Search

Background : Several reports have shown a high mortality rate in patients with liver cirrhosis (LC) who undergo pancreaticoduodenectomy, however, there are few reports on its long-term prognosis. Methods : Twelve patients with LC who had undergone pancreatic resection were enrolled. To compare clinicopathological variables, 159 non-LC patients who had undergone resection for pancreatic cancer were enrolled. Results : Pancreaticoduodenectomy (PD) was performed in 5 LC patients and distal pancreatectomy (DP) was performed in 7 LC patients. Patients in the LC group had more co-morbidities, lower platelet counts and higher Fib4 index than the non-LC group. The postoperative complication rate was higher in the LC group (83.3% vs 47.8%). While the postoperative hospital stay and 30-day mortality rate were not different, the 90-day mortality rate was higher in the LC group (25.0% vs 2.5% ; p < 0.01). Comparison by operative procedure showed no significant differences of postoperative outcomes in DP cases. However, in PD cases, postoperative complications were more frequent (100% vs 42.3%) and 90-day mortality was higher (40.0% vs 2.9% ; p < 0.01) in the LC group. Conclusions : PD resulted in higher postoperative morbidity and mortality rates in patients with LC compared with non-LC patients. DP could be tolerated in the LC patients.

Background: We investigated the usefulness of apparent diffusion coefficients (ADC) from diffusion-weighted images (DWI) obtained using magnetic resonance imaging (MRI) for prognosis of hepatocellular carcinoma (HCC) within Milan criteria. Methods: We enrolled 102 patients who had undergone surgical resection for HCC within Milan criteria, and calculated their minimum ADC using DWI-MRI. We divided patients into ADCHigh (n=72) and ADCLow (n=30) groups, and compared clinicopathological factors between the two groups. Results: The ADCLow group showed higher protein induced by vitamin K absence-II (PIVKA-II) levels (p=0.04) and higher rates of infiltrative growth (p=0.06) compared with the ADCHigh group. In overall survival, the ADCLow group showed significantly worse prognosis than the ADCHigh group (pConclusions: ADC values can be used to estimate the prognosis of HCC within Milan criteria.

Background : Appendectomy can be challenging and occasionally converted to extensive resection for complicated appendicitis. However, optimal treatment strategies can be developed using preoperative risk assessment. Thus, we aimed to investigate the preoperative predictors of extensive resection in complicated appendicitis patients undergoing surgery. Materials and methods : In total, 173 complicated appendicitis patients undergoing surgery between 2014 and 2019 were classified into the appendectomy (n = 153) or extensive resection (n = 20) groups. Clinicopathological factors and surgical outcomes were compared between groups. Results : Extensive resection was performed in 20 of 173 complicated appendicitis patients (11.5%). The rates of having defects in the wall structure at the appendix root on computed tomography images were significantly higher, and the duration from onset to surgery was significantly longer in the extensive resection group. Significant differences were found in operative duration, blood loss and postoperative hospitalization, but none in the incidence of postoperative complications between groups. Multivariate analyses showed that defects in the wall structure at the appendix root and five days or longer from onset were identified as independent predictors of extensive resection. Conclusions : Defects in the wall structure at the appendix root and five days or longer from onset predict extensive resection performance in complicated appendicitis patients. J. Med. Invest. 68 : 334-341, August, 2021.

Gastric cancer surgery for obese patients is regarded as a technically challenging procedure. The morbidity after gastrectomy has been reported to be significantly higher in patients with high visceral fat area (VFA). Robotic gastrectomy (RG) is expected to be advantageous for complicated operations. However, whether RG is superior to conventional laparoscopic gastrectomy (LG) for patients with visceral fat obesity remains unclear. The present study aimed to clarify the impact of RG on the short- and long-term outcomes of patients with high VFAs.This study included 1306 patients with clinical stage I/II gastric cancer who underwent minimally invasive gastrectomy between January 2012 and December 2020. The patients were subclassified according to VFA. The short- and long-term outcomes of RG were compared with those of LG in two VFA categories.This study included 394 (high-VFA, 151; low-VFA, 243) and 882 patients (high-VFA, 366; low-VFA, 516) in the RG and LG groups, respectively. RG was associated with a significantly longer operative time than LG (high-VFA, P 0.001; low-VFA, P 0.001). The incidence rates of overall and intra-abdominal infectious complications in the high-VFA patients were lower in the RG group than in the LG group (P = 0.019 and P = 0.048, respectively) but not significantly different from those in the low-VFA patients. In the multivariate analysis, LG was identified as the only independent risk factor of overall (odds ratio [OR] 3.281; P = 0.012) and intra-abdominal infectious complications (OR 3.462; P = 0.021) in the high-VFA patients. The overall survival of high-VFA patients was significantly better in the RG group than in the LG group (P = 0.045).For patients with visceral fat obesity, RG appears to be advantageous to LG in terms of reducing the risk of complications and better long-term survival.

