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BACKGROUND: Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for remnant gastric cancer (RGC) remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC. PATIENTS AND METHODS: Patients with RGC who underwent surgery between 2005 and 2020 at 17 institutions were included, and a propensity score matching analysis was performed to compare the short- and long-term outcomes of MIS with open surgery. RESULTS: A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 [95% confidence interval (CI): 0.45, 1.27] and 0.65 (95% CI: 0.32, 1.29), respectively. The MIS group had significantly less blood loss [mean difference (MD), -409 mL; 95% CI: -538, -281] and a shorter hospital stay (MD, -6.5 days; 95% CI: -13.1, 0.1) than the open surgery group. The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival were 77.9% and 76.2% in the MIS and open surgery groups, respectively [hazard ratio (HR), 0.78; 95% CI: 0.45, 1.36]. The 3-year relapse-free survival were 71.9% and 62.2% in the MIS and open surgery groups, respectively (HR, 0.71; 95% CI: 0.44, 1.16). CONCLUSIONS: MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Background The best treatment strategy for borderline resectable locally advanced esophageal squamous cell carcinoma (ESCC) is unknown. Although neoadjuvant chemoradiotherapy (NACRT) provides good local control, the subsequent surgery is complicated by edema or fibrosis, particularly in minimally invasive esophagectomy (MIE). This retrospective cohort study sought to assess the feasibility of NACRT followed by MIE for borderline resectable ESCC. Methods Consecutive patients who underwent NACRT (40Gy radiotherapy with chemotherapy of 5-FU and Cisplatin) followed by MIE with gastric tube reconstruction for locally advanced ESCC were included. Following a review of pretreatment CT by 2 independent physicians, clinically borderline resectable T3 (cT3br) tumors were chosen, with resectable (cT3r) and unresectable (cT4b) tumors excluded. The short- and mid-term oncological outcomes were assessed. Results Patients with 33 cT3br tumors were included. There was no postoperative mortality, and 11 and 7 patients had postoperative Clavien-Dindo Grade ≥ II and Grade ≥ III complications, respectively. R0 resection was achieved in 32 patients, with 4 patients showing pathological complete response. With a median follow-up of 675 days, 15 patients had relapsed, the majority of which included distant metastasis, and only one patient had a pure locoregional recurrence. Patients who experienced postoperative complications had significantly lower relapse-free survival (RFS) than those who did not (p = 0.049) (2-year RFS: 0% and 65%, respectively). Conclusions NACRT followed by MIE for cT3br tumors was feasible with adequate R0 resection rates. Although locoregional control was adequate, distant metastasis was poorly controlled. MIE with fewer postoperative complications would provide better oncological results.

The necessity of the standard D2 gastrectomy for elderly patients with advanced gastric cancer (GC) is controversial because only limited data are available to demonstrate its oncological benefit for them. Our aim was to compare the outcomes of D2 and Non-D2 and to evaluate the survival benefit of D2 laparoscopic gastrectomy (LG) in elderly patients.We retrospectively identified 865 patients with GC who underwent radical LG at our hospital between 2011 and 2017. Patients aged ≥75 years who were diagnosed with clinical T1N+ or clinical T2-4 were eligible. The primary outcome was the 3-year overall survival (OS) rate. The confounding factors were minimized using propensity score matching.This study included 119 patients (63 D2 LG and 56 Non-D2 LG), and 52 patients (26 each for D2 LG and Non-D2 LG) were analyzed after matching. Although no significant difference was found in overall major complications (P=1.00), complications tended to occur in the D2 group (D2This study demonstrated the possible association between D2 LG and increased complication rate and no survival benefit of D2 LG in elderly patients.

Internal hernia (IH) is one of the critical complications after gastrectomy with Roux-en-Y reconstruction, which can be prevented by closing mesenteric defects. However, only few studies have investigated the incidence of IH after laparoscopic total gastrectomy (LTG) with Roux-en-Y reconstruction for gastric cancer till date. This study aimed to assess the efficacy of defect closure for the prevention of IH after LTG. This multicenter, retrospective cohort study collected data from 714 gastric cancer patients who underwent LTG with Rou-en-Y reconstruction between 2010 and 2016 in 13 hospitals. We evaluated the incidence of postoperative IH by comparing closure and non-closure groups of Petersen’s defect, jejunojejunostomy mesenteric defect, and transverse mesenteric defect. The closure group for Petersen’s defect included 609 cases, while the non-closure group included 105 cases. The incidence of postoperative IH in the closure group for Petersen’s defect was significantly lower than it was in the non-closure group (0.5% vs. 4.8%, p

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Total gastrectomy with splenectomy (TGS) is routinely performed in patients with type 4 or large type 3 gastric cancer (GC), which sometimes metastasize to splenic hilar lymph nodes (LNs). However, the indication for and significance of TGS remain controversial. This multicenter retrospective study aimed to evaluate the oncological feasibility of laparoscopic TGS (LTGS) in patients with advanced proximal GC.We retrospectively studied patients with type 4 or large type 3 GC who underwent LTGS at three Institutes between January 2010 and December 2018.We identified 26 consecutive eligible patients for analysis. Large type 3/type 4 were observed in 10 (38.5%)/16 (61.5%) cases. Involvement of the greater curvature was observed in 19 cases (73.1%), and GC spread to the whole stomach was observed in 12 cases (46.2%). R0 resection was achieved in 23 cases (88.5%). The median number of retrieved splenic hilar LNs was 4.0 (1-15), and the number of cases with splenic hilar LN metastasis was 3 (11.5%). Postoperative grade II intra-abdominal abscess was observed in 1 case (3.8%), and pancreatic fistula was not observed in any patient. Recurrence was observed in 18 cases (69.2%), of which 16 (88.9%) presented peritoneal recurrence. The median overall survival (OS) was 40.6 months, and the 5-year OS rate was 30.3%. The 5-year survival rate of patients with splenic hilar LN metastasis was 33.3% and the therapeutic value of splenectomy was 3.83.LTGS was performed safely, but the oncological benefit of the procedure for type 4 or large type 3 GC was very limited.

