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Purpose This study evaluated the short-term outcomes and prognosis after laparoscopic total gastrectomy (LTG) in elderly patients aged >= 80 years in a multicenter retrospective cohort study using propensity score matching. Methods We retrospectively enrolled 440 patients who underwent curative LTG for gastric cancer at six institutions between January 2004 and December 2018. Patients were categorized into an elderly patient group (EG; age >= 80 years) and non-elderly patient group (non-EG; age < 80 years). Patients were matched using the following propensity score covariates: sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Short-term outcomes and prognoses were compared. Results We identified 37 propensity score-matched pairs. The median operative time was significantly shorter, and postoperative stay was longer in the EG. In terms of postoperative outcomes, the rates of all complications were comparable. The median follow-up period of the EG and non-EG was 11.5 (1-106.4) months and 35.7 (1-110.0) months, respectively; there were significant differences in 5-year overall survival between the two groups (EG, 58.5% vs. non-EG, 91.5%; P = 0.031). However, there were no significant differences in 5-year disease-specific survival (EG, 62.1% vs. non-EG, 91.5%; P = 0.068) or 5-year disease-free survival (EG, 52.9% vs. non-EG, 60.8%; P = 0.132). Conclusions LTG seems to be safe and feasible in elderly patients. LTG had a limited effect on morbidity, disease recurrence, and survival in elderly patients. Therefore, age should not prevent elderly patients from benefitting from LTG.

Purpose: This study aimed to evaluate the relationship between the body mass index (BMI) and the short-term outcomes of laparoscopic total gastrectomy (LTG). Subjects and Methods: Data of patients who underwent LTG for gastric cancer at six institutions between 2004 and 2018 were retrospectively collected. The patients were classified into three groups: low BMI (= 18.5 and = 25 kg/m2). In these patients, clinicopathological variables were analysed using propensity score matching for age, sex, the American Society of Anaesthesiologists physical state, clinical stage, surgical method, D2 lymph node dissection, combined resection of other organs, anastomosis method and jejunal pouch reconstruction. The surgical results and post-operative outcomes were compared among the three groups. Results: A total of 82 patients were matched in the analysis of the low BMI and normal BMI groups. There were no differences in operative time (P = 0.693), blood loss (P = 0.150), post-operative complication (P = 0.762) and post-operative hospital stay (P = 0.448). In the analysis of the normal BMI and high BMI groups, 208 patients were matched. There were also no differences in blood loss (P = 0.377), post-operative complication (P = 0.249) and post-operative hospital stay (P = 0.676). However, the operative time was significantly longer in the high BMI group (P = 0.023). Conclusions: Despite the association with a longer operative time in the high BMI group, BMI had no significant effect on the surgical outcomes of LTG. LTG could be performed safely regardless of BMI.

Background Although neoadjuvant therapy (Nac) is recommended for high-risk resectable pancreatic cancer (R-PDAC), evidence regarding specific regimes is scarce. This report aimed to investigate the efficacy of S-1 Nac for R-PDAC. Methods In a multicenter phase II trial, we investigated the efficacy of Nac S-1 (an oral fluoropyrimidine agent containing tegafur, gimeracil, and oteracil potassium) in R-PDAC patients. The protocol involved two cycles of preoperative S-1 chemotherapy, followed by surgery, and four cycles of postoperative S-1 chemotherapy. Two-year progression-free survival rates were the primary endpoint. Overall survival (OS) rates and median survival time (MST) were secondary endpoints. Results Forty-nine patients were eligible, and thirty-one patients underwent resection following Nac, as per protocol (31/49; 63.3%). Per-protocol analysis included data from 31 patients, yielding the 2-year PFS rate of 58.1%, and 2-, 3-, and 5-year OS rates of 96.8%, 54.8%, and 44.0%, respectively. MST was 49.2 months. Intention-to-treat analysis involved 49 patients, yielding the 2-year PFS rate of 40.8%, and the 2-, 3-, and 5-year OS rates of 87.8%, 46.9%, and 33.9%, respectively. MST was 35.5 months. Conclusions S-1 single regimen might be an option for Nac in R-PDAC; however, the high drop-out rate (36.7%) was a limitation of this study.

