Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer

Abstract

Background: Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.

Methods: We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.

Results: Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.

Conclusion: Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

Keywords: Endoscopy; Gastric Cancer; Locoregional Recurrence; Postoperative Adverse Events; Surveillance; Total Gastrectomy.

Fig. 1. Flowchart of patient enrollment and follow-up results.

TG = total gastrectomy, EGC = early gastric cancer, AGC = advanced gastric cancer.

Fig. 2. The distribution of patients and patterns of recurrence over time. (A) The distribution of patients according to the follow-up period. (B) The patterns and timing of recurrence in the 167 patients. Values in the histogram represent the number of patients.

Fig. 3. Endoscopic and contrast abdominopelvic CT findings of peri-anastomotic recurrence. The photos are each from patient #1 through patient #5 (left to right) in Table 2. (A) Mass of irregular shape around the anastomotic site. (B) Asymmetric low attenuated wall thickening at the anastomotic site. (C) Irregular nodularity with hyperemia on proximal part of the efferent loop. (D) Ill-defined low-density mass in the posterolateral aspect of the anastomotic site. (E) Irregular ulcerative lesion with luminal narrowing at the anastomotic site. (F) Wall thickening with enhancement just distal to the E-J anastomotic area. (G) Stricture of the anastomotic site with irregular mucosal nodularity. (H) Wall thickening with enhancement in the anastomotic site. (I) Irregular nodularity with hyperemia on the proximal part of the efferent loop. (J) Wall thickening with an enhancement of jejunum below the anastomotic site.

CT = computed tomography, E-J = esophagojejunal.