IntroductionPoor Trastuzumab (Tmab) response in human epidermal growth factor receptor 2-overexpressing gastric or gastroesophageal junction adenocarcinoma (HER2-GEA) is reported to be associated with loss of phosphatase and tensin homolog (PTEN) expression.MethodsIn a multicenter, retrospective observational study, pathological samples of HER2-GEA patients receiving Tmab-combined chemotherapy were immunohistochemically analyzed for PTEN expression. Primary endpoints were disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). The effect of PI3K pathway inhibitors on HER2-GEA cell lines were evaluated in in-vitro.ResultsAmong 145 HER2-GEA patients, 29 formed the PTEN-loss group and 116 the PTEN-positive group. In patients with target region, DCR was significantly lower in PTEN-loss than in PTEN-positive patients (67% and 87%, respectively, p=0.049). Multivariate analysis demonstrated that PTEN loss was significantly associated with shorter PFS (HR=1.63, p=0.035) and OS (HR=1.83, p=0.022). PTEN knockdown did not affect the cytostatic effect of 5-FU and cisplatin, while Tmab combined with PI3K/mTOR inhibitor NPV-BEZ235 suppressed the proliferation of PTEN knockdown cells which were resistant to Tmab alone.ConclusionIn HER2-GEA patients, PTEN loss is a predictive biomarker of Tmab resistance and prognostic factor. Molecular-targeted therapy with PI3K/mTOR inhibitor would be an effective treatment option for HER2-GEA with PTEN loss.

We previously reported a novel method of mesenteric excision for esophageal cancer surgery. The esophagus, trachea, recurrent laryngeal nerves (RLNs), and surrounding lymph nodes (LNs) are contained in a common mesenterium, which we termed the “mesotracheoesophagus”. In addition, near-infrared (NIR) image-guided lymphatic mapping has recently been used. The purpose of this study was to confirm the feasibility of NIR image-guided lymphatic mapping for upper mediastinal LN dissection, and to confirm the oncological feasibility of our surgical approach. Fifteen patients with resectable esophageal cancer underwent submucosal injection of indocyanine green (ICG), and underwent robot-assisted esophagectomy. The frequency of ICG positivity in the LN basins along the RLNs, and metastatic frequency were assessed. Regarding the oncological feasibility of our thoracoscopic esophagectomy, the recurrence patterns and survival of 72 consecutive patients who underwent curative resection from 2011 to 2016 were analyzed. ICG-positive LN basins along the right and left RLNs were found in 12 (80% of 15) patients (3 patients positive for metastatic LNs) and 11 (73% of 15) patients (2 positive for metastatic LNs and 1 false-negative), respectively. All ICG-positive LN basins were found within the mesotracheoesophagus. The sensitivity was 5/6 (83%), and the negative predictive value was 6/7 (86%). Among the 72 patients, with a median follow-up period of 1644 days, only 3 (4.2%) patients developed locoregional recurrence. The NIR image-guided lymphatic mapping was feasible. Our results with no ICG-positive basins outside of the ‘”mesotracheoesophagus”, supported our surgical approach. It might become standard, with acceptable locoregional control.

Introduction Appropriate dissection of the infrapyloric lymph nodes (no. 6 LNs) is important in gastric cancer surgery. In laparoscopic surgery, dissection of the no. 6 LNs along the inner dissectable layer from the left side of patient has been reported. However, it is difficult for surgeons to provide appropriate traction with their left hand from the left side. To resolve this difficulty, we dissected the no. 6 LNs from the patient's right side to identify the optimal layer. We then evaluated the oncologic reliability of the layer and the safety of this procedure. Methods From the patient's right side, the surgeon used their left hand to provide appropriate traction when pulling the adipose tissue, including the no. 6 LNs. This exposed the optimal layer between the adipose tissue and the pancreas. To assess this maneuver, the surgical outcomes of patients who underwent laparoscopic distal gastrectomy from April 2011 to March 2013 were retrospectively analyzed. The surgical outcomes included the number of the no. 6 LNs resected, time to dissect the no. 6 LNs, incidence of pancreatic complications, and recurrence in the no. 6 LNs. Results There were 112 patients identified. The median number of the no. 6 LNs resected was five. The median time to dissect the no. 6 LNs was 14 minutes. Four patients developed pancreatic fistula, and another four patients developed intra-abdominal abscess. There was no recurrence in the no. 6 LNs. Conclusion The optimal layer was oncologically reliable, and these procedures were safe.

