Cyclin D1 Serves as a Poor Prognostic Biomarker in Stage I Gastric Cancer.

TNM stage still serves as the best prognostic marker in gastric cancer (GC). The next step is to find prognostic biomarkers that detect subgroups with different prognoses in the same TNM stage. In this study, the expression levels of epidermal growth factor receptor (EGFR) and cyclin D1 were assessed in 96 tissue samples, including non-tumorous tissue, adenoma, and carcinoma. Then, the prognostic impact of EGFR and cyclin D1 was retrospectively investigated in 316 patients who underwent R0 resection for GC. EGFR positivity increased as gastric tissue became malignant, and cyclin D1 positivity was increased in all the tumorous tissues. However, there was no survival difference caused by the EGFR positivity, while the cyclin D1-postive group had worse overall survival (OS) than the cyclin D1-negative group in stage I GC (10-year survival rate (10-YSR): 62.8% vs. 86.5%, p = 0.010). In subgroup analyses for the propensity score-matched (PSM) cohort, there were also significant differences in the OS according to the cyclin D1 positivity in stage I GC but not in stage II and III GC. Upon multivariate analysis, cyclin D1 positivity was an independent prognostic factor in stage I GC. In conclusion, cyclin D1 may be a useful biomarker for predicting prognosis in stage I GC.

Feasibility of a novel laparoscopic technique with unidirectional knotless barbed sutures for the primary closure of duodenal ulcer perforation.

BACKGROUND: Laparoscopic primary repair is one of the main procedures used for perforated gastric ulcers, and this technique requires reproducible and secure suturing. The aim of this study was to investigate the safety and efficacy of a novel continuous suture method with barbed sutures during laparoscopic repair for perforated peptic ulcers. PATIENTS AND METHODS: Clinical data from 116 consecutive patients undergoing laparoscopic repair for perforated peptic ulcers were collected between November 2009 and October 2015. Continuous suturing with 15-cm-long unidirectional absorbable barbed sutures was used for laparoscopic repair in the study group, termed group V (n = 51). Patients who underwent laparoscopic repair with conventional interrupted sutures were defined as group C (n = 65). The complication and operative data were compared between groups. RESULTS: Although there was no difference between group V and group C in the overall complication rate (15.7% vs. 24.6%; p = 0.259), the complication rate related to suturing was lower (3.9% vs. 15.4%; p = 0.04) in group V. Group V showed rates of 0% for leakage, 2% for intra-abdominal fluid collection, and 2% for stricture; the corresponding rates in group C were 3.1, 7.7, and 4.6%, respectively. Regarding operative data, the total operation time (V vs. C, 87.7 min vs. 131.2 min), total suture time (7.1 min vs. 25.3 min), and suture time per stitch (1.2 min vs. 6.2 min) were significantly shorter in group V than in group C (p < 0.001). CONCLUSION: The use of a continuous suture technique with unidirectional barbed sutures is as safe as the conventional suture technique and allows easier and faster suturing in the repair of perforated peptic ulcers.

Prognostic importance of ultrasound BI-RADS classification in breast cancer patients.

OBJECTIVE: We investigated the prognostic importance of pre-operative Breast Imaging Reporting and Data System classification in ultrasound imaging. METHODS: Histopathological differences and disease-free survival were analyzed in Breast Imaging Reporting and Data System classification subgroups. Univariate and multivariate analyses were used to identify the prognostic factors. RESULTS: We identified 531 invasive breast cancer patients eligible for this study. Most patients classified as Breast Imaging Reporting and Data System 5 had large tumors and a higher rate of lymph node metastasis. However, hormonal receptor or HER-2 status did not differ according to Breast Imaging Reporting and Data System classification. During a median post-operative follow-up of 42.0 months, 43 patients were diagnosed with a disease-specific event. Disease-free survival was significantly lower in patients with Breast Imaging Reporting and Data System 5 than in patients with Breast Imaging Reporting and Data System 3-4. Subgroup analysis of patients with invasive breast cancer of Stage I showed that Breast Imaging Reporting and Data System 5 was an independent negative prognostic indicator of disease-free survival (hazard ratio 9.195; 95% confidence interval, 1.175-71.955; P = 0.035). CONCLUSIONS: Breast Imaging Reporting and Data System classification might be considered as prognostic factors especially in Stage I breast cancer. Further confirmatory studies are needed.

A noble method for intraoperative fine localization during laparoscopic gastric local resection: endoscopic submucosal cutting and light transmission.

BACKGROUND: The main requirements when performing laparoscopic local resection for early mucosal tumors of the stomach are a clearly defined cancer-free margin and precise tumor localization. In this study, a novel method for precise intraoperative tumor localization and appropriate resection in a porcine model is introduced: endoscopic submucosal cutting and light transmission (ESCLT). METHODS: A total of 15 cases of laparoscopic local resection were performed in 6 pigs. The size of the target lesions was approximately 20 mm. The imaginary lesions were located in the high body anterior wall, posterior wall, lower body posterior wall, angle, and antrum anterior wall of the stomach. Mucosal marking around the lesions, mucosal precutting surrounding the marking, and submucosal cutting along the precutting line using white light endoscopy were sequentially performed. Next, an endoscopic light source was placed directly in front of the lesion. Exact oval-shaped submucosal cutting margins were identified via laparoscopy. Laparoscopic local resection was performed after the minimal distance from the stapler line to the submucosal cutting line was confirmed. The sizes of the mucosal marking, submucosal cutting line, and the entire resected mucosa and serosa were measured. RESULTS: The procedure was completed successfully in all pigs. Local resection was completed on all of the lesions. The mean endoscopic and laparoscopic procedure times were 26.1 and 12.7 min, respectively. The mean size of the resected specimens was: (i) marking lesion, 22 × 19.5 mm; (ii) submucosal cutting line, 26.7 × 23.2 mm; (iii) entire resected mucosa, 37 × 31 mm; and (iv) entire resected serosa, 41.7 × 33.1 mm. There was no intraoperative morbidity. CONCLUSION: ESCLT provides a precise and useful method of intraoperative tumor localization during laparoscopic local resection of the stomach in terms of minimizing the resection of normal stomach tissue and guaranteeing adequate mucosal safety margins.

Impact of tumor size on subclinical central lymph node metastasis in papillary thyroid microcarcinoma depends on age.

BACKGROUND: The aim of this study is to evaluate whether the associations between clinicopathologic factors of papillary thyroid microcarcinoma (PTMC), especially tumor size, and subclinical central lymph node metastasis (LNM) are dependent on patient age. METHODS: The medical records of 428 patients who underwent thyroid surgery for PTC measuring ≤1 cm were reviewed. All patients were clinically lymph node negative and underwent thyroidectomy with unilateral or bilateral central lymph node dissection. Univariate and multivariate analyses were performed to identify clinicopathologic factors associated with central LNM. RESULTS: Central LNM was identified in 96 of 428 (22.4%) patients. Mean tumor size was significantly greater in patients with than without central LNM (0.74 ± 0.22 cm vs. 0.64 ± 0.23 cm, P = 0.001). Tumor size > 0.5 cm was significantly predictive of central LNM. Subgroup analysis according to age groups showed that tumor size was an independent predictor of subclinical central LNM only in patients aged ≥45 years. CONCLUSIONS: Factors predictive of central LNM in patients with PTMC differed by age. PTMC size was an independent predictor of subclinical central LNM only in patients aged ≥45 years.

OCT-1 overexpression is associated with poor prognosis in patients with well-differentiated gastric cancer.

