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169 Background: ESD is the one of the options of treatment even for lateral spreading (size is over 5 cm) esophageal squamous cell carcinoma (L-S ESCC). Some patients have to undergo additional treatment because tumor is invaded to submucosal layer or lymphovascular invasion. On the other hand, wide resection by ESD could cause the delay of additional treatment because of the treatment for esophageal stricture after ESD. Thus, treatment strategy for L-S ESCC has to include additional treatment after ESD. Methods: From January 2010 to December 2014, 49 cases of l L-S ESCC were resected by surgery or ESD. Diagnosis, treatment methods and outcomes are evaluated. Results: In 49 cases of L-S ESCC, 32 cases were treated by ESD and 17 case were treated by surgery. Average size of tumor treated by ESD is 59.4 mm(50-85 mm). Accuracy of estimated depth of invasion by endoscopy for ESD cases is 65.7%. Four of 32 cases of ESD underwent additional therapy (3 for surgery and 1 for CRT) because of pT1b (SM2) or lymphvascular invasion, and one case has lymph-node metastasis. Rate of stricture after ESD is 20.0% for sub-circumference ESD and 77.8% for circumference ESD instead of steroid injection. Average time and duration for control of esophageal stricture by Balloon Bougie is 13.5 times and 18 weeks. Average size of tumor treated by surgery is 76.5 mm(50-130 mm). Accuracy of estimated depth of invasion by endoscopy for surgical cases is 47.1%. Seven cases in 17 (41.2%) have lymph node metastasis. One case died by recurrence after surgery and 48 cases were survived without any recurrences. Conclusions: Accuracy of estimated depth of invasion by endoscopy for L-S ESCC is cute low compared to normal superficial ESCC. Most of strictures after sub-circumference ESD could be prevented by steroid injection. However control of strictures after circumference ESD is difficult. Thus, diagnostic ESD should not be performed for circumferencial lesions of L-S ESCC for the patients who will select CRT for additional treatment, and CRT should be selected for first treatment of these cases. Long survival could be obtained by ESD or surgery for the patients of L-S ESCC by our treatment strategy.

168 Background: Laparoscopic wedge resection is widely performed for managing gastric submucosal tumors (SMTs) that measure ≤5 cm in diameter. Laparoscopy and endoscopy cooperative surgery (LECS) is performed to ensure a sufficient margin while avoiding deformation or stenosis. Methods: We conducted a retrospective review of the data of 76 patients who underwent LECS for SMTs or early gastric cancers at our institution between April 2012 and July 2017. While Non-exposed Endoscopic Wall-inversion Surgery (NEWS) was performed for tumors with a major axis diameter of ≤5 cm and minor axis diameter of ≤3 cm, for other tumors, we adopted classical LECS or used the combination of laparoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET). Results: The tumor was located in the upper-/middle-/lower-third of the stomach in 49/20/7 cases. The mean operation time was 201.7 ± 66.2 min, and the mean blood loss was 4.7 ± 12.8 ml. The mean tumor size was 28.6 ± 11.6 mm. The histological tumor types included GIST (n = 38), leiomyoma (n = 14), schwannoma (n = 6), early gastric cancer (n = 8) and others (n = 10). The surgical procedure consisted of classical LECS/CLEAN-NET/NEWS in 17/15/44 cases; all early gastric cancers were treated by NEWS. The mean length of postoperative hospital stay was 8.7 ± 3.9 days. The mean serum levels of C-reactive protein on POD1 and POD3 were 3.2 ± 1.9 and 4.4 ± 3.4 mg/dl, respectively. The postoperative complications were anastomotic stenosis (n = 1), delayed gastric emptying (n = 3), pneumonia (>Grade II by the Clavien-Dindo classification) (n = 1) and exacerbation of GERD (>Grade II by the Clavien-Dindo classification) (n = 3). In the patient group that developed complications, the postoperative resumption of water intake was later, and the postoperative hospital stay was longer as compared to the group without complications (p = 0.04, 0.028). No relationship was observed between the likelihood of development of complications and the tumor location. Conclusions: Use of minimally invasive surgical procedures such as LECS could minimize the extent of gastric resection without deformation, stenosis. We consider that for surgical complications the LECS approach can be employed, regardless of the tumor location.

12 Background: The sentinel node (SN) concept is safely applied and validated in early gastric cancer. Gastric lymph nodes are divided into five basins with the main gastric arteries. The suprapyloric lymph nodes (No. 5) and the anterosuperior lymph nodes with the common hepatic artery (No. 8a) are classified in the right gastric artery (r-GA) basin, and the subpyloric lymph nodes (No. 6) are classified in the right gastroepiploic artery (r-GEA) basin. The aim of this study is to analyze the lymphatic flows between these lymph nodes and basins. Methods: Five hundred and fourty-nine patients with cT1N0 or cT2N0 gastric cancer underwent SN mapping. We used technetium-99 tin colloid solution and blue dye as a tracer. Results: We detected SN No. 5 in 36 (6.6 %) patients. In these patients, we detected SN No. 5 with SNs that belonged to the left gastric artery (l-GA) basin (69 %), r-GA basin (14 %), and r-GEA basin (44 %). No. 6 was detected as SN significantly more frequently with SN No. 5. We detected SN No. 6 in 100 (18.2 %) patients. In these patients, we detected SN No. 6 with SNs that belonged to the l-GA basin (42 %), left gastroepiploic artery (l-GEA) basin (4 %), r-GA basin (28 %), and r-GEA basin (41 %). No. 4d, No. 5 and No. 8a were detected as SNs significantly more frequently with SN No. 6. We detected SN No. 8a in 43 (7.8 %) patients. In these patients, we detected SN No. 8a with SNs that belonged to the l-GA basin (65 %), l-GEA basin (7 %), r-GA basin (21 %), r-GEA basin (58 %), and posterior gastric artery (p-GA) basin (7 %). No. 6 and No. 9 were detected as SNs significantly more frequently with SN No. 8a. SN No. 5 and No. 8a were tend to be detected with not SNs that belonged to the r-GA basin but No. 6, and SN No. 6 was detected significantly more frequently with No. 4d, No. 5 and No. 8a. Conclusions: Our findings show that lymphatic flows exist not only between lymph nodes which are belonged to the same basin, but also between No. 5 and No.6, and No.6 and No. 8a. On the other hand, the lymphatic flows between No. 5 and No. 8a seem to be limited. Our results suggest that the lymph node dissection of No. 6 given lymphatic flows from lesser curvature side and retroperitoneal side is important for surgery of gastric cancer.

23 Background: Some studies suggest anastomotic leakage (AL) may adversely affect long-term survival in patients undergoing radical gastrectomy (RG) for gastric cancer (GC). Therefore, we assume that common risk evaluation system for short-term and long-term prognosis can be devised in patients with GC that have undergone RG. Methods: Five hundred and twenty patients undergone RG against GC during May 2012 to March 2017 were enrolled. Patients’ characteristics, preoperative laboratory data, operative information and pathological factors were analyzed. Also AL with Clavien-Dindo classification Grade≥III (AL≥III), disease free survival (DFS) and disease specific survival (DSS) were examined. Results: By bringing patients under classification of “with or without relapse” and “with or without AL≥III”, we identified preoperative body weight (BW), serum C-reactive protein (CRP) and albumin (Alb) level were independent risk factors of both relapse and AL≥III. Stratifying patients with recurrence, we obtained crude hazard ratio (HR) of 1.04 (95% CI: 1.02-1.06) for 1kg-increase of BW, 1.51 (95% CI: 1.08-1.40) for 1mg/dl-increase of CRP and 1.23 (95% CI: 1.34-1.64) for 1g/dl-decrease of Alb. With these HR and median value of each parameters of none-relapse group, we defined ABC score (ABCs) is calculated by following formula; ABCs = (4.1-Alb)*51+(58.5-BW)*4+(CRP-0.05)*23. AL≥III were observed in 3.1% of the cases and ABCs of patients with AL≥III was significantly low (with AL≥III; -22.4, without AL≥III; 9.03, p = 0.045). We determine a cut off value of ABCs to -7 on the basis of the ROC curve. Patients with ABCs≤-7 had significantly high risk of AL≥III and we found ABCs≤-7 is an independent risk factor of AL≥III (HR 1.775, p = 0.003). Also, we stratified patients as Low group (L), Mid group (M), High group (H), by approximate tertile value of ABCs, -20 and 30. We found significant shortening of DFS and DSS in order of L, M and H (DFS; L vs M p = 0.006, Mid vs High p = 0.03, DSS; L vs M p = 0.002, L vs H p < 0.001). Moreover, HR for disease specific death for ABCs≥-20 was 4.2 (p = 0.003) in multivariate analysis. Conclusions: ABCs can be a risk evaluation system for short-term and long-term prognosis in patients with GC that have undergone RG.

39 Background: Obese patients with esophageal cancer have been increasing worldwide. However, the impact of obesity on esophagectomy still remains controversial. In this study, we clarified the relations between obesity and postoperative outcomes after esophagectomy in patients with esophageal cancer. Methods: A total of 215 patients who underwent esophagectomy for esophageal cancer between 2008 and 2014 were retrospectively assessed. We qualified the body mass index (BMI), visceral fat area (VFA) and subcutaneous fat area (SFA) using CYNAPSE VINCENT™. Clincopathological factors, postoperative morbidity, and survival after esophagectomy were assessed with these obesity-related factors. Results: The mean BMI, VFA, and SFA were 22.0 kg/m², 83.0cm², and 87.3cm². BMI, VFA and SFA were significantly correlated each other (P < 0.001). The prevalence of diabetes mellitus and hypertension were significantly more in high SFA than normal SFA (20% vs 10%, 30% vs 14%). When the patients were divided to two groups according to BMI (< 25 or ≥25kg/m²), VFA ( < 100 or ≥100cm²) and SFA ( < 100 or ≥100cm²), operative time was significantly longer in high SFA (P = 0.03) than normal SFA, and tended to be longer in high BMI, but blood loss were similar in each groups. Maximum level of postoperative CRP was significantly higher in high BMI (P < 0.001), in high VFA (P < 0.001), and in high SFA (P < 0.001). Length of systemic inflammatory response syndrome was significantly longer in high BMI than normal BMI (1.9 days vs 1.4 days P = 0.04), and length of ventilator support was significantly longer in high SFA than normal SFA (3.0 days vs 2.2 days P = 0.006). The incidence of anastomotic leakage and surgical site infection were significantly higher in high SFA than normal SFA (27% vs 10%, 37% vs 19%). There were no significant difference in overall survival, however, patients in high VFA tended to be longer survival than those in normal VFA (P = 0.078). Conclusions: Anastomotic leakage and surgical site infection occurred more frequently in high SFA. It might be useful to examine SFA preoperatively in obese patients with esophageal cancer for prevention of postoperative complications. Patients in high VFA tended to be longer survival than those in normal VFA.

22 Background: C-reactive protein to albumin (CRP/Alb) ratio is a novel inflammation-based prognostic score. It was originally reported as a prognostic score in septic patients, however, recent reports show CRP/Alb can be a prognostic score in some cancer patients. There are a few reports about CRP/Alb in patients with esophageal cancer. The usefulness of CRP/Alb in patients with esophageal cancer is still unclear. Methods: The aim of this study is to ensure the evidence of CRP/Alb in patients with esophageal cancer as a prognostic score. One hundred and sixty patients with esophageal cancer were reviewed in the current study. CRP/Alb was calculated before the treatment: In neoadjuvant chemotherapy (NAC) patients, CRP/Alb was calculated before NAC, in non-NAC patients, CRP/Alb was calculated before surgery. CRP/Alb was divided into high group and low group, using cut off value 0.035. The number of 0.035 was determined, referred from other reports of CRP/Alb. Results: The distributions of postoperative pathologic stages 0, 1, 2, 3, and 4 were respectively 4, 51, 33, 56, and 16. The number of high CRP/Alb group was 58 (36.3%). That of low CRP/Alb group was 102 (63.7%). In the survival analysis, the patients with high CRP/Alb showed a significantly shorter overall survival. In the multivariate analysis with pathological stage, neoadjuvant treatment, field of lymph node dissection, and CRP/Alb as covariates, CRP/Alb was detected as a significantly independent prognostic score (hazard ratio 2.602; P < 0.001). Conclusions: In this study, CRP/Alb was thought to be a prognostic score with statistical significance in esophageal cancer. Therefore, further investigation of reducing preoperative inflammation and increasing preoperative nutrition in esophageal cancer is needed.

26 Background: Recent meta-analyses have shown acceptable SN detection rates and accuracy of determination of lymph node status. SN mapping may play a key role to obtain individual metastatic information and allows modification of the surgical procedures such as function-preserving gastrectomy for early gastric cancer. Methods: A dual-tracer method that employs radioactive colloids and blue dyes is currently considered the most reliable method for the stable detection of SNs in patients with early gastric cancer. The new technologies such as indocyanine green infrared or fluorescence imaging are also useful for accurate SN mapping in gastric cancer. Results: SN mapping has been performed for 489 patients with clinically T1N0M0 gastric cancer in our institute since 1999. Sensitivity to predict the lymph node metastasis was 90%, and overall accuracy of nodal status based on SN concept was 99 % (484 of 489). Sentinel lymphatic basin dissection is strongly recommended to cover the false-negative results of SN mapping in clinical practices. Based on these results, laparoscopic minimized gastrectomy such as partial resection, proximal gastrectomy, segmental gastrectomy and pylorus-preserving gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with negative SN has been performed in our institution. The recent appearance of a new technique, referred to as non-exposed endoscopic wall-inversion surgery (NEWS) is a technique of full thickness resection using endoscopy and laparoscopic surgery without transluminal access mainly designed to treat gastric cancer with partial resection. The combination of NEWS with SN biopsy is expected to become a promising, ideal minimally invasive, function-preserving surgery for cN0 early gastric cancer. We initiated a new multicenter prospective trial to evaluate function-preserving gastrectomy with SN mapping in terms of long-term survival and patients’ QOL. Conclusions: Our results suggested that SN concept for cN0 early gastric cancer could be validated, and function-preserving surgery based on the SN concept which might retain the patients’ quality of life should be established as the next surgical challenge.

31 Background: Wide variety of Predictive factors (PF) of postoperative complications (PC) in patients with gastric cancer(GC) that have undergone laparoscopic gastrectomy(LG) has been reported. The aim of this study is to devise simple PF for PC for LG that can estimate risk of PC preoperatively. Methods: Two hundred and ninety-eight patients that have been underwent curative LG against GC during May 2012 to March 2016 were enrolled. Patients’ characteristics, preoperative (pre-) laboratory data, operative information and pathological factors were analyzed. Also PC with Clavien-Dindo classification Grade (CD)≥II (PC≥II), pancreatic fistula (PF), intraabdominal abscess (IA), pneumonia (PN) and anastomotic leakage (AL) with CD≥III were examined. Results: Patients with pStage I, II, III and IV was 83%, 11%, 5.6% and 0.4%, respectively. Patients with PC≥II, PF or IA, PN and AL was 17.4%, 5%, 1% and 2.3%, respectively. Patients with PC≥II were significantly elder (p=0.01) and had higher pre-serum-C-reactive protein level (CRP) (p=0.02). Also, patients with AL had significantly higher Body Mass Index (BMI) (p=0.04). We devised “ABC score” by Age, BMI and CRP. It is defined as a number of factors in age, BMI and CRP that are higher than cutoff value of 66 years’ old, 23 kg/m2 and 0.04 mg/dL, respectively. Patients with ABCs 0, 1, 2, and 3 were 26%, 33%, 34% and 7%, respectively. Patients with ABCs 3 had significant high risk of PC≥II and AL (HR 2.8, p=0.03 and HR 9.9, p=0.004, respectively). Also we found higher ABCs has higher risk of AL (HR1.2, p=0.07 for ABCs 2 and HR2.2, p=0.04 for ABCs 3). Conclusions: ABCs can be a PF for PC in patients with LG. Especially it may evaluate an incidence ratio of AL.

