Impact of mixed-infection rate of clarithromycin-susceptible and clarithromycin-resistant Helicobacter pylori strains on the success rate of clarithromycin-based eradication treatment.

BACKGROUND: Clarithromycin (CAM) resistance is a major contributor to the failure to eradicate Helicobacter pylori (H. pylori). The mixed-infection ratio of CAM-susceptible and CAM-resistant H. pylori strains differs among individuals. Pyrosequencing analysis can be used to quantify gene mutations at position each 2142 and 2143 of the H. pylori 23S rRNA gene in intragastric fluid samples. Herein, we aimed to clarify the impact of the rate of mixed infection with CAM-susceptible and CAM-resistant H. pylori strains on the success rate of CAM-containing eradication therapy. MATERIALS AND METHODS: Sixty-four H. pylori-positive participants who received CAM-based eradication therapy, also comprising vonoprazan and amoxicillin, were enrolled in this prospective cohort study. Biopsy and intragastric fluid samples were collected during esophagogastroduodenoscopy. H. pylori culture and CAM-susceptibility tests were performed on the biopsy samples, and real-time PCR and pyrosequencing analyses were performed on the intragastric fluid samples. The mutation rates and eradication success rates were compared. RESULTS: The overall CAM-based eradication success rate was 84% (54/64): 62% (13/21) for CAM-resistant strains, and 95% (39/41) for CAM-sensitive strains. When the mutation rate of the 23S rRNA gene was 20% or lower for both positions (2142 and 2143), the eradication success rate was 90% or more. However, when the mutation rate was 20% or higher, the eradication success rate was lower (60%). CONCLUSIONS: The mutation rate of the CAM-resistance gene was related to the success of eradication therapy, as determined via pyrosequencing analysis.

Improvement of detection sensitivity of upper gastrointestinal epithelial neoplasia in linked color imaging based on data of eye tracking.

BACKGROUND AND AIM: Linked color imaging (LCI) is useful for screening in the gastrointestinal tract; however, its true clinical benefit has not been determined. The aim of this study was to determine the objective advantage of LCI for detection of upper gastrointestinal neoplasms. METHODS: Nine endoscopists, including three novices, three trainees, and three experts, prospectively performed eye tracking. From 30 cases of esophageal or gastric neoplasm and 30 normal cases without neoplasms, a total of 120 images, including 60 pair images of white light imaging (WLI) and LCI taken at the same positions and angles, were randomly shown for 10 s. The sensitivity of tumor detection as a primary endpoint was evaluated and sensitivities by organ, size, and visual gaze pattern were also assessed. Color differences (ΔE using CIE1976 [L*a*b*]) between lesions and surrounding mucosa were measured and compared with detectability. RESULTS: A total of 1080 experiments were completed. The sensitivities of tumor detection in WLI and LCI were 53.7% (50.1-56.8%) and 68.1% (64.8-70.8%), respectively (P = 0.002). LCI provided higher sensitivity than WLI for the novice and trainee groups (novice: 42.2% [WLI] vs 65.6% [LCI], P = 0.003; trainee: 54.4% vs 70.0%, P = 0.045). No significant correlations were found between sensitivity and visual gaze patterns. LCI significantly increased ΔE, and the diagnostic accuracy with WLI depended on ΔE. CONCLUSIONS: In conclusion, LCI significantly improved sensitivity in the detection of epithelial neoplasia and enabled epithelial neoplasia detection that is not possible with the small color difference in WLI. (UMIN000047944).

Clinical evaluation of a novel molecular diagnosis kit for detecting Helicobacter pylori and clarithromycin-resistant using intragastric fluid.

BACKGROUND: Although there are many Helicobacter pylori (H. pylori) diagnostic methods, the culture and antibiotic susceptibility test is an important method for selecting the most effective H. pylori eradication regimen. However, this diagnostic method is complicated and takes several days; therefore, the development of a rapid and simple diagnostic method is required. Eradication failure due to clarithromycin (CAM) resistance should also be considered. In this study, we report the clinical evaluation of point-of-care testing (POCT) kit using intragastric fluid, a novel kit for detecting H. pylori and CAM resistance. MATERIALS AND METHODS: The study participants were 143 patients suspected of H. pylori infection and had an endoscopic examination. The novel diagnostic kit diagnosed H. pylori infection and CAM resistance-associated mutation using intragastric fluid. To diagnose H. pylori infection, the relationship between the diagnostic kit and conventional diagnostic methods (urea breath test, stool antigen test, culture test, and real-time polymerase chain reaction [PCR]) was evaluated. For CAM resistance-associated mutation detection, the concordance between the diagnostic kit and antibiotic susceptibility test was evaluated. RESULTS: The diagnosis of H. pylori infection with the novel molecular diagnostic kit using intragastric fluid showed significant relationship with conventional diagnostic methods. Especially when the culture was control, the sensitivity was 100% (67/67), the specificity was 95.9% (71/74), and the overall concordance was 97.9% (138/141). The detection of CAM resistance-associated mutations had a concordance rate of 97.0% (65/67) when compared with the antibiotic susceptibility test. CONCLUSIONS: The H. pylori molecular POCT kit uses intragastric fluid as a sample and can diagnose H. pylori infection and detect CAM resistance-associated mutations within an hour. This novel kit is expected to prove useful in selecting the most effective eradication regimen for H. pylori.

Very urgent endoscopic retrograde cholangiopancreatography is associated with early discharge in patients with non-severe acute cholangitis.

BACKGROUND: endoscopic retrograde cholangiopancreatography (ERCP) is a first-line procedure for biliary drainage in patients with acute cholangitis, and there are no studies focused on very urgent ERCP within several hours of hospital arrival. This study aimed to elucidate the use of very urgent ERCP for non-severe acute cholangitis. METHODS: this retrospective observational study included patients with non-severe acute cholangitis who underwent ERCP between April 2011 and June 2020 in our institution. Patients were stratified into three groups based on time to ERCP after hospital arrival: very urgent (≤ 3 hours), urgent (3-24 hours) and elective (> 24 hours). The primary outcome was length of hospital stay (LOS). RESULTS: the study cohort included 291 patients, 168 males (57.7 %), with a median age of 76 (interquartile range, 70-83) years. In all, 47, 196 and 48 patients underwent very urgent, urgent and elective ERCP, respectively. Median LOS in the very urgent, urgent, and elective groups was 12, 14, and 15 days, respectively (Kaplan-Meier method). A shorter LOS was associated with earlier ERCP (log-rank trend test, p = 0.04). The rates of readmission within 30 days of discharge and of adverse events were not significantly different among the three groups. By multivariate analysis, very urgent ERCP was associated with a significantly earlier discharge than urgent and elective ERCP (HR, 0.71, p = 0.04 and HR, 0.47, p < 0.01, respectively). In addition, age ≥ 75 years, pancreatitis, albumin ≤ 2.8 g/dL and two or more ERCP procedures were associated with a significantly longer LOS (HRs < 1, p < 0.05). CONCLUSIONS: very urgent ERCP for non-severe acute cholangitis was associated with early discharge.

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.

Application of polyglycolic acid sheets and basic fibroblast growth factor to prevent esophageal stricture after endoscopic submucosal dissection in pigs.

BACKGROUND: Endoscopic submucosal dissection (ESD) has been the first-line treatment for early-stage esophageal cancer. However, it often causes postoperative stricture in cases requiring wide dissection. Basic fibroblast growth factor (bFGF) reportedly has anti-scarring effects during cutaneous wound healing. We hypothesized that suppressing myofibroblast activation will prevent stricture after esophageal ESD. METHODS: We resected a complete porcine esophagus circumference section by ESD. To investigate the preventive effect of bFGF on esophageal stricture formation after ESD, we endoscopically applied bFGF-soaked poly-glycolic acid (PGA) sheets onto the wound bed after ESD and fixed them by spraying fibrin glue (PGA + bFGF group), PGA sheets alone onto the wound bed and fixed them by spraying fibrin glue (PGA group), or nothing (control group). After removing the esophagus on day 22, we evaluated the mucosal constriction rate. RESULTS: Compared with those in the control group, esophageal stricture was significantly reduced in the PGA + bFGF group, and the areas stained with α-SMA and calponin-1 antibodies were significantly inhibited in the PGA + bFGF and PGA groups. The thickness of the fibrous layer in the PGA + bFGF group was uniform compared to that of the other groups. Thus, PGA + bFGF inhibited the development of unregulated fibroblasts in the acute phase, leading to uniform wound healing. CONCLUSIONS: Stenosis after esophageal ESD is related to fibrosis in the acute phase. Administration of PGA and bFGF suppresses myofibroblast activation in the acute phase, thereby preventing esophageal constriction in pigs.

Primary Duodenal Adenocarcinoma Expressing Carbonic Anhydrase IX.

Primary duodenal adenocarcinoma is a rare malignancy whose carbonic anhydrase IX (CA9) expression remains poorly understood. A 73-year-old man visited our hospital for a medical checkup. Transnasal endoscopy revealed a submucosal, tumor-like lesion with a central depression located in the descending part of the duodenum on white light imaging. On texture and color enhancement imaging mode 1, the lesion was highlighted as a reddish, elevated lesion with an irregular mucosa in its central depressed area. Pancreaticoduodenectomy was performed on the suspicion of duodenal adenocarcinoma for biopsy and endoscopic diagnosis, which led to the lesion being diagnosed as tubular adenocarcinoma, pT1b (SM). Immunohistological staining revealed an adenocarcinomatous component positive for CA9, as well as a normal duodenal mucosa. To our knowledge, this report is among the first to describe CA9-expressing primary duodenal adenocarcinoma.

Fitz-Hugh-Curtis Syndrome Presenting as Perihepatic and Subcapsular Enhancement on MRI.

Fitz-Hugh-Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease and its MRI findings remain poorly described. A 34-year-old woman was raced to our hospital with slight fever and severe right upper quadrant pain. Gadoxetic acid-enhanced magnetic resonance imaging revealed high-intensity regions in the surface and subcapsule of the right liver on T2-weighted imaging and on diffusion-weighted imaging. A definitive diagnosis of FHCS was confirmed based on high titers of serum IgA and IgG antibodies to Chlamydia trachomatis. She was treated with oral azithromycin and discharged 6 days after admission with improvement of her symptoms. To our knowledge, this report represents a valuable addition to the FHCS literature describing MRI findings in the early stage of FHCS onset.

Xanthine oxidase inhibitory activities and crystal structures of methoxyflavones from Kaempferia parviflora rhizome.

Kaempferia parviflora (KP), a Zingiberaceae plant, is used as a folk medicine in Thailand for the treatment of various symptoms, including general pains, colic gastrointestinal disorders, and male impotence. In this study, the inhibitory activities of KP against xanthine oxidase (XOD) were investigated. The extract of KP rhizomes showed more potent inhibitory activity (38% at 500 µg/ml) than those of the other Zingiberaceae plants tested. Ten methoxyflavones were isolated from the KP extract as the major chemical components and their chemical structures were elucidated by X-ray crystallography. The structurally confirmed methoxyflavones were subjected to the XOD inhibitory test. Among them, 3,5,7,4',5'-pentamethoxyflavone and 3',4',5,7-tetramethoxyflavone showed inhibitory activities (IC(50) of 0.9 and >4 mM, respectively) and their modes of inhibition are clarified as competitive/non-competitive mixed type. To the best of our knowledge, this is the first report to present the inhibitory activities of KP, 3,5,7,4',5'-pentamethoxyflavone and 3',4',5,7-tetramethoxyflavone against XOD.

Oxaliplatin-Associated Amaurosis Fugax.

Oxaliplatin-associated amaurosis fugax has not been reported, and its clinical course and treatment remain largely unclear. A 70-year-old man with advanced gastric cancer was treated with the SOX regimen. After cycle 1 of oxaliplatin infusion, the patient realized that his right eye had visual field impairment, which he described as darkening of the right half of his visual field and loss of vision lasting about 1 min and occurring about 7 times a day. The daily frequency of this occurrence gradually decreased, and his visual field impairment improved in 1 week. However, as the same symptoms recurred from cycle 2 to cycle 5 of treatment, oxaliplatin was discontinued from cycle 6 and switched to S-1 monotherapy. Subsequently, the patient's amaurosis fugax improved. To our knowledge, this is the first report describing clinical course and treatment of oxaliplatin-associated amaurosis fugax.

Vonoprazan-Associated Gastric Mucosal Redness in Non-Helicobacter pylori-Infected and Helicobacter pylori-Eradicated Stomach.

Vonoprazan-associated gastric mucosal redness is rare, and its endoscopic and pathological features remain poorly described. We report 4 cases of vonoprazan-associated gastric mucosal redness, that is, 2 cases each in non-Helicobacter pylori-infected and -eradicated stomach. In all cases, esophagogastroduodenoscopy demonstrated spotty and linear redness newly appearing in the greater curvature of the gastric body after initiation of vonoprazan but disappearing after its discontinuation. A tissue biopsy taken from the gastric mucosa with redness revealed various pathological findings and included inflammatory cell infiltration, parietal cell protrusions, oxyntic gland dilatations, congestion, focal hemorrhage with congestion beneath the basement membrane, and vacuolar degeneration of parietal cells. To our knowledge, this is the second report describing the endoscopic and pathological features of vonoprazan-associated gastric mucosal redness.

Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine.

BACKGROUND: Advanced gastric cancer can respond to S-1, an oral fluoropyrimidine. We tested S-1 as adjuvant chemotherapy in patients with curatively resected gastric cancer. METHODS: Patients in Japan with stage II or III gastric cancer who underwent gastrectomy with extended (D2) lymph-node dissection were randomly assigned to undergo surgery followed by adjuvant therapy with S-1 or to undergo surgery only. In the S-1 group, administration of S-1 was started within 6 weeks after surgery and continued for 1 year. The treatment regimen consisted of 6-week cycles in which, in principle, 80 mg of oral S-1 per square meter of body-surface area per day was given for 4 weeks and no chemotherapy was given for the following 2 weeks. The primary end point was overall survival. RESULTS: We randomly assigned 529 patients to the S-1 group and 530 patients to the surgery-only group between October 2001 and December 2004. The trial was stopped on the recommendation of the independent data and safety monitoring committee, because the first interim analysis, performed 1 year after enrollment was completed, showed that the S-1 group had a higher rate of overall survival than the surgery-only group (P=0.002). Analysis of follow-up data showed that the 3-year overall survival rate was 80.1% in the S-1 group and 70.1% in the surgery-only group. The hazard ratio for death in the S-1 group, as compared with the surgery-only group, was 0.68 (95% confidence interval, 0.52 to 0.87; P=0.003). Adverse events of grade 3 or grade 4 (defined according to the Common Toxicity Criteria of the National Cancer Institute) that were relatively common in the S-1 group were anorexia (6.0%), nausea (3.7%), and diarrhea (3.1%). CONCLUSIONS: S-1 is an effective adjuvant treatment for East Asian patients who have undergone a D2 dissection for locally advanced gastric cancer. (ClinicalTrials.gov number, NCT00152217 [ClinicalTrials.gov].).

Laparoscopic rectal surgery for middle and lower rectal cancer.

