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From 1976 to 1989, a total of 1303 patients with gastric cancers underwent gastrectomies in the First Department of Surgery, Kurume University Hospital. Of these, 358 (27.5%) were total gastrectomies, 84 (6.4%) were proximal gastrectomies and 825 (63.1%) were distal gastrectomies. The 5-year survival rate was 44.8% after the total gastrectomies, 38.9% after the proximal and 72.4% after the distal gastrectomies. The 5-year survival rate was 86.2% with the absolute curative resection, 36.3% with the relative curative resection, 29.3% with the relative non-curative resection and 9.4% with the absolute non-curative resection. Macroscopically, the 5-year survival rate was 95.1% for type 0 (early cancers), 61.3% for Borrmann type 1, 58.8% for Borrmann type 2, 37.5% for Borrmann type 3 and 16.5% for Borrmann type 4. According to the pathological cancer stage, the 5-year survival rate was 94.8% for stage I, 79.3% for stage II, 49.2% for stage III and only 11.3% for stage IV.

Thirty-two cases of gastric cancer associated with hepatic cirrhosis were reviewed, retrospectively. These patients represented 1.3% of 2590 patients with gastric cancer who were treated over the 23 year period from 1966 to 1988. The male to female ratio was 9.7:1 for gastric cancer patients with hepatic cirrhosis (mean age, 63.2 years) and 2:1 for all patients with gastric cancer (mean age, 61.2 years). Among the 32 patients, one was inoperable, and 31 patients underwent surgical exploration. The gastric cancers were resected in 28 patients (90.3%), while the cancers in 3 patients (9.7%) were non-resectable. Twenty-two patients underwent curative resections with a five-year survival rate of 51%. Postoperative complications occurred in 6 patients (20%), but no anastomotic leakage occurred. There were no operative mortalities. On the basis of the present study, different surgical procedures are indicated depending on the preoperative hepatic conditions for patients with gastric cancer accompanied by hepatic cirrhosis.

Experimental studies have revealed that duodenogastric reflux subsequent to gastrectomy was one of the most significant factors for the development of carcinoma in the remnant stomach. For this reason, the binding of carcinogenic agents to the nucleic acids in the gastric mucosa exposed to the duodenal contents were studied using an organ culture method. The intracellular DNA levels bound with carcinogenic agents were significantly increased in the mucosa of the remnant stomach, as compared to the parietal mucosa in the whole stomach. The remnant stomach may therefore provide an environment that enhances the development of cancer.

From 1978 to 1989, a total of 1272 patients with gastric cancer were admitted to Kurume University Hospital. Of these, 1184 (93%) underwent gastric resections. Of the resected cancers, 140 cases were gastric cancers invading the esophagus, as confirmed by postoperative pathological studies. For all 168 gastric cancers invading the esophagus, the resectability rate was 83% (140/168). These cancers were subdivided chronologically, with those during 1978-1983 included in Group 1 and those during 1984-1989 in Group 2. Group 2 patients were treated with a higher proportion of aggressive extended radical operations, such as combined resections of the diaphragm and lymph node dissections as far as the paraaortic lymph nodes (N4). The resectability rate was 76% in Group 1 and 93% in Group 2, due to the more aggressive operations. A lower esophagectomy with a total gastrectomy, mainly from a left thoracoabdominal approach, was performed for 71% of the patients in Group 1, and for 90% in Group 2. Lymph node metastasis was related to the extent of esophageal invasion and inversely related to the 5 year-survival rate. In all cases of esophgeal invasion of less than 1 cm, there were no mediastinal lymph node metastases, and the 5 year-survival rate was 76%. On the other hand, when esophageal invasion was more than 4cm, 50% had mediastinal lymph node metastases and the 5 year-survival rate was zero. The tumor size was also related to lymph node metastasis. When the maximal tumor length was less than 5cm, a negative lymph node metastasis was found in 78% of cases, and the 5 year-survival rate was 76%. On the other hand, when the tumor length was more than 10 cm, only 6% had a negative lymph node metastasis and the 5 year-survival rate was only 15%. The 5 year-survival rate with curative resection was 45% for Group 1, and 71% for Group 2. For those at stage III, 12% of Group 1 could be curatively resected with an extended radical operation, 46% of Group 2 (p

Two rare cases of a spontaneous portacaval shunt occurring in patients with gastric cancer and hepatic cirrhosis are retrospectively reviewed with special attention for the operative indications and techniques. One patient underwent proximal gastrectomy for a IIa cancer in the C region with splenectomy and closure of the splenorenal shunt, and died two years and 3 months later due to hepatic failure. The other patient underwent distal gastrectomy for IIa + IIc, IIc double cancers in the M and A regions with splenectomy through an upper transverse abdominal incision that ligated and divided the paraumbilico-caval shunt, and is alive and well 1 year and 2 months, postoperatively. The ICG-R15 was markedly decreased and the K-ICG and ICG-Rmax were improved following the operation in both cases. The preoperative chronic encephalopathy and hyperammonemia disappeared postoperatively in both cases.

