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Tracheo-gastric conduit fistula is an extremely rare but severe complication that is difficult to manage. Conservative care, esophageal or tracheal stent placement, or cutaneomuscular flaps have been suggested; however, no definite treatment has been proven. We report a case of tracheo-gastric conduit fistula that occurred after a minimally invasive radical three-field esophagectomy. Following the primary surgery, the diagnosis was made while evaluating the patient's frequent aspiration and coughing. Conservative management failed, and a surgical correction was undertaken to identify the multifocal mucosal defect and exposed tracheal ring. A sternocleidomastoid muscle rotation flap and subsequent Histoacryl injection into the remaining fistula were performed, and the fistula was successfully managed.

Laparoscopic distal gastrectomy for early gastric cancer has been widely accepted, but laparoscopic total gastrectomy has still not gained popularity because of technical difficulty and unsolved safety issue. We conducted a single-arm multicenter phase II clinical trial to evaluate the safety and the feasibility of laparoscopic total gastrectomy for clinical stage I proximal gastric cancer in terms of postoperative morbidity and mortality in Korea. The secondary endpoint of this trial was comparison of surgical outcomes among the groups that received different methods of esophagojejunostomy (EJ). The 160 patients of the full analysis set group were divided into three groups according to the method of EJ, the extracorporeal circular stapling group (EC; n = 45), the intracorporeal circular stapling group (IC; n = 64), and the intracorporeal linear stapling group (IL; n = 51). The clinicopathologic characteristics and the surgical outcomes were compared among these three groups. There were no significant differences in the early complication rates among the three groups (26.7% vs. 18.8% vs. 17.6%, EC vs. IC vs. IL; p = 0.516). The length of mini-laparotomy incision was significantly longer in the EC group than in the IC or IL group. The anastomosis time was significantly shorter in the EC group than in the IL group. The time to first flatus was significantly shorter in the IL group than in the EC group. The long-term complication rate was not significantly different among the three groups (4.4% vs. 12.7% vs. 7.8%; EC vs. IC vs. IL; p = 0.359), however, the long-term incidence of EJ stenosis in IC group (10.9%) was significantly higher than in EC (0%) and IL (2.0%) groups (p = 0.020). The extracorporeal circular stapling and the intracorporeal linear stapling were safe and feasible in laparoscopic total gastrectomy, however, intracorporeal circular stapling increased EJ stenosis.

Purpose The objective of the present retrospective analysis was to describe the experience of intraperitoneal (IP) paclitaxel and systemic chemotherapy in patients with peritoneal metastasis (PM) of advanced gastric cancer (AGC) in a multicenter setting in Korea. Materials and methods The medical records of patients with AGC, who were diagnosed with PM between January 2015 and December 2018, were reviewed. IP catheter was placed in the pouch of Douglas and was used for the administration of IP paclitaxel chemotherapy. Results We reviewed the clinical outcomes of IP paclitaxel and systemic chemotherapy administration in 82 patients at six institutions in Korea. Mean number of IP chemotherapy cycles was 6.6. The mean peritoneal cancer index (PCI) was 21.9. Postoperative complications related to IP catheter and port were observed in 15 patients. The overall median survival was 20.0 months. A significant difference was observed in the survival rate according to the ascites grade (grade I and II, 24.1 months; grade III and IV, 15.3 months; P=0.014) and PCI grade (grade I, 25.6 months; grade II and III, 16.3 months; P=0.023). Conclusions The feasibility of IP paclitaxel and systemic chemotherapy administration was demonstrated in this experience-based retrospective analysis suggesting that the procedure is beneficial in patients with PM of AGC.

The aim of the study was to evaluate the short-term outcomes of KLASS-02-RCT, a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy (LDG) with D2 lymphadenectomy with open distal gastrectomy (ODG).Although several benefits of laparoscopic gastric cancer surgery have been reported, strong evidence is still limited, especially in locally advanced gastric cancer which requires extensive lymph node dissection.Enrollment criteria included histologically confirmed cT2-4a and N0-1 gastric adenocarcinoma. Thirty-day morbidity, 90-day mortality, postoperative pain, and recovery were compared between LDG and ODG groups.A total of 1050 patients were randomly assigned to LDG (n = 526) or ODG group (n = 524) between November 2011 and April 2015. After excluding patients who received bypass or no surgery, 1011 patients were analyzed as actual treatment group. Mean number of totally retrieved lymph nodes was similar in both groups (LDG = 46.6 vs ODG = 47.4, P = 0.451). Early morbidity rate was significantly lower after LDG (16.6%) than after ODG (24.1%; P = 0.003). Postoperative analgesics use and patients' reported pain score were significantly lower after LDG. First day of flatus was earlier after LDG (3.5 vs 3.7 d, P = 0.025) and postoperative hospital stay was shorter in LDG group (8.1 vs 9.3 d, P = 0.005). Ninety days' mortality rate was similar in both groups (LDG = 0.4% vs ODG = 0.6%, P = 0.682).Laparoscopic distal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer shows benefits in terms of lower complication rate, faster recovery, and less pain compared with open surgery.

