Stomach cancer surgery: Difference between revisions

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{{CMG}}{{AE}}{{PSD}}
 
{{CMG}}; {{AE}} {{PSD}} {{MAD}}
{{Stomach cancer}}
{{Stomach cancer}}


==Overview==
==Overview==
Surgery is the mainstay of treatment for stomach cancer.
[[Surgery]] is the mainstay of treatment for [[stomach cancer]]. [[Endoscopic surgery|Endoscopic resection]] is suggested for early [[gastric cancer]]. There are criteria for [[Endoscopic surgery|endoscopic resection]] of ealry [[gastric cancer]]. Methods for [[Endoscopic surgery|endoscopic resection]] include [[Endoscopic surgery|endoscopic mucosal resection]] (EMR) and [[Endoscopic surgery|endoscopic submucosal dissection]] (ESD). [[Side effects]] of [[endoscopy]] includes [[bleeding]] and [[perforation]]. For T1 [[tumors]], a 2cm macroscopic [[resection]] of [[tumor]] margin  should be performed. Proximal margin of at least 3 cm is recommended for T2 or deeper [[Tumor|tumors]] with an expansive growth pattern and 5 cm for those with an [[Infiltration analgesia|infiltrative]] growth pattern. For [[tumors]] invading the [[Esophagus|esophagus,]] a 5-cm margin is not necessarily required, but [[frozen section]] examination of the [[resection]] line is desirable to ensure a R0 [[resection]]. There is a debate about optimal [[lymph node]] removal. D1 [[lymphadenectomy]] refers to a dissection of only the perigastric [[lymph nodes]]. D2 [[lymphadenectomy]] is an extended [[lymph node]] dissection, includes removal of [[Lymph node|nodes]] along the [[hepatic]], [[Left gastric artery|left gastric]], [[Celiac artery|celiac]], and [[Spleen|splenic]] [[arteries]], as well as those in the [[splenic hilum]]. D3 dissection is a super-extended [[lymphadenectomy]]. The surgery includes D2 [[lymphadenectomy]] plus the removal of [[Lymph nodes|nodes]] within the [[porta hepatis]] and periaortic regions.
 
== Surgical Management Of Early Gastric Cancer ==
*Early gastric cancer is an invasive gastric cancer that invades no more than the [[submucosa]] whatever the [[lymph node]] [[metastasis]] condition (T1 and any N)
*[[Endoscopy|Endoscopic resection]] is suggested for:
**Patients without suspected [[lymph node]] involvement
**[[Tumor]] size <20 mm in diameter
**Differentiated [[intestinal]] [[histology]]
*In most trials, there are no differences in outcome between the [[Surgery|surgical]] and the [[Endoscopic surgery|endoscopic treatment]].<ref name="pmid16301028">{{cite journal| author=Etoh T, Katai H, Fukagawa T, Sano T, Oda I, Gotoda T et al.| title=Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan. | journal=Gastrointest Endosc | year= 2005 | volume= 62 | issue= 6 | pages= 868-71 | pmid=16301028 | doi=10.1016/j.gie.2005.09.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16301028  }}</ref>
 
=== Standard criteria for endoscopic resection: ===
The standard criteria for lesions qualifying for endoscopic resection are the following:<ref name="pmid27664260">{{cite journal| author=Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D et al.| title=Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. | journal=Ann Oncol | year= 2016 | volume= 27 | issue= suppl 5 | pages= v38-v49 | pmid=27664260 | doi=10.1093/annonc/mdw350 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27664260  }}</ref><ref name="pmid24914327">{{cite journal| author=Bollschweiler E, Berlth F, Baltin C, Mönig S, Hölscher AH| title=Treatment of early gastric cancer in the Western World. | journal=World J Gastroenterol | year= 2014 | volume= 20 | issue= 19 | pages= 5672-8 | pmid=24914327 | doi=10.3748/wjg.v20.i19.5672 | pmc=4024776 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914327  }}</ref>
 
'''1)''' Confined to the [[Mucosal|mucosa]]
 
'''2)''' Smaller than 2 cm for superficially elevated type lesions
 
'''3)''' Smaller than 1 cm for the flat and depressed type lesions
 
'''4)''' No [[ulcer]] or [[ulcer]] [[scar]]
 
'''5)''' No [[venous]] or [[Lymphatic system|lymphatic]] involvement
 
Expansion of the criteria to involve more [[tumors]] eligible for endoscopic resection was suggested by Japanese centers and these criteria include:<ref name="pmid23023388">{{cite journal| author=Lee JH, Choi MG, Min BH, Noh JH, Sohn TS, Bae JM et al.| title=Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer. | journal=Br J Surg | year= 2012 | volume= 99 | issue= 12 | pages= 1688-92 | pmid=23023388 | doi=10.1002/bjs.8934 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23023388  }}</ref>
* Differentiated type without [[ulceration]], and [[Mucous membrane|mucosal]] [[tumors]] of any size
* Differentiated type, with [[ulceration]], and [[mucosal]] [[tumors]] less than 30 mm
* Undifferentiated type, without ulceration, and mucosal [[tumors]] 20 mm in size or smaller
 
=== Methods of endoscopic resection ===
The following are the different types of endoscopic resection techniques for gastric cancer:<ref name="pmid26317585">{{cite journal| author=Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A et al.| title=Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. | journal=Endoscopy | year= 2015 | volume= 47 | issue= 9 | pages= 829-54 | pmid=26317585 | doi=10.1055/s-0034-1392882 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26317585  }}</ref>
* '''Endoscopic mucosal resection (EMR)''':
** The lesion and the surrounding [[Mucosal|mucosa]] are lifted by [[Submucosa|submucosal]] injection of [[Saline (medicine)|saline]] and removed using a [[Snare device|steel snare]].
 