From 1979 to 1988, a total of 1265 cases of gastric cancer were admitted to our Institute. Of these, 80 cases (6.3%) involved hepatic metastasis. Thirty-eight cases (47.3%) underwent gastrectomy (24 distal, 2 proximal, 11 total and one partial). Of these 38 cases, 7 underwent a combined resection of a simultaneous metastatic hepatic tumor. A total of 19 (67.9%) of the 28 cases in H1, 6 (37.5 %) of the 16 cases in H2, and 13 (36.1%) of the 36 cases in H3 underwent gastrectomy. Hepatic metastasis occurred most frequently (18.2%) in Borrmann type 1, 5 % in type 2, 14.9% in type 3 and 8.7% in type 4. Of all 593 resected advanced cases, there were 283 differentiated type, with a hepatic metastasis rate of 14.5%, and 310 undifferentiated type with 7.1 % rate of hepatic metastasis. In H1 and H2, the prognosis after primary gastric cancer resection was better than for unresected cases. Moreover, there have been reports recently of long-term survival using continuous hepatic arterial infusion of anti-cancer durgs, and of combined resection of the metastatic hepatic tumor after curative gastrectomy. Therefore we should not give up these H1 and H2 patients.

We report 9 rare cases (7 males and 2 females) of early gastric cancer of the esophagogastric junction. From 1976 to 1988, 1308 cases of gastric cancer were resected in our Institute. Of these, 479 (36.6%) cases were early gastric cancer. Among all 479 early gastric cancers, 9 (1.9%) were located within 2 cm of the esophagogastric junction on the lesser curvature and/or posterior wall of the cardia. This represents 11.7% (9/77) of the cases of cancer at the esophagogastric junction. This incidence contrasts with the 39.5% of early cancers elsewhere in the stomach. Overall, 36.6% (479/1308) were early gastric cancer. Eight of these 9 patients were resected through the abdominal approach and one by the thoracoabdominal approach. Seven underwent proximal and 2 underwent total gastrectomy. On microscopic examination, one cancer was m-cancer, and 8 were sm-cancer. Lymphnode metastasis was found to be absent in all 9 cases. The prognosis of cancer of the cardia is generally poorer than that for adenocarcinoma in the corpus or distal stomach. However, cancer recurrence 22-91 months postoperatively was zero in these 9 cases of early gastric cancer at the esophagogastric junction.

Although there is a decreasing number of gastric cancer patients in Japan, the number of patients over 80 years of age is increasing. Forty patients over 80 years of age (from 80 to 88 years) with gastric cancer (Group 1) during the 10 years from 1980 to 1989 were retrospectively investigated and compared with those 70-79 years of age (Group 2). The resectability rate was 80% in Group 1 and 89% in Group 2. Early gastric cancer was observed at a rate of only 25% in Group 1 and 39% in Group 2. Pathologically, the differentiated type occurred in 78% of those in Group 1 and 68% of Group 2. Total gastrectomy was performed in only 6% of the resected cases in Group 1 and in 25% of Group 2. A combined resection including such operations as pancreatico-splenectomy or splenectomy (PS) was employed in none of the total gastrectomy cases in Group 1 and in 30% of Group 2. R3 gastrectomy was performed in none of the patients in Group 1 and in 21% of those in Group 2. Postoperative complications occurred in 25% of Group 1 patients and in 12% of Group 2 patients. Anastomotic leakage occurred in 3% of those in Group 1 and in 4% of those in Group 2. The 5-year survival rate was 47% for all the resected cases in Group 1 and 68% for Group 2. The 5-year survival rate was 61% for those who underwent a curative (radical) gastrectomy in Group 1, and 84% for those in Group 2.

A case of a massive advanced gastric cancer of the Borrmann type III in a patient with the rare blood group of negative Gregory antigen (Gregory (a-)) is reported. On admission, he was found to have a severe anemia (Hb 6.1 g/dl) requiring a direct blood infusion. He had never received a blood infusion, previously. In blood crossmatching tests, his blood was agglutinated by all the antisera for the common antigens, and he was discovered to have a rare blood type of Gregory (a-). There was no appropriate blood donor in his family. Before the operation, only 600 ml (6 i.u.) of frozen red blood cells could be found in storage from only 2 people with Gregory (a-), O blood type and Rh (+) in Japan. To increase the RBC, erythropoietin (3000 i.u.) was administered 6 times; and the Hb increased to 7.4 g/dl. However, the anemia remained and 200 ml (2 i.u.) Gregory (a-) blood was infused, preoperatively. The final preoperative Hb was 7.8 g/dl and the RBC was 283 x 10(4)/mm3. A massive gastric cancer directly infiltrated the pancreas, the transverse colon and the mesocolon. A palliative subtotal gastrectomy with combined resection of the transverse colon was performed. The intraoperative blood loss was 460 ml and the volume of blood infused was 400 ml (4 i.u.). The postoperative Hb was 7.9 g/dl, and more blood was needed. However, there was no more Gregory (a-) donor blood in storage in Japan.(ABSTRACT TRUNCATED AT 250 WORDS)

