Safety and feasibility of minimally invasive gastrectomy following preoperative chemotherapy for highly advanced gastric cancer.

BACKGROUND: This study aimed to determine the safety and feasibility of minimally invasive gastrectomy in patients who underwent preoperative chemotherapy for highly advanced gastric cancer. METHODS: Preoperative chemotherapy was indicated for patients with advanced large tumors (≥ cT3 and ≥ 5 cm) and/or bulky node metastasis (≥ 3 cm × 1 or ≥ 1.5 cm × 2). Between January 2009 and March 2022, 150 patients underwent preoperative chemotherapy followed by gastrectomy with R0 resection, including conversion surgery (robotic, 62; laparoscopic, 88). The outcomes of these patients were retrospectively examined. RESULTS: Among them, 41 and 47 patients had stage IV disease and underwent splenectomy, respectively. Regarding operative outcomes, operative time was 475 min, blood loss was 72 g, morbidity (grade ≥ 3a) rate was 12%, local complication rate was 10.7%, and postoperative hospital stay was 14 days (Interquartile range: 11-18 days). Fifty patients (33.3%) achieved grade ≥ 2 histological responses. Regarding resection types, total/proximal gastrectomy plus splenectomy (29.8%) was associated with significantly higher morbidity than other types (distal gastrectomy, 3.2%; total/proximal gastrectomy, 4.9%; P < 0.001). Specifically, among splenectomy cases, the rate of postoperative complications associated with the laparoscopic approach was significantly higher than that associated with the robotic approach (40.0% vs. 0%, P = 0.009). In the multivariate analysis, splenectomy was an independent risk factor for postoperative complications [odds ratio, 8.574; 95% confidence interval (CI), 2.584-28.443; P < 0.001]. CONCLUSIONS: Minimally invasive gastrectomy following preoperative chemotherapy was feasible and safe for patients with highly advanced gastric cancer. Robotic gastrectomy may improve surgical safety, particularly in the case of total/proximal gastrectomy combined with splenectomy.

Standardized procedure for preventing late intestinal complications following minimally invasive total gastrectomy for gastric cancer: a single-center retrospective cohort study.

BACKGROUND: Although minimally invasive total gastrectomy for gastric cancer is commonly performed, reports regarding late complications are limited. We have made several improvements each time we experienced severe late complications since 2009. This study aimed to evaluate the clinical efficacy of these improved procedures in preventing late complications. METHODS: Between January 2009 and December 2019, 302 patients who underwent laparoscopic or robotic total gastrectomy for gastric cancer were enrolled. The patients were divided into two groups: Period-I (2009-2013, before established standardization of procedure, 166 patients) and Period-II (2014-2019, after established standardization of procedure, 136 patients). The standardized procedure comprised four major steps, including closure of the mesentery defects and diaphragm crus, circumferential fixation of the anastomotic site into the diaphragm, and linearization around the anastomotic site of esophagojejunostomy. The incidence of late complications was retrospectively compared between the two groups. RESULTS: Late overall complications that occurred over 30 days after surgery were observed in 19 (6.3%) patients. In all, 14 of 24 (58.3%) patients admitted due to late intestinal complications eventually required reoperation for treatment. The most frequent complication was nonstenotic outlet obstruction of the distal jejunal limb. The incidence of late overall complications was significantly lower in Period-II than in Period-I (2.9 vs 9.0%, p = 0.030). Intestinal complications were reduced considerably in Period-II. The 3-year cumulative incidence rate of late overall complications was significantly lower in Period-II than in Period-I (0.03 vs 0.10, p = 0.035). Period-I as the only independent risk factor for the development of late intestinal complications. CONCLUSION: Late complications after laparoscopic total gastrectomy sometimes occurred, and more than half of the patients with intestinal complications required reoperation. Our standardized procedure was associated with a lower risk of late intestinal complications after minimally invasive total gastrectomy followed by intracorporeal esophagojejunostomy using linear staplers in a cohort of patients with gastric cancer.