* '''Endoscopic submucosal dissection (ESD)''':
** The [[mucosa]] surrounding the lesion is incised using a high-frequency electric knife.
** ESD is more likely to result in complete resection of early gastric cancer but requires more time and [[endoscopic]] skills.
 
=== Side effects and complications: ===
 
====== '''Bleeding''' ======
* [[Bleeding]]<ref name="pmid22402983">{{cite journal| author=Nishide N, Ono H, Kakushima N, Takizawa K, Tanaka M, Matsubayashi H et al.| title=Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube. | journal=Endoscopy | year= 2012 | volume= 44 | issue= 6 | pages= 577-83 | pmid=22402983 | doi=10.1055/s-0031-1291712 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22402983  }}</ref>
* A [[tumor]] size of more than 4 cm is a [[risk factor]] for acute [[bleeding]]
* [[Antithrombotic medication|Antithrombotic drug]] therapy is a [[risk factor]] for delayed [[bleeding]]
* [[Bleeding]] treatment is injection therapy, [[electrocoagulation]], ligation with a detectable [[Snare device|snare]], and [[endoscopic]] clipping.
 
====== '''Perforation''' ======
* [[Perforation]] rate for ESD is 4.5 percent, compared with 1.0 percent for EMR.<ref name="pmid19621730">{{cite journal| author=Abe Y, Inamori M, Iida H, Endo H, Akiyama T, Yoneda K et al.| title=Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer. | journal=Hepatogastroenterology | year= 2009 | volume= 56 | issue= 91-92 | pages= 921-4 | pmid=19621730 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19621730  }}</ref>
* [[Tumor]] location in the upper stomach and size more than 2 cm have been associated with an increased risk of perforation with ESD.
* Treatment of a perforation is [[endoscopic]] clipping, open or [[laparoscopic surgery]] in case of failed clipping.
 
=== Curative resection ===
The following criteria need to be fulfilled to consider endoscopic resection curative:<ref name="pmid273426892">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese gastric cancer treatment guidelines 2014 (ver. 4). | journal=Gastric Cancer | year= 2017 | volume= 20 | issue= 1 | pages= 1-19 | pmid=27342689 | doi=10.1007/s10120-016-0622-4 | pmc=5215069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27342689  }}</ref>
* Enbloc resection
* [[Tumor]] size < 2 cm
* [[Histologically]] of [[Differentiation|differentiated]] type
* Staging of [[tumor]] < T1a
* Negative horizontal margin
* Negative vertical margin
* No [[lymphatic]] or [[vascular]] infiltration
Any resection that does not satisfy any of the above criteria is considered non-curative.
 
=== '''Management of non-curative resection''' ===
*There is no standard approach for managing patients with non-curative resection. [[Gastrectomy]] has been recommended especially for [[tumors]] associated with a higher risk for [[lymph node]] [[metastases]].
*[[Gastrectomy]] with removal of perigastric [[lymph nodes]] is recommended.<ref name="pmid13521695">{{cite journal |vauthors=FLY OA, PRIESTLEY JT, COMFORT MW, GAGE RP |title=Total gastrectomy: mortality and survival |journal=Ann. Surg. |volume=147 |issue=5 |pages=760–8; discussion 768–70 |date=May 1958 |pmid=13521695 |pmc=1450692 |doi= |url=}}</ref>
* Seven percent of patients who had [[gastrectomy]] and [[lymph node]] dissection after non-curative [[Endoscopic surgery|endoscopic resection]] for early gastric cancer had [[lymph node]] [[metastasis]] after the procedure.
 
=== '''Management of positive margins'''<ref name="pmid19636636">{{cite journal |vauthors=Wang SY, Yeh CN, Lee HL, Liu YY, Chao TC, Hwang TL, Jan YY, Chen MF |title=Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy |journal=Ann. Surg. Oncol. |volume=16 |issue=10 |pages=2738–43 |date=October 2009 |pmid=19636636 |doi=10.1245/s10434-009-0616-0 |url=}}</ref> ===
* Patients with only positive lateral margins can be managed with [[endoscopic]] therapy rather than surgery.
* Almost 90 percent of lateral postitve margins were followed [[Endoscopic|endoscopically]] with no recurrences.
* Patients with positive vertical margins, [[submucosal]] invasion, or lymphovascular invasion, are treated by [[surgery]].
 
