0
Original Article |

Actual 3-Year Survival After Laparoscopy-Assisted Gastrectomy for Gastric Cancer FREE

Sun-Hwi Hwang, MD; Do Joong Park, MD; Ye Seob Jee, MD; Min-Chan Kim, MD; Hyung-Ho Kim, MD; Hyuk-Joon Lee, MD; Han-Kwang Yang, MD; Kuhn Uk Lee, MD
[+] Author Affiliations

Author Affiliations: Departments of Surgery, Seoul National University Bundang Hospital, Gyeonggi (Drs Hwang, Park, Jee, and H.-H. Kim), Seoul National University College of Medicine, Seoul (Drs H.-H. Kim, H.-J. Lee, Yang, and K. U. Lee), and Dong-A University College of Medicine, Busan (Dr M.-C. Kim); and Cancer Research Institute, Seoul National University College of Medicine (Drs H.-J. Lee and Yang), Korea.


Arch Surg. 2009;144(6):559-564. doi:10.1001/archsurg.2009.110.
Text Size: A A A
Published online

Objective  To analyze 3-year actual disease-free survival after laparoscopy-assisted gastrectomy for gastric cancer on the assumption that 3-year disease-free survival may represent 5-year overall survival.

Design  Retrospective analysis.

Setting  Department of surgery of a university hospital.

Patients  A total of 197 patients who underwent laparoscopy-assisted gastrectomy for gastric cancer from May 1998 to September 2007 and who were followed up for more than 3 years.

Main Outcome Measures  Feasibility and long-term survival rate with survival analysis by the Kaplan-Meier method.

Results  Subtotal and total gastrectomies were performed in 178 and 19 patients, respectively. The scope of the lymph node dissections were D1 + β (n = 152) and D2 (n = 45). There were 153, 28, 8, 6, 1, and 1 patients in stages Ia, Ib, II, IIIa, IIIb, and IV, respectively. The median follow-up was 45 months (range, 1-113 months), and there were 7 recurrences. Multivariate analysis of disease-specific survival showed that depth of invasion and lymph node metastasis influenced the prognosis independently. The actual 3-year disease-free survival rate for all patients was 96.9%. The 173 patients with early gastric cancer and 24 with advanced gastric cancer showed 98.8% and 79.1% actual 3-year disease-free survival rates, respectively.

Conclusions  Laparoscopy-assisted gastrectomy is acceptable oncologically in early gastric cancer if 3-year disease-free survival represents 5-year overall survival. Laparoscopy-assisted gastrectomy may also play an important role in the treatment of advanced gastric cancer.

Figures in this Article

Despite the universal decline in gastric cancer incidence and mortality, particularly in the United States and Western Europe, gastric cancer is still the second most common cancer worldwide.1,2 In Far Eastern countries such as Korea, Japan, and China, and also in many developing countries, gastric cancer is the most prevalent malignant neoplasm and the leading cause of cancer death.3,4 The technical aspects of its treatment are constantly evolving to reduce the particularly high preoperative and postoperative mortality and morbidity,57 and minimally invasive surgery should be considered a tool worth evaluating for optimizing therapy for gastric cancer. Recently, laparoscopic approaches have been introduced to treat patients with early gastric cancer.810

Since the first report in 1992 of laparoscopy-assisted distal gastrectomy (LADG) with Billroth II anastomosis for a case of peptic ulcer disease,11 laparoscopy-assisted gastrectomy (LAG) and lymph node dissection with curative intent have been recommended and practiced for the treatment of early gastric cancers in Korea and Japan.12,13 Those studies demonstrated that LADG is less invasive than open surgery, thus leading to faster recovery.13 However, only a few reports concerning the prognosis of patients who underwent LAG for early gastric cancer or LAG outcome data have been published.12,14,15

Recurrence rates after gastrectomy for gastric cancer remain high, ranging from 40% to 80%, depending on the series.16,17 Most recurrences occur within the first 3 years.18 Moreover, most patients with recurrent gastric cancer die within 1 to 2 years. Therefore, actual 3-year disease-free survival has important implications in terms of curability.

We report the 3-year survival of a retrospective series of 197 patients with gastric adenocarcinoma who underwent LAG and whose treatment included minimally invasive surgery used a surgical tool with “intention-to-treat” laparoscopy.

