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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.

In this study, we investigated the clinicopathologic significance of the low-affinity p75 neurotrophin receptor (p75NTR; which is expressed in the stem/progenitor cell fraction of normal esophageal epithelial cells) in 187 resected esophageal squamous cell carcinoma (ESCC) specimens and found that ∼50% of ESCC expressed p75NTR. Our investigation using ESCC cell lines showed that p75NTR was intensely expressed in the cells with high colony-forming capacity but they were sensitive to cell death on inhibition of p75NTR expression with transient transfection of small interfering RNA (siRNA). These findings suggest that p75NTR is necessary for survival and maintenance of ESCC tumors, providing us with a potential target for novel therapies.Purpose: p75NTR is expressed in a stem/progenitor cell fraction of human normal esophageal epithelial cells. In this study, we investigated the expression and biological role of p75NTR in ESCC.Experimental Design: The expression of p75NTR in 187 resected ESCC specimens was immunohistochemically investigated. The expression of p75NTR in 30 ESCC cell lines (KYSEs) was assessed by reverse transcription-PCR, immunocytochemistry, and flow cytometry. The p75NTR-bright and p75NTR-dim/negative cells were isolated from KYSE150 by magnetic beads and colony formation was investigated. The role of p75NTR in KYSEs was assessed by transient transfection of siRNA.Results: p75NTR was expressed in 92 of 187 (49.2%) tumors. In well-differentiated tumors, positive staining was apparent in the first one to two layers from infiltrative margin of the tumors where most of the cells were actively proliferating. In moderately differentiated tumors, p75NTR was expressed in wider range from the margin of the tumors whereas p75NTR was diffusely distributed in poorly differentiated tumors. p75NTR was expressed in all examined KYSEs and the mean proportion of the p75NTR-bright fraction was 30.1%. The size of p75NTR-positive colonies was larger than that of p75NTR-negative colonies derived from KYSE150 (P < 0.0001). The purified p75NTR-bright cells formed p75NTR-positive large colonies more frequently than the p75NTR-dim/negative cells (P < 0.0001). Down-regulation of p75NTR expression by siRNA resulted in marked growth inhibition with induction of apoptosis.Conclusions: Our findings suggest that p75NTR is necessary for survival and maintenance of ESCC tumors, providing us with a potential target for novel therapies.

Purpose: We previously reported that the expression of Aurora-A was frequently up-regulated in human esophageal squamous cell carcinoma (ESCC) tissues as well as cell lines and the up-regulation contributed to a poor prognosis. In this study, we assessed the possibility of Aurora-A suppression as a therapeutic target for ESCC using ESCC cell lines.Experimental Design: We established subclones using vector-based short hairpin RNA (shRNA). Then, we investigated the effect of Aurora-A suppression on proliferation and cell cycle changes in vitro. Next, chemosensitivity against docetaxel was investigated by tetrazolium salt–based proliferation assay (WST assay) and cell number determinations, and furthermore, the type of cell death induced by docetaxel was analyzed by flow cytometry. Finally, to examine the effect of Aurora-A shRNA on proliferation and chemosensitivity against docetaxel in vivo, a s.c. tumor formation assay in nude mice was done.Results: We established two genetically different stable cell lines (510 A and 1440 A) in which levels of Aurora-A were reduced. Cell growth was inhibited by 38.7% in 510 A and by 24.3% in 1440 A in vitro compared with empty vector–transfected controls (510 m and 1440 m), and this growth inhibition was mediated through G2-M arrest as confirmed by flow cytometry. Next, in a WST assay, the IC50 for Aurora-A shRNA-transfected cells was lower than that of empty vector–transfected cells (510 A, 2.7 × 10−7 mol/L; 510 m, 4.8 × 10−7 mol/L; 1440 A, 2.6 × 10−7 mol/L; 1440 m, 4.9 × 10−7 mol/L). In addition, 0.3 nmol/L docetaxel induced a notable level of apoptosis in Aurora-A shRNA-transfected cells compared with empty vector–transfected cells. In the assay of s.c. tumors in nude mice, tumor growth in 510 A was inhibited by 36.1% compared with that in 510 m, and in tumors treated with docetaxel, the suppression of Aurora-A resulted in 44.0% tumor growth suppression in vivo.Conclusions: These results indicated that Aurora-A might play an important role in chemosensitivity to docetaxel, and the suppression of its expression might be a potential therapeutic target for ESCC.

