The Amount and Concentration of Drain Amylase Together Predict Postoperative Pancreatic Fistula after Gastric Cancer Surgery More Accurately than the Concentration Alone.

INTRODUCTION: The drain amylase concentration (dAmy-C) is a useful marker for predicting pancreatic fistula after gastric cancer surgery. However, dAmy-C might be reduced in cases of high drainage volume. Therefore, we hypothesized that we could accurately assess the amount of amylase leaked from the pancreas by multiplying dAmy-C by the daily drainage volume. In this study, we investigated the clinical utility of the amount of drain amylase (A-dAmy: concentration × volume) for predicting pancreatic fistula. We investigated the clinical utility of the combination of dAmy-C and A-dAmy for predicting pancreatic fistula. METHODS: We investigated patients who underwent gastrectomy for gastric cancer at Yodogawa Christian Hospital between 2012 and 2020. The optimal cutoff levels of dAmy-C and A-dAmy on postoperative day 1 for predicting Clavien-Dindo (CD) grade II or higher pancreatic fistula was calculated using receiver operating characteristic (ROC) curves. We calculate the positive predictive value and negative predictive value for predicting pancreatic fistula using these cutoff levels. RESULTS: A total of 448 patients were eligible for analysis. Twenty-two patients experienced CD grade II or higher pancreatic fistula. ROC curves identified 1,615 IU/L as the optimal cutoff level of dAmy-C, predicting pancreatic fistula. When the simple cutoff level of dAmy-C was 1,600 IU/L, the positive predictive value for was 22.8%, and the negative predictive value was 99.7%. ROC curves identified 177.52 IU as the optimal cutoff level of A-dAmy predicting pancreatic fistula. When the simple cutoff level of A-dAmy was 177 IU, the positive predictive value was 21.2%, and the negative predictive value was 99.7%. Using these two cutoff levels together, the positive predictive value was 34.4%, and the negative predictive value was 99.7%. CONCLUSION: A-dAmy could predict and exclude pancreatic fistula after gastrectomy as with dAmy-C. The combination of dAmy-C and A-dAmy predict pancreatic fistula more accurately than dAmy-C alone.

Is the ISGPS definition of pancreatic fistula applicable after gastrectomy?

BACKGROUND: Pancreatic fistula is one of the most common and potentially fatal surgical complications after radical gastrectomy. The purpose of this study was to assess the validity of extrapolating the definition of pancreatic fistula by the International Study Group on Pancreatic Surgery to include situations surrounding gastric cancer surgery. METHODS: The clinicopathological data of 443 patients who underwent elective gastrectomy with suprapancreatic lymph node dissection (D1+, D2, or D2+ dissection) without pancreatic resection were reviewed. The relationship between postoperative pancreas-related complications (PPRC) and laboratory data, including drain fluid amylase levels on postoperative day 1 (dAmy1) and day 3 (dAmy3), were investigated. RESULTS: Twenty-four patients (5.4%) developed PPRC of ≥ grade II according to Clavien-Dindo classification. Among them, 15 patients had dAmy3 levels ≥ 375 IU/L, while all 24 patients had dAmy1 levels ≥ 375 IU/L. None of the patients with dAmy1 levels < 375 IU/L developed PPRC. The area under the curve of dAmy1 and dAmy3, calculated by drawing receiver operating characteristic curves, were 0.896 and 0.791, respectively. Univariate and multivariate analyses demonstrated that both dAmy1 and dAmy3 were significant predictors of PPRC; however, dAmy1 (p < 0.001) was more strongly correlated with PPRC than dAmy3 (p = 0.049). CONCLUSIONS: DAmy1 is more sensitive than dAmy3 as an indicator of pancreatic fistula after gastric cancer surgery.

Correction to: ASO Author Reflections: Minimally Invasive Esophagectomy for Esophageal Cancer in the Prone and Lateral Position.

This article is a duplicate publication. It was originally published under.

Correction to: Thoracic Duct Resection During Esophagectomy Does Not Contribute to Improved Prognosis in Esophageal Squamous Cell Carcinoma: A Propensity Score Matched-Cohort Study.