PATIENTS

A review of our prospective gastric cancer database and electronic medical records from May 1998 to September 2007 found 197 patients with gastric cancer who underwent LAG in the Department of Surgery at Dong-A University and Seoul National University Bundang Hospital. All patients were followed up for more than 3 years after their operations. All surgeries were performed by a single surgeon (H.-H.K.). Endoscopic ultrasonography and stomach computed tomography were performed routinely to discriminate early from advanced gastric cancer. We performed LAG in patients diagnosed as having cT1N0M0 to cT2N0M0 gastric cancer, regardless of sex, age, body mass index, previous abdominal operative history, or comorbidities. Of the 197 patients who underwent LAG, 178 had LADG and 19 had laparoscopy-assisted total gastrectomy (LATG).

OPERATION

Depending on the extent of lymph node dissection, modified surgery is classified as D1 + α or D1 + β dissection. The No. 7 lymph nodes are dissected during a D1 + α procedure, regardless of the location of the lesions; in addition, No. 8a lesions are dissected in cases in which lesions are located in the lower third of the stomach. The No. 7, 8a, and 9 lymph nodes are dissected during a D1 + β procedure. In this study, there were 2 types of lymphadenectomy. Patients with T1sm lesions invading to the submucosa underwent D1 + β dissection; those with lesions classified as T2 or greater underwent D2 dissection.

For LAG, after a pneumoperitoneum was established by the open technique, 6 ports were placed. The procedure began by dividing the greater omentum 3 to 4 cm from the gastroepiploic arcade toward the branch of the short gastric vessels, including lymph nodes 4d and 4sb in LADG. In LATG, all short gastric vessels were divided with dissection of their lymph nodes (group 4sa), followed by division of the gastrophrenic ligament. Division of the gastrocolic ligament was continued distally toward the first portion of the duodenum. The right gastroepiploic vein and artery were individually divided after clipping to clear lymph node 6. After the right gastric artery, proper hepatic artery, and anterior surface of the portal vein had been exposed for clearing lymph nodes 5 and 12a, the right gastric artery was divided at its origin by means of vessel ligating clips (Hem-O-Lok; Weck Closure Systems, Teleflex Inc, Research Triangle Park, North Carolina). Caudal retraction of the pancreas with a 5-mm fan retractor facilitated exposure of the common hepatic artery, splenic artery, and celiac trunk. Lymph nodes 8a, 9, and 11p were dissected along each artery with an ultrasonic scalpel (Harmonic; Ethicon Inc, Somerville, New Jersey) or by electrocautery. In addition, the right cardiac node (node 1), left cardiac node (node 2), splenic hilar node (node 10), and the nodes along splenic vessels (No. 11 nodes) were dissected in LATG. The left gastric artery and vein were exposed and divided individually with vessel ligation clips, allowing dissection of the No. 7 lymph nodes. Additional dissection of the No. 9 lymph nodes was added proximally. Lymph nodes 1 and 3 were dissected, and the upper third of the lesser curvature was skeletonized. After full mobilization of the stomach, a 4- to 5-cm transverse incision was made for removal of the specimen and for reconstruction. Billroth I or II or Roux-en-Y reconstruction was performed in LADG, and Roux-en-Y esophagojejunostomy was performed in LATG.

FOLLOW-UP OF PATIENTS

Follow-up investigations were scheduled in our department at 3-month intervals for the first 2 years, then every 6 months for the next 3 years, and annually until the patient's death. The follow-up program consisted of a physical examination, laboratory blood tests, endoscopy, and ultrasonography or computed tomography. Recurrence was diagnosed from clinical, radiologic, or endoscopic signs of disease.

STATISTICAL ANALYSIS

Data were collected by reviewing electronic medical records and our gastric cancer database. Patient characteristics, operative findings, clinicopathological measures, and postoperative progress including complications were recorded and analyzed.

Statistical analysis was performed by SPSS software (basic and advanced program, version 11.0; SPSS Inc, Chicago, Illinois). All values are expressed as the mean and standard error of the mean. Overall and disease-free survival rates were assessed by Kaplan-Meier analysis and compared by the log-rank test. Significance was taken as P < .05.

The 197 patients treated in this series consisted of 112 men and 85 women with a mean age of 58.3 years (SEM, 12.6 years; range, 24-87 years) and a mean body mass index of 22.7 (SEM, 2.8) (calculated as weight in kilograms divided by height in meters squared).

Short-term outcomes, including operative details and postoperative course, are shown in Table 1. All procedures were completed successfully without conversion. The mean estimated blood loss was 58.3 mL. Patients were hospitalized for a median of 8.9 days. The mean (SEM) time until the start of oral intake was 3.9 (1.3) days.

