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Peritoneal metastasis (PM) remains a major obstacle in the treatment of stage IV gastric cancer. This is a dose-escalation study of intraperitoneal (IP) paclitaxel combined with intravenous (IV) fluorouracil, leucovorin, and oxaliplatin (FOLFOX) to determine the recommended phase II dose in gastric cancer patients.Patients with gastric adenocarcinoma and PM were enrolled. The recommended phase II dose of IP paclitaxel was determined using the standard "3 + 3" dose escalation with planned doses ranging from 40 to 100 mg/mAmong the 13 patients, there was no DLT at 40 and 60 mg/mThe biweekly regimen of IP paclitaxel and FOLFOX is safe and the recommended dose of IP paclitaxel for a phase II trial is 60 mg/m

Background. The optimal type of anastomosis after proximal gastrectomy (PG) is still controversial. A novel technique termed “double-flap” esophagogastrostomy (EG) has been introduced. The application of this technique after PG is reported to have little gastroesophageal reflux without the need of creating an esophagojejunostomy. However, this procedure is technically challenging and hence difficult to apply in laparoscopic PG. This technical report describes in detail how to perform single-incision proximal gastrectomy (SIPG) with double-flap EG with the use of novel laparoscopic instruments. Methods. Two patients diagnosed with early gastric cancer underwent SIPG. A 2.5 cm incision was made, and a scope holder was used in place of a scopist. After performing PG with D1+ lymphadenectomy, double seromuscular flaps were created on the anterior wall of the stomach. After tagging the esophagus to the inferior edge of the flap window, the stomach and esophagus were opened through electrocautery. EG was performed intracorporeally using continuous barbed sutures, and the flap is then secured to the anastomosis. To facilitate this procedure, an intra-abdominal organ retractor and an articulating needle holder were used. The supplementary video illustrates in detail how these devices are used to perform the technique. Results. Total operation times were 190 and 110 minutes each, and anastomosis took 75 and 46 minutes each. Patients had no complications and were both discharged on postoperative day 6. Conclusion. Double-flap PG is technically feasible through a single incision with the use of articulating laparoscopic devices and intra-abdominal organ retractors to assist in intracorporeal anastomosis.

There are currently no reports on the application of three-dimensional (3D) vision to single-incision laparoscopic surgery. This study compared 3D vision to the previous two-dimensional (2D) system in single-incision laparoscopic distal gastrectomy (SIDG). Medical charts of 179 gastric cancer patients who underwent SIDG from February 2014 to December 2017 were retrospectively reviewed. Patients were grouped into either a 2D group or 3D group depending on the type of camera that was used. All operations were performed using a flexible camera (Olympus, Japan). Operative data and postoperative outcome were analyzed. There were 90 patients in the 2D group and 89 patients in the 3D group. No differences were found in terms of the age, body mass index, staging, and other demographics of the patients. Operative time was significantly faster in the 3D group (115.6 ± 34.0 vs. 129.4 ± 38.5 min, p = 0.012), and estimated blood loss (EBL) was less in the 3D group (20.7 ± 30.0 vs. 35.1 ± 56.0 ml, p = 0.034). Patients in the 3D group were able to start a small fluid diet earlier (2.5, range 1–6 vs. 3.0, range 2–8 postoperative days, p = 0.006) and were discharged faster (5.4, range 3–12 vs. 6.2, range 4–24 postoperative days, p = 0.024). There was no statistical difference between early and late complications. The use of the 3D camera shortened operative time with possible clinical benefits for patients undergoing SIDG.

Due to the technological advance in resolution and stereoscopic depth, the 3-dimensional (3D) laparoscopic system has been widely used in real surgery. However, there have been few studies to confirm the clinical usefulness of the 3D laparoscopic distal gastrectomy (LDG). This study aimed to compare perioperative outcomes between the 2-dimensional (2D) and 3D LDG for gastric cancer patients. This was a prospective, randomized controlled, single-center, and superiority trial. This study was carried in Seoul National University Bundang Hospital. Patients with histologically confirmed gastric adenocarcinoma which could be radically resected by LDG were randomly assigned (1:1) to the 2D or 3D group. From October 2016 to August 2018, 84 patients were included in this study and randomly assigned into the 2D group (44 patients) or the 3D group (40 patients). A total of 5 patients were excluded; 3 in the 2D group and 2 were in the 3D group. Consequently, the data from 79 patients were analyzed (2D: 41 cases; 3D: 38 cases). For the LDG procedure, 3D and 2D camera and display system were applied according to the assigned group. The primary end point was the duration of total laparoscopic operation time. Secondary end points included the amount of intraoperative blood loss (IBL), the number of harvested lymph nodes, postoperative complications and open conversion rate. There were no differences between 2 and 3D groups with respect to clinicopathologic characteristics. The total operation time in 3D groups was significantly shorter than 2D group (122 [106.5–161] versus 101 [77.75–125.5] minutes; P = 0.001). The postoperative complication rates in the 3D groups was significantly lower than 2D group (24.4% versus 7.9%, respectively; P = 0.045). 3D LDG shorten the operation time compared with 2D LDG in gastric cancer patients. And 3D laparoscopy provided the benefit of less postoperative complications. cris.nih.go.kr number KCT0003717