A split dose (SPD) of purgative is the recommended bowel-preparation method for colonoscopy, although for colonoscopy scheduled for the afternoon, a same-day dose (SDD) of purgative is recommended. However, it has not been determined whether SPD or SDD is better in patients with gastrectomy who are at high risk of suboptimal bowel cleansing. We compared the bowel-cleansing efficacy of SPD and SDD regimens in patients with gastrectomy who underwent colonoscopy in the afternoon. This was a prospective, randomized, assessor-blinded study. For the SDD group, polyethylene glycol (PEG) was ingested on the day of colonoscopy starting at 7 AM. In the SPD group, 2 L PEG was ingested at 9 PM the day before colonoscopy, and the remaining 2 L from 10 AM on the day of colonoscopy. Colonoscopy was performed from 1:30 PM. Before colonoscopy, the participants completed questionnaires asking about bowel-movement kinetics, adverse events, tolerability, overall satisfaction, and willingness to reuse the protocol. The bowel-cleansing efficacy was assessed using the Boston Bowel Preparation Scale. A total of 193 subjects were included (SDD, 95; SPD, 98). The rate of successful bowel cleansing was comparable between the two groups (SDD, 92.6% vs. SPD, 95.9%; P = 0.37). The incidence of adverse events (nausea, vomiting, bloating, abdominal pain, and dizziness/headache) was also comparable between the two groups. However, sleep disturbance was higher in the SPD group (SDD, 10.5% vs. SPD, 25.5%; P = 0.01). Tolerability did not differ between the SDD and SPD groups (satisfaction, P = 0.11; willingness to reuse, P = 0.29). The bowel-cleansing efficacy, safety profile, and patient tolerability of SDD and SPD were comparable. Both SDD and SPD regimens are feasible bowel-preparation methods for patients with gastrectomy who undergo colonoscopy in the afternoon. Clinical trial registration number: KCT0002699.

Backgrounds/Aims This multicenter study aims to evaluate the effect and feasibility of anti-reflux surgery compared with medical treatment for gastroesophageal reflux disease (GERD). Methods Patients with GERD who were undergoing medical treatment with proton pump inhibitors for more than 8 weeks and those who were scheduled to undergo anti-reflux surgery were enrolled. Efficacy of pre-operative medical treatment was evaluated retrospectively and effect of anti-reflux surgery was prospectively evaluated at 1 week and 3 months after surgery. Quality of life (QOL) was also investigated before and after surgery. Results Between February and October 2018, 51 patients underwent laparoscopic Nissen fundoplication for treating GERD at 5 hospitals in Korea. Thirty-four patients (66.7%) showed poor proton pump inhibitor response. At 3 months after surgery, heartburn was completely resolved in 87.9% patients and partially improved in 9.1%. Acid regurgitation was completely resolved in 82.9% and partially improved in 11.4%. Atypical extraesophageal symptoms were completely controlled in 45.5% and partially controlled in 36.4%. GERD-related QOL scores at 1 week after surgery significantly improved compared with pre-operative scores. There was no difference in GERD-related QOL scores between 1 week and 3 months after surgery. General QOL measured with European QOL-5 dimensions and health-related QOL instrument with 8 items significantly improved after anti-reflux surgery. Satisfaction with treatment was significantly higher after surgery than before surgery (72.5% vs 11.8%, P < 0.001). Conclusion Anti-reflux surgery improved GERD symptoms and QOL in patients. Anti-reflux surgery is an effective treatment option compared with medical treatment for GERD patients selected for surgical treatment. (J Neurogastroenterol Motil 2019;25:394-402)

In 2014, the results derived from the nationwide data of the Korean Anti-reflux Surgery Study (KARS) demonstrated short-term feasibility and safety of anti-reflux surgery. This study aimed to update the longer-term safety and feasibility of laparoscopic anti-reflux surgery up to 1-year follow-up with the KARS nationwide cohort.The data of 310 patients with GERD who received anti-reflux surgery up to 2018 were analyzed. Baseline patient characteristics, postoperative symptom resolution, and postoperative complications were evaluated at postoperative 3 months and 1 year using the questionnaire designed by KARS. We divided the patients into two groups according to the operation period (up to and after 2014) to identify changes in the trends of the characteristics of surgical patients and operative qualities.The typical preoperative symptoms were present in 275 patients (91.7%), and atypical symptoms were present in 208 patients (71.0%). Ninety-seven (35.5%) and 124 patients (46.1%) had inadequate PPI responses and hiatal hernia, respectively. At postoperative 1 year, typical and atypical symptoms were either completely or partially controlled in 90.3% and 73.5.0% of patients, respectively. Moderate-to-severe dysphagia, inability to belch, gas bloating, and flatulence at postoperative 1 year were identified in 23.5%, 29.4%, 23.2%, and 22.0% of patients, respectively. The number of surgical patients continuously increased from 2011 to 2018 in Korea. The proportion of patients with hiatal hernia and comorbidities increased (p 0.01, p = 0.053), and the operation time decreased significantly (p 0.01) in the late period (2015-2018) as compared with the early period (2011-2014). Symptom control and complication rate were equivalent between the two periods.Anti-reflux surgery was effective with 90% of typical symptom resolution and posed a comparable postoperative complication rate with those in Western studies with mid-term to long-term follow-up. This result supports the feasibility and safety of anti-reflux surgery as a treatment for GERD in the Korean population.

Background/Aims: Several studies have shown that colorectal neoplasms (CRN) including colorectal cancer (CRC) may be prevalent in patients with gastric cancer. However, in most of these studies, colonoscopy to investigate the prevalence of CRN was performed prior to surgery. We aimed to investigate whether CRN was more prevalent in postgastrectomy gastric cancer patients than in healthy individuals.Methods: We reviewed the medical records of those patients within a cohort of gastric cancer patients with gastrectomy who underwent colonoscopy between 2016 and 2017. Controls age- and sex-matched with gastric cancer patients at a 2:1 ratio were identified among those who underwent colonoscopy at a health-promotion center. The frequencies of CRN, advanced CRN (ACRN), and CRC among patients with gastrectomy were compared with those in the control subjects. A total of 744 individuals (gastric cancer, 248; control, 496) were included.Results: The rates of CRN and ACRN in the gastric cancer group were higher than those in the healthy individuals (CRN, 47.6% vs. 34.7%, P< 0.001; ACRN, 16.9% vs. 10.9%, P= 0.020). The rate of CRC was comparable between the 2 groups (2.0% vs. 0.6%, P= 0.125). Multivariate analysis identified previous gastrectomy for gastric cancer and male sex as significant risk factors for (A)CRN.Conclusions: CRN and ACRN were more prevalent in patients who underwent surgery for gastric cancer than in the control group. Regular surveillance colonoscopy at appropriate intervals is indicated after gastrectomy.