Table Graphic Jump LocationTable 1. Clinicopathologic Results After Laparoscopy-Assisted Gastrectomy

Complications occurred in 18 of the 197 patients (9.1%). Major postoperative complications consisted of 3 cases of postoperative bleeding, 2 of gastrointestinal tract bleeding, 3 wound infections, 3 cases of intra-abdominal fluid collection, and 1 case each of ascites due to underlying liver cirrhosis, esophagojejunostomy anastomotic leakage, duodenal stump leakage, splenic infarction, delayed gastric emptying, leakage of lymphatics, and respiratory complication. Among them, 3 cases of postoperative bleeding, 1 of duodenal stump leakage, 1 of anastomotic leakage, and 1 of splenic infarction were treated by reoperation. The other patients recovered with nonoperative management. One patient (0.5%) died 1 month after the operation. The patient developed bleeding, which required reoperation, and subsequently died of multiple organ failure.

Among the 197 patients, 24 had advanced gastric cancer (12.2%). The stages of the tumor were IA in 153 (77.7%) patients, IB in 28 (14.2%), II in 8 (4.1%), IIIA in 6 (3.0%), IIIB in 1 (0.5%), and IV in 1 (0.5%).

Table 2 shows recurrences after operation. There were 7 cancer recurrences (3.5%): 2 ovarian metastases, 3 bony recurrences, 1 lymph node metastasis, and 1 lung metastasis during the median follow-up period of 45 months (range, 1-112 months). All recurrences occurred within 34 months of operation. The mean time to recurrence was 18.7 (SEM, 10.4) months (range, 8-34 months).

Table Graphic Jump LocationTable 2. Recurrences After Laparoscopy-Assisted Gastrectomy

The disease-free actual 3-year survival rates were 98.8% (171 of 173) and 79.2% (19 of 24) for early and advanced gastric cancers, respectively (P < .001) (Figure 1). The overall actual 3-year survival rate was 96.9% (Figure 2). The factors affecting the disease-free survival of the patients were the presence of lymph node metastasis (P < .001), tumor size of 5 cm or larger (P = .02), and depth of invasion (early vs advanced gastric cancer; P < .001; Table 3). On multivariate analysis, the depth of invasion (P = .02; odds ratio, 5.94; 95% confidence interval, 1.26-27.8) and presence of lymph node metastasis (P < .001; odds ratio, 21.3; 95% confidence interval, 2.32-196.5) were independent factors affecting overall survival (Table 4).

Place holder to copy figure label and caption
Figure 1.

Actual 3-year disease-free survival. AGC indicates advanced gastric cancer; EGC, early gastric cancer.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Overall actual 3-year disease-free survival. Five deaths were excluded from the analysis (from a traffic accident in 1, fulminant hepatitis in 1, multiple organ failure in 2, and suicide in 1).

Graphic Jump Location
Table Graphic Jump LocationTable 3. Factors Affecting Disease-Free Survival (Univariate Analysis)
Table Graphic Jump LocationTable 4. Multivariate Analysis for Factors Affecting 3-Year Disease-Free Survival Rate

Despite a declining incidence, gastric cancer remains an important cause of cancer death.19 This high incidence of gastric cancer, coupled with strong public and physician cooperation in screening, has enabled the Koreans to institute a national effort to diagnose gastric cancers.

Surgical resection for gastric cancer is the only therapeutic modality for curability.20 Recently, several studies have demonstrated immediate postoperative advantages of laparoscopic surgery over conventional open surgery for resection of gastric cancers.13 Furthermore, short-term oncologic outcomes were not compromised by the laparoscopic approach.9,12,21 The Japanese Gastric Cancer Association22 has provided indications for LADG, including (1) mucosal cancer without preoperatively diagnosed lymph node metastases and (2) cancer with submucosal invasion and without preoperatively diagnosed lymph node metastases. However, in our institution, gastric cancers in categories less than cT2aN0M0 are treated by LAG.

The use of LAG has been criticized for its radical nature, and some of these criticisms are apt in this study. However, Kim et al23 recently confirmed that LADG with extraperigastric lymph node dissection (No. 7, 8, and 9) proved to be a feasible and acceptable surgical technique for early gastric cancer. The optimal extent of lymph node dissection for early gastric cancer remains controversial; however, most surgeons consider D1 + β gastrectomy to be the standard and optimal surgical procedure for patients with early gastric cancer2426 and D2 gastrectomy for patients with advanced gastric cancer.27 Song et al28 showed that the number of lymph nodes retrieved laparoscopically is adequate for staging, and LAG with D2 gastrectomy is a technically feasible procedure when compared with open surgery.

The patterns of recurrence also did not appear to be different between laparoscopic and open gastrectomy.15 However, LAG for the treatment of malignant neoplasms remains controversial because of the lack of large-scale study data on short-term and long-term outcomes.