Supplementary Figure S3 from The Suppression of Aurora-A/STK15/BTAK Expression Enhances Chemosensitivity to Docetaxel in Human Esophageal Squamous Cell Carcinoma

Supplementary Figure 3 from The Biological Role of the Low-Affinity p75 Neurotrophin Receptor in Esophageal Squamous Cell Carcinoma

Supplementary Figure Legend from The Suppression of Aurora-A/STK15/BTAK Expression Enhances Chemosensitivity to Docetaxel in Human Esophageal Squamous Cell Carcinoma

Supplementary Figures 1,2,4,5,6 from The Biological Role of the Low-Affinity p75 Neurotrophin Receptor in Esophageal Squamous Cell Carcinoma

Routine placement of a feeding jejunostomy tube (FJT) following esophagectomy remains controversial due to the risk of complications including small bowel obstruction (SBO). This study aimed to evaluate FJT placement following esophagectomy.This retrospective cohort study included consecutive 229 patients undergoing thoracoscopic esophagectomy between January 2010 and June 2020. Short-term outcomes, postoperative nutritional status, incidence of SBO, and long-term outcomes were compared between patients according to FJT placement.The total operative duration was significantly longer in the FJT group compared to the no FJT group (P 0.0001); however, no differences in overall or severe postoperative morbidity were observed. Body weight loss at discharge was significantly attenuated in patients with FJT (5% vs 7%, P = 0.001). Serum cholinesterase levels were significantly higher in patients with FJT (P = 0.002), while no difference was observed in serum albumin levels. At 6-month follow-up, no statistically significant differences were observed in serological markers or percentage body weight. The incidence of SBO was significantly higher in the FJT group (P = 0.006). The 5-year incidence of SBO was 12%. Patients in the FJT group had higher progression-free and overall survival compared to patients in the no FJT group (P = 0.041 and P = 0.033, respectively). A similar trend toward better survival in the FJT group was observed after propensity score matching.Routine placement of FJT significantly improves postoperative nutritional status and may contribute to improved long-term survival but is associated with increased long-term risk of SBO.

ASO Visual Abstract

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

Introduction In median arcuate ligament syndrome (MALS), a hyperplastic MAL causes compression and stenosis of the celiac artery (CA). The treatment involves releasing the external pressure on this artery by dissecting the ligament. However, it is difficult to identify the artery because of its deep anatomical location. Stereotactic navigation provides real-time information regarding the surgical instrument's location on computed tomography (CT) images. We utilized this system to overcome the difficulty of anatomical identification. Materials and surgical technique We present a case of aneurysm rupture caused by MALS, which was treated with laparoscopic MAL dissection with real-time stereotactic navigation. Surgery was performed in a hybrid operating room with three-dimensional C-arm CT (Artis Zeego, Siemens) and an installed Curve navigation system (BrainLab). Preoperative CT images were aligned with intraoperative C-arm CT-like images and the surgical instrument position was projected onto preoperative CT images. After the left gastric artery isolation, the fibrous tissue surrounding the left gastric artery was dissected toward the CA while confirming the location of the CA and aortic wall using the navigation system. The CA's diameter was dilated from 1.8 to 2.6 mm with intraoperative angiography. Discussion This is the first report of laparoscopic MAL dissection using real-time stereotactic navigation. Although navigation setting was time-intensive, this system helped us understand the anatomical structures and in safely and precisely dissecting the MAL.