With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer. Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien–Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control. Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%). LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.

Purpose: Many studies have demonstrated the advantage of maintaining intraoperative deep neuromuscular block (NMB) with sugammadex. This trial is designed to evaluate the impact of muscle relaxation during laparoscopic subtotal gastrectomy on the oncological benefits, particularly in obese patients with gastric cancer. Materials and methods: This is a double-blind, randomized controlled multicenter prospective trial. Patients with clinical stage I–II gastric cancer with a body mass index of 25 and over, who undergo laparoscopic subtotal gastrectomy will be eligible for trial inclusion. The patients will be randomized into a deep NMB group or a moderate NMB group with a 1:1 ratio. A total of 196 patients (98 per group) are required. The primary endpoint is the number of harvested lymph nodes, which is a critical index of the quality of surgery in gastric cancer treatment. The secondary endpoints are surgeon's surgical condition score, patient's sedation score, and surgical outcomes including peak inspiratory pressure, operation time, postoperative pain, and morbidity. Discussion: This is the first study that compares deep NMB with moderate NMB during laparoscopic gastrectomy in obese patients with gastric cancer. We hope to show the oncologic benefits of deep NMB compared with moderate NMB during subtotal gastrectomy. Trial registration number: ClinicalTrials.gov (NCT03196791), date of registration: October 10, 2017.

Purpose This study aims to investigate the actual compliance with chemotherapy and analyze several factors affecting the compliance in patients with gastric cancer. Methods From February 2012 to December 2014, we collected data of patients with gastric cancer who received adjuvant chemotherapy (TS-1 monotherapy or XELOX: capecitabine/oxaliplatin) in Korea. Results We collected data of 1,089 patients from 31 institutions. The completion rate and dose reduction rate by age (≥60 years vs.

Purpose The surgical outcomes of end-stage renal disease (ESRD) patients undergoing radical gastrectomy for gastric cancer were inferior compared with those of non-ESRD patients. This study aimed to evaluate the short- and long-term surgical outcomes of ESRD patients undergoing laparoscopic gastrectomy (LG) and open gastrectomy (OG) for gastric cancer. Materials and methods Between 2004 and 2014, 38 patients (OG: 21 patients, LG: 17 patients) with ESRD underwent gastrectomy for gastric cancer. Comparisons were made based on the clinicopathological characteristics, surgical outcomes, and long-term survival rates. Results No significant differences were noted in the clinicopathological characteristics of either group. LG patients had lower estimated blood loss volumes than OG patients (LG vs. OG: 94 vs. 275 mL, P=0.005). The operation time and postoperative hospital stay were similar in both the groups. The postoperative morbidity for LG and OG patients was 41.1% and 33.3%, respectively (P=0.873). No significant difference was observed in the long-term overall survival rates between the 2 groups (5-year overall survival, LG vs. OG: 82.4% vs. 64.7%, P=0.947). Conclusions In ESRD patients, LG yielded non-inferior short- and long-term surgical outcomes compared to OG. Laparoscopic procedures might be safely adopted for ESRD patients who can benefit from the advantages of minimally invasive surgery.

BACKGROUND: Despite the development of newer treatments, the prognosis for patients with stage IV gastric cancer remains grave. This study evaluated the efficacy of gastrectomy following response to chemotherapy in patients with stage IV gastric cancer.A total of 419 patients who were diagnosed with stage IV gastric cancer were identified from the multi-institutional Catholic Gastric Cancer Study Group database. The patients were divided into four groups: 212 were in the chemotherapy only (CTx) group, 124 were in the chemotherapy after palliative gastrectomy (G-CTx) group, 23 were in the radical gastrectomy after chemotherapy (CTx-G) group, and 60 were in the best supportive care group. To compensate for the effects of chemotherapy, cases of chemotherapy responsive were analyzed separately. To identify factors affecting survival rates, cure rates for surgery in the surgery group were analyzed.The 3-year survival rate of the CTx-G group was significantly higher than that of the CTx group (42.8 vs. 12.0%, p = 0.001). Moreover, the CTx-G group's 3-year survival rate was greater than that of the G-CTx group (42.8 vs. 37.1%, p = 0.207). Chemotherapy-responsive patients in the CTx-G group had a better 3-year survival rate than those in the G-CTx group (46.1 vs. 18.4%, respectively, p = 0.011). In the surgery group, R0 resection led to a significantly better 3-year survival rate than palliative gastrectomy (61.1 vs. 16.2%, p = 0.003).Adjuvant surgery might improve the survival rate of patients with stage IV gastric cancer, particularly in R0 resection cases.

PURPOSE The aim of this study was to compare the short-term surgical and long-term functional outcomes of Billroth I, Billroth II, and Roux-en-Y reconstruction after laparoscopic distal gastrectomy. MATERIALS AND METHODS We retrospectively collected data from 697 patients who underwent laparoscopic distal gastrectomy for operable gastric cancer between January 2009 and December 2012. The patients were classified into three groups according to the reconstruction methods: Billroth I, Billroth II, and Roux-en-Y. The parameters evaluated included patient and tumor characteristics, operative details, and postoperative complications classified according to the Clavien-Dindo classification. Endoscopic findings of the remnant stomach were evaluated according to the residue, gastritis, bile (RGB) classification and the Los Angeles classification 1 year postoperatively. RESULTS Billroth I, Billroth II, and Roux-en-Y were performed in 165 (23.7%), 371 (53.2%), and 161 patients (23.1%), respectively. Operation time was significantly shorter (173.4±44.7 minute, P

Recently, single port laparoscopic surgery has begun to develop as an extension of minimally invasive surgery, but there have been only a few reports of single port laparoscopic totally extraperitoneal (SPLTEP) hernioplasty. In addition, there are few comparative studies with conventional laparoscopic totally extraperitoneal (CLTEP) hernioplasty. The aim of the present study was to report our experience with SPLTEP hernioplasty and to compare short-term outcomes for SPLTEP hernioplasty with CLTEP hernioplasty.Data were prospectively collected for all patients undergoing SPLTEP hernioplasty for inguinal hernia at Incheon St. Mary's Hospital, Incheon, Korea. Data for the SPLTEP group (n = 76 patients enrolled between June 2010 and May 2011) were compared retrospectively with data for the CLTEP group (n = 93 patients enrolled between June 2009 and May 2010).There were no significant differences in patient demographics. This study showed no significant difference in terms of operative time between the two groups (SPLTEP group 54.0 min vs. CLTEP group 47.8 min; p = 0.07). There were no conversions to conventional TEP hernioplasty or transabdominal preperitoneal hernioplasty or open surgery in SPLTEP hernioplasty. Morbidity rates were 7.9 % (n = 6) in the SPLTEP group and 10.8 % (n = 10) in the CLTEP group, and the difference was not significant.Single port laparoscopic totally extraperitoneal hernioplasty is technically feasible and the short-term operative outcome is comparable to that of CLTEP hernioplasty. Future large-scale prospective controlled studies and long-term analysis are needed to establish the cosmetic outcomes, quality of life, long-term recurrence rate, and long-term complication rate of SPLTEP hernioplasty.

Laparoscopic gastrectomy (LG) in gastric cancer patients with liver cirrhosis (LC) has rarely been reported. In this study, we aimed to elucidate the feasibility of LG compared with that of open gastrectomy (OG) for LC patients. Of the 75 LC patients who underwent radical gastrectomy for gastric cancer between April 2005 and March 2014, 36 patients who underwent LG were compared with 39 patients who underwent OG. Comparisons were based on clinicopathologic characteristics, surgical outcomes, and long-term survival rates. Comparison of LG and OG revealed no significant differences in the clinicopathologic characteristics. Five patients in the LG group and eight in the OG group showed a Child–Turcotte–Pugh score (CTPs) over A. In surgical outcomes, we observed shorter operation times (191.4 ± 63.9 vs. 225.9 ± 77.1 min, p = 0.039), reduced estimated blood loss (175.5 ± 214.1 vs. 396.9 ± 514.8 ml, p = 0.021), and shorter hospital stays (10.4 ± 4.6 vs. 13.7 ± 5.8 days, p = 0.008) in LG than OG. Regarding postoperative morbidity, 7 (19.4%) and 10 (25.6%) complications were observed in the LG and OG groups, respectively. There was no difference in complications between the two groups regardless of the CTPs. One patient with a CTPs of C succumbed to hepatic failure following LG. Long-term survival and overall and recurrence-free survival rates did not differ between the two groups. Even in cases with CTPs B, LG with lymph node dissection for gastric cancer patient was safer and acceptable than OG was. Therefore, LG can be considered an alternative surgical approach in gastric cancer with LC.

We report our experience of transumbilical single port laparoscopic surgery (TUSPLS) for multiple concomitant intraabdominal pathologies, and assess the feasibility of this technique with several technical tips.Various combined procedures using TUSPLS were performed since April, 2008. All records of concomitant laparoscopic procedures using TUSPLS were searched at three hospitals.Forty-one patients underwent 82 combined procedures using TUSPLS in a single session. The perioperative outcomes of simultaneously performed cholecystectomy and ovarian cystectomy using TUSPLS (n = 14) are compared with those of using CLS (n = 11). The operating time was significantly longer with the TUSPLS method than with the CLS method. However, postoperative convalescent outcomes such as postoperative hospital stay, VAS pain score, and required analgesics showed no differences between the two methods. Also, there were no significant operative complications associated with the two methods. Fewer trocars were used with the TUSPLS method.Combined laparoscopic procedures for various concomitant pathologies in the abdomen can be performed using transumbilical single port laparoscopic surgery without increasing morbidity or hospital stay in patients with acceptable risk.

Background A transhiatal approach in esophageal cancer surgery has limitation for mediastinal lymph node dissection compared with thransthoracic approach for esophageal cancer. Because of insufficient lymph node clearance, single incision mediastinoscopic surgery is an one of the minimally invasive surgical option for esophageal cancer. Herein, we introduce our initial experience with use of the procedure in 3 patients with esophageal cancer Methods We retrospectively collected data from 3 patients who diagnosed with esophageal cancer and who underwent 3 field transmediastinal radical esophagectomy (TMRE) between Jun 2016 and December 2017. TMRE was performed in old age patients (> 75 years) and patients with limited cardiopulmonary reserve in whom thransthoracic approach could not be used. After the left cervical incision and cervical lymphadenectomy, a single port was inserted into the wound. Esophageal mobilization with en bloc lymphadenectomy along the left and right recurrent laryngeal nerve was then performed. Carbon dioxide insufflation expanded the intramediastinal space, and deep mediastinal structures were clearly visualized, allowing lymphadenectomy to be safely and carefully performed along the nerves. Laparoscopic transhiatal esophagectomy was then performed with en bloc lymphadenectomy for lower and/or middle mediastinal nodes. Results The mean age was 75.5 ± 3.5. Among the 3 patients, two patients had severe cardiopulmonary dysfunction. The mean operation time in transmediastinal approach and transhiatal approach were 202.0 ± 18.0 and 350.0 ± 27.8, respectively. The mean retrieval number of mediastinal lymph node was 39.0 ± 5.3. There were no severe postoperative complications and there was no postoperative mortality. Mild pleural effusion was occurred in only one patient. Conclusion TMRE with single incision mediastinoscopic approach was technically feasible and oncologically safe procedure for esophageal cancer, especially in patients with old age or with limited cardiopulmonary reserve. Disclosure All authors have declared no conflicts of interest.