357 Background: Remnant gastric cancer (RGC) is defined as a cancer arising in the remnant stomach after initial gastrectomy, regardless of the previous disease or surgical procedure. Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for RGC remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC. Methods: We collected the data of patients with RGC who underwent surgery with curative intent between 2005 and 2020 from 17 institutions in Japan, and performed a propensity score (PS) matching analysis to compare the short- and long-term outcomes of MIS with open surgery. Results: A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 (95% confidence interval [CI]: 0.45–1.27) and 0.65 (95% CI: 0.32–1.29), respectively. The MIS group had significantly less blood loss (50 ml vs. 361 ml, P

The safety of robotic gastrectomy (RG) for gastric cancer in daily clinical settings and the process by which surgeons are introduced and taught RG remain unclear. This study aimed to evaluate the safety of RG in daily clinical practice and assess the learning process in surgeons introduced to RG.Patients who underwent RG for gastric cancer at Kyoto University and 12 affiliated hospitals across Japan from January 2017 to October 2019 were included. Any morbidity with a Clavien-Dindo classification grade of II or higher was evaluated. Moreover, the influence of the surgeon's accumulated RG experience on surgical outcomes and surgeon-reported postoperative fatigue were assessed.A total of 336 patients were included in this study. No conversion to open or laparoscopic surgery and no in-hospital mortality were observed. Overall, 50 (14.9%) patients developed morbidity. During the study period, 14 surgeons were introduced to robotic procedures. The initial five cases had surprisingly lower incidence of morbidity compared to the following cases (odds ratio 0.29), although their operative time was longer (+ 74.2 min) and surgeon's fatigue scores were higher (+ 18.4 out of 100 in visual analog scale).RG was safely performed in actual clinical settings. Although the initial case series had longer operative time and promoted greater levels of surgeon fatigue compared to subsequent cases, our results suggested that RG had been introduced safely.

We reported the esophagus, trachea, recurrent laryngeal nerves (RLNs), and regional lymph nodes are contained in a common compartment, which we named mesotracheoesophagus. We believe complete resection of the mesotracheoesophagus is ‘mesenteric excision’ for esophageal cancer, which is the fundamental principle of intestinal cancer surgery. Since June 2011, we have performed minimal invasive esophagectomy (MIE) based on this concept. This study was aimed to evaluate outcomes of our MIE. Methods We performed a retrospective study of patients with esophageal cancer who underwent MIE at our hospital between June 2011 and March 2019. Procedure First, the dorsal side of the esophagus was dissected along a dissectable layer recognized outside the mesotracheoesophagus. After complete mobilization of the dorsal side of the esophagus, the trachea and RLNs were released from the mesotracheoesophagus and the rest of the fat tissue was dissected for radical LN dissection in the upper mediastinum. Results We identified consecutive 151 eligible patients. The median age was 68 year-old (IQR 35–83) and 117 patients were male. Tumor location was Ce:Ut:Mt:Lt:Ae = 1:12:67:58:13. Histologic cell-type was squamous cell carcinoma (SqCC):adenocarcinoma = 142:9. The clinical stage (TNM 8th edition) was I:II:III:IVa = 45:39:56:2 and I:IIB:III:IVA = 2:1:5:1 in patients with SqCC and in those with adenocarcinoma, respectively. R0 resection was performed in all patients. The Clavian-Dindo classification grade III and higher RLN paralysis rate was 7.3% and the pneumonia 5.3%. The mortality rate was 1.3%. Three-year disease free survival rate was 62.3%. Three-year overall survival rate was 71.7%. Conclusion The outcomes of mesenteric excision for esophageal cancer surgery were acceptable. Video https://www.dropbox.com/s/y1lm3uurr4t86vq/2020%20ISDE%20Abstract.mov?dl=0.

Both laparoscopic proximal gastrectomy with lower esophagectomy (extended LPG) and minimally invasive Ivor Lewis esophagectomy (MIILE) are acceptable treatments for adenocarcinoma of the esophagogastric junction (AEG), but the optimal reconstruction technique for mediastinal esophagogastrostomy (one that provides adequate reflux prevention) has not been established. We devised a novel side-overlap esophagogastric-tube (SO-EG) reconstruction. We performed a retrospective review of patient records after LPG or MIILE. In each patient, we created a 3-cm wide gastric tube, overlapping the esophagus by 5 cm. A linear stapler was inserted into the left side of the esophageal stump and the anterior gastric wall along the greater curvature. The entry hole was closed to make a slit-like anastomosis, and the right side of the esophageal wall was fixed to the anterior gastric wall. Ten consecutive patients underwent this procedure between June 2020 and July 2021. Five patients had Siewert type II AEG: 4 with lower thoracic esophageal cancer and 1 with benign lower esophageal stenosis. A total of 3 patients underwent extended LPG, and 7 underwent MIILE. The median operative time was 352 min (range, 221–556 min). The postoperative course was uneventful in 9 patients; a single patient developed pneumonia. Seven patients underwent follow-up endoscopy at 6 months. One patient with anastomotic stenosis and 2 with mild reflux esophagitis were treated conservatively. Our novel SO-EG reconstruction is simple and feasible, with acceptable results for preventing reflux esophagitis. This technique can be performed with either extended LPG or MIILE.

