Intestinal metaplasia and anastomotic recurrence of gastric carcinoma

Gastric adenocarcinoma is a tumour derived from the lining mucosa which usually presents late in its natural history. This advanced cancer is the sixth most common and causes approximately 7,600 deaths per annum in the UK although the incidence has inexplicably been falling for several decades (1,2). The most widely accepted histological classification of gastric carcinoma is that by Lauren who divided the tumours into two main types. Those which formed glandular structures were known as intestinal (53%) whereas those without any structure and secreting mucin were known as diffuse type carcinomas (33%). The remaining 14% had a mixed appearance with elements from both types and were regarded as unclassified (3). The number of patients who undergo endoscopic surveillance after subtotal gastrectomy has recently been increasing, which is due to the improved survival rate in gastric cancer patients (4,5). However, it is difficult to detect early gastric cancer (EGC) during endoscopic surveillance because the remnant stomach is usually deformed after surgical resection, and the mucosal changes at the gastric stump are severe due to bile reflux (6). The incomplete type intestinal metaplasia (IM) (type III) has been shown to increase the relative risk of gastric cancer by a factor of 4.58 (7,8). Fortunately, it is less frequent than the complete type (21.5% of IM) (9). Therefore, it would be very helpful if the endoscopic features of EGC or IM that exist on a specific location of the gastric remnant such as at the anastomosis site or at a non-anastomosis site, could be characterized (4-7)