Surgical Approach to the Upper Side of the Gastrosplenic Ligament During Laparoscopic Total Gastrectomy for Proximal Gastric Cancer: Operative Techniques and Initial Results.

Background: Laparoscopic gastrectomy for gastric cancer has become widespread as minimally invasive surgical treatment, but use of laparoscopic total gastrectomy (LTG) remains limited because of the technical difficulty and complexity of lymphadenectomy at the splenic hilum. Surgical techniques and initial experiences with the surgical approach to the upper side of the gastrosplenic ligament during LTG are introduced. Materials and Methods: Between January 2019 and December 2022, 57 patients with proximal gastric cancer underwent LTG using this approach. Results: Regarding the extent of lymphadenectomy, D1+, D2, spleen-preserving D2 + 10, and D2 + 10 with splenectomy were performed in 31, 18, 4, and 4 patients, respectively. Operative time was 341 (192-724) minutes, and estimated blood loss was 30 (0-515) g. There were no conversions to laparotomy and no postoperative complications of Clavien-Dindo grade ≥III. Conclusions: The present procedure is safe and feasible and provides an excellent operative view at the splenic hilum, making it easier to determine exactly the extent of lymphadenectomy in accordance with cancer progression.

A nonrandomized controlled trial: long-term outcomes of LATG/LAPG for cStage I gastric cancer: Japan Clinical Oncology Group Study JCOG1401.

BACKGROUND: A previous report confirmed the safety of laparoscopy-assisted total and proximal gastrectomies (LATG and LAPG) (JCOG1401). This report demonstrates the 5-year relapse-free survival (RFS) and overall survival (OS) after long-term follow-up to confirm the efficacy of these surgical methods as key secondary endpoints for cStage I gastric cancer. METHODS: This study enrolled patients who had histologically proven gastric adenocarcinoma and were diagnosed with clinical T1N0, T1N(+), or T2N0 tumors according to the 14th edition of the Japanese Classification of Gastric Carcinoma (3rd English edition). RESULTS: Between April 2015 and February 2017, 246 patients were enrolled, although one patient was excluded because of misregistration. Meticulous follow-up was continued for > 5 years for each patient, and the data were analyzed in March 2022. The 5-year RFS was 90.0% (95% confidence interval [CI] 85.5-93.2%), and the 5-year OS was 91.2% (95% CI 86.9-94.2%) in all enrolled patients. Grade 3 or 4 late postoperative complications were detected in 12.7% of patients. CONCLUSIONS: This single-arm study showed that the long-term outcomes of LATG/LAPG for cStage I gastric cancer were acceptable, which is considered one of the standard treatments when performed by experienced surgeons. Trail registration UMIN000017155 ( http://www.umin.ac.jp/ctr/ ).

Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy.

Subcutaneous emphysema (SE), a complication of robotic gastrectomy (RG), occurs when the gas used to establish pneumoperitoneum escapes and enters the soft tissue. SE typically does not result in major clinical problems, but massive SE can have life-threatening consequences. Hence, developing adequate preventive methods against postoperative SE is essential. We aimed to determine whether an existing protective device, the LAP PROTECTOR™ (LP), can be used to reduce the incidence of SE after RG. We analyzed the data of 194 patients who underwent RG at our hospital between August 2016 and December 2022. Since September 2021 (the 102nd patient), we have used the LP (FF0504; Hakko Medical, Hongo, Tokyo, Japan) at the trocar site, as this was expected to reduce the incidence of SE. The primary endpoint of this study was the efficacy of the LP in reducing the incidence of clinically relevant SE (defined as SE extending into the cervical area) a day after RG. Univariate analysis revealed that sex, body mass index (BMI), and LP usage differed significantly between patients with and without postoperative SE. Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15-0.72, P < 0.001), high BMI (OR: 0.13, 95% CI: 1.23-4.45, P = 0.009), and LP usage (OR: 0.11, 95% CI: 0.04-0.3, P < 0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE. Placing an LP at the trocar site may be a safe and effective method of preventing SE after RG.

