submucosal dissection for remnant gastric cancer
CTG (n=17, range) ESD (n=5, range)
OP time (minutes) 216 (125~300) 70 (30 ~ 140)Hospital stay (days) 8 (6~83) 2 (2~9)
ComplicationsMinor
Atelectasis : 3 (1 NAS, 2 anastomosis)Transfusion : 1 (NAS)1
Intra-abdominal abscess : 1 (NAS)MajorIntra-abdominal abscess with pleural effusion : 1 (NAS)1
Re-operation with intensive care unit care : 1 (NAS)
Others Combined splenectomy due to injury
MinorFree air : 1OthersIn procedure bleeding : 2
Need clipping : 1Need coagulation : 1
Results
The largest data but still insufficient
Same indication would be possible
Need more evidence from multinational & multicenter review
Discussion
Thanks for your attention!