Robotic distal gastrectomy plus spleen-preserving distal pancreatectomy: optimal resection for simultaneous gastric cancer and intraductal papillary mucinous neoplasm of the pancreatic body.

BACKGROUND: Organ-preserving surgery has recently gained increasing attention. However, performing the surgery for duplicated gastric and distal pancreatic tumors is difficult because of procedural complexity and concerns of remnant gastric necrosis. We present the first case of simultaneous robotic distal gastrectomy plus spleen-preserving distal pancreatectomy in a patient with overlapping gastric cancer and intraductal papillary mucinous neoplasm. CASE PRESENTATION: A 78-year-old man was diagnosed with gastric cancer in the middle stomach and intraductal papillary mucinous neoplasm of the pancreatic body. Radical cure surgery was performed using the da Vinci Xi robotic system. Conventional distal gastrectomy was initially completed using near-infrared ray guidance when transecting the stomach. After dividing the pancreas, the parenchyma of the distal pancreas was detached from the splenic artery and vein; multiple branches from these splenic vessels were dissected. Indocyanine green imaging confirmed sufficient blood flow in the splenic vessels and perfusion of the remnant stomach. Ultimately, gastrointestinal reconstruction was performed, and the postoperative course was uneventful. CONCLUSIONS: The robotic distal gastrectomy plus spleen-preserving distal pancreatectomy procedure was safely performed. Compared to the total gastrectomy plus distal pancreatectomy with splenectomy procedure, this technique may improve the quality of dietary life, reduce weight loss, and prevent complications associated with splenectomy.

Laparoscopic pancreas-preserving duodenectomy: Minimally invasive surgery for superficial nonampullary duodenal epithelial tumors.

No consensus exists regarding the optimal treatment for superficial nonampullary duodenal epithelial tumors. Herein, we describe a laparoscopic pancreas-preserving duodenectomy for the treatment of a 30-mm adenoma located in the third portion of the duodenum. The adenoma was located on the pancreatic side, further hindering safe endoscopic resection. Via laparoscopy, the jejunum was transected first. After releasing the third portion of the duodenum from the retroperitoneal space, the jejunum was pulled to the right side of the superior mesenteric artery and separated from the pancreas. Under endoscopic guidance, the duodenum was then transected and duodenojejunostomy performed intracorporeally. Laparoscopic pancreas-preserving duodenectomy can be considered minimally invasive, achieving tumor radicality while preserving organs and causing minimal destruction to the abdominal wall. In conclusion, although technically demanding, laparoscopic pancreas-preserving duodenectomy is a valuable treatment option for superficial nonampullary duodenal epithelial tumors.

Severe esophageal stricture after perforation and necrotizing esophagitis: unusual presentation of a duodenal gastrinoma.

Gastrinomas are pancreatic or duodenal endocrine tumors that secrete excess gastrin, which causes gastroesophageal reflux disease, peptic ulcers, and chronic diarrhea. Due to the rarity of the disease, nonspecific symptoms, and the outstanding effect of proton pump inhibitors, diagnosing gastrinomas is difficult. Here, we present the case of a 58-year-old woman who had a duodenal gastrinoma that caused rare but critical events, including esophageal perforation, necrotizing esophagitis, and severe esophageal stricture. She presented with a non-malignant severe lower esophageal stricture, which was resistant to endoscopic dilatation. During esophagectomy, a duodenal mass was excised and diagnosed as gastrinoma. This was considered the main cause of all events. Gastrinomas are rarely encountered in clinical practice, but early diagnosis is necessary to avoid serious conditions. Therefore, whenever we encounter a patient with gastroesophageal reflux disease requiring long-term treatment or is refractory, we must not forget to screen for gastrinomas.

Simultaneous robotic distal gastrectomy and distal pancreatectomy: Avoiding total gastrectomy using indocyanine green fluorescence imaging.

Remnant gastric ischemia is the most significant complication in distal pancreatectomy (DP) after distal gastrectomy (DG). Some studies have reported the safety of asynchronous DP in patients who underwent DG. We report a case of simultaneous robotic DG and DP. A 78-year-old man was diagnosed with gastric and pancreatic cancer. We preoperatively confirmed the absence of anomalies in the left inferior phrenic artery. Robotic simultaneous DG and DP was performed; subtotal resection of the stomach was carried out, enabling the left inferior phrenic artery to maintain perfusion of the remnant stomach, even after ligation of the splenic artery. The remnant stomach was preserved as scheduled, and indocyanine green fluorescence imaging confirmed sufficient remnant stomach tissue perfusion. Robotic surgery using the da Vinci surgical system (with a fluorescence imaging system and technology enabling surgical precision) is suitable for this surgical procedure because it considers tumor radicality and allows for function preservation.