The standard recommended treatment of stage IV gastric cancer is palliative chemotherapy. The aim of this study is to evaluate the role of radical gastrectomy with metastasectomy in these patients, as well as to explore the feasibility and safety of a laparoscopic approach. 117 consecutive patients with pathologically proven Stage IV gastric cancer who underwent radical gastrectomy with metastasectomy were enrolled in this study. We evaluated short-term and long-term outcomes, comparing laparoscopic surgery with open surgery by propensity score matching. The 5-year overall survival rate (OSR) was 23.2% and the median survival time (MST) was 19.8 months. After propensity scoring matching, the 5-year OSR and MST of laparoscopy group was 23.4%, 17.9 months and in the open group, it was 25.0%, 22.8 months (p = 0.882). The complication rate was 5.6% in the laparoscopy group and 23.4% in the open group (p = 0.069). In multivariate analysis, adjuvant chemotherapy, chemotherapy cycle, and postoperative complication were independent prognostic factors of overall survival. Radical gastrectomy with metastasectomy could have a potential role in stage IV gastric cancer. Laparoscopic gastrectomy with metastasectomy in selected stage IV gastric cancer patients is safe and feasible.

Although laparoscopic surgery had been performed in clinical practice for over 30 years, there has not been much improvement on instruments. Several articulating laparoscopic instruments have been developed including the robotic system. A new multi-degree of freedom (DOF) articulating laparoscopic device has been developed. We compared the ability to perform challenging sutures between the new device and the robotic system.Five experienced surgeons with over 100 laparoscopic surgery cases performed the suture task with both instruments. Everyone was new at articulating instruments including a robotic system. The suturing task consisted of two vertical sutures, downward and upward vertical direction. The duration of needle grabbing, first surgical tie, square tie, and the final reverse tie was measured.When doing the downward suture, the median time to complete the suture was 127 vs. 136 seconds for ArtiSentialBoth instruments performed the suturing tasks with no difference in duration. ArtiSential

The standard treatment for gastric subepithelial tumor (SET) is surgical resection, which is primarily performed via laparoscopy. The aims of this study were firstly to evaluate factors influencing morbidity and hospitalization after treatment of gastric SET, and secondly, to figure out the factors how to make shorter hospitalization with equal safety.We retrospectively enrolled 229 consecutive patients who underwent laparoscopic gastric wedge resection (LGWR) for gastric SET between August 2003 and December 2015. Patients were divided into two groups: the 3 days or less hospitalization group (N=82, group A) and the greater than 3 days hospitalization group (N=147, group B).Median tumor size was 3.0 cm (range, 0.2~13.0 cm) and mean postoperative hospitalization was 4.27±2.15 days. There were 6 complications (2.6%), with no cases of mortality. In group A, tumors were smaller (3.0±1.1 cm vs. 3.6±1.9 cm,We could reduce the hospitalization of patients with gastric SET less than 5cm sized and located on other than the posterior wall within 3days. Those patients could be a candidate for day surgery.

This report discusses the technique of solo single-incision pylorus-preserving gastrectomy (SIPPG) for early gastric cancer. To overcome difficulties regarding lymph node dissection (LND), a scope holder and an energy device were used, allowing fine dissection in a fixed field of view. The overlap gastro-gastrostomy technique was used for anastomosis. Seventeen patients underwent solo SIPGG. The mean operation time was 150.1 ± 28.7 min, and no patients developed postoperative complications or delayed gastric emptying within 30 days of the operation. Using scope holders and performing fine dissection with the energy device, challenges regarding LND in SIPPG can be overcome. INTACT anastomosis was initially used; however, due to its inconsistency and the high degree of surgical skill required, it was changed to the overlap method. Solo SIPPG with overlap gastro-gastrostomy may be safe and feasible with good cosmetic results and fast patient recovery.

Oncometabolic surgery (OS) is a modification of the Roux-en Y reconstruction method, in which the lengths of the biliopancreatic and Roux limbs are longer than that with conventional surgery (CS). Although OS is performed to improve postoperative glycemic control in gastric cancer patients with type 2 diabetes mellitus (T2DM), its postoperative nutritional safety has not been clarified. This prospective pilot study evaluated the safety and feasibility of OS in early gastric cancer patients. This study evaluated 20 patients with clinical T1N0 stage and preoperative body mass index (BMI) ≥ 32.5 kg/m2, or ≥ 27.5 kg/m2 with comorbidities, who underwent OS. Primary outcomes were cumulative incidences of anemia and deficiencies in iron and vitamin B12 after 1 year. The outcomes were compared to those of a matched historical control group. The cumulative incidences of anemia (15.0% vs. 10.0%, P = 0.99), iron deficiency (15.0% vs. 10.0%, P = 0.99), and vitamin B12 deficiency (10.0% vs. 0%, P = 0.47) did not differ significantly in the OS and CS groups. However, median vitamin B12 concentration tended to be lower (395.8 vs. 493.7 pg/mL, P = 0.06) and reductions in vitamin B12 concentration tended to be greater (174.7 vs. 123.0 pg/mL, P = 0.07) in the OS group. BMI loss was similar in the two groups (2.9 vs. 2.8 kg/m2, P = 0.80). Remission rates of hypertension (68.8% vs. 41.2%, P = 0.22) and T2DM (77.8% vs. 50.0%, P = 0.58) were higher in the OS group. Nutritional parameters did not differ significantly in the OS and CS groups. Vitamin B12 levels should be carefully monitored after OS.

To investigate the quality of life (QOL) of patients after laparoscopic sentinel node navigation surgery (SNNS) compared to conventional laparoscopy-assisted distal gastrectomy (LADG) in early gastric cancer patients. Patients recruited for laparoscopic SNNS surgery between July 2010 and April 2013 were assessed for their QOL. A historical control group was established, consisting of patients who underwent conventional LADG with radical lymphadenectomy from the same institution. QOL questionnaire was taken serially from preoperative week 1 until 12 months postoperatively (1, 3, 6, and 12 months) using the Korean version of the European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaire-core (QLQ-C30) and gastric cancer-specific questionnaire (STO22). A total of 80 prospectively gathered patients who received SNNS were categorized into the comparison group (SNNS group). The QOL was compared with 78 patients identified to have received LADG from the gastric cancer database of our institution and were sorted into the control group (LADG group). In QLQ-C30, SNNS group showed better functioning scales in all except role functioning and better scores from the symptom scales in fatigue, insomnia, and diarrhea compared to the LADG group. In QLQ-STO22, scores on dysphagia, eating restriction, anxiety, and body image disturbance were better in SNNS group. Postoperative QOL in laparoscopic gastrectomy combined with SNNS is superior compared to conventional laparoscopic distal gastrectomy in patients with stage I gastric cancer.

Introduction: There is a dearth of literature on frailty specifically in elderly (aged ≥65 years) gastric cancer patients undergoing gastrectomy. We aim to assess the effects of frailty on postoperative outcomes. Methods: A review of a prospective database was performed from November 2011 to April 2019. Frailty was assessed by multidimensional frailty score (MFS). Outcomes assessed were early postoperative complications and mortality, and length of stay. Results: 289 patients were included. The mean age was 77.3 (range 66–94) years. 183 (63.3%) were males and 172 (59.5%) had early cancer. 275 (95.2%) underwent minimally invasive gastrectomy. 79 (27.3%) patients suffered early postoperative complications, with 47 (16.3%) suffering from Clavien-Dindo grade ≥2 complications. One-year, 90-day, 30-day, and inhospital mortality were 6.6, 1.4, 0.7, and 0%, respectively. 111 (38.4%) of patients were classified as “frail” based on MFS > 5. “Frail” patients were associated with higher 1-year mortality (odds ratio (OR) 4.51, 95% CI 1.57–12.98, p = 0.005) on univariate analysis. On multivariate analysis, “frail” patients did not have significantly increased 1-year mortality. However, when definition of “frail” was changed from MFS > 5 to MFS > 6, frailty was significantly associated with increased 1-year mortality (OR 3.73, 95% CI 1.11–12.53, p = 0.033). Conclusions: Elderly gastric cancer patients undergoing gastrectomy with MFS > 5 do not have increased mortality risk. The influence of frailty on postoperative outcomes may vary based on the risk of the surgical procedure.