Background. The aim of this study is to evaluate the incidence of gallstone after gastrectomy, risk factors for gallstone formation, and the surgical outcome of cholecystectomy after gastrectomy.Methods. A total of 2480 gastric cancer patients who underwent curative resection at two institutions between January 1997 and December 2012 were retrospectively reviewed. The patients’ age, gender, diabetes mellitus, type of gastrectomy, extent of node dissection, and type of reconstruction were evaluated.Results. Gallstone formation occurred in 128 of 2480 (5.2%) patients who had undergone gastrectomy for gastric cancer. The incidence of gallstones was significantly higher after total compared with subtotal gastrectomy. Roux-en-Y reconstruction and lymph node dissection in the hepatoduodenal ligament were associated with a significantly higher incidence. In multivariate analysis, diabetes mellitus and reconstruction method were identified as significant risk factors for gallstone development. The proportion of silent stone was higher in the laparoscopic cholecystectomy (LC) group than in the open cholecystectomy (OC) group. Operation time and hospital stay were shorter in the LC group than in the OC group.Conclusions. Diabetes mellitus and Roux-en-Y reconstruction are risk factors for gallstones after gastrectomy. Only a few postoperative complications after subsequent cholecystectomy occurred, even when using a laparoscopic approach.

Delta-shaped anastomosis (DA) is a new Billroth I reconstruction technique using only a laparoscopic linear stapler under a totally laparoscopic approach. The present study compared the outcomes of DA with those of laparoscopic conventional Billroth I anastomosis (cBIA).A total of 138 and 100 patients with gastric cancer who underwent laparoscopic distal gastrectomy with DA and cBIA, respectively, were selected. Clinicopathological data and short- and long-term outcomes were compared between the two groups.The mean operating time in the DA group was similar to that in the cBIA group. Short-term outcomes, such as bowel function recovery, morbidity, and mortality, did not differ between the DA and cBIA groups. There were no significant differences in the 5-year disease-free and overall survival rates between the two groups. All nutritional indices (body weight change, albumin level, transferrin level, and total lymphocyte count) were similar between the two groups with the exception of a few points in the early follow-up period. Endoscopic evaluation using the Residual food, Gastritis, Bile reflux classification revealed relatively better gastritis findings in the DA group despite worse bile reflux for 5 postoperative years. The food amount was significantly larger in the DA group for 2 postoperative years.The outcomes of DA were comparable to those of cBIA. DA is a recommendable reconstruction method, especially in totally laparoscopic distal gastrectomy.

4062Background: Although lots of benefits of laparoscopic gastric cancer surgery have been reported, strong evidences of laparoscopic surgery are still limited, especially in locally advanced gastr...

Gastroduodenostomy (Billroth I) is one of the most common reconstruction methods after distal gastrectomy. The advantage of Billroth I over Billroth II or Roux-en-Y gastrojejunostomy is that the operating time is short, the normal duodenal passage of food is preserved, and the afferent loop syndrome is avoided. According to the Korean nationwide survey performed by the Korean Gastric Cancer Association, Billroth I reconstruction was performed in 55.3% of all distal gastrectomy cases in 2004 [1].

Gastrointestinal leakage is one of the most serious post surgical complications and is a major source of mortality and morbidity. The insertion of a covered self-expandable metal stent could be a treatment option in selected cases. However, it is unclear how long the stent should be retained to achieve complete sealing, and membrane-covered stents have the problem of a high migration rate. We observed four cases of postsurgical leakage following the primary closure of a duodenal perforation, esophagojejunostomy, and esophagogastrostomy, each of which was successfully managed by the temporary placement of covered stents. In all cases, the optimal time of stent removal could be estimated by the markedly decreased amount of drainage, the lack of leakage observed on radiocontrast images, and the endoscopic findings. In this case series, all of the stents could be removed within 7 weeks. For those cases with a high risk of migration, stents with temporary fixations to earlobes and/or partially uncovered proximal flanges were used. These results suggest that the application of a covered stent could be a treatment option for various gastrointestinal leaks after surgery, particularly when the defect cannot be sealed by conservative care and the leakage has good external drainage.

Background To date, published reports have shown an increased length of hospital stay and increased morbidity for patients undergoing simultaneous cholecystectomy during Roux-en-Y gastric bypass (RYGB). We hypothesized that our experience would not show such adverse outcomes. Methods All RYGB procedures (n = 752) performed by 1 surgeon at our institution from 1995 to 2006 were reviewed for demographic data, operative data, and postoperative outcomes. A laparoscopic approach (LRYGB) was used for 438 procedures. The data from a prospectively gathered institutional database were retrospectively compared using standard statistical analysis. Results Comparing LRYGB with cholecystectomy to LRYGB without cholecystectomy, the operative time was significantly longer (198.4 ± 61.9 versus 177.7 ± 57.7 min, P = .001), but the mean hospital stay (3.3 ± 5.5 versus 2.9 ± 6.1 d, P = .555), postoperative complication rate (18.3% versus 18.5%, P = .100), and postoperative mortality (0% and .6%, P = 1.000) were not different between the 2 groups. Comparing the open RYGB patients with and without simultaneous cholecystectomy, the operative time was similarly longer (223.4 ± 63.9 versus 203.5 ± 57.3 min, P = .005), and the mean hospital stay (5.0 ± 3.7 versus 4.7 ± 5.9 d, P = .644), postoperative complication rate (61.4% versus 55.2%, P = .293), and postoperative mortality rate (1.6% versus 2.4%, P = .685) were not different between the 2 groups. Conclusion Although it took, on average, 20 minutes longer, cholecystectomy can be safely added to RYGB without increasing the hospital stay, postoperative morbidity, or mortality in both laparoscopic and open surgery using comparable operative techniques. We recommend routine simultaneous cholecystectomy be performed for patients with documented gallstones during RYGB.