First clinical experiences of robotic gastrectomy for gastric cancer using the hinotori™ surgical robot system.

BACKGROUND: Although the da Vinci™ Surgical System is the most predominantly used surgical robot worldwide, other surgical robots are being developed. The Japanese surgical robot hinotori™ Surgical Robot System was launched and approved for clinical use in Japan in November 2022. We performed the first robotic gastrectomy for gastric cancer using hinotori in the world. Here, we report our initial experience and evaluation of the feasibility and safety of robotic gastrectomy for gastric cancer using hinotori. METHODS: A single-institution retrospective study was conducted. Between November 2022 and October 2023, 24 patients with gastric cancer underwent robotic gastrectomy with hinotori. Five ports, including one for an assistant, were placed in the upper abdomen, and gastric resection with standard lymphadenectomy and intracorporeal reconstruction were performed. The primary endpoint was the postoperative complication rate within 30 days after surgery. The secondary outcomes were surgical outcomes, including intraoperative adverse events, operative time, blood loss, and the number of dissected nodes. RESULTS: Of the 24 patients, 16 (66.7%) were male. The median age and body mass index were 73.5 years and 22.9 kg/m2, respectively. Twenty-three patients (95.8%) had tumors in the middle to lower stomach. Sixteen (66.7%) and seven (29.2%) patients had clinical stage I and II diseases, respectively. Twenty-three (95.8%) patients underwent distal gastrectomy. No patient had postoperative complications of Clavien-Dindo classification IIIa or higher, whereas two (8.3%) had the grade II complications (enteritis and pneumonia). No intraoperative adverse events, including conversion to other approaches, were observed. All patients received R0 resection. The median operative and console times were 400 and 305 min, respectively. The median blood loss was 14.5 mL, and the number of lymph nodes dissected was 51.5. CONCLUSIONS: This study found that robotic gastrectomy with standard lymphadenectomy for gastric cancer using hinotori can be safely performed.

Efficacy of minimally invasive proximal gastrectomy followed by valvuloplastic esophagogastrostomy using the double flap technique in preventing reflux oesophagitis.

BACKGROUND: Valvuloplastic esophagogastrostomy (VEG) using the double flap technique (DFT) after proximal gastrectomy (PG) represents a promising procedure for the prevention of reflux oesophagitis. We aimed to retrospectively investigate the efficacy of minimally invasive PG followed by VEG-DFT in preventing reflux oesophagitis among patients who require intra-mediastinal anastomosis. METHODS: A total of 80 patients who underwent reconstruction with DFT after LPG from November 2013 to January 2021 were enrolled in the present study. Data were obtained through a review of our prospectively maintained database. At 1 year after surgery, multivariate analyses were performed to identify risk factors for gastroesophageal reflux disease of Los Angeles (LA) classification grade B or higher. RESULTS: The incidence of LA grade B or higher reflux oesophagitis 1 year after surgery was 10%. Multivariate analyses revealed that the longitudinal length of the resected oesophagus of > 20 mm was the only significant risk factor for reflux oesophagitis. Patients with a longitudinal length of the resected oesophagus > 20 mm (group-L, n = 35) had a significantly longer total operative time and a higher rate of complications within 30 days of surgery than those with a length of ≤ 20 mm (group-S, n = 45). LA grade B or higher reflux oesophagitis was significantly higher in group-L than in group-S (20% vs. 2.2%; P = 0.011). CONCLUSIONS: There is a need for surgical procedures with improved efficacy for the prevention of reflux oesophagitis in patients requiring oesophageal resection of > 20-mm.

Muscle mass ratio in male gastric cancer patients as an independent predictor of postoperative complications after minimally invasive distal gastrectomy.