The cisplatin-induced acute kidney injury is a novel risk factor for postoperative complications in patients with esophageal cancer: a retrospective cohort study.

BACKGROUND: Cisplatin-induced acute kidney injury (AKI) is common during preoperative chemotherapy for esophageal cancer. The purpose of this study was to investigate the association between AKI after preoperative chemotherapy and postoperative complications in patients with esophageal cancer. METHODS: In this retrospective cohort study, we included patients who had received preoperative chemotherapy with cisplatin and underwent surgical resection for esophageal cancer under general anesthesia from January 2017 to February 2022 at an education hospital. A predictor was stage 2 or higher cisplatin-induced AKI (c-AKI) defined by the KDIGO criteria within 10 days after chemotherapy. Outcomes were postoperative complications and length of hospital stays. Associations between c-AKI and outcomes including postoperative complications and length of hospital stays were examined with logistic regression models. RESULTS: Among 101 subjects, 22 developed c-AKI with full recovery of the estimated glomerular filtration (eGFR) before surgery. Demographics were not significantly different between patients with and without c-AKI. Patients with c-AKI had significantly longer hospital stays than those without c-AKI [mean (95% confidence interval (95%CI)) 27.6 days (23.3-31.9) and 43.8 days (26.5-61.2), respectively, mean difference (95%CI) 16.2 days (4.4-28.1)]. Those with c-AKI had higher C-reactive protein (CRP) levels and prolonged weight gain after surgery and before the events of interest despite having comparable eGFR trajectories after surgery. c-AKI was significantly associated with anastomotic leakage and postoperative pneumonia [odds ratios (95%CI) 4.14 (1.30-13.18) and 3.87 (1.35-11.0), respectively]. Propensity score adjustment and inverse probability weighing yielded similar results. Mediation analysis showed that a higher incidence of anastomotic leakage in patients with c-AKI was primarily mediated by CRP levels (mediation percentage 48%). CONCLUSION: c-AKI after preoperative chemotherapy in esophageal cancer patients was significantly associated with the development of postoperative complications and led to a resultant longer hospital stay. Increased vascular permeability and tissue edema due to prolonged inflammation might explain the mechanisms for the higher incidence of postoperative complications.

Robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy.

The utility of robotic surgery for remnant gastric cancer remains unclear. We report a case of a robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy and Child reconstruction with Braun enteroenterostomy. Adhesiolysis, lymphadenectomy, and gastrectomy were robotically performed. Indocyanine green fluorescence imaging confirmed the tissue perfusion of the reconstructive tract. The patient's postoperative course was uneventful. Robotic surgery facilitates safety for gastrectomy after pancreaticoduodenectomy because of its precise manipulation; its advantages can be further exploited by maximizing usage of the assistant's forceps. Indocyanine green fluorescence imaging capability of the da Vinci Xi Surgical System allows timely evaluation of tissue perfusion at the site of interest, leading to a more reliable procedure.

Benefits of laparoscopic trans-hiatal approach with Heller-Dor surgery in a case of mid-esophageal diverticulum.

Compared to the more common epiphrenic diverticula, those located at the central section of the esophagus are quite rare. Minimally invasive approaches for mid-esophageal diverticula have lacked standardization. Certain mid-esophageal diverticula, like epiphrenic diverticula, have been attributed to esophageal motility disorders. Thus, we believe that surgery for esophageal diverticula requires preoperative evaluation of esophageal function, with additional surgery being performed in case of abnormalities. The laparoscopic trans-hiatal approach has been a common technique for managing epiphrenic diverticula but can also be used for mid-esophageal diverticula located far from the esophagogastric junction provided that the port location is carefully considered. Laparoscopic surgery is also preferable given that it is a minimally invasive procedure and allows for diverticulum resection and Heller myotomy and Dor surgery to prevent reflux in the same field of view. Hence, laparoscopic surgery may be a beneficial alternative to the traditional thoracic or thoracoabdominal techniques.

Laparoscopic gastrectomy for gastric cancer with two left gastric arteries: Safe and adequate lymphadenectomy in a rare arterial abnormality.

Clinical studies have established the safety and advantages of laparoscopic surgery for gastric cancer; therefore, laparoscopic gastrectomy (LG) in clinical practice is increasing. We report the case of a 77-year-old patient with gastric cancer who was referred to our center for LG. Esophagogastroduodenoscopy revealed a type 3 tumor identified as adenocarcinoma on biopsy. Three-dimensional computed tomography-angiography revealed two left gastric arteries (LGAs) branching from the celiac trunk. By laparoscopically performing the outermost layer-oriented lymphadenectomy (OML-OL), the two LGAs were detected and appropriately divided. Subtotal gastrectomy was completed, and the patient had an uneventful postoperative course. The OML-OL was appropriate for LG in this situation. This case demonstrates the necessity of preoperative three-dimensional computed tomography-angiography with 1-mm slices and the importance of performing OML-OL.

Potential Role of TRPV4 in Stretch-Induced Ghrelin Secretion and Obesity.

Obesity is an important health problem, which can be prevented through appetite control. Ghrelin is an appetite-stimulating hormone considered to promote obesity. Thus, we examined whether gastric stretching affects ghrelin secretion. We investigated the role of transient receptor potential vanilloid 4 (TRPV4) in gastric glands in the regulation of ghrelin secretion. TRPV4 immunostaining was performed in tissue samples from 57 patients who underwent gastrectomy. TRPV4 expression was compared between patients with (body mass index (BMI) ≥ 30) and without (BMI <30) obesity. For in vitro experiments, we used MGN3-1 cells, a ghrelin-producing cell line derived from mice. To investigate the bioactivity of TRPV4, MGN3-1 cells were treated with TRPV4 agonists and antagonists, and changes in intracellular Ca2+ concentration were confirmed. The concentration of ghrelin in the cell supernatant was measured using the ELISA with and without 120% stretch stimulation. TRPV4 expression was significantly higher in patients with obesity than in those without at all sites, except the fornix. Immunostaining confirmed the expression of TRPV4 in MGN3-1 cells. TRPV4 agonist administration increased intracellular Ca2+ concentration and ghrelin secretion in MGN3-1 cells, whereas the administration of the agonist combined with the antagonist decreased intracellular Ca2+ concentration and ghrelin secretion. Ghrelin secretion significantly increased in response to a 120% stretch in MGN3-1 cells. However, secretion was not increased by stretch when cells were treated with a TRPV4 antagonist. TRPV4 regulates ghrelin secretion in response to stretch in the stomach, which may affect body weight.

Robotic distal gastrectomy for gastric cancer in a patient with situs inversus totalis and a vascular anomaly.

Situs inversus totalis is defined as a complete mirror-image transposition of the thoracic and abdominal viscera. Cancer surgery in patients with situs inversus totalis can be more difficult than in patients without situs inversus totalis; however, robotic surgery using the da Vinci Surgical System allows for intuitive operation with its multi-articular function and stereopsis effect. In addition, prevention of shaking and the motion scale allows for efficient surgical procedures. We evaluated a 64-year-old man who had gastric cancer, and situs inversus totalis and a blood-vessel variation. To facilitate intuitive handling of the robot in this patient with organs reversed from the norm, we arranged the instruments and ports in such a way that the Maryland bipolar forceps could be used with the surgeon's right hand. We performed a successful robotic distal gastrectomy with lymph node dissection. The operative time was 286 min, and the blood loss was 44 mL. There were no intra- or post-operative complications. The patient was discharged on postoperative day 7 and has had no evidence of a recurrence for 18 months. We conclude that robotic surgery is an efficient tool for operating on patients with gastric cancer, and situs inversus totalis and vessel variations.

Progressive loss of the thyroid tissue integrity visualised by serial CT scans.

A man in his 70s developed thyrotoxicosis due to painless thyroiditis after starting nivolumab, which was subsequently followed by severe hypothyroidism. We diagnosed him as chronic thyroiditis, initiated levothyroxine supplementation and treated appropriately. Retrospective CT images of the thyroid gland during the clinical course revealed that the CT attenuation value was high at first but gradually decreased. The high-density signal of the normal thyroid tissues reflects its function of concentrating inorganic iodine, and the progressive decrease of the CT density in the present case can be viewed as a reflection of the thyroid destruction and progressive loss of iodine during the clinical course of the development of chronic thyroiditis. Considering the high incidence rate of functional thyroid disease in patients treated with immune checkpoint inhibitors, CT density of the thyroid gland needs to be paid attention to as the first sign of thyroiditis in this patient population.

Near infrared ray-guided surgery using Firefly technology of the daVinci Xi system and intraoperative upper gastrointestinal endoscopy for subtotal gastrectomy and surgery for cancer of the gastroesophageal junction.

BACKGROUND: In gastrectomies, especially subtotal gastrectomies and operations on the gastroesophageal junction, identifying the exact location of the tumor and establishing the appropriate resection line is very important. Accurate resection lines have a major impact on the preservation of organ function and curability. Preservation of as much as possible of the remaining stomach, including the fornix, may be an important surgical goal for maintaining an adequate postoperative quality of life. In adenocarcinoma of the gastroesophageal junction, the height of the esophageal dissection may affect reconstruction of the transhiatal approach. METHODS: We perform a new technique, near infrared ray-guided surgery, for the accurate localization of a tumor using the Firefly technology of the daVinci Xi system and intra-operative upper gastrointestinal endoscopy. We used this new technique for cases of upper gastric cancer or adenocarcinoma of the gastroesophageal junction. In this retrospective study, we examined to determine the extent (mm) of the tumor invasion of the esophagus, visualization of near infrared ray contained within endoscopic light, and distance from the proximal margin of the tumor to the surgical cut line on rapid histopathology and in the permanent preparation, including the operative videos and extracted specimens. RESULTS: We performed near infrared ray-guided surgery for 12 patients with gastric cancer or adenocarcinoma of the gastroesophageal junction, and the near infrared ray was clearly seen as green light with Firefly mode in all the patients. Near infrared ray-guided surgery was useful for obtaining localization of the tumor. In addition, it was possible to resect organ with adequate margins from tumor. Rapid intraoperative histopathological examinations confirmed that the resected specimens had negative margins. None of the patients required additional resection. CONCLUSIONS: We believe that because near infrared ray-guided surgery can provide an accurate resection line, it will be useful for the resection of upper gastric cancer and adenocarcinoma of the gastroesophageal junction. It will also provide patients with a good postoperative quality of life after surgery.

Impact of the indocyanine green fluorescence method for anastomotic blood flow in robotic distal gastrectomy.

PURPOSE: To evaluate the blood flow at the site of delta-shaped anastomosis during robotic distal gastrectomy and determine surgical outcomes and risk factors for ischemia at the anastomotic site from the perspective of clinical characteristics, surgical outcomes and perigastric vascular anatomy. METHODS: We included 55 patients who underwent robotic distal gastrectomy with a blood flow evaluation in the duodenal walls using intravenous indocyanine green injection with the da Vinci Xi-equipped Firefly system. Additional resection was performed in patients with a poor blood flow. Clinical characteristics, surgical outcomes and perigastric vascular anatomy were compared between the 45 patients with sufficient blood flow (group S) and the 10 patients with insufficient blood flow (group I). Vascular anatomy was assessed by preoperative contrast-enhanced computed tomography according to Hiatt's classification. RESULTS: The patient characteristics and surgical outcomes were not significantly different. No patient developed anastomotic complications requiring intervention; more patients in group I had aberrant branching of the left hepatic artery than those in group S (p = 0.047). CONCLUSIONS: An indocyanine green-based blood flow evaluation might be an effective method of preventing anastomotic complications of delta-shaped anastomosis. Anatomical branching variations of the left hepatic artery might be a risk factor for impaired vascular perfusion of the anastomotic site.

ESD-aid surgery as a new treatment strategy for duodenal adenoma.

OBJECTIVE: The treatment for nonampullary duodenal adenoma remains to have no consensus and established methods. Although endoscopic treatment is minimally invasive, it was reported to cause delayed perforation in more than 20% of cases. For adenomas in the duodenum, we performed endoscopic submucosal dissection (ESD)-aid surgery, which is a procedure to prophylactically suture the seromuscular structure of the duodenum after ESD. In this procedure, we did not perform Kocher mobilization prior to ESD to facilitate endoscopic resection and full-thickness resection to prevent spread of the tumor and infection to the abdominal cavity. The duodenal wall was reinforced in planes using a suture clip. RESULTS: Of the 13 cases of duodenal adenoma that underwent ESD-aid surgery at our hospital between April 2018 and December 2020, 1 developed postoperative bleeding, but there was no late perforation. For duodenal adenomas, ESD-aid surgery was considered a safe and minimally invasive treatment.

Serum IgG level is a predicting factor for the response to neoadjuvant chemotherapy in patients with esophageal squamous cell carcinoma.