Skeletal muscle quality is a prognostic factor in various cancers. However, similar studies on curatively resected gastric cancer are lacking. We evaluated skeletal muscle quality using intramuscular adipose tissue content (IMAC) to clarify its impact on survival in patients with locally advanced gastric cancer. We reviewed 370 patients who underwent curative resection for stage II/III gastric cancer. IMAC was calculated using preoperative computed tomography images. IMAC cutoff values were determined for each sex and were set at the 75th percentile. The patients were classified into normal and high IMAC groups according to the cutoff values. Clinicopathological factors and survival outcomes were compared between the two groups. Multivariate Cox regression analysis was used to identify independent prognostic factors for overall survival (OS) and cancer-specific survival (CSS). In all, 277 patients were classified into the normal IMAC group and 93 were classified into the high IMAC group. The patients in the high IMAC group were older, more obese, and had more comorbidities and poor Eastern Cooperative Oncology Group performance status than those in the normal IMAC group. Although no significant differences were observed in the pathological findings between the two groups, a high IMAC was significantly associated with poor OS and CSS. Multivariate analysis identified high IMAC as an independent prognostic factor for both OS and CSS (p = 0.046 and p = 0.035, respectively). High IMAC was significantly associated with poor survival, suggesting that skeletal muscle quality has oncological implications in patients with locally advanced gastric cancer.

Preoperative wait time is affected by various factors, and a certain time is needed before surgery. There is a concern that cancer treatment delay can lead to poor survival. The present study aimed to evaluate the impact of preoperative wait time on survival in patients with clinical stage (cStage) II/III gastric cancer. The study included patients with cStage II/III primary gastric cancer undergoing surgery between 2002 and 2012. Preoperative wait time was defined as the time from endoscopy for initial diagnosis to surgery. Patients were divided into the following three groups according to wait time: short wait group (≤ 30 days), intermediate wait group (> 30 and ≤ 60 days), and long wait group (> 60 and ≤ 90 days). Patient characteristics and survival were compared among the groups. This study included 467 male (67%) and 229 female (33%) patients, and the median patient age was 67 years. The numbers of cStage II and III patients were 332 (48%) and 364 (52%), respectively. The median wait time was 45 days. The body mass index was lower in the short wait group than in the other groups. A shorter wait time tended to be associated with a more advanced cStage. Although survival was significantly worse in the short wait group than in the long wait group, wait time was not identified as an independent prognostic factor in multivariate analysis. Preoperative wait time up to 90 days does not affect survival in patients with cStage II/III gastric cancer.

A replaced left hepatic artery (RLHA) arising from the left gastric artery (LGA) is occasionally encountered during laparoscopic gastrectomy. Although the RLHA is usually divided at the root level as RLHA preservation might result in inadequate lymph node dissection, blood flow disruption by RLHA division may lead to hepatic ischemia. To date, there is no consensus on RLHA preservation. Thus, we aimed to evaluate the efficacy of RLHA preservation by investigating the short-term outcomes of patients with RLHA who underwent laparoscopic distal gastrectomy (LDG). A total of 106 patients with an aberrant LHA from the LGA were identified as having gastric cancer and underwent LDG from 2012 to 2018. Finally, 55 patients were retrospectively diagnosed with RLHA by preoperative computed tomography and included in this study. Patients were classified into the divided (n = 18) or preserved (n = 37) group. Clinicopathological factors and surgical outcomes were compared between the two groups. The RLHA preservation rate in patients who had been preoperatively diagnosed with RLHA was 88%. No significant difference was found in the number of harvested lymph nodes between the groups. The incidence of hepatic infarction was significantly higher in the divided group (16.7% vs. 0%, p = 0.031). Moreover, RLHA division caused postoperative transaminase elevation and was an independent risk factor for postoperative transaminase elevation (odds ratio: 55.8, p

A 67-year-old woman with epigastric pain was diagnosed with resectable pancreatic head cancer and underwent pancreatoduodenectomy. Preoperative computed tomography showed that the common hepatic artery formed a common trunk with the left gastric artery running to the liver through the lesser omentum, and no other arterial supply to the liver was identified. Pancreatoduodenectomy was performed uneventfully without injury to any hepatic arteries. The postoperative clinical course was largely uneventful, and the patient was discharged on postoperative day 19. An anatomical variation of the common hepatic artery arising from a common trunk with the left gastric artery and coursing within the lesser omentum is rare. Notably, this is the first case report of pancreatoduodenectomy with this anatomical variation. Thorough understanding of hepatic arterial anatomical variations is necessary to prevent complications caused by inadvertent vascular injury and hepatic ischemia.

