Efficacy of Pancreatic Dissection With a Triple-row Stapler in Laparoscopic Distal Pancreatectomy: A Retrospective Observational Study.

BACKGROUND: Postoperative pancreatic fistulas (POPFs) occur after 20% to 30% of laparoscopic distal pancreatectomies. This study aimed to evaluate the clinical efficacy of laparoscopic distal pancreatectomy using triple-row staplers in preventing POPFs. METHODS: Between April 2016 and May 2023, 59 patients underwent complete laparoscopic distal pancreatectomies. There were more females (n=34, 57.6%) than males (n=25, 42.4%). The median age of the patients was 68.9 years. The patients were divided into slow-compression (n=19) and no-compression (n=40) groups and examined for pancreatic leakage. Both groups were examined with respect to age, sex, body mass index (BMI), pancreatic thickness at the pancreatic dissection site, pancreatic texture, diagnosis, operative time, blood loss, presence of POPF, date of drain removal, and length of hospital stay. In addition, risk factors for POPF were examined in a multivariate analysis. RESULTS: Grade B POPFs were found in 9 patients (15.3%). Using univariate analysis, the operative time, blood loss, postoperative pancreatic fluid leakage, day of drain removal, and hospital stay were shorter in the no-compression group than in the slow-compression group. Using multivariate analysis, the absence of POPFs was significantly more frequent in the no-compression group (odds ratio, 5.69; 95% CI, 1.241-26.109; P=0.025). The no-compression pancreatic dissection method was a simple method for reducing POPF incidence. CONCLUSIONS: The method of quickly dissecting the pancreas without compression yielded better results than the method of slowly dissecting the pancreas with slow compression. This quick dissection without compression was a simple and safe method that minimized postoperative pancreatic fluid leakage, shortened the operative time and length of hospital stay, and reduced medical costs. Therefore, this method might be a clinically successful option.

The association between surgical site infection and postoperative colorectal cancer recurrence and the effect of laparoscopic surgery on prognosis.

PURPOSE: Studies have shown that surgical site infection (SSI) incidence is lower in patients undergoing laparoscopic surgery. Therefore, we reported the SSI countermeasures adopted by our institution and aimed to evaluate the association between SSI occurrence and postoperative colorectal cancer recurrence and the usefulness of laparoscopic surgery for prognosis. METHODS: Among the patients with colorectal cancer who underwent radical surgery at our hospital between January 2015 and December 2017, 197 with stage I-III cancer without distant metastases were included. We retrospectively analyzed patients' electronic medical records and classified them into the non-SSI (without SSI, n = 159) and SSI (with SSI, n = 38) groups. We calculated and compared the 5-year relapse-free survival (RFS) and overall survival (OS) rates. Additionally, we assessed the relationship between prognosis in the non-SSI, incisional SSI, and organ/space SSI groups and the usefulness of laparoscopic surgery. RESULTS: The 5-year RFS and OS were 80.5% versus 63.2% (P = 0.024; hazard ratio [HR], 2.065; 95% confidence interval [CI], 1.099-3.883) and 88.7% versus 84.2% (P = 0.443; HR, 1.436; 95% CI, 0.570-3.617), respectively. The SSI group had a significantly worse 5-year RFS prognosis. Regarding the relationship with laparoscopic surgery, the SSI incidence was 45.0% (9/20 cases) and 16.4% (29/177 cases) with laparotomy and laparoscopic surgery, respectively, indicating a significantly reduced SSI occurrence with laparoscopic surgery (P = 0.005). CONCLUSION: Patients with SSI were at high risk for colorectal cancer recurrence, and laparoscopic surgery may be useful for reducing SSI.

Subserosal Layer and/or Pancreatic Invasion Based on Anatomical Features as a Novel Prognostic Indicator in Patients with Distal Cholangiocarcinoma.