Although neoadjuvant therapy (Nac) is recommended for high-risk resectable pancreatic cancer (R-PDAC), evidence regarding specific regimes is scarce. This report aimed to investigate the efficacy of S-1 Nac for R-PDAC. In a multicenter phase II trial, we investigated the efficacy of Nac S-1 (an oral fluoropyrimidine agent containing tegafur, gimeracil, and oteracil potassium) in R-PDAC patients. The protocol involved two cycles of preoperative S-1 chemotherapy, followed by surgery, and four cycles of postoperative S-1 chemotherapy. Two-year progression-free survival (PFS) rates were the primary endpoint. Overall survival (OS) rates and median survival time (MST) were secondary endpoints. Forty-nine patients were eligible, and 31 patients underwent resection following Nac, as per protocol (31/49; 63.3%). Per-protocol analysis included data from 31 patients, yielding the 2-year PFS rate of 58.1%, and 2-, 3-, and 5-year OS rates of 96.8%, 54.8%, and 44.0%, respectively. MST was 49.2 months. Intention-to-treat analysis involved 49 patients, yielding the 2-year PFS rate of 40.8%, and the 2-, 3-, and 5-year OS rates of 87.8%, 46.9%, and 33.9%, respectively. MST was 35.5 months. S-1 single regimen might be an option for Nac in R-PDAC; however, the high drop-out rate (36.7%) was a limitation of this study.

Objective: IgG4-related sclerosing cholecystitis is generally associated with IgG4-related sclerosing cholangitis and presents with diffuse, circumferential thickening of the gallbladder wall. We report a rare case of localized IgG4-related sclerosing cholecystitis without IgG4-related sclerosing cholangitis, which was difficult to differentiate from gallbladder cancer preoperatively. Patient: A 56-year-old man with suspected IgG4-related disease or gallbladder cancer was admitted to our ward. The serum IgG4 level was elevated at 721 mg/dL. Computed tomography (CT) demonstrated focal wall thickening of the gallbladder fundus. Drip infusion cholecystocholangiography with CT revealed no dilation, stenosis, or border irregularity of the bile duct. Results: For diagnostic and treatment purposes, cholecystectomy with wedge resection of the gallbladder bed was performed. The pathological diagnosis was IgG4-related sclerosing cholecystitis. Conclusion: It is difficult to differentiate IgG4-related sclerosing cholecystitis from gallbladder cancer in cases involving localized thickening of the gallbladder wall. In similar cases, surgical resection with cancer in mind might be performed based on present clinical knowledge.

Background: This study aimed to compare the postoperative outcomes after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using the overlap method or the functional method in a multicenter retrospective study with propensity score matching. Methods: We retrospectively enrolled all patients who underwent curative LTG for gastric cancer at 6 institutions between January 2004 and December 2018. Patients were categorized into the overlap group (OG) or functional group (FG) based on the type of anastomosis used in EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. The surgical results and postoperative outcomes were compared. Results: We identified 69 propensity score-matched pairs among 440 patients who underwent LTG. There was no significant between-group difference in the median operative time, intraoperative blood, or number of lymph nodes resected. In terms of postoperative outcomes, the rates of all complications [Clavien-Dindo (CD) classification >= II; OG 13.0 vs. FG 24.6%, respectively; P=0.082], complications more severe than CD grade III (OG 8.7 vs. FG 18.8%, respectively; P=0.084), and the occurrence of EJS leakage and stenosis more severe than CD grade III (OG 7.3% vs. FG 2.9%, P=0.245; OG 1.5 vs. FG 8.7%, P=0.115, respectively) were comparable. The median follow-up period was 830 days (range, 18 to 3376 d), and there were no differences in overall survival between the 2 groups. Conclusions: There was no difference in surgical outcomes and overall survival based on the type of anastomosis used for EJS after LTG. Therefore, selection of anastomosis in EJS should be based on each surgeon's preference and experience.

The ProGrip™ laparoscopic self-fixating mesh provides advantages such as low cost and reduced pain following tack-free fixation in laparoscopic hernia repair through a transabdominal preperitoneal approach. Obturator hernia repair needs adequate fixation around the hernial orifice without the use of tacking, and ProGrip™ mesh provides options for secure fixation. However, it is often difficult to adequately adjust the mesh placement to cover the obturator hernia orifice with a ProGrip™ mesh, due to adhesion of the grips to the surrounding tissues. We introduce our technique to avoid unintentional adhesion during ProGrip mesh repair and discuss its utility in the treatment of obturator hernias. We repaired seven obturator hernia lesions in five patients using this technique without any complications. The biggest advantage of our technique is that the position of the mesh can be adjusted after it is expanded, unless the sheet is completely removed, allowing the surgeons to fix the mesh without any unintended adhesion to surrounding tissue.

