Concerns of quality, utility, and reliability of laparoscopic gastrectomy for gastric cancer in public video sharing platform.

BACKGROUND: The rapid expansion of laparoscopic gastrectomy (LG) for gastric cancer has generated interest among surgeons. The adequate dissemination of correct information about such advanced laparoscopic surgery can certainly be useful for surgeons and trainees. Online video resources such as YouTube are frequently used for education. This study aimed to evaluate the quality, utility, and completeness of LG videos for gastric cancer on the video website YouTube. METHODS: The terms "laparoscopic gastrectomy" and "gastric cancer" were searched on YouTube on August 16, 2019. The first 100 videos in three sorting categories (website's default setting, view count, and length of duration) were checked by two experienced surgeons. The popularity was evaluated with the video power index (VPI). The reliability was measured using the Journal of American Medical Association (JAMA) benchmark criteria. The educational value and completeness were evaluated with a checklist developed by the researchers. RESULTS: A total of 102 videos were analyzed. Laparoscopic distal gastrectomy (LDG) and laparoscopic total gastrectomy were the most frequently recorded techniques. Lymph node (LN) dissection was the most frequently covered topic (89.2%), followed in descending order by GI reconstruction (87.3%). The mean VPI, JAMA benchmark score and completeness score of all videos were 2.63, 1.94 and 8.53, respectively. The types of sources were as follows: private users, 73 (71.6%); academic institutions, 20 (19.6%); and others, 9 (8%). A total of 97 videos with an identifiable primary surgeon originated from eighteen different countries. CONCLUSIONS: Laparoscopic videos represented by YouTube represent a useful and appropriate educational tool. However, the quality of videos varied, and the level of information incompleteness was fairly high due to insufficient reviews. The role of private uploaders and academic institutions in surgical education cannot be overestimated. It is necessary that surgeon trainers and surgical educators critically analyze the quality of video content and exercise responsibility in directing trainee surgeons. In the current era, it is best for trainees to search for peer-reviewed content.

Hemi-double stapling technique performed with a transorally inserted anvil for esophagojejunostomy in the surgical treatment of gastric cancer.

INTRODUCTION: A transorally inserted anvil has been developed to facilitate the creation of a stapled anastomosis without the need for a purse string to secure the anvil into place during laparoscopic total gastrectomy (LTG). We describe a hemi-double stapling technique and application of a transorally inserted anvil for esophagojejunostomy during LTG, and we report the results of a retrospective study in which we examined the feasibility and safety of this method. We also describe the key technical details of the method. METHODS: Our anastomotic method has four chief features: (a) the esophagus is cut at a slant, and its left cut end is cut and punched for the hemi-double stapling technique; (b) the anvil and circular stapler are connected, placing the distal jejunum in cranial traction; (c) a single layer of sutures is used to correct dog-earing and overlapping, and these points are completely closed with Lembert sutures; and (d) the jejunal limb is fixed to the duodenal stump to prevent kinking of the jejunal limb and to decrease tension on the anastomosis. RESULTS: This method has been used in 53 patients thus far. LTG with Roux-en-Y reconstruction was successful in all patients, and there was no need for conversion to open surgery. The mean operative time was 313 minutes, and the mean blood loss was 106 mL. The mean postoperative hospital stay was 18 days. There was no anastomotic leakage or stenosis. CONCLUSION: Hemi-double stapling technique with a transorally inserted anvil for LTG can be performed safely and easily and safely. It can also product good outcomes.

[A Case of Advanced Gastric Cancer with Pathological Complete Response after Chemotherapy(S-1/Cisplatin)].

A 68-year-old female patient presented with advanced gastric cancer and multiple hepatic tumors. Upper GI endoscopy showed a type 3 lesion in the posterior wall of the gastric body. Abdominal computed tomography revealed multiple liver metastases, and staging laparoscopy identified peritoneal dissemination. She was diagnosed with clinical Stage Ⅳ gastric cancer(cT3N2M1H1). She received 3 courses of combined chemotherapy containing S-1 and cisplatin. The therapeutic response was PR. We performed total gastrectomy with D2 lymph node dissection and splenectomy. Histopathological examination revealed no residual cancer cells, indicating pCR. She continued S-1 adjuvant chemotherapy and has remained free from recurrence for 18 months.

Technique and outcome of percutaneous endoscopic transgastric jejunostomy for continuous infusion of levodopa-carbidopa intestinal gel for treatment of Parkinson's disease.

