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For total laparoscopic distal gastrectomies for gastric cancer, the reconstruction method is critical to the clinical outcome of the procedure. However, which reconstruction technique is optimal remains controversial. We originally reported the augmented rectangle technique (ART) as a reconstruction option for total laparoscopic Billroth I reconstructions. Still, little is known about its effect on long-term outcomes, specifically the incidence of postgastrectomy syndrome and its impact on quality of life.To analyze postgastrectomy syndrome and quality of life after ART using the Postgastrectomy Syndrome Assessment Scale-37 (PGSAS-37) questionnaire.At Juntendo University, a total of 94 patients who underwent ART for Billroth I reconstruction with total laparoscopic distal gastrectomies for gastric cancer between July 2016 and March 2020 completed the PGSAS-37 questionnaire. Multidimensional analysis was performed, comparing those 94 ART cases from our institution (ART group) to 909 distal gastrectomy cases with a Billroth I reconstruction from other Japanese institutions who also completed the PGSAS-37 as part of a larger national database (PGSAS group).Patients in the ART group had significantly better total symptom scores in all the symptom subscales (ART for Billroth I reconstruction provided beneficial long-term results for postgastrectomy syndrome and quality of life in patients undergoing total laparoscopic distal gastrectomies for gastric cancer.

Aim: The transorally inserted anvil (OrVilTM) is often selected for esophagojejunostomy after total laparoscopic gastrectomy due to its versatility. During anastomosis with OrVilTM, it is possible to select a double stapling technique (DST) or a hemi-double technique (HDST) by overlapping the linear stapler and the circular stapler, although there has been no report on the anastomotic strength. Thus, an animal experiment was conducted and verified this study. Methods: This experiment used 10 fresh porcine esophageal and jejunal specimens. Two models were created: a model in which the rod is placed at the center of the esophageal transection line (DST model) and a model in which the rod is placed at the lateral end of the esophageal transection line (HDST model). A pressure gage was inserted into the anastomosed intestine while continuously measuring pressure to determine the leakage site and leakage pressure. Results: The leakage site in both the DST (n = 5) and HDST models (n = 5) were at the staple overlapping with a leakage pressure of 151.2 ± 14.2 mmHg in the DST model and 148.2 ± 6.3 mmHg in the HDST model (P = 0.678). When the leakage site was repaired with hand-sewn sutures and conducted remeasuring pressure, leakage was observed from the contralateral crossing in the DST model and the leakage pressure was 155.8 ± 12.2 mmHg. In the HDST model, all models were capable of withstanding 300-mmHg pressures. Conclusion: HDST with a single staple intersection is beneficial for esophagojejunostomy, in terms of pressure resistance, and the repairing suture at the staple intersection can increase pressure resistance.

Background Levodopa–carbidopa intestinal gel (LCIG) treatment, a unique drug delivery system for patients with advanced Parkinson’s disease (PD), is covered by health insurance in Japan since September 2016. Various LCIG procedure/device-associated adverse events (AEs) have been reported; however, reports on their treatment have been limited. This is the first multicenter study to clarify the frequency and timing of device-related AEs. Methods Between September 2016 and December 2018, 104 patients introduced to the LCIG treatment for advanced PD in 11 hospitals were included. The patients’ characteristics, AEs incidence, AEs time, and tube exchange time were investigated. Results The median follow-up period was 21.5 months. Minor AE cases were 29.4%, whereas major AE cases were 43.1%. Majority of major AEs (n = 55, 94.8%) were managed with endoscopic treatment, such as tube exchange. Few severe AEs required surgical treatment (n =3, 5.2%). The mean (range) exposure to percutaneous endoscopic gastrojejunostomy (PEG-J) was 14.7 (0–33) months. One year after the LCIG treatment introduction, 55 patients (54.0%) retained the original PEG-J tube. The mean PEG-J tube exchange time was 10.8 ± 7.0 months in all patients, 11.6 ± 4.7 and 10.5 ± 7.7 months in patients with scheduled exchange and who underwent exchange due to AEs, respectively. Conclusions Some device-related AEs occurred during the LCIG treatment; however, only few were serious, most of which could be treated with simple procedures or tube replacement with endoscopy. Therefore, the LCIG treatment is feasible and safe and is a unique treatment option for PD, requiring endoscopists’ understanding and cooperation.

