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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Surgery for gastric remnant carcinoma following Billroth II gastrectomy

and .

Department of Surgery, University of Leuven, Leuven, Belgium

Definition

A gastric remnant carcinoma is defined as a carcinoma arising in the stomach remnant following previous Billroth II partial gastrectomy for benign disease, most frequently peptic ulcer disease.

Incidence

The incidence of gastric remnant carcinoma is difficult to assess, since adequate calculations are missing. The risk for developing a gastric remnant carcinoma is two-to-threefold higher than the risk for developing a primary gastric cancer in the normal population. Since peptic ulcer disease is more frequent in males, the incidence of a gastric remnant carcinoma shows a strong male preponderance. The risk for gastric remnant carcinoma is increased 15–20 years after Billroth II partial gastrectomy. The average latency period (i.e. the interval between the Billroth II partial gastrectomy and the diagnosis of the gastric remnant carcinoma) is 30 years (range 5–40 y).

Pathogenesis

Gastric remnant carcinoma occurs more frequently around the gastroenterostomy than at other areas of the gastric remnant. Therefore, reflux of duodenal contents is considered one of the most important etiologic factors. Both bile acids and pancreatic juice seem to be carcinogenic factors, although some reports are conflicting. Since the bile acid secretion increases with a cholesterolrich diet, increased fat intake promotes the development of gastric remnant carcinoma.

In contrast with primary gastric cancer, Helicobacter pylori does not seem to play an important role in the pathogenesis of gastric remnant carcinoma.

Symptoms

Most of the patients with gastric remnant carcinoma present with either anaemia-related symptoms or vague epigastric complaints. Due to the scarcity of symptoms and due to the lack of intensive screening programs “early” gastric remnant carcinomas are uncommon.

Diagnosis

The only way to confirm the presence of a gastric remnant carcinoma is by oesophagogastroscopy with multiple biopsies. X-ray contrast studies are inferior diagnostic tools. Local staging involves gastroscopy and endoscopic ultrasound examination.

Screening for distant metastasis includes beside the clinical examination (Virchow node, palpatio per anum for peritoneal metastasis) a chest X-ray and an abdominal spiral CT-scan.

In 40–50% of the patients with gastric remnant carcinoma the tumor is found in an advanced stage (stage III or IV).

Staging

The staging of gastric remnant carcinoma is the same as for primary gastric cancer.

Treatment

Provided that screening for distant metastasis is negative, surgery is the only treatment that may cure the patient with a gastric remnant carcinoma.

Total gastrectomy is the treatment of choice. After partial resection of the gastric remnant the risk for local recurrence is unacceptable high, synchronous tumors may be left behind and moreover metachronous tumors may develop in the remnant.

In advanced stages, an extended resection including adjacent organs (spleen, pancreas, colon, liver) is necessary in almost half of the patients.

Extended lymphadenectomy increases the perioperative morbidity and mortality but it does not improve the 5-year survival.

Globally 70–75% of the gastric remnant carcinomas are resectable and 60–70% are resected for cure.

Adjuvant chemotherapy or adjuvant radiation therapy may be considered in the context of on-going clinical trials, but a benefit has not been proven.

In patients with distant metastasis, resection may be the best palliation. Of course, this decision must take into account age, operative risk factors, symptoms (bleeding, obstruction, …) as well as the extent of the distant metastasis. These patients may have benefit (i.e. better quality of life and/or longer survival) of palliative chemotherapy if the pre-treatment Karnowski-index and the potential side-effects are considered.

Complications

The morbidity (20–35%) as well as the mortality (10–15%) after surgical treatment are quite high. This is related to the high incidence of surgical risk factors (55%) in this older population and to the necessity of resection of adjacent organs in 50% of the patients.

Prognosis

Due to the late diagnosis, the prognosis remains bad. The global 5-year survival after resection is about 30%. If the pathological examination reveals lymph node metastasis 5-year survival is extremely rare. The disease-free 5-year survival of patients that underwent extended resections for cure reaches 50%. This seems to be equal to, if not better than, that of primary gastric carcinoma.

Prevention

Intensive endoscopic screening programs with multiple biopsies starting 15 years after Billroth II partial gastrectomy should result in a higher incidence of “early” gastric remnant carcinomas with a better prognosis.

If, nowadays, partial gastrectomy for benign disease is indicated, the surgeon should perform a Roux-en-Y reconstruction, since with this technique the duodenal contents is diverted from the gastric remnant.

Table I. Staging of Gastric remnant carcinoma.

Table I

Staging of Gastric remnant carcinoma.

References

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Isozaki H, Tanaka N, Fujii K. et al. Surgical treatment for advanced carcinoma of the gastric remnant. Hepato-Gastroenterol. (1998);45:1896–1900. [PubMed: 9840172]
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Lissens P, Filez L, Aerts R. et al. Surgery for gastric remnant carcinoma following Billroth II gastrectomy. Eur J Surg Oncol. (1997);23:518–521. [PubMed: 9484922]
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Lo S S, Wu C W, Hsieh M C, Lui W Y. Is gastric remnant cancer clinically different from primary gastric cancer. Hepato-Gastroenterol. (1997);44:299–301. [PubMed: 9058163]
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Newman E, Brennan M F, Hochwald S N. et al. Gastric remnant carcinoma : just another proximal gastric cancer or a unique entity? Am J Surg. (1997);173:292–297. [PubMed: 9136783]
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Kodera Y, Yamamura Y, Torii A. et al. Gastric stump carcinoma after gastrectomy for benign gastric lesion : what is feasible as standard surgical treatment? J Surg Oncol. (1996);63:119–124. [PubMed: 8888805]
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Kodera Y, Yamamura Y, Torii A. et al. Gastric remnant carcinoma after partial gastrectomy for benign and malignant gastric lesions. J Am Coll Surg. (1996);182:1–6. [PubMed: 8542082]
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Kondo K, Kojima H, Akiyama S. et al. Pathogenesis of adenocarcinoma induced by gastrojejunostomy in Wistar rats: role of duodenogastric reflux. Carcinogenesis. (1995);18:1747–1751. [PubMed: 7634399]
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Yonemura Y, Sugiyama K, Fujimura T. et al. A new surgical technique (left upper abdominal evisceration) for advanced carcinoma of the gastric stump. Hepato-Gastroenterol. (1994);41:130–133. [PubMed: 8056399]
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Pointer R, Wetscher G J, Gadenstatter M. et al. Gastric remnant cancer has a better prognosis than primary gastric cancer. Arch Surg. (1994);129:615–619. [PubMed: 8204036]
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Ikeguchi M, Kondou A S S, Shibata A. et al. Clinicopathologic differences between carcinoma in the remnant stump after distal gastrectomy for benign gastroduodenal lesions and primary carcinoma in the upper third of the stomach. Cancer. (1994);73:15–21. [PubMed: 8275417]
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6885
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