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Recently, a decrease in serum zinc levels and the need for zinc preparations have been reported in the perioperative period of gastrointestinal surgery. In this study, we examined treatment outcomes among patients supplemented with zinc after pancreaticoduodenectomy (PD) and evaluated the significance of zinc replacement therapy.From June 2020 to April 2021, 56 patients who received zinc acetate hydrate (50 mg/day) from postoperative day 3 after PD in our department were retrospectively reviewed. Patients' characteristics and preoperative as well as postoperative data, including serum zinc levels and surgical results at 1 month were reviewed.Preoperative zinc deficiency was present in 86.1% (46/56) of the patients. Moreover, despite zinc supplementation, 17.8% (10/56) of patients had postoperative zinc deficiency. A comparison between the low zinc level group (Zn80 μg/dl) and the normal zinc level group (Zn ≥80 μg/dl) after surgery showed siginificant differences among patients with malignant diseases (vs. benign diseases, p=0.044), those undergoing open surgery (vs. minimally invasive surgery, p=0.036), and those with intraoperative blood loss ≥346 ml (vs.346 ml: p=0.041) in the univariate analysis. Multivariate analysis revealed that zinc deficiency was significantly associated with open surgery [odds ratio (OR)=15.885, 95% confidence interval (CI)=1.77-142.01, p=0.013] and intraoperative blood loss (OR=9.329, 95% CI=1.50-57.74, p=0.016).In patients undergoing open PD for pancreatic cancer, zinc preparations of 50 mg may not be sufficient and further supplementation may be necessary.

Although the number of minimally invasive liver resections (MILRs) has been steadily increasing in many institutions, minimally invasive anatomic liver resection (MIALR) remains a complicated procedure that has not been standardized. We present the results of a survey among expert liver surgeons as a benchmark for standardizing MIALR.We administered this survey to 34 expert liver surgeons who routinely perform MIALR. The survey contained questions on personal experience with liver resection, inflow/outflow control methods, and identification techniques of intersegmental/sectional planes (IPs).All 34 participants completed the survey; 24 experts (70%) had more than 11 years of experience with MILR, and over 80% of experts had performed over 100 open resections and MILRs each. Regarding the methods used for laparoscopic or robotic anatomic resection, the Glissonean approach (GA) was a more frequent procedure than the hilar approach (HA). Although hepatic veins were considered essential landmarks, the exposure methods varied. The top three techniques that the experts recommended for identifying IPs were creating a demarcation line, indocyanine green negative staining method, and intraoperative ultrasound.Minimally invasive anatomic liver resection remains a challenging procedure; however, a certain degree of consensus exists among expert liver surgeons.

EUS-guided biliary drainage (EUS-BD) has recently been reported to be a useful salvage technique after ERCP fail. However, data on EUS-BD used for preoperative biliary drainage (PBD) are limited. The aim of this study was to verify the clinical feasibility of EUS-BD for PBD.PBD was performed for malignant biliary obstruction in 318 patients at our institution between July 2014 and April 2022. Fifteen (4.7%) of these patients underwent surgical resection after preoperative EUS-BD (HGS 13; HDS 1; AGS with HGS 1) and were retrospectively analyzed.The stent was successfully placed in all 15 cases with a median procedure time of 15 min (technical success rate 100%). The median total bilirubin value decreased significantly from 3.7 before drainage to 0.9 after surgery (p0.001) and cholangitis was well managed (clinical success rate 100%). Surgery was performed at a median of 22 days after drainage, and there were no stent-related adverse events or recurrences of biliary obstruction. Severe surgery-related adverse events occurred in 3 cases, but none were associated with EUS-BD. The stent was removed during surgery in 12 cases.EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.

BACKGROUND Few reports describe the relationship between preoperative cholangitis and surgical site infections (SSIs) after pancreaticoduodenectomy (PD). We aimed to determine the association between the incidence of preoperative cholangitis and surgical site infection following PD. METHODS The surgical outcomes of 359 patients who underwent PD were compared between patients with (n = 92) and without (n = 267) preoperative cholangitis. Bacterial cultures from the postoperative drainage fluid were examined. Risk factors for postoperative infectious complication were evaluated. RESULTS The incidence of postoperative infectious complications including grade B/C postoperative pancreatic fistula was high among patients with preoperative cholangitis (P