We started robot-assisted minimally invasive esophagectomy (RAMIE) in 2012 using da Vinci S. After the reimbursement in the national insurance system in 2018, RAMIE has been indicated as an institutional standard surgery simply depending on the da Vinci availability. Our early series of 45 RAMIEs showed significantly less postoperative morbidity (p = 0.03) mainly due to less pulmonary complication (p = 0.006) compared to conventional minimally invasive esophagectomy using propensity score matching (Ann Surg Oncol. 2020). This study aims to retrospectively evaluate the feasibility of RAMIE and to demonstrate our standardized RAMIE with updated data. Our surgical technique is as follows. A patient is placed in a prone position with both lung ventilation with 8-10 mmHg artificial pneumothorax. In the upper mediastinum, the thoracic duct is usually preserved unless there is tumor invasion. Then, the tracheoesophageal arteries flowing into the visceral sheath over the recurrent laryngeal nerve (RLN) are divided first and RLN is isolated laterally. Then, the lymphatic tissue is dissected from the trachea. This procedure is identical on both sides of RLN nodal dissection. By January 2022, 89 RAMIEs (S: 6 cases and Xi: 83 cases) were performed. Thoracic operation time was 348 min and console time was 296 min. Intraoperative blood loss was 80 g and the number of harvested thoracic nodes is 23. There was no conversion from RAMIE to MIE nor to open procedure. Overall severe postoperative morbidity (Clavien-Dindo Grade 3 or higher) was 17% (15/89) and clinically relevant postoperative recurrent laryngeal nerve palsy (Clavien-Dindo Grade 2 or higher) was 10% (9/89). There was no postoperative mortality. RAMIE was safe and feasible.

Minimally invasive esophagectomy (MIE) is increasingly performed to expect lower complication rate compared to open esophagectomy. Studies of minimally invasive Ivor Lewis esophagectomy (MIILE) with circular staplers have reported better outcomes compared to MIE with cervical anastomosis, but frequent anastomotic complications have also been reported. MIILE with linear staplers is a promising alternative, but the long-term functional and oncological outcomes are uncertain. To evaluate the functional and oncological outcomes of MIILE with linear stapled anastomosis, a retrospective cohort study was performed in 104 patients who underwent MIILE with linear stapled anastomosis for esophageal malignant tumors. The primary endpoints were the overall complication and anastomotic leak rates. The secondary endpoints were late complications, overall and disease-free survival, and nutritional status at 6 and 12 months after MIILE. Anastomotic leak occurred in 4 patients (3.8%). The short-term complication rate of grade IIIb or higher was 6.7%. During a median 57-month follow-up period, anastomotic stricture occurred in one patient, 7 required hiatal hernia repair, and 2 underwent conduit revision surgery. The 5-year overall survival and disease-free survival rates were 69.3% and 59.5%, respectively. Status of reflux esophagitis at the time of most recent evaluation was grade N/A/B/C/D in 52/10/10/13/8 among 93 patients who had follow-up endoscopy. The mean body weight loss at 6 and 12 months after MIILE was 11.3 and 11.8% with maintenance of the serum albumin level. MIILE with linear stapled anastomosis is a safe procedure with a low anastomotic complication rate and favorable long-term functional and survival outcomes.

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.