Atherosclerotic lesions in the abdominal aorta or its major branches are often incidentally detected on abdominal CT. However, clinical implications and optimal subsequent management are mostly left undetermined.Consecutive, asymptomatic adults (age≥30) who underwent both abdominal CT and coronary computed tomography angiography as part of a self-referred health check-up were investigated (n = 1494).Adjusted for cardiovascular risk factors, abdominal atherosclerotic lesions with stenosis25% were associated with significant coronary stenosis, especially in the abdominal aorta (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 0.99-11.45) and any common iliac artery (aOR 2.99, 95% CI 1.43-6.26). The association was higher in atherosclerotic lesions with stenosis≥25%, respectively (aOR 16.39, 95% CI 4.00-67.11; aOR 7.32, 95% CI 2.84-18.86). Furthermore, any major abdominal artery stenosis added predictive value to significant coronary stenosis (area under the receiver operating curve: 0.7598 vs. 0.8019, P 0.001). The extent of arterial territory involvement was associated with the presence of significant coronary stenoses (P for trend0.001).Stenotic atherosclerotic lesions in the abdominal aorta or its major branches incidentally detected on abdominal CT are relatively prevalent and carry high risk for asymptomatic coronary arterial disease.

309 Background: Peritoneal metastasis (PM) still remains a major obstacle in the treatment of stage IV gastric cancer. This study was designed as a dose-escalation study of intraperitoneal (IP) paclitaxel combined with intravenous (IV) fluorouracil, leucovorin, and oxaliplatin (FOLFOX) to determine the recommended phase II dose in gastric cancer patients. Methods: Patients with gastric adenocarcinoma with PM were enrolled. Peritoneal cancer index (PCI) score was evaluated, and IP + IV chemoport insertion was done. The initial dose of IP paclitaxel was 40mg/m2, then stepped up to 60 then 80mg/m2. Target dose was 100mg/m2. IV FOLFOX was administered on the same day (oxaliplatin 100mg/m2, leucovorin 100mg/m2, fluorouracil 2400mg/m2). Dose limiting toxicity (DLT) was defined as leukopenia ≥ grade 4, thrombocytopenia ≥ grade 3, febrile neutropenia ≥ grade 3, and other nonhematologic toxicity ≥ grade 3. Results: Fifteen patients were enrolled, and two patients were dropped due to patient consent withdrawal. There was no DLT at 40 and 60mg/m2 doses. Two patients had grade 3 febrile neutropenia at dose 80mg/m2, and thus the final recommended phase II dose was 60mg/m2. Other patients underwent IP paclitaxel and FOLFOX without serious adverse events. Seven patients underwent second-look diagnostic laparoscopy, and the average change in PCI score was -5.6 ± 9.3. Four patients received gastrectomy, and the ascites conversion rate was 4/5 (80%). Median survival time was 16.6 months (95% CI, 7.2 – N/A). Conclusions: The biweekly regimen of IP paclitaxel and FOLFOX is safe and the recommended dose for a phase II trial is 60mg/m2. Clinical trial information: NCT03618758.

There are currently no reports on the application of three-dimensional (3D) vision to single-incision laparoscopic surgery. This study compared 3D vision to the previous two-dimensional (2D) system in single-incision laparoscopic distal gastrectomy (SIDG).Medical charts of 179 gastric cancer patients who underwent SIDG from February 2014 to December 2017 were retrospectively reviewed. Patients were grouped into either a 2D group or 3D group depending on the type of camera that was used. All operations were performed using a flexible camera (Olympus, Japan). Operative data and postoperative outcome were analyzed.There were 90 patients in the 2D group and 89 patients in the 3D group. No differences were found in terms of the age, body mass index, staging, and other demographics of the patients. Operative time was significantly faster in the 3D group (115.6 ± 34.0 vs. 129.4 ± 38.5 min, p = 0.012), and estimated blood loss (EBL) was less in the 3D group (20.7 ± 30.0 vs. 35.1 ± 56.0 ml, p = 0.034). Patients in the 3D group were able to start a small fluid diet earlier (2.5, range 1-6 vs. 3.0, range 2-8 postoperative days, p = 0.006) and were discharged faster (5.4, range 3-12 vs. 6.2, range 4-24 postoperative days, p = 0.024). There was no statistical difference between early and late complications.The use of the 3D camera shortened operative time with possible clinical benefits for patients undergoing SIDG.