Objective: A new method of drug delivery via the small bowel, continuous infusion of levodopa-carbidopa intestinal gel (LCIG), for patients with advanced Parkinson's disease (PD) has been developed and shown to improve patients' quality of life. Levodopa is infused directly and continuously into the proximal jejunum via a percutaneous endoscopic transgastric jejunostomy (PEG-J) tube that is connected to a portable infusion pump. The aim of this study was to evaluate the safety and outcomes of our PEG-J technique performed in advance of LCIG therapy in patients with advanced PD. Material and methods: We reviewed the cases of 37 patients who underwent PEG-J for LCIG therapy at our hospital between November 2016 and May 2018. Pull-through percutaneous endoscopic gastrostomy (PEG) and gastropexy were performed in all patients. The J-tube was inserted through the PEG tube and placed beyond the ligament of Treitz endoscopically under fluoroscopic guidance. After two weeks, the gastropexy sutures were removed. Results: PEG-J with placement of the tube beyond the ligament of Treitz was successful in all 37 patients. Median procedure time was 26.4 min. Median hospital stay after the procedure was 16 days. Median follow-up with the PEG-J tube in place was 11 months. There were five procedure-related complications (13.5%) and 13 device-related complications (35.1%). There was no death related to the procedure. Conclusions: Our PEG-J technique can be performed safely in patients with advanced PD, and favorable outcomes have been achieved to date.

Triple-stapled quadrilateral anastomosis: a new technique for creation of an esophagogastric anastomosis.

BACKGROUND: Esophagogastric anastomosis performed after esophagectomy is technically complex and often the source of postoperative complications. The best technique for this anastomosis remains a matter of debate. We describe a new all-stapled side-to-side anastomosis, which we refer to as triple-stapled quadrilateral anastomosis (TRIQ), that can be performed after minimally invasive surgery, and we report results of a retrospective evaluation of postoperative outcomes among the 60 patients in whom this anastomosis has been performed thus far. METHODS: The anastomosis is created by apposition of the posterior walls of the esophagus and stomach. A linear stapler is applied to create a V-shaped posterior anastomotic wall. The anterior wall is closed in a gentle chevron-like shape with the use of 2 separate linear staplers, resulting in a wide quadrilateral anastomosis. The anastomosis is then wrapped with a greater omentum flap. RESULTS: The patient group comprised 48 men and 12 women with a mean age of 67.8 years. Neoadjuvant chemotherapy was performed in 43 of these patients. Neither the thoracoscopic or laparoscopic procedure was converted to open surgery in any patient. The median operation time was 474 min (range 680-320 min). The intraoperative blood loss volume was 104.4 mL (range 240-30 mL). There were no anastomosis-related complications above Clavien-Dindo grade II. CONCLUSIONS: TRIQ can be performed easily and safely, and good short-term outcome can be expected.

Augmented rectangle technique for Billroth I anastomosis in totally laparoscopic distal gastrectomy for gastric cancer.

BACKGROUND: Billroth I reconstruction is a means of anastomosis that is widely performed after surgical resection for distal gastric cancer. Interest has grown in totally laparoscopic gastrectomy, and several methods for totally laparoscopic performance of Billroth I reconstruction have been reported. However, the methods are cumbersome, and postoperative complications such as twisting at the site of anastomosis and obstruction due to stenosis have arisen. We developed an augmented rectangle technique (ART) by which the anastomosis is created laparoscopically with the use of three automatic endoscopic linear staplers, and the resulting anastomotic opening is wide and less likely to become twisted or stenosed. The technical details of our ART-based Billroth I anastomosis are presented herein along with results of the procedure to date. METHODS: The technique was applied in 160 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer between December 2013 and August 2017. Clinicopathological data, surgical data, and postoperative outcomes were analyzed. RESULTS: During surgery, there were no troubles associated with gastrointestinal reconstruction and there was no transition to laparotomy. There were no postoperative complications, including suture failure and stenosis, associated with the gastrointestinal reconstruction, and the average postoperative hospital stay was 12 days. CONCLUSION: Totally laparoscopic ART-based Billroth I reconstruction is both feasible and safe. We expect this technique to contribute to the spread of safe totally laparoscopic surgery for gastric cancer.

A Case of Laparoscopic Resection for Carcinoma of the Gastric Remnant following Proximal Gastrectomy Reconstructed with Jejunal Interposition.

A 72-year-old Japanese man had a history of proximal gastrectomy for early gastric cancer located in the upper third of the stomach in 2007. Our usual treatment strategy for early gastric cancer in the upper third of the stomach in 2007 was open proximal gastrectomy reconstructing by jejunal interposition with a 10 cm single loop. Upper gastrointestinal fiberscopy for annual follow-up revealed a type 0-IIc-shaped tumor with ulcer scar, 4.0 cm in size, located in the gastric remnant near the jejunogastrostomy. A clinical diagnosis of cancer of the gastric remnant, clinical T1b(SM)N0M0, Stage IA, following the proximal gastrectomy was made and a laparoscopic approach was selected because of the cancer's early stage. Remnant total gastrectomy with D1 plus lymphadenectomy was carried out with five ports by a pneumoperitoneal method. Complete resection of the reconstructed jejunum was undergone along with the jejunal mesentery. Reconstruction by the Roux-en-Y method via the antecolic route was selected. Total operative time was 395 min and blood loss was 40 mL. Our patient was the first successful case of resection for carcinoma of the gastric remnant following proximal gastrectomy reconstructed with jejunal interposition in a laparoscopic approach.