The American Joint Committee on Cancer (AJCC) 8th edition T-staging system for distal cholangiocarcinoma (DCC) proposes classification according to the depth of invasion (DOI); nevertheless, DOI measurement is complex and irreproducible. This study focused on the fibromuscular layer and evaluated whether the presence or absence of penetrating fibromuscular invasion of DCC contributes to recurrence and prognosis. In total, 55 patients pathologically diagnosed with DCC who underwent surgical resection from 2002 to 2022 were clinicopathologically examined. Subserosal layer and/or pancreatic (SS/Panc) invasion, defined as penetration of the fibromuscular layer and invasion of the subserosal layer or pancreas by the cancer, was assessed with other clinicopathological prognostic factors to investigate recurrence and prognostic factors. According to the AJCC 8th edition, there were 11 T1, 28 T2, and 16 T3 cases, with 44 (80%) cases of SS/Panc invasion. The DOI was not significantly different for both recurrence and prognostic factors. In the multivariate analysis, only SS/Panc was identified as an independent factor for prognosis (hazard ratio: 16.1; 95% confidence interval: 2.1-118.8, p = 0.006). In conclusion, while the determination of DOI in DCC does not accurately reflect recurrence and prognosis, the presence of SS/Panc invasion may contribute to the T-staging system.

Endovascular treatment of postoperative hemorrhage after pancreatectomy: a retrospective study.

BACKGROUND: Ruptured aneurysm is a serious complication of distal pancreatectomy (DP) or pancreatoduodenectomy (PD) that can be life-threatening if not treated promptly. This study aimed to examine the efficacy of a Viabahn stent graft for stopping bleeding after pancreatectomy. METHODS: Between April 2016 and June 2022, we performed 245 pancreatectomies in our institution. Six patients experienced postoperative bleeding and underwent endovascular treatment. RESULTS: All six cases of bleeding occurred post-PD (3.7%). The bleeding was from gastroduodenal artery (GDA) pseudoaneurysms in three patients, and Viabahn stent grafts were inserted. All three patients did not show liver function abnormalities or hepatic blood flow disorders. One patient with a Viabahn stent graft experienced rebleeding, which required further management to obtain hemostasis. Of the six cases in which there was hemorrhage, one case of bleeding from the native hepatic artery could not be managed. CONCLUSIONS: Using the Viabahn stent graft is an effective treatment option for postoperative bleeding from GDA pseudoaneurysms following PD. In most cases, using this device resulted in successful hemostasis, without observed abnormalities in hepatic function or blood flow.

Factors contributing to nonalcoholic fatty liver disease (NAFLD) and fat deposition after pancreaticoduodenectomy: A retrospective analysis.

Aim: Nonalcoholic fatty liver disease (NAFLD) can occur due to various reasons after pancreaticoduodenectomy (PD). This study examined the risk and perioperative determinants of NAFLD and fat deposition after PD. Methods: A total of 101 patients who had undergone computed tomography 6 months after PD were included. We compared perioperative factors between patients who developed NAFLD and those who developed fatty deposits after PD. Results: In the NAFLD group, pancreatic cancer was significantly more prevalent among patients who developed postoperative NAFLD (p = 0.024) and had a lower postoperative body mass index (BMI; p = 0.008). Multivariate analysis revealed that pancreatic carcinoma (hazard ratio [HR] 4.42, 95% confidence interval [CI] 1.118-17.442, p = 0.034) and lower postoperative BMI (HR 0.51, 95% CI 0.274-0.954, p = 0.0355) were risk factors for fatty liver. Pancreatic leakage (p = 0.024) and postoperative BMI (p = 0.002) were significantly lower in the fat deposition group than those in the NAFLD group. Multivariate analysis also revealed that a lower postoperative BMI was a risk factor for fat deposition (HR 0.56, 95% CI 0.523-0.982, p = 0.042). Moreover, multivariate analysis revealed that the fat deposition group had significantly lower pancreatic leakage than the NAFLD group (HR 7.944, 95% CI 1.993-63.562, p = 0.049). Conclusion: The findings of this study suggest that postoperative BMI and pancreatic cancer are associated with a higher risk of NAFLD after PD, possibly because of pancreatic exocrine insufficiency and impaired fat absorption.

A single-center retrospective analysis of the efficacy and safety of a modified regimen of irinotecan plus S-1 (IRIS) with molecular targeting agents as second-line chemotherapy in Japanese patients with recurrent or nonresectable colorectal cancer.

Background: As the second-line chemotherapy for stage IV recurrent or nonresectable colorectal cancer, our hospital started a modified treatment regimen comprising of irinotecan plus S-1 (IRIS) [tegafur/gimeracil/oteracil (S-1)] plus molecular targeting agents (MTAs), i.e., an epidermal growth factor receptor (EGFR) inhibitor such as panitumumab (P-mab) or cetuximab (C-mab) or vascular endothelial growth factor (VEGF) inhibitor such as bevacizumab (B-mab) since October 2012. The purpose of this study is to evaluate the efficacy and safety of this modified regimen. Methods: This retrospective study included 41 patients with advanced recurrent colorectal cancer at our hospital whom at least 3 courses of chemotherapy were conducted from January 2015 to December 2021. Based on the location of the primary tumor, patients were classified into two group (right-sided group, proximal to the splenic curve, and left-sided, distal to the splenic curve). We assessed archived data on RAS and BRAF status and UGT1A1 polymorphisms and use of the VEGF inhibitor bevacizumab (B-mab) and the EGFR inhibitors panitumumab (P-mab) and cetuximab (C-mab). In addition, progression-free survival rate (36M-PFS) and the overall survival rate (36M-OS) were calculated. Furthermore, the respective median survival time (MST), the median number of treatment courses; the objective response rate (ORR) and clinical benefit rate (CBR) and the incidence of adverse events (AEs) were assessed as well. Results: There were 11 patients (26.8%) in the right-sided group, and 30 patients (73.2%) in the left-sided group. There were 19 patients with RAS wild type (46.3%) (1 in the right sided group and 18 in the left sided group). P-mab was used for 16 of these patients (84.2%), C-mab for 2 (10.5%), and B-mab for 1 (5.3%); the remaining 22 patients (53.7%). Ten patients in the right group and 12 patients in the left group were a mutated type and received B-mab. BRAF testing was performed in 17 patients (41.5%); as more than 50% of patients (58.5%) were included before the assay's introduction. Five patients in the right-sided group and 12 patients in the left-sided group had wild type. There was no mutated type. UGT1A1 polymorphism was tested in 16/41 patients: Eight were wild type (8/41 patients, 19.5%) and 8, mutated type. Regarding the *6/*28 double heterozygous type, there was only 1 patient in the right-sided group and the remaining 7 patients were in the left-sided group. The total number of chemotherapy courses was 299, and the median number, 6.0 (range, 3-20). PFS, OS, and MST were as follows: 36M-PFS (total/Rt/Lt), 6.2%/0.0%/8.5% (MST; 7.6/6.3/8.9 months); and 36M-OS (total/Rt/Lt), 32.1%/0.0%/44.0% (MST; 22.1/18.8/28.6 months). The ORR and CBR were 24.4% and 75.6%, respectively. The majority of AEs were grades 1 or 2 and were improved with conservative treatment. Grade 3 leukopenia was observed in 2 cases (4.9%), neutropenia in 4 cases (9.8%), and malaise/nausea/diarrhea/perforation in 1 case each (2.4%). Grade 3 leukopenia (2 patients) and neutropenia (3 patients) were more commonly observed in the left-sided group. Diarrhea and perforation were also common in the left-sided group. Conclusions: This second-line modified IRIS regimen with MTAs is safe and effective and results in good PFS and OS.

Functional evaluations comparing Billroth I with a large remnant stomach and Roux en Y with a small remnant stomach following laparoscopic distal gastrectomy for gastric cancer: An investigation including laparoscopic total gastrectomy.