Purpose: We used propensity score matching to compare the complication rates after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using a circular or a linear stapler. Methods: We retrospectively enrolled all patients who underwent curative LTG between November 2004 and March 2016. Patients were categorized into the circular and linear groups according to the stapler type used for the subsequent EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Clinicopathological characteristics and surgical outcomes were compared. Results: We identified 66 propensity score-matched pairs among 379 patients who underwent LTG. There was no significant between-group difference in the median operative time, extent of lymph node dissection, number of lymph nodes resected, rate of conversion to open surgery, or number of surgeries performed by a surgeon certified by the Japanese Society of Endoscopic Surgery. In the circular and linear groups, the rate of all complications (Clavien-Dindo [CD] classification ≥ I; 21 vs. 26%, respectively; p = 0.538), complications more severe than CD grade III (14 vs. 14%, respectively; p = 1.000), and occurrence of EJS leakage and stenosis more severe than CD grade III (5 vs. 2%, p = 0.301; 9 vs. 8%, p = 0.753, respectively) were comparable. Conclusions: There is no difference in the postoperative complication rate related to the type of stapler used for EJS after LTG.

Despite its spread and advances, laparoscopic gastrectomy (LG) for advanced gastric cancer (AGC) remains controversial. The aim of this study was to evaluate the oncologic outcomes and to identify the potential risk factors for recurrence and survival after LG in AGC patients. The medical records of patients who underwent radical LG for histopathologically diagnosed stage IB or more advanced gastric cancer from 2004 to 2012 were collected. The clinicopathologic factors and outcomes were evaluated retrospectively. LG was performed for 300 patients, with a median operative time of 278 min and blood loss of 46 ml. Postoperative morbidity was defined as Clavien-Dindo grades III and IV and occurred in 13 patients (6.3%) in the laparoscopic distal gastrectomy group. The pathologic stage was IB in 109 patients (36.3%), IIA in 77 patients (25.7%), IIB in 48 patients (16.0%), IIIA in 31 patients (10.3%), IIIB in 19 patients (6.3%), and IIIC in 16 patients (5.3%). Median follow-up period was 55.2 months. The 3-year relapse-free survival (RFS) rate was 92.7% for stage IB, 87.0% for IIA, 68.8% for IIB, 64.5% for IIIA, 47.4% for IIIB, and 43.8% for IIIC. The 5-year actual overall survival rate was 91.1% for stage IB, 72.7% for II, and 62.5% for III. Multivariate analysis revealed postoperative complication as an independent risk factor for RFS. LG for AGC was feasible and provided comparable oncologic outcomes with those previously reported. Postoperative complications correlated with poor prognosis. Randomized control trials should be conducted to confirm these results of LG for AGC in the general population.

Background Various methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and published, whereas only a limited number of reports are available on the utility of the delta-shaped anastomosis (Delta). This study compared Delta and Roux-en-Y anastomoses (RY), with the aim to clarify the utility of Delta. Methods Stage 1 gastric cancer patients who had undergone LDG with Delta (group D, n = 68) and those who had undergone LDG with RY (group RY, n = 60) were compared in terms of operative outcomes, postoperative clinical symptoms, gastrointestinal fiberscopic findings, and changes in body weight. Results Both the operative and anastomotic times were significantly shorter in group D (230 and 13 min, respectively) than in group RY (258 and 38 min, respectively) (p

症例は56歳男性．血便を主訴に受診．下部消化管内視鏡にて，直腸に隆起性病変を認め，生検にて直腸癌と診断した．その肛門側には10mm弱の亜有茎性ポリープを認めた．手術は腹腔鏡補助下低位前方切除術を施行．切除標本では直腸Rbに20mmの1型腫瘍と，6mmのIspポリープを認めた．病理学的所見では直腸癌は高分化型腺癌でpSM1, pN0であった．ポリープはカルチノイドで，pSM1, ly1, v0, 1群リンパ節1個に転移を認めた． 10mm以下のカルチノイドはリンパ節転移を認める可能性が低く，局所切除となる場合が多い．しかし微小カルチノイドであっても，脈管侵襲が認められれば，リンパ節転移の可能性があり，根治手術が必要と考えられた．微小直腸カルチノイドに対する腹腔鏡手術は低侵襲であり，良い適応と考えられた．

症例は77歳, 女性. 右季肋部痛を主訴に受診, 胆嚢炎の診断で入院となった. CTにて胆嚢腫大, 壁肥厚および胆石を認めた. MRCPでは総胆管結石を認めず, 右後区域枝が中部胆管より分岐し, そこから胆嚢管が分岐していた. 腹腔鏡下胆嚢摘出術を施行. 順行性に胆嚢を剥離したのち, 胆嚢管をクリップにて切離した. 術後3日目より腹痛出現. CT, ERCにて乳頭部への胆石落石嵌頓による胆石膵炎および胆汁漏と診断し, 内視鏡的経鼻胆管ドレナージ (ENBD) にて保存的に治療を行った. 処置後5日目, 胆汁漏の改善が認められたため, その翌日ENBDチューブ抜去, 術後20日目に退院となった. 本症例は, 総胆管への落石, 嵌頓により胆嚢管閉鎖部が開放され, 胆汁漏を認めたものと考えられ, これらを十分考慮した慎重な術中操作を行うことが重要と考えられた. 以上, 腹腔鏡下胆嚢摘出術後, 落下結石嵌頓により引き起こされた胆汁漏の1例を経験したので報告する.