BACKGROUND: Despite the established oncological benefits of neoadjuvant chemotherapy for esophageal squamous cell cancer, not all cases demonstrate benefit. Hence, predicting the response to chemotherapy before treatment is desirable. Some reports have shown that immune factors are related to the chemotherapy response. This study aimed to investigate the utility of serum IgG levels for predicting chemotherapy response. METHODS: Among the patients who underwent esophagectomy after neoadjuvant chemotherapy at Nagoya City University Hospital between December 2012 and June 2019, 130 cases were included in this study. Response to chemotherapy and pretreatment serum IgG levels were examined in 77 cases. FP (5-fluorouracil and cisplatin) therapy or DCF (docetaxel, cisplatin, and 5-FU) therapy was performed as neoadjuvant chemotherapy. DCF therapy was selected for patients aged <75 years, who could be safely administered chemotherapy based on their medical history. RESULTS: This study divided cases into two groups: the effective response group (PR) and ineffective response group (SD and PD). We classified 1, 37, and 39 cases as PD, PR, and SD, respectively. None of the cases were classified as CR. The effective response group had significantly lower serum IgG levels than the ineffective response group (p < 0.001). The cutoff serum IgG value was determined to be 1087 mg/dL. The low IgG group had significantly more cases who had effective response to chemotherapy compared with the high IgG group (odds ratio [OR] = 9.009; 95% confidence interval [CI] = 2.974-30.157; p < 0.001). Univariate and multivariate analyses revealed serum IgG level to be an independent predictor for response to chemotherapy (p = 0.001). Furthermore, cases with effective pathological response had significantly lower pretreatment serum IgG levels than those who did not (p = 0.006). CONCLUSIONS: Our finding showed that serum IgG levels can be an independent predictor of the response to neoadjuvant chemotherapy for esophageal squamous cell carcinoma. TRIAL REGISTRATION: This retrospective study was approved by the review board of Nagoya City University Graduate School of Medical Sciences (reception number: 60-18-0008 ).

Suitable Diagnosis and Treatment of Esophageal Ruptures in Cases of Non-Boerhaave Syndrome: A Comparison With Boerhaave Syndrome.

Boerhaave syndrome (BS) is frequently reported in cases of esophageal perforation; however, there are relatively few studies on non-Boerhaave syndrome (nBS). This study clarifies the appropriate diagnosis and treatment for patients with nBS among those with esophageal ruptures. Twelve patients with esophageal ruptures who underwent surgery at our department over 14 years were classified into 2 groups: 4 in the nBS group and 8 in the BS group. Patient characteristics, surgical methods, surgical outcomes, and complications were compared between the groups. The chief complaints varied between the groups. The nBS group had significantly higher preoperative C-reactive protein (P = .007) and required 5 days (median) from onset to surgery. Moreover, the perforation diameter was significantly smaller in the nBS group than in the BS group (P = .013). Suturing of the perforation site was performed during the initial surgery in 8 BS group patients (100%) and 1 nBS group patient (25%; P = .018). Only drainage was performed during the initial surgery for 3 nBS group patients (75%). The complications did not significantly differ between the groups (P = 1.000), and no deaths were reported. The chief complaints of patients with nBS are diverse, and esophageal perforation should be cited as a differential diagnosis even in the absence of vomiting or chest pain symptoms. In the initial surgery for patients with nBS, the perforation site does not necessarily need to be closed. It is treatable by second-stage surgery or by natural closing.

Diagnosis of recurrent laryngeal nerve paralysis following esophagectomy by evaluating movement of the vocal cords and arytenoid cartilages using ultrasonography.

Advancements in thoracoscopic surgery have provided us with a deeper anatomical understanding of recurrent laryngeal nerve paralysis (RLNP), which is likely to occur after lymph node dissection. Taking a novel approach to researching the diagnosis of RLNP, we evaluated movement of the vocal cords and arytenoid cartilages using ultrasonography in patients who underwent thoracoscopic esophagectomy. RLNP occurred in six of the 24 patient cohort. The rate of hoarseness and difficulty in discharging sputum was significantly higher in the paralyzed group than in the non-paralyzed group. The diagnostic accuracy of RLNP by ultrasonography had a sensitivity of 83.3% (5/6), a specificity of 88.8% (16/18), a false positive rate of 5.6% (1/18), and a false negative rate of 0% (0/6). Although it is not completely accurate, our findings indicate that ultrasonography is quite effective for diagnosing RLNP, more so in combination with clinical symptoms. Ultrasonography may also be effective for identifying patients who are amenable to laryngoscopy for diagnosing RLNP, or for evaluating the recovery status of nerve paralysis.