In the original article, there are errors in Fig. 1. Following is the corrected figure.

Tooth Loss Predicts Long-Term Prognosis of Esophageal Cancer After Esophagectomy.

BACKGROUND: Oral health is associated with various diseases, including cancer. Tooth loss is a simple and objective index of oral health. OBJECTIVE: The purpose of this study was to investigate the association between preoperative tooth loss and esophageal cancer prognosis after esophagectomy. METHODS: This study included 191 patients who underwent esophagectomy for esophageal cancer after perioperative dental evaluation and oral care at Kobe University Hospital from April 2011 to March 2016. Patients were divided into two groups: Group A (tooth loss < 7) and Group B (tooth loss ≥ 7). Three-year overall survival (OS) and multivariate analysis were performed, along with subgroup analysis for elderly patients (age ≥ 65 years). RESULTS: The 3-year OS rate was 68.1% in Group A (104 patients) and 49.2% in Group B (87 patients). Group A had significantly higher OS than Group B (p = 0.002), and there were no significant differences in sex and clinical T or N stage between the two groups. However, the mean age of Group A was younger than that of Group B (64.2 vs. 68.5 years; p = 0.0002). Among elderly patients, the 3-year OS rate was 68.2% in Group A (55 patients) and 45.1% in Group B (65 patients) [p = 0.003]. Multivariate analysis that included age demonstrated that tooth loss is an independent prognostic factor (hazard ratio 1.87, 95% confidence interval 1.22-2.87), in addition to clinical T stage and preoperative serum albumin. CONCLUSION: Tooth loss is an independent prognostic factor for esophageal cancer after esophagectomy.

Long-Term Outcomes of Thoracoscopic Esophagectomy in the Prone versus Lateral Position: A Propensity Score-Matched Analysis.

BACKGROUND: Several studies have suggested that thoracoscopic esophagectomy (TE) in the prone position (TEP) may be more feasible than TE in the lateral position (TEL); however, few studies have compared long-term survival between the two procedures. We evaluated whether TEP is oncologically equivalent to TEL. METHODS: Surgical outcomes of TEs performed from January 2006 to December 2013 at our hospital were retrospectively analyzed. Propensity score matching was used to control for confounding factors. RESULTS: TE was performed in 200 patients diagnosed with esophageal squamous cell carcinoma; 78 patients were matched in two procedures. The mean thoracic operative time in TEL was shorter than in TEP (228.9 min vs. 299.1 min; p < 0.001); however, the mean thoracic blood loss in TEL was higher than in TEP (186.9 ml vs. 76.5 ml; p < 0.001). The mean number of thoracic lymph nodes harvested in TEL was lower than in TEP (23.5 vs. 26.9; p < 0.05), and the pulmonary complication rate in TEL was higher than in TEP (30.8% vs. 15.4%; p < 0.05). The 5-year overall survival rates in pathological stage I (81.2% vs. 81.6%; p = 0.82), stage II (65.3% vs. 80.9%; p = 0.21), stage III (26.7% vs. 24.2%; p = 0.86) and all stages (63.6% vs. 62.3%; p = 0.88), and the 5-year progression-free survival rates in pathological stage I (78.0% vs. 81.8%; p = 0.54), stage II (53.5% vs. 77.6%; p = 0.13), stage III (10.5% vs. 12.8%; p = 0.81) and all stages (53.6% vs. 57.9%; p = 0.50) were not significantly different between the two procedures. CONCLUSION: TEP and TEL provide equal oncological efficiency.

Thoracic Duct Resection During Esophagectomy Does Not Contribute to Improved Prognosis in Esophageal Squamous Cell Carcinoma: A Propensity Score Matched-Cohort Study.

PURPOSE: Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal squamous cell carcinoma (ESCC). Thoracic duct (TD) resection has been recommended as part of extended lymphadenectomy, although its merits are unclear. The aim of this two-institutional, matched-cohort study is to clarify whether TD resection improves prognosis in esophagectomy for ESCC. PATIENTS AND METHODS: In this two-institutional, matched-cohort study of 399 patients with ESCC who underwent McKeown esophagectomy between 2010 and 2014, the primary outcomes were overall survival (OS), disease-free survival (DFS), and cause-specific survival (CSS). Secondary outcomes were perioperative results and recurrence patterns. RESULTS: Based on a propensity score, 122 TD-resected or 122 TD-preserved patients in all stages were selected (median follow-up 4.5 years). The 5-year OS, DFS, and CSS rates in the TD-resected versus TD-preserved groups were 49% versus 60%, 53% versus 57%, and 58% versus 70%, respectively, without any significant differences. Operative time for the thoracic procedure was significantly longer and the number of retrieved mediastinal nodes was significantly higher in the TD-resected group (P = 0.009 and 0.005, respectively). The rates of chylothorax and left recurrent laryngeal nerve (RLN) palsy were significantly higher in the TD-resected group (P = 0.041 and 0.018, respectively). There were no significant differences in rates of local or distant metastases between the two groups. CONCLUSIONS: TD resection does not contribute to improve OS, DFS, or CSS in ESCC but increases incidence of chylothorax and left RLN palsy. Prophylactic TD resection should be avoided in esophagectomy for ESCC.

Medial approach for subcarinal lymphadenectomy during thoracoscopic esophagectomy in the prone position.

PURPOSE: In esophageal squamous cell carcinoma (ESCC), lymph nodes (LNs) around the subcarina and main bronchi are thought to be highly involved. Therefore, complete dissection of these LNs with preservation of the pulmonary branches of the vagus nerves, which control important pulmonary functions, is recommended. The aim of this retrospective study was to investigate the feasibility of reliable method for lymphadenectomy around the subcarina and main bronchi, named the medial approach, during thoracoscopic esophagectomy in the prone position (TEP). METHODS: This was a case-matched control study of patients who underwent TEP for ESCC. The fundamental concept in this method is to first exfoliate the LNs around the subcarina and main bronchi from the pericardium. Developing the operative field contributes to visualizing and preserving the pulmonary branches of the right vagus nerve. Twenty-three patients who underwent the medial approach and 23 patients who underwent the conventional approach were selected by the use of propensity score matching to compare the operative outcomes. RESULTS: The medial approach significantly reduced operative time for procedure (16 ± 3 vs 30 ± 6 min, p < 0.0001) and operative blood loss (123 ± 108 vs 207 ± 162 ml, p = 0.046) comparing with conventional approach. The incidence of postoperative pneumonia was lower in the medial approach group (4%) than in the conventional approach group (15%) (p = 0.069). CONCLUSIONS: The medial approach for lymphadenectomy around the subcarina and both main bronchi during TEP is technically safe and feasible in shorting the operative time with possibility to reduce postoperative pneumonia.

Our experience with laparoscopic partial gastrectomy by the 'lift-and-cut method' for gastric gastrointestinal stromal tumor with maximal preservation of the remnant stomach.

BACKGROUND: Wedge resection is the most commonly used method in laparoscopic partial gastrectomy for gastric gastrointestinal stromal tumor (GIST). However, this method can involve inadvertent resection of additional gastric tissue and cause gastric deformation. To minimize the volume of resected gastric tissue, we have developed a laparoscopic partial gastrectomy with seromyotomy which we call the 'lift-and-cut method' for gastric GIST. Here, we report a case series of this surgery. METHOD: First, the seromuscular layer around the tumor is cut. Because the mucosa and submucosa are extensible, the tumor is lifted toward the abdominal cavity. After sufficient lifting, the gastric tissue under the tumor is cut at the submucosal layer with a linear stapler (thus 'lift-and-cut method'). Finally, the defect in the seromuscular layer is closed with a hand-sewn suture. RESULTS: From April 2011 to December 2015, 28 patients underwent laparoscopic partial gastrectomy by this method at Osaka Red Cross Hospital. Average operation time was 126 min (range 65-302 min) and average blood loss was 10 ml (range 0-200 ml). No intraoperative complications including tumor rupture or postoperative complications regarded as Clavien-Dindo Grade II or higher occurred. All patients took sufficient solid diet at discharge. Median postoperative hospital stay was 7 days (range 5-21 days). On median follow-up of 26.6 months (range 6-54 months), no recurrence was reported. CONCLUSION: Laparoscopic partial gastrectomy by the lift-and-cut method is safe and simple, and widely applicable for gastric GIST.