Due to the technological advance in resolution and stereoscopic depth, the 3-dimensional (3D) laparoscopic system has been widely used in real surgery. However, there have been few studies to confirm the clinical usefulness of the 3D laparoscopic distal gastrectomy (LDG). This study aimed to compare perioperative outcomes between the 2-dimensional (2D) and 3D LDG for gastric cancer patients.This was a prospective, randomized controlled, single-center, and superiority trial. This study was carried in Seoul National University Bundang Hospital. Patients with histologically confirmed gastric adenocarcinoma which could be radically resected by LDG were randomly assigned (1:1) to the 2D or 3D group. From October 2016 to August 2018, 84 patients were included in this study and randomly assigned into the 2D group (44 patients) or the 3D group (40 patients). A total of 5 patients were excluded; 3 in the 2D group and 2 were in the 3D group. Consequently, the data from 79 patients were analyzed (2D: 41 cases; 3D: 38 cases). For the LDG procedure, 3D and 2D camera and display system were applied according to the assigned group. The primary end point was the duration of total laparoscopic operation time. Secondary end points included the amount of intraoperative blood loss (IBL), the number of harvested lymph nodes, postoperative complications and open conversion rate.There were no differences between 2 and 3D groups with respect to clinicopathologic characteristics. The total operation time in 3D groups was significantly shorter than 2D group (122 [106.5-161] versus 101 [77.75-125.5] minutes; P = 0.001). The postoperative complication rates in the 3D groups was significantly lower than 2D group (24.4% versus 7.9%, respectively; P = 0.045).3D LDG shorten the operation time compared with 2D LDG in gastric cancer patients. And 3D laparoscopy provided the benefit of less postoperative complications.cris.nih.go.kr number KCT0003717.

Laparoscopic gastrectomy (LG) is now a widely accepted treatment option for gastric cancer. However, there is insufficient evidence for LG for advanced gastric cancer (AGC). Many retrospective studies have shown that LG for AGC is safe and feasible, but very few studies have shown the actual outcome in general practice. The aim of this study is to analyze our last 15 years of experience in LG for AGC. This is a retrospective review from May 2003 to May 2017 in Seoul National University Bundang Hospital. A total of 1592 patients who had LG for AGC were enrolled of which 109 patients with open conversion were excluded. We evaluated the short-term and long-term oncologic outcomes of LG for AGC. A total of 1483 patients were analyzed. There were 432 cases of total gastrectomy, 982 cases of distal gastrectomy, and 69 cases of proximal gastrectomy. The total complication rate was 9.1% (135/1483), which included wound-related complications (0.7%), postoperative bleeding (0.5%), anastomosis or stump leakage (2.2%), intestinal obstruction (0.9%), pancreatic fistula (0.1%), intra-abdominal abscess (1.6%), and lung morbidity (3.0%). The rate of Clavien-Dindo grade 3 and above complications was 4.9%. Age was the only significant risk factor in multivariate analysis (OR 1.02; 95% CI, 1.01–1.04, P = 0.01). 5-year overall survival stratified by stage was as follows: stage IB 88.9%, stage IIA 88.7%, stage IIB 84.2%, stage IIIA 71.7%, stage IIIB 56.8%, stage IIIC 45.4%, and stage IV 25%. Total recurrence rate was 14.4%, which included local recurrence (1.1%) and distant metastases (13.3%). During our 15 years of experience, we have successfully performed 1483 cases of AGC with laparoscopy. Our results showed short-term and long-term oncologic outcomes that were comparable with other studies. LG is safe and feasible in general practice for advanced gastric cancer when performed by experienced surgeons.

The standard recommended treatment of stage IV gastric cancer is palliative chemotherapy. The aim of this study is to evaluate the role of radical gastrectomy with metastasectomy in these patients, as well as to explore the feasibility and safety of a laparoscopic approach.117 consecutive patients with pathologically proven Stage IV gastric cancer who underwent radical gastrectomy with metastasectomy were enrolled in this study. We evaluated short-term and long-term outcomes, comparing laparoscopic surgery with open surgery by propensity score matching.The 5-year overall survival rate (OSR) was 23.2% and the median survival time (MST) was 19.8 months. After propensity scoring matching, the 5-year OSR and MST of laparoscopy group was 23.4%, 17.9 months and in the open group, it was 25.0%, 22.8 months (p = 0.882). The complication rate was 5.6% in the laparoscopy group and 23.4% in the open group (p = 0.069). In multivariate analysis, adjuvant chemotherapy, chemotherapy cycle, and postoperative complication were independent prognostic factors of overall survival.Radical gastrectomy with metastasectomy could have a potential role in stage IV gastric cancer. Laparoscopic gastrectomy with metastasectomy in selected stage IV gastric cancer patients is safe and feasible.

