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Background Retrosternal reconstruction is associated with a lower risk of mediastinitis, gastro-tracheal fistula, and hiatal hernia. Historically, traumatic manual creation of the retrosternal tunnel has been performed using one's fist. We report a novel and atraumatic laparoscopic procedure to create the retrosternal route. Methods We have laparoscopically created the retrosternal route in 25 thoracoscopic, mediastinoscopic, or robot-assisted minimally invasive esophagectomies since August 2019. Specifically, a peritoneal incision is started at the dorsal side of the xiphoid process. Through a 12-mm port inserted slightly to the right of and superior to the umbilical camera port, we dissect loose connective tissues from the caudal to the cranial side using behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route was calculated. Then, the cumulative sum (CUSUM) method and the simple moving average of five cases were used to evaluate the learning curve of this novel procedure. Operative outcomes were analyzed according to the learning curve results and also compared with 25 cases of postmediastinal reconstruction counterparts. Results Twenty-five patients were divided into the early group (six patients) and late group (19 patients) based on the peak of the CUSUM chart. The time required for route creation was 28.5 min (median) in the early and 15 min in the late group, indicating a significant difference (P = 0.038). The overall incidence of pleural injury was 20% (5 of 25 patients), with no significant difference between the groups. There was no significant difference in the incidence of perioperative complications. Also, there were no significant differences in perioperative complications or gastric conduit functions 1 year after surgery between the retrosternal and the postmediastinal reconstruction. Conclusion Laparoscopic creation of a retrosternal route for gastric conduit reconstruction is safe and feasible and has a short learning curve.

BACKGROUND Multidisciplinary treatment for esophageal squamous cell carcinoma (ESCC) has improved outcomes, but the prognosis for ESCC remains poor. Nutritional and inflammatory indicators are reported to be associated with cancer prognosis. The combination of albumin and the derived neutrophil-to-lymphocyte ratio (Alb-dNLR) score was established to measure the immune system and nutritional status. The authors hypothesized that the Alb-dNLR score could be a new reliable prognostic factor for ESCC patients. METHODS The study evaluated 269 patients who underwent esophagectomy between April 2010 and March 2018, including 185 patients who received neoadjuvant chemotherapy. The Alb-dNLR score was calculated using serum albumin and the dNLR. The dNLR was calculated as neutrophils to (leukocyte-neutrophil count). The cutoff values of the albumin and dNLR for overall survival (OS) were determined using the receiver operating characteristic curve. Patients were divided into "high" and "low" groups according to the Alb-dNLR score. RESULTS A high Alb-dNLR score was found in 61 cases (22.7%). The 5-year OS was 34% in the high Alb-dNLR group and 66.2% in the low Alb-dNLR group (p < 0.0001). The 5-year cause-specific survival (CSS) was 51.5% in the high Alb-dNLR group and 74.7% in the low Alb-dNLR group (p < 0.0001). Multivariate analyses demonstrated that the Alb-dNLR score was an independent prognostic factor for OS (hazard ratio [HR], 2.198; 95% confidence interval [CI], 1.460-3.263; p = 0.0002) and CSS (HR, 1.733; 95% CI, 1.035-2.835; p = 0.0371). CONCLUSIONS The Alb-dNLR score is an extremely useful, easy-to-use parameter to predict OS and CSS for ESCC patients.

Background One of the primary treatment for resectable advanced esophageal squamous cell cancer (ESCC) is neoadjuvant chemotherapy (NAC) followed by minimally invasive esophagectomy (MIE). Because the neutrophil-to-lymphocyte ratio (NLR) is a widely reported prognostic factor in several cancers, we investigated whether the preoperative NLR is a biomarker in ESCC patients treated with NAC and MIE. Methods In this study, we investigated 174 ESCC patients who underwent MIE from January 2010 to December 2015, including 121 patients who received NAC. The cutoff value of the NLR was analyzed using the receiver operating characteristic curve. Multivariate analyses were performed to clarify independent prognostic factors for overall survival (OS). Results The cutoff value of the NLR for OS in 121 patients who received NAC was 2.5 ng/ml, and the area under the curve was 0.63026 (p = 0.0127). The 5-year OS rate was 64% in those with an NLR 415 ml were independent poor prognostic factors. Conclusions NLR is a biomarker of prognosis in ESCC patients who undergo MIE after NAC.