The depth of cancer invasion through the gastric wall and the presence or absence of lymph node involvement are 2 important factors influencing survival in resectable gastric cancer.29,30 Lee et al31 reported that early gastric cancer with lymph node metastasis has a higher possibility of recurring, especially when there are more than 6 positive lymph nodes. They also reported that the median interval between gastrectomy and recurrence was 18.5 months, that 76.1% of cases recurred within 36 months, and that 23.9% recurred after 36 months. In our series, 7 among 197 cases recurred within the median follow-up period of 45 months. All recurrences occurred within 34 months.

The rationale for minimally invasive treatment is the low incidence of lymph node metastasis for mucosal cancer (T1m). Recent reports of the histopathological features of more than 13 000 mainly Japanese patients with early gastric cancer established that only 2% (range, 0%-4.8%) of patients with mucosal cancer have positive lymph nodes.32 However, when the tumor invades the submucosal layer (T1sm), this rate increases to about 20% (range, 15%-25%). Interestingly, the metastasis is not confined to the perigastric nodes (N1 level) only, but in about 5% (range, 2.8%-6.4%) of patients with submucosal cancers it will also involve the extraperigastric lymph nodes (N2 level). A risk factor for N2 disease is a submucosal lesion larger than 2 cm.33 This finding is important clinically; there is a clear consensus that R0 resection is the most important independent treatment-related prognostic factor, and complete removal of metastatic N2 nodes would only be achieved by the more radical D2 lymph node dissection.34,35

The prognosis of patients with early gastric cancer is known to be excellent, with 5-year survival rates of 90% or more.36,37 However, lymph node metastasis, large tumors, submucosal invasion, and lymphatic involvement of cancer cells remain risk factors for recurrence of early gastric cancer.3840 Kwon et al41 reported that 3-year disease-free survival can be substituted for 5-year survival in curatively resected gastric cancer, and, considering the previously reported results,42 this study showed that patients with early gastric cancer treated by LAG had an excellent 3-year survival rate, despite the short median follow-up period of 45 months. Moreover, mortality and morbidity rates appear to be comparable to those in conventional surgery.

The survival rates after gastrectomy for gastric cancer in published series are summarized in Table 5.5,12,4345 Our survival results after LAG were slightly better than those of other open gastrectomy or LAG series, although accurate comparison is not possible because of the relatively shorter follow-up period and smaller patient numbers with stage IIIA, IIIB, and IV tumors compared with other series.

Table Graphic Jump LocationTable 5. Comparison of Survival Rates After Gastrectomy for Gastric Cancer

We demonstrated the following clinicopathological factors to be correlated with recurrence: (1) muscularis propria invasion, (2) lymph node metastasis, and (3) large tumor size (≥5 cm). This observation is consistent with previous reports by other investigators.30,39 However, multivariate analysis showed that the first 2 factors, but not the last one, are independent risk factors for recurrence. Therefore, we believe that LAG is feasible in patients with node-negative early gastric cancer. However, it is difficult to discriminate positive nodes from normal nodes and early from advanced gastric cancer preoperatively or intraoperatively. There have been various attempts to improve the accuracy of preoperative and intraoperative diagnosis, with generally unsatisfactory results.46 Therefore, accurate diagnostic modalities for determining preoperative tumor depth and lymph node metastasis should be evaluated so that LAG can be performed more safely.

In conclusion, LAG with regional lymph node dissection for early gastric cancer is considered a safe and curative procedure. A large-scale multicenter randomized trial is needed to document with certainty the benefits and oncologic safety of laparoscopic vs open gastrectomy in both early and advanced gastric cancers.

Correspondence: Hyung-Ho Kim, MD, Department of Surgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi, Korea (hhkim@snubh.org).

Accepted for Publication: May 22, 2008.

Author Contributions:Study concept and design: Hwang, Park, Yang, and K. U. Lee. Acquisition of data: Jee, M.-C. Kim, H.-H. Kim, and H.-J. Lee. Analysis and interpretation of data: Hwang. Drafting of the manuscript: Hwang and M.-C. Kim. Critical revision of the manuscript for important intellectual content: Park, Jee, H.-H. Kim, H.-J. Lee, Yang, and K. U. Lee. Statistical analysis: Jee. Obtained funding: H.-H. Kim. Administrative, technical, and material support: K. U. Lee. Study supervision: Hwang, Park, M.-C. Kim, H.-H. Kim, H.-J. Lee, and Yang.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant 0520310-3 from the National Research and Development Program for Cancer Control, Ministry of Health and Welfare, Republic of Korea.

Parkin  DMBray  FIDevesa  SS Cancer burden in the year 2000: the global picture. Eur J Cancer 2001;37 ((suppl 8)) S4- S66
PubMed
Parkin  DM International variation. Oncogene 2004;23 (38) 6329- 6340
PubMed
Lee  HJYang  HKAhn  YO Gastric cancer in Korea. Gastric Cancer 2002;5 (3) 177- 182
PubMed
Inoue  MTsugane  S Epidemiology of gastric cancer in Japan. Postgrad Med J 2005;81 (957) 419- 424
PubMed
Bonenkamp  JJHermans  JSasako  M  et al. Dutch Gastric Cancer Group, Extended lymph-node dissection for gastric cancer. N Engl J Med 1999;340 (12) 908- 914
PubMed
Cuschieri  AWeeden  SFielding  J  et al. Surgical Co-operative Group, Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Br J Cancer 1999;79 (9-10) 1522- 1530
PubMed
Kim  JP Current status of surgical treatment of gastric cancer. J Surg Oncol 2002;79 (2) 79- 80
PubMed
Asao  THosouchi  YNakabayashi  THaga  NMochiki  EKuwano  H Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer. Br J Surg 2001;88 (1) 128- 132
PubMed
Mochiki  ENakabayashi  TKamimura  HHaga  NAsao  TKuwano  H Gastrointestinal recovery and outcome after laparoscopy-assisted versus conventional open distal gastrectomy for early gastric cancer. World J Surg 2002;26 (9) 1145- 1149
PubMed
Mochiki  EKamimura  HHaga  NAsao  TKuwano  H The technique of laparoscopically assisted total gastrectomy with jejunal interposition for early gastric cancer. Surg Endosc 2002;16 (3) 540- 544
PubMed
Goh  PTekant  YIsaac  JKum  CKNgoi  SS The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc 1992;2 (3) 258- 260
PubMed
Kitano  SShiraishi  NUyama  ISugihara  KTanigawa  NJapanese Laparoscopic Surgery Study Group, A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg 2007;245 (1) 68- 72
PubMed
Lee  SIChoi  YSPark  DJKim  HHYang  HKKim  MC Comparative study of laparoscopy-assisted distal gastrectomy and open distal gastrectomy. J Am Coll Surg 2006;202 (6) 874- 880
PubMed
Mochiki  EKamiyama  YAihara  RNakabayashi  TAsao  TKuwano  H Laparoscopic assisted distal gastrectomy for early gastric cancer: five years' experience. Surgery 2005;137 (3) 317- 322
PubMed
Huscher  CGMingoli  ASgarzini  G  et al.  Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann Surg 2005;241 (2) 232- 237
PubMed
Park  CHSong  KYKim  SN Treatment results for gastric cancer surgery: 12 years' experience at a single institute in Korea. Eur J Surg Oncol 2008;34 (1) 36- 41
PubMed
Moriguchi  SMaehara  YKorenaga  DSugimachi  KNose  Y Risk factors which predict pattern of recurrence after curative surgery for patients with advanced gastric cancer. Surg Oncol 1992;1 (5) 341- 346
PubMed
Otsuji  EKuriu  YIchikawa  D  et al.  Time to death and pattern of death in recurrence following curative resection of gastric carcinoma: analysis based on depth of invasion. World J Surg 2004;28 (9) 866- 869
PubMed
Shibuya  KMathers  CDBoschi-Pinto  CLopez  ADMurray  CJ Global and regional estimates of cancer mortality and incidence by site, II: results for the global burden of disease 2000. BMC Cancer 2002;237
PubMed
van de Velde  CJPeeters  KC The gastric cancer treatment controversy. J Clin Oncol 2003;21 (12) 2234- 2236
PubMed
Dulucq  JLWintringer  PStabilini  CSolinas  LPerissat  JMahajna  A Laparoscopic and open gastric resections for malignant lesions: a prospective comparative study. Surg Endosc 2005;19 (7) 933- 938
PubMed
Shimada  Y JGCA (The Japan Gastric Cancer Association): gastric cancer treatment guidelines. Jpn J Clin Oncol 2004;34 (1) 58
PubMed
Kim  MCKim  KHKim  HHJung  GJ Comparison of laparoscopy assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer. J Surg Oncol 2005;91 (1) 90- 94
PubMed
Nomura  SKaminishi  M Surgical treatment of early gastric cancer. Dig Surg 2007;24 (2) 96- 100
PubMed
Adachi  YShiraishi  NKitano  S Modern treatment of early gastric cancer: review of the Japanese experience. Dig Surg 2002;19 (5) 333- 339
PubMed
Nakajima  T Gastric cancer treatment guidelines in Japan. Gastric Cancer 2002;5 (1) 1- 5
PubMed
Sasako  MSaka  MFukagawa  TKatai  HSano  T Surgical treatment of advanced gastric cancer: Japanese perspective. Dig Surg 2007;24 (2) 101- 107