PURPOSE: This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively. METHODS: We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5). RESULTS: Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups. CONCLUSIONS: L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

A 73-Year-Old Woman Treated for Rheumatoid Arthritis with Lower Rectal Carcinoma Who Underwent Abdominoperineal Resection, Lateral Regional Lymph Node Resection, and Partial Hepatectomy by Hand-Assisted Laparoscopic Surgery (HALS): A Case Report.

BACKGROUND This report describes the case of a 73-year-old woman treated for rheumatoid arthritis with lower rectal carcinoma who underwent abdominoperineal resection, lateral regional lymph node resection, and partial hepatectomy by hand-assisted laparoscopic surgery (HALS). More recently, HALS has proven to be useful in multiple organ resections. CASE REPORT A 73-year-old woman who presented with hematochezia was diagnosed with lower rectal cancer and referred to our hospital. The patient had a history of rheumatoid arthritis and was taking oral nonsteroidal anti-inflammatory drugs. After further evaluation, the patient was diagnosed with stage IV rectal cancer with a metastatic liver lesion and a right lateral lymph node metastasis. All lesions were resected using HALS. A 50-mm longitudinal umbilical incision was created for use as a hand access site, and 3 ports with a diameter of 5 mm each were inserted into the lower abdomen to perform right lateral lymph node dissection and abdominoperineal resection. HALS was performed in the upper abdomen, where the liver was used to partially resect segment S6. The patient was discharged without complications 13 days after the operation. CONCLUSIONS In this complex case of advanced rectal carcinoma with liver metastases, use of the HALS surgical method was shown to be possible. Immunomodulatory treatment for rheumatoid arthritis may have influenced the outcome for this patient.

Efficacy of hand-assisted laparoscopic surgery (HALS) in older adult patients (≥80 years) with primary colorectal cancer.

Background: From 2004 to 2014, 821 colorectal cancer primary resections were conducted at our institution. Of these, 102 patients (12.4%) were older adults over 80 years old. underwent either the conventional laparotomy group (72 patients) or the hand-assisted laparoscopic surgery (HALS) group (30 patients). Methods: Data were extracted for 102 patients over 80 years old who underwent primary resection for colorectal cancer and were divided into two groups: conventional laparotomy (CL) (n=72) and hand-assisted laparoscopy (n=30). Pre-operative characteristics and outcomes were compared. Results: Baseline characteristics were similar between groups, except for age: CL group median 83.5 years old (range, 80-92 years old) and hand-assisted laparoscopy (HALS) group median 81.5 years old (range, 80-88 years old) (P=0.027). Pre-operative cardiac and lung function risk, performance status, and pathological classification stage (pStage) were almost similar between groups (P=0.668, P=0.176, P>0.999, P=0.217). No significant differences were found for operation time. The HALS group resulted in less blood loss (median 204 mL in the CL group and median 68 mL in the HALS group, P=0.003), shorter postoperative hospital stay (median was 18 days in the CL group and median was 12 days in the HALS group, P<0.001), and fewer postoperative wound infections (18 cases in the CL group and 2 cases in the HALS group, P=0.034). Five-year relapse-free survival (5Y-RFS) was 48.1% in the CL group and 73.3% in the HALS group (P=0.028). Five-year overall survival (5Y-OS) was 48.2% in the CL group and 73.3% in the HALS group (P=0.027). Conclusions: Approximately 70% of surgical treatment for patients over 80 years old with colorectal carcinoma were performed by CL. However, HALS had significant advantages including less blood loss, fewer wound infections, and shorter hospital stays. Therefore, HALS could proactively be considered to older adult patients with colorectal cancer.

Fibrin glue injection method for complex fistula after laparoscopic distal pancreatectomy: a case report.