症例は67歳男性.横行結腸癌の診断下に,拡大結腸右半切除術を施行した.術中所見では第1群から第3群までリンパ節の腫大を認めこれらを郭清した.また,大動脈周囲リンパ節も腫大していたため,その一部をサンプルとして摘出した.病理組織学的検索にて腫瘍は高分化型腺癌,深達度ss, ly1, v0であった.一方,リンパ節は第1群から第3群の84個については転移を認めなかったが,摘出した大動脈周囲リンパ節4個中1個に転移が認められた.術後1年3カ月現在, CTその他による検査にて再発の所見を認めていない.

症例は75歳女性. 6年前に腹腔鏡下胆嚢摘出術の既往がある.腹部CTで臍下部に直径約6cmのヘルニア門を認め,ヘルニア嚢内には小腸が嵌入していた.腹腔鏡下胆嚢摘出術後の腹壁瘢痕ヘルニアの術前診断にて手術を施行した.しかし,ポート挿入部には脂肪の癒着を認めるのみであり,その下方にヘルニア門があり,下腹部白線ヘルニアと術中診断し,ヘルニア門の単純縫縮を行った.白線ヘルニアは稀であり,下腹部症例は本邦でわずか5例の報告をみるに過ぎない. CTによって腹壁瘢痕ヘルニアと白線ヘルニアの鑑別は困難であったが,腹腔鏡が最終診断を得る上で有用であった.

HOX genes are known not only as master genes that control the morphogenesis, but also as regulator genes that maintain tissue or organ specificity in the adult body. We hypothesized that dysregulated expression of HOX genes was associated with tumor development and malignant progression such as invasion and metastasis. In this study, we analyzed the expression patterns of 39 HOX genes in human invasive ductal breast cancer tissues and normal tissues by the real-time RT-PCR method. We found 11 HOX genes (HOXA1, A2, A3, A5, A9, C11, D3, D4, D8, D9 and D10) expression levels of which were significantly different between cancerous and normal tissues. All 10 genes except HOXC11 were expressed at lower levels in cancerous tissues than normal tissues. Comparing expression levels of each HOX gene among the different types of cancer tissues, the expression level of HOXB7 was lower in lymph node metastasis-positive cancer tissues than negative cancer tissues; those of HOXD12 and D13 were higher in progesterone receptor-positive cancer tissues than negative cancer tissues; and the expression level of HOXC5 was lower in cancerous tissues with mutated-type p53 than in normal and cancerous tissues with wild-type p53. These results suggest that the aberrant expression of HOX genes is related to the development of breast cancer and malignant behavior of cancer cells.

INTRODUCTIONIntestinal metastasis from gastric cancer is rare, although the most common cause of secondary neoplastic infiltration of the colon is gastric cancer. However, little data is available on recurrence or death in patients with gastric cancer surviving >5 years post-gastrectomy. Here we report two cases of lower intestinal metastasis from gastric cancer >5 years after primary resection and discuss with reference to the literature.PRESENTATION OF CASECase 1: A 61-year-old man with a history of total gastrectomy for gastric cancer 9 years earlier was referred to our hospital with constipation and abdominal distention. We diagnosed primary colon cancer and subsequently performed extended left hemicolectomy. Histological examination revealed poorly differentiated adenocarcinoma resembling the gastric tumor he had 9 years earlier. The patient refused postoperative adjuvant chemotherapy and remained alive with cancerous peritonitis and skin metastases as of 17 months later. Case 2: A 46-year-old woman with a history of total gastrectomy for gastric cancer 9 years earlier presented with constipation. She also had a history of Krukenberg tumor 3 years earlier. We diagnosed metastatic rectal cancer and subsequently performed low anterior resection and hysterectomy. Pathological examination revealed poorly differentiated tubular adenocarcinoma, resembling the gastric tumor. The patient remained alive without recurrence as of 17 months later.DISCUSSIONWe found 19 reported cases of patients with resection of colon metastases from gastric cancer. Median disease-free interval was 74 months.CONCLUSIONResection of late-onset colorectal recurrence from gastric cancer appears worthwhile for selected patients.