=== Local recurrence after EMR/ESD ===
Local [[mucosal]] recurrence after EMR/ESD for [[tumors]] that had fulfilled the criteria for indication for [[Endoscopic surgery|endoscopic resection]] may be treated by another ESD.<ref name="pmid20454494">{{cite journal |vauthors=Chaves DM, Maluf Filho F, de Moura EG, Santos ME, Arrais LR, Kawaguti F, Sakai P |title=Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer--initial experience of a western center |journal=Clinics (Sao Paulo) |volume=65 |issue=4 |pages=377–82 |date=April 2010 |pmid=20454494 |pmc=2862673 |doi=10.1590/S1807-59322010000400005 |url=}}</ref>
 
=== Follow-up after endoscopic resection ===
 
===== Follow-up after curative resection =====
*Annual [[endoscopy]] with [[abdominal]] [[Ultrasound|ultrasonography]] or [[Computed tomography|CT]] scan follow-up is recommended.
*[[Helicobacter pylori]] should be tested and treated if found.
 
===== Follow-up after non-curative resection =====
*[[Surgery|Surgical]] treatment should be performed after non-curative resection such as [[endoscopic]] [[coagulation]] using a laser or [[Argon plasma coagulation|argon-plasma coagulator]].
 
== Surgical Management Of Invasive Gastric Cancer ==
[[Surgery|Surgical]] management of a gastric [[tumor]] with resection of adjacent [[lymph nodes]] presents the best chance for long-term survival.
 
=== Types of gastric surgery ===
 
==== Curative surgery ====
* '''Standard gastrectomy''': In the standard [[Gastrectomy|gastrectomy,]] two-thirds of the [[stomach]] is [[Resection|resected]]. It is the principal surgical procedure used.
* '''Non-standard gastrectomy''': In non-standard [[gastrectomy]], the extent of [[gastric]] [[resection]] and [[lymphadenectomy]] is altered according to the stage of [[tumor]].
 
* '''Modified surgery:''' The extent of gastric resection and [[lymphadenectomy]] is reduced if compared to standard [[surgery]].
 
* '''Extended surgery'''
 
* Gastrectomy with resection of adjacent involved [[organs]]
 
* [[Gastrectomy]] with extended [[lymphadenectomy]]
 
==== Non-curative surgery ====
* '''Palliative surgery:''' Palliative [[gastrectomy]] or [[gastrojejunostomy]] is selected depending on the resectability of the primary [[tumor]] and surgical risks to relieve symptoms such as [[bleeding]] or [[Obstruction|obstruction.]]
* '''Reduction surgery:''' Reduction surgery aim is to prolong survival by reducing [[tumor]] volume.
 
=== Surgeries for gastric cancer ===
* '''Total gastrectomy''': Total resection of the stomach '''including the [[cardia]]''' and [[pylorus]]
* '''Distal gastrectomy:''' Stomach resection including the [[pylorus]]. The '''[[cardia]] is preserved'''
* '''Pylorus-preserving gastrectomy''': [[Stomach]] resection preserving the upper third of the [[stomach]] and the [[pylorus]] with a portion of the [[antrum]]
* '''Proximal gastrectomy''': [[Stomach]] resection including the [[cardia]]. The [[pylorus]] is preserved
* '''Segmental gastrectomy:''' Circumferential resection of the [[stomach]] preserving the [[cardia]] and [[pylorus]]
* '''Local resection'''
* '''Non-resectional surgery''' (bypass surgery, [[gastrostomy]], and jejunostomy)
 
==== Determination of gastric resection ====
* For '''T1''' [[Tumor|tumors]], a gross resection margin of '''2 cm''' should be obtained. 
* Proximal margin of at least '''3 cm''' is recommended for '''T2''' or deeper [[tumors]] with an expansive growth pattern and '''5 cm''' for those with an infiltrative growth pattern.
* For tumors invading the [[esophagus]], a '''5-cm''' margin is not necessarily required, but [[Frozen section procedure|frozen section]] examination of the resection line is desirable to ensure a R0 resection.
* When the [[tumor]] border is unclear, preoperative [[Endoscopy|endoscopic]] marking by clips of the [[tumor]] border based on [[biopsy]] results will be helpful for decision making regarding the resection line.
 
==== Selection of the surgery'''<ref name="pmid25436387">{{cite journal| author=Kim JY, Ha TK, le Roux CW| title=Metabolic effects of gastrectomy with or without omentectomy in gastric cancer. | journal=Hepatogastroenterology | year= 2014 | volume= 61 | issue= 134 | pages= 1830-4 | pmid=25436387 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25436387  }}</ref><ref name="pmid27342689">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese gastric cancer treatment guidelines 2014 (ver. 4). | journal=Gastric Cancer | year= 2017 | volume= 20 | issue= 1 | pages= 1-19 | pmid=27342689 | doi=10.1007/s10120-016-0622-4 | pmc=5215069 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27342689  }}</ref>''' ====
* The standard surgical procedure is total or distal [[gastrectomy]].
* '''Pancreaticosplenectomy'''
**[[Pancreas|Pancreatic]] invasion by tumor requires total [[gastrectomy]] regardless of the [[tumor]] location.
* '''Total gastrectomy with splenectomy'''
**It should be considered for [[Tumor|tumors]] that are located along the greater curvature with [[metastasis]] to no. 4 [[Lymph node|lymph nodes]].
* '''Esophagectomy and proximal gastrectomy'''
**It should be considered for [[adenocarcinoma]] located on the proximal side of the esophagogastric junction.
* '''Pylorus-preserving gastrectomy'''
**For [[Tumor|tumors]] in the middle portion of the stomach with the distal [[tumor]] border at least 4 cm proximal to the [[pylorus]].
 