BACKGROUND: The usefulness of laparoscopic low anterior resection for middle and lower rectal cancer remains controversial. METHODS: Retrospective assessment was performed on 98 patients (51 with middle and 47 with lower rectal cancer) who underwent laparoscopic rectal surgery since 1998. Total mesorectal excision was standard. Cancers were classified as middle or lower rectal based on distance from the distal tumor border to the anal verge (<8 cm or >or=8 cm). Laparoscopic rectal surgery was performed with five or six ports and carbon dioxide pneumoperitoneum. Rectal mobilization was usually done by electrocautery and vessels were sealed with a LigaSureV. Pelvic anatomy was accurately visualized by endoscopic magnification, so autonomic nerves could be preserved. The rectum was mobilized just above the levator muscles. Operative variables and the short- and long-term outcomes were investigated. RESULTS: Five open conversions were required, including three early cases related to rectal transection problems. The other two were for a large tumor and adhesions. Mean operating time was 236 min and blood loss was 147 g. Postoperative complications were 13 cases of anastomotic leakage (13.1%), 6 wound infections (6.1%), 4 cases of anastomotic bleeding (4.0%), and 3 cases of urinary retention (3.0%). Total morbidity was 32.2%, but there were no fatal complications or operative deaths. Mean postoperative period until bowel movement, oral intake, and hospital discharge was 1.6, 1.3, and 19.7 days, respectively. Twelve patients had recurrence: local in 3, lymph node in 2, lung in 5, and liver in 2. The 5-year disease-free/overall survival rates were 82.3/95.7% in stage I, 55.1/72.0% in stage II, and 59.5/80.7% in stage III. CONCLUSION: Laparoscopic low anterior resection achieves acceptable short- and long-term outcomes. It is a useful option even for advanced lower rectal cancer.

Laparoscopic surgery for stage IV colorectal cancer.

BACKGROUND: The role of laparoscopic surgery in the management of stage IV colorectal cancer remains uncertain. METHODS: Sixty-five patients with stage IV disease from among 578 colorectal cancer patients who underwent laparoscopic surgery since 2001 were compared with 513 patients who had stage 0-III disease. The criteria for excluding stage IV patients from laparoscopic surgery were huge tumors, low rectal cancer, massive ascites due to peritoneal seeding, bowel perforation and/or obstruction, and poor general condition and/or cachexia. Data were analyzed by chi-square test or Student's t-test, with P < 0.05 being considered significant. RESULTS: The two groups of patients had similar demographic features. The open conversion rate was 4.6% (3/65 patients) in the stage IV group and 2.7% (14/513 patients) in the stage 0-III group, and the difference between the groups was not significant. In the stage IV group, depth of tumor invasion and tumor diameter were both significantly greater than in the stage 0-III group. However, operating time and blood loss were similar in the two groups (stage IV: 189.0 min and 95.0 g; stage 0-III: 182.5 min and 60.0 g), although blood loss was significantly greater in the stage IV group when patients undergoing rectal surgery were compared. The incidence of postoperative complications and the postoperative course of the two groups were similar. CONCLUSIONS: Despite their larger and more invasive tumors, the short-term outcome of laparoscopic surgery in patients with stage IV colorectal cancer was similar to that for stage 0-III patients. This result indicates that laparoscopic surgery can be successfully performed in selected stage IV colorectal cancer patients.

Long-term outcomes and risk factors of recurrent biliary obstruction after permanent endoscopic biliary stenting for choledocholithiasis in high-risk patients.

OBJECTIVE: To elucidate the long-term outcomes of permanent endoscopic biliary stenting (EBS) and risk factors for recurrent biliary obstruction (RBO) in high-risk or elderly patients with common bile duct (CBD) stones. METHODS: The electronic database of Hakodate Municipal Hospital was searched to identify elderly or high-risk patients with CBD stones who had undergone permanent EBS using a plastic stent without stone removal and were followed up between April 2011 and May 2019, with no further intervention until symptoms occurred. RESULTS: We analyzed a total of 47 patients, of whom 19 (40.4%) were men, with a median age of 86 years (interquartile range 80-90 years). RBO and death without biliary disease occurred in 14 (29.8%) and 19 (40.4%) patients, respectively. The cumulative RBO rates at 20, 40, and 60 months were 22.1%, 31.8%, and 35.5%, respectively. The median time to RBO was 13.0 and 38.0 months in the group with CBD stone ≥15 mm and 11-14 mm in diameter, respectively. The cumulative RBO incidence rate in the group with CBD stone ≤10 mm in diameter did not reach 50%. The cumulative RBO incidence rates were significantly different among the three groups based on the CBD stone diameter (competing risk analysis, P < 0.01). Multivariate analysis showed that an increase in CBD stone diameter predicted the increased risk of RBO (hazard ratio 1.26, P = 0.01). CONCLUSIONS: Permanent EBS is a feasible option for high-risk patients with small CBD stones.