Octamer transcription factor-1 (OCT-1) is a well-known transcription factor that is reportedly overexpressed in intestinal metaplasia and gastric carcinoma in the intestine. In this study, we investigated OCT-1 overexpression as a prognostic factor for gastric cancer. The association between OCT-1 overexpression (detected using immunohistochemistry) and clinicopathological features including survival was evaluated. In vitro gain-of-function approaches were utilized to assess the function of OCT-1 in malignancy. Analysis of OCT-1 expression in patients with gastric cancer with well-differentiated carcinoma as per the World Health Organization classification showed that OCT-1 overexpression was correlated with advanced tumor invasion (58.8 % of patients with advanced tumor invasion vs. 21.2 % of patients with early tumor invasion; p<0.01), lymph node metastasis (63.9 % of patients with metastasis vs. 24.1 % of those without; p=0.015), and cancer recurrence (83.3 % of patients with recurrence vs. 25.4 % of those without; p<0.01), as well as a lower survival rate (62.8 vs. 87.9 Mo; p<0.01). However, there were no significant differences in the levels of OCT-1 expression in gastric cancer patients with other carcinoma types (p>0.05). Furthermore, we found that the proliferation rate of OCT-1-overexpressing MKN-45 cells was higher than that of the control cells. OCT-1 overexpression may be a marker for poor prognosis in patients with well-differentiated gastric adenocarcinoma.

Feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body endoscopic submucosal dissection: a porcine model.

BACKGROUND: Total gastrectomy is performed for early gastric cancer in the upper body of the stomach because of the high complication rate of endoscopic submucosal dissection (ESD). The aims of the present animal study in pigs were to verify: (1) the feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body ESD; (2) the non-inferiority of single port laparoscopic lymph node dissection (LLND) compared with multiport LLND; and (3) the safety of 2-basin LLND (upper greater and lesser curvature). METHODS: We separated the pigs (~40 kg each) into two groups: conventional and experimental (n = 5 per group). We performed ESD in the fundus and upper body anterior wall (UBAW) via the trans-oral route and multiport LLND in the conventional group, and via the trans-umbilical route and single port LLND in the experimental group. RESULTS: The completion rates, tissue weights, and specimen diameters of both routes showed no statistical differences in either the fundus or the UBAW. The operative time was shorter with the trans-umbilical route than with the trans-oral route in both areas (p < 0.05). In LLND, there were no differences in surgical outcomes between the multiport and single port groups. Intraoperative perforation was seen in the trans-oral route group (n = 1). Delayed perforation was observed in 30 % of the ESD sites. CONCLUSIONS: The trans-umbilical route is feasible and has lower complication rates than the trans-oral route in gastric upper body ESD. Additionally, single port LLND is not inferior to multiport LLND, and one-side-basin dissection is safer than two-side.

Pyrophosphatase overexpression is associated with cell migration, invasion, and poor prognosis in gastric cancer.

Inorganic pyrophosphatase (PPase) catalyzes the hydrolysis of pyrophosphate to form orthophosphate. Pyrophosphate can substitute for ATP under certain circumstances. We previously conducted a proteomic analysis to investigate tumor-specific protein expression in gastric cancer, and PPase was identified as a potential gastric tumor-specific marker; it was therefore selected for further study. Clinicopathological analysis, using proteomic analysis and immunohistochemistry, was used to validate PPase as a prognostic marker in gastric cancers. Proteomic analysis showed that PPase was overexpressed in patients with lymph node (LN) metastases and high tumor node metastasis (TNM) stages (p < 0.05). Based on immunohistochemistry, patients whose tumors overexpressed PPase had higher T stages, LN metastasis, a higher TNM stage, a higher cancer recurrence rate, and shorter survival times than patients whose tumors exhibited PPase underexpression (p < 0.05). Gain-of-function and loss-of-function approaches were employed to examine the malignant phenotypes of PPase-overexpressing or PPase-depleted cells. A decrease in PPase expression caused a significant decrease in gastric cancer cell migration and invasion in vitro, whereas forced overexpression of PPase enhanced migration but not invasion. Our findings indicate that PPase is involved in gastric tumor progression and that PPase may be a useful marker for poor prognosis of human gastric cancers.

Prognostic value of sonic hedgehog protein expression in gastric cancer.

OBJECTIVE: Sonic hedgehog is produced in gastric epithelial cells and plays a crucial role in parietal cell function and the regulation of gastric epithelial cell differentiation. Emerging evidence suggests that the sonic hedgehog pathway is not only involved in the development of cancers but also in their progression and aggressiveness. METHODS: To assess its prognostic value in gastric cancer, sonic hedgehog protein expression was measured by immunohistochemistry in a clinically annotated tissue microarray comprising 319 human gastric cancer specimens. Cytoplasmic sonic hedgehog expression was scored from 0 to 4, reflecting the percentage of sonic hedgehog-positive cells. RESULTS: Specimens were classified into two groups according to their sonic hedgehog score: those with a score ranging from 0 to 3 were considered low expressers and those with a score of 4 were considered overexpressers. The sonic hedgehog overexpression group included more patients with early gastric cancer than the low sonic hedgehog expression group (25.9 vs. 74.1%, P=0.000). Sonic hedgehog expression was lower in patients with lymph node metastasis than in patients without lymph node metastasis (31.4 vs. 68.4%, P=0.02). Similarly, patients with a lower TNM stage showed significantly higher sonic hedgehog expression. In addition, the survival time of patients with sonic hedgehog overexpression was significantly prolonged (69.27±1.39 months) compared with that of patients with low sonic hedgehog expression (61.23±2.04 months, log-rank test, P=0.03). CONCLUSIONS: These results indicate that sonic hedgehog overexpression may be a marker of good prognosis in gastric cancer.

Trans-vaginal specimen extraction following totally laparoscopic subtotal gastrectomy in early gastric cancer.

BACKGROUND: Although natural orifice extraction is now widely performed, there have been no reports of this procedure following subtotal gastrectomy for gastric cancer. This report describes trans-vaginal specimen extraction in four patients with early gastric cancer. METHODS: The clinical data of four patients with early gastric cancer were reviewed. Totally laparoscopic subtotal gastrectomy and D1 + ß lymph node dissection was performed using five trocars and a conventional procedure. Posterior colpotomy was performed by an experienced gynecologist, who retrieved the specimens in a retrieval bag via the trans-vaginal route. The colpotomy site was repaired immediately following specimen removal. Reconstruction was performed using the intracorporeal Billroth II method and an endo-GIA 60. RESULTS: Totally laparoscopic subtotal gastrectomy and trans-vaginal specimen extraction was successfully accomplished in all patients without intraoperative complications. CONCLUSIONS: The present technique may be a safe and feasible operative procedure for some limited groups of elderly female patients with early gastric cancer.

Risk of recurrence after laparoscopy-assisted radical gastrectomy for gastric cancer performed by a single surgeon.

BACKGROUND: The risk of recurrence after laparoscopy-assisted radical gastrectomy (LAG) was investigated. MATERIALS AND METHODS: Clinical data of 398 consecutive patients who underwent radical gastrectomy with R0 resection for gastric cancer at Gyeongsang National University Hospital between January 2005 and December 2007 were reviewed retrospectively. RESULTS: Of the patients, 65.4% (n = 261) and 34.6% (n = 138) underwent LAG and open radical gastrectomy (OG), respectively. Of the LAG cases, 73.2% (n = 192), 10.7% (n = 28), 12.6% (n = 33), and 3.1% (n = 8) had stage I, II, III, and IV gastric cancer, respectively. All patients were followed up for a mean of 36.8 ± 13.7 months, and 14.6% (n = 58) had recurrence during the follow-up period. Univariate analysis revealed that tumor size, tumor-node-metastasis (TNM) stage, method of approach (LAG versus OG), and operation type were associated significantly with recurrence. Multivariate analysis revealed that only high TNM stage was significantly associated with recurrence (P = 0.00). While patients who underwent OG had higher incidence of recurrence than patients who underwent LAG, OG was not significantly associated with recurrence on multivariate analysis (P = 0.06). CONCLUSIONS: LAG and OG did not differ significantly in terms of recurrence, even when used in advanced gastric cancer cases. Multivariate analysis revealed that high TNM stage was significantly associated with recurrence. Thus, LAG appears to be a safe and feasible procedure that has the potential to be an alternative to open surgery, even for advanced gastric cancer.

Gastric lymphatic basin dissection for sentinel node biopsy using hybrid natural orifice transluminal endoscopic surgery (NOTES).

The aim of the present study was to describe a method of gastric lymphatic basin dissection for sentinel node biopsy using natural orifice transluminal endoscopic surgery with laparoscopic assistance (hybrid NOTES) in a porcine model. Lymph node dissection was performed in three healthy female domestic farm pigs (each around 40 kg) between October, 2007, and December, 2007. The pigs were administered a general anesthetic and laparoscopy-guided transvaginal colpotomy was performed. A two-channel endoscope was then inserted through the incision into the peritoneal cavity via the transvaginal route. An endoscope was inserted simultaneously into the mouth and indocyanine green solution was injected into the submucosal layer of the gastric wall at four sites. Dyed omentum and lymphatics were dissected using a laparoscopic dissector and the grasping forceps of a transvaginal endoscope. Lymphatics and omentum (mean 13.3 cm, range 8-20 cm) were removed transvaginally. The mean number of detected and resected sentinel nodes was 2.6 (range 1-4, diameter 2~12 mm). Sentinel lymphatic basin dissection was performed successfully and without intraoperative complications in all three cases. Hybrid NOTES is technically feasible, and this procedure may represent an alternative to laparoscopic sentinel lymph node dissection of the stomach.

Clinical factors affecting the length of minilaparotomy incision in laparoscopy-assisted distal gastrectomy.

This study investigated the factors affecting the length of the minilaparotomy incision (LOMI) in laparoscopy-assisted distal gastrectomy with Billroth I reconstruction. By using abdominal computed tomography scans, we measured the thickness of the rectus muscle (TRM), the thickness of the abdominal wall (TAW), and the distance from the gastroduodenal artery to the skin (GDAS) in 80 patients with early gastric cancer who had undergone surgery. There were positive correlations between the LOMI and body mass index (BMI), TRM, and TAW, and the LOMI increased significantly in patients with BMI > or =25 kg/m2, TAW > or =2.1 cm, and TRM > or =1.0 cm. These observations suggest that patients with two or more of the following clinical factors, BMI > or =25 kg/m2, TAW > or =2.1 cm, and TRM > or =1.0 cm, may require surgical procedures other than laparoscopy-assisted Billroth I, such as total laparoscopic intracorporeal Billroth I, Billroth II, or uncut Roux-en-Y reconstruction.

The Use of CD44 Variant 9 and Ki-67 Combination Can Predicts Prognosis Better Than Their Single Use in Early Gastric Cancer.

PURPOSE: We previously demonstrated that CD44v9 and Ki-67 played an important role in predicting poor prognosis of early gastric cancer (EGC). However, little is known about combined use of both biomarkers as prognostic biomarker. The present study was performed to investigate the significance of CD44v9 and Ki-67 expression as a combination biomarker for EGC. MATERIALS AND METHODS: With tissue microarray for 158 EGC tissues, we performed immunohistochemical staining for CD44v9 and Ki-67. The whole patients were divided into three groups (group A, CD44v9- negative/Ki-67-low; group B, neither group A or C; and group C, CD44v9-positive/Ki-67- high). Its clinical significance was re-analyzed with adjustment via propensity score matching (PSM). For validation, we performed bootstrap resampling. RESULTS: The median follow-up duration was 90.4 months (range, 3.7 to 120.4 months). In the comparison according to CD44v9/Ki-67 expression, the combined use of the two biomarker clearly separated the three groups by 5-year survival rates (5-YSR, 96.3%, 89.8%, and 76.8% in group A, B, and C, respectively; p=0.009). After PSM, 5-YSR were 97.7% and 76.8% in group A+B and group C, respectively (p=0.002). Multivariable analysis demonstrated that group C had independently poor prognosis (hazard ratio, 9.137; 95% confidence interval, 1.187 to 70.366; p=0.034) compared with group A. Bootstrap resampling internally validated this result (p=0.016). CONCLUSION: This study suggests that both positive CD44v9 and high Ki-67 expression are associated with poor prognosis in EGC, and the combined use of these markers provides better prognostic stratification than the single use of them.