* '''Vagal nerve preservation'''
**It is reported that preservation of the hepatic branch of the anterior [[Vagus nerve|vagus]] and the celiac branch of the posterior [[Vagus nerve|vagus]] contributes to improving postoperative quality of life through reducing [[post-gastrectomy]] [[Gallstone disease|gallstone]] formation, [[diarrhea]] and [[weight loss]]. In case of PPG, the hepatic branch should be preserved to maintain the [[Pylorus|pyloric]] function.
* '''Omentectomy'''
**Removal of the [[greater omentum]] is usually integrated into the standard gastrectomy for T3 or deeper [[Tumor|tumors]].
For T1/T2 tumors, t[[Omentum|he omentum]] more than 3 cm away from the gastroepiploic arcade may be preserved.
* '''[[Bursectomy]]'''<ref name="pmid25704429">{{cite journal| author=Hirao M, Kurokawa Y, Fujita J, Imamura H, Fujiwara Y, Kimura Y et al.| title=Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial. | journal=Surgery | year= 2015 | volume= 157 | issue= 6 | pages= 1099-105 | pmid=25704429 | doi=10.1016/j.surg.2014.12.024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25704429  }}</ref>
**[[Bursectomy]] is removal of the inner [[Peritoneum|peritonea]]<nowiki/>l surface of the [[bursa omentalis]].
**It should be avoided in T1/T2 [[tumors]] to prevent injury to the pancreas and adjacent [[blood vessels]].
**There are some survival benefits for [[bursectomy]] in T3/T4a [[tumors]].
 
=== Lymph nodes resection ===
* One of the most controversial areas in the surgical management of gastric cancer is the optimal extent of [[lymph node]] dissection.<ref name="pmid11147594">{{cite journal| author=Noguchi Y, Yoshikawa T, Tsuburaya A, Motohashi H, Karpeh MS, Brennan MF| title=Is gastric carcinoma different between Japan and the United States? | journal=Cancer | year= 2000 | volume= 89 | issue= 11 | pages= 2237-46 | pmid=11147594 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11147594  }}</ref>
* The draining [[Lymph node|lymph nodes]] for the [[stomach]] have been meticulously divided into 16 stations by Japanese surgeons; stations 1 to 6 are perigastric, and the remaining 10 are located adjacent to major vessels, behind the [[pancreas]], and along the [[aorta]].<ref name="pmid21573743">{{cite journal| author=Japanese Gastric Cancer Association| title=Japanese classification of gastric carcinoma: 3rd English edition. | journal=Gastric Cancer | year= 2011 | volume= 14 | issue= 2 | pages= 101-12 | pmid=21573743 | doi=10.1007/s10120-011-0041-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21573743  }}</ref>
'''D1 lymphadenectomy'''
* It refers to a dissection of only the perigastric [[Lymph node|lymph nodes]].
* A D1 [[lymphadenectomy]] is indicated for T1a [[Tumor|tumors]] that do not meet the criteria for EMR/ ESD and for T1bN0 tumors that are histologically of differentiated type and 1.5 cm or smaller in diameter.
'''D2 lymphadenectomy'''
* It is an extended [[lymph node]] dissection, includes removal of nodes along the [[hepatic]], [[Left gastric artery|left gastric]], [[Celiac artery|celiac]], and [[Spleen|splenic]] arteries, as well as those in the [[splenic hilum]].
* It is indicated for potentially curable T2-T4 tumors.
* A D2 [[lymphadenectomy]] should be performed whenever nodal involvement is suspected.
'''D3 dissection'''
* It is a superextended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of '''nodes within the [[porta hepatis]] and periaortic regions.'''<ref name="pmid18669424">{{cite journal| author=Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A et al.| title=D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. | journal=N Engl J Med | year= 2008 | volume= 359 | issue= 5 | pages= 453-62 | pmid=18669424 | doi=10.1056/NEJMoa0707035 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18669424  }}</ref>
 
=== Local palliative preocedures===
* Therapeutic options to control [[symptoms]] of local [[disease]] progression, such as [[nausea]], [[pain]], [[bleeding]], and [[obstruction]], include [[palliative]] surgical [[resection]], [[surgical]] bypass ([[gastrojejunostomy]]), [[radiation therapy]] (RT), and [[endoscopic]] techniques.
 
* '''Palliative resection'''
**[[Palliative]] [[gastrectomy]] should be reserved for extreme, highly [[symptomatic]] cases where less invasive methods cannot be used.<ref name="pmid10791239">{{cite journal| author=Kikuchi S, Arai Y, Kobayashi N, Tsukamoto H, Shimao H, Sakakibara Y et al.| title=Is extended lymphadenectomy valuable in palliatively gastrectomized patients with gastric cancer and simultaneous peritoneal metastasis? | journal=Hepatogastroenterology | year= 2000 | volume= 47 | issue= 32 | pages= 563-6 | pmid=10791239 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10791239  }}</ref>
**Two-year survival for [[chemotherapy]] alone versus [[gastrectomy]] plus [[chemotherapy]] was 32 versus 25 percent.
**Patients undergoing [[gastrectomy]] had a significantly higher [[incidence]] of several serious adverse events related to [[chemotherapy]], including [[Leukopenia|leucopenia]], [[nausea]], [[anorexia]], and [[hyponatremia]].