Current therapeutic strategies for anal squamous cell carcinoma in Japan.

BACKGROUND: In Western countries, chemoradiotherapy (CRT) is well established as the standard therapy for stages II/III anal squamous cell carcinoma (ASCC). In Japan, the therapeutic modalities for and outcomes of this disease have not been clarified because ASCC is quite rare. The Colorectal Cancer Study Group of the Japan Clinical Oncology Group (JCOG-CCSG) conducted a survey to determine the current therapeutic strategies for ASCC in Japan. METHODS: In July 2006, a questionnaire was sent to 49 institutions affiliated with the JCOG-CCSG to gather information on numbers of cases, therapeutic modalities, and outcomes. The target subjects were patients with stages II/III ASCC, diagnosed from January 2000 to December 2004, who were 20-80 years of age with normal major organ function and no severe complications. RESULTS: Replies were received from 40 institutions. A total of 59 patients satisfied the subject criteria. Detailed information was obtained for 55 subjects; 25 (45%) had stage II ASCC and 30 (55%) had stage III ASCC. CRT was performed in 25 patients (45%); surgery in 17 (31%); surgery combined with radiotherapy (RT), chemotherapy, or CRT in 8 (15%); and RT in 5 (9%). Complete response rate in CRT was 80% (20/25). The 3-year progression-free survival rates for all subjects and for CRT-only subjects were 67% and 77%, respectively. CONCLUSION: From 2000 to 2004, only 59 patients with ASCC were identified in the JCOG-CCSG survey and about half of them underwent CRT.

Laparoscopic colorectal surgery for neoplasm. A large series by a single surgeon.

BACKGROUND: The value and efficacy of laparoscopic colorectal surgery has been validated by large multicenter, randomized, controlled trials. However the results of a large series by a single surgeon in a single center have yet to be reported. We reviewed the short-term outcome of our series of laparoscopic colorectal procedures to better define the learning curve for acquiring these skills. METHODS: Four hundred four patients with a colorectal neoplasm underwent laparoscopic surgery between August 1998 and December 2005. Surgery was performed under 8 to 10 cm H(2)O CO(2) pneumoperitoneum. Type of operation, time of operation, and estimated blood loss were compared for each level of lymph node dissection, and the rate and reason for conversion to open procedures were determined. Time to passage of flatus, hospital stay, and postoperative complications were recorded. The learning curve for right hemicolectomy, sigmoidectomy, and low anterior resection was calculated. RESULTS: Open conversion was required in 13 patients (3.2%). Uncontrollable bleeding occurred in four cases, and inability to divide the rectum because of adhesions or local invasion occurred in three. The time of operation for D3 level lymph node dissection was longer than for D2 in ileocecal resection, right hemicolectomy, and sigmoidectomy. Estimated blood loss was similar among the different types of operation. Blood loss of last 40 right hemicolectomies was less than in the first 40 cases, and the incidence of intraoperative complications in the first 40 sigmoidectomies was higher than subsequent cases. Time of operation, estimated blood loss, and number of complications did not change over time for low anterior resection. CONCLUSION: The large series performed by a single surgeon is consistent with large multicenter studies that have validated the superiority of laparoscopic colorectal surgery over conventional open procedures. The learning curve flattens out after about 40 cases of right hemicolectomy and sigmoidectomy.

Intracorporeal Billroth 1 reconstruction by triangulating stapling technique after laparoscopic distal gastrectomy for gastric cancer.

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patient's figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The "triangulating stapling technique" (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patient's figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.