The feasibility of interval laparoscopic appendectomy and appropriate patient selection: A retrospective study of adult appendiceal masses.

INTRODUCTION: We examined the safety and effectiveness of interval laparoscopic appendectomy (ILA) for adult appendiceal mass (AAM) and then used a novel white blood cell (WBC) parameter to identify the types of AAM cases for which nonsurgical treatment followed by ILA is effective. METHODS: We reviewed the cases of 956 patients who had undergone appendectomy between April 2012 and March 2018 at our facility. Of these patients, 49 had AAM, including 34 who underwent ILA. We examined the safety and effectiveness of ILA by comparing it with laparoscopic appendectomy (LA); specifically, the 34 cases treated with ILA were compared with 477 cases of adult uncomplicated appendicitis treated with LA from the same patient cohort. We then examined the factors associated with not successfully completing the planned nonsurgical treatment and interval before ILA. Patient demographics and clinical variables were reviewed. RESULTS: Patients who had undergone ILA had longer operative times than those who had undergone LA (P = .0059), but they also had shorter postoperative hospital stays (P < .001). There were no significant differences in other perioperative variables. Multivariate analysis showed that a ratio of WBC count on day 3 and day 0 from the start of nonsurgical treatment (WBC day3/day0) of 0.906 or higher was significantly associated with not completing the nonsurgical treatment and interval before ILA (P = .045). CONCLUSION: A comparison of the procedures found that ILA for AAM was almost as safe and effective as LA for adult uncomplicated appendicitis. The WBC day3/day0 ratio can be an objective parameter to assess the effectiveness of the nonsurgical treatment before ILA earlier in the course of treatment.

The impact of skeletal muscle wasting during neoadjuvant chemotherapy on postoperative anastomotic leakage in patients with esophageal cancer.

BACKGROUND: Sarcopenia is defined by low muscle mass and low muscle strength and is a prognostic factor of unfavorable outcomes in various diseases. The purpose of this study is to examine the correlation between skeletal muscle wasting (SMW) during neoadjuvant chemotherapy (NAC) and postoperative complications in patients with esophageal cancer, particularly in relation to anastomotic leakage. METHODS: The present study involved 99 patients with thoracic esophageal cancer and esophago-gastric junctional cancer who received NAC followed by radical esophagectomy between August 2008 to June 2019, and who were pStage 0-III. Patient demographics and clinical variables were retrospectively reviewed. For assessing the extent of SMW, the rate of change in skeletal muscle mass index (SMI) was measured from CT images at the level of the third lumbar vertebra. Factors associated with postoperative complications were also examined. RESULTS: The median rate of change in total SMI in patients was - 1.87%. The decreased rates in SMI of the side abdominal muscles and rectus abdominis were significantly greater than that of the psoas major (side abdominal muscles: p = 0.0084, rectus abdominis: p = 0.036). Multivariate analysis showed a decreased rate in SMI, especially in the erector spinae muscle, and the Charlson comorbidity index (CCI) was significantly associated with Grade IIIa of higher anastomotic leakage (Grade ≥ IIIa) (SMI cutoff (favorable): ≤ - 7.84, p = 0.0040; CCI cutoff (favorable): ≥ 2, p = 0.0032). CONCLUSION: In patients with esophageal cancer, SMI tend to decrease during NAC treatment. It is therefore important to prevent the additional impact that SMW during NAC has on postoperative anastomotic leakage.

Robot-assisted gastrectomy for gastric cancer in a patient with a colostomy: A case report with adaptive techniques and technical points.

Robot-assisted surgery is considered a standard option for procedures on many organs. However, there are still few reports of useful adaptations for various patient conditions. We were able to safely perform robot-assisted distal gastrectomy on a patient with a colostomy. A 75-year-old man presented with gastric cancer, type 0-IIc, 2.5 cm in diameter. Before the gastric surgery, colectomy was performed for obstructive rectal cancer and a colostomy was formed in the right upper abdomen. The following adaptations were required to perform robot-assisted distal gastrectomy to avoid injuring the colon. After moving the port placement to the left side, we used a Penrose drain to retract the intra-abdominal colon connecting to the colostomy, pulling it to the head side. Then we projected the image of the colostomy in the da Vinci console. This case has shown that it is possible to safely perform robot-assisted surgery with adaptations tailored to the patient's conditions.