The left renal vein is technically difficult to expose during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma despite being an important landmark for posterior dissection. We hereby propose a novel technique to safely expose the left renal vein while avoiding the associated anatomical pitfalls. The anatomy of the left renal artery and vein was analyzed using multidetector computed tomography. We initially exposed the left renal vein on the left posterior side of the superior mesenteric artery followed by exposure toward the left kidney. We retrospectively examined the perioperative results of this technique in 33 patients who underwent laparoscopic distal pancreatectomy. 15.7% of the patients had an accessory left renal artery coursing cranial to the vein. In 43.1%, the left renal arterial branch ventrally traversed the vein at the renal hilum, thereby posing a risk for arterial injury. The location of the left renal vein varies cranial (17.6%) or caudal (82.4%) to the pancreas. The left renal vein was exposed without any vascular injury using this technique. The median operative time was 259 min, blood loss was 18 mL, and R0 resection rate was 97.0%. The initial exposure of the left renal vein should, therefore, be on the left posterior side of the superior mesenteric artery.

Background Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021). Methods Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts. Conclusions The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

Hand-sewing (HS) and stapling are common parenchymal closure techniques after distal pancreatectomy. However, these methods cannot completely prevent postoperative pancreatic fistula (POPF). The mechanisms of POPF formation after closure are unknown. We performed distal pancreatectomy in mongrel dogs to identify the mechanisms of POPF formation after HS and staple closure. We measured the closed pancreatic duct burst pressures and examined the histology of the remnant pancreas. The after staple-closure burst pressures depended on stapler height; lower pressures were associated with greater stapler heights. Post-HS closure burst pressures were significantly higher than those at each stapler height (P

Simple Summary Although the survival benefit of “regional lymph node dissection” for pancreatic head cancer remains unclear, the R0 resection rate is reportedly associated with prognosis. We reviewed the literature that could be helpful in determining the appropriate resection range. The recent development of high-quality computed tomography has made it possible to evaluate the extent of cancer infiltration. Even if the “dissection to achieve R0 resection” range is simulated based on the computed tomography evaluation, it is difficult to identify the range intraoperatively. It is necessary to be aware of the anatomical landmarks to determine the appropriate dissection range intraoperatively. Abstract Patients with resectable pancreatic cancer are considered to already have micro-distant metastasis, because most of the recurrence patterns postoperatively are distant metastases. Multimodal treatment dramatically improves prognosis; thus, micro-distant metastasis is considered to be controlled by chemotherapy. The survival benefit of “regional lymph node dissection” for pancreatic head cancer remains unclear. We reviewed the literature that could be helpful in determining the appropriate resection range. Regional lymph nodes with no suspected metastases on preoperative imaging may become areas treated with preoperative and postoperative adjuvant chemotherapy. Many studies have reported that the R0 resection rate is associated with prognosis. Thus, “dissection to achieve R0 resection” is required. The recent development of high-quality computed tomography has made it possible to evaluate the extent of cancer infiltration. Therefore, it is possible to simulate the dissection range to achieve R0 resection preoperatively. However, it is often difficult to distinguish between areas of inflammatory changes and cancer infiltration during resection. Even if the “dissection to achieve R0 resection” range is simulated based on the computed tomography evaluation, it is difficult to identify the range intraoperatively. It is necessary to be aware of anatomical landmarks to determine the appropriate dissection range during surgery.

Clinically relevant postoperative pancreatic fistulas (CR-POPF) occurring after distal pancreatectomy often cause intra-abdominal infections. We monitored the presence of bacterial contamination in the ascitic fluid after distal pancreatectomy to clarify the bacterial origin of intra-abdominal infections associated with CR-POPF. In 176 patients who underwent distal pancreatectomy, ascitic fluid bacterial cultures were performed on postoperative days (POD) 1–4 and when the drainage fluid became turbid. The association between postoperative ascitic bacterial contamination and CR-POPF incidence was investigated. CR-POPF occurred in 18 cases (10.2%). Among the patients with CR-POPF, bacterial contamination was detected in 0% on POD 1, in 38.9% on POD 4, and in 72.2% on the day (median, day 9.5) when the drainage fluid became turbid. A univariate analysis revealed a significant difference in ascitic bacterial contamination on POD 4 (p

Background The anatomical structure around the pancreatic head is very complex, and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD. Methods Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection. Conclusions MIPD experts suggest to surgical trainees to perform resection based on precise anatomical landmarks for safe and reliable MIPD.