BACKGROUND: The current study aimed to investigate the relationship between muscle mass proportion and the incidence of total complications in male gastric cancer (GC) patients after minimally invasive distal gastrectomy (MIDG). METHODS: Between March 2017 and March 2020, 152 male GC patients with clinical stage III or lower GC who underwent MIDG were enrolled in this study. The muscle mass ratio (MMR) was calculated by dividing the total muscle weight obtained from bioelectrical impedance analysis by the whole-body weight. Thereafter, the association between MMR and surgical outcomes was determined. RESULTS: Based on the optimal MMR cutoff value of 0.712 obtained using the receiver operating characteristic (ROC) curve, patients were divided into two groups (69 and 83 patients in the MMR-L and MMR-H groups). The MMR-L group had a significantly higher total complication rate compared to the MMR-H group (MMR-L, 24.6% vs. MMR-H, 7.2%; P = 0.005). Multivariate analysis also identified MMR-L as a significant independent risk factor for total complications and intra-abdominal infectious complications after MIDG. CONCLUSIONS: The MMR calculated using bioelectrical impedance analysis can be a useful predictor for postoperative complications after MIDG in male GC patients.

Robotic esophagectomy with outermost layer-oriented dissection for esophageal cancer: technical aspects and a retrospective review of a single-institution database.

BACKGROUND: Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and similar concept has been extensively used for robotic esophagectomy (RE) since 2018. This study aimed to determine the surgical and oncological safety of RE using the outermost layer-oriented approach for esophageal cancer (EC). METHODS: Sixty-six patients who underwent RE with total mediastinal lymphadenectomy for primary EC between April 2018 and December 2021 were retrospectively reviewed. All underwent the outermost layer-oriented approach with intraoperative nerve monitoring (IONM). Postoperative complications within 30 days were analyzed. RESULTS: Among the patients, 51 (77.3%) were male. The median age was 64 years, and the body mass index was 21.8 kg/m2. Furthermore, 58 (87.9%) patients had squamous cell carcinoma and eight (12.1%) patients had adenocarcinoma. Clinical stages I, II, and III were seen in 23 (34.8%), 23 (34.8%), and 16 (24.2%) patients, respectively. Thirty-four (51.5%) patients received preoperative treatment. No patient shifted to conventional thoracoscopic or open procedure intraoperatively. The median operative time was 716 min with 119 mL of blood loss. Additionally, 64 (97%) patients underwent R0 resection. The morbidity rates based on Clavien-Dindo grades ≥ II and ≥ IIIa were 30.3% and 10.6%, respectively, within 30 postoperative days. None died within 90 days postoperatively. Three (4.5%) patients exhibited recurrent laryngeal nerve (RLN) palsy (CD grade ≥ II). The sensitivity and specificity of IONM for RLN palsy were 50% and 98.3% at the right RLN and 33.3% and 98.0% at the left RLN, respectively. CONCLUSION: RE with the outermost layer-oriented approach can provide safe short-term outcomes.

Incidence and clinical relevance of postoperative diarrhea after minimally invasive gastrectomy for gastric cancer: a single institution retrospective study of 1476 patients.

PURPOSE: Postoperative diarrhea (PD) remains one of the significant complications. Only a few studies focused on PD after minimally invasive surgery. We aimed to investigate PD after minimally invasive gastrectomy for gastric cancer. METHODS: A total of 1476 consecutive patients with gastric cancer undergoing laparoscopic or robotic gastrectomy between 2009 and 2019 at our institution were retrospectively reviewed. PD was defined as continuous diarrhea for ≥ 2 days, positive stool culture, or positive clostridial antigen test. The incidence, causes, and related clinical factors were analyzed. RESULTS: Of the 1476 patients, the median age was 69 years. Laparoscopic and robotic approaches were performed in 1072 (72.6%) and 404 (27.4%), respectively. Postoperative complications with Clavien-Dindo classification grade of ≥ IIIa occurred in 108 (7.4%) patients. PD occurred in 89 (6.0%) patients. Of the 89 patients with PD, Clostridium difficile, enteropathogenic Escherichia coli, and methicillin-resistant Staphylococcus aureus were detected in 24 (27.0%), 16 (33.3%), and 7 (14.6%) patients, respectively. Multivariate analysis revealed that age ≥ 75 years (OR 1.62, 95% CI [1.02-2.60], p = 0.042) and postoperative complications (OR 6.04, 95% CI [3.54-10.32], p < 0.001) were independent risk factors for PD. In patients without complications, TG (OR 1.88) and age of ≥ 75 years(OR 1.71) were determined as independent risk factors. CONCLUSION: The incidence of PD following minimally invasive gastrectomy for gastric cancer was 6.0%. Older age and TG were obvious risk factors in such a surgery, with the latter being a significant risk even in the absence of complications.