Visceral obesity may affect oncologic outcome in patients with colorectal cancer.

PURPOSE: Obesity is closely related to the development of colorectal cancer as well as other metabolic complications. We investigated the prognostic significance of visceral obesity and body mass index (BMI) in 161 resectable colorectal cancer patients. METHODS: Ratios of visceral fat area (VFA) to subcutaneous fat area (SFA) were measured from the digital images of patients' computed tomography taken before the surgery, and patients were divided into those with high and those with low VFA/SFA ratio according to the degree of proportional visceral adiposity, and into an overweight and a normal-weight group according to their preoperative BMI. RESULTS: The overweight group showed a borderline decrease in cumulative disease-free survival compared to the normal-weight group (P = 0.064). Patients with high VFA/SFA ratio (more than 50 percentiles) had significantly lower cumulative disease-free survival rate compared to patients with low VFA/SFA ratio (P = 0.008). BMI and visceral adiposity showed no influence on overall survival of patients. CONCLUSION: Increased visceral adiposity was a significant predictor of disease-free survival in patients with resectable colorectal cancer. The prognostic significance of visceral adiposity should further be determined in a larger set of patients.

Clinical significance of loss of heterozygosity for M6P/IGF2R in patients with primary hepatocellular carcinoma.

AIM: To investigate the relationship between loss of heterozygosity (LOH) for mannose 6-phosphate/insulin-like growth factor 2 receptor (M6P/IGF2R) and the outcomes for primary HCC patients treated with partial hepatectomy. METHODS: The LOH for M6P/IGF2R in primary HCC patients was assessed using six different gene-specific nucleotide polymorphisms. The patients studied were enrolled to undergo partial hepatectomy. RESULTS: M6P/IGF2R was found to be polymorphic in 73.3% (22/30) of the patients, and of these patients, 50.0% (11/22) had tumors showing LOH in M6P/IGF2R. Loss of heterozygosity in M6P/IGF2R was associated with significant reductions in the two year overall survival rate (24.9% vs 65.5%; P=0.04) and the disease-free survival rate (17.8% vs 59.3%; P=0.03). CONCLUSION: These results show M6P/IGF2R LOH predicts poor clinical outcomes in surgically resected primary HCC patients.

Which biopsy method is more suitable between a basin dissection and pick-up biopsy for sentinel nodes in laparoscopic sentinel-node navigation surgery (LSNNS) for gastric cancer?

BACKGROUND: Sentinel-node navigation surgery (SNNS) for breast cancer and melanoma has been accepted as a reasonable oncologic surgery worldwide. On the other hand, in gastric cancers that do metastasize well to the lymph node, the use of SNNS has been approached with care and performed in only limited cases. Some obstacles still have to be overcome, such as the shortcomings of SN tracers and the technical limitations of laparoscopic SN detection. The aims of this study were to determine whether laparoscopic SNNS is possible, and which biopsy method is more suitable for SN tracers, in gastric cancer, preoperatively diagnosed as < or =T2 and with < or =4-cm-sized lesions. MATERIALS AND METHODS: Between January 2005 and October 2006, 92 consecutive patients that underwent LSNNS, using a combined indocyanine green and (99m)Tc-labeled tin colloid technique, were prospectively studied. SNs were laparoscopically removed by using two biopsy methods: a basin dissection and pick-up method, with the results of these two SN biopsy methods then compared with the final diagnosis obtained from a permanent section. RESULTS: With the pick-up method, SNs were identified in 23 of 42 patients (54.8%); however, with basin dissection, the detection rate was 96% (48 of 50 patients). The average number of SNs detected by the two methods were 2.1 (range, 0-4) and 3.5 (range, 1-7), respectively. The sensitivities of the two methods were 66% (4/6) and 85.7% (12/14), with specificities of 100% (17/17) and 100% (34/34), respectively. CONCLUSION: In gastric cancer, it was possible to perform LSNNS. At this moment, we believe the laparoscopic basin dissection technique with a dual-tracer injection, followed by SN detection on the back table, will be a reasonable procedure for gastric cancer, owing to the shortcomings related to the dye and radioisotope, the so-called "stained lymphatic duct only" and "shine-through phenomenon."

