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!