Safe implementation of robotic distal gastrectomy performed by non-endoscopic surgical skill qualification system-qualified surgeons.

PURPOSE: Robotic gastrectomy (RG) for gastric cancer (GC) was approved for national medical insurance coverage in April, 2018, since when its use has increased dramatically throughout Japan. However, the safety of RG performed by surgeons who are not Endoscopic Surgical Skill Qualification System (ESSQS)-qualified has yet to be established. We conducted this study to verify the short-term outcomes of the initial series of RG procedures performed by non-ESSQS-qualified surgeons. METHODS: Between January, 2020 and December, 2021, 30 patients with clinical Stage I and II GC underwent RG performed by four non-ESSQS-qualified surgeons according to the Japan Society for Endoscopic Surgery guideline. We evaluated, retrospectively, the morbidity rates according to Clavien-Dindo (CD) classification grade II or higher. RESULTS: Each operating surgeon completed all procedures without any serious intraoperative adverse events. The median operative time, console time, and estimated blood loss were 413 (308-547) min, 361 (264-482) min, and 25.5 (4-167) mL, respectively. No patient required conversion to laparoscopic or open surgery. Three (10%) patients suffered CD grade II complications postoperatively. The median postoperative hospitalization was 11 (8-51) days. CONCLUSION: Non-ESSQS-qualified surgeons trained by expert RG surgeons could perform robotic distal gastrectomy safely for initial cases.

Circular-stapled esophagogastrostomy using the keyhole procedure after radical esophagectomy for esophageal cancer.

BACKGROUND: Anastomotic leakage of cervical esophagogastrostomy following radical esophagectomy for esophageal cancer has reduced over time; however, postoperative anastomotic stricture still occurs at a considerably high rate. We developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler to enlarge the anastomotic opening made with a circular stapler (CS). METHODS: We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery. RESULTS: Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). No differences were observed in patients' age, sex, body mass index, performance status, American Society of Anesthesiologists physical status, Charlson's comorbidity index, tumor histological type, tumor location, clinical stage, or preoperative treatment. A smaller stapler was used in the CS + K group (p < 0.001). Incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). Univariate analysis confirmed that CS ≤ 23 without keyhole was a significant risk factor (p = 0.001). CONCLUSIONS: The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

Regioselective and Stereospecific ß-Arabinofuranosylation by Boron-Mediated Aglycon Delivery.

Regio- and stereoselective formation of the 1,2-cis-furanosidic linkage has been in great demand for efficient synthesis of biologically active natural glycosides. In this study, we developed a regioselective and ß-stereospecific d-/l-arabinofuranosylation promoted by a boronic acid catalyst under mild conditions. The glycosylations proceeded smoothly for a variety of diols, triols, and unprotected sugar acceptors to give the corresponding ß-arabinofuranosides (ß-Arbf) in high yields with complete ß-stereoselectivity and high regioselectivity. The regioselectivity was completely reversed depending on the optical isomerism of the donor used and was predictable a priori using predictive models. Mechanistic studies based on DFT calculations revealed that the present glycosylation occurs through a highly dissociative concerted SN i mechanism. The usefulness of the glycosylation method was demonstrated by the chemical synthesis of trisaccharide structures of arabinogalactan fragments.