183 Background: AF is common after thoracic and esophageal surgical procedures. The full spectrum of risk factors, associations, and implications are unclear. Objective:The aim of this study was to assess the impact of new-onset atrial fibrillation (AF) after esophagectomy on short- and long-term outcome. Methods: A retrospective analysis was performed on patients with esophageal cancer who underwent esophagectomy with thoracotomy and laparotomy, with R0 or R1 resection between January 1997 and December 2012. For the 402 patients included in this study, we analyzed the stage of disease, neoadjuvant therapies, surgical approaches, surgical complications, postoperative medical complications, and overall and relapse-free survivals using medical records. Results: The median age was 62 (range 34-82). Most patients were male (90.0%) and had squamous cell carcinoma (90.3%). Pathological staging of the esophageal cancers according to UICC 7th TNM classification system was categorized as follows: 17 (4.2%), 96 (23.9%), 16 (4.0%), 43 (10.7%), 57 (14.2%), 78 (19.4%), 39 (9.7%), 37 (9.2%), and 19 (4.7%) patients were designated as stage 0, ⅠA, ⅠB, ⅡA, ⅡB, ⅢA, ⅢB, ⅢC and Ⅳ respectively. Of the 402 patients studied, 42 (10.6%) had AF, 87 (21.6%) had pneumonia, 80 (20.0%) had anastomotic leakage, and 69 (17.2%) had recurrent laryngeal nerve paralysis. At a median follow-up of 133 months, the median survival was 49 months, and 5-year survival was 48% in the AF group, compared with 138 months and 60% in the non-AF group (p = 0.212). AF was significantly associated with recurrent laryngeal nerve paralysis (p = 0.001), but not with pneumonia or anastomotic leakage. Conclusions: New-onset AF is common, mostly associated with recurrent laryngeal nerve paralysis, but not with pneumonia or anastomotic leakage. AF has no impact on oncologic outcomes.

36 Background: The clinical outcome of esophageal cancer has recently improved. However, the relapse rate in any stages is still high. Prognostic classification in patients with esophageal cancer has not yet established. If the patients with poor prognosis could be extracted before surgery, we can add more intensive preoperative treatment, which might lead more favorable prognosis. We have previously reported clinical utility of fibrinogen (FNG) and Albumin (Alb) Score (FA score) in esophageal cancer. The purpose of this study was to analyze the utility of FA score comparing at each stage as a prognostic factor in esophageal cancer. Methods: Patient characteristics, clinicopathological factors, and preoperative biochemical markers (FNG, Alb, and CRP) were investigated in esophageal cancer patients who underwent transthoracic esophagectomy between January 2004 and November 2013. Correlation between preoperative FNG, CRP, Alb, clnicopathological factors and survival were investigated. We evaluated between recurrence-free survival (RFS), overall survival (OS) and FA score comparing at each stage. The cut-off value was defined according to previous reports; fibrinogen 350mg/dl, albumin 3.8mg/dl. Results: 252 patients were recorded. High FA score were correlated to worse OS and RFS (p < 0.001). Especially in cStageI, high FA score showed remarkably worse 5-year RFS (score0/ score1/ score2, 5-year RFS 84%/ 64%/ 33%; p = 0.038). Conclusions: FA score was significantly associated with postoperative survival in esophageal cancer patients. If the patients with poor prognosis in cStageI could be extracted before surgery, we can add more intensive preoperative treatment, which might lead more favorable prognosis.