Whether surgical device usage in laparoscopic gastrectomy differs with respect to operator’s skill levels is unknown. Further, device usage analysis using artificial intelligence has not been reported to date. Herein, we compared the patterns of surgical device usage during laparoscopic gastrectomy for gastric cancer among surgeons at different skill levels. The data of device usage was acquired from laparoscopic video recordings using an automated surgical-instrument detection system. In total, 100 video recordings of infrapyloric lymphadenectomy and 33 of D2 suprapancreatic lymphadenectomy during laparoscopic gastrectomy for gastric cancer were analyzed in this retrospective study. The system’s accuracy was evaluated by comparing the automatic and the manual usage time. Surgical device usage patterns were compared between qualified and nonqualified surgeons of The Japan Society for Endoscopic Surgery Endoscopic Surgical Skill Qualification System. For every device, the automatic detection time and manual detection time were consistent with each other. In infrapyloric lymphadenectomy, the usage time proportions of dissector forceps and clip applier were higher among nonqualified operators than among qualified operators (dissector, 5.1% vs. 2.3%, P

Background Esophagectomy with lymphadenectomy is the principal treatment for localized esophageal cancer. Conventional minimally invasive esophagectomy (C-MIE) in prone position has spread worldwide as it is less invasive. However, its efficacy remains controversial. Robot-assisted MIE (RAMIE) can have more advantages than C-MIE. Therefore, the current study aimed to validate whether RAMIE is associated with lower incidence of left recurrent laryngeal nerve (RLN) palsy compared with C-MIE in prone position. Patients and Methods In total, 404 patients with esophageal carcinoma underwent MIE (353 C-MIEs and 51 RAMIEs) in prone position at Kobe University between 2010 and 2020. Then, propensity score matching was performed, and results showed that 51 patients should be included in each group. Thereafter, the perioperative outcomes between the two groups were compared. Results The RAMIE group had a significantly longer operative time than the C-MIE group (P < 0.0001). However, the number of lymph nodes resected along the left RLN was similar in both groups. Moreover, the incidence of left RLN palsy was significantly lower in the RAMIE group than in the C-MIE [Clavien-Dindo classification grade II; 0 (0%) versus 32 (9%), P = 0.022 in entire cohort, and 0 (0%) versus 5 (10%), P = 0.022 in matched cohort. Esophagectomy Complications Consensus Group definitions type I; 8 (16%) versus 101 (29%), P = 0.041 in entire cohort and 8 (16%) versus 18 (35%) in matched cohort, P = 0.023]. Conclusion RAMIE is superior to C-MIE in prone position in decreasing the incidence of left RLN palsy.

INTRODUCTION Although lateral pelvic lymph node dissection is considered as a treatment option for advanced rectal cancer, it is technically demanding. Recently, the transanal approach for total mesorectal excision has become increasingly used. In this Technical Note, we describe lateral pelvic lymph node dissection using a 2-team method that was assisted by the transanal approach. TECHNIQUE First, the lateral pelvic area was entered from the anal side by dissection between the S4 sacral splanchnic nerve and levator ani muscle. Then, the fatty tissues including the obturator compartment and the distal part of the internal iliac compartment were separated from the inferior and superior vesical vessels and the bladder wall. Next, the fatty tissues were separated from the lateral pelvic wall. The obturator nerve was isolated and preserved, whereas the obturator vessels were resected at their peripheral end. Then, the fatty tissues were dissected from the bottom plane. Finally, the fatty tissues were dissected from the ventral bladder wall and were completely isolated from the obturator nerve in cooperation with the transabdominal team. RESULTS The 2-team method shortened the operative time dramatically and decreased mental and physical burden on the operators during lateral dissection. Assistance with the transanal approach helped with a secure and effective dissection, especially of the most distal parts, such as around the internal pudendal and inferior vesical arteries, because substantial skill is required for the transabdominal approach alone. CONCLUSIONS This procedure is useful for the safe and effective performance of lateral pelvic lymph node dissection for patients with rectal cancer.

Laparoscopic local resection for gastrointestinal stromal tumors (GISTs) near the esophagogastric junction (EGJ) increases the risk of injuring the EGJ. We investigated the safety of laparoscopic local resection for GISTs near the EGJ according to the distance from the EGJ to the tumor edge. We retrