Intracorporeal linear­stapled gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: Consideration of the intraoperative management of the duodenal wall between the transecting staple line and anastomotic staple line (Review).

The first part of the duodenum consists of the intraperitoneal segment, called the duodenal bulb, and the retroperitoneal segment. Regarding the blood supplying the duodenal bulb, which is the portion utilized in anastomosing the duodenum and remnant stomach following distal gastrectomy, the arterial pedicles branching off from the gastroduodenal artery are reported to reach the posterior wall first and then spread over the anterior wall, where they anastomose. When performing intracorporeal linear-stapled gastroduodenostomy following totally laparoscopic distal gastrectomy, the blood supply of the duodenal wall between the transecting staple line and anastomotic staple line needs to be considered because both transection of the duodenal bulb and the gastroduodenostomy are performed using an endoscopic linear stapler and the duodenal wall between the staple lines can be ischemic after the anastomosis. Since it needs to be decided intraoperatively whether this duodenal site is preserved or removed, the present review discusses the technical differences among several procedures for intracorporeal linear-stapled gastroduodenostomy, classifying them into two groups on the basis of the intraoperative management of this duodenal site. When this site is preserved, the blood supply of the duodenal wall needs to be retained with certainty. On the other hand, when this site is removed, the ischemic portion of the duodenal wall needs to be identified and removed. Furthermore, in both groups, an adequate anastomotic area needs to be secured. In conclusion, surgeons need to be familiar with the anatomical features of the duodenal bulb, including its blood perfusion and shape, when carrying out intracorporeal linear-stapled gastroduodenostomy.

Intracorporeal gastrojejunostomy in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy: A case report.

The drawback of intracorporeal gastrojejunostomy using only endoscopic linear staplers in antecolic Roux-en-Y (R-Y) reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy (TLDG) is the occurrence of anastomotic failure, even though this reconstruction system is assumed to prevent intraoperative and postoperative twisting of the gastrojejunostomy and lifted jejunum. This case report presents two patients with gastric cancer who underwent intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG to prevent anastomotic failure of the gastrojejunostomy. After the sacrificed jejunum was created, linear stapling of the greater curvature of the remnant stomach and the lifted jejunum without dividing the jejunum was performed. After removing the sacrificed jejunum and creating a good view of the posterior side of the stapler entry hole, the stapler entry hole was closed from the posterior side to the anterior side, using a single-layer full-thickness and serosubmucosal hand suturing technique with knotted sutures and a knotless barbed suture. No anastomotic failure of the gastrojejunostomy occurred in either patient. Intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing could be an option for gastrojejunostomy in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG because it can aid in the prevention of anastomotic failure.

Modified delta-shaped gastroduodenostomy consisting of linear stapling and single-layer suturing with the operator positioned between the patient's legs: A technique preventing intraoperative duodenal injury and postoperative anastomotic stenosis.

BACKGROUND: The drawback of the delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG) is the presence of intraoperative duodenal injury and postoperative anastomotic stenosis, which can occur due to a relatively short duodenal bulb diameter. MATERIALS AND METHODS: From June 2013 to June 2019, 35 patients with gastric cancer underwent TLDG with a modified DSG consisting of linear stapling and single-layer hand suturing in our institution. All anastomotic procedures were performed by the right hand of the operator positioned between the patient's legs. Linear stapling of the posterior walls of the remnant stomach and duodenum without creating a gap was performed using a 45-mm linear stapler, considering the prevention of intraoperative duodenal injury. The stapler entry hole was closed using a single-layer full-thickness hand suturing technique with knotted sutures and a knotless barbed suture. We described the clinical data and outcomes in the present retrospective patient series. RESULTS: No intraoperative duodenal injury occurred in any of the 35 patients. The median staple length at linear stapling of the posterior walls of the remnant stomach and duodenum was 41.7 ± 4.2 (30-45) mm, and 2 patients (5.7%) had a staple length of 30 mm. There were no incidences of postoperative anastomotic stenosis. CONCLUSIONS: We suggest that a modified DSG consisting of linear stapling and single-layer hand suturing performed by an operator positioned between the patient's legs can be one option for B-Ⅰ reconstruction following TLDG because it can aid in preventing both intraoperative duodenal injury and postoperative anastomotic stenosis.

