Long-Term Outcomes of Laparoscopic Radical Gastrectomy for Highly Advanced Gastric Cancer: Final Report of a Prospective Phase II Trial (KUGC04).

BACKGROUND: This is the final report evaluating the long-term outcomes of a single-arm phase II clinical trial that demonstrated the short-term efficacy of laparoscopic gastrectomy (LG) for highly advanced gastric cancer (AGC) [KUGC04]. PATIENTS AND METHODS: Seventy-three patients with histologically confirmed gastric adenocarcinoma and diagnosed with clinical stage II or higher, who potentially underwent curative resection between August 2009 and November 2014, were prospectively enrolled. Long-term outcomes with 5-year progression-free survival (PFS) and 5-year overall survival (OS) were evaluated according to clinical or pathological stages. Recurrence and progression patterns were also investigated. These outcomes were compared with those of previous reports to assess the applicability of LG for highly advanced gastric cancer (HAGC). RESULTS: The median observation period of all surviving patients was 75.1 months. The 5-year PFS and 5-year OS of all patients was 47.4% and 54.4%, respectively. Clinical stage-specific 5-year PFS and 5-year OS was 75.0, 69.1, 53.9, 39.4, 40.0 and 9.1, and 75.0, 68.8, 61.5, 45.0, 60.0 and 27.3, respectively, in stages IIA, IIB, IIIA, IIIB, IIIC, and IV, respectively. Pathological stage-specific 5-year PFS and 5-year OS, including ypStage with preoperative chemotherapy, was 100, 80.0, 100, 62.5, 80.0, 51.3, 16.7, 22.2 and 12.5, and 100, 80.0, 100, 75.0, 80.0, 64.2, 25.0, 33.3 and 12.5, respectively, in stage X (no residual tumor with preoperative chemotherapy), IA, IB, IIA, IIB, IIIA, IIIB, IIIC, and IV, respectively. Recurrence or progression was observed in 30 patients (41.1%). CONCLUSION: LG for HAGC performed by experienced surgeons is safe and oncologically acceptable.

Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer.

BACKGROUND: Gastric cancer is the fifth most common cancer diagnosed worldwide. Due to improved early detection rates of gastric cancer and technological advances in treatments, a significant improvement in survival rates has been achieved in people with cancer undergoing gastrectomy. Subsequently, there has been increasing emphasis on postgastrectomy syndrome (e.g. fullness, delayed emptying, and cold sweat, amongst others) and quality of life postsurgery. However, it is uncertain which types of reconstruction result in better outcomes postsurgery. OBJECTIVES: To assess the evidence on health-related quality of life and safety outcomes of Roux-en-Y and Billroth-I reconstructions after distal gastrectomy for people with gastric cancer. SEARCH METHODS: We searched the Cochrane Library and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 4 May 2021. We checked the reference lists of the included studies and contacted manufacturers and professionals in the field. There were no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) allocating participants to Roux-en-Y reconstruction or Billroth-I reconstruction after distal gastrectomy for gastric cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies identified by the search for eligibility and extracted data. The primary outcomes were health-related quality of life after surgery and incidence of anastomotic leakage. The secondary outcomes included body weight loss, incidence of bile reflux, length of hospital stay, and overall morbidity. We used a random-effects model to conduct meta-analyses. We assessed risk of bias of the included studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included eight RCTs (942 participants) in the review. One study included both cancer patients and benign disease patients such as stomach ulcers. Two studies compared Roux-en-Y, Billroth-I, and Billroth-II reconstructions, whilst the other studies compared Roux-en-Y and Billroth-I directly.  For the primary outcomes, the evidence suggests that there may be little to no difference in health-related quality of life between Roux-en-Y and Billroth-I reconstruction (standardised mean difference 0.04, 95% confidence interval (CI) -0.11 to 0.18; I² = 0%; 6 studies; 695 participants; low-certainty evidence due to study limitations and imprecision). The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain (risk ratio (RR) 0.63, 95% CI 0.16 to 2.53; I² = 0%; 5 studies; 711 participants; very low-certainty evidence). The incidence of anastomotic leakage was 0.6% and 1.4% in the Roux-en-Y and Billroth-I groups, respectively. For the secondary outcomes, the evidence suggests that Billroth-I reconstruction may result in little to no difference in loss of body weight compared to Roux-en-Y reconstruction (mean difference (MD) 0.41, 95% CI -0.77 to 1.59; I² = 0%; 4 studies; 541 participants; low-certainty evidence). Roux-en-Y reconstruction probably reduces the incidence of bile reflux compared to Billroth-I reconstruction (RR 0.40, 95% CI 0.25 to 0.63; I² = 22%; 4 studies; 399 participants; moderate-certainty evidence). Billroth-I reconstruction may shorten postoperative hospital stay, but the evidence for this outcome is very uncertain (MD 0.96, 95% CI 0.16 to 1.76; I² = 56%; 7 studies; 894 participants; very low-certainty evidence). Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction (RR 1.47, 95% CI 1.02 to 2.11; I² = 0%; 7 studies; 891 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: The evidence suggests that there is little to no difference between Roux-en-Y and Billroth-I reconstruction for the outcome health-related quality of life. The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain as the incidence of this outcome was low. Although the certainty of evidence was low, we found some possibly clinically meaningful differences between Roux-en-Y and Billroth-I reconstruction for short-term outcomes. Roux-en-Y reconstruction probably reduces the incidence of bile reflux into the remnant stomach compared to Billroth-I reconstruction. Billroth-I reconstruction may shorten postoperative hospital stay compared to Roux-en-Y reconstruction, but the evidence is very uncertain. Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction. Future trials should include long-term follow-up of health-related quality of life and body weight loss.

[A Case of Spontaneous Spinal Epidural Hematoma during Chemotherapy with Paclitaxel and Ramucirumab for Advanced Gastric Cancer].

Spontaneous spinal epidural hematomas(SSEH)are rare. The causes of SSEH include hematologic disorders, anticoagulation and antiplatelet therapy, vascular malformations, neoplasms, trauma, or medical interventions, such as epidural catheterization or spinal surgery. However, the cause is usually unclear in most cases. We report a case of SSEH during chemotherapy with paclitaxel and ramucirumab for advanced gastric cancer. A 68-year-old woman was referred to our hospital with a diagnosis of advanced gastric cancer. After 4 courses of neoadjuvant chemotherapy containing S-1 plus oxaliplatin, distal gastrectomy with D2 lymphadenectomy was performed. Postoperative chemotherapy with paclitaxel and ramucirumab was initiated, with a diagnosis of ypStage Ⅲc(T4aN3bM0). She was later transported by ambulance to our hospital with symptoms of sudden onset posterior neck pain and weakness of the extremities. Magnetic resonance imaging(MRI)of her cervical spine showed an epidural hematoma from C2 to C5. The symptoms improved gradually after admission, and the epidural hematoma decreased in size on MRI. Hemorrhagic events such as SSEH should be considered during treatment with angiogenesis inhibitors.

Subcuticular sutures for skin closure in non-obstetric surgery.