Expanding on the professional role of dental hygienists as key managers of medical-dental and hospital-dental clinic collaboration in a local Japanese hospital without a dentistry department: From a questionnaire survey after a web seminar.

INTRODUCTION: Perioperative oral management (POM) was introduced into the Japanese universal health insurance system in 2012. Collaboration with dental clinics is important for hospitals without a dentistry department. A dental hygienist newly assigned as a member of the patient flow management centre led a seminar to promote collaboration via the web. This study represents the first step to explore the possible role of the hospital-based dental hygienist in the field of regional medical-dental cooperation of POM by assessing their willingness to participate in providing this type of care by a survey. METHODS: The rate of attendees' satisfaction and the current problems of the collaboration for POM were evaluated through a questionnaire survey after the web seminar. RESULTS: All respondents reported satisfaction with the web seminar although it was the first experience of an online seminar for half of the respondents. All hospital dentists, but only 47.8% of dentists working at clinics, had participated in POM. Dental hygienist tended to show greater desire to participate in POM than dentists. All respondents appreciated the role played by the dental hygienist as a key manager of medical-dental collaboration between the hospital and local clinics. CONCLUSION: The hospital-based dental hygienist can play a role in planning and management of web seminars for POM, to raise awareness and promote regional medical-dental cooperation of POM.

Pancreatic thickness as a predictor of postoperative pancreatic fistula after laparoscopic or robotic gastrectomy.

BACKGROUND: Despite technical advances in minimally invasive gastrectomy for gastric cancer, an increased incidence of postoperative pancreatic fistula (POPF) has been reported. POPF can cause infectious and bleeding complications, which could lead to surgery-related death; therefore, reduction of the post-gastrectomy POPF risk is crucial. This study aimed to investigate the importance of pancreatic anatomy as a predictor of POPF in patients undergoing laparoscopic or robotic gastrectomy. METHODS: Data were collected from 331 consecutive patients who underwent laparoscopic or robotic gastrectomy for gastric cancer. The thickness of the pancreas anterior to the most ventral level of the splenic artery (TPS) was measured. The correlation between TPS and POPF incidence was investigated using univariate and multivariate analyses. RESULTS: The cutoff value of TPS was 11.8 mm, which predicted a high drain amylase concentration on postoperative day 1, and patients were categorized into thin (Tn group) and thick TPS groups (Tk group). There was no significant difference in the background characteristics between the two groups, except for sex (P = 0.009) and body mass index (P < 0.001). The incidences of POPF grade B or higher (2% vs. 16%, P < 0.001), all postoperative complications of grade II or higher (12% vs. 28%, P = 0.004), and postoperative intra-abdominal infections of grade II or higher (4% vs. 17%, P = 0.001) were significantly higher in the Tk group. Multivariable analysis identified that high TPS was the only independent risk factor for grade B or higher POPF and grade II or higher postoperative intra-abdominal infectious complications. CONCLUSIONS: The TPS is a specific predictive factor for POPF and postoperative intra-abdominal infectious complications in patients undergoing laparoscopic or robotic gastrectomy. Careful pancreatic manipulation during suprapancreatic lymphadenectomy is necessary for patients with increased TPS (> 11.8 mm) to avoid postoperative complications.

Solitary pleural metastasis in rectal cancer.

Pleural metastasis in rectal cancer is often due to secondary invasion or dissemination from intrapulmonary metastases. To date, there are no reports on solitary pleural metastasis. Here, we report a rare case of lower rectal cancer that recurred as pleural metastasis 4 years after surgical resection of the primary tumor. He was a 65-year-old man who visited our department with an abnormal shadow on his chest X-ray. He had a history of lower rectal cancer and had undergone laparoscopic low anterior resection of the rectum and bilateral lymph node dissection after neoadjuvant chemotherapy. Pathological ypT3N1M0 stage IIIA tumor was diagnosed, and adjuvant chemotherapy was administered. According to the computed tomography scan, a pleural tumor or pulmonary metastasis was suspected. Thoracoscopic partial resection of the lung and a partial pleurectomy were performed for diagnostic and therapeutic purposes. Histopathological examination revealed a highly differentiated tubular adenocarcinoma, consistent with metastatic rectal cancer. The nodule arose from the visceral pleura and invaded the parietal pleura with few malignant cells in the lung parenchyma. The lesion was surgically resected. However, 3 months after the second surgery, tumor recurrence with pleural dissemination was observed, and chemotherapy was initiated.