Background Laparoscopic distal gastrectomy (LDG) for gastric cancer has been progressed and popular in Japan, since it was first described in 1994. Several reconstruction methods can be adopted according to remnant stomach size, and balance of pros and cons. Roux-en-Y (R-Y) reconstruction is a one of standard options after LDG. Its complications include Petersen's hernia and Roux stasis syndrome. Here we report our ingenious attempt, fixation of Roux limb and duodenal stump, for decreasing the development of Petersen's hernia and Roux stasis syndrome. Aim To develop a method to decrease the development of Petersen's hernia and Roux stasis syndrome. Methods We performed ante-colic R-Y reconstruction after LDG. After R-Y reconstruction, we fixed Roux limb onto the duodenal stump in a smooth radian. Via this small improvement in Roux limb, Roux limb was placed to the right of the ligament of Treitz. This not only changed the anatomy of the Petersen's defect, but it also kept a fluent direction of gastrointestinal anastomosis and avoided a cross-angle after jejunojejunostomy. 31 patients with gastric cancer was performed this technique after R-Y reconstruction. Clinical parameters including clinicopathologic characteristics, perioperative outcomes, postoperative complication and follow-up data were evaluated. Results The operative time was (308.0 ± 84.6 min). This improvement method took about 10 min. Two (6.5%) patients experienced pneumonia and pancreatitis, respectively. No patient required reoperation or readmission. All patients were followed up for at least 3 year, and none of the patients developed postoperative complications related to internal hernia or Roux stasis syndrome. Conclusion This 10 min technique is a very effective method to decrease the development of Petersen's hernia and Roux stasis syndrome in patients who undergo LDG.

BACKGROUND Total laparoscopic distal gastrectomy (TLDG) is increasing due to some advantages over open surgery, which has generated interest in gastrointestinal surgeons. However, TLDG is technically demanding especially for lymphadenectomy and gastrointestinal reconstruction. During the course of training, trainee surgeons have less chances to perform open gastrectomy compared with that of senior surgeons. AIM To evaluate an appropriate, efficient and safe laparoscopic training procedures suitable for trainee surgeons. METHODS Ninety-two consecutive patients with gastric cancer who underwent TLDG plus Billroth I reconstruction using an augmented rectangle technique and involving trainees were reviewed. The trainees were taught a laparoscopic view of surgical anatomy, standard operative procedures and practiced essential laparoscopic skills. The TLDG procedure was divided into regional lymph node dissections and gastrointestinal reconstruction for analyzing trainee skills. Early surgical outcomes were compared between trainees and trainers to clarify the feasibility and safety of TLDG performed by trainees. Learning curves were used to assess the utility of our training system. RESULTS Five trainees performed a total of 52 TLDGs (56.5%), while 40 TLDGs were conducted by two trainers (43.5%). Except for depth of invasion and pathologic stage, there were no differences in clinicopathological characteristics. Trainers performed more D2 gastrectomies than trainees. The total operation time was significantly longer in the trainee group. The time spent during the lesser curvature lymph node dissection and the Billroth I reconstruction were similar between the two groups. No difference was found in postoperative complications between the two groups. The learning curve of the trainees plateaued after five TLDG cases. CONCLUSION Preparing trainees with a laparoscopic view of surgical anatomy, standard operative procedures and practice in essential laparoscopic skills enabled trainees to perform TLDG safely and feasibly.

Introduction A transorally inserted anvil has been developed to facilitate the creation of a stapled anastomosis without the need for a purse string to secure the anvil into place during laparoscopic total gastrectomy (LTG). We describe a hemi-double stapling technique and application of a transorally inserted anvil for esophagojejunostomy during LTG, and we report the results of a retrospective study in which we examined the feasibility and safety of this method. We also describe the key technical details of the method. Methods Our anastomotic method has four chief features: (a) the esophagus is cut at a slant, and its left cut end is cut and punched for the hemi-double stapling technique; (b) the anvil and circular stapler are connected, placing the distal jejunum in cranial traction; (c) a single layer of sutures is used to correct dog-earing and overlapping, and these points are completely closed with Lembert sutures; and (d) the jejunal limb is fixed to the duodenal stump to prevent kinking of the jejunal limb and to decrease tension on the anastomosis. Results This method has been used in 53 patients thus far. LTG with Roux-en-Y reconstruction was successful in all patients, and there was no need for conversion to open surgery. The mean operative time was 313 minutes, and the mean blood loss was 106 mL. The mean postoperative hospital stay was 18 days. There was no anastomotic leakage or stenosis. Conclusion Hemi-double stapling technique with a transorally inserted anvil for LTG can be performed safely and easily and safely. It can also product good outcomes.