Purpose Single-incision laparoscopic distal gastrectomy (SIDG) requires experienced camera operators for a stable image. Since it is difficult for skilled camera operators to participate in all SIDG, we began performing solo surgery using mechanical camera holders. We aimed to compare the short-term outcomes and cost between solo SIDG and conventional multiport laparoscopic distal gastrectomy (MLDG) for early gastric cancer (EGC). Methods From January 2014 to December 2016, a total of 938 consecutive patients underwent laparoscopic gastrectomy for EGC. Solo SIDG (n = 99) and MLDG patients (n = 198) were selected and 1:2 propensity score matching was done to compare the quality of operation and cost-effectiveness. All solo SIDG was performed by a surgeon using a camera holder, without any assistant. Results Mean operation time (120 ± 35.3 vs. 178 ± 53.4 minutes, P = 0.001) and estimated blood loss (24.6 ± 47.4 vs. 46.7 ± 66.5 mL, P = 0.001) were significantly lower in the solo SIDG group. Hospital stay, use of analgesics, and postoperative inflammatory markers (WBC, CRP) were similar between the 2 groups. The early (

This article was updated to correct Do Joong Park’s name: Do Joong (given name) Park (family name).

Purpose There is no consensus on the optimal method for intracorporeal esophagojejunostomy (EJ) in laparoscopic total gastrectomy (LTG). This study aims to compare 2 established methods of EJ anastomosis in LTG. Materials and methods A total of 314 patients diagnosed with gastric cancer that underwent LTG in the period from January 2013 to October 2016 were enrolled in the study. In 254 patients, the circular stapler with purse-string "Lap-Jack" method was used, and in the other 60 patients the linear stapling method was used for EJ anastomosis. After propensity score matching, 58 were matched 1:1, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed. Results The 2 groups showed no significant difference in age, body mass index, or other clinicopathological characteristics. After propensity score matching analysis, the linear group had shorter operating time than the circular group (200.3±62.0 vs. 244.0±65.5, P≤0.001). Early postoperative complications in the circular and linear groups occurred in 12 (20.7%) and 15 (25.9%, P=0.660) patients, respectively. EJ leakage occurred in 3 (5.2%) patients from each group, with 1 patient from each group needing intervention of Clavien-Dindo grade III or more. Late complications were observed in 3 (5.1%) patients from the linear group only, including 1 EJ anastomosis stricture, but there was no statistical significance. Conclusions Both circular and linear stapling techniques are feasible and safe in performing intracorporeal EJ anastomosis during LTG. The linear group had shorter operative time, but there was no difference in anastomosis complications.

Single-incision distal gastrectomy (SIDG) is technically difficult due to limited range of motion and unstable field of view. Solo surgery using a passive scope holder may be the key in allowing SIDG to be safer and efficient. We report our initial 100 cases of, to what we know, the world’s first solo SIDG, and calculate the learning curve. Prospectively collected database of 100 patients clinically diagnosed as gastric cancer who underwent solo SIDG from October 2013 until July 2016 was analyzed. All the operations were held by a single surgeon with no assistants. A passive laparoscopic scope holder was used to fix the field of view. The mean operation time was 120.6 ± 30.2 min, and the average estimated blood loss was 33.5 ± 55.7 ml. Average body mass index was 23.4 ± 2.9 kg/m2. The median hospital stay was 5 (4–14) days, and the mean number of retrieved lymph nodes was 56.0 ± 22.8. There was no conversion to multiport or open surgery. Early complication of Clavien–Dindo grade III or more was 3%. Learning curve was calculated on operation time, and showed that an experienced surgeon in SIDG required 20 cases or less in stabilizing the operation time for solo SIDG. Solo SIDG seems to be feasible and safe. The stable field of view created by a scope holder provides a favorable environment for a finer and more consistent operation. In addition, manpower can also be saved without affecting the quality of surgery.