Background The number of patients who are undergoing laparoscopic gastrectomy for treating gastric cancer is increasing. Although prophylactic drains have been widely employed following the procedure, there are few studies reporting the efficacy of prophylactic drainage. Therefore, this study assessed the efficacy of prophylactic drains following laparoscopic gastrectomy for gastric cancer. Methods Data of patients who received laparoscopic gastrectomy for treating gastric cancer in our institution between April 2011 and March 2017 were reviewed, and the outcomes of patients with and without a prophylactic drainage were compared. Propensity score matching was used to minimize potential selection bias. Results A total of 779 patients who underwent surgery for gastric cancer were reviewed; of these, 628 patients who received elective laparoscopic gastrectomy were included in this study. After propensity score matching, data of 145 pairs of patients were extracted. No significant differences were noted in the incidence of postoperative complications between the drain and no-drain groups (19.3% vs 11.0%, P = 0.071). The days after the surgery until the initiation of soft diet (6.3 ± 7.4 vs 4.9 ± 2.9 days, P = 0.036) and the length of postoperative hospital stay (15.7 ± 12.9 vs 13.0 ± 6.3 days, P = 0.023) were greater in the drain group than those in the no-drain group. Conclusions This study suggests that routinely using prophylactic drainage following laparoscopic gastrectomy for treating gastric cancer is not obligatory.

Effective treatment of esophageal cancer requires dissection of the regional lymph nodes (LNs) from the cervical to the abdominal area. In this study, we hypothesized that adequate no. 101R dissection is achieved through a thoracoscopic approach in the prone position. The study cohort was limited to 42 patients who underwent thoracoscopic subtotal esophagectomy with bilateral cervical lymphadenectomy for thoracic esophageal cancer between January 2015 and March 2017. The number of LNs and the incidence of metastasis were analyzed. During the proposed thoracoscopic procedure, cervical paraesophageal LNs were dissected continuously, with the LNs surrounding the recurrent laryngeal nerve (RLN; no. 106rec) as an en bloc resection. In this study, LNs that required further picking up via a cervical incision were defined as no. 101. The recurrent sites among the consecutive patients during the 3-year follow-up, for whom bilateral cervical lymphadenectomy was omitted for lower and middle thoracic tumors between 2012 and 2014, were analyzed further. The data of 42 patients were analyzed. The lymphatic tissues dorsal to the right cervical RLN were almost completely dissected via thoracoscopy. A median of 0 (0–6) LNs were ventral to the right RLN (no. 101R) and no LN metastasis was observed. There were no lymph nodes in 27 patients (64%). By contrast, there was a median of 1(0–10) no. 101L nodes, and LN metastasis was observed in two patients (4.7%). The numbers of LNs at no. 106recR and no. 106recL were 3 (0–9) and 2(0–13), respectively, and the corresponding numbers of patients with metastases at these sites were 11(26%) and 5(12%), respectively. Among the 33 patients who completed the 3-year follow-up, 9 patients developed recurrence, but none involved 101R LNs. There were no residual LNs in the area ventral to the right cervical RLN in 64% of the patients who underwent additional cervical lymphadenectomy after the right thoracoscopic approach in the prone position. Further studies with larger patient cohort or randomization are required to confirm our results.

A 67-year-old man diagnosed with clinical Stage Ⅳ gastric cancer was administered nivolumab as fourth-line chemotherapy. After 9 courses, he was emergently admitted with complaints of low blood pressure and general malaise. On the fourth hospital day, he had high-grade fever and elevated serum C-reactive protein. Computed tomography showed a moderate amount of pericardial effusion. He was administered 1.7 mg/kg of methylprednisolone and improved rapidly. A hormonal blood examination showed his adrenal gland disorder. This is the first case in our country of pericardial effusion as an immune-reactive adverse event, which is not well known in Japan.

Video review is a reliable method for surgical education in laparoscopic gastrectomy (LG), but more objective methods are still needed. The purpose of this study was to determine whether the energy device records reflected surgical competency, and thereby may improve surgical education. A total of 16 patients who underwent LG for gastric cancer using the Thunderbeat® device were preliminarily retrospectively analyzed. This device has the function of ‘intelligent tissue monitoring’ (ITM), a safety assist system stopping energy output, and can record ITM detections and firing time during surgery. The number of ITM detections and firings, and the total firing time during gastrocolic ligament dissection and infrapyloric dissection were compared between trainees (n = 9 by 5 surgeons) and experts (n = 7 by 5 surgeons). The non-edited videos (n = 16) were scored, and the correlations between the scores and the records were then analyzed. Significantly more ITM detections, firings, and a longer total firing time were observed in trainees than in experts. The number of ITM detections and firing had negative correlations with the scores of the operation speed, the use of the non-dominant hand, and the use of an energy device. Our preliminary study suggested that the above described energy device records reflected surgical competency, and thereby may improve surgical education.

Post-hepatectomy portal vein thrombosis (PH-PVT) is a severe complication. The risk factors of PH-PVT after laparoscopic and open hepatectomy have not been clarified yet. We aimed to retrospectively investigate the risk factors and outcome of PH-PVT in patients with primary liver cancer. We enrolled 622 consecutive patients who underwent hepatectomy in our hospital between January 2006 and August 2016. Of 21 patients (3.4%) with PH-PVT, 7 had grade I; 13, grade II; and 1, grade III. The patients with PH-PVT were significantly older than those without PH-PVT. Of the 413 patients who underwent open hepatectomy, those who underwent a major right hepatectomy (4.1%) had a slightly higher incidence of PH-PVT. Of the 209 patients who underwent laparoscopic hepatectomy, those who underwent a left lateral sectionectomy (21.2%) and major right hepatectomy (16.7%) had high incidence rates of PH-PVT. The treatment was only observation in five patients, medication with an antithrombotic drug in 15 patients, and reoperation in one patient. PH-PVT diminished in 17 patients. Cavernous transformation and/or stenosis of the portal vein developed in three patients. The patient with grade III PH-PVT after open right hemihepatectomy underwent reoperation but died of hepatic failure. This study demonstrated that patient age, left lateral sectionectomy were risk factors of PH-PVT. Laparoscopic left lateral sectionectomy and major right hepatectomy might bring about relatively higher risk of PH-PVT. Major right hepatectomy tends to lead to severe PH-PVT. Careful handling of the PV during hepatectomy and early treatment of PH-PVT are necessary.

Introduction. According to previous studies, transhiatal lower mediastinal lymph node (LMLN) dissection is recommended for patients with adenocarcinoma of esophagogastric junction (AEG) with esophageal involvement of [1] , [2] , [3] ]. Herein, we reported our procedure and the short-term outcomes. Surgical procedure. The patient was placed in a supine position under general anesthesia, and five ports were placed into the upper abdomen. After radical suprapancreatic lymph node dissection, the center of the phrenic tendon was cut and each phrenic crus was retracted laterally to obtain good operative field. The ventral tissue along the lower esophagus was dissected from the pericardia. The dissection proceeded to the right atrium along the IVC. The dorsal tissue was dissected from the aorta. The remaining plate-like tissue was dissected from the pleura. Finally, the dissected tissue was peeled back from the esophagus. Results. Twenty-four patients with Siewert type II/III AEG underwent this procedure at our hospital between April 2011 and December 2019. Two cases were administered with the right thoracic approach to secure proximal margin or perform anastomosis safely. All cases underwent R0 resection. Although the Clavien-Dindo grade IIIa anastomotic leakage was confirmed in two cases (8.3%), there were no complications associated with the procedure. The median number of retrieved LMLN was five (range 0–14). Two patients had metastatic LMLN. The length of esophageal involvement in patients with metastatic LMLN was longer than that in patients with nonmetastatic LMLN (26 mm vs 12.5 mm). Conclusion. Our procedure was safe and feasible for lymph node dissection in AEG.

We invented a simple and secure method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis (DA), using endoscopic linear stapler only and standardized the DA procedure by resecting two-thirds of the stomach based on the anatomical landmarks. This study aimed to evaluate the feasibility of the standardized DA as the standard reconstruction procedure after a laparoscopic distal gastrectomy assessing functional outcomes including postoperative complications, body weight loss, nutritional status, and endoscopic findings. The medical records of 349 patients with gastric cancer who underwent laparoscopic distal gastrectomy from April 2011 to December 2017 at our hospital were retrospectively reviewed. Functional outcomes were assessed according to nutritional status and endoscopic findings. The operation time was shorter and complication rate was lower in the standardized DA than those in Billroth-II (BII) and Roux-en-Y (RY). The body weight loss in DA was 10% 1 year postoperatively and remained stable during the follow-up period, which showed no significant difference. The endoscopic findings showed the ratio of residual food in DA was lower than that in RY (DA:RY = 13.3%:13.6% and 8.4%:33.3% at 1 and 3 years postoperatively, respectively). Severe gastritis was extremely rare in DA (6.7% at 1 year and 15.6% at 3 years postoperatively). Bile reflux was more often found in DA than RY (DA:RY = 19.9%:4.8% and 26.6%:0% at 1 and 3 years postoperatively, respectively). Reflux esophagitis was found 10% of DA only. Functional outcomes of the standardized DA were satisfactory and feasible. Our intracorporeal Billroth-I reconstruction, by resecting two-thirds of the stomach, can be one of the standard reconstruction methods after a laparoscopic distal gastrectomy.

Presently, there is no consensus as to what procedure of intracorporeal esophagojejunostomy (EJS) in totally laparoscopic total gastrectomy (TLTG) is best to reduce postoperative complications. The aim of this study was to demonstrate the superiority of linear stapled reconstruction in terms of anastomotic-related complications for EJS in TLTG. We collected data on 829 consecutive gastric cancer patients who underwent TLTG reconstructed by the Roux-en-Y method with radical lymphadenectomy between January 2010 and December 2016 in 13 hospitals. The patients were divided into two groups according to reconstruction method and matched by propensity score. Postoperative EJS-related complications were compared between the linear stapler (LS) and the circular stapler (CS) groups. After matching, data from 196 patients in each group were analyzed. The overall incidence of EJS-related complications was significantly lower in the LS group than in the CS group (4.1% vs. 11.7%, p = 0.008). The incidence of EJS anastomotic stenosis during the first year after surgery was significantly lower in the LS group than in the CS group (1.5% vs. 7.1%, p = 0.011). The incidence of EJS bleeding did not differ significantly between the groups, although no bleeding was observed in the LS group (0% vs. 2.0%, p = 0.123). The incidence of EJS leakage did not differ significantly between the groups (2.6% vs. 3.6%, p = 0.771). The use of linear stapled reconstruction is safer than the use of circular stapled reconstruction for intracorporeal EJS in TLTG because of its lower risks of stenosis.