==Surgery==
* '''Gastrojejunostomy'''
**[[Palliative]] [[gastrojejunostomy]] for [[gastric outlet obstruction]] associated with unresectable advanced gastric cancer can improve food intake.<ref name="pmid9762890">{{cite journal| author=Ouchi K, Sugawara T, Ono H, Fujiya T, Kamiyama Y, Kakugawa Y et al.| title=Therapeutic significance of palliative operations for gastric cancer for survival and quality of life. | journal=J Surg Oncol | year= 1998 | volume= 69 | issue= 1 | pages= 41-4 | pmid=9762890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9762890  }}</ref>
**[[Palliative]] [[gastrojejunostomy]] for patients with [[Metastasis|metastatic]] gastric cancer is reserved for cases where less invasive methods cannot be used.


Surgery is a common treatment of all stages of gastric cancer. The following types of surgery may be used:
* '''Endoscopic stent placement<ref name="pmid17559659">{{cite journal| author=Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD| title=Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. | journal=BMC Gastroenterol | year= 2007 | volume= 7 | issue=  | pages= 18 | pmid=17559659 | doi=10.1186/1471-230X-7-18 | pmc=1904222 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17559659  }}</ref><ref name="pmid10905359">{{cite journal| author=Wu KL, Tsao WL, Shyu RY| title=Low-power laser therapy for gastrointestinal neoplasia. | journal=J Gastroenterol | year= 2000 | volume= 35 | issue= 7 | pages= 518-23 | pmid=10905359 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10905359  }}</ref>'''
**For [[palliation]] of [[Obstruction|obstructive]] [[symptoms]], [[endoscopic]] placement of a stent provides a less invasive alternative to [[surgery]] for [[symptom]] [[palliation]] and may possibly be more effective in [[symptom]] relief.
**[[Stenting]] may achieve a better [[quality of life]] compared with other forms of [[palliation]].
**In a review of two randomized trials of [[Endoscopy|endoscopic]] [[stenting]] versus palliative [[Gastrojejunostomy|gastrojejunostomy,]] there were no statistically significant differences between the two procedures in terms of efficacy or complications.


*Subtotal gastrectomy: Removal of the part of the stomach that contains cancer, nearby [[lymph nodes]], and parts of other [[tissues]] and organs near the tumor. The [[spleen]] may be removed. The spleen is an organ in the upper abdomen that filters the blood and removes old blood cells.
* '''Endoscopic laser therapy<ref name="pmid8751226">{{cite journal| author=Freitas D, Gouveia H, Sofia C, Cabral JP, Donato A| title=Endoscopic Nd-YAG laser therapy as palliative treatment for esophageal and cardial cancer. | journal=Hepatogastroenterology | year= 1995 | volume= 42 | issue= 5 | pages= 633-7 | pmid=8751226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8751226  }}</ref>'''
**Laser [[photocoagulation]] can be effective, particularly for large [[tumors]] with diffuse [[bleeding]].
**An alternative that is being used increasingly is argon plasma coagulation.


*Total gastrectomy: Removal of the entire stomach, nearby lymph nodes, and parts of the [[esophagus]], [[small intestine]], and other tissues near the tumor. The spleen may be removed. The esophagus is connected to the small intestine so the patient can continue to eat and swallow.
=== Reconstruction after gastrectomy ===
'''Total gastrectomy'''
* Roux-en-Y esophagojejunostomy<ref name="pmid26379405">{{cite journal| author=Xiao JW, Liu ZL, Ye PC, Luo YJ, Fu ZM, Zou Q et al.| title=Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction. | journal=World J Gastroenterol | year= 2015 | volume= 21 | issue= 34 | pages= 9999-10007 | pmid=26379405 | doi=10.3748/wjg.v21.i34.9999 | pmc=4566393 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26379405  }}</ref>
* Jejunal interposition
* Double tract method
'''Distal gastrectomy'''
* Billroth I [[gastroduodenostomy]]<ref name="pmid26895918">{{cite journal| author=Byun C, Cui LH, Son SY, Hur H, Cho YK, Han SU| title=Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis. | journal=Surg Endosc | year= 2016 | volume= 30 | issue= 10 | pages= 4505-14 | pmid=26895918 | doi=10.1007/s00464-016-4783-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26895918  }}</ref>
* Billroth II [[gastrojejunostomy]]
* Roux-en-Y [[gastrojejunostomy]]
* Jejunal interposition
'''Pylorus-preserving gastrectomy'''<ref name="pmid25243417">{{cite journal| author=Song P, Lu M, Pu F, Zhang D, Wang B, Zhao Q| title=Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer. | journal=J Laparoendosc Adv Surg Tech A | year= 2014 | volume= 24 | issue= 10 | pages= 718-27 | pmid=25243417 | doi=10.1089/lap.2014.0123 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25243417  }}</ref>
* Gastro-[[gastrostomy]]
* Proximal [[gastrectomy]]
* Esophagogastrostomy
* Jejunal interposition
* Double tract method


