Introduction 1–3% of gastric cancers arise from hereditary predisposition syndromes. E-cadherin gene (CDH1) mutations are the best characterised of these and confer a life-time risk of approximately 80% for patients developing diffuse gastric cancer. Currently, the only definitive treatment available is prophylactic total gastrectomy (PTG). We present our experience of open PTG, focusing on the early outcomes.
Method Twenty four consecutive patients with CDH 1 mutation underwent PTG from 2005 to 2014 (median age 33, range 22–51). All patients had at least one gastroscopy with biopsies taken according to the Cambridge Protocol and were assessed by a multi-disciplinary team within a high-volume Cancer Centre. All patients had an open posterior vagal sparing total gastrectomy with stapled oesophagojejunal anastomosis and Roux-en-Y reconstruction by a single surgeon. Twenty three patients had a D0.5 -1 lymphadenectomy; one patient with suspected invasive tumour had a D2 resection. Nasogastric tubes and abdominal drains were not used. Patients were mobilised on the first postoperative day with epidural analgesia. Oral fluids were restarted on postop day 3 and diet on day 5.
Results There were two postoperative complications (8%) but no deaths; One patient had a jejuno-jejuno anastomotic leak 10 days after surgery requiring revisional surgery but made a full recovery. Another patient had bleeding which was managed conservatively with transfusion. Two patients developed anastomotic strictures and were successfully treated with endoscopic balloon dilatation. Median follow-up to date is 5 years (range: 3 months to 9 years).
Histology showed scattered microscopic foci of intramucosal signet ring carcinoma (pT1a) in 23/24 patients (96%); the median number of foci was 7 (range: 1–182). No invasive tumours were found, all nodes were negative for tumour and all longitudinal margins were clear.
The median lymph node yield was 5.5 (range: 1–26) and median hospital stay was 8 days (range: 6–10).
Conclusion Open PTG can be performed with acceptable mortality and morbidity. Our challenge for the future is to offer minimally invasive PTG without increasing the risks.
Disclosure of interest None Declared.