The prognosis of patients with highly advanced gastric cancer with distant metastasis, such as peritoneal dissemination or hematogenous metastasis, is usually very poor. When peritoneal dissemination is present, curative surgery cannot be achieved. However, aggressive treatment, including cytoreductive surgery with peritonectomy and intraperitoneal chemotherapy, have been reported for such patients . Recently, Yonemura et al. developed a new multimodal treatment referred to as bidirectional chemotherapy (neoadjuvant intraperitoneal-systemic chemotherapy protocol) for the treatment of peritoneal carcinomatosis . They reported a 50% complete cytoreduction rate by cytoreductive surgery after neoadjuvant intraperitoneal and systemic chemotherapy. The median survival time of all 51 patients in that study was 14.4 months.
For bidirectional chemotherapy, various chemotherapeutic agents have been used for intraperitoneal and systemic chemotherapy [1, 5]. For intraperitoneal chemotherapy in the present report, 40 mg of docetaxel and 150 mg of carboplatin were introduced, as described by Yonemura et al..
For metastatic advanced gastric cancer, S-1 plus cisplatin was introduced as a standard treatment in Japan based on the randomized controlled trial . Oxaliplatin has powerful anti-neoplasm activity, an intriguing alternative to cisplatin with at least comparable activity, a synergistic effect with 5-FU, and a satisfactory safety profile. The combination of oxaliplatin with 5-FU and leucovorin (FOLFOX regimen) was selected for systemic chemotherapy because it has a favorable activity as first-line therapy with locally advanced and metastatic gastric cancer or second-line treatment in advanced or metastatic gastric cancer patients, and may be considered a viable treatment alternative. This regimen was suggested to be active with a 40%-55% objective response rate in patients with gastric cancer [10–12]. However, this regimen has rarely been reported as a neoadjuvant chemotherapy agent in the treatment of advanced gastric cancer .
Neoadjuvant chemotherapeutic agents in the previous studies included S-1 [4, 5], S-1 plus cisplatin , methotrexate plus 5-fluorouracil , paclitaxel plus doxifluridine , EEP (etoposide, epirubicin, and cisplatin) , and cisplatin plus 5-fluorouracil with leucovorin . The FOLFOX regimen has usually been used for palliative chemotherapy for patients with metastatic gastric cancer. We used the FOLFOX regimen as neoadjuvant chemotherapy, which is widely used for metastatic advanced gastric cancer after curative or palliative resection or for unresectable gastric cancer in our institute.
In the present case, the patient had several incurable factors, including peritoneal carcinomatosis, hepatic metastasis, and locally advanced tumor that induced GOO. Therefore, the first aim of treatment was palliation of the GOO symptoms. We performed laparoscopic bypass surgery first, and at that time, an intraperitoneal port was implanted for the following intraperitoneal chemotherapy.
GOO is a challenging problem in patients with advanced gastric cancer in the distal part of the stomach. The presence of GOO is an independent prognostic factor, even after radical surgery . Additionally, for systemic chemotherapy, GOO is a problem that should be treated first because adequate oral intake is essential for systemic chemotherapy. For GOO, various treatment options, such as endoscopic stenting, palliative bypass surgery (open or laparoscopic), or palliative resection, can be chosen. Resection is theoretically the most effective treatment option for GOO by achieving intestinal continuity and a reductive therapeutic effect. In the present case, however, other incurable factors existed, such as hepatic metastasis and peritoneal carcinomatosis. Furthermore, palliative bypass surgery (gastrojejunostomy) is thought to provide better long-term results compared to endoscopic stent placement, and is therefore the treatment of choice in patients with a life expectancy of > 2 months . Thus, we performed laparoscopic palliative gastric bypass surgery rather than palliative resection or stent placement.
If curative resection is not possible or not effective, and response to chemotherapy is expected, laparoscopic palliative procedure is an effective and safe procedure option for the patient with GOO because this palliative procedure is minimally invasive and enable the patient to receive early post-operative chemotherapy. In addition, the port for the intraperitoneal chemotherapy can be placed during this procedure. Furthermore, laparoscopic bypass surgery can prevent post-operative adhesions and enable easy, definitive surgery for the patient who has a response to the chemotherapy.
For the second operation after CR was suspected by image study and endoscopic biopsy, we performed radical subtotal gastrectomy with extended lymph node dissection. The aim of the surgical resection was to confirm the CR by pathologic examination and to provide the therapeutic effect of resection if the residual cancer cells were present. However, hepatic resection was not performed because the initial hepatic metastasis was multiple and bilobar, and the location of hepatic metastasis could not be identified at the time of the second operation.
According to previous reports regarding neoadjuvant chemotherapy for advanced gastric cancer, aggressive treatment for peritoneal dissemination has been limited to patients with peritoneal carcinomatosis alone, rather than hematogenous metastasis, such as hepatic metastasis or distant lymph node metastasis [1, 5, 8, 13]. D'Ugo et al.  reported neoadjuvant chemotherapy in patients with resectable gastric cancer. However, in the present case, a CR was observed in spite of the fact that he had three individual incurable factors; peritoneal dissemination, hepatic metastasis, and GOO caused by locally advanced primary tumor. The reason for the good response of our case may be related to the following: 1) the size of the multiple hepatic metastases was small; 2) peritoneal dissemination was limited to the omentum and not disseminated to the distant peritoneum; and 3) the tumor size was relatively small in spite of GOO, and there was no adjacent organ invasion (pancreas or colon). Thus, to evaluate the effectiveness of chemotherapy following bypass surgery for unresectable gastric cancer with GOO, a large randomized controlled trial is needed.