Laparoscopic hepatojejunostomy (HJ) with continuous sutures is commonly performed in laparoscopic pancreaticoduodenectomy (LPD). This study aimed to investigate the long-term surgical outcomes of HJ in LPD. We retrospectively evaluated 103 consecutive patients who underwent pancreaticoduodenectomy via laparoscopic HJ with continuous suturing using multifilament (n = 48) or monofilament-absorbable sutures (n = 47). During follow-up, anastomotic stricture of HJ was identified in 8 (7.8%) patients via balloon enteroscopy-assisted cholangiography. The median time from surgery to confirmation of stricture formation was 7.6 months (range 3.6–19.4). The incidence of HJ stricture was significantly higher in patients with a thin bile duct (diameter

Purpose To evaluate the feasibility of pancreaticoduodenectomy with resection of the second jejunal vein (J2V) for pancreatic ductal adenocarcinoma (PDAC). Methods Among 114 patients with PDAC undergoing pancreaticoduodenectomy with portal-superior mesenteric vein resection (PVR), surgical outcomes, and prognoses of 10 patients with resection of J2V or later branches of the superior mesenteric vein (J2VR) were compared to 104 patients with PVR above J2V (standard PVR). The reconstruction methods in the J2VR group were reviewed. Results There were no significant differences in the operative time (470 vs 435 min), morbidity (30% vs 27%), presence of portal vein stenosis (10% vs 5%) or thrombosis (10% vs 1%), and induction of adjuvant therapy (80% vs 88%) between the J2VR and standard PVR groups, although blood loss was higher in the J2VR group (1184 vs 494 ml; P = .002). R0 proportion and 2-year survival rates were not significantly worse in the J2VR group compared to the standard PVR group (90 and 88%; 67 and 45%, respectively). At least one branch of the superior mesenteric vein was reconstructed in the J2VR group. Conclusion Pancreaticoduodenectomy with J2VR for PDAC can be safely performed with a satisfactory overall survival rate.

The proximal jejunal vein which branches from the dorsal side of the superior mesenteric vein (SMV) usually drains the inferior pancreatoduodenal veins (IPDVs) and contacts the uncinate process of the pancreas. We focused on this vein, termed the proximal dorsal jejunal vein (PDJV), and evaluated the anatomical classification of the PDJV and surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) with PDJV involvement (PDJVI). The jejunal veins that branch from the dorsal side of the SMV above the inferior border of the duodenum are defined as PDJVs. We investigated 121 patients who underwent upfront pancreaticoduodenectomy for PDAC between 2011 and 2017; PDJVs were resected in all patients. The anatomical classification of PDJV was evaluated using multidetector computed tomography. Surgical and prognostic outcomes of pancreticoduodenectomy for PDAC with PDJVI were evaluated. The PDJVs were classified into seven types depending on the position of the first and second jejunal veins relative to the superior mesenteric artery. In all patients, the morbidity and mortality rates were 15.7 and 0.8%, respectively. The rates for parameters including SMV resection, presence of pathological T3–4, R0 resection, and 3-year survival were 46.2, 92.3, 92.3, and 61.1%, respectively, when there was PDJVI (n = 13). When there was no PDJVI (n = 108), the rates were 60.2, 93.5, 86.1, and 58.3%, respectively. Overall, there were no significant differences. Pancreaticoduodenectomy with PDJV resection is feasible for PDAC with PDJVI and satisfactory overall survival rates are achievable. It may be necessary to reconsider the resectability of PDAC with PDJVI.

Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the inferior pancreaticoduodenal artery (IPDA) from the left side of the superior mesenteric artery (SMA). By contrast, damaging the inferior pancreaticoduodenal veins (IPDVs) is possible when approaching the IPDA from the right side of the SMA. To facilitate the artery-first approach in laparoscopic pancreaticoduodenectomy (LPD), we focused on the proximal-dorsal jejunal vein (PDJV) that branched from the superior mesenteric vein (SMV) dorsal side and drained the IPDVs. This study aimed to clarify the usefulness of the right SMA approach using the PDJV preisolation method. The PDJV was first isolated, and the IPDVs were divided along the PDJV on the right side of the SMA. Then, the IPDA was divided at the root without first separating the pancreatic head from the portal vein and the SMV. Overall, 21 patients underwent this approach, and the results were retrospectively compared with those of 21 patients who underwent the artery-first approach, which was performed on the left side of the SMA. Anatomical characteristics of the PDJV were evaluated using multidetector computed tomography for the two groups. Operative times and resection times were significantly lower for the PDJV preisolation group than for the conventional LPD group (489.3 vs. 541.7 min, respectively; p = 0.002). During anatomical evaluation, 41 patients (97.6%) had a PDJV that drained from the SMV dorsally and was in contact with the anterior aspect of the uncinate process. The PDJV was confirmed as the first jejunal vein in 31 patients (73.8%) and as the second jejunal vein in 10 patients (23.8%). This approach facilitates dissection of the IPDA on the right side of the SMA, thereby reducing operative times.