Clinical advantage of standardized robotic total gastrectomy for gastric cancer: a single-center retrospective cohort study using propensity-score matching analysis.

BACKGROUND: Although recent studies have shown that robotic gastrectomy offers clinical advantages over laparoscopic gastrectomy in decreasing gastric cancer (GC) morbidity, studies focusing on robotic total gastrectomy (RTG) remain limited. The current study aimed to clarify whether the use of a robotic system could clinically improve short-term outcomes. METHODS: Between January 2009 and June 2021, 371 patients diagnosed with both clinical and pathological Stage III or lower GC and underwent RTG or laparoscopic total gastrectomy (LTG) were enrolled in this study. The primary outcome was the incidence of intra-abdominal infectious complications over Clavien-Dindo classification grade IIIa. Demographic characteristics of those who underwent the RTG and LTG were matched using propensity-score matching (PSM), after which short-term outcomes were compared retrospectively. RESULTS: After PSM, 100 patients were included in each group. The RTG group had a significantly shorter duration of hospitalization following surgery [RTG 13 (11-16) days vs. LTG 14 (11-19) days; p = 0.032] and a greater number of dissected LNs [RTG 48 (39-59) vs. LTG 43 (35-54) mL; p = 0.025], despite having a greater total operative time [RTG 511 (450-646) min vs. LTG 448 (387-549) min; p < 0.001]. In addition, the RTG group had significantly fewer total complications (3% vs. 13%, p = 0.019) and intra-abdominal infectious complications (1% vs. 9%; p = 0.023). CONCLUSIONS: The current study showed that robotic surgery might improve short-term outcomes following minimally invasive radical total gastrectomy by reducing intra-abdominal infectious complications.

Impact of routine preoperative sonographic screening with early intervention for deep venous thrombosis in lower extremities on preventing postoperative venous thromboembolism in patients with gastric cancer scheduled for minimally invasive surgery.

PURPOSE: This study aimed to investigate the clinical efficacy of lower-extremity ultrasonography screening with early intervention for deep venous thrombosis (DVT) on the incidence of venous thromboembolism (VTE) after minimally invasive surgery (MIS) for gastric cancer (GC). METHODS: Between January 2012 and December 2019, 1070 patients were diagnosed with both clinical and pathological stage I-III GC and underwent MIS at our institution. Routine ultrasonographic screening for DVT in lower extremities is performed before MIS. Patients diagnosed with DVT were preoperatively administered anticoagulant therapy. Enoxaparin was routinely administrated after surgery irrespective of the presence of DVT. The incidence of postoperative symptomatic VTE was examined retrospectively. RESULTS: A total of 74 (6.9%) patients were preoperatively diagnosed with DVT. Multivariate analyses revealed that age > 70 years (p = 0.015), female sex (p < 0.001), and positive serum D-dimer test (p < 0.001) were significant and independent risk factors for preoperative DVT. The incidence of symptomatic postoperative VTE was 1 (0.09%); symptomatic VTE developed in one patient among patients without DVT, whereas no patient with DVT developed VTE. CONCLUSIONS: Preoperative DVT screening using lower-extremity ultrasonography followed by preoperative anticoagulant therapy should be considered as a useful strategy to safely perform MIS for GC without increasing the incidence of VTE.

Establishment of a new practical telesurgical platform using the hinotori™ Surgical Robot System: a preclinical study.