Stenosis after esophagojejunostomy with the hemi-double-stapling technique using the transorally inserted anvil (OrVil™) in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following laparoscopic total gastrectomy.

BACKGROUND: The drawback of intracorporeal esophagojejunostomy with the double-stapling technique (DST) using a transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA) following laparoscopic total gastrectomy (LTG) is not only the high incidence of stenosis but also the presence of intractable stenosis that is refractory to endoscopic treatments. METHODS: From November 2013 to December 2016, 24 patients with gastric cancer underwent intracorporeal circular-stapled esophagojejunostomy with the hemi-double-stapling technique (hemi-DST) using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient following LTG to prevent twisting of the esophagojejunostomy and lifted jejunum, which might cause intractable stenosis of the esophagojejunostomy. RESULTS: In this patient series, no twisting of the esophagojejunostomy and lifted jejunum was encountered intraoperatively or postoperatively. Two stenoses of the esophagojejunostomy occurred. Because neither was involved with twisting and both were localized at the anastomotic plane, endoscopic treatments including balloon dilation and electrocautery incisional therapy were successful in both cases. There were no patients with intractable stenosis in this series. CONCLUSIONS: Intracorporeal esophagojejunostomy with the hemi-DST using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient can be one option for a circular stapling technique in LTG due to its prevention of intractable stenosis of the esophagojejunostomy that is refractory to endoscopic treatments.

An option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: A single-layer suturing technique for the stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures.

We report an option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We detail a single-layer suturing technique for the endoscopic linear stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures. From June 2013 to February 2017, we performed TLDG with delta-shaped gastroduodenostomy in 20 patients with gastric cancer. The linear stapler was closed and fired to attach the posterior walls of the remnant stomach and the duodenum together. After creating a good view of the greater curvature side of the entry hole for the stapler by retracting the knotted suture on the lesser curvature side toward the ventral side, we performed single-layer entire-thickness continuous suturing of this hole using a 15-cm-long barbed suture running from the greater curvature side to the lesser curvature side. We placed the second and third stitches between the seromuscular layer of the remnant stomach and the entire-thickness layer of the duodenum while suturing the duodenal mucosa as minutely as possible. In addition, we routinely added one or two entire-thickness knotted sutures at the site near the greater curvature side. We placed similar additional knotted sutures at the site with a broad pitch. TLDG with this reconstruction technique was successfully performed in all patients with no occurrences of anastomotic leakage or intraabdominal abscess around the anastomosis. It is suggested that this method can be one option for delta-shaped gastroduodenostomy in TLDG due to its cost-effectiveness and feasibility.

A novel option for preoperative endoscopic marking with India ink in totally laparoscopic distal gastrectomy for gastric cancer: A useful technique considering the morphological characteristics of the stomach.

In totally laparoscopic distal gastrectomy (TLDG) for gastric cancer, accurately determining the proximal resection line may be difficult. This is because identifying the lesion intracorporeally is impossible, due to the lack of tactile sense, and, in addition, unlike the intestine, the most proximal site of the lesion is often different from the main site due to the distorted shape of the stomach. The aim of this study was to introduce a novel method of preoperative endoscopic marking with India ink, taking into consideration the morphological characteristics of the stomach. Between July, 2013 and April, 2016, 20 patients who underwent TLDG were enrolled in this study. Within the 3 days preceding the operation, after identifying the most proximal site of the lesion on the overlooking image of an endoscope, India ink was injected into the spot on the oral side of this site. The stomach was transected along the proximal border of the marked area. In all cases, the marked sites were localized and clearly identified during the operation, and the proximal resection margins were found to be negative on postoperative pathological examination. The mean length of the proximal margin was 46.0±14.0 mm. In conclusion, this preoperative endoscopic marking method may be useful in TLDG for gastric cancer.

Laparoscopic gastrointestinal anastomoses using knotless barbed absorbable sutures are safe and reproducible: a single-center experience with 242 patients.