LATG with extracorporeal esophagojejunostomy: is this minimal invasive surgery for gastric cancer?

BACKGROUND: This retrospective study determined whether extracorporeal esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) for gastric cancer can be considered minimally invasive surgery, compared to the conventional open total gastrectomy (OTG). PATIENTS AND METHODS: This retrospective study involved 60 patients seen between January 2004 and July 2006. Twenty-seven patients underwent LATG, and 33 patients had OTG. The surgical procedure included the use of five ports with an upper vertical midline incision. In all patients, reconstruction was performed by using a Roux-en-Y esophagojejunostomy through the minilaparotomy site. In all cases, the jejunojejunostomy was performed extracorporeally as the conventional method. In OTG, a Roux-en-Y esophagojejunostomy was performed with an upper midline incision. RESULTS: The mean number of retrieved lymph nodes was smaller and the mean operating time was longer in the LATG group. The postoperative hospital course was similar in both groups. In the LATG group, the mean length of the minilaparotomy incision was 8.0+/-1.2 cm (maximum length, 11 cm), and a direct relationship was observed between the distance from the xiphoid process to the esophageal hiatus (DisXE) and the minilaparotomy incision length (Spearman's correlation of rank coefficient: 0.386; P=0.046). CONCLUSIONS: With the concept of minimal invasiveness, if the patient's DisXE exceeds 9 cm, the length of the minilaparotomy incision in laparoscopic surgery could be disadvantageous. Nevertheless, we consider LATG the treatment of choice for early gastric cancer. If the patient's DisXE exceeds 9 cm, we consider intracorporeal anastomosis with the laparoscopic total gastrectomy. The type of esophagojejunostomy may be determined preoperatively by using three-dimensional abdominal computed tomography.

Port-site recurrence after laparoscopy-assisted gastrectomy: report of the first case.

In advanced gastric cancer, laparoscopic management has been associated with trocar-site recurrence, even though laparoscopy-assisted gastrectomies have reported positive results to treat early-stage gastric cancer in the world. There are no reports of port-site recurrence after laparoscopic gastrectomy in the literature. In this paper, we present a case report of advanced gastric cancer with port-site recurrence 12 month after the initial operation. A wide excision of this recurrence was performed. Otherwise, the evaluation of metastasis in other sites remained negative at 18 months after the original operation. The laparoscopic surgeon should be aware of trocar-site recurrence when dealing with advanced gastric cancer.

Endoscopic thyroidectomy using a gasless axillary approach.

PURPOSE: We have recently developed an endoscopic thyroidectomy using a gasless axillary approach and report the surgical outcome of the procedure. MATERIALS AND METHODS: The gasless axillary approach was performed through a 3-cm axillary incision using a retractor instead of carbon dioxide insufflation. We performed a total of 35 thyroidectomies using this technique in patients with benign thyroid nodules. RESULTS: Thirty-four cases were successfully completed with the gasless axillary approach; one case had to be converted to a conventional technique after intraoperative frozen section revealed papillary carcinoma. The mean operative time and mean hospital stay were 180.6 +/- 54.5 minutes and 7.1 +/- 0.9 days, respectively. The mean tumor size was 2.9 +/- 1.4 cm. There were three minor postoperative complications: one case each of wound seroma, transient voice change, and persistent wound pain. All patients were satisfied with the cosmetic result. The axillary scars were not visible when the ipsilateral arms were in their natural position. CONCLUSION: Endoscopic thyroidectomy using a gasless axillary approach is a safe procedure that offers a good cosmetic result and has the merits of minimal invasiveness even in patients with a large thyroid mass. It is a safe and feasible alternative to traditional thyroid surgery, especially in young female patients with a large thyroid mass.