Two rare cases involving distal gastrectomies for gastric cancer after an earlier gastrojejunostomies without gastrectomy for duodenal or gastric stricture due to a duodenal or pre-pyloric ulcer are reported. The time interval between the initial gastrojejunostomy and the resection of the distal stomach with gastrojejunal stoma were 17 and 36 years. One patient underwent reconstruction by Billroth II and the other by Roux-en-Y end-to-side gastrojejunostomies, both retrocolically without any peri or postoperative complications. The histological classification was confirmed for both as type IIc mucosal early gastric cancer. Only 6 other primary early gastric cancers following gastrojejunostomies without gastrectomy have been reported in the Japanese literature.

Twenty-four cases of resected remnant cancers following partial gastrectomy were retrospectively investigated for benign gastroduodenal disease. The time interval between the initial gastrectomy and the remnant gastrectomy was more than 10 years in 19 (79%) patients and less than 10 years in 5 (21%) patients. There were 2 cases with remnant cancer at stage I, 1 at stage II, 3 at stage III and 13 at stage IV for the all cases with a time interval of more than 10 years. Early-type remnant gastric cancer has a frequency of only 5%. The proportion of positive lymph node metastases was high, in 84%.

To improve surgical results of duodenal ulcer, transgastric myotomy (TGM) was added to the traditional selective proximal vagotomy (SPV) and its efficacy was evaluated clinically in 40 patients. 35 men and 5 women were involved, with a mean age of 33.07 +/- 14.25 years. Pyloroplasty was added in 12 operations for stenosis and perforation. 28 patients in this series underwent TGM with SPV without drainage. In the 36 patients, basal and maximal acid output (BAO and MAO) was compared preoperatively and at 6 months postoperatively. A satisfactory reduction of acid output was achieved, with a mean reduction rate of 71.4% in BAO and of 79.9% in MAO. All 40 patients were negative in Hollander's insulin stimulation test at 6 months postoperatively. The gastric mucosa was injured during myotomy in 2 of the patients (5.0%), and was simply sutured using 3-0 Dexon, without causing any problems. No other early or late postoperative complication was present. In addition, no peptic ulcer recurrence has been noted over a maximal follow-up of 8 years. The present results suggest the completeness of gastric denervation by TGM+SPV, and establish the efficacy of TGM with SPV, and therefore this method is recommended in the surgical treatment of duodenal ulcer.

From 1966 to 1985, 2130 patients with gastric cancer were admitted to our surgical department. Among these cancers, gastric cancer following partial gastrectomy for benign gastroduodenal lesion were present in 22 (1%) patients. The original pathology was gastric ulcers in 64% (14 patients), duodenal ulcers in 23% (5 patients), combined gastric and duodenal ulcers in 9% (2 patients), and leiomyoma of the gastric cardia in 4% (1 patient). Fourteen patients were reconstructed by Billroth II, 7 by Billroth I, and one had an esophagogastrostomy after a proximal gastrectomy. The cancer in 19 (86%) patients was resected and 3 (14%) could not be resected. Only 2 (9%) were early cancer, 20 (89%) were advanced cancer including 11 (50%) with Borrmann type 3. A higher proportion of positive lymphnode metastasis was observed for residual gastric cancer (84%) than for primary gastric cancer (49%). The overall 5-year survival rate was 32%, with a 5-year survival rate of 45% for those who underwent curative resection.

Three patients with hepatic cirrhosis who had undergone gastric operations following endoscopic sclerotherapy were retrospectively reviewed. One patient had undergone total gastrectomy for gastric cancer and two had Hassab and Tanner operations for gastric and esophageal varices. All patients were recovering with no complications related to the operations and were free of disease for 2 years, postoperatively. When esophageal varices are found in combination with an upper gastric cancer that requires total gastrectomy, endoscopic sclerotherapy for esophageal varices is contraindicated because severe esophageal injuries may be induced by the sclerosing agent. The Hassab and Tanner method is useful for esophageal and gastric varices after sclerotherapy. A repeat endoscopic sclerotherapy should be performed after this operation.