BACKGROUND: Pancreatic fistula is the most problematic complication in pancreatectomy. Although drainage can be used to relieve this complication, pancreatic surgeons often encounter refractory pancreatic fistula. Fibrin glue injection, with the use of a twofold diluted solution B and a double-lumen tube, was found effective in treating this complicated pancreatic fistula. CASE PRESENTATION: We report the case of a 64-year-old Japanese man who underwent laparoscopic distal pancreatectomy for pancreatic tail cancer. After initial drainage of the pancreatic fistula diagnosed 4 days postoperatively, on day 134, refractory pancreatic fistula was observed using contrast-enhanced computed tomography. We used fibrin glue injection, with a twofold diluted solution containing thrombin and calcium chloride and a double-lumen tube, for treating the refractory fistula; the fluid drainage was almost stopped with no fever or abdominal pain. No recurrence of pancreatic cancer has been observed since the procedure. CONCLUSIONS: Fibrin glue injection was effective for complicated pancreatic fistula after distal pancreatectomy. Using a twofold diluted solution B containing thrombin and calcium chloride and a double-lumen tube makes possible the thorough injection of fibrin glue.

Impact of Subclassification of Serosal Invasion on the Survival of Patients With T4a Gastric Cancer.

BACKGROUND/AIM: In the Japanese Classification of Gastric Carcinoma, T4a gastric cancer is defined as tumor invasion contiguous to the serosa or penetrating the serosa with exposure to the peritoneal cavity. The aim of this study was to assess the impact of T4a subclassification of gastric cancer on survival. PATIENTS AND METHODS: A total of 326 patients with T4a cancer who had undergone gastrectomy were enrolled. The T4a tumors were classified into two groups: serosa-contiguous or serosa-exposed. RESULTS: The serosa-exposed group had a significantly worse prognosis, and multivariate analysis identified the T4a subclass as an independent prognostic factor. Analysis of the risk factors for recurrence identified the T4a subclass as a significant risk factor for peritoneal recurrence in patients undergoing curative gastrectomy. CONCLUSION: The serosa-contiguous and serosa-exposed subgroups of T4a gastric cancer showed different biological behaviors. These groups may need to be treated as separate.

Postoperative functional evaluation of gastrectomy for gastric cancer.

To improve the quality of surgical procedures for gastric cancer, it is essential to consider many components comprehensively, including gastric motility, small intestinal absorption, hormones that affect gastric motility and appetite, presence or absence of vagus nerve preservation, esophageal regurgitation on endoscopic findings, in addition to whether or not there is a physiological route for food passage through the duodenum. Furthermore, proper functional evaluation cannot be performed without considering the form and amount of energy in the nutritional supplement to be loaded, and the posture at the time of investigation. The results of functional evaluation vary according to the method selected from many available options, but we believe that use of the most physiologically accurate, appropriate and selectable option will enable us to arrive at the best resection/reconstruction technique. We have reported that it is important to consider the preservation of three elements when performing gastrectomy: 1) reduction of the extent of gastrectomy, 2) preservation of the pylorus, and 3) preservation of the vagus nerve; among which preservation of the remnant stomach is the most important. Furthermore, the selection of a reconstruction method that maintains secretion of hormones beneficial to gastric motility preserves the energy balance inherent in the human body, and also provides better quality of life.

Scatter patterns in lymph node metastases as a novel prognostic indicator in patients with stage III/N2 colorectal cancer.

To classify patients with stage III/N2 colorectal cancer into high- and low-risk groups for recurrence, the present study compared clinicopathological features by immunohistochemical staining. The single-center analysis included 53/668 patients (7.9%) with stage III/N2 colorectal cancer who underwent radical resection between January 2006 and December 2014. The present study examined cancer cell distribution in metastatic lymph nodes and classified patients into a group with circumferential localization patterns like a cystic mass (CLP) and a group with scatter patterns like fireworks (SPF). Subsequently, 5-year relapse-free survival (5Y-RFS) and 5-year overall survival (5Y-OS) rates were compared and the histological type (differentiation degree) of the primary adenocarcinoma was included. The CLP group included 16 patients (30.2%) and the SPF group included 37 patients (69.8%). The 5Y-RFS rates in these groups were 75.0 vs. 37.8%, respectively (P=0.021), and the 5Y-OS rates were 81.3 vs. 48.6% (P=0.033). Patient clinicopathological characteristics exhibited no significant differences between groups. The adenocarcinoma was well differentiated in 14 patients (Well; 26.4%) and moderately (Mod; n=37) or poorly (Por; n=2) differentiated in 39 patients (Mod+Por; 73.6%). Patients were further classified into four groups: Well/CLP (n=6), Well/SPF (n=8), Mod+Por/CLP (n=10) and Mod+Por/SPF (n=29). For Well/CLP vs. Well/SPF, the 5Y-RFS rates were 66.7 vs. 25.0%, respectively (P=0.293), and for Mod+Por/CLP vs. Mod+Por/SPF (80.0 vs. 41.4%; P=0.052), the respective values for 5Y-OS were 66.7 vs. 50.0% (P=0.552) and 90.0 vs. 48.3% (P=0.059). Based on the aforementioned results, the CLP group was considered a low-risk group for recurrence with a relatively good prognosis; however, the SPF group was considered a high-risk group for recurrence with a poor prognosis, suggesting a need for more potent multi-combination chemotherapy in these patients from the early postoperative period.

A patient with paraganglioma undergoing laparoscopic resection: A case report.

Paraganglioma is a very rare extraadrenal nonepithelial tumor. The number of cases of laparoscopic surgery in Paraganglioma is small and controversial. This study encountered a case of successful transperitoneal laparoscopic surgery for a 56-mm paraganglioma in a 53-year-old female. Moreover, previous reports on laparoscopic surgery for paraganglioma are reviewed.

Efficacy of modified bevacizumab-XELOX therapy in Japanese patients with stage IV recurrent or non-resectable colorectal cancer.

BACKGROUND: Neoadjuvant chemotherapy (NAC) has been conducted for patients with non-resectable colorectal cancer; however, few reports of a systematic approach to NAC exist. At our hospital, bevacizumab with capecitabine and oxaliplatin (B-mab XELOX) has been used as chemotherapy for Stage IV colorectal cancer since 2014. We aimed to evaluate the efficacy and safety of NAC with a molecular-targeting agent for Stage IV colorectal cancer. METHODS: A retrospective, single-institute analysis was performed including 27 patients with advanced recurrent cancer following primary tumor resection and 43 patients with non-resectable tumors and remote metastasis. At the time of resection, 17 were receiving chemotherapy. All 70 patients received at least 3 cycles of B-mab XELOX (total: 920 cycles). We determined the 1-year progression-free survival (1Y-PFS), 1-year overall survival (1Y-OS), 3Y-PFS, 3Y-OS, and number of treatment cycles. The objective response rate, clinical benefit rate, and adverse events were assessed. The number of chemotherapy cycles, survival time, and R0 surgery rate were determined for patients who underwent RO conversion surgery. RESULTS: The 1Y-PFS was 28.5% [median survival time (MST): 7.4 months], 1Y-OS was 76.6% (MST not reached), 3Y-PFS was 5.5% (MST: 7.4 months), and 3Y-OS was 26.4% (MST: 25.2 months). The mean and median number of cycles of B-mab XELOX was 13.1 and 10.5, respectively. The objective response rate was 28.6%, and the clinical benefit rate was 58.6%. Grade 1 or Grade 2 adverse events occurred in 60 patients (85.7%); however, they all resolved without intervention. A single Grade 4 event (perforation of the primary tumor) occurred in 1 patient (1.4%). RO conversion surgery was performed in 7 patients (10.0%; primary + liver in 2 patients, primary + lung in 1 patient, liver in 3 patients, and primary in 1 patient). These patients received 3 to 10 cycles preoperatively (mean: 7.3; median: 6.5). R0 surgery was achieved in 5 of the 7 patients (71.4%). Postoperative survival ranged from 1 to 26 months (MST: 8 months). CONCLUSIONS: This modified regimen was safe and effective in Japanese patients, and a high quality of life/quality-adjusted life-year was achieved. To further evaluate PFS and OS, more patients are being investigated.