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

TPS474 Background: Supraclavicular lymph nodes (SCLN) have been regarded as regional nodes of thoracic esophageal cancer in Japan and resected along with cervical paraesophageal lymph nodes as a cervical part of the standard three-field dissection, while the involvement of SCLN is regarded as distant metastasis in Western countries. However, there is no clear evidence that supports or rejects prophylactic SCLN dissection. As postoperative SCLN metastasis can often be managed by either surgery or chemoradiotherapy at the time of relapse, routine prophylactic SCLN dissection may not be essential. Here we conduct the clinical trial to confirm the non-inferiority of esophagectomy with D2 lymphadenectomy except for SCLN to standard D2 lymphadenectomy in terms of overall survival (OS) for patients with resectable upper or middle thoracic esophageal cancer. Methods: Eligibility criteria include the followings; upper or middle thoracic esophageal squamous cell carcinoma, adenosquamous carcinoma, or basaloid cell carcinoma with clinical stage I, II, III, or IVA (except for T4) based on the 8th UICC-TNM, age 18 to 80, ECOG performance status 0 or 1, and adequate organ function. Neoadjuvant chemotherapy (cisplatin plus 5- fluorouracil or docetaxel plus cisplatin plus 5-fluorouracil) is allowed, but preoperative chemoradiotherapy is not allowed. Patients are randomly assigned to the following two arms using the minimization method with a random component to balance institution, clinical stage (Stage I (T1N0M0) versus Stage I (T1N1M0)/II/III/IVA), age (76 or older versus 75 or younger), and tumor location (upper thoracic versus middle thoracic). Patients undergo either esophagectomy with standard D2 dissection (Arm A) or esophagectomy with D2 lymphadenectomy except for SCLN (Arm B). The primary endpoint is OS in all randomized patients. The secondary endpoints are relapse-free survival, the incidence of perioperative and delayed complications, the incidence of SCLN recurrence, the incidence of salvage cervical treatment, the proportion of synchronous cervical and abdominal procedure, and operation time and the number of operating surgeons. A sample size of 456 patients would be required to observe 147 events to demonstrate the non-inferiority of Arm B in terms of OS, with a one-sided alpha of 5%, power of 70%, an accrual period of 5 years, a follow-up period of 3 years, and a non-inferiority margin of 6% at 3-year OS, assuming the expected 3-year OS of Arm A and Arm B are 80% and 81%, respectively. The planned sample size was set at 480 patients (240 patients per arm). This trial was registered at the Japan Registry of Clinical Trials (jRCT) as study number jRCT1030220248 and started in August 2022. Clinical trial information: jRCT1030220248 .

The supraclavicular lymph nodes (SCLNs) have been regarded as regional nodes for esophageal squamous cell carcinoma (ESCC) in Japan and eastern Asian countries, whereas their involvement has been regarded as distant metastasis in Western countries. The importance of thorough dissection of the lymphatic chain along the recurrent laryngeal nerve, including the cervical paraesophageal nodes, has become well understood; therefore, the contemporary clinical question is whether prophylactic SCLN dissection (SLND) in addition to cervical paraesophageal node dissection is beneficial for patients with ESCC. We analyzed studies comparing esophagectomy with SLND vs. esophagectomy without SLND, in both of which cervical paraesophageal node dissection had been completed, based on a comprehensive literature search of the PubMed, Scopus, and Cochrane databases. Our meta-analysis focused on two long-term outcomes: 3-year and 5-year overall survival (OS) rates; and three short-term outcomes: pneumonia, recurrent nerve palsy, and anastomotic leakage. Four studies, with a collective total of 1584 patients were included in the review. No significant differences were found between esophagectomy with SLND vs. esophagectomy without SLND in the meta-analysis of both long-term (3-year and 5-year OS; risk ratio 1.09, 95% CI 0.94-1.26, P = 0.28, and risk ratio 1.14, 95% CI 0.96-1.35, P = 0.15, respectively) and short-term outcomes. Based on our analysis, no clear data support prophylactic SLND on the cervical paraesophageal node dissection.

Whether robot-assisted minimally invasive surgery (RAMIE) is more beneficial than conventional minimally invasive surgery (MIE) remains unclear. In total, 165 consecutive patients with esophageal carcinoma who underwent esophagectomy between January 2015 and April 2020 were retrospectively assessed. A 1:1 propensity score matching analysis was performed to compare the short-term outcomes between RAMIE and conventional MIE. After matching, 45 patients were included in the RAMIE and conventional MIE groups. RAMIE had a significantly longer total operative time (708 vs. 612 min, P < 0.001) and thoracic operative time (348 vs. 285 min, P < 0.001) than conventional MIE. However, there were no significant differences in terms of oncological outcomes, such as R0 resection rate and number of resected lymph nodes. The overall postoperative morbidity (Clavien–Dindo [C–D] grade II or higher) rate of RAMIE and conventional MIE were 51% and 73% (P = 0.03), respectively, and the severe postoperative morbidity (C–D grade III or higher) rates were 11% and 29% (P = 0.04), respectively. The incidence rate of recurrent laryngeal nerve palsy was halved in RAMIE (7%) compared with conventional MIE (20%) (P = 0.06). Finally, the pulmonary complication rate (18%) was significantly lower in patients who underwent RAMIE than in those who underwent conventional MIE (44%) (P = 0.006). RAMIE was safe and feasible, even during the early period of its application at a specialized center. Moreover, it may be a promising alternative to conventional MIE, with better short-term outcomes, including significantly lower incidence of pulmonary complications.