PubMed
Song  KYKim  SNPark  CH Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer: technical and oncologic aspects. Surg Endosc 2008;22 (3) 655- 659
PubMed
Wu  CWHsieh  MCLo  SS  et al.  Prognostic indicators for survival after curative resection for patients with carcinoma of the stomach. Dig Dis Sci 1997;42 (6) 1265- 1269
PubMed
Bozzetti  FBonfanti  GMorabito  A  et al.  A multifactorial approach for the prognosis of patients with carcinoma of the stomach after curative resection. Surg Gynecol Obstet 1986;162 (3) 229- 234
PubMed
Lee  HJKim  YHKim  WH  et al.  Clinicopathological analysis for recurrence of early gastric cancer. Jpn J Clin Oncol 2003;33 (5) 209- 214
PubMed
Kitamura  KYamaguchi  TTaniguchi  HHagiwara  ASawai  KTakahashi  T Analysis of lymph node metastasis in early gastric cancer: rationale of limited surgery. J Surg Oncol 1997;64 (1) 42- 47
PubMed
Tsujitani  SOka  SSaito  H  et al.  Less invasive surgery for early gastric cancer based on the low probability of lymph node metastasis. Surgery 1999;125 (2) 148- 154
PubMed
Deng  JYLiang  HSun  DZhan  HJWang  XN The most appropriate category of metastatic lymph nodes to evaluate overall survival of gastric cancer following curative resection. J Surg Oncol 2008;98 (5) 343- 348
PubMed
Sakar  BKaragol  HGumus  M  et al.  Timing of death from tumor recurrence after curative gastrectomy for gastric cancer. Am J Clin Oncol 2004;27 (2) 205- 209
PubMed
Maruyama  KSasako  MKinoshita  TSano  TKatai  H Surgical treatment for gastric cancer: the Japanese approach. Semin Oncol 1996;23 (3) 360- 368
PubMed
Siewert  JRSendler  A The current management of gastric cancer. Adv Surg 1999;3369- 93
PubMed
Maehara  YOrita  HOkuyama  T  et al.  Predictors of lymph node metastasis in early gastric cancer. Br J Surg 1992;79 (3) 245- 247
PubMed
Folli  SDente  MDell’Amore  D  et al.  Early gastric cancer: prognostic factors in 223 patients. Br J Surg 1995;82 (7) 952- 956
PubMed
Farley  DRDonohue  JHNagorney  DMCarpenter  HAKatzmann  JAIlstrup  DM Early gastric cancer. Br J Surg 1992;79 (6) 539- 542
PubMed
Kwon  SJKwon  SJKim  HJKim  HJKim  MKKim  MK Can 3-year disease-free survival be substituted for 5-year overall survival in curatively resected gastric cancer? J Korean Gastric Cancer Assoc 2005;5 (3) 174- 179
Kennedy  BJ Cure for early gastric cancer. Cancer 1993;72 (11) 3139- 3140
PubMed
Kim  JPLee  JHKim  SJYu  HJYang  HK Clinicopathologic characteristics and prognostic factors in 10 783 patients with gastric cancer. Gastric Cancer 1998;1 (2) 125- 133
PubMed
Maruyama  KKaminishi  MHayashi  K  et al. Japanese Gastric Cancer Association Registration Committee, Gastric cancer treated in 1991 in Japan: data analysis of nationwide registry. Gastric Cancer 2006;9 (2) 51- 66
PubMed
Karpeh  MSLeon  LKlimstra  DBrennan  MF Lymph node staging in gastric cancer: is location more important than number? an analysis of 1,038 patients. Ann Surg 2000;232 (3) 362- 371
PubMed
Wakelin  SJDeans  CCrofts  TJAllan  PLPlevris  JNPaterson-Brown  S A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophago-gastric carcinoma. Eur J Radiol 2002;41 (2) 161- 167
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Actual 3-year disease-free survival. AGC indicates advanced gastric cancer; EGC, early gastric cancer.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Overall actual 3-year disease-free survival. Five deaths were excluded from the analysis (from a traffic accident in 1, fulminant hepatitis in 1, multiple organ failure in 2, and suicide in 1).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Clinicopathologic Results After Laparoscopy-Assisted Gastrectomy
Table Graphic Jump LocationTable 2. Recurrences After Laparoscopy-Assisted Gastrectomy
Table Graphic Jump LocationTable 3. Factors Affecting Disease-Free Survival (Univariate Analysis)
Table Graphic Jump LocationTable 4. Multivariate Analysis for Factors Affecting 3-Year Disease-Free Survival Rate
Table Graphic Jump LocationTable 5. Comparison of Survival Rates After Gastrectomy for Gastric Cancer