Billroth I reconstruction is a means of anastomosis that is widely performed after surgical resection for distal gastric cancer. Interest has grown in totally laparoscopic gastrectomy, and several methods for totally laparoscopic performance of Billroth I reconstruction have been reported. However, the methods are cumbersome, and postoperative complications such as twisting at the site of anastomosis and obstruction due to stenosis have arisen. We developed an augmented rectangle technique (ART) by which the anastomosis is created laparoscopically with the use of three automatic endoscopic linear staplers, and the resulting anastomotic opening is wide and less likely to become twisted or stenosed. The technical details of our ART-based Billroth I anastomosis are presented herein along with results of the procedure to date. The technique was applied in 160 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer between December 2013 and August 2017. Clinicopathological data, surgical data, and postoperative outcomes were analyzed. During surgery, there were no troubles associated with gastrointestinal reconstruction and there was no transition to laparotomy. There were no postoperative complications, including suture failure and stenosis, associated with the gastrointestinal reconstruction, and the average postoperative hospital stay was 12 days. Totally laparoscopic ART-based Billroth I reconstruction is both feasible and safe. We expect this technique to contribute to the spread of safe totally laparoscopic surgery for gastric cancer.

Background Esophagogastric anastomosis performed after esophagectomy is technically complex and often the source of postoperative complications. The best technique for this anastomosis remains a matter of debate. We describe a new all-stapled side-to-side anastomosis, which we refer to as triple-stapled quadrilateral anastomosis (TRIQ), that can be performed after minimally invasive surgery, and we report results of a retrospective evaluation of postoperative outcomes among the 60 patients in whom this anastomosis has been performed thus far. Methods The anastomosis is created by apposition of the posterior walls of the esophagus and stomach. A linear stapler is applied to create a V-shaped posterior anastomotic wall. The anterior wall is closed in a gentle chevron-like shape with the use of 2 separate linear staplers, resulting in a wide quadrilateral anastomosis. The anastomosis is then wrapped with a greater omentum flap. Results The patient group comprised 48 men and 12 women with a mean age of 67.8 years. Neoadjuvant chemotherapy was performed in 43 of these patients. Neither the thoracoscopic or laparoscopic procedure was converted to open surgery in any patient. The median operation time was 474 min (range 680–320 min). The intraoperative blood loss volume was 104.4 mL (range 240–30 mL). There were no anastomosis-related complications above Clavien-Dindo grade II. Conclusions TRIQ can be performed easily and safely, and good short-term outcome can be expected.

Background Roux-en-Y (R-Y) reconstruction is a standard option for reconstruction after laparoscopic distal gastrectomy (LDG). Though this technique takes more time than Billroth I (B-I) reconstruction, leakage is rare, and it is useful for management of a small remnant stomach. Complications occur and include Petersen’s hernia and Roux stasis syndrome. Petersen’s hernia is a rare complication that results in significant morbidity and poor quality of life.Here we report a case series of a simple and effective method for preventing Petersen’s hernia and Roux stasis syndrome.Methods We performed ante-colic R-Y reconstruction after LDG. After R-Y reconstruction, we fixed the alimentary limb onto the duodenal stump in a proper radian. Via this small improvement in the Roux limb, the alimentary limb was placed to the right of the ligament of Treitz. This not only changed the anatomy of the Petersen’s defect, but it also kept a fluent direction of gastrointestinal anastomosis and avoided a cross-angle after jejunojejunostomy.Results From July 2015 to March 2017, we performed this technique in 31 consecutive patients. The operative time was (308.0 ± 84.6 minutes). Fixation of the alimentary limb onto the duodenal stump took about 10 minutes. Two (6.5%) patients experienced pneumonia and pancreatitis, respectively. No patient required reoperation or readmission. All patients were followed up for at least 2 years, and none of the patients developed postoperative complications related to internal hernia or Roux stasis syndrome.Conclusions This 10 minute technique is a very effective method to reduce the onset of Petersen’s hernia and Roux stasis syndrome in patients who undergo LDG.

A 68-year-old female patient presented with advanced gastric cancer and multiple hepatic tumors. Upper GI endoscopy showed a type 3 lesion in the posterior wall of the gastric body. Abdominal computed tomography revealed multiple liver metastases, and staging laparoscopy identified peritoneal dissemination. She was diagnosed with clinical Stage Ⅳ gastric cancer(cT3N2M1H1). She received 3 courses of combined chemotherapy containing S-1 and cisplatin. The therapeutic response was PR. We performed total gastrectomy with D2 lymph node dissection and splenectomy. Histopathological examination revealed no residual cancer cells, indicating pCR. She continued S-1 adjuvant chemotherapy and has remained free from recurrence for 18 months.

Objective: A new method of drug delivery via the small bowel, continuous infusion of levodopa-carbidopa intestinal gel (LCIG), for patients with advanced Parkinson’s disease (PD) has been developed...

Background The rapid expansion of laparoscopic gastrectomy (LG) for gastric cancer has generated interest among surgeons. The adequate dissemination of correct information about such advanced laparoscopic surgery can certainly be useful for surgeons and trainees. Online video resources such as YouTube are frequently used for education. This study aimed to evaluate the quality, utility, and completeness of LG videos for gastric cancer on the video website YouTube. Methods The terms "laparoscopic gastrectomy" and "gastric cancer" were searched on YouTube on August 16, 2019. The first 100 videos in three sorting categories (website's default setting, view count, and length of duration) were checked by two experienced surgeons. The popularity was evaluated with the video power index (VPI). The reliability was measured using the Journal of American Medical Association (JAMA) benchmark criteria. The educational value and completeness were evaluated with a checklist developed by the researchers. Results A total of 102 videos were analyzed. Laparoscopic distal gastrectomy (LDG) and laparoscopic total gastrectomy were the most frequently recorded techniques. Lymph node (LN) dissection was the most frequently covered topic (89.2%), followed in descending order by GI reconstruction (87.3%). The mean VPI, JAMA benchmark score and completeness score of all videos were 2.63, 1.94 and 8.53, respectively. The types of sources were as follows: private users, 73 (71.6%); academic institutions, 20 (19.6%); and others, 9 (8%). A total of 97 videos with an identifiable primary surgeon originated from eighteen different countries. Conclusions Laparoscopic videos represented by YouTube represent a useful and appropriate educational tool. However, the quality of videos varied, and the level of information incompleteness was fairly high due to insufficient reviews. The role of private uploaders and academic institutions in surgical education cannot be overestimated. It is necessary that surgeon trainers and surgical educators critically analyze the quality of video content and exercise responsibility in directing trainee surgeons. In the current era, it is best for trainees to search for peer-reviewed content.

Background and Aim: Surgical site infection (SSI) remains an important concern in Japan. The Japanese Soci‐ ety for Infection and Prevention Control disclosed that the incidence of SSIs has been lowered only by a fraction over the past 10 years. The importance of taking steps to reduce the occurrence of SSIs is recognized by many hospitals, but to date, no truly effective countermeasures have been reported. We executed a plan to better un‐ derstand the spec fic surveillance needs at St. Marianna University School of Medicine Hospital and then de‐ velop and institute procedures that would reduce the incidence of SSIs. Methods and Results: In 2005, we began development of an enhanced SSI surveillance system. With our basic CDC-based surveillance system in place, we assembled a team of doctors and nurses to oversee surveillance. We practiced strict record keeping and data analysis, gleaned information from staff, and enlisted the coopera‐ tion of other departments. New procedures were established accordingly and implemented in three phases. Be‐ tween 2005 and 2013, we witnessed informative fluctuat ons in the incidence of SSIs. Key components of our new system were standardized postoperative wound cleansing, use of buried absorbable sutures to close surgical wounds, consistent provision of 6 antibacterial agents, each one active against a common organ spec fic patho‐ gen, and establishment of a prophylactic protocol. New methods of information sharing were also instituted. We lowered the incidence of SSIs from 8% in 2006 to approximately 6.9% in 2012. We continue to monitor the number of SSIs occurring and are encouraged by a steady decline. Conclusion: Establishment of the SSI team at our hospital has proven to be a useful multidisciplinary approach to nosocomial infection awareness and control. Gradual introduction of the system to the various departments and step-by-step implementation have decreased the occurrence of SSIs and the nosocomial spread of infectious agents.