Laparoscopic surgery has been adopted for the treatment of gastric cancer, and many reports have confirmed its favorable outcomes. Most surgeons prefer to laparoscopy-assisted gastrectomy using minilaparotomy rather than totally laparoscopic procedures because of technical difficulties of intracorporeal anastomosis. We conducted this study to compare laparoscopy-assisted distal gastrectomy with totally laparoscopic distal gastrectomy. In addition, laparoscopic procedures were compared with open distal gastrectomy.This prospective, nonrandomized, multicenter study enrolled 60 patients with early gastric cancer at three branch hospitals of our institutes. Twenty-five- to 30-cm-long mid-line incision, 5-cm midline or transverse incision, and 3-cm U-shaped incision were used in open distal gastrectomy, laparoscopy-assisted distal gastrectomy, and totally laparoscopic distal gastrectomy, respectively. Postoperative outcomes, immunologic changes, and operation-related costs were compared between the three groups.There was no difference in gender, mean age, body mass index, and tumor characteristics between the three groups. No operation-related death occurred. Estimated blood loss, number of additional analgesics use, first flatus, and soft meal diet time were significantly different between the three groups (P0.05). In totally laparoscopic distal gastrectomy, the time to first flatus was significantly shorter than laparoscopy-assisted distal gastrectomy (3.7 vs. 2.8 days, in laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy, respectively, P0.05). White blood cell count and C-reactive protein level at postoperative day 1 were significantly higher in open distal gastrectomy than the other groups; however, there was no difference between laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy. The operation-related costs were significantly greater in totally laparoscopic distal gastrectomy (P0.05).Although totally laparoscopic distal gastrectomy needs more cost, totally laparoscopic distal gastrectomy provides shorter bowel recovery time than laparoscopy-assisted distal gastrectomy.

We analyzed our preliminary clinical data for totally laparoscopic gastrectomy (TLG) in order to evaluate its effectiveness in terms of minimal invasiveness, technical feasibility, and safety. Forty-five consecutive patients who underwent TLG in our institution between June 2004 and February 2006 were enrolled in this study. There were 26 men and 19 women, with a mean age of 58.8 years and a mean body mass index (BMI) of 23.2. In all cases, only laparoscopic linear staplers were used for intracorporeal anastomosis. The reasons that gastrectomy was performed were adenocarcinoma in 41 cases, benign disease in three cases and gastrointestinal stromal tumor in one case, and the types of surgery were distal gastrectomy (40), total gastrectomy (four) and pylorus-preserving gastrectomy (one). Among the distal gastrectomies, Billroth I (25) was the most frequent procedure, followed by uncut Roux-en-Y gastrojejunostomy (14) and Billroth II (one), respectively. The mean operation time was 314 minutes, the mean anastomotic time was 41 minutes, the mean number of staples used was eight, and the mean estimated blood loss was 150 ml. There was no case of conversion to an open procedure. The first flatus was observed at 2.9 days, and liquid diet was started at 3.7 days. The mean number of postoperative analgesic use, except for patient-controlled analgesia (PCA), was 1.4 times, and the mean postoperative hospital stay was 11 days. Postoperative complication occurred in six patients (13.3 %), but no postoperative mortality occurred. There were two cases of delayed gastric empting and one case of anastomotic leakage, anastomotic stenosis, intraabdominal bleeding, and ventral hernia each. All of the patients recovered well with conservative or surgical management. TLG with intracorporeal anastomosis using laparoscopic linear staplers was safe and feasible, and we were able to obtain acceptable surgical outcomes in terms of minimal invasiveness.

Staging laparoscopy has been shown to be useful for increasing the accuracy of preoperative staging. However, controversy still exists regarding patient selection and subsequent treatment. The aim of this study was to determine the role of staging laparoscopy for a group that has a policy to perform aggressive surgery for advanced gastric cancer. Twenty-four patients with clinical T3 or T4 gastric cancer expected to undergo curative resection, based on conventional preoperative diagnostic methods underwent staging laparoscopy. We examined the accuracy and the impact of staging laparoscopy on the further treatment options. The mean running time for the staging laparoscopy was 40.7 min (range: 25–75 min), and one complication was noted (4.2%). In regard to the tumor depth, 11 of 24 (45.8%) cases had a discrepancy after staging laparoscopy. In addition, 15 of 24 patients (62.5%) were found to have unsuspected peritoneal metastases, and 8 patients (33.3%) were excluded from laparotomy. The remaining 16 patients (66.7%), including 9 patients with localized peritoneal metastases (P1), underwent resection. The diagnostic accuracy for T factor was 81.3% in 16 laparotomy cases and overall accuracy of P factor was 91.7%. Staging laparoscopy had a significant impact on decisions regarding the treatment plan in patients with advanced gastric cancer for a group that has an aggressive treatment strategy.

120 Background: Endoscopic submucosal dissection (ESD) is now accepted as an alternative to surgery for the treatment of early gastric cancer (EGC). However, long-term clinical outcome of ESD for EGC compared to surgical resection has not been evaluated. The aim of this study is to evaluate the clinical outcome of ESD for EGC compared to surgical resection. Methods: A retrospective analysis was performed in 152 patients who underwent ESD or surgical resection for EGC according to Gotoda’s extended criteria from 2006 and 2008 in Incheon St. Mary’s Hospital and Seoul St. Mary’s Hospital, The Catholic University of Korea. Overall survival and recurrence rates were compared between the two groups. Results: A total of 56 patients underwent surgical gastrectomy and 96 patients underwent ESD. The medial follow-up was 76 months in surgical resection group and 71 months in ESD group. Metachronous recurrences including dysplasia were found in 9 patients in ESD group and none in surgical resection group (P=0.001). There was no significant difference between the groups in overall survival. Conclusions: Gotoda’s extended criteria for ESD might be acceptable for the treatment of EGC considering the oval survival. However, meticulous surveillance program should be established because metachronous recurrence is more common after ESD.