The safe performance of robotic gastrectomy by second-generation surgeons meeting the operating surgeon's criteria in the Japan Society for Endoscopic Surgery guidelines.

BACKGROUND: Robotic gastrectomy (RG) for gastric cancer (GC) has gradually gained nationwide prominence following 2011 guidelines from the Japan Society for Endoscopic Surgery (JSES), including the surgeons' criteria and the proctor system. In this retrospective study, we examined the short-term outcomes of the initial series of RGs performed by second-generation operating surgeons trained within our institute. METHODS: Between January 2017 and April 2020, five surgeons each performed RG in 20 patients with clinical stage III or lower GC in accordance with the JSES guidelines. We evaluated both the rate of Clavien-Dindo grade II or higher morbidities and the console time required to reach the learning plateau via cumulative summation (CUSUM) analysis. RESULTS: We observed no mortality and 3% of morbidity following RG. Both the operative time (430 vs 387.5 min, P = 0.019) and console time (380 vs . 331.5 min, P = 0.009) were significantly shorter in the second 10 cases than in the initial 10 cases. We observed a remarkable trend in cases of distal gastrectomy (DG), in which the total operative time and console time were significantly shorter in the later cases. Our CUSUM analysis revealed that seven cases were required to achieve a learning plateau in RG when confined to DG. CONCLUSIONS: Non-expert RG surgeons meeting the operating surgeon's criteria from the JSES who had trained under an expert RG surgeon safely performed RG in an initial 20 cases.

Prognostic factors of minimally invasive surgery for gastric cancer: Does robotic gastrectomy bring oncological benefit?

BACKGROUND: Gastric cancer is the third leading cause of cancer-related death worldwide and surgical resection remains the sole curative treatment for gastric cancer. Minimally invasive gastrectomy including laparoscopic and robotic approaches has been increasingly used in a few decades. Thus far, only a few reports have investigated the oncological outcomes following minimally invasive gastrectomy. AIM: To determine the 5-year survival following minimally invasive gastrectomy for gastric cancer and identify prognostic predictors. METHODS: This retrospective cohort study identified 939 patients who underwent gastrectomy for gastric cancer during the study period. After excluding 125 patients with non-curative surgery (n = 77), other synchronous cancer (n = 2), remnant gastric cancer (n = 25), insufficient physical function (n = 13), and open gastrectomy (n = 8), a total of 814 consecutive patients with primary gastric cancer who underwent minimally invasive R0 gastrectomy at our institution between 2009 and 2014 were retrospectively examined. Accordingly, 5-year overall and recurrence-free survival were analyzed using the Kaplan-Meier method with the log-rank test and Cox regression analyses, while factors associated with survival were determined using multivariate analysis. RESULTS: Our analysis showed that age > 65 years, American Society of Anesthesiologists (ASA) physical status 3, total or proximal gastrectomy, and pathological T4 and N positive status were independent predictors of both 5-year overall and recurrence-free survival. Accordingly, the included patients had a 5-year overall and recurrence-free survival of 80.3% and 78.2%, respectively. Among the 814 patients, 157 (19.3%) underwent robotic gastrectomy, while 308 (37.2%) were diagnosed with pathological stage II or III disease. Notably, our findings showed that robotic gastrectomy was an independent positive predictor for recurrence-free survival in patients with pathological stage II/III [hazard ratio: 0.56 (0.33-0.96), P = 0.035]. Comparison of recurrence-free survival between the robotic and laparoscopic approach using propensity score matching analysis verified that the robotic group had less morbidity (P = 0.005). CONCLUSION: Age, ASA status, gastrectomy type, and pathological T and N status were prognostic factors of minimally invasive gastrectomy, with the robot approach possibly improving long-term outcomes of advanced gastric cancer.

Unusual case of cavitary lung metastasis of esophageal cancer: A case report.