If the tumor is blocking the stomach but cancer cannot be completely removed by standard surgery, the following procedures may be used:
== Video shows gastrectomy steps ==
{{#ev:youtube|5rj7M4kZKp0}}


*Endoluminal stent placement: A procedure to insert a stent (a thin, expandable tube) in order to keep a passage (such as arteries or the esophagus) open. For tumors blocking the passage into or out of the stomach, surgery may be done to place a stent from the esophagus to the stomach or from the stomach to the small intestine to allow the patient to eat normally.
== Gastric cancer treatment algorithm ==
*Endoluminal laser therapy: A procedure in which an endoscope (a thin, lighted tube) with a laser attached is inserted into the body. A laser is an intense beam of light that can be used as a knife.
*[[Gastrojejunostomy]]: Surgery to remove the part of the stomach with cancer that is blocking the opening into the small intestine. The stomach is connected to the jejunum (a part of the small intestine) to allow food and medicine to pass from the stomach into the small intestine.


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Latest revision as of 21:52, 25 January 2019


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2] Mohammed Abdelwahed M.D[3]

Stomach cancer Microchapters

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Overview

Surgery is the mainstay of treatment for stomach cancer. Endoscopic resection is suggested for early gastric cancer. There are criteria for endoscopic resection of ealry gastric cancer. Methods for endoscopic resection include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Side effects of endoscopy includes bleeding and perforation. For T1 tumors, a 2cm macroscopic resection of tumor margin should be performed. Proximal margin of at least 3 cm is recommended for T2 or deeper tumors with an expansive growth pattern and 5 cm for those with an infiltrative growth pattern. For tumors invading the esophagus, a 5-cm margin is not necessarily required, but frozen section examination of the resection line is desirable to ensure a R0 resection. There is a debate about optimal lymph node removal. D1 lymphadenectomy refers to a dissection of only the perigastric lymph nodes. D2 lymphadenectomy is an extended lymph node dissection, includes removal of nodes along the hepatic, left gastric, celiac, and splenic arteries, as well as those in the splenic hilum. D3 dissection is a super-extended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions.

Surgical Management Of Early Gastric Cancer

Standard criteria for endoscopic resection:

The standard criteria for lesions qualifying for endoscopic resection are the following:[2][3]

1) Confined to the mucosa

2) Smaller than 2 cm for superficially elevated type lesions

3) Smaller than 1 cm for the flat and depressed type lesions

4) No ulcer or ulcer scar

5) No venous or lymphatic involvement

Expansion of the criteria to involve more tumors eligible for endoscopic resection was suggested by Japanese centers and these criteria include:[4]

Methods of endoscopic resection

The following are the different types of endoscopic resection techniques for gastric cancer:[5]

  • Endoscopic submucosal dissection (ESD):
    • The mucosa surrounding the lesion is incised using a high-frequency electric knife.
    • ESD is more likely to result in complete resection of early gastric cancer but requires more time and endoscopic skills.

Side effects and complications:

Bleeding
Perforation
  • Perforation rate for ESD is 4.5 percent, compared with 1.0 percent for EMR.[7]
  • Tumor location in the upper stomach and size more than 2 cm have been associated with an increased risk of perforation with ESD.
  • Treatment of a perforation is endoscopic clipping, open or laparoscopic surgery in case of failed clipping.

Curative resection

The following criteria need to be fulfilled to consider endoscopic resection curative:[8]

Any resection that does not satisfy any of the above criteria is considered non-curative.

Management of non-curative resection 

Management of positive margins[10]

  • Patients with only positive lateral margins can be managed with endoscopic therapy rather than surgery.
  • Almost 90 percent of lateral postitve margins were followed endoscopically with no recurrences.
  • Patients with positive vertical margins, submucosal invasion, or lymphovascular invasion, are treated by surgery.

Local recurrence after EMR/ESD

Local mucosal recurrence after EMR/ESD for tumors that had fulfilled the criteria for indication for endoscopic resection may be treated by another ESD.[11]

Follow-up after endoscopic resection

Follow-up after curative resection
Follow-up after non-curative resection

Surgical Management Of Invasive Gastric Cancer

Surgical management of a gastric tumor with resection of adjacent lymph nodes presents the best chance for long-term survival.

Types of gastric surgery

Curative surgery

  • Modified surgery: The extent of gastric resection and lymphadenectomy is reduced if compared to standard surgery.
  • Extended surgery
  • Gastrectomy with resection of adjacent involved organs

Non-curative surgery

Surgeries for gastric cancer

  • Total gastrectomy: Total resection of the stomach including the cardia and pylorus
  • Distal gastrectomy: Stomach resection including the pylorus. The cardia is preserved
  • Pylorus-preserving gastrectomy: Stomach resection preserving the upper third of the stomach and the pylorus with a portion of the antrum
  • Proximal gastrectomy: Stomach resection including the cardia. The pylorus is preserved
  • Segmental gastrectomy: Circumferential resection of the stomach preserving the cardia and pylorus
  • Local resection
  • Non-resectional surgery (bypass surgery, gastrostomy, and jejunostomy)

Determination of gastric resection

  • For T1 tumors, a gross resection margin of 2 cm should be obtained.
  • Proximal margin of at least 3 cm is recommended for T2 or deeper tumors with an expansive growth pattern and 5 cm for those with an infiltrative growth pattern.
  • For tumors invading the esophagus, a 5-cm margin is not necessarily required, but frozen section examination of the resection line is desirable to ensure a R0 resection.
  • When the tumor border is unclear, preoperative endoscopic marking by clips of the tumor border based on biopsy results will be helpful for decision making regarding the resection line.

Selection of the surgery[12][13]

  • The standard surgical procedure is total or distal gastrectomy.
  • Pancreaticosplenectomy
  • Total gastrectomy with splenectomy
  • Esophagectomy and proximal gastrectomy
    • It should be considered for adenocarcinoma located on the proximal side of the esophagogastric junction.
  • Pylorus-preserving gastrectomy
    • For tumors in the middle portion of the stomach with the distal tumor border at least 4 cm proximal to the pylorus.
  • Vagal nerve preservation
    • It is reported that preservation of the hepatic branch of the anterior vagus and the celiac branch of the posterior vagus contributes to improving postoperative quality of life through reducing post-gastrectomy gallstone formation, diarrhea and weight loss. In case of PPG, the hepatic branch should be preserved to maintain the pyloric function.
  • Omentectomy
    • Removal of the greater omentum is usually integrated into the standard gastrectomy for T3 or deeper tumors.

For T1/T2 tumors, the omentum more than 3 cm away from the gastroepiploic arcade may be preserved.

Lymph nodes resection

  • One of the most controversial areas in the surgical management of gastric cancer is the optimal extent of lymph node dissection.[15]
  • The draining lymph nodes for the stomach have been meticulously divided into 16 stations by Japanese surgeons; stations 1 to 6 are perigastric, and the remaining 10 are located adjacent to major vessels, behind the pancreas, and along the aorta.[16]

D1 lymphadenectomy

  • It refers to a dissection of only the perigastric lymph nodes.
  • A D1 lymphadenectomy is indicated for T1a tumors that do not meet the criteria for EMR/ ESD and for T1bN0 tumors that are histologically of differentiated type and 1.5 cm or smaller in diameter.

D2 lymphadenectomy

D3 dissection

  • It is a superextended lymphadenectomy. The surgery includes D2 lymphadenectomy plus the removal of nodes within the porta hepatis and periaortic regions.[17]

Local palliative preocedures

  • Endoscopic laser therapy[22]
    • Laser photocoagulation can be effective, particularly for large tumors with diffuse bleeding.
    • An alternative that is being used increasingly is argon plasma coagulation.

Reconstruction after gastrectomy

Total gastrectomy

  • Roux-en-Y esophagojejunostomy[23]
  • Jejunal interposition
  • Double tract method

Distal gastrectomy

Pylorus-preserving gastrectomy[25]

Video shows gastrectomy steps

{{#ev:youtube|5rj7M4kZKp0}}

Gastric cancer treatment algorithm

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gastic carcinoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
M0
 
 
 
 
 
 
 
 
M1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
T1
 
 
 
 
T2,T3,T4A
 
 
 
 
T4B
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N0
 
 
 
N1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
T1a
 
 
 
 
 
T1b
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differenitated,≤1.5cm
 
 
 
 
 
Differenitated,≤1.5cm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopic resection
 
 
 
Gastrectomy,D1
 
 
 
Gastrectomy,D+1
 
Gastrectomy,D2
 
 
 