AIM: The recent development of new surgical robots and network telecommunication technology has opened new avenues for robotic telesurgery. Although a few gastroenterological surgeries have been performed in the telesurgery setting, more technically demanding procedures including gastrectomy with D2 lymphadenectomy and intracorporeal anastomosis have never been reported. We examined the feasibility of telesurgical robotic gastrectomy using the hinotori™ Surgical Robot System in a preclinical setting. METHODS: First, the suturing time in the dry model was measured in the virtual telesurgery setting to determine the latency time threshold. Second, a surgeon cockpit and a patient unit were installed at Okazaki Medical Center and Fujita Health University, respectively (approximately 30 km apart), and connected using a 10-Gbps leased optic-fiber network. After evaluating the feasibility in the dry gastrectomy model, robotic distal gastrectomies with D2 lymphadenectomy and intracorporeal B-I anastomosis were performed in two porcine models. RESULTS: The virtual telesurgery study identified a latency time threshold of 125 ms. In the actual telesurgery setting, the latency time was 27 ms, including a 2-ms telecommunication network delay and a 25-ms local information process delay. After verifying the feasibility of the operative procedures using a gastrectomy model, two telesurgical gastrectomies were successfully completed without any unexpected events. No fluctuation was observed across the actual telesurgeries. CONCLUSION: Short-distance telesurgical robotic surgery for technically more demanding procedure may be safely conducted using the hinotori Surgical Robot System connected by high-speed optic-fiber communication.

[Robot-Assisted Surgery for Stage â £ Gastric Cancer with Liver Metastases-Report of a Case].

We report a successful case of robot-assisted surgery for Stage Ⅳ gastric cancer with liver metastasis. A 70s man diagnosed with advanced gastric cancer with S3 solitary liver metastasis, and received a chemotherapy with S-1 and cisplatin. After 4 courses of chemotherapy, liver metastatic lesion was disappeared. Thus, robotic distal gastrectomy and partial liver resection were performed. Operating time was 391 minutes, and amount of intraoperative blood loss was 11 mL. The postoperative course was uneventful, and the patient was discharged 11 days after surgery. Histologic examination revealed no viable malignant cells in the resected liver, with a diagnosis of ypT2N1M0, ypStage ⅡA. The patient is alive with no recurrence 12 months after surgery, without adjuvant chemotherapy.

[A Case of Gastric Granular Cell Tumor Resected by a Surgical Robot].

A 46-year-old man was referred to further treatment for a 20 mm submucosal tumor at the gastric angle found during a medical check-up. Endoscopic ultrasonography and chest abdominal contrast-enhanced CT revealed the tumor was located at the 4th(proper muscular)layer of the posterior wall of the gastric antrum and slightly enhanced. No metastasis was found. Although a biopsy failed to reveal an accurate diagnosis, GIST was clinically suspected. A robotic distal gastrectomy was planned to manage the residual gastric stricture. The intraoperative findings indicated possible passage of the remnant stomach; therefore, local resection was performed. The patient's postoperative course was uneventful, and he was discharged on postoperative day 9. A histopathological examination confirmed the diagnosis of a PAS-positive, S100-positive granular cell tumor with no nuclear atypia. These findings suggest that use of the robotic approach could help determine the stomach resection extent.

[A Case of Curative Resection for Gastric Cancer with Single Giant Lymph Node Metastasis].

A 79-year-old male presented with epigastric discomfort and appetite loss. A type 1 advanced gastric tumor was detected by upper gastrointestinal endoscopy. Contrast-enhanced CT revealed a 7 cm mass with contrast effect at the greater curvature of the lower body of the stomach. No distant metastases were found. Staging laparoscopy confirmed gastric cancer with single giant lymph node metastasis, which was resectable, although the metastatic node possibly invaded the transverse colon. We performed total gastrectomy and partial colectomy. Pathological examination revealed the tumor was pT3N1; the mass was #4sa lymph node metastasis of gastric cancer. The postoperative course was uneventful. No tumor recurrence has been found for 12 months postoperatively.

[A Case of Robotic Distal Pancreatectomy for Pancreatic Metastasis of Gastric Cancer].