OBJECTIVE: Intracorporeal reconstruction of the digestive tract is technically challenging. The V-Loc 180 wound closure device (Covidien) is a self-anchoring unidirectional barbed suture that obviates the need for knot tying. The aim of this prospective cohort study was to investigate the use of the novel suture in gastrointestinal enterotomy closure. METHODS: The subjects comprised patients with malignant disease who were scheduled to undergo laparoscopic gastrectomy with curative intent. The barbed suture was used to close the entry hole for the linear stapler during intracorporeal reconstruction following laparoscopic gastric resection. The primary endpoint was the proportion of patients who developed anastomotic leakage at the site where the barbed suture was applied. RESULTS: Between July 2012 and March 2015, 242 patients were enrolled. Of 362 anastomoses, the enterotomy hole at 256 sites was closed using the barbed suture. These 256 sites consisted of 95 gastroduodenostomies, 25 gastrogastrostomies, 13 gastrojejunostomies, 90 jejunojejunostomies, 17 esophagojejunostomies and 16 primary closures of the stomach following local gastric resection. There were no anastomosis-related complications, conversion to usual sutures, mechanical closure of the entry hole and reoperation due to adhesive obstructions or mortality over a median follow-up period of 17.8 months. CONCLUSIONS: The use of the unidirectional barbed absorbable suture for gastrointestinal closure is safe and effective in laparoscopic gastrectomy.

A new option for intracorporeal circular-stapled esophagojejunostomy in laparoscopic total gastrectomy: Roux-en-Y reconstruction with its efferent loop located at the left side of the patient to prevent twisting of the esophagojejunostomy.

BACKGROUND/AIMS: Laparoscopic total gastrectomy (LTG) has not gained widespread acceptance because of the difficult reconstruction technique, especially for esophagojejunostomy. Although various modified procedures using a circular stapler for esophagojejunostomy have been reported, an optimal technique has not yet been established. In addition, in intracorporeal techniques, twisting of the esophagojejunostomy, which might be the cause of stenosis, is often encountered because application of the shaft is restricted. To prevent twisting of the esophagoejunostomy, we underwent LTG with Roux-en-Y reconstruction with its efferent loop located at the left side of the patient. METHODOLOGY: From November 2013 to November 2014, a series of 9 patients underwent LTG with Roux-en-Y reconstruction using the transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA), whose efferent loop was located at the left side of the patient. RESULTS: No twisting of the esophagojejunostomy was encountered in all cases. In addition, no stenosis or leakage of the esophagojejunostomy occurred. CONCLUSIONS: This reconstruction system may be a feasible surgical procedure in LTG.

Functional outcomes according to the size of the gastric remnant and the type of reconstruction following distal gastrectomy for gastric cancer: an investigation including total gastrectomy.

OBJECTIVE: In gastric cancer, various methods of gastric resection have been devised according to the location of the primary tumor and the depth of invasion. Functional outcomes were compared among different types of reconstruction following open 2/3- or 4/5 distal gastrectomy for gastric cancer. METHODS: Resection and reconstruction were performed by one of the following three methods, depending on the depth of cancer invasion and the date of the procedure relative to the introduction of Roux-en-Y reconstruction: distal 2/3 gastrectomy with Roux-en-Y reconstruction (1/3 Roux-en-Y, n = 30); distal 4/5 gastrectomy with Roux-en-Y reconstruction (1/5 Roux-en-Y, n = 15) and distal 2/3 gastrectomy with Billroth I reconstruction (1/3B1, n = 30). Open total gastrectomy with Roux-en-Y reconstruction (total gastrectomy with RY reconstruction, n = 30) was taken as the control procedure. RESULTS: Comparison of postoperative/preoperative body weight ratios and food intake ratios revealed better preservation among patients with a larger remnant stomach (the 1/3 Roux-en-Y and 1/3B1 groups), regardless of the reconstruction. The gastric emptying pattern in larger remnant stomach groups was milder than in the 1/5 Roux-en-Y and total gastrectomy with RY reconstruction groups. Reflux esophagitis was often observed on endoscopy in the 1/3B1 group. CONCLUSIONS: Better functional outcomes were observed in patients with a large remnant stomach regardless of the reconstruction.

Benefits of intracorporeal gastrointestinal anastomosis following laparoscopic distal gastrectomy.

BACKGROUND: Laparoscopic gastrectomy has recently been gaining popularity as a treatment for cancer; however, little is known about the benefits of intracorporeal (IC) gastrointestinal anastomosis with pure laparoscopic distal gastrectomy (LDG) compared with extracorporeal (EC) anastomosis with laparoscopy-assisted distal gastrectomy (LADG). METHODS: Between June 2000 and December 2011, we assessed 449 consecutive patients with early-stage gastric cancer who underwent LDG. The patients were classified into three groups according to the method of reconstruction LADG followed by EC hand-sewn anastomosis (LADG + EC) (n = 73), using any of three anastomosis methods (Billroth-I (B-I), Billroth-II (B-II) or Roux-en-Y (R-Y); LDG followed by IC B-I anastomosis (LDG + B-I) (n = 248); or LDG followed by IC R-Y anastomosis (LDG + R-Y) (n = 128)). The analyzed parameters included patient and tumor characteristics, operation details, and post-operative outcomes. RESULTS: The tumor location was significantly more proximal in the LDG + R-Y group than in the LDG + B-I group (P < 0.01). Mean operation time, intra-operative blood loss, and the length of post-operative hospital stay were all shortest in the LDG + B-I group (P < 0.05). Regarding post-operative morbidities, anastomosis-related complications occurred significantly less frequently in with the LDG + B-I group than in the LADG + EC group (P < 0.01), whereas there were no differences in the other parameters of patients' characteristics. CONCLUSIONS: Intracorporeal mechanical anastomosis by either the B-I or R-Y method following LDG has several advantages over at the LADG + EC, including small wound size, reduced invasiveness, and safe anastomosis. Although additional randomized control studies are warranted to confirm these findings, we consider that pure LDG is a useful technique for patients with early gastric cancer.

V-shaped lymph node dissection in laparoscopic distal gastrectomy; new technique of intra-abdominal dissection and surgical outcomes.

BACKGROUND: Recently, laparoscopic-assisted distal gastrectomy (LADG) has become popular for the treatment of early gastric cancer. Furthermore, the use of totally laparoscopic gastrectomy (TLG), a more difficult procedure than LADG, has been increasing in Japan. Laparoscopic-assisted distal gastrectomy is currently performed more frequently than laparoscopic distal gastrectomy (LDG) in hospitals in Japan. METHOD: Reconstruction after LDG is commonly performed extra-abdominally and lymph node dissection of the lesser curvature is performed at the same time. We have developed a new method of intra-abdominal lymph node dissection for the lesser curvature. RESULTS: Our technique showed positive results, is easy to perform, and is reasonable in terms of general oncology theory. CONCLUSION: In oncological therapy, this technique could be a valuable surgical option for totally laparoscopic surgery.

Functional outcomes according to the size of the gastric remnant and type of reconstruction following open and laparoscopic proximal gastrectomy for gastric cancer.

BACKGROUND/AIMS: We compared functional outcomes between different types of reconstruction following open or laparoscopic 1/2- or 2/3-proximal gastrectomy for gastric cancer. METHODOLOGY: Resection and reconstruction were performed by one of the following 6 methods, depending on the depth of cancer invasion and the date of the procedure relative to introduction of laparoscopic proximal gastrectomy: open proximal 2/3-gastrectomy with jejunal interposition (2/3 PG-int, n=7), open proximal 1/2-gastrectomy with jejunal interposition (1/2 PG-int, n=5), laparoscopic proximal 1/2-gastrectomy followed by double tract reconstructions with small (3 cm) jejunogastrostomy (L1/2 PG-DT(S), n=19) and laparoscopic proximal 1/2-gastrectomy followed by double tract reconstructions with large (6 cm) jejunogastrostomy (L1/2PG-DT(L), n=10). Open total gastrectomy with jejunal interposition (TG, n=12) and laparoscopic total gastrectomy with Roux-en-Y reconstruction (LTG, n=14) represented control procedures. RESULTS: Comparison of postoperative/preoperative body weight ratios and food intake ratios revealed better preservation among patients with a larger remnant stomach and with easy flow of food into the remnant stomach (the 1/2PG-int and L1/2PG-DT(L) groups). CONCLUSIONS: Better functional outcomes were observed in patients with a large remnant stomach and with easy flow of food into the remnant stomach regardless of whether they underwent open or laparoscopic procedures.