INTRODUCTION AND IMPORTANCE: Cavitary lung metastases are rare. We experienced lung metastasis of esophageal cancer with a cavity, which is extremely rare. CASE PRESENTATION: A 69-year-old female diagnosed with thoracic esophageal cancer underwent radical esophagectomy. Pathological diagnosis was T3N0M0-pStageII. Cavitary lesion appeared in the lower lobe of the right lung 12 months after surgery. We suspected an inflammatory change and followed up strictly. On Computed tomography (CT) image 18 months after surgery, the cavitary lesion slightly increased in size, showing wall thickening and fluid inside. Fluid collection disappeared after antibiotic treatment. The patient was followed for 4 weeks without antibiotics and fluid collection reappeared. Cavitary lesion resection for the purpose of diagnosis was planned because malignancy could not be excluded, although the readministration of antibiotics was also considered. Thoracoscopic partial resection of the right lower lobe of the lung was performed. Histopathological examination showed squamous cell carcinoma which was similar in morphology to esophageal cancer. The final diagnosis was lung metastasis of esophageal cancer. CLINICAL DISCUSSION: Metastatic lung cancer with a cavity is rare, accounting for approximately 4% of all cases. Moreover, Lung metastasis of esophageal cancer with a cavity is extremely rare. CONCLUSIONS: The specimen collection, including total biopsy, should be aggressively performed when diagnosing cavitary lung disease in patients with a history of neoplastic disease.

Standardization of laparoscopic reversal of the Hartmann procedure: A single-center report.

INTRODUCTION: Reestablishing continuity after the Hartmann procedure, the Hartmann reversal has been recognized as a complex procedure with a high morbidity rate. Laparoscopic reversal of the Hartmann procedure (LHR) is technically challenging, although good short-term results have been reported. We formulated this technique in 2013 and have been gradually devising and standardizing it. MATERIAL AND SURGICAL TECHNIQUE: Ten patients who had undergone the Hartmann procedure from January 2013 to December 2019 and subsequently LHR were retrospectively examined. During the procedure, a circular incision was made at the original site of the colostomy to safely reach the abdominal cavity, and pneumoperitoneum was performed using the glove technique. Next, pelvic adhesions and the descending colon were dissected. If the rectal stump was difficult to identify, an intraoperative endoscope was used. Finally, either a Gambee or stapled anastomosis without tension was performed. The median surgical time was 265 minutes (range, 160-435 minutes), and the median blood loss was 100 mL (range, 10-700 mL). The median postoperative hospital stay was 11 days (range, 8-14 days). In one case, laparotomy was performed because of severe intra-abdominal adhesion. DISCUSSION: No major complication was observed during or after surgery. Therefore, LHR can be performed safely. Standardizing this procedure could render it minimally invasive, although a high level of evidence is needed.

A multicenter non-randomized phase III study of sentinel node navigation surgery for early gastric cancer.

This prospective multicenter non-randomized phase III study aims to evaluate the long-term outcome of sentinel node navigation surgery for early gastric cancer compared with conventional distal or total gastrectomy. Clinically diagnosed primary T1N0M0 gastric cancer patients with a single lesion (≤40 mm) and without previous endoscopic treatment will be enrolled in this study. Sentinel nodes are identified by dye and radioisotope tracers and are subjected to intraoperative rapid pathology. For patients with negative sentinel node metastasis, individualized surgery consisting of limited stomach resection and sentinel node basin dissection is performed, while standard gastrectomy with D2 lymph node dissection is employed for the positive sentinel node patients. A total of 225 patients will be accrued from 13 hospitals that have experience in sentinel node mapping. The primary endpoint is 5-year relapse-free survival. The secondary endpoints are overall survival, sentinel node detection rate, diagnostic accuracy for sentinel node, distribution of sentinel nodes and metastatic sentinel node/non-sentinel node, and postoperative quality of life.

Jejunal mesenteric lymphangioma treated by pancreaticoduodenectomy: A case report.