BACKGROUND: Following surgery, surgical wounds can be closed using a variety of devices including sutures (subcuticular or transdermal), staples and tissue adhesives. Subcuticular sutures are intradermal stitches (placed immediately below the epidermal layer). The increased availability of synthetic absorbable filaments (stitches which are absorbed by the body and do not have to be removed) has led to an increased use of subcuticular sutures. However, in non-obstetric surgery, there is still controversy about whether subcuticular sutures increase the incidence of wound complications. OBJECTIVES: To examine the efficacy and acceptability of subcuticular sutures for skin closure in non-obstetric surgery. SEARCH METHODS: In March 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: All randomised controlled trials which compared subcuticular sutures with any other methods for skin closure in non-obstetric surgery were included in the review. DATA COLLECTION AND ANALYSIS: Two review authors independently identified the trials, extracted data and carried out risk of bias and GRADE assessment of the certainty of the evidence. MAIN RESULTS: We included 66 studies (7487 participants); 11 included trials had more than two arms. Most trials had poorly-reported methodology, meaning that it is unclear whether they were at high risk of bias. Most trials compared subcuticular sutures with transdermal sutures, skin staples or tissue adhesives. Most outcomes prespecified in the review protocol were reported. The certainty of evidence varied from high to very low in the comparisons of subcuticular sutures with transdermal sutures or staples and tissue adhesives; the certainty of the evidence for the comparison with surgical tapes and zippers was low to very low. Most evidence was downgraded for imprecision or risk of bias. Although the majority of studies enrolled people who underwent CDC class 1 (clean) surgeries, two-thirds of participants were enrolled in studies which included CDC class 2 to 4 surgeries, such as appendectomies and gastrointestinal surgeries. Most participants were adults in a hospital setting. Subcuticular sutures versus transdermal sutures There may be little difference in the incidence of SSI (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.80 to 1.52; 3107 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce wound complications (RR 0.83; 95% CI 0.40 to 1.71; 1489 participants; very low-certainty evidence). Subcuticular sutures probably improve patient satisfaction (score from 1 to 10) (at 30 days; MD 1.60, 95% CI 1.32 to 1.88; 290 participants; moderate-certainty evidence). Wound closure time is probably longer when subcuticular sutures are used (MD 5.81 minutes; 95% CI 5.13 to 6.49 minutes; 585 participants; moderate-certainty evidence). Subcuticular sutures versus skin staples There is moderate-certainty evidence that, when compared with skin staples, subcuticular sutures probably have little effect on SSI (RR 0.81, 95% CI 0.64 to 1.01; 4163 participants); but probably decrease the incidence of wound complications (RR 0.79, 95% CI 0.64 to 0.98; 2973 participants). Subcuticular sutures are associated with slightly higher patient satisfaction (score from 1 to 5) (MD 0.20, 95% CI 0.10 to 0.30; 1232 participants; high-certainty evidence). Wound closure time may also be longer compared with staples (MD 0.30 to 5.50 minutes; 1384 participants; low-certainty evidence). Subcuticular sutures versus tissue adhesives, surgical tapes and zippers There is moderate-certainty evidence showing no clear difference in the incidence of SSI between participants treated with subcuticular sutures and those treated with tissue adhesives (RR 0.77, 95% CI 0.41 to 1.45; 869 participants). There is also no clear difference in the incidence of wound complications (RR 0.62, 95% CI 0.35 to 1.11; 1058 participants; low-certainty evidence). Subcuticular sutures may also achieve lower patient satisfaction ratings (score from 1 to 10) (MD -2.05, 95% CI -3.05 to -1.05; 131 participants) (low-certainty evidence). In terms of SSI incidence, the evidence is uncertain when subcuticular sutures are compared with surgical tapes (RR 1.31, 95% CI 0.40 to 4.27; 354 participants; very low-certainty evidence) or surgical zippers (RR 0.80, 95% CI 0.08 to 8.48; 424 participants; very low-certainty evidence). There may be little difference in the incidence of wound complications between participants treated with subcuticular sutures and those treated with surgical tapes (RR 0.90, 95% CI 0.61 to 1.34; 492 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce the risk of wound complications compared with surgical zippers (RR 0.55, 95% CI 0.15 to 2.04; 424 participants; very low-certainty evidence). It is also uncertain whether it takes longer to close a wound with subcuticular sutures compared with tissue adhesives (MD -0.34 to 10.39 minutes; 895 participants), surgical tapes (MD 0.74 to 6.36 minutes; 169 participants) or zippers (MD 4.38 to 8.25 minutes; 424 participants) (very low-certainty evidence). No study reported results for patient satisfaction compared with surgical tapes or zippers. AUTHORS' CONCLUSIONS: There is no clear difference in the incidence of SSI for subcuticular sutures in comparison with any other skin closure methods. Subcuticular sutures probably reduce wound complications compared with staples, and probably improve patient satisfaction compared with transdermal sutures or staples. However, tissue adhesives may improve patient satisfaction compared with subcuticular sutures, and transdermal sutures and skin staples may be quicker to apply than subcuticular sutures. The quality of the evidence ranged from high to very low; evidence for almost all comparisons was subject to some limitations. There seems to be no need for additional new trials to explore the comparison with staples because there are high-quality studies with large sample sizes and some ongoing studies. However, there is a need for studies exploring the comparisons with transdermal sutures, tissue adhesives, tapes and zippers, with high-quality studies and large sample sizes, including long-term assessments.

Optimal treatment strategy for rectal cancer based on the risk factors for recurrence patterns.

BACKGROUND: For rectal cancer, multimodality therapeutic approach is necessary to prevent local recurrence and distant metastasis. However, the efficacy of additional treatments, such as neoadjuvant chemoradiotherapy (nCRT), neoadjuvant chemotherapy (NAC), and lateral pelvic lymph node dissection (LPLND), has not been scrutinized. METHODS: Recurrence patterns were categorized into local recurrence and distant metastasis. Local recurrence was classified into two types: (1) pelvic cavity recurrence and (2) LPLN recurrence. First, we analyzed the risk factors for each recurrence pattern. Second, based on the status of clinically suspected involvement of circumferential resection margin (cCRM), the efficacy of additional treatments was investigated. RESULTS: A total of 240 patients was enrolled. nCRT was performed for 25 (10%), NAC was for 46 (19%), and LPLND was for 35 patients (15%). As the recurrence patterns, pelvic cavity recurrence occurred in 15 (6%), LPLN recurrence in 8 (3%), and distant metastasis in 42 patients (18%). Five-year overall survival and relapse-free survival were 87% and 70%, respectively. Multivariate analysis indicated that pelvic cavity recurrence was associated with cCRM status and tumor histology, that LPLN recurrence was with serum carcinoembryonic antigen level and LPLN swelling, and that distant metastasis was with clinical N category. In the cCRM-positive subgroup (n = 66), cumulative rate of pelvic cavity recurrence was lower in the nCRT group than in the NAC or non-NAC/nCRT group (P = 0.02 and 0.09, respectively). CONCLUSION: cCRM status was associated with pelvic cavity recurrence, and LPLN swelling was with LPLN recurrence. nCRT could reduce pelvic cavity recurrence in cCRM-positive subgroup.

Goshajinkigan for reducing chemotherapy-induced peripheral neuropathy: a systematic review and meta-analysis.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is common and presents with persistent and challenging symptoms for which there is no effective means of prevention. This systematic review assessed the efficacy and safety of Goshajinkigan in the prevention of CIPN. METHODS: A comprehensive literature search was conducted using Scopus, Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and ICHUSHI. Randomised controlled trials comparing Goshajinkigan with an alternative strategy for preventing CIPN were selected. RESULTS: Of five studies included in the review, Goshajinkigan did not reduce the risk of CIPN when the common terminology criteria for adverse events was used [risk ratio (RR) 0.94, 95% confidence interval (CI) 0.57-1.57 for grade ≥2 CIPN and RR 1.08, 95% CI 0.59-2.00 for grade ≥3 CIPN]. When the neurotoxicity criteria of Debiopharm was used, Goshajinkigan tended to decrease the risk of CIPN, but not significantly (RR 0.74, 95% CI 0.33-1.64 for grade ≥2 CIPN and RR 0.65, 95% CI 0.28-1.52 for grade ≥3 CIPN). CONCLUSIONS: Goshajinkigan tended to prevent persistence but not severity of CIPN. Higher quality trials using multiple measures are needed in the future to clarify the preventive effect of Goshajinkigan and to assess the various aspects of CIPN.

Goshajinkigan for reducing chemotherapy-induced peripheral neuropathy: protocol for a systematic review and meta-analysis.

PURPOSE: Chemotherapy-induced peripheral neuropathy (CIPN) is an issue for both cancer patients and specialists, and the number of cases of CIPN is growing with the increasing number of cancer patients worldwide. CIPN is often caused by common anticancer drugs such as taxanes and platinum analogs. These are key drugs for various cancers including colorectal and gastric cancers. However, there are currently no effective drugs to prevent CIPN. Goshajinkigan, a Japanese traditional herbal medicine (Kampo), is a promising drug which is used to treat diabetic neuropathy in Japan. This systematic review will assess the efficacy and safety of Goshajinkigan for reducing CIPN in cancer patients receiving chemotherapy. METHODS AND ANALYSIS: We will conduct a comprehensive search of relevant randomized controlled trials in Scopus, Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and ICHUSHI. Two review authors will independently assess studies for inclusion and consult a third review author if necessary. The risk of bias of the included studies will be assessed according to the Cochrane risk of bias tool. We will investigate heterogeneity using forest plots and the chi-square test. When there are enough studies and any heterogeneity, we will use a random-effects model. Otherwise, we will use a fixed-effects model. ETHICS AND DISSEMINATION: This is a protocol for systematic review and meta-analysis and does not need ethics approval. We will disseminate the findings of this review through publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: PROSPERO CRD42016045224.

Nomogram for predicting recurrence in stage II colorectal cancer.

BACKGROUND: There have been no established criteria to distinguish patients at high and low risk of recurrence in stage II colorectal cancer. Several risk factors have been identified but recurrence could not be fully predicted by each factor alone. This retrospective study sought to develop a nomogram for accurate prediction of recurrence in stage II colorectal cancer. MATERIAL AND METHODS: We reviewed the data for 4167 patients with stage II colorectal cancer who underwent surgery between January 1997 and December 2006. The risk factors for recurrence were identified, and a nomogram for recurrence was created using the factors. The performance of the nomogram was assessed with a bootstrapped-concordance index and calibration plots. RESULTS: Sex, carcinoembryonic antigen, tumor location, tumor depth, lymphatic invasion, venous invasion and number of lymph nodes studied were significantly associated with recurrence. A nomogram for five-year freedom from recurrence was created with these factors. The bootstrapped-concordance index of the nomogram was 0.64, and it was well calibrated. CONCLUSIONS: Our nomogram can be a useful tool for accurate prediction of recurrence in stage II colorectal cancer.

A case of acute appendicitis incarcerated in obturator hernia.

An 85 year-old woman was transferred with a chief complaint of right thigh pain persisting for 5 days. Abdominal contrast-enhanced computed tomography clearly depicted a swollen appendix incarcerated in the right obturator cavity. She underwent an emergent laparoscopic appendectomy and the simultaneous repair of the obturator hernia. At laparoscopy, appendix was found to be incarcerated in the right obturator canal. The incarcerated appendix was successfully flushed out from the sac by spurting saline into the obturator hernia sac through the catheter inserted into the hernia sac. After a laparoscopic appendectomy, the hernia orifice was repaired using the uterine flap. The patient was discharged from the hospital without any sequelae. This report demonstrates a very rare case of obturator hernia incarcerated with appendix. Although patients with obturator hernia incarcerated with small intestine present with the symptoms related to bowel obstruction, patients with incarceration of appendix do not. Moreover, they would show no typical abdominal symptoms associated with acute appendicitis. Therefore, it is important to perform a radiological evaluation promptly to make a definitive diagnosis when a patient with persisting pain of the right thigh or right ileac fossa with a possibility of obturator hernia with incarceration of the appendix is encountered.

Laparoscopic surgery for median arcuate ligament syndrome using real-time stereotactic navigation.

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.

Idiopathic Omental Bleeding Treated by Laparoscopic Partial Omentectomy: A Case Report and Review of the Literature.

