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Department of Gastric Surgery

Takahiro Kinoshita, Hidehito Shibasaki, Akio Kaito, Toshirou Nishida, Takuya Hamakawa

Introduction

Our Division consists of three staff surgeons, one senior resident and six junior resident surgeons. Our managing of tumors includes common gastric adenocarcinoma, adenocarcinoma of the esophagogastric junction (AEG: Siewert type 2/3), and gastric submucosal tumors (GIST, etc.). Annually, 260-300 patients are operated on either by means of open surgery or laparoscopic surgery. Laparoscopic gastrectomy with radical node dissection was introduced in 2010, and now our department is one of the leading institutions in Japan. In 2014, about 80% of gastrectomies were performed under laparoscopy, and also robot-assisted surgery has been done as an advanced medical service system (endorsed by the government). The basis of our surgery is radical extirpation of cancer lesions, but at the same time, organ functions and better quality of life (QOL) should be maintained. In addition, we strive to obtain better clinical outcomes for patients with diseases with dismal prognoses (type 4 gastric cancer or with progressive metastasis) by surgery combined with a modern chemotherapy regimen, including molecular-targeting drugs in cooperation with medical oncologists.

Routine activities

Usually 12-14 patients are hospitalized and five to seven patients undergo operations per week. A clinical conference of our Division is held once a week to decide our treatment strategy. Further, a conference with internal medicine is held every Monday evening with doctors of the Department of Diagnostic Radiology, Gastrointestinal Endoscopy, and Gastrointestinal Oncology, discussing the accurate diagnosis of the patients with gastric tumors to decide the optimal treatment method for each patient. Every Tuesday morning, a small conference is held with medical oncologists to discuss border-line cases. In principle, patients with low-risk superficial gastric cancer lesions (cT1a) are treated by endoscopic submucosal dissection (ESD) following the criteria of the guideline. Some are required to undergo subsequent completion laparoscopic surgery with nodal dissection based on pathological findings of specimens obtained by ESD. Laparoscopic surgery covers distal, proximal, pylorus-preserving, and total gastrectomy. D2 dissection can also be done under laparoscopy, and its applicability for advanced cancer is under investigation. When the tumor infiltrates to adjacent organs, sometimes extended operations are chosen. Recently, due to the progress of modern chemotherapy regimen, down-staging from cStageIV is sometimes seen. For such patients, we selectively perform conversion surgery to achieve favorable outcomes. For AEGs, the transhiatal approach can be safely employed under laparoscopy with a better surgical view.

Research activities

We aggressively publish our clinical research data in domestic or international congresses. In addition, we participate in multi-institutional clinical trials conducted by the Japan Clinical Oncology Group (JCOG) – Gastric Surgery Study Group or other organizations. Patients with gastric cancer are, if eligible for each study, invited to take part in one of the ongoing clinical trials.

Clinical trials

The list of clinical trials in which we participated in 2015 is as below.

  1. JCOG 1104 A phase II trial to define the optimal period of adjuvant S-1 chemotherapy for pathological stage II gastric cancer patients who underwent D2 gastrectomy
  2. JCOG 1401 Nonrandomized confirmatory study of laparoscopic total/proximal gastrectomy for clinical stage I gastric cancer
  3. A prospective study to evaluate safety, feasibility and economy of robot-assisted radical gastrectomy using da Vinci Surgical System (DVSS) (advanced medical service)
  4. JLSSG 0901 A phase III randomized trial comparing open and laparoscopic distal gastrectomy for clinical stage II/III gastric cancer
  5. A prospective randomized phase II trial comparing ci rcular and linear stapled esophagojejunostomy after laparoscopic total/ proximal gastrectomy (cooperation with Osaka University)
  6. A prospective cohort study to evaluate the proper extent of lymph node dissection for esophagogastric junction cancer

Education

Resident doctors are trained to be specialized surgical oncologists with sufficient techniques and knowledge. Nowadays, opportunities to perform laparoscopic and open surgery are simultaneously given to them. We also place importance on the education of surgeons of other institutions. In 2015, surgeons from domestic and foreign hospitals (from China, Korea, Philippine, Spain and Germany) visited our division to learn surgical techniques.

Future prospects

We will keep striving to obtain better survival outcomes for the patients with far advanced diseases; for multidisciplinary therapy (chemotherapy, molecular-target agents or immune check-point inhibitor), collaborating with medical oncologists is essential. Additionally, we will continue to develop less-invasive as well as highquality surgical methods (laparoscopic or robotic surgery), to increase patients' QOL and realize complete cures. It is also our obligation to expand our knowledge and experience globally as one of the most main countries in terms of gastric cancer occurrence.