Comparative analysis of station-specific lymph node yield in laparoscopic and open distal gastrectomy for early gastric cancer.

BACKGROUND: Randomized trials and cohort studies show that laparoscopic distal gastrectomy (LDG) achieves similar oncological results to open distal gastrectomy (ODG). However, studies have consistently demonstrated lower lymph node yield (LNY) for laparoscopic lymphadenectomy. Analysis of station-specific LNY may be useful in evaluating the reasons behind this difference. OBJECTIVES: Comparison of station-specific LNY, surgical, and oncological outcomes between LDG and ODG for early gastric cancer. METHODS: Patients who underwent R0 distal gastrectomy with histologically confirmed early gastric cancer were eligible for the study. All consecutive cases of LDG since the beginning of our experience with laparoscopic gastrectomy and synchronous cases of ODG with R0 resection were included in the study. Demographic, operative, histopathologic, and follow-up data were recorded in all patients. RESULTS: A total of 259 cases of LDG and 95 cases of ODG were performed between 2000 and 2009. Patients undergoing LDG had longer operations but less bleeding (P<0.05). Postoperative complications were similar in both groups. The preoperatively planned extent of lymphadenectomy was D1 (stations 1, 3, 4sb, 4d, 5, 6, and 7), D1+ (D1with stations 8a and 9), or D2 (D1+ with stations 11p and 12a). During surgery, dissection of stations 3, 4d, 5, 6, and 7 was performed in all cases of LDG and ODG. Dissection of stations 1, 4sb, 8a, 9, 11p, and 12a was performed more frequently during ODG than during LDG. Consequently, the total LNY was 26.71 and 31.43 for LDG and ODG, respectively. Station-specific LNY was significantly lower for LDG than for ODG in the common hepatic artery nodes only (P<0.05). The mean follow-up was 43.6 months. Lymph node metastases, metastatic-to-resected lymph node ratio, recurrence, and cancer-related deaths were similar for LDG and ODG. CONCLUSIONS: LDG was associated with less extensive lymph node dissection compared with ODG. Station-specific LNY was similar in all nodal stations except for the common hepatic artery nodes. In our experience, laparoscopic sub-D2 lymphadenectomy was adequate in the context of early gastric cancer and represents the future of gastric cancer resection in Japan.

Functional outcomes according to the size of the gastric remnant and type of reconstruction following laparoscopic distal gastrectomy for gastric cancer.

BACKGROUND: In gastric cancer, various methods of gastric resection and reconstruction have been devised according to the location of the primary tumor and the depth of invasion. The functional outcomes of patients treated by laparoscopy-assisted or totally laparoscopic distal gastrectomy were compared with respect to the approach, size of the remnant stomach, and type of reconstruction. METHODS: Patients who required distal gastrectomy to treat early-stage cancer between May 2000 and December 2008 were treated by one of the four following procedures: Billroth Type I (B-1) reconstruction for 1/2 remnant stomach (1/2B1ML) or B-1 for 1/3 remnant stomach (1/3B1ML), through a mini-laparotomy following laparoscopy-assisted surgery; intra-corporeal B-1 for 1/2 remnant stomach (1/2 B1IC); or intra-corporeal Roux-en-Y for 1/3 remnant stomach (1/3RYIC). The primary outcome measure was digestive function, assessed by body weight, food intake, and degree of abdominal symptoms. The secondary outcome was morbidity. RESULTS: The 1/2B1ML (n = 27) and 1/2B1IC (n = 56) groups were significantly superior to the 1/3 resection groups in terms of the preservation of body weight. The 1/3B1ML (n = 29) and 1/3RYIC (n = 64) groups were associated with significantly decreased food intake compared with the 1/2B1ML group. Endoscopy revealed a greater incidence of esophagitis and gastritis among the 1/3B1ML patients compared with the 1/3RYIC patients. There were no operative deaths, and no differences in morbidity between the groups. CONCLUSION: Patients with early-stage cancer actually benefit from 1/2 gastrectomy rather than the typical 2/3 gastrectomy. B-1 reconstruction is appropriate for patients with large gastric remnants, and intra-corporeal reconstruction in experienced hands is associated with no apparent disadvantages, while offering a favorable cosmetic result.

Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction: evolution in a totally intracorporeal technique.

INTRODUCTION: Laparoscopic gastrectomy is gaining popularity. Increasingly, Roux-en-Y reconstruction after distal gastrectomy is preferred because of reduced reflux and associated symptoms. Therefore, efficient and reliable techniques for intracorporeal Roux-en-Y reconstruction are in demand. AIMS: To determine the surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction in the treatment of gastric cancer. PATIENTS AND METHODS: Laparoscopic gastrectomy is indicated for gastric cancer up to stage T1N1. Our technique for laparoscopic Roux-en-Y reconstruction incorporates intracorporeal-stapled gastrojejunostomy with extracorporeal hand-sewn jejunojejunostomy, or more recently, totally intracorporeal reconstruction. RESULTS: From 2003 to 2009, 82 patients underwent laparoscopic distal gastrectomy with Roux-en-Y reconstruction. The mean age of the patients was 64.6 years (range, 39 to 83 y) and the male:female ratio was 2.4:1. Most patients (85%) had stage I disease. The mean operation time was 354 minutes (SD 82.7). The conversion rate was 0%. The mean lymph node yield was 27.2 nodes (SD 12.4). Eleven patients had totally intracorporeal reconstruction. Overall, anastomotic leakage of the gastrojejunostomy occurred in 2 patients (2.4%) both requiring reoperation. There were 2 cases (2.4%) of duodenal stump leakage, which were treated conservatively. Postoperative stasis was encountered in 2 patients (2.4%). The mean follow-up was 21 months (range, 5 to 50 mo). None of the patients developed reflux symptoms or endoscopic evidence of reflux during follow-up. Recurrence occurred in 1 patient who was the only patient with metastasis to the third tier of lymph nodes. CONCLUSIONS: Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction were acceptable in the context of early gastric cancer. Totally intracorporeal reconstruction was technically feasible, safe, and associated with no obvious drawbacks.

Long-term oncologic outcomes from laparoscopic gastrectomy for gastric cancer: a single-center experience of 601 consecutive resections.

BACKGROUND: Laparoscopic gastrectomy (LG) is becoming increasingly popular for management of early gastric cancer (EGC). Although short-term efficacy is proven, reports on long-term effectiveness are still infrequent. STUDY DESIGN: All patients with a diagnosis of gastric cancer undergoing LG from the beginning of our laparoscopic experience were included in the analysis. At our unit, LG is indicated for all cancers up to preoperative stage T2N1. RESULTS: Six-hundred and one laparoscopic resections were included in the analysis. There were 392 men and 209 women. Mean age was 64.2 +/- 10.9 years. Distal gastrectomy was performed in 305 patients, pylorus-preserving gastrectomy in 148, segmental gastrectomy in 42, proximal gastrectomy in 53, total gastrectomy in 27, and wedge resection in 26. Histological staging revealed that 478 patients had stage IA disease, 47 had stage IB, 44 had stage IIA, 19 had stage IIB, 8 had stage IIIA, 3 had stage IIIB, and 2 had stage IIIC. Morbidity and mortality rates were 17.6% and 0.3%, respectively. Median follow-up was 35.9 months (range 3 to 113 months). Cancer recurrence occurred in 15 patients and metachronous gastric remnant cancer was detected in 6 patients. The 5-year overall and disease-free survival rates were 94.2% and 89.9%, respectively, for stage IA tumors, 87.4% and 82.7% for stage IB, 80.8% and 70.7% for stage IIA, and 69.6% and 63.1% for stage IIB. CONCLUSIONS: In our experience, long-term oncological outcomes from LG for EGC are acceptable. Wherever expertise permits, LG should be considered as the primary treatment in patients with EGC.

Intracorporeal stapled anastomosis following laparoscopic segmental gastrectomy for gastric cancer: technical report and surgical outcomes.