Whey peptide ingestion suppresses body fat accumulation in senescence-accelerated mouse prone 6 (SAMP6).

PURPOSE: Body weight in young growing and young adult animals was reduced by a high dietary density of whey protein concentrate; however, it is unclear whether dietary proteins similarly affect body weight in aging animals. Here, we examined whether whey protein or whey peptide ingestion suppressed body fat accumulation and affected protein expression and phosphorylation in skeletal muscle in aging mice. METHODS: Twenty-six male senescence-accelerated mouse prone 6 (SAMP6) mice were assigned randomly to three dietary treatment groups: 18.7% casein control (CON), 18.7% whey protein (WPR), and 18.7% whey peptide (WPE). After 28 weeks of treatment, skeletal tissues were dissected and weighed for analysis. Western blotting was performed to examine the expression of AMP-activated protein kinase (AMPK), acetyl-CoA carboxylase (ACC), and adipose triglyceride lipase (ATGL) in quadriceps muscles. RESULTS: Body (CON: 47.6 ± 2.2 g, WPR: 48.2 ± 2.7 g, WPE: 38.3 ± 2.0 g) and relative white adipose tissue (CON: 38.5 ± 3.5 mg/g, WPR: 43.8 ± 4.0 mg/g, WPE: 21.1 ± 4.4 mg/g) weights were lower in the WPE group compared with the other two groups (p < 0.05), and no significant differences were observed between the CON and WPR groups. The relative weights of tibialis anterior muscle (CON: 1.04 ± 0.04 mg/g, WPR: 0.97 ± 0.03 mg/g, 1.23 ± 0.05 mg/g) and gastrocnemius muscle (CON: 3.02 ± 0.12 mg/g, WPR: 2.92 ± 0.15 mg/g, WPE: 3.65 ± 0.18 mg/g) were higher in the WPE group compared with the other groups (p < 0.05). The phosphorylation of AMPK (WPR: 1.03 ± 0.11, WPE: 1.36 ± 0.12; fold change from control) and ACC (WPR: 1.08 ± 0.07, WPE: 1.18 ± 0.05; fold change from control) in WPE was higher than in CON (p < 0.05). There were no significant differences in the expression levels of ATGL among the three groups. CONCLUSIONS: These data suggest that a normal (or moderate excess) dietary density of whey peptide attenuates body fat accumulation via upregulation of fatty acid oxidation in skeletal muscle in aging mice.

[Russell body gastritis].

A 63-year-old woman who presented with chest and back pain underwent an upper gastrointestinal endoscopy which revealed elevated legion in the antrum mucosa. Histologic examinations of gastric biopsies were showing monoclonal proliferation plasma cells containing Russell bodies. Differential diagnosis from B-cell lymphoma and plasmacytoma is difficult, because of monoclonality. Molecular analyses of immunoglobulin heavy chain (IgH) gene demonstrated that gene rearrangement was negative. Thus, diagnosis of Russell body gastritis was made. The Giemsa stains were also showing infection of Helicobacter pylori (H.pylori). After eradication therapy for H.pylori, follow-up upper gastrointestinal endoscopy was performed. She then recovered.

Optimal Timing to Assess Drain Amylase Concentration after Elective Gastrectomy.