Many systematic reviews have been published to evaluate the clinical benefits of robotic surgery for gastric cancer. However, these reviews have investigated various outcomes and differ considerably in quality. In this overview, we summarize the findings and quality of these reviews. A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials to identify systematic reviews and meta-analyses that compared robotic surgery with laparoscopic surgery for gastric cancer. We summarized the results of the meta-analyses and evaluated the quality of the reviews using the AMSTAR-2 tool. The literature search identified 14 eligible reviews. The reviews showed that estimated blood loss was significantly less and time to resumption of oral intake was significantly shorter in patients who underwent robotic surgery than in those who underwent laparoscopic surgery. However, no significant differences in other outcomes were found between the two types of surgery. The quality of the included reviews was judged to be critically low. In conclusion, the available evidence, albeit of critically low quality, suggests that robotic surgery decreases estimated blood loss and shortens the time to resumption of oral intake in patients with gastric cancer. There is currently no high-quality evidence that robotic surgery has clinical benefits for gastric cancer patients.

This study investigated survival outcomes of resection for pulmonary malignancies after esophagectomy for esophageal carcinoma, comparing non-small cell lung cancer and pulmonary metastases. We retrospectively reviewed consecutive patients who underwent resection for pulmonary malignancies after esophagectomy for esophageal carcinoma between 2009 and 2018. The overall survival and relapse-free survival rate were assessed using Kaplan–Meier analysis. Eleven patients had non-small cell lung cancer and eight patients had pulmonary metastases from esophageal carcinoma. The 5-year overall survival rate was 92.9% in all patients with a median follow-up period of 50.4 (range: 9.1–130.2) months. While the 5-year overall survival rate was 100.0% in patients with non-small cell lung cancer, it was 85.7% in patients with pulmonary metastases from esophageal carcinoma. The 5-year relapse-free survival rate was 85.7% in patients with non-small cell lung cancer. Our data suggest that resection for pulmonary malignancies after esophagectomy for esophageal carcinoma is associated with favorable survival outcomes and should be considered in selected patients.

Epiphrenic diverticulum is frequently associated with esophageal motility disorder, including esophageal achalasia. Heller's myotomy should accompany diverticulectomy to reduce the bulging pressure in surgery for epiphrenic diverticulum with esophageal achalasia. In such cases, designing myotomy is sometimes difficult, depending on the size and location of the diverticulum. Ventrally located diverticula require special caution to spare some muscular tissue between the longitudinal staple line of the diverticulectomy and myotomy, which is a crucial step to prevent staple-line dehiscence. In this article, we describe a case with ventrally located epiphrenic diverticulum who underwent successful laparoscopic resection and myotomy for esophageal achalasia with an informative surgical video.

Highlights • We report a rare case of delayed diaphragmatic hernia caused by laparoscopic biopsy. • Coagulation for hemostasis after biopsy could cause diaphragmatic hernia. • The heat by soft coagulation might unexpectedly damage diaphragmatic muscle., Introduction Iatrogenic diaphragmatic hernias have been reported as a rare complication of abdominal surgery, and only a few reports have suggested minimal intraoperative injury to the diaphragm as a cause. Presentation of case We report a rare case of delayed diaphragmatic hernia caused by laparoscopic excisional biopsy of a peritoneal lesion on the diaphragmatic peritoneum. A 70-year-old woman with gastric gastrointestinal stromal tumor underwent laparoscopic partial gastrectomy and excisional biopsy for white nodules on the left diaphragmatic peritoneum using laparoscopic scissors. Slight bleeding that occurred after excisional biopsy was stopped using a soft-coagulation system. Six months after her first surgery, a left diaphragmatic defect and transverse colon migration into the thoracic cavity were detected on computed tomography. The patient subsequently underwent laparoscopic diaphragmatic hernia repair. The site at which the diaphragm defect occurred was consistent with the site of excisional biopsy. The defect was closed with interrupted suturing using non-absorbable threads, following which a composite mesh was applied above the suture site for reinforcement. Discussion This is the first report of an iatrogenic diaphragmatic hernia after diagnostic laparoscopy for peritoneal excision biopsy of the diaphragmatic surface. In the present case, the coagulation procedure for hemostasis after peritoneal resection was considered to be the cause of the diaphragmatic hernia. The heat generated by soft coagulation might have unexpectedly reached and damaged the deep areas of the diaphragmatic muscle. Conclusion Surgeons performing laparoscopic excisional biopsy of the diaphragmatic peritoneum should consider the potential risk for iatrogenic diaphragmatic hernias.

