Surgical results of remnant gastric cancer treatment

Background: remnant gastric cancer (RGC) develops five years or later after previous resection for benign or malignant lesion. The treatment is performed through completion total gastrectomy (CTG) with radical lymphadenectomy. Some reports consider this procedure may be associated with higher rates of morbidity and mortality. Objective: to evaluate surgical results and survival after CTG in patients with RGC. Methods: 54 patients who underwent CTG between 2009 and 2019 were included in the study. As a comparison group 215 patients with primary gastric cancer (PGC) who underwent total gastrectomy (TG) in the same period were selected. Results: among the initial characteristics, age (68.0 vs. 60.5; p<0.001), hemoglobin values (10.9 vs. 12.3; p<0.001) and body mass index (22.5 vs. 24.6; p=0.005) were different between the RGC and PGC groups, respectively. The most frequent postoperative complications were related to pulmonary complications, infection and fistula in both groups. There was a higher incidence of esophagojejunal fistula in the CTG group (14.8% vs 6.5%, p=0.055). Perioperative mortality was higher in RGC patients (9.3% vs. 5.1%), but without significance (p=0.329). Hospital length of stay, postoperative complications graded by the Clavien-Dindo classification, mortality at 30 and 90 days were not different between groups. There was no significant difference in disease-free and overall survival between RGC and PGC groups. Conclusion: despite previous reports, surgical results and survival were similar between groups. Higher risk of esophagojejunal fistula must be considered.


INTRODUCTION
G astric cancer (GC) is the fifth most common cancer in the world, persisting as an important global public health issue 1 . According to its location, GC is usually divided into distal and proximal tumors or even tumors involving the entire organ. However, there is a type of GC that does not fit this classification, which is the gastric stump tumor -or remnant gastric cancer (RGC). It is defined as a tumor that develops five years or later after previous gastrectomy 2 . Its incidence varies between 2 to 6% among all cases of GC 3,4 . The RGC can occur in the remnant stomach after previous resection for benign or malignant lesions 5 .
The exact carcinogenic mechanism of RGC is Although there is a recommendation for follow-up after partial gastrectomy, the long period of carcinogenesis after previous resection may discourage patients to maintain a continuous regular monitoring.
This may lead to late diagnosis of RGC, with more advanced clinical stages and worse prognosis 3,8,9 . The surgical treatment for RGC is performed through completion total gastrectomy (CTG) with radical lymphadenectomy. Adhesion to adjacent organs and displacement of anatomical structures are common difficulties during the procedure, turning it longer and more prone to combined repair or resection of adjacent

Ramos
Surgical results of remnant gastric cancer treatment organs. Cases in which the first surgery was performed for perforated gastric ulcer also causes the formation of more extensive adhesions. Therefore, higher rates of morbidity and mortality after CTG are reported 10 .
The aim of this study was to evaluate the surgical outcomes and survival of patients after completion total gastrectomy (CTG) compared to patients with primary gastric cancer (PGC) who underwent total gastrectomy (TG).  11 and laboratory tests. CCI was considered without inclusion of age and gastric cancer as comorbidity.

METHODS
Additionally, patients were evaluated for lymph node status according to the "lymph node ratio", as proposed by Deng et al. 12

Statistical analysis
The Chi-square tests were used for categorical

RESULTS
During the selected period, 1,157 GC patients were admitted to surgical treatment at our Hospital. Clinical and surgical characteristics of the CTG and TG groups are summarized in Table 1. Patients in CTG group were significantly older (p<0.001), had lower BMI (p=0.005) and hemoglobin levels (p<0.001).     SD, standard deviation * The highest grade if patient had more than one complication.

Survival analysis
After a mean follow-up of 34 months, 91 patients had disease recurrence and 121 died. The median OS for the entire cohort was 54 months.
Kaplan-Meier curves are demonstrated in Figure 1

DISCUSSION
In the present study, we analyzed the surgical outcomes of RGC patients who underwent CTG and compared with PGC patients. Patients with RGC were older, with lower BMI and lower hemoglobin levels, but they were not diagnosed in more advanced stages.

CONCLUSIONS
Patients who underwent completion total gastrectomy for RGC had same frequency and severity of clinical and surgical complications compared to total gastrectomy patients with primary GC. The long-term DFS and OS also did not differ between CTG and TG groups. However, a higher risk of esophagojejunal fistula must be considered in CTG.