References

Parkin  DMBray  FIDevesa  SS Cancer burden in the year 2000: the global picture. Eur J Cancer 2001;37 ((suppl 8)) S4- S66
PubMed
Parkin  DM International variation. Oncogene 2004;23 (38) 6329- 6340
PubMed
Lee  HJYang  HKAhn  YO Gastric cancer in Korea. Gastric Cancer 2002;5 (3) 177- 182
PubMed
Inoue  MTsugane  S Epidemiology of gastric cancer in Japan. Postgrad Med J 2005;81 (957) 419- 424
PubMed
Bonenkamp  JJHermans  JSasako  M  et al. Dutch Gastric Cancer Group, Extended lymph-node dissection for gastric cancer. N Engl J Med 1999;340 (12) 908- 914
PubMed
Cuschieri  AWeeden  SFielding  J  et al. Surgical Co-operative Group, Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Br J Cancer 1999;79 (9-10) 1522- 1530
PubMed
Kim  JP Current status of surgical treatment of gastric cancer. J Surg Oncol 2002;79 (2) 79- 80
PubMed
Asao  THosouchi  YNakabayashi  THaga  NMochiki  EKuwano  H Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer. Br J Surg 2001;88 (1) 128- 132
PubMed
Mochiki  ENakabayashi  TKamimura  HHaga  NAsao  TKuwano  H Gastrointestinal recovery and outcome after laparoscopy-assisted versus conventional open distal gastrectomy for early gastric cancer. World J Surg 2002;26 (9) 1145- 1149
PubMed
Mochiki  EKamimura  HHaga  NAsao  TKuwano  H The technique of laparoscopically assisted total gastrectomy with jejunal interposition for early gastric cancer. Surg Endosc 2002;16 (3) 540- 544
PubMed
Goh  PTekant  YIsaac  JKum  CKNgoi  SS The technique of laparoscopic Billroth II gastrectomy. Surg Laparosc Endosc 1992;2 (3) 258- 260
PubMed
Kitano  SShiraishi  NUyama  ISugihara  KTanigawa  NJapanese Laparoscopic Surgery Study Group, A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg 2007;245 (1) 68- 72
PubMed
Lee  SIChoi  YSPark  DJKim  HHYang  HKKim  MC Comparative study of laparoscopy-assisted distal gastrectomy and open distal gastrectomy. J Am Coll Surg 2006;202 (6) 874- 880
PubMed
Mochiki  EKamiyama  YAihara  RNakabayashi  TAsao  TKuwano  H Laparoscopic assisted distal gastrectomy for early gastric cancer: five years' experience. Surgery 2005;137 (3) 317- 322
PubMed
Huscher  CGMingoli  ASgarzini  G  et al.  Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann Surg 2005;241 (2) 232- 237
PubMed
Park  CHSong  KYKim  SN Treatment results for gastric cancer surgery: 12 years' experience at a single institute in Korea. Eur J Surg Oncol 2008;34 (1) 36- 41
PubMed
Moriguchi  SMaehara  YKorenaga  DSugimachi  KNose  Y Risk factors which predict pattern of recurrence after curative surgery for patients with advanced gastric cancer. Surg Oncol 1992;1 (5) 341- 346
PubMed
Otsuji  EKuriu  YIchikawa  D  et al.  Time to death and pattern of death in recurrence following curative resection of gastric carcinoma: analysis based on depth of invasion. World J Surg 2004;28 (9) 866- 869
PubMed
Shibuya  KMathers  CDBoschi-Pinto  CLopez  ADMurray  CJ Global and regional estimates of cancer mortality and incidence by site, II: results for the global burden of disease 2000. BMC Cancer 2002;237
PubMed
van de Velde  CJPeeters  KC The gastric cancer treatment controversy. J Clin Oncol 2003;21 (12) 2234- 2236
PubMed
Dulucq  JLWintringer  PStabilini  CSolinas  LPerissat  JMahajna  A Laparoscopic and open gastric resections for malignant lesions: a prospective comparative study. Surg Endosc 2005;19 (7) 933- 938
PubMed
Shimada  Y JGCA (The Japan Gastric Cancer Association): gastric cancer treatment guidelines. Jpn J Clin Oncol 2004;34 (1) 58
PubMed
Kim  MCKim  KHKim  HHJung  GJ Comparison of laparoscopy assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer. J Surg Oncol 2005;91 (1) 90- 94
PubMed