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.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To compare the efficacy and safety the anterior and posterior mediastinal reconstruction routes after esophagectomy in patients with esophageal cancer.

Background Previous studies have suggested that patients with esophageal squamous cell carcinoma (ESCC) are still at a high risk of developing second primary malignancies (SPMs) after definitive therapies. We evaluated the development of SPMs and explored its risk factors in patients with clinical T1bN0 ESCC. Methods JCOG0502 prospectively compared esophagectomy with definitive chemo-radiotherapy for clinical T1bN0 ESCC. Here, we reviewed all JCOG0502 patients’ data for SPMs and investigated the risk factors for SPMs using uni-variable and multivariable analyses by Fine and Gray model. Results Among 379 enrolled patients, 213 underwent esophagectomy and 166 received chemo-radiotherapy. Patient characteristics were male (85%); median age [63 (range 41–75) years; location of the primary tumor (upper/middle/lower thoracic esophagus, 11%/63%/27%, respectively]; alcohol consumption history (79%); smoking history (66%); prevalence of no/several/many/unknown Lugol-voiding lesions (LVLs) (45%/36%/8%/11%, respectively). In a median follow-up of 7.1 years, 118 SPMs occurred in 99 (26%) patients. Cumulative incidences of SPMs after 3, 5, and 10 years were 9%, 15%, and 36%, respectively. The most common primary tumor sites were the head and neck (35%), stomach (20%) and lungs (14%). In multivariable analyses, compared to no LVLs, several LVLs [hazard ratio (HR) 2.24, 95% confidential interval (CI) 1.32–3.81] and many LVLs (HR 2.88, 95% CI 1.27–6.52) were significantly associated with the development of SPMs. Sixteen patients died due to the SPMs. Conclusion The incidence of SPMs was high. The presence of LVLs, which was a predictive factor for SPMs, may be useful for surveillance planning.

Da Vinci Surgical System Xi was introduced in our institution in 2017. Since then we started robot-assisted minimally invasive esophagectomy (RAMIE) as private practice. Japanese national insurance system started to reimburse RAMIE in 2018. Since then, the number of RAMIE is explosively increasing. Currently the indication of RAMIE in our institution purely depends on machine availability. However, the real clinical benefit of RAMIE over conventional minimally invasive esophagectomy (MIE) remains unknown. Methods Between January 2015 and January 2020, data of 156 consecutive patients with esophageal carcinoma undergoing esophagectomy was retrospectively reviewed. After exclusion of 12 salvage esophagectomy for patients after definitive chemoradiotherapy (>50Gy), 10 mediastinoscopic esophagectomy, 5 esophagectomy without upper mediastinal dissection, 2 two-stage esophagectomy and 1 total pharyngo-laryngo-esophagectomy, 126 patients (46 RAMIE and 80 MIE) were included in the analysis. The 1:1 propensity score match analysis was performed to compare the short-term outcomes between RAMIE and MIE. Results After matching, 45 RAMIE and 45 MIE were analyzed. RAMIE took significantly longer thoracic operation time (370 min vs. 288 min; P Conclusion Although this result contains our early learning curve period of RAMIE, short term outcome of RAMIE is acceptable from a safety point of view.