Table 1. Number of patients Table 2. Type of procedure

List of papers published in 2015

Journal

  1. Kinoshita T, Kinoshita T, Saiura A, Esaki M, Sakamoto H, Yamanaka T. Multicentre analysis of long-term outcome after surgical resection for gastric cancer liver metastases. Br J Surg, 102:102-107, 2015
  2. Nishida T, Doi T, Naito Y. Tyrosine kinase inhibitors in the treatment of unresectable or metastatic gastrointestinal stromal tumors. Expert Opin Pharmacother, 15:1979-1989, 2015
  3. Fujii S, Fujihara A, Natori K, Abe A, Kuboki Y, Higuchi Y, Aizawa M, Kuwata T, Kinoshita T, Yasui W, Ochiai A. TEM1 expression in cancer-associated fibroblasts is correlated with a poor prognosis in patients with gastric cancer. Cancer Med, 4:1667-1678, 2015
  4. Takahashi T, Nakajima K, Miyazaki Y, Miyazaki Y, Kurokawa Y, Yamasaki M, Miyata H, Takiguchi S, Nishida T, Mori M, Doki Y. Surgical strategy for the gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm: laparoscopic surgery is feasible, safe, and oncologically acceptable. Surg Laparosc Endosc Percutan Tech, 25:114-118, 2015
  5. Yanagimoto Y, Takahashi T, Muguruma K, Toyokawa T, Kusanagi H, Omori T, Masuzawa T, Tanaka K, Hirota S, Nishida T. Re-appraisal of risk classifications for primary gastrointestinal stromal tumors (GISTs) after complete resection: indications for adjuvant therapy. Gastric Cancer, 18:426-433, 2015
  6. Hirota M, Nakajima K, Miyazaki Y, Takahashi T, Kurokawa Y, Yamasaki M, Miyata H, Takiguchi S, Nishida T, Mori M, Doki Y. Clinical outcomes of laparoscopic partial gastrectomy for gastric submucosal tumors. Asian J Endosc Surg, 8:24-28, 2015
  7. Joensuu H, Rutkowski P, Nishida T, Steigen SE, Brabec P, Plank L, Nilsson B, Braconi C, Bordoni A, Magnusson MK, Sufliarsky J, Federico M, Jonasson JG, Hostein I, Bringuier PP, Emile JF. KIT and PDGFRA mutations and the risk of GI stromal tumor recurrence. J Clin Oncol, 33:634-642, 2015
  8. Takiguchi S, Fujiwara Y, Yamasaki M, Miyata H, Nakajima K, Nishida T, Sekimoto M, Hori M, Nakamura H, Mori M, Doki Y. Laparoscopic intraoperative navigation surgery for gastric cancer using real-time rendered 3D CT images. Surg Today, 45:618-624, 2015
  9. Akamaru Y, Takahashi T, Nishida T, Omori T, Nishikawa K, Mikata S, Yamamura N, Miyazaki S, Noro H, Takiguchi S, Mori M, Doki Y. Effects of daikenchuto, a Japanese herb, on intestinal motility after total gastrectomy: a prospective randomized trial. J Gastrointest Surg, 19:467-472, 2015
  10. Nishida T, Matsushima T, Tsujimoto M, Takahashi T, Kawasaki Y, Nakayama S, Omori T, Yamamura M, Cho H, Hirota S, Ueshima S, Ishihara H. Cyclin-Dependent Kinase Activity Correlates with the Prognosis of Patients Who Have Gastrointestinal Stromal Tumors. Ann Surg Oncol, 22:3565-3573, 2015
  11. Komatsu Y, Doi T, Sawaki A, Kanda T, Yamada Y, Kuss I, Demetri GD, Nishida T. Regorafenib for advanced gastrointestinal stromal tumors following imatinib and sunitinib treatment: a subgroup analysis evaluating Japanese patients in the phase III GRID trial. Int J Clin Oncol, 20:905-912, 2015
  12. Nishida T. The role of endoscopy in the diagnosis of gastric gastrointestinal stromal tumors. Ann Surg Oncol, 22:2810-2811, 2015
  13. Maki RG, Blay JY, Demetri GD, Fletcher JA, Joensuu H, Martín-Broto J, Nishida T, Reichardt P, Schöffski P, Trent JC. Key Issues in the Clinical Management of Gastrointestinal Stromal Tumors: An Expert Discussion. Oncologist, 20:823-830, 2015
  14. Joensuu H, Martin-Broto J, Nishida T, Reichardt P, Schöffski P, Maki RG. Follow-up strategies for patients with gastrointestinal stromal tumour treated with or without adjuvant imatinib after surgery. Eur J Cancer, 51:1611-1617, 2015
  15. Isosaka M, Niinuma T, Nojima M, Kai M, Yamamoto E, Maruyama R, Nobuoka T, Nishida T, Kanda T, Taguchi T, Hasegawa T, Tokino T, Hirata K, Suzuki H, Shinomura Y. A Screen for Epigenetically Silenced microRNA Genes in Gastrointestinal Stromal Tumors. PLoS One, 10:e0133754, 2015
  16. Barrios CH, Blackstein ME, Blay JY, Casali PG, Chacon M, Gu J, Kang YK, Nishida T, Purkayastha D, Woodman RC, Reichardt P. The GOLD ReGISTry: a Global, Prospective, Observational Registry Collecting Longitudinal Data on Patients with Advanced and Localised Gastrointestinal Stromal Tumours. Eur J Cancer, 51:2423-2433, 2015
  17. Natatsuka R, Takahashi T, Serada S, Fujimoto M, Ookawara T, Nishida T, Hara H, Nishigaki T, Harada E, Murakami T, Miyazaki Y, Makino T, Kurokawa Y, Yamasaki M, Miyata H, Nakajima K, Takiguchi S, Kishimoto T, Mori M, Doki Y, Naka T. Gene therapy with SOCS1 for gastric cancer induces G2/M arrest and has an antitumour effect on peritoneal carcinomatosis. Br J Cancer, 113:433-442, 2015
  18. Komatsu Y, Ohki E, Ueno N, Yoshida A, Toyoshima Y, Ueda E, Houzawa H, Togo K, Nishida T. Safety, efficacy and prognostic analyses of sunitinib in the post-marketing surveillance study of Japanese patients with gastrointestinal stromal tumor. Jpn J Clin Oncol, 45:1016-1022, 2015