Background The incidence and clinical presentation of internal hernia after gastrectomy have been changing in the minimally invasive surgery era. This study aimed to analyze the clinical features and risk factors for internal hernia after gastrectomy for gastric cancer. Methods We retrospectively analyzed internal hernia after gastrectomy for gastric cancer in 6474 patients between January 2003 and December 2016 at Seoul National University Bundang Hospital. Multivariable logistic regression was performed to evaluate risk factors. Results Internal hernias identified by computed tomography or surgical exploration were 111/6474 (1.7%) and the median interval time was 450 days after gastrectomy. Fourteen (0.9%) of the 1510 patients who underwent open gastrectomy and 97 (2.0%) of the 4964 patients who underwent laparoscopic gastrectomy developed internal hernia. Of the 6474 patients, internal hernia developed in 0 (0%), 9 (1.1%), 40 (3.1%), 56 (3.3%), 6 (2.3%), and 0 (0%) patients who underwent Billroth I, Billroth II, Roux-en-Y, uncut Roux-en-Y, double tract, and esophagogastrostomy reconstructions, respectively. Fifty-nine (53.2%) of 111 patients with symptomatic hernia underwent surgery. Of the 59 internal hernias, treated surgically, 32 (53.2%), 27 (45.8%), and 0 (0%) were identified in jejunojejunostomy mesenteric, Petersen’s, and transverse colon mesenteric defects, respectively. In multivariate analysis, non-closure of mesenteric defects (P P P = 0.03) were independent risk factors for internal hernia. Conclusions The potential spaces such as Petersen’s, jejunojejunostomy mesenteric, and transverse colon mesenteric defects should be closed to prevent internal hernia after gastrectomy for gastric cancer.

Feeding gastrostomy is widely used for children with feeding impairment. The replacement of gastrostomy tube is known as an easy and safe procedure. However, various complications associated with replacement of gastrostomy tube were reported, including fistula disruption and colo-cutaneous fistula. For replacement of gastrostomy tube in small children with small stomach, special cautions are needed. Here, we report a rare case of duodenal perforation as an acute complication after the replacement of gastrostomy tube for a 33-month-old girl.

Purpose: Since introduction of the laparoscopic procedure for cholecystectomy, it has become the treatment of choice for symptomatic gallbladder diseases. Previous studies have demonstrated that implementation of critical pathway (CP) in laparoscopic cholecystectomy (LC) is effective in reducing cost in terms of length of stay (LOS) and revisit rates. However, few studies have proven the effectiveness of critical pathway specifically in patients with acute cholecystitis (AC). Methods: CP was introduced for LC for chronic cholecystitis (CC) in April 2008. Then, indication for CP was extended to AC in May 2010. We compared outcomes of LC for patients with AC between two eras, including Pre-CP (Jan 2007 to Mar 2008) and Post-CP (May 2010 to Jun 2011). Among 78 patients with AC, 70 patients (90%) were enrolled for the critical pathway. Among them, 55 patients (79%) were discharged with full application of CP; however, it was suspended in 15 patients (21%). Results: No differences in demographics and clinical characteristics were observed between Pre-CP (n=97) and Post-CP (n=70) patients. The mean LOS before surgery was shorter in the Post-CP group (2.6 vs. 4.0 days, p=.012). In addition, the mean total LOS was shorter in the Post-CP group (5.5 vs. 8.7 days, p ＜.001). However no differences in postoperative complications were observed between the two groups (10 vs. 5 cases, p=.483). Conclusion: Implementation of CP in AC resulted in a decrease in the LOS in total and before surgery, without increasing morbidity. Therefore, critical pathway can be safely implemented for selected patients with AC.

Purpose The laparoscopic transhiatal approach (LA) for adenocarcinoma of the esophagogastric junction (AEJ) is advantageous since it allows better visualization of the surgical field than the open approach (OA). We compared the surgical outcomes of the 2 approaches. Materials and methods We analyzed 108 patients with AEJ who underwent transhiatal distal esophagectomy and gastrectomy with curative intent between 2003 and 2015. Surgical outcomes were reviewed using electronic medical records. Results The LA and OA were performed in 37 and 71 patients, respectively. Compared to the OA, the LA was associated with significantly shorter duration of postoperative hospital stay (9 vs. 11 days, P=0.001), shorter proximal resection margins (3 vs. 7 mm, P=0.004), and extended operative times (240 vs. 191 min, P=0.001). No significant difference was observed between the LA and OA for intraoperative blood loss (100 vs. 100 mL, P=0.392) or surgical morbidity rate (grade≥II) for complications (8.1% vs. 23.9%, P=0.080). Two cases of anastomotic leakage occurred in the OA group. The number of harvested lymph nodes was not significantly different between the LA and OA groups (54 vs. 51, P=0.889). The 5-year overall and 3-year relapse-free survival rates were 81.8% and 50.7% (P=0.024) and 77.3% and 46.4% (P=0.009) for the LA and OA groups, respectively. Multivariable analyses revealed no independent factors associated with overall survival. Conclusions The LA is feasible and safe with short- and long-term oncologic outcomes similar to those of the OA.