BACKGROUND/AIM To assess the prognostic effect of muscle loss after esophagectomy and before discharge. PATIENTS AND METHODS This study retrospectively analysed 159 consecutive patients with oesophageal and gastroesophageal junction cancer who underwent esophagectomy between August 2011 and October 2015. Body composition was evaluated one week before surgery and at discharge using a bioelectrical impedance analyser. RESULTS The median rate of muscle mass loss (RMML) was 4.38% (range=-3.3 to +18.8). Patients with increased RMML had significantly poorer outcomes of overall survival than those with decreased RMML (p=0.015). On multivariate analysis, RMML [≥4.38, hazard ratio (HR)=2.033, 95% confidence interval (CI)=1.018-5.924, p=0.044) and pathological tumour depth (≥2, HR=3.099, 95%CI=1.339-7.172, p=0.008) were selected as independent prognostic factors. CONCLUSION RMML after esophagectomy is indicative of poor prognosis in patients with esophageal cancer.

Surgery for gastric cancer should be performed as soon as possible after diagnosis. However, sometimes the waiting time for surgery tends to be longer. The relation between the waiting time for surgery and survival in patients with gastric cancer remains to be fully investigated. This retrospective, single-center cohort study evaluated patients with gastric cancer who underwent curative surgery from 2006 through 2012 at Kanagawa Cancer Center in Japan. Patients who received neoadjuvant chemotherapy were excluded. The waiting time for surgery was defined as the time between the first visit and surgery. We investigated whether the waiting time for surgery has a linear negative impact on outcomes by using a Cox regression model with clinical prognostic factors. In total, 801 patients were eligible. The median waiting time was 45 days (range 10–269 days). The restricted cubic spline regression curve showed that the adjusted time-specific hazard ratios of waiting times did not indicate a linear negative trend on survival between 20 and 100 days (p = 0.759). In the Cox model with a quartile of waiting times, waiting times in the 32–44-day group, 43–62-day group, and ≥63 day groups were not associated with poorer overall survival as compared with the ≤31 day group (HR: 1.01, 95% CI 0.63–1.60, p = 0.984, HR: 1.17, 95% CI 0.70–1.94, p = 0.550, HR: 1.06, 95% CI 0.60–1.88, p = 0.831, respectively). There was no negative relation between the waiting time for surgery (within 100 days) and survival in patients with gastric cancer.

BACKGROUND The aim of the present study was to investigate the feasibility of resection based on the nerve and fibrous tissue (NFT) structures around the superior mesenteric artery (SMA) for resectable pancreatic adenocarcinoma (R-PDAC) patients. METHODS NFTs around the SMA were classified into four "intensive NTFs area" with spreading the NFTs around the SMA and three SMA nerve plexus regions without branching nerves according to autopsy findings. Complete dissection of four "intensive NTFs areas" was performed by pre-exposing three SMA nerve plexus regions without branching nerves as "dissection-guiding points" with SMA nerve plexus preservation (NFT-based resection). Among 157 R-PDAC patients undergoing pancreaticoduodenectomy, surgical outcomes of 78 patients with NFT-based resection were compared with 59 patients with half-SMA nerve plexus dissection and 20 patients without NFTs dissection. RESULTS In the NFT-based resection group, 76.5% had tumor involvement and metastasis in each intensive NTFs area. Operative time, blood loss, and postoperative diarrhea rate were significantly lower in NFT-based resection than in half-SMA nerve plexus group (321 vs 390 min; P

We report a case of mediastinal lymph node recurrence of esophageal cancer after endoscopic submucosal dissection (ESD). We first administered chemotherapy and then performed esophagectomy. A 78-year-old man underwent ESD for early esophageal cancer at a different hospital in January 2015. H e was diagnosed pathologically with scc, pSM1, pHM1, pVM0, ly0, v0. Additional treatment was not administered because of his age. In June 2017, chest enhanced CT showed swollen mediastinal lymph nodes. This was diagnosed as a recurrence of esophageal cancer, and he presented at our hospital. We first performed chemotherapy for that lesion, because the swollen lymph node was large and may have invaded the surrounding organs. We then performed esophagectomy.