Laparoscopic gastrectomy is a widely used minimally invasive technique for the treatment of gastric cancer. Since the introduction of extracorporeal reconstruction through a minilaparotomy in laparoscopy-assisted gastrectomy, efforts have been made to establish techniques for intracorporeal reconstruction in both laparoscopic distal gastrectomy (LDG) and laparoscopic total gastrectomy (LTG). In LDG, linear staplers are preferable to circular staplers for the creation of the gastroduodenostomy or gastrojejunostomy, and both linear and circular staplers have a role in LTG. These techniques have had acceptable surgical outcomes as described in the literature. We use linear staplers for reconstruction with the advantage of easier handling in a limited space and a better operative view during the anastomosis. In this chapter, technical tips and pitfalls of intracorporeal reconstruction in LDG and LTG are reported. The reconstruction-related short-term outcomes in our institution are described.

A 65-year-old man reported nausea and anorexia after falling down a flight of stairs. Computed tomography (CT) showed a ruptured descending thoracic aortic aneurysm, and emergency thoracic endovascular aortic repair (TEVAR) was performed. However, after resuming food intake, the patient developed a fever. CT scan showed severe pneumomediastinum and a mediastinal abscess, and the patient was diagnosed with esophageal perforation. Emergency esophagectomy was performed, with an esophageal fistula made at the cervix. Jejunostomy was then performed to enable enteral nutrition. Histological examination showed substantial necrosis at the middle intrathoracic esophagus, and the patient was diagnosed with esophageal necrosis leading to perforation. Five months after the esophagectomy, gastric conduit reconstruction through the retrosternal route was performed. The patient was able to resume food intake, and survived more than 1 year after this surgery. Here, we describe the successful management of this rare case of esophageal necrosis after TEVAR for ruptured traumatic aortic aneurysm.

Background The prognosis of stage IV gastric cancer and human epidermal growth factor 2 (HER2)-positive gastric cancer is poor, although new drugs and regimens have been developed. We report a case of a patient with stage IV HER2-positive gastric cancer treated successfully by conversion therapy and trastuzumab. Case presentation The patient was a 73-year-old Japanese man diagnosed as L, type 3, circ, T4aNxCy1P1M1, stage IV (the Japanese classification of gastric carcinoma). The patient was treated with docetaxel, cisplatin, and TS-1 (DCS regimen). After two courses of the regimen, peritoneal dissemination disappeared, and peritoneal lavage cytology revealed no tumor cells in the abdominal cavity. Subsequently, he underwent laparoscopic distal gastrectomy with D1+. Pathological findings were ypT2(MP), ypN2(3/15), ypP0, ypCY0, M0, ypstage II. He received TS-1 as an adjuvant chemotherapy, but he had peritoneal recurrence. The original gastric cancer was HER2-positive. We therefore treated him with TS-1 with trastuzumab. This regimen was quite effective and achieved a complete response. After complete response, we switched the patient to trastuzumab monotherapy. He had no evidence of recurrence for 6 years, 3 months after surgery. Conclusion DCS regimen, R0 resection, and adjuvant chemotherapy with trastuzumab can be a powerful strategy for stage IV HER2-positive gastric cancer.

The recurrent laryngeal nerve (RLN) lymph nodes are among the most frequently involved lymph nodes in esophageal cancer. Surgical removal of these lymph nodes is considered beneficial for postoperative prognosis, especially in patients with squamous cell carcinoma. Unfortunately, the precise surgical anatomy of the upper mediastinum is not well understood and no distinct high-resolution images are currently available. In this article, we provide a simple intuitive concept of upper mediastinal surgical anatomy that could facilitate rational anatomical lymphadenectomy of the RLN lymph nodes. The essential concept of this mesenteric excision is to mobilize mesoesophagus including RLN in an en bloc fashion and to save RLN laterally by incising visceral sheath. This is applicable identically to both right and left upper mediastinum. Between January 2009 and December 2017, thoracoscopic esophagectomy with upper mediastinal lymphadenectomy for primary esophageal cancer was performed in 189 patients. Median thoracoscopic procedure time was 297 (range 205–568) min and median intraoperative blood loss was 70 ml (range unmeasurable up to 2545 ml). Median number of harvested upper mediastinal lymph nodes was 12. Postoperative complication of Clavien–Dindo classification grade III or higher events was observed in 14% of patients. RLN palsy of grade II or higher occurred in 20 patients (11%). The mesoesophagus in the upper mediastinum is an anatomical unit surrounded by fibrous connective tissue containing the esophagus, trachea, tracheoesophageal vessels, lymphatic tissue, and RLNs. Thus, mesenteric excision of esophagus is defined to resect this area by sparing trachea and RLNs for rational anatomical lymphadenectomy. We believe that this concept makes upper mediastinal lymphadenectomy safer and more appropriate.

We evaluate surgical outcomes of intracorporeal esophagojejunostomy in laparoscopic total gastrectomy using 2 linear stapler methods.The functional end-to-end anastomosis (FEEA) method was chosen as a first choice. The overlap method was chosen in cases with esophageal invasion. We retrospectively analyzed the early and late surgical outcomes of consecutive 168 laparoscopic total gastrectomy cases from April 2011 to December 2016.The FEEA method was selected in 120 cases, and the overlap method was selected in 48 cases. The mean time of esophagojejunostomy for the FEEA and overlap method was 13.2 and 36.5 minutes, respectively. Two cases with FEEA method and 3 cases with overlap method experienced complications due to esophagojejunostomy leakage. These cases were treated without performing a reoperation. One case with FEEA method was complicated due to esophagojejunostomy stenosis. This case was endoscopically treated. Our procedures are safe and feasible.

