1. Can we apply the same indications of
ESD for primary gastric cancer to
remnant gastric cancer?
Saeed Alshomimi, Yoon Young Choi, In Gyu Kwon, Woo Jin Hyung,
Sung Hoon Noh
Department of Surgery, Yonsei University Health system

2. Cancer in the remnant stomach
1~7% of all gastric cancer
Risk of cancer : 4~7 fold after 20 years
risk increasing 28% by every 5 years
Introduction

3. Introduction
Partial Gastrectomy
↓ Blood supply
Denervation
Duodenal
reflux
Hormonal
change
Damage of gastric mucosa
Cell proliferation↑
↑ pH
in stomach
Nitrate
reducing
bacteria↑
Nitrosamine
↑
RGC

4. Introduction
Cancer in Remnant Stomach
Remnant Gastric Cancer
(cancer after cancer)
Gastric Stump Cancer
( Cancer after Benign )
1- Curative gastrectomy
2- interval of 12 months
3- pathologically confirmed
adenocarcinoma in the remnant stomach
Incidence

5. Introduction
Treatment?
Complete resection of carcinoma with
radical LN dissection
Difficult to do because of :
postoperative adhesion
anatomical deformation

6. Role of EMR & ESD for primary gastric cancer
Introduction

7. Role of EMR & ESD for RGC?
Has yet been decided because of
possible effects of previous cancer
lack of sufficient data
However,
RGC will increase
early detection would be possible
Need the indication of ESD for RGC
Introduction

8. 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

9. 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

10. T-stage Number of patients
(LN+ patients/total patien
ts)
LN (positive LN/retrieved L
N)
Early RGC
(n=41)
m 0/25 0/224
sm 1*/16 1/120
Total 1/41 1/344
Results
CTG for RGC
( n = 105 )
Early RGC
n=41(39%)
ESD for RGC
( n = 5 )

11. Number
of case
Age Sex T-stage Histologic
al type
Presence
of Ulcer
Size Location Lymph Node
positive 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

12. Case
Age3 Sex
Reconstruction typ
e
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

13. 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)
Complications
Minor
Atelectasis : 3 (1 NAS, 2 anastomosis)
Transfusion : 1 (NAS)1
Intra-abdominal abscess : 1 (NAS)
Major
Intra-abdominal abscess with pleural effusion
: 1 (NAS)1
Re-operation with intensive care unit care : 1
(NAS)
Others
Combined splenectomy due to injury
Minor
Free air : 1
Others
In procedure bleeding : 2
Need clipping : 1
Need coagulation : 1
Results

14. The largest data but still insufficient
Same indication would be possible
Need more evidence from multinational &
multicenter review
Discussion

15. Thanks for your
attention!