Purpose Generally, adjuvant chemotherapy (AC) should be initiated as soon as possible after surgery to eradicate microscopic cancer cells. In this study, we investigated the effect of early AC on the survival of stage II/III gastric cancer patients. Materials and methods Four hundred sixty patients who received AC (S-1 or XELOX) for pathologic stage II/III gastric cancer at Seoul National University Bundang Hospital between January 2008 and December 2014 were included. Patients were divided into 2 groups: early AC administration (within 4 weeks) and late AC administration (more than 4 weeks). Patients in the early AC group (n=174) were matched 1:1 with patients in the late AC group (n=174) by propensity scoring to adjust for clinical differences. Three-year relapse-free survival (RFS) was evaluated according to the timing of AC. Results Three-year RFS was 98.1% in stage IIA (n=109), 85.0% in stage IIB (n=83), 87.4% in stage IIIA (n=96), 83.5% in stage IIIB (n=91), and 62.5% in stage IIIC (n=81). After propensity score matching, RFS was similar between early and late AC groups (hazard ratio [HR],1.04; 95% confidence interval [CI], 0.62-1.74; P=0.889). Pathologic stage and histological type were independent prognostic factors of RFS (HR, 2.05; 95% CI, 1.06-3.96; P=0.033 and HR, 2.61; 95% CI, 1.42-4.80; P=0.002, respectively). Conclusions Early initiation of AC within 4 weeks does not affect survival rates in stage II/III gastric cancer.

Purpose To compare the outcome between laparoscopic gastrojejunostomy (LapGJ) and duodenal stenting (DS) in terms of oral intake, nutritional status, patency duration, effect on chemotherapy and survival. Methods Medical records of 115 patients, who had LapGJ or duodenal stent placement between July 2005 and September 2015 in Seoul National University Bundang Hospital, have been reviewed retrospectively. Oral intake was measured with Gastric Outlet Obstruction Scoring System. Serum albumin and body weight was measured as indicators of nutritional status. The duration of patency was measured until the date of reintervention. Chemotherapy effect was calculated after the procedures. Survival period and oral intake was analyzed by propensity score matching age, sex, T-stage, comorbidities, and chemotherapy status. Results Forty-three LapGJ patients and 58 DS patients were enrolled. Improvement in oral intake was shown in LapGJ group versus DS group (88% vs. 59%, P = 0.011). Serum albumin showed slight but significant increase after LapGJ (+0.75 mg/dL vs. −0.15 mg/dL, P = 0.002); however, there was no difference in their body weight (+5.1 kg vs. −1.0 kg, P = 0.670). Patients tolerated chemotherapy longer without dosage reduction after LapGJ (243 days vs. 74 days, P = 0.006) and maintained the entire chemotherapy regimen after the procedure longer in LapGJ group (247 days vs. 137 days, P = 0.042). LapGJ showed significantly longer survival than DS (220 vs. 114 days, P = 0.004). Conclusion DS can provide faster symptom relief but LapGJ can provide improved oral intake, better compliance to chemotherapy, and longer survival. Therefore, LapGJ should be the first choice in gastric outlet obstruction patients for long-term and better quality of life.

We report our experience with two cases of situs inversus totalis, both involving patients diagnosed with gastric cancer. These were a 52-year-old male with a preoperative staging of cT1bN0M0 and a 68-year-old male with a staging of cT2N0M0, both of whom underwent surgery. The former was found to have vascular anomalies in the preoperative computed tomography, so we performed a computed tomography angiography with three-dimensional reconstruction. Laparoscopy-assisted distal gastrectomy with Billroth I anastomosis was performed with D1+ lymph node dissection, and a small laparotomy was made for extracorporeal anastomosis. In contrast, the latter case showed no vascular anomalies in the preoperative computed tomography, and totally laparoscopic distal gastrectomy with delta anastomosis was performed with D1+ lymph node dissection. There were no intraoperative problems in either patient and they were discharged without postoperative complications. Histopathological examination revealed a poorly differentiated adenocarcinoma (pT2N0M0) and a well-differentiated adenocarcinoma (pT1aN0M0), respectively.