Robotic surgery using da Vinci®Surgical System which has the high resolution 3-dimensional images, the forceps with 7 degrees freedom, the function for prevention of tremors and motion scaling enables to perform meticulous operation circumventing the action of forceps movement which is the major problem in conventional laparoscopic surgery. In 2003, initial robotic gastrectomy for gastric cancer has been reported. Since then robotic gastrectomy has been developed mainly in Japan, Korea and Italy. From January 2012, we launched robotic gastrectomy at our institute as prospective clinical phase II trials to clarify the safety of robotic gastrectomy. The results of these trials have already been published and the safety of robotic gastrectomy was confirmed. In the several retrospective analyses, robotic gastrectomy has been reported to show longer operation time, less blood loss and lower morbidity compared with conventional laparoscopic surgery. However, the superiority of robotic gastrectomy to laparoscopic gastrectomy has not yet been demonstrated in terms of short- and long-term outcomes in a randomized controlled trial. Since robotic gastrectomy has been approved in Japanese health insurance system at April 2018, it is expected to rapidly expand throughout the country in the near future. Therefore, it is urgent matter to establish an evidence and educational program. In this article, the current status and future perspective about robotic surgery for gastric cancer are presented.

290 Background: In patients with gastric cancer (GC), the most common double cancer is colorectal cancer (CRC). However, the meaning of screening colonoscopy has not been established. The aim of this retrospective study was to evaluate the useful of screening colonoscopy in preoperative patients with GC. Methods: This study included 689 patients who received screening colonoscopy before gastric surgery between 2012 and 2016. Multivariate analysis using logistic regression model was conducted to elucidate independent risk factors of CRC. Then, we investigated the clinicopathological factors for CRC. Results: Colorectal adenomas and CRC were observed in 315 patients (46%) and 37 patients (5.4%), respectively. The clinical T classification of the CRC were as follows; Tis: 24 patients (65%), T1: 8 patients (21%), T2: 2 patients (6%), and T3: 3 patients (8%). In multivariate analysis, male (OR 5.04, 95% C.I. 1.29-19.6, p = 0.020) was revealed as risk factor for affecting CRC. The treatments for CRC were as follows; EMR was performed in 27 patients, simultaneous resection with GC was performed in 9 patients, resection after gastrectomy was performed in 1 patient, respectively. Pathological stage of CRC was as follows; Stage 0: 24 patients, Stage I: 10 patients, and Stage IIA: 3 patients, respectively. As for the patients who underwent surgery for CRC, all of them received radical colectomy. No patient died for CRC who received colonoscopy before gastric surgery. Conclusions: Screening colonoscopy is useful for GC patients. Because most of the synchronous CRC were found early stage and curatively treated.

Pylorus-preserving gastrectomy (PPG) has the postoperative advantages of a better quality of life and less weight loss than distal gastrectomy. However, postoperative delayed gastric emptying (DGE) due to antral hypomotility can be a problem. Although preserving the infra-pyloric vein (IPV) is reported to improve congestion of the antrum and prevent DGE, the benefits of this procedure have not been confirmed. The present study aimed to clarify the preventive effect on DGE of preserving the IPV. A total of 148 patients [IPV-preserved (IPVP): 78 patients and IPV-non-preserved (IPVN): 70 patients] who underwent laparoscopic and robotic PPG (LRPPG) for early gastric cancer were enrolled in this study. The clinicopathologic characteristics and incidence of DGE were compared between the groups. The nutritional risk index (NRI) at 1, 2, and 3 years after the operation and the relapse-free survival (RFS) were also compared. There were no significant differences in the clinicopathological characteristics between the two groups. DGE was observed in 15 of 148 patients (10.1%). The incidence of DGE did not differ markedly between the 2 groups (IPVP vs. IPVN; 11.5% vs. 8.6% p = 0.596). There were no significant differences in other complications between the groups either (IPVP vs. IPVN; 19.2% vs. 21.4%; p = 0.838). The NRI and 3-year RFS were not significantly different between the two groups. Regarding LRPPG, preserving the IPV did not help prevent DGE and resulted in no significant difference in the outcomes.