BACKGROUND: Limited gastrectomy for early gastric body cancers can offer a better functional outcome by preserving more remnant stomach. Intracorporeal stapled techniques result in cosmesis and avoid awkward anastomosis through a minilaparotomy. METHODS: Laparoscopic segmental gastrectomy is indicated for early gastric cancers of the body of the stomach with no evidence of lymph node involvement. Laparoscopic pylorus-preserving gastrectomy is a specific type of segmental resection for lower-body lesions with dissection of lymph nodes in station 6. Intracorporeal gastrogastric anastomosis is performed by the delta-shaped technique using linear staplers. RESULTS: Since January 2008 we have performed 12 laparoscopic pylorus-preserving gastrectomies and 13 laparoscopic segmental gastrectomies. All procedures were completed by laparoscopy. One patient with minor anastomotic leakage was managed conservatively. Bleeding from the anastomosis was not encountered in any of the patients. One patient developed narrowing at the anastomotic site and was treated successfully by balloon dilatation. There was no stasis encountered in any of the patients. CONCLUSIONS: Laparoscopic segmental gastrectomy with acceptable surgical outcomes is technically feasible. Although the impact of such resections on oncological outcomes remains to be further evaluated, laparoscopic segmental gastrectomy represents a minimally invasive limited resection that maximizes the potential for a better quality of life following gastric cancer surgery.

Evaluation of lymph node metastases in gastric cancer using magnetic resonance imaging with ultrasmall superparamagnetic iron oxide (USPIO): diagnostic performance in post-contrast images using new diagnostic criteria.

BACKGROUND: We assessed the value of magnetic resonance imaging (MRI), using ultrasmall superparamagnetic iron oxide (USPIO) with new diagnostic criteria, in the evaluation of regional lymph node metastases in gastric cancer. METHODS: Thirty-one patients with gastric cancer were enrolled. 1000 lymph nodes were dissected during surgery, and of these, 519 nodes (51.9%) were identified by currently used MRI imaging analysis. We evaluated lymph nodes on USPIO-post-contrast T2*-weighted images using the following two criteria: (1) we diagnosed the nodes on T2*-weighted images according to conventional criteria, where a node having an overall low signal intensity (pattern A) was nonmetastatic, while a node having partial (pattern B) or overall (pattern C) high signal intensity was metastatic; (2) we subdivided pattern B nodes on T1-weighted images using the new criteria, in which a node for which the high-intensity area on T2*-weighted images was not defined as adipose tissue on T1-weighted images (pattern B1) was metastatic, while a node for which the high-intensity area was defined as adipose tissue (pattern B2) was nonmetastatic. RESULTS: (1) The results using the conventional criteria were 96.2% sensitivity, 92.5% specificity, 76.3% positive predictive value (PPV), 99.0% negative predictive value (NPV), and 93.3% accuracy. (2) The results using the new criteria were 96.2% sensitivity, 98.3% specificity, 90.1% PPV, 99.0% NPV, and 97.1% accuracy. CONCLUSION: The assessment of lymph node metastases from USPIO-post-contrast MRI alone using the new criteria was useful in the diagnosis of regional lymph node metastases in gastric cancer.

[A case of inoperable scirrhous gastric cancer that responded remarkably to a combination of TS-1+paclitaxel and showed complete loss of ascites].

Complete loss of malignant ascites by combination chemotherapy of TS-1+paclitaxel was experienced. The case was a 56-year-old woman who was diagnosed with inoperable scirrhous gastric cancer with malignant ascites. The administered regimen of chemotherapy was TS-1 100 mg/day (80 mg/m2) for 2 weeks. Paclitaxel 60 mg/day (50 mg/m2) on day 1 and 8 of TS-1 intake, followed by 2-weeks rest. Partial response was confirmed by gastrography and gastrofiberscope after 3 courses were performed. Furthermore, computed tomography (CT) showed complete loss of malignant ascites. Adverse reactions were grade 3 leukopenia and grade 2 nausea, vomiting and diarrhea. This result indicates the possibility of combination chemotherapy of TS-1+paclitaxel becoming an effective option in treating inoperable scirrhous gastric cancer.