Omental bleeding is potentially life-threatening. There are many causes of omental bleeding including trauma, neoplasia, arterial aneurysm rupture, omental torsion, vasculitis, or segmental arterial mediolysis (SAM). Without remarkable pathological features, the diagnosis of idiopathic omental bleeding is made. Omental bleeding is relatively a rare disease, and there is no established treatment strategy.  A 53-year-old woman was brought to the ED for sudden onset abdominal pain. CT revealed hematoma in the omentum and was diagnosed as idiopathic omental bleeding accordingly. The patient underwent laparoscopic partial omentectomy and was discharged nine days after surgery. The pathological findings of the resected omentum were not remarkable, and the final diagnosis was made as idiopathic omental bleeding. In some case reports of omental bleeding, interventional radiology (IVR) was chosen for hemostasis, but IVR cannot resect tissue of omentum so it is difficult to make a pathological diagnosis. The surgical approach of idiopathic omental bleeding is uncommon. However, the use of the laparoscopic approach hasn't been reported in the literature. Laparoscopic partial omentectomy can provide effective hemostasis. We report laparoscopic partial omentectomy surgical procedure and review of the literature.

The number of obstructive colorectal cancers in Japan has increased during the COVID-19 pandemic: A retrospective single-center cohort study.

BACKGROUND: The global pandemic of COVID-19 has changed cancer treatment environments. In Japan, cancer screenings were halted and the numbers of endoscopies and surgeries were restricted in some hospitals based on the state of emergency declared. Herein, we investigated the impact of the COVID-19 pandemic on the characteristics of colorectal cancer (CRC) patients in facilities that are on the frontline of both COVID-19 and cancer treatments. PATIENTS AND METHODS: We retrospectively analyzed the cases of all of the CRC patients (n = 123) who underwent surgery at our regional cancer treatment center and tertiary emergency hospital in Japan during a 120-day period ranging from before to after the state of emergency declaration. CRC patients during the corresponding period in the previous year were also examined. RESULTS: Although the number of CRC patients did not show a significant change related to the pandemic, the incidence of obstructive CRCs significantly increased after the pandemic's start. The numbers of outpatients and colonoscopies both decreased, which could have resulted in the decrease of CRC patients detected by cancer screening during the pandemic. The numbers of symptomatic CRC patients and emergency admissions both increased significantly during the pandemic. CONCLUSION: Our findings indicate the possibility that the discovery of CRCs in patients could be delayed due to the halt in screenings caused by the COVID-19 pandemic, resulting in the increase of obstructive CRCs. These results highlight the importance of cancer screening and suggest that the screening system for cancers should be reorganized before future pandemics.

Three-dimensional Stereoscopic Visualization Shortens Operative Time in Laparoscopic Gastrectomy for Gastric Cancer.

Laparoscopic gastrectomy for gastric cancer is now widely accepted and has become a standard surgery. This study investigated the advantages of three-dimensional (3D) stereoscopic visualization for laparoscopic gastrectomy over a conventional two-dimensional (2D) planar screen. The primary outcome of this study was operative time. Ninety-four consecutive cases of gastric cancer patients who underwent laparoscopic total gastrectomy (LTG) (25 cases) or laparoscopic distal gastrectomy (LDG) (69 cases) were enrolled in this study before and after the introduction of the 3D system. Operative time was significantly shorter in the 3D groups for both LTG (351 vs. 406 min, P = 0.026) and LDG (269 vs. 344 min, P < 0.01). During intracorporeal procedures, dissection time was significantly shorter in the 3D groups for both LTG (183 vs. 232 min, P = 0.011) and LDG (161 vs. 213 min, P < 0.01), although the time needed for anastomosis was similar between the groups. However, operators preferred intracorporeal knot-tying as a ligature for anastomosis under 3D (LTG, P = 0.012; LDG, P < 0.01). These data suggest that 3D stereoscopic visualization shortens the operative time of laparoscopic gastrectomy by reducing the intracorporeal dissection time.

Correction to: Polymyxin B-immobilized hemoperfusion and mortality in critically ill adult patients with sepsis/septic shock: a systematic review with meta-analysis and trial sequential analysis.

Owing to an oversight by the authors, Figure 2 in this article was not the version intended for publication. The correct Figure 2, reproduced here, features footnote symbols and Figure 2b includes three studies as described in the main text.

Polymyxin B-immobilized hemoperfusion and mortality in critically ill adult patients with sepsis/septic shock: a systematic review with meta-analysis and trial sequential analysis.

PURPOSE: Polymyxin B-immobilized hemoperfusion (PMX-HP) is an adjuvant therapy for sepsis or septic shock that clears circulating endotoxin. Prior trials have shown that PMX-HP improves surrogate endpoints. We aimed to conduct an evidence synthesis to evaluate the efficacy and safety of PMX-HP in critically ill adult patients with sepsis or septic shock. METHODS: We searched for randomized controlled trials (RCTs) in MEDLINE, EMBASE, the Cochrane Library, the Health Technology Assessment Database, CINAHL, "Igaku Chuo Zasshi", the National Institute of Health Clinical Trials Register, the World Health Organization International Clinical Trials Registry Platform, the University Hospital Medical Information Network Clinical Trials Registry, the reference lists of retrieved articles, and publications by manufacturers of PMX-HP. The primary outcomes were 28-day all-cause mortality, the number of patients with at least one serious adverse event, and organ dysfunction scores. The GRADE methodology for the certainty of evidence was used. RESULTS: Six trials (857 participants; weighted mean age 62.5 years) proved eligible. Patient-oriented primary outcomes were assessed. The pooled risk ratio (RR) for 28-day mortality associated with PMX-HP was 1.03 [95% confidence interval (CI) 0.78-1.36; I 2 = 25%; n = 797]. The pooled RR for adverse events was 2.17 (95% CI 0.68-6.94; I 2 = 0%; n = 717). Organ dysfunction scores over 24-72 h after PMX-HP treatment did not change significantly (standardized mean difference - 0.26; 95% CI - 0.64 to 0.12; I 2 = 78%; n = 797). The certainty of the body of evidence was judged as low for both benefit and harm using the GRADE methodology. CONCLUSIONS: There is currently insufficient evidence to support the routine use of PMX-HP to treat patients with sepsis or septic shock. REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews (CRD42016038356).

Polymyxin B-immobilised haemoperfusion and mortality in critically ill patients with sepsis/septic shock: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Polymyxin-B immobilised haemoperfusion (PMX-HP) is a promising adjuvant strategy for the treatment of sepsis and septic shock. PMX-HP therapy works by clearing circulating endotoxin through binding to polymyxin-immobilised fibres during haemoperfusion. Small clinical trials have shown that PMX-HP therapy is associated with improved haemodynamic profile, oxygenation and survival. However, clear inferences have been largely inconclusive due to limitations in study design (eg, small, unblinded) and generalisability. We therefore propose to perform an up-to-date systematic review and evidence synthesis to describe the efficacy, safety and effectiveness of PMX-HP for adult patients with sepsis or septic shock. METHODS AND ANALYSIS: We will search the following databases from 1946 to 2016 MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, Health Technology Assessment Database (HTA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed and 'Igaku Chuo Zasshi' (ICHUSHI) for randomised controlled trials of PMX-HP in critically ill patients with sepsis or septic shock. There will be no language restrictions in the electronic search for studies. Two reviewers will extract data and appraise the quality of each study independently. The primary outcome will be the pooled risk ratio of 28-day all-cause mortality. Serious adverse events and changes in organ dysfunction scores will also be evaluated. The secondary outcomes will be 90-day all-cause mortality, changes in haemodynamic profile and endotoxin levels, and health services use. ETHICS AND DISSEMINATION: Our systematic review will synthesise the evidence on use of the PMX-HP as an adjuvant therapy in sepsis/septic shock to improve patient-centred, physiological and health services outcomes. Research ethics is not required for this review. The study will be disseminated by peer-reviewed publication and conference presentation. TRIAL REGISTRATION NUMBER: CRD42016038356.