An 81-year-old man with esophageal cancer had undergone subtotal thoracic esophagectomy and retrosternal reconstruction using a gastric tube. He developed anemia. Gastrointestinal endoscopy was performed, which revealed a tumor in the posterior wall of the lower part of the gastric tube. Biopsy revealed well-differentiated adenocarcinoma. There was no lymph node metastasis and no distal metastasis on CT. We performed partial resection of the stomach tube because of his age and physical condition. We identified the position of the tumor by upper gastrointestinal series CT and gastrointestinal endoscopy. The tumor was located on the posterior wall of the lower part of the gastric tube and the back of the sternum lower border. Marking was performed by gastrointestinal endoscopy before operation. We simulated the operation and decided to perform laparostomy without sternotomy incision. We cut the anterior wall of the gastric tube in front of the tumor using the endoscope. We could then confirm the diagnosis of cancer, and clipped and removed the tumor from the posterior wall. The resected site was sutured with 4-0 absorbable thread. The pathological diagnosis was T1a(M)N0M0, ly0, v0, PM0, DM0, pStage ⅠA.

We report a rare case of liver recurrence of gastric cancer 14 years and 3 months after curative gastrectomy. An 81-yearold man underwent total gastrectomy, D2 lymphadenectomy, Roux-en-Y reconstruction, and cholecystectomy for advanced gastric cancer in November 2002. H e was diagnosed pathologically with M, Type 5, 53×42 mm, tub2tub1, pT4a, ly2, v2, pN1, pPM0, pDM0, M0, pStage ⅢA(JGCA 15th). Postoperative adjuvant therapy was not administered. He was followed up for 5 years after surgery without adjuvant therapy, and he did not exhibit recurrence. In February 2017, he experienced difficulties in swallowing and visited our hospital. Abdominal contrast-enhanced CT showed an 8×5 cm liver tumor in the lateral segment. Part of the tumor protruded to outside of the liver, and the tumor invaded and pushed the jejunum in the Roux limb. We performed liver biopsy and diagnosed him with liver metastasis of recurrent gastric cancer. Late relapse after gastrectomy, especially after 10 years or more, is very rare.

The modified Blumgart method for pancreaticojejunostomy has been shown to reduce the rate of postoperative pancreatic fistula (POPF) in open surgery. We describe a modified Blumgart method using LAPRA-TY suture clips to facilitate laparoscopic pancreaticojejunostomy. We prepared a double-armed 4-0 nonabsorbable monofilament, which was ligated using the LAPRA-TY clip at the tail end, 12-cm in length. Next, the U-suture was placed through the pancreatic stump and the seromuscular layer of the jejunum. We performed duct-to-mucosa suturing with a 5-0 absorbable monofilament. After completing the duct-to-mucosa suturing, as a final step we placed the sutures through the seromuscular layer of the jejunum on the ventral side and tightly secured the thread with the LAPRA-TY clips. We performed laparoscopic Blumgart pancreaticojejunostomy during pancreaticoduodenectomy in 39 patients. We compared the surgical outcomes of 19 patients who underwent Blumgart pancreaticojejunostomy using the LAPRA-TY clips (LAPRA-TY group) with 20 patients undergoing surgery not using the LAPRA-TY clips (conventional group). The rate of clinically relevant postoperative pancreatic fistula in the LAPRA-TY group was 21.1%, which did not differ significantly from the rate of the conventional group. However, the mean time of pancreaticojejunostomy in the LAPRA-TY group was 56.2 min (range, 39–79 min), which was significantly shorter than that of the conventional group (69.7 min; range, 53–105 min, P

Neuroendocrine tumors of the pancreas (pNETs) are a rare group of neoplasms that originate from the endocrine portion of the pancreas. Tumors that either secrete or do not secrete compounds, resulting in symptoms, can be classified as functioning and non-functioning pNETs, respectively. The prevalence of such tumors has recently increased due to the use of more sensitive imaging techniques, such as multidetector computed tomography, magnetic resonance imaging and endoscopic ultrasound. The biological behavior of pNETs varies widely from indolent, well-differentiated tumors to those that are far more aggressive. The most effective and radical treatment for pNETs is surgical resection. Over the last decade, minimally invasive surgery has been increasingly used in pancreatectomy, with laparoscopic pancreatic surgery (LPS) emerging as an alternative to open pancreatic surgery (OPS) in patients with pNETs. Non-comparative studies have shown that LPS is safe and effective. In well-selected groups of patients with pancreatic lesions, LPS was found to results in good perioperative outcomes, including reduced intraoperative blood loss, postoperative pain, time to recovery, and length of hospital stay. Despite the encouraging results of studies from highly specialized centers with extensive experience, no randomized trials to date have conclusively validated these findings. Indications for minimally invasive LPS for patients with pNETs remain unclear. This review presents the current state of LPS for pNETs.