49 Background: Immune checkpoint inhibitors (ICPIs) have provided clinical benefit for various malignancies. A new attempt was recently made to combine PD-1/PD-L1 inhibitors and other ICPIs. In order to establish a new strategy for ICPI combination therapy, we must first understand the expression patterns of PD-L1 and other ICP molecules. To identify possible candidate agents for application in combination therapy with PD-1/PD-L1, we analyzed the expression patterns of ICP molecules in gastric cancer. Methods: Tumor samples were obtained from 278 patients who underwent gastrectomy for gastric cancer from 2014 to 2016, and a comprehensive gene expression analysis using a DNA microarray. We analyzed the TCGA dataset to identify the candidate ICP molecules in relation to PD-L1. The immune landscape was evaluated according to the expression patterns of known immune cell markers reported by Bindea et al. Results: Seven ICP molecules ( PD-L2, IDO1, CD80, ICOS, CTLA4, LAG3 and TIM3) were coexpressed with PD-L1 in the TCGA dataset. In our cohort, all of these molecules were also coexpressed (R > 0.5, P < 0.0001). Using a cluster analysis based on these gene expression profiles, patients were divided into Group A, characterized by the co-overexpression of PD-L1 and other ICP molecules, and Group B, characterized by the underexpression of PD-L1. In Group A, PD-L2 (R = 0.67) and IDO1 (R = 0.61) were particularly strongly associated with the PD-L1 expression. In Group B, elevated expressions of CTLA4 and ICOS were predominantly observed, and these expressions were strongly correlated with each other (R = 0.90). The tumor stage was significantly more advanced in Group B than in Group A (P = 0.02). Accordingly, Group A exhibited a better survival outcome than Group B. The immune landscape of Group A was particularly enriched for Th1, NK CD56dim and activated dendritic cells. Conclusions: PD-L1 and several immune checkpoint molecules tend to be coexpressed in gastric cancer. The combination of PD-L1/-L2 and IDO1 target agents may be a new strategy for treating gastric cancer with PD-L1 overexpression. In contrast, the underexpression of PD-L1 might be an indication for the use of CTLA4- and/or ICOS-directed therapies.

55 Background: We have previously reported the safety of robotic gastrectomy (RG) for clinical Stage IA or IB gastric cancer in single arm phase II studies. To date, a number of retrospective case control studies comparing RG and laparoscopic gastrectomy (LG) have been performed. However, since randomized controlled trials have never been conducted, no definitive conclusion demonstrating benefits of RG over LG has been demonstrated. In this study, we aimed to evaluate the safety of RG compared to LG using propensity score matching (PSM) methods. Methods: We retrospectively reviewed 766 consecutive patients who underwent either RG (n = 231) or LG (n = 535) for gastric cancer between January 2012 and December 2017. A 1:1 PSM was performed with the matched variables of age, sex, body mass index, performance status, clinical Stage, type of gastrectomy, and extent of lymphadenectomy. We compared short-term outcomes between the patients who underwent RG (RG group) and LG (LG group). Results: After PSM analysis, 231 patients were included in the RG group and 230 in the LG group. Intraoperative blood loss was similar between the groups. Operation time was significantly longer in the RG group (326 min vs. 281 min, P < 0.001). Significantly more lymph nodes were retrieved in the RG group (42 vs. 38.5, P = 0.031). Serum CRP level were significantly lower in the RG group in postoperative day 3 (9.0 mg/dL vs. 9.8 mg/dL, P = 0.049) and 6 (3.1 mg/dL vs. 3.7 mg/dL, P = 0.034), and drain amylase level in postoperative day 3 was also significantly lower in the RG group (612 U/L vs. 856 U/L, P < 0.001). Overall postoperative complication (Clavien–Dindo classification grade IIIA or greater) was similar between the groups (RG: 3.9% vs. LG: 5.6%, P = 0.656). However, pancreatic fistula tended to be less frequent in the RG group than in the LG group (0.4% vs. 2.2%, P = 0.122), although it did not reach statistically significant difference. Conclusions: Although RG takes longer operation time, it appears to be less invasive than LG with the possibility of decreased postoperative complications. To validate the results, randomized controlled trial should be performed.