A 78-year-old male who had received laparoscopic total gastrectomy for upper gastric cancer 30 months ago(pT3N0, pStage ⅡB)was referred for further treatment for a 30-mm in size mass at the splenic hilum. The mass was suspected of lymph node metastasis was suspected. Two courses of SOX therapy failed to achieve the tumor response. Since there was no other metastasis, surgical treatment was indicated. Robot distal pancreatectomy with splenectomy was performed. There was no finding of peritoneal metastasis during the operation. The operative time was 384 min, the blood loss 22 mL, respectively. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. The histopathological examination found that the resected mass was pancreatic metastasis of gastric cancer. Despite 3 courses of SOX therapy after the operation, the tumor recurred at the liver and paraaortic lymph nodes 2 months later. The second-line ramucirumab plus paclitaxel was started and has continued for 11 months with partial response. Although oncological benefit of surgical resection for isolated metastasis of gastric cancer, including pancreatic metastasis, was unclear, the robotic approach for such an atypical case was safe and feasible, leading to smooth initiation of postoperative systemic therapy.

Impact of the Endoscopic Surgical Skill Qualification System on the safety of laparoscopic gastrectomy for gastric cancer.

BACKGROUND: We hypothesized that the Endoscopic Surgical Skill Qualification System (ESSQS) can shorten operative time, resulting in a decrease in postoperative morbidity. Here, we aimed to clarify whether ESSQS-qualified surgeons could decrease the incidence of complications. METHODS: Between January 2009 and June 2019, 1042 patients diagnosed with both clinical and pathological Stage ≤ III gastric cancer and undergoing LG were enrolled. In all LG procedures involving ESSQS-qualified surgeons, these served as the operator or the instructive assistant. The short-term outcomes were retrospectively compared between the ESSQS-qualified and the non-ESSQS-qualified surgeons using a propensity-score matched analysis. RESULTS: After propensity-score matching, 321 patients were included in each group. No significant differences were observed in morbidity rate, and length of hospitalization following surgery, although the non-ESSQS-qualified surgeon group had a significantly longer total operative time (Non-ESSQS-qualified group, 368 [170-779] min vs. ESSQS-qualified group, 316 [147-772] min; p < 0.001), and larger estimated blood loss (Non-ESSQS-qualified group, 28 [0-702] mL vs. ESSQS-qualified group 25, [0-1069] mL; p = 0.042). Multivariate analysis revealed that operative time ≥ 360 min (OR 1.818 [1.069-3.094], p = 0.027) was identified as the only significant independent risk factor determining morbidity. CONCLUSIONS: The incidence of postoperative morbidity did not differ between patients operated by the qualified and nonqualified surgeons, as long as ESSQS-qualified surgeons provide intraoperative instructions.

[A Successful Case of Treatment by Lymphangiography for Chylothorax after Robotic Esophagectomy-A Case of Report].

A 50-year-old woman diagnosed with clinical Stage Ⅲ esophageal squamous cell carcinoma, received 2 cycles of docetaxel, cisplatin, 5-fluorouracil(DCF)therapy followed by robotic esophagectomy. In the 15th postoperative day, she suddenly had difficulty in breathing and a chest CT finding showed a large amount of right pleural effusion. Thoracocentesis yield a 1 L of chylous fluid confirmed diagnosis with postoperative chylothorax and conservative treatment was initiated. However, chylothorax was not improved. Therefore, a lipiodol lymphangiography from the inguinal lymph node was performed at the 20th postoperative day. Although the site of leakage could not identify, amount of drained pleural effusion was gradually decreased after lymphangiography, and drain was decannulated in the 28th postoperative day. Lipiodol lymphangiography may be a useful modality for both diagnosis and treatment for chylothorax after esophagectomy.

Total Synthesis of Terpioside B.

The first total synthesis of terpioside B (1) has been accomplished. Key steps include the stereoselective installments of a set of challenging 1,2-cis-glycosidic linkages. Thus, α(1,4)-linked d-galactoside was effectively constructed from a 1,2-anhydrogalactose donor and an unprotected 1,6-anhydrogalactose acceptor by using a boron-mediated aglycon delivery (BMAD) method. In addition, α-l-fucofuranosides were stereoselectively and simultaneously constructed by remote group-assisted 1,2-cis-α-stereoselective glycosylations.