A 79-year-old man with cStage II A(T2N1H0P0CYXM0)advanced gastric cancer in angle. Distal gastrectomy was performed and liver metastasis was recognized during the operation. The pathological diagnosis was shown as neuroendocrine carcinoma(NEC). Chemotherapy(S-1/cisplatin[CDDP]: 1 course, etoposide/CDDP: 5 courses)was administered. After chemotherapy, liver metastasis disappeared for 9months.

Case 1: A 69-year-old man underwent distal gastrectomy in September 2007 for type 2 gastric cancer with liver metastasis (S5). After the operation, we administered chemotherapy. After that, we performed partial hepatectomy in July 2008. After hepatectomy, liver metastases appeared as 2 lesions in February 2009. Thus, we administered another type of chemotherapy. The effect of the chemotherapy was not favorable. Therefore, SBRT was performed for the liver metastases in December. After SBRT, he did not present with any recurrent tumors. Case 2: A 67-year-old woman underwent distal gastrectomy in March 2015. In August 2015, hepatic metastasis(S5 single shoot)was confirmed. Although chemotherapy was administered and SD was continued, it was ceased due to the patient's request. Thus, SBRT was performed in July 2016. However, from October 2016, multiple liver metastases developed and she died in January 2017.

Background Esophageal cancer surgery with lymphadenectomy is known as a cause of weight loss during perioperative period, but the change of body composition is unclear. Methods The aim of study is to clarify the influence of body composition change after esophagectomy. 144 patients(51 cases without NAC and 93 cases with NAC: 98 cases with less than G2 perioperative complications and 46 cases with G2 or more perioperative complications: 36 cases with recurrence and 108 cases without recurrence were included) of esophageal cancer who underwent esophagectomy with lymphadenectomy from August 2011 to December 2016 and evaluated body composition examination before operation and after operation(1, 3, 6 month) were included in this study. We compared the change of body composition between with or without preoperative chemotherapy, postoperative complication, and recurrence. Results The weight loss rate at discharging hospital, 1,3,6 month after discharge for without NAC group/with NAC group was 3.3/3.8%, 7.8/6.8%, 10.1/9.2%, 11.1/9.1% (NS), and the lean body mass reduction rate was 4.1/4.5%, 7.1/6.6%, 6.5/6.7% (N.S.), 6.6/4.3% (P Conclusion Due to postoperative complications after esophagectomy, the rate of weight loss increased from hospital discharge to 6 months after discharge. Particularly, lean body mass was reduced within 3 months. So, we may have a strategy such as continuing enteral nutrition even after discharge for complicated cases. Disclosure All authors have declared no conflicts of interest.

Multiplanar reconstruction (MPR) images are used for assessing horizontal and vertical extent of hilar cholangiocarcinoma, while peroral cholangioscopy (POCS) is used for diagnosing ductal spread and mapping biopsy. We fused conventional 3-dimensional computed tomography (3DCT) with MPR images and POCS findings for preoperative assessment of cholangiocarcinoma. The extent of cancer was assessed using MPR images, which were plotted and fused onto 3DCT cholangiography. In addition, the results of mapping biopsy performed under POCS were marked on virtual endoscopic imaging and transferred onto a 3DCT image. Once an angiographic CT image was fused, a multi-3DCT image was created. The incision line was determined based on these images. Multi-3DCT images were created for 13 patients with hilar cholangiocarcinoma. Of 10 patients who underwent POCS, superficial spread was observed in two. Resection was performed in 12 patients. In two cases, the cut end of the intrahepatic bile duct was positive, resulting in 83.3% diagnostic accuracy for horizontal spread. In all patients, the estimated number of bile ducts was the same as the number of the actual resections. R0 resection was achieved in 10 patients (83.3%). Multi-3DCT imaging proved useful in diagnosing longitudinal ductal spread of hilar cholangiocarcinoma.

A 70-year-old man with cStage III A(cT3N2H0P0CYXM0)advanced gastric cancer in the lesser curvature with esophageal invasion and bulky lymph nodes was treated with S-1/CDDP. After 4 courses of chemotherapy, the tumor and lymph nodes were found to be reduced in a CT examination. Total gastrectomy with lymph node dissection(D2)was performed. Histopathological examination revealed no cancer cells in the stomach or lymph nodes, indicating Grade 3.

Neoadjuvant chemotherapy(NAC)for esophageal cancer is standard in Japan. However, the value of neoadjuvant chemoradiation therapy(NACRT)is unknown. Thirteen patients with cStage II and III squamous cell carcinoma of the esopha- gus were treated with NACRT(CDDP 70mg/m2/day on day 1, 5-FU 70 mg/m2/day on days 1-4, radiation 30 Gy/15 Fr). We report 3 pathological CR cases and 10 non-CR cases of esophageal cancer. Between the CR and non-CR group there was no difference in the incidence of postoperative complications. No serious adverse events were observed. There were no significant differences in OS and RFS. Five cases relapsed in the non-CR group. There were no relapsed cases in the CR group.

We examined the effectiveness of partial gastrectomy in the elderly. Twelve patients who underwent partial gastrectomy for gastric cancer in our hospital had an average of 2.75 comorbidities before surgery. Two patients relapsed, and 2 patients died from other diseases. The depth of the gastric tumor was T2 in patients with recurrence. Partial gastrectomy should be considered carefully for advanced stage cancer. There were only small changes in weight, PS, and nutrition before and after surgery, suggesting that partial gastrectomy is effective.

e16012Background: During preoperative chemotherapy, appropriate nutritional support is necessary. Especially advanced esophageal cancer patients sometimes have a difficulty of oral ingestion. In Ja...

183 Background: The laparoscopic gastrectomy is becoming widespread. But acquisition of its technique is challenging. We investigated whether supervision by a technically qualified surgeon (QS) affects the feasibility and safety of laparoscopic gastrectomy performed by trainee (TR). Methods: The outcomes of laparoscopy-assisted distal gastrectomy for gastric cancer performed by QS group and TR group between 2013 and 2016 were assessed. A laparoscopic surgeon qualified by the Endoscopic Surgical Skill Qualification System (Japan Society for Endoscopic Surgery) participated in surgeries that ware performed by trainee as the teaching assistant. Results: All patient characteristics were not different between QS group and TR group, except of BMI (median BMI 23.9 vs 22.2, p = 0.01). Although operation time of TR group was longer than that of QS group (median time: 248 min. vs 285 min., p = 0.01), Blood loss and number of harvested lymph nodes were not different. One patient (0.3%) in QS group and two patients (0.4%) in TR group required conversion to open surgery (p = 0.58). Postoperative complication, that was defined by Clavien-Dindo classification grade 3 and more, occurred in four patients (11.4%) in QS group and nine patients (5.4%) in TR group (p = 0.25). Complication in QS group were anastomotic leakage (n = 2) and abdominal abscess (n = 2), whereas that in TR group were anastomotic leakage (n = 3), anastomotic stenosis (n = 2), pancreatic fistula (n = 1), bowel obstruction (n = 1), pneumothorax (n = 1), and cerebral hemorrhage (n = 1). One patient in QS group (2.9%) and four patients in TR group (2.4%) underwent reoperation (p = 1.00). Postoperative mortality occurred in one cases in TR group (0.01%). Conclusions: The laparoscopy-assisted distal gastrectomy of TR group supervised by QS was feasible and safe procedure as well as that of QS group.

42 Background: Neoadjuvant chemotherapy (NAC) followed by surgery is a standard treatment for esophageal squamous cell carcinoma (ESCC) in Japan. Efficacy of NAC on the primary tumor is clinically evaluated during NAC and before surgery and is pathologically examined after surgery. Clinical evaluation of the primary tumor is sometimes difficult because primary tumor is nonmesurable lesion and is usually evaluated subjectively, while pathological finding is objective and a gold standard to evaluate efficacy of NAC. In the present study, we tried to evaluate clinicaly efficacy objectively by calcurating tumor volume by esophagography and concordance between volume reduction rate and pathological efficacy. Methods: This retrospective study examined 53 patients who fullfilled the following criteria; (1) thoracic ESCC, (2) underwent resection following NAC between January 2011 and February 2017, and (3) T2-3N0 before surgey. Clinically, volume of the primary tumor was calculated by multiplying length and thickness in the lateral view of esophagography. Pathological efficacy was examined by the proportion of the tumor disappearance of the primary tumor and was classified as Grade 0-1 when degeneration area was < 2/3, Grade 2 when those area was > 2/3 and < 3/3, and Grade 3 when there was no residual tumor. Volume reduction rate calculrated by the difference of pre- and post-NAC was compared by stratifying pathological grade. Results: T2/T3 was 23/30, respectively. Regimen of neoadjuvant chemotherapy was 5-FU/CDDP in 50 patients,docetaxel/5-FU/CDDP in 1,and 5-FU/CDDP and Radiotherapy in 2. Overall volume reduction rate was 58.9% in median (range -127-100%). Pathological response (Grade 0-1/2/3) was 28/18/4, respectively. Median volume reduction rate (range) was 38.5% (-127-100%) in Grade 0-1, 72.2% (21.7-100%) in Grade 2, and 91.1% (75.5-100%) in Grade 3, which was significantly different (p < 0.01). Conclusions: The volume reduction rate of the primary tumor was correlated with pathological efficacy, suggesting that volume reduction rate could be a objective measure to evaluate efficacy of neoadjuvant chemotherapy for ESCC.

184 Background: Advanced esophageal cancer patients sometimes have a difficulty to swallow food. On the other hand, standard treatment for resectable advanced esophageal cancer patients is surgery after 2 course preoperative chemotherapy of CDDP-5-FU (JCOG 9907). So we usually use naso-gastric ED tube for patients with difficulty of oral intake during preoperative chemotherapy to administrate adequate nutrition. But there is no report of the safety of this trial. Methods: The aim of this study is to clarify the safety of using ED tube during preoperative chemotherapy and compare the nutritional status between using ED tube or not. From Jan 2012 to June 2017, 122 patients were undergone esophagectomy with 2 course of preoperative chemotherapy, and 14 patients were treated with ED tube for nutrition(Group A) and 108 patients without ED tube(Group B). We evaluated the changes of nutritional status and postoperative complication as an indicator of safety. Results: Changes before and after preoperative chemotherapy(GroupA/B): average of body weight: 53.1→50.8/58.1→57.0, BMI: 20.0→19.2/22.0→21.6, TP: 6.7→6.9/7.3→6.9, alb: 3.5→3.8/4.3→4.2, pre-alb: 20.1→21.7/24.8→23.4, RBP: 2.77→3.33/3.15→3.23. Adverse events during chemotherapy: 1 case of Grade 3 hematologic toxicity and 1 case of Grade 2 non-hematologic toxicity were found at Group A(14.2%), and 11 cases of Grade 3 hematologic toxicity and 8 cases of Grade 2 non-hematologic toxicity were found at Group B(17.61%)(p = 0.758). Postoperative complications (clavien-dindo classification, Grade3 or more): 2 cases were observed at Group A(14.2%), and 21 cases were observed at Group B(19.4%)(p = 0.62). Conclusions: Preoperative chemotherapy with ED tube for nutrition was safe and effective to maintain the preoperative nutritional status.

24 Background: Patients with gastric cancer should receive treatment for the cure as soon as possible because cancer cells are considered to grow and metastasize quickly. However, patients sometimes have to wait for the treatment because of further examinations of comorbidity, social background, and limited medical resources. It remained unclear whether interval between diagnosis and surgery is a risk factor for the survival. Methods: This retrospective single-center study examined 801 patients who visited outpatient clinic for gastric cancer and underwent curative surgery from 2006 to 2012 at Kanagawa Cancer Center in Japan. The patients who received neoadjuvant chemotherapy were excluded. Interval was defined as the time from the date of the first visit to the date of surgery. Interval was divided by the median and was classified to the early (less than median) and the late (exceeding the median) groups. Survival was analyzed by separating clinical T1 and T2-4. Results: 461 patients had clinical T1 and 340 had clinical T2-4. Median interval was 55 days (15-269 days) in clinical T1 and 35 days (10-148 days) in clinical T2-4, respectively. In clinical T1, 5-year survival rate was 93.1% in the early group and 91.2% in the late group (p = 0.456). In clinical T2-4, 5-year survival rate was 77.8% in the early group and 78.9% in the late group (p = 0.864). In the multivariate analysis, significant independent risk factors were over 75 years of age and clinical T4, and clinical N+, over 75 years of age in clinical T1, and over 75 years of age and clinical T4 in clinical T2-4. Interval was not significant factor both in clinical T1 (HR: 1.242, 95%CI 0.641-2.407 p = 0.522) and in clinical T2-4 (HR: 1.078, 95%CI 0.672-1.729 p = 0.756). Conclusions: Interval between diagnosis and surgery did not have a negative impact on the prognosis in patients with gastric cancer. Necessary interval for the clinical practice would be acceptable.

s / Pancreatology 13 (2013) S1–S80 S63 ml). There was no conversion to open. 2 patients had developed pancreatic fistula (Grade A), which resolved spontaneously. In five of 7 patient (71.4%), R0 resection could be achieved, but the remaining two patients showed R1 resection. The mean numbers of retrieved lymph nodes were 17 (range, 9w40). The average postoperative hospital stay was 17.4 days (range, 7w47 days). Median follow up was 12 months (range, 6w33months). Peritoneal recurrence occurred in 2 patients. One of them died by primary disease. The remaining 5 patients are alive without recurrence. Conclusions: LDP for PDAC can be feasible, safe, and effective in highly selected patients. Clearly, a prospective, randomized study is needed to elucidate appropriate indications and effects of the present procedure.