27 Background: Although prolonged preoperative waiting period (PWP) for gastric cancer (GC) may influence the prognosis, the relationship between PWP and survival outcome has not been elucidated. The aim of this study is to identify the impact of PWP on survival in patients with clinical stage (cStage) II / III GC. Methods: A total of 483 patients who underwent surgery for cStage II / III GC according to Japanese classification of GC, 14th edition, between January 2002 and December 2012 were included. The patients who underwent endoscopic submucosal dissection or neoadjuvant chemotherapy, or who had multiple cancer, special histological types of tumor, or urgent symptoms were excluded. We defined PWP as the period from the date of endoscopy for initial diagnose to that of surgery. Patients were divided into two groups according to PWP; short waiting period group (SWPG, PWP ≤ 60 days, n = 357) and long waiting period group (LWPG, PWP > 60 days, n = 126). Survival outcomes were compared between the groups and multivariate analysis for overall survival (OS) was conducted to identify independent prognostic factors. Results: The median PWP was 49 (21-323) days. In LWPG, patients were significantly older (P = 0.001) and had more comorbidities (P = 0.042) than those in SWPG. Preoperative lymph node status was significantly lower in LWPG (P = 0.031), although there were no differences in tumor depth and cStage between the groups. There was no difference in OS between the groups (5-year OS, SWPG: 61.0%, LWPG: 63.2%, P = 0.612). Multivariate analysis for OS identified age, BMI, histological type, and cStage as independent prognostic factors. Conclusions: Preoperative waiting period appears to have no influence on survival in patients with cStage II / III GC.

653 Background: The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colorectal surgery was retrospectively investigated. This retrospective cohort study was conducted from May 2004 through October 2012. This study was conducted at Tokushima University Hospital and Ehime Prefectural Central Hospital. Methods: A total of 145 consecutive patients who had undergone laparoscopic resection of the sigmoid colon and upper rectum were classified as not having previous abdominal surgery (NPAS group, n = 123) or as having previous abdominal surgery (PAS group, n = 22). Short-term outcomes were assessed between the two groups. Results: The population of previous abdominal surgery consisted of 6 appendectomy, 3 gastrectomy for gastric ulcer, 2 nephrectomy, 2 peritonitis and 11 others (2 duplication). There were no significant differences in age, gender, BMI, tumor location, tumor size, Stage, operating time, blood loss and number of lymph node harvest between the two groups. The conversion to open surgery was performed in 1 patient (4.5%) in the PAS group and 6 patients (4.9%) in the NPAS group. The intraoperative inadvertent enterotomy occurred in 1 patient in the NPAS group. There was no difference in postoperative morbility between the two groups. In the NPAS group, anastomotic leakage was observed in 3 cases. Ileus was observed in one case in the NPAS and none in the PAS. Postoperative hospital stay was 14 days in the PAS group and 16 days in the NPAS group. Conclusions: Short-term outcomes following laparoscopic surgery for sigmoid colon and upper rectal cancer with previous abdominal surgery are acceptable.

643 Background: Safety and validity of performing laparoscopic surgery after preoperative lavege using the self-expandable metallic stent (SEMS) for left-sided obstructive colorectal cancer were examined. We evaluated the short-term outcome of SEMS insertion compared with laparoscopic surgery without SEMS. Methods: Patients with left-sided colorectal cancer treated by either laparoscopic surgery with stent placement (n = 8) or laparoscopic surgery only (n = 42) in our hospital between April, 2012 and January, 2013 were registered. Short-term outcomes were compared with the two groups about patient characteristics (sex, age, American Society of Anesthesiologists Physical Status, body mass index, prior abdominal surgery), pathological data of patients (tumor location, size of tumor , tumor differentiation, number of harvested lymph nodes, pTNM classification, UICC pathological stage), and operative and post operative results (procedures, conversion, operative time, blood loss, morbidity, solid food intake, postoperative hospital stay, total hospital stay). Results: Except for tumor size in the patient characteristic parameters, there were no statistically significant difference between the two groups. Conversion rate to laparotomy was higher in the stent group (2 versus 1, p = 0.013). There was no difference in operation time, blood loss and postoperative complications between the two groups. Conclusions: Although the long-term oncological result requires further investigation, laparoscopic surgery after self-expandable metallic stent is a safe and feasible treatment as a “brige to surgery” for left-sided obstructive colorectal cancer.