Preventive procedure for stenosis after esophagojejunostomy using a circular stapler and transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy and total gastrectomy involving reduction of anastomotic tension.

BACKGROUND: Recently, due to increasing reports of stenosis after esophagojejunostomy created using circular staplers and a transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy (LPG) and total gastrectomy (LTG), linear staplers are being used instead. We investigated our preventive procedure for esophagojejunostomy stenosis following use of circular staplers. METHODS: Since the anastomotic stenosis is considered to be mainly caused by tension in the esophageal and jejunal stumps at the anastomotic site, we have been performing procedures to relieve this tension, by cutting off the rubber band and pushing the shaft of the circular stapler toward the esophageal side, since July 2015. We retrospectively compared the incidence of anastomotic stenosis in cases of LPG and LTG performed before July 2015 (early phase, 30 cases) versus those performed after this period (later phase, 22 cases). RESULTS: Comparison of the incidence of anastomotic stenosis according to the type of surgery, LPG or LTG, and between the two time periods versus all cases, indicated a significantly lower incidence in the later phase than in the early phase (4.5 vs. 26.7%, p < 0.05), especially for LPG (0 vs. 38.5%, p < 0.05). CONCLUSIONS: It is possible to use a circular stapler during laparoscopic esophagojejunostomy, as with open surgery, if steps to reduce tension on the anastomotic site are undertaken. These procedures will contribute to the spread of safe and simple laparoscopic anastomotic techniques.

Pelvic local recurrence as first relapse predicts prognosis for clinical stage II/III lower rectal cancer: A clinicopathological investigation.

The present study investigated the association between the mode of tumor recurrence and prognosis in 123 patients with clinical stage II/III rectal cancer. In the past 10 years, patients received systemic chemotherapy following radical (R0, with no macroscopic residual tumor lesions) resection using total or tumor-specific mesorectal excision. Patients with rectosigmoid cancer and T4 + chemoradiation therapy were excluded from the present study. The 5-year relapse-free survival rate (5Y-RFS), 5-year overall survival rate (5Y-OS), and associations between early post-operative complications, recurrence mode and prognosis, as well as the 5Y-OS of patients with relapsed cancer, were calculated. The overall 5Y-RFS and 5Y-OS were 71.4 and 83.5%, respectively, and the overall recurrence rate was 22.8% (28/123 patients). Among relapses, remote metastases were observed in 17/123 patients (13.8%): The lung in 8 patients (6.5%), the liver in 5 patients (4.1%) and elsewhere in 4 patients (3.3%). A total of 11 patients (8.9%) had pelvic local recurrence as the first relapse, which was located anterior to the sacrum in 7 patients (5.7%), at the anastomosis site in 2 patients (1.6%), and in the inner pelvis in 2 patients (1.6%). Among relapsed patients, the 5Y-OS was 69.3% in those with distant metastases and 27.3% in those with local relapse (P=0.02; no significant differences in patient demographics). The results indicated that advanced rectal cancer and control of pelvic local recurrence are manageable by R0 resection and postoperative chemotherapy. However, for patients whose initial relapse was pelvic local recurrence, the relapsed tumor initiated a new metastatic cascade to organs, such as the lung and liver, and affected prognosis.

Short-term outcomes of OTSC for anastomotic leakage after laparoscopic colorectal surgery.

INTRODUCTION: There are several reports on the use of the over-the-scope clip (OTSC) for gastrointestinal bleeding/fistula and endoscopic iatrogenic perforation. However, there are almost no reports on OTSC use for anastomotic leakage (AL) after colorectal cancer surgery. The purpose of this study was to evaluate the outcome of AL closure using the OTSC. MATERIAL AND METHODS: Five patients who had undergone AL after laparoscopic surgery for colorectal cancer from April 2017 to April 2019 were evaluated. RESULTS: The average distance from the anal verge of the anastomosis site was 12 (5-18) cm. The average diameter of the dehiscent part was 10.9 (9.3-14.4) mm. The average number of OTSC days after the occurrence of AL was 11 (5-22). On the contrast examination immediately after OTSC, all cases were completely closed, but in the later contrast examination, only one case remained completely closed. The average incompletely closed diameter was 3.6 (2.9-5.1) mm, and the diameter of the dehiscent part was reduced in all cases. Only one patient ultimately underwent colostomy; the rest were cured with OTSC alone. CONCLUSION: AL site closure using the OTSC after colorectal cancer surgery is a useful minimally invasive treatment when combined with appropriate drain management.

Sclerosing Angiomatoid Nodular Transformation of the Spleen: A Case Report.

BACKGROUND: Sclerosing angiomatoid nodular transformation (SANT) of the spleen is a non-tumorous benign lesion that originates in the spleen and It is rare. CASE PRESENTATION: A 59-year-old man visited his physician for a checkup. Ultrasonography showed a mass in the spleen, and the patient was referred to our hospital. He tested negative for tumor markers and soluble interleukin-2 receptor (sIL-2R). Abdominal computed tomography revealed a 51-mm hypovascular mass that was slowly enhanced from the portal venous to the equilibrium phases, at the inferior extremity of the spleen. Abdominal magnetic resonance imaging showed a spoke-wheel pattern. Fluorodeoxyglucose positron emission tomography indicated a mild tumor accumulation, with a standardized uptake value max of 5.3. These results led to the suspicion of SANT, angioma, and angiosarcoma. Because the onset of malignant diseases could not be excluded, laparoscopic splenectomy was performed. A brown, round mass, without a capsule but with clear boundaries, was macroscopically observed on the cut surface. In addition, white fibrosis was found in the mass. Histopathological examination revealed nodular angioma lesions, and the proliferation of fibrotic interstices and inflammatory cells was observed between the lesions. Immunohistological examination revealed proliferation in the 3 types of narrow capillaries inside angiomatoid nodules;CD31+/CD34+/CD8-, CD31+/CD34-/CD8+, and CD31+/CD34-/CD8- cells; therefore, the patient was diagnosed with SANT. CONCLUSIONS: Here, we reported one patient who developed the typical symptoms of SANT. SANT is easily diagnosed by histopathological examination; however, its causes remain unknown. More cases with SANT are required for further analysis.

Neoadjuvant chemoradiotherapy for locally advanced gastric cancer with bulky lymph node metastasis: Five case reports.

BACKGROUND: Neoadjuvant chemoradiotherapy (NACRT) has not been accepted as a general therapy for gastric cancer because of its localized effect and toxicity for radiosensitive organs. However, if radiation therapy could compensate for the limited or inadequate treatment choices available for elderly patients and/or those at high risk, the available therapeutic options for advanced gastric cancer might increase. From this perspective, we present our experiences of five patients with advanced gastric cancer in whom we used NACRT therapy with interesting results. CASE SUMMARY: We admitted five patients with clinical Stage III gastric cancer and bulky lymph node metastasis or adjacent organ invasion at the time of diagnosis. A total of 50 Gy of preoperative intensity modulated radiation therapy was delivered to the patients in doses of 2.0 Gy/d, together with a regimen of concomitant chemotherapy comprising two courses of oral tegafur/gimeracil/oteracil (S-1; 65 mg/m2 per day) for three consecutive weeks followed by two weeks of rest, starting at the same time as radiotherapy. All patients underwent no residual tumor resection and a pathological complete response of the primary tumors was achieved in two patients. The incidence of hematological toxicity was low, although the digestive toxicities of anorexia and diarrhea developed in three of the five patients, necessitating termination of radiation therapy at 30 Gy and S-1 at three weeks. However, even 30 Gy of irradiation and half the dose of S-1 resulted in sufficient downstaging, indicating that even a reduced amount of NACRT could confer considerable effects. CONCLUSION: Slightly reduced NACRT might be useful and safe for patients with locally advanced gastric cancer.