INTRODUCTION: A lymphangioma is a benign congenital malformation of the lymphatic system that generally appears in the head, neck, and axillary regions. Small bowel mesenteric lymphangiomas have been described in less than 1% of lymphangiomas. PRESENTATION OF CASE: We report the case of a 20-year-old woman who presented with abdominal pain. Computed tomography revealed a large (22 cm in diameter) multi-cystic lesion inferior to the processus uncinatus of the pancreas. As the presumptive diagnosis was a lymphangioma of the jejunal mesentery, we decided to perform a laparotomy. Intraoperatively, the peritoneal cavity was found to be fully occupied by a multi-cystic lesion that arose from the root of the jejunal mesentery and the processus uncinatus of the pancreas. It was adherent to the duodenum and inseparable from the duodenum and the processus uncinatus. A subtotal stomach-preserving pancreaticoduodenectomy was performed. The tumor was diagnosed as a lymphangioma of the jejunal mesentery after histopathological analysis. DISCUSSION: Although lymphangioma is benign, complete resection, including resection of the involved organs, is necessary. Incomplete resection has a 10% postoperative recurrence rate and may also be associated with complications. To the best of our knowledge, this is the first reported case of a mesenteric lymphangioma treated by pancreaticoduodenectomy. CONCLUSION: Although the lymphangioma was pathologically benign, a pancreaticoduodenectomy was required to remove it completely. When a tumor's location and size cause impingement on surrounding structures, surgeons should consider performing a pancreaticoduodenectomy to treat similar cases.

Long-term outcomes of omentum-preserving versus resecting gastrectomy for locally advanced gastric cancer with propensity score analysis.

Omentectomy is conducted for advanced gastric cancer (AGC) patients as radical surgery without an adequate discussion of the effect. This study was conducted to reveal the impact of omentum-preserving gastrectomy on postoperative outcomes. AGC patients with cT3 and 4 disease who underwent total or distal gastrectomy with R0 resection were identified retrospectively. They were divided into the omentum-preserved group (OPG) and the omentum-resected group (ORG) and matched with propensity score matching with multiple imputation for missing values. Three-year overall survival (OS) and 3-year relapse-free survival (RFS) were compared, and the first recurrence site and complications were analysed. The numbers of eligible patients were 94 in the OPG and 144 in the ORG, and after matching, the number was 73 in each group. No significant difference was found in the 3-year OS rate (OPG: 78.9 vs. ORG: 78.9, P = 0.54) or the 3-year RFS rate (OPG: 77.8 vs. ORG: 68.2, P = 0.24). The proportions of peritoneal carcinomatosis and peritoneal dissemination as the first recurrence site and the rate and severity of complications were similar in the two groups. Omentectomy is not required for radical gastrectomy for AGC.

Closed laparoscopic and endoscopic cooperative surgery for early gastric cancer with difficulty in endoscopic submucosal dissection: a report of three cases.

BACKGROUND: Endoscopic submucosal dissection (ESD) is increasingly applied for early gastric cancer. ESD is a less invasive procedure and could be a radical treatment. However, in some cases, ESD cannot be completed owing to patient or technical factors. In such cases, which could have the potential for curative resection with ESD, standard gastrectomy is excessively invasive. Through closed laparoscopic and endoscopic cooperative surgery (LECS), gastric tumor can be precisely resected without exposing tumor cells to the abdominal cavity. Compared with standard gastrectomy, closed LECS is less invasive for the treatment of early gastric cancer. CASE PRESENTATION: We performed closed LECS for three cases of early gastric cancer after failed ESD. In all three cases, ESD was interrupted owing to technical and patient factors, including perforation, respiratory failure, and carbon dioxide narcosis. All three cases successfully underwent closed LECS with complete tumor resection and showed an uneventful postoperative course. All three patients remain alive and have experienced no complications or recurrence, with a median follow up of 30 (14-30) months. CONCLUSIONS: Closed LECS is less invasive and useful procedure for the treatment of early gastric cancer, particularly in cases with difficulty in ESD.

T-drain esophagostomy under thoracoscopy for intrathoracic esophagogastric anastomotic leakage following esophagectomy for esophagogastric junction cancer: A case report.

INTRODUCTION: Intrathoracic esophagogastric anastomotic leakage is considered the most severe complication. We successfully performed T-drain esophagostomy under thoracoscopy for intrathoracic esophagogastric anastomotic leakage. PRESENTATION OF CASE: A 44-year-old man visited a local hospital because of vomiting during the night. Upon examination, the patient was diagnosed with c-T2N0M0 stage II adenocarcinoma in Barrett's esophagus. We performed laparoscopic proximal gastrectomy and lower esophagectomy and gastric conduit reconstruction using the posterior mediastinal route with intrathoracic anastomosis under thoracoscopy. The patient developed fever, chest pain and dyspnea on postoperative day 5. We diagnosed anastomotic leakage and performed reoperation via thoracoscopy. The perforation, which was approximately 8 mm in length, was found on the back side of the esophagogastric anastomosis. There was no clear finding of necrosis in the gastric tube or the esophagus. After sufficiently deterging the thoracic cavity, a T-drain was inserted through the perforation and fixed. After fistula formation, the T-drain was slowly phased out. The postoperative course was uneventful. DISCUSSION: It is important to note that early treatment of severe leaks is mandatory to limit related mortality. However, current therapies for treating anastomotic leakage are still inefficient and controversial. CONCLUSION: T-drain esophagostomy under thoracoscopy for intrathoracic esophagogastric anastomotic leakage could be minimally invasive and effective.

Giant esophageal diverticulum with stenosis treated with mediastinoscopic esophagectomy: A case report.

INTRODUCTION: An esophageal diverticulum is a rare condition, and surgery is indicated if symptomatic. We successfully performed mediastinoscopic esophagectomy for a giant esophageal diverticulum with stenosis. PRESENTATION OF CASE: A 63-year-old man visited our hospital because of dysphagia. He had been pointed out an esophageal diverticulum at a local hospital 13 years before visiting our hospital. Upper gastrointestinal endoscopy revealed an esophageal diverticulum at the lower thoracic esophagus and the structural stenosis in the anal side of the diverticulum. Computed tomography showed a 54 mm esophageal diverticulum at the lower thoracic esophagus. Esophagectomy was required because of the structural stenosis. His medical history included chronic obstructive pulmonary disorder. So, we chose the mediastinal approach to avoid a respiratory complication. We performed mediastinoscopic esophagectomy and esophagogastrostomy via the retrosternal route. The postoperative course was good. At 9 months postoperation, there were no symptoms. DISCUSSION: Recently, laparoscopic diverticulectomy with myotomy and fundoplication has been considered the best approach in most cases. In the case with the structural stenosis, esophagectomy may be required. CONCLUSION: Mediastinoscopic esophagectomy for the patient with poor respiratory function and who need esophagectomy could be an effective and noninvasive candidate procedure.

[A Case of Rectal Cancer with Virchow Lymph Node Metastasis in Which Complete Response Was Achieved with Chemoradiation Therapy].

A 43-year-old man underwent a low anterior resection of the rectum due to upper rectal cancer. The pathological Stage was Ⅳ with para-aortic lymph node metastasis. Postoperative chemotherapy with CapeOX was initiated, but para-aortic lymph node metastasis was discovered 4months after the surgery. Chemoradiation therapy with Cape and Bev, and 70 Gy/28 Fr led to the disappearance of the metastasized lesions. At 13months after the surgery, FDG accumulation was observed in the Virchow's lymph node, and chemotherapy with IRIS and Bev was initially administered. Subsequently, chemoradiation therapy with S-1 and Bev, and 66 Gy/33Fr was administered, followed by chemotherapy with S-1 and Bev, S-1. These therapies led to complete response(CR). However, 35 months after the surgery, the Virchow's lymph node had enlarged again, and chemoradiation therapy with S-1 and 60 Gy/30Fr was administered. Although no FDG accumulation was detected in the lymph node at 40 months after the surgery, metastasis was found in the mediastinal lymph nodes. Panitumumab therapy achieved CR, and no metastasis had been identified at 60 months after the final therapy. Chemoradiation therapy is a treatment option to improve the prognosis of patients with metastasis only in the Virchow's lymph node.