Nomura  SKaminishi  M Surgical treatment of early gastric cancer. Dig Surg 2007;24 (2) 96- 100
PubMed
Adachi  YShiraishi  NKitano  S Modern treatment of early gastric cancer: review of the Japanese experience. Dig Surg 2002;19 (5) 333- 339
PubMed
Nakajima  T Gastric cancer treatment guidelines in Japan. Gastric Cancer 2002;5 (1) 1- 5
PubMed
Sasako  MSaka  MFukagawa  TKatai  HSano  T Surgical treatment of advanced gastric cancer: Japanese perspective. Dig Surg 2007;24 (2) 101- 107
PubMed
Song  KYKim  SNPark  CH Laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer: technical and oncologic aspects. Surg Endosc 2008;22 (3) 655- 659
PubMed
Wu  CWHsieh  MCLo  SS  et al.  Prognostic indicators for survival after curative resection for patients with carcinoma of the stomach. Dig Dis Sci 1997;42 (6) 1265- 1269
PubMed
Bozzetti  FBonfanti  GMorabito  A  et al.  A multifactorial approach for the prognosis of patients with carcinoma of the stomach after curative resection. Surg Gynecol Obstet 1986;162 (3) 229- 234
PubMed
Lee  HJKim  YHKim  WH  et al.  Clinicopathological analysis for recurrence of early gastric cancer. Jpn J Clin Oncol 2003;33 (5) 209- 214
PubMed
Kitamura  KYamaguchi  TTaniguchi  HHagiwara  ASawai  KTakahashi  T Analysis of lymph node metastasis in early gastric cancer: rationale of limited surgery. J Surg Oncol 1997;64 (1) 42- 47
PubMed
Tsujitani  SOka  SSaito  H  et al.  Less invasive surgery for early gastric cancer based on the low probability of lymph node metastasis. Surgery 1999;125 (2) 148- 154
PubMed
Deng  JYLiang  HSun  DZhan  HJWang  XN The most appropriate category of metastatic lymph nodes to evaluate overall survival of gastric cancer following curative resection. J Surg Oncol 2008;98 (5) 343- 348
PubMed
Sakar  BKaragol  HGumus  M  et al.  Timing of death from tumor recurrence after curative gastrectomy for gastric cancer. Am J Clin Oncol 2004;27 (2) 205- 209
PubMed
Maruyama  KSasako  MKinoshita  TSano  TKatai  H Surgical treatment for gastric cancer: the Japanese approach. Semin Oncol 1996;23 (3) 360- 368
PubMed
Siewert  JRSendler  A The current management of gastric cancer. Adv Surg 1999;3369- 93
PubMed
Maehara  YOrita  HOkuyama  T  et al.  Predictors of lymph node metastasis in early gastric cancer. Br J Surg 1992;79 (3) 245- 247
PubMed
Folli  SDente  MDell’Amore  D  et al.  Early gastric cancer: prognostic factors in 223 patients. Br J Surg 1995;82 (7) 952- 956
PubMed
Farley  DRDonohue  JHNagorney  DMCarpenter  HAKatzmann  JAIlstrup  DM Early gastric cancer. Br J Surg 1992;79 (6) 539- 542
PubMed
Kwon  SJKwon  SJKim  HJKim  HJKim  MKKim  MK Can 3-year disease-free survival be substituted for 5-year overall survival in curatively resected gastric cancer? J Korean Gastric Cancer Assoc 2005;5 (3) 174- 179
Kennedy  BJ Cure for early gastric cancer. Cancer 1993;72 (11) 3139- 3140
PubMed
Kim  JPLee  JHKim  SJYu  HJYang  HK Clinicopathologic characteristics and prognostic factors in 10 783 patients with gastric cancer. Gastric Cancer 1998;1 (2) 125- 133
PubMed
Maruyama  KKaminishi  MHayashi  K  et al. Japanese Gastric Cancer Association Registration Committee, Gastric cancer treated in 1991 in Japan: data analysis of nationwide registry. Gastric Cancer 2006;9 (2) 51- 66
PubMed
Karpeh  MSLeon  LKlimstra  DBrennan  MF Lymph node staging in gastric cancer: is location more important than number? an analysis of 1,038 patients. Ann Surg 2000;232 (3) 362- 371
PubMed
Wakelin  SJDeans  CCrofts  TJAllan  PLPlevris  JNPaterson-Brown  S A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophago-gastric carcinoma. Eur J Radiol 2002;41 (2) 161- 167
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles
JAMAevidence.com

The Rational Clinical Examination
Case 2