The oncologic safety and feasibility of laparoscopic D2 gastrectomy for advanced gastric cancer are still uncertain. The aim of this study is to compare our results for laparoscopic D2 gastrectomy with those for open D2 gastrectomy. Between 1998 and 2008, a total of 336 patients with clinical T2, T3, or T4 tumors underwent laparoscopic (n = 186) or open (n = 150) gastrectomy involving D2 lymph node dissection with curative intent. To produce this study population, 123 patients in the open group who matched those of the laparoscopic group with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, tumor location, and clinical tumor stage were retrospectively selected. The short- and long-term outcomes of these patients were examined. Laparoscopic D2 gastrectomy was associated with significantly less operative blood loss and shorter hospital stay, but longer operative time, compared with open D2 gastrectomy. The mortality and morbidity rates of the laparoscopic group were comparable to those of the open group (1.1 % vs. 0, P = 0.519, and 24.2 % vs. 28.5 %, P = 0.402). The 5-year disease-free and overall survival rates were 65.8 and 68.1 % in the laparoscopic group and 62.0 and 63.7 % in the open group (P = 0.737 and P = 0.968). There were no differences in the patterns of recurrence between the two groups. This study suggests that laparoscopic D2 gastrectomy provides reasonable oncologic outcomes with acceptable morbidity and low mortality rates. Although operation time is currently long, this approach is associated with several advantages of laparoscopic surgery, including quick recovery of bowel function and short hospital stay. Laparoscopic D2 gastrectomy may offer a favorable alternative to open D2 gastrectomy for patients with advanced gastric cancer.

Meticulous mediastinal lymphadenectomy frequently induces recurrent laryngeal nerve palsy (RLNP). Surgical robots with impressive dexterity and precise dissection skills have been developed to help surgeons perform operations. The objective of this study was to determine the impact on short-term outcomes of robot-assisted thoracoscopic radical esophagectomy performed on patients in the prone position for the treatment of esophageal squamous cell carcinoma, including its impact on RLNP. A single-institution nonrandomized prospective study was performed. The patients (n = 36) with resectable esophageal squamous cell carcinoma were divided into two groups: patients who agreed to robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy performed in the prone position (n = 16, robot-assisted group) without insurance reimbursement, and those who agreed to undergo the same operation without robot assistance but with health insurance coverage (n = 20, control group). These patients were observed for 30 days following surgery to assess short-term surgical outcomes, including the incidence of vocal cord palsy, hoarseness, and aspiration. Robot assistance significantly reduced the incidence of vocal cord palsy (p = 0.018) and hoarseness (p = 0.015) and the time on the ventilator (p = 0.025). There was no in-hospital mortality in either group. There were no significant differences between the two groups with respect to patient background, except for the use of preoperative therapy (robot-assisted group

Background: Although laparoscopic gastrectomy has been recognized as a treatment of early gastric cancer, the indication for laparoscopic gastrectomy with D2 lymph node dissection has remained controversial. D2 lymph node dissection is considered to be feasible for advanced gastric cancer in some high-volume institutions specifically trained for the laparoscopic procedure. This study was undertaken to determine the clinical outcome and clinicopathological characteristics of patients who showed recurrence following laparoscopic gastrectomy for advanced gastric cancer. Methods: From August 1999 through February 2009, among 805 patients who underwent laparoscopic gastrectomy associated with regional lymph node dissection, a total of 209 patients undergoing gastrectomy associated with lymph node dissection who consequently obtained complete resection for advanced gastric cancer were subjected to the retrospective analysis to evaluate clinical outcome. Results: The mean period of postoperative observation was 1,068 days. The final stages of the 209 cases were as follows: 83 in IB, 56 in II, 46 in IIIA, and 24 in IIIB. The 5-year survival rate was 89.1% in stage IB, 93.1% in stage II, 52.5% in stage IIIA, and 46.5% in stage IIIB, respectively. A total of 27 patients (12.9%) had recurrence. Postoperative recurrence of gastric carcinoma occurred in peritoneal dissemination in 13 patients, liver in 7, distant lymph nodes in 6, ovary in 3, lung in 2, skin in 1, and meninges in 1 patient. There were neither port-site metastases nor locoregional recurrence. Conclusion: The characteristics and the rate of postoperative recurrence after laparoscopic gastrectomy for advanced gastric cancer were not greatly different from those of the open conventional procedure. Although further observation is required to finally conclude long-term survival, laparoscopic radical gastrectomy may possibly be indicated for patients with advanced gastric cancer.

Objective: The robot-assisted surgical system was developed for minimally invasive surgery and is thought to have the potential to overcome the shortcomings of laparoscopic surgery. We introduced this system for the treatment of gastric cancer in 2008. Here we report our initial experiences of robot-assisted surgery using the da Vinci system. Methods: A retrospective review of robot-assisted gastrectomy for gastric cancer patients was performed in our institute. The clinicopathological features and surgical outcomes were analyzed. Whereas the procedures of the gastrectomy were similar to those of the usual laparoscopic surgery, several aspects such as the port placement and the role of the assistant were modified from those for conventional laparoscopic surgery. Results: From January 2008 to December 2010, 61 patients with gastric cancer underwent robot-assisted surgery. Gastrectomy was distal in 46 patients, total in 14, proximal in 1 and no operation was converted to the open procedure. D2 lymph node dissection was performed on 28 patients in the distal gastrectomy group and on 11 in the total gastrectomy group. Complications occurred in 2 cases (4%): these consisted of ruptured sutures and hemorrhage from the anastomotic site. Conclusions: This study demonstrated that robot-assisted gastrectomy using the da Vinci system can be applied safely and effectively for patients with gastric cancer.