PURPOSE: While the amylase concentration of the drainage fluid (dAmy) has been reported to be a predictor of postoperative pancreas-related complications (PPRC), the optimal timing for its measurement has not been fully investigated. MATERIALS AND METHODS: The clinicopathological data of 387 patients who underwent elective gastrectomy for gastric cancer were reviewed. Laboratory data, including dAmy on postoperative days 1 (dAmy1) and 3 (dAmy3), and serum C-reactive protein (sCRP) concentrations on postoperative days 1 (sCRP1) and 3 (sCRP3) were compared between patients with PPRC and without PPRC. RESULTS: Nineteen of the 387 patients (4.9%) developed PPRC. The optimal cutoff values of dAmy1, dAmy3, sCRP1, and sCRP3 were 1514 IU/L, 761 IU/L, 8.32 mg/dL, and 15.15 mg/dL, respectively. The area under the curve of dAmy1 was greater than that of dAmy3 (0.915 vs. 0.826), and that of sCRP3 was greater than that of sCRP1 (0.820 vs. 0.659). In the multivariate analysis, dAmy1 (P<0.001) and sCRP3 (P=0.004) were significant predictors of PPRC, while dAmy3 (P=0.069) and sCRP1 (P=0.831) were not. Thirteen (41.9%) of 31 patients with both dAmy1 ≥1,545 IU/L and sCRP3 ≥15.15 mg/dL had PPRC ≥Clavien-Dindo II. In contrast, among 260 patients with both dAmy1 <1,545 IU/L and sCRP3 <15.15 mg/dL, none developed PPRC. CONCLUSIONS: dAmy1 was more useful than dAmy3 in predicting PPRC. The combination of dAmy1 and sCRP3 may be a useful criterion for the removal of drains on postoperative day 3.

Polymicrobial Solitary Retroperitoneal Abscess Due to Sigmoid Colon Perforation.

We treated an 85-year-old man with an abscess perforating into the retroperitoneal space from the sigmoid colon, with retroperitoneal drainage combined with antibiotics. CT showed no abscess formation in the intraperitoneal space. The patient consulted a doctor with a chief complaint of left-side low back pain and fever. He was first diagnosed with bacteremia due to Escherichia coli and close examination by CT revealed a retroperitoneal abscess. On referral to our hospital, we determined by CT that the cause of abscess formation was perforation of the intestine into the retroperitoneal space and spreading into the psoas muscle compartment. We then performed colostomy and abscess drainage through the retroperitoneal space to prevent the abscess disseminating into the intraperitoneal space. The abscess and necrotic tissue cultures were polymicrobial, including Enterobacteriaceae and Bacteroides spp. The abscess almost disappeared after drainage, and the patient's general condition gradually improved. The retroperitoneal abscess did not relapse by follow-up CT. In conclusion, this rare case presented with perforation of the intestine (Sigmoid colon) disseminated only to the retroperitoneal space without no intraperitoneal space abscess formation. We performed drainage only by a retroperitoneal approach without entering the intraperitoneal space.

Appropriate traction can help identify the optimal dissectable layer for infrapyloric lymph node dissection in laparoscopic gastrectomy.

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.

Non-placement versus placement of a drainage tube around the cervical anastomosis in McKeown esophagectomy: study protocol for a randomized controlled trial.

BACKGROUND: Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal cancer. Currently, transthoracic and abdominal esophagectomy with cervical anastomosis (McKeown esophagectomy) is a frequently used technique in Japan. However, cervical anastomosis is still an invasive procedure with a high incidence of anastomotic leakage. The use of a drainage tube to treat anastomotic leakage is effective, but the routine placement of a closed suction drain around the anastomosis at the end of the operation remains controversial. The objective of this study is to evaluate the postoperative anastomotic leakage rate, duration to oral intake, hospital stay, and analgesic use with nonplacement of a cervical drainage tube as an alternative to placement of a cervical drainage tube. METHODS: This is an investigator-initiated, investigator-driven, open-label, randomized controlled parallel-group, noninferiority trial. All adult patients (aged ≥20 and ≤85 years) with histologically proven, surgically resectable (cT1-3 N0-3 M0) squamous cell carcinoma, adenosquamous cell carcinoma, or basaloid squamous cell carcinoma of the intrathoracic esophagus, and European Clinical Oncology Group performance status 0, 1, or 2 are assessed for eligibility. Patients (n = 110) with resectable esophageal cancer who provide informed consent in the outpatient clinic are randomized to either nonplacement of a cervical drainage tube (n = 55) or placement of a cervical drainage tube (n = 55). The primary outcome is the percentage of Clavien-Dindo grade 2 or higher anastomotic leakage. DISCUSSION: This is the first randomized controlled trial comparing nonplacement versus placement of a cervical drainage tube during McKeown esophagectomy with regards to the usefulness of a drain for anastomotic leakage. If our hypothesis is correct, nonplacement of a cervical drainage tube will be recommended because it is associated with a similar anastomotic leakage rate but less pain than placement of a cervical drainage tube. TRIAL REGISTRATION: UMIN-CTR, 000031244. Registered on 1 May 2018.

Current status of minimally invasive esophagectomy for esophageal cancer: Is it truly less invasive?

Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal cancer. However, it is one of the most invasive procedures with high morbidity. To reduce invasiveness, minimally invasive esophagectomy (MIE), which includes thoracoscopic, laparoscopic, mediastinoscopic, and robotic surgery, is becoming popular worldwide. Thoracoscopic esophagectomy in the prone position is ergonomic for the surgeon and has better perioperative arterial oxygen pressure/fraction of inspired oxygen (P/F) ratio. Thoracoscopic esophagectomy in the left decubitus position is easy to introduce because it is similar to standard right posterolateral open esophagectomy (OE) in position. It has a relatively short operative time. Laparoscopic approach could potentially have a substantial effect on pneumonia prevention under the condition of thoracotomy. Mediastinoscopic surgery has the potential to reduce pulmonary complications because it can avoid a transthoracic procedure. In robotic surgery, in the future, less recurrent laryngeal nerve palsy will be expected as a result of polyarticular fine maneuvering without human tremors. In studies comparing MIE with OE, mediastinoscopic surgery and robotic surgery are usually not included; these studies show that MIE has a longer operative time and less blood loss than OE. MIE is particularly beneficial in reducing postoperative respiratory complications such as atelectasis, despite no dramatic decrease in pneumonia. Reoperation might occur more frequently with MIE. There is no significant difference in mortality rate between MIE and OE. It is important to recognize that the advantages of MIE, particularly "less invasiveness", can be of benefit at facilities with experienced medical personnel.

Optimal monitor positioning and camera rotation angle for mirror image: overcoming reverse alignment during laparoscopic colorectal surgery.

Mirror image is one of the most difficult situations that the assistant surgeon encounters in laparoscopic colorectal surgery. The aim of the present study was to investigate whether task performance with mirror images improves by changing the position of the monitor and the rotation angle of the camera. Twenty-four surgeons performed the task under different conditions: Coaxial image (C), Mirror image (M), Mirror image + Monitor on the left side of participants (M + Mon), Mirror image + Camera rotated 90 degrees to the right (M + Cam), and Mirror image + Monitor on the left side + Camera rotated to the right (M + Mon + Cam) in a training box. The outcome measure was the mean time for completing the task. The mean time for completing the task, in decreasing order, was M (111.4 ± 58.9 seconds) > M + Mon (70.5 ± 29.4 seconds) > M + Cam (47.1 ± 17.1 seconds) > M + Mon + Cam (33.4 ± 10.3 seconds) > C (20.5 ± 3.5 seconds). (multivariable analysis of variance (MANOVA), p = 7.9 × 10-7) Task performance with mirror images improved by changing the monitor positioning and camera rotation angle. This novel method is a simple way to overcome mirror image in laparoscopic colorectal surgery.

Esophagojejunostomy With Linear Staplers in Laparoscopic Total Gastrectomy: Experience With 168 Cases in 5 Consecutive Years.

PURPOSE: We evaluate surgical outcomes of intracorporeal esophagojejunostomy in laparoscopic total gastrectomy using 2 linear stapler methods. MATERIALS AND 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. RESULTS AND CONCLUSIONS: 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.