Gastrectomy,combined resection,D2
 
 
Chemotherapy,Radiptherapy,Palliative surgery
 

References

  1. ↑ Etoh T, Katai H, Fukagawa T, Sano T, Oda I, Gotoda T; et al. (2005). "Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan". Gastrointest Endosc. 62 (6): 868–71. doi:10.1016/j.gie.2005.09.012. PMID 16301028.
  2. ↑ Smyth EC, Verheij M, Allum W, Cunningham D, Cervantes A, Arnold D; et al. (2016). "Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up". Ann Oncol. 27 (suppl 5): v38–v49. doi:10.1093/annonc/mdw350. PMID 27664260.
  3. ↑ Bollschweiler E, Berlth F, Baltin C, Mönig S, Hölscher AH (2014). "Treatment of early gastric cancer in the Western World". World J Gastroenterol. 20 (19): 5672–8. doi:10.3748/wjg.v20.i19.5672. PMC 4024776. PMID 24914327.
  4. ↑ Lee JH, Choi MG, Min BH, Noh JH, Sohn TS, Bae JM; et al. (2012). "Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer". Br J Surg. 99 (12): 1688–92. doi:10.1002/bjs.8934. PMID 23023388.
  5. ↑ Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A; et al. (2015). "Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline". Endoscopy. 47 (9): 829–54. doi:10.1055/s-0034-1392882. PMID 26317585.
  6. ↑ Nishide N, Ono H, Kakushima N, Takizawa K, Tanaka M, Matsubayashi H; et al. (2012). "Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube". Endoscopy. 44 (6): 577–83. doi:10.1055/s-0031-1291712. PMID 22402983.
  7. ↑ Abe Y, Inamori M, Iida H, Endo H, Akiyama T, Yoneda K; et al. (2009). "Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer". Hepatogastroenterology. 56 (91–92): 921–4. PMID 19621730.
  8. ↑ Japanese Gastric Cancer Association (2017). "Japanese gastric cancer treatment guidelines 2014 (ver. 4)". Gastric Cancer. 20 (1): 1–19. doi:10.1007/s10120-016-0622-4. PMC 5215069. PMID 27342689.
  9. ↑ FLY OA, PRIESTLEY JT, COMFORT MW, GAGE RP (May 1958). "Total gastrectomy: mortality and survival". Ann. Surg. 147 (5): 760–8, discussion 768–70. PMC 1450692. PMID 13521695.
  10. ↑ Wang SY, Yeh CN, Lee HL, Liu YY, Chao TC, Hwang TL, Jan YY, Chen MF (October 2009). "Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy". Ann. Surg. Oncol. 16 (10): 2738–43. doi:10.1245/s10434-009-0616-0. PMID 19636636.
  11. ↑ Chaves DM, Maluf Filho F, de Moura EG, Santos ME, Arrais LR, Kawaguti F, Sakai P (April 2010). "Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer--initial experience of a western center". Clinics (Sao Paulo). 65 (4): 377–82. doi:10.1590/S1807-59322010000400005. PMC 2862673. PMID 20454494.
  12. ↑ Kim JY, Ha TK, le Roux CW (2014). "Metabolic effects of gastrectomy with or without omentectomy in gastric cancer". Hepatogastroenterology. 61 (134): 1830–4. PMID 25436387.
  13. ↑ Japanese Gastric Cancer Association (2017). "Japanese gastric cancer treatment guidelines 2014 (ver. 4)". Gastric Cancer. 20 (1): 1–19. doi:10.1007/s10120-016-0622-4. PMC 5215069. PMID 27342689.
  14. ↑ Hirao M, Kurokawa Y, Fujita J, Imamura H, Fujiwara Y, Kimura Y; et al. (2015). "Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial". Surgery. 157 (6): 1099–105. doi:10.1016/j.surg.2014.12.024. PMID 25704429.
  15. ↑ Noguchi Y, Yoshikawa T, Tsuburaya A, Motohashi H, Karpeh MS, Brennan MF (2000). "Is gastric carcinoma different between Japan and the United States?". Cancer. 89 (11): 2237–46. PMID 11147594.
  16. ↑ Japanese Gastric Cancer Association (2011). "Japanese classification of gastric carcinoma: 3rd English edition". Gastric Cancer. 14 (2): 101–12. doi:10.1007/s10120-011-0041-5. PMID 21573743.
  17. ↑ Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A; et al. (2008). "D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer". N Engl J Med. 359 (5): 453–62. doi:10.1056/NEJMoa0707035. PMID 18669424.
  18. ↑ Kikuchi S, Arai Y, Kobayashi N, Tsukamoto H, Shimao H, Sakakibara Y; et al. (2000). "Is extended lymphadenectomy valuable in palliatively gastrectomized patients with gastric cancer and simultaneous peritoneal metastasis?". Hepatogastroenterology. 47 (32): 563–6. PMID 10791239.
  19. ↑ Ouchi K, Sugawara T, Ono H, Fujiya T, Kamiyama Y, Kakugawa Y; et al. (1998). "Therapeutic significance of palliative operations for gastric cancer for survival and quality of life". J Surg Oncol. 69 (1): 41–4. PMID 9762890.
  20. ↑ Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD (2007). "Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review". BMC Gastroenterol. 7: 18. doi:10.1186/1471-230X-7-18. PMC 1904222. PMID 17559659.
  21. ↑ Wu KL, Tsao WL, Shyu RY (2000). "Low-power laser therapy for gastrointestinal neoplasia". J Gastroenterol. 35 (7): 518–23. PMID 10905359.
  22. ↑ Freitas D, Gouveia H, Sofia C, Cabral JP, Donato A (1995). "Endoscopic Nd-YAG laser therapy as palliative treatment for esophageal and cardial cancer". Hepatogastroenterology. 42 (5): 633–7. PMID 8751226.
  23. ↑ Xiao JW, Liu ZL, Ye PC, Luo YJ, Fu ZM, Zou Q; et al. (2015). "Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction". World J Gastroenterol. 21 (34): 9999–10007. doi:10.3748/wjg.v21.i34.9999. PMC 4566393. PMID 26379405.
  24. ↑ Byun C, Cui LH, Son SY, Hur H, Cho YK, Han SU (2016). "Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis". Surg Endosc. 30 (10): 4505–14. doi:10.1007/s00464-016-4783-3. PMID 26895918.
  25. ↑ Song P, Lu M, Pu F, Zhang D, Wang B, Zhao Q (2014). "Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer". J Laparoendosc Adv Surg Tech A. 24 (10): 718–27. doi:10.1089/lap.2014.0123. PMID 25243417.

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