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis of the esophageal body and failure of relaxation of the lower esophageal sphincter, which is caused by loss of ganglionic cells of myenteric plexus. Medical therapy is usually ineffective and pneumatic dilation and esophagocardiomyotomy are known to be the treatment of choice. In the past, pneumatic dilation was preferred because of the invasiveness of myotomy even though, the posttreatment outcome was better in myotomy than in pneumatic dilation. However, after introduction of minimally invasive surgery for myotomy, such preference is moving towards myotomy. In this article, current trends of minimally invasive surgery in the treatment of achalasia and the surgical outcome of minimally invasive myotomy in comparison with that of pneumatic dilation are reviewed. (Korean J Helicobacter Up Gastrointest Res 2014;14:87-90)

Purpose: In the early 1990’s laparoscopic hernioplasty gained popularity worldwide. Thereafter, laparoscopic surgeons have attempted to improve cosmesis using single port surgery. This study aims to introduce and assess the safety and feasibility of single port laparoscopic total extraperitoneal (TEP) hernia repair with a nearly-scarless umbilical incision. Methods: Sixty three single port laparoscopic TEP hernia repairs were performed in sixty patients from June 2010 to March 2011 at Incheon St. Mary’s Hospital, with the use of a glove single-port device and standard laparoscopic instruments. Demographic and clinical data, intraoperative findings, and postoperative course were reviewed. Results: Of the 63 hernias treated, 31 were right inguinal hernias, 26 were left inguinal hernias and 3 were both inguinal hernias. There was one conversion to conventional three port laparoscopic transabdominal preperitoneal hernioplasty. Mean operative time was 62 minutes (range, 32 to 150 minutes). There were no intraoperative complications. Postoperative complications occurred in two cases (wound seroma and urinary retension) and were successfully treated conservatively. Mean hospital stay was 2.15 days. Conclusion: Single port laparoscopic TEP hernia repair is safe and feasible. Umbilical incision provides an excellent cosmetic outcome. Prospective randomized studies comparing single port and conventional three port laparoscopic TEP repairs with short-term outcome and long-term recurrence rate are needed for confirmation.

Bezoars are retained concretions of undigested animal or vegetable material that can produce gastrointestinal obstruction, ulceration, and bleeding. Therapeutic options for gastric bezoars include enzyme therapy (papain, cellulase, or acetylcysteine), endoscopic disruption and removal, and surgical removal. Multiple large gastric bezoars generally require conventional surgical management through an upper abdominal incision. With the recent improvement of laparoscopy, a lot of portions of abdominal operations have been performed laparoscopically. We successfully removed multiple large gastric phytobezoars in a 52-year-old female completely through laparoscopy. This supported the feasibility of laparoscopic surgery for patients with gastric bezoars.

Purpose: In Korea, the number of laparoscopy-assisted distal gastrectomies for early gastric cancer patients has been on the increase. Although minimally invasive surgery is more beneficial, no reported case of a total laparoscopic gastrectomy has been reported because of difficulty with intracorporeal anastomosis. This study attempts, through our experience, to determine the safety and feasibility of a total laparoscopic gastrectomy with various types of intracorporeal anastomosis using laparoscopic linears stapler in treating early gastric carcinomas. Materials and Methods: We investigated the surgical results and clinicopatholgical characteristics of 81 patients that underwent a totally laparoscopic distal gastrectomy at our department between June 2004 and May 2007. The intracorporeal anastomoses were performed by using laparoscopic linear staplers. Results: The mean operative time was 287 minutes, the mean anastomotic time was 40 minutes, and the mean number of laparoscopic linear staplers used for an operation was 7.5. The mean time to the first flatus, the first food intake, and discharge from hospital was 2.9, 3.6, and 10.3 days respectively. There were 11 cases of postoperative complications, but no case of postoperative mortality or conversion to an open procedure. In 75 patients with an adenocarcinoma, the mean number of lymph nodes harvested was 38.1 and the stage distribution was as follows: stage I, 72 patients; stage II, 2 patients; stage IV, 1 patient. During the mean follow-up period of 14 months, 5 patients died of other causes and there were no cases of cancer recurrence. Conclusion: A total laparoscopic gastrectomy with intracorporeal anastomosis by using a laparoscopic linear stapler was found to be safe and feasible. We were able to obtain acceptable surgical outcomes in terms of minimal invasiveness.

Purpose: Routine pancreatico-splenectomy with total gastrectomy should no longer be considered as the standard surgical procedure for gastric cancer because of the lack of proven surgical benefit for survival. The aim of this study is to evaluate the clinicopathologic factors and the survival of patients with locally advanced gastric cancer and they had undergone combined pancreatico-splenectomy with a curative intent. Material and Methods: We retrospectively reviewed a total of 118 patients who had undergone total gastrectomy with distal pancreatico-splenectomy from 1990 to 2001. The patients were divided into 2 groups: 90 patients who were free from cancer invasion (group I), and 28 patients with histologically proven cancer invasion into the pancreas (group II). The various clinicopathologic factors that were presumed to influence survival and the survival rates were analyzed. Results: The rate of pathological pancreatic invasion was 23.7%. The tumor stage, depth of invasion, pancreas invasion, lymph node metastasis, lymph node ratio, curability and the hepatic and peritoneal metastasis were statistically significance on univariate analysis. Among these factors, the tumor stage, lymph node ratio and curability were found to be independent prognostic factor on multivariate analysis. The 5-years survival rates were 36.2% for group I and 13.9% for group II. The morbidity rate was 22.1%, and this included pancreatic fistula (5.1%), intra-abdominal abscess (4.2%) and bleeding (4.2%). The overall mortality rate was 0.8%. Conclusion: Combined distal pancreatico-splenectomy with total gastrectomy with a curative intent was selectively indicated for those patients with visible tumor invasion to the pancreas, a difficult complete lymph node dissection around the distal pancreas and spleen, and no evidence of liver metastasis or peritoneal dissemination.