大腸癌に対するda Vinci Surgical System®を用いたロボット手術は医学中央雑誌およびPubMedで「大腸癌（colorectal cancer）」, 「ロボット手術（robot surgery）」をキーワードとして1999年10月から2009年9月末までの10年間において，検索しえた範囲内で本邦での報告はなく，本症例が初の報告である．症例は77歳の男性でBMIは22.4であった．S状結腸腫瘍に対して内視鏡下粘膜切除術を施行した結果，病理組織学的検査でSM浸潤度1,000 μm以上であったため，追加手術目的にて外科へ紹介となった．内側アプローチによる下腸間膜動脈周囲のリンパ節郭清や血管処理，外側からのS状結腸の授動，直腸の剥離操作などをロボット手術下に施行した．初例のため，手術時間は要したが，術後に特記すべき合併症は認めず，術後6日目に軽快退院となった．今回教室で経験したロボット支援下手術によるS状結腸切除術について文献的考察を加えて報告する．

Although recent studies have shown that early enteral nutrition (EEN) has certain advantages over parenteral nutrition for preventing postoperative complications, few previous studies have examined the effects of enteral nutrition in patients undergoing esophagectomy. Here we review the effects of EEN with regular polymeric or other disease-specific enteral formulas in patients undergoing esophagectomy. Previously reported data suggest that nutritional management with early enteral feeding may be beneficial and that an appropriate selection of specific enteral formula enriched with disease-specific nutrients is important to prevent postoperative complications in patients undergoing radical esophagectomy. The use of immune-enhancing enteral formula (IEF) showed a certain benefit to enhance postoperative immunological function after esophagectomy. The use of IEF in the critically ill condition is still controversial, however, and thus the indication for using IEF in patients with septic complications after surgery should be considered carefully. IEF without the enrichment of arginine may be another option for patients with septic complications. EEN with a specific enteral formula may be important for patients with esophageal cancer after neoadjuvant chemotherapy or radiation therapy and salvage surgery to prevent postoperative complications and to improve nutritional status. Appropriate perioperative enteral formula enriched with disease-specific nutrients may be an important target of future clinical research for patients undergoing esophagectomy.

当科では，低侵襲性と機能温存を期待して，早期胃癌に対し，腹腔鏡下自律神経温存D1+β郭清術を行ってきた．本稿では，特にその迷走神経腹腔枝温存の手技と臨床評価について報告する．2001年5月から2008年6月までに当院で施行した腹腔鏡下幽門側胃切除術（デルタ吻合によるB-I再建）150例のうち追跡調査可能であった129例（温存群:84例，非温存群:45例）の患者アンケートおよび内視鏡検査により評価した．結果，非温存群では，便の性状が軟便傾向となる率が高く（20.5％対44.4％），胃内容こみ上げも有意差を認めた（17.9％対33.3％）．内視鏡検査所見では，胆汁逆流が非温存群で有意に高い結果（44.1％対62.2％）となった．今回の検討では，両群間で郭清程度，病期といった背景が異なるものの，迷走神経腹腔枝の温存によって，下痢，逆流症状といった，術後後遺症が軽減される可能性があると考えている．

BACKGROUND: To facilitate acceptance of laparoscopic total gastrectomy (LTG) for patients with upper gastric cancer, a simple, secure technique of reconstruction is necessary. The authors developed a new technique for intracorporeal esophagojejunal anastomosis that does not require hand sewing. METHODS: From September 2006 to January 2008, 16 patients (11 men and 5 women) with gastric cancer underwent LTG at the authors' institution. Laparoscopic esophagojejunal anastomosis using the following method was attempted for all patients. The esophagus was transected while being rotated by about 45 degrees counterclockwise to make the subsequent anastomosis easier. After the Y-anastomosis was created, an endoscopic linear stapler was applied to create a side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was first closed roughly with hernia staplers. Subsequently, an endoscopic linear stapler was applied so that all hernia staplers could be removed and the closure completed. RESULTS: Laparoscopic esophagojejunal anastomosis was successfully performed for 15 patients. Intracorporeal anastomosis failed for one patient because a nasogastric tube was caught between the jaws of an endostapler, which resulted in a conversion to open procedure. No postoperative anastomotic complications occurred. CONCLUSIONS: Using the new technique, intracorporeal linear-stapled esophagojejunal anastomosis can be performed easily and securely. This technique could become one of the standard methods for reconstruction after LTG, facilitating the acceptance of LTG as a surgical option for patients with upper gastric cancer.

Laparoscopic distal gastrectomy has become widespread as a treatment for early gastric cancer in eastern Asia, but a standard method for setting the stomach transection line has not been established. Here we report a novel method of setting this line based on anatomical landmarks. At the start of the operation, two anatomical landmarks along the greater curvature of the stomach were marked with ink: the proximal landmark at the avascular area between the last branch of the short gastric artery and the first branch of the left gastroepiploic artery, and the distal landmark at the point of communication between the right and left gastroepiploic arteries. Just before specimen retrieval, the stomach was transected from the center of these two landmarks toward the lesser curvature. Then, about two-third of the stomach was reproducibly resected, and gastroduodenostomy was successfully performed in 26 consecutive cases. This novel method could be used as a standard technique for setting the transection line in laparoscopic distal gastrectomy.