Efficiency of fluorescent cholangiography during laparoscopic cholecystectomy for subvesical bile ducts: A case report.

INTRODUCTION: The subvesical bile ducts are located in the peri-hepatic connective tissue of the gallbladder fossa. Injury of the subvesical bile ducts provokes the severe complication of bile leak. Until now, fluorescent cholangiography has been employed during hepatobiliary surgery. Herein, we report the detection of subvesical bile ducts by fluorescent cholangiography during laparoscopic cholecystectomy. PRESENTATION OF CASE: A 63-year-old female was admitted to our department for surgery for symptomatic cholelithiasis. The subvesical bile ducts were not observed on drip-infusion cholangiography with computed tomography. Immediately following induction of anesthesia, 2.5 mg of indocyanine green was intravenously injected. Fluorescent cholangiography demonstrated two thin aberrant bile ducts during dissection of Calot's triangle. We considered them to be subvesical bile ducts. We ligated them with clips, divided them, and then performed laparoscopic cholecystectomy using a standard procedure. The patient had a good post-operative recovery without bile leakage. Postoperative laboratory test results were all within normal limits. Computed tomography revealed no dilatation of the intrahepatic bile duct after laparoscopic cholecystectomy. The patient was discharged on postoperative day 4. DISCUSSION: Injury to the subvesical bile ducts is one of the most common causes of bile leakage associated with cholecystectomy. Fluorescent cholangiography enabled real-time identification of the thin subvesical bile ducts, which were undetectable by drip-infusion cholangiography with computed tomography. CONCLUSION: Fluorescent cholangiography during laparoscopic cholecystectomy may be useful for preventing postoperative bile leakage.

[A Case of Robot-Assisted Conversion Surgery for Gastric Cancer with Peritoneal Dissemination That Responded to Intravenous and Intraperitoneal Paclitaxel Combined with S-1 Chemotherapy].

This case involved a 69-year-old female patient with peritoneal dissemination of an advanced gastric cancer. She underwent chemotherapy comprisingintravenous and intraperitoneal paclitaxel combined with S-1. After 20 courses, a staging laparoscopy was performed, and pathological analysis of the peritoneal dissemination and cytologic analysis of ascites fluid yielded negative results. A radical robot-assisted total gastrectomy was successfully performed. The pathological stage was determined to be ypT4aN2M0, ypStage ⅢB. We continued to administer the same chemotherapy regimen for 15 courses (total: 35 courses)after surgery. No recurrence has been detected during the 1-year period after surgery.

Robot-assisted mediastinoscopic esophagectomy for esophageal cancer: the first clinical series.

BACKGROUND: Radical esophagectomy for esophageal cancer is associated with high morbidity, especially with pulmonary complications. Mediastinoscopic esophagectomy via a small left neck incision combined with the esophageal hiatus, without using transthoracic approach, has been reported to reduce pulmonary complication; however, from technical point of view, this approach using non-articulating, straight, long forceps is extremely challenging, especially in the middle mediastinal area. Its technical difficulties may be attenuated using da Vinci Surgical System. The aim of this study was to evaluate the feasibility and safety of robot-assisted mediastinoscopic esophagectomy. METHODS: Robot-assisted mediastinoscopic esophagectomy was performed in six patients between October 2016 and May 2017. Robotic esophageal mobilization with upper and middle mediastinal lymphadenectomy was performed via the three da Vinci Xi (Intuitive Surgical, Inc. Sunnyvale, CA) trocars placed on the 5-cm left cervical incision. Thereafter, the remaining part of radical esophagectomy was completed via a transhiatal approach. RESULTS: Upper and middle mediastinal lymphadenectomy was robotically completed via the transcervical approach in all cases without conversion to transthoracic approach. No postoperative complications (Clavien-Dindo classification grade ≥ III) were observed. CONCLUSIONS: Robot-assisted mediastinoscopic esophagectomy was technically feasible and safe. Use of da Vinci Surgical System may help attenuate technical difficulties in transcervical middle mediastinal lymph node dissection.