Purpose: An uncut Roux-en-Y gastrojejunostomy has been known to be effective in preventing bile reflux gastritis in the remnant stomach and the Roux stasis syndrome. Materials and Methods: To evaluate the usefulness of a totally laparoscopic uncut Roux-en-Y gastrojejunostomy (TLuRYGJ) after a distal gastrectomy, we reviewed the medical records of 19 consecutive patients that underwent a TLuRYGJ at our institution, and 11 consecutive patients who underwent a totally laparoscopic Billroth I gastrectomy (TLB-I) during the same period. Results: Postoperative gastrointestinal symptoms related to the postgastrectomy syndrome and the Visick classification at six months after surgery were not different in the two groups; however, there was no case of symptomatic bile reflux gastritis and only one case of delayed gastric empting, for which medication was required, in the TLuRYGJ group. The endoscopic findings of the remnant stomach for bile reflux gastritis at six months after surgery were better in the TLuRYGJ group than in the TLB-I group. Conclusion: A TLuRYGJ was found to be effective in preventing bile reflux gastritis and the Roux stasis syndrome.

Purpose: Bone metastasis is not a common event in patients with gastric cancer. Therefore, most studies of bone metastasis in such patients have been in the form of case reports, so the clinical features of the bone metastasis are not well understood. To clarify metastatic patterns, the efficacy of radiation or chemotherapy, and the prognosis, we analyzed 29 cases of patients with bone metastases after curative surgery for gastric cancer. Materials and Methods: Twenty-nine (29) gastric cancer patients with bone metastasis who underwent curative resection from January 1989 to December 2002 at the Departments of Surgery, Kangnam St. Mary's Hospital and Our Lady of Mercy's Hospital, The Catholic University of Korea, were analyzed. Results: Nineteen (19) patients were males and, 10 patients were females. The mean age of the patients was years. There were more Borrmann type-3 and type-4 cancers and more undifferentiated histologic types. Most of the original cancers were stage III or IV. The most frequently involved bone was the spine. Treatment after recurrence was done in 16 patients (). The median survival time after recurrence of the patients who received treatment was seven (7) months ( months in range), which was significantly longer than that of the patients who did not received treatment (P=0.019). However, there was no difference according to the treatment modality (P=0.388). Conclusion: Bone metastasis after a curative resection of gastric cancer tends to occur in Borrmann type-3 and type-4 cancers, cancers with undifferentiated histology and, in stage III/IV disease. The prognosis of bone metastasis is dismal, and aggressive treatment is the only way to prolong survival.

Purpose: In Korea, the number of laparoscopy-assisted distal gastrectomies for early gastric cancer patients has been increasing lately. Although minimally invasive surgery is more beneficial, no reported case of a totally laparoscopic distal gastrectomy has been reported because of difficulty with intracorporeal anastomosis. This study attempts, through our experiences, to determine the feasibility of a totally laparoscopic distal gastrectomy using an intracorporeal gastroduodenostomy in treating early gastric carcinoma. Materials and Methods: We investigated surgical results and clinicopatholgic characteristics of eight(8) patients with an early gastric carcinoma who underwent a totally laparoscopic distal gastrectomy at the Department of Surgery, Our Lady of Mercy Hospital, The Catholic University of Korea, between June 2004 and September 2004. The intracorporeal gastroduodenostomy was performed with a delta-shaped ananstomosis by using only laparoscopic linear staplers (Endocutter 45mm; Ethicon Endosurgery, OH, USA). Results: The operative time was minutes (range minutes), and the anastomotic time was minutes (range minutes). The anastomotic time was shortened as surgical experience was gained. The number of laparoscopic linear staplers for an operation was . The number of lymph nodes harvested was . There was 1 case of transfusion and no case of conversion to an open procedure. The time to the first flatus was 2.80.5 days, and the time to the first food intake was days. There were no early postoperative complications, and the postoperative hospital stay was days. Conclusion: A totally laparoscopic distal gastrectomy using an intracorporeal gastroduodenostomy with a delta-shaped anastomosis is technically feasible and can maximize the benefit of laparoscopic surgery for early gastric cancer.

Purpose: This study was designed to explore quality of life (QOL) in patients with stomach cancer by using the World Health Organization Quality of Life (WHOQOL) Instrument- Korean version. Materials and Methods: Thirty-one (31) patients with stomach cancer after curative resection were recruited with informed consent. Age- and gender-matched hospital staff served as controls. The 100-item WHOQOL Instrument, including physical domain, psychological domain, social domain, independence domain, environment domain, and spiritual domain, was employed for the all subjects. Results: In patients with stomach cancer after operation, only two domains, physical and independence, were associated with worse quality of life. In those domains, patients with advanced stage, with total gastrectomy, with adjuvant chemotherapy, and early or late postoperative period (2 years or >5 years after operation), could be perceived of having a worse quality of life. Conclusion: Not only scientific objective success but also individual subjective perception of condition could be important for managing patients with stomach carcinomas after curative resection. In this context, the WHOQOL reflecting multi-dimensional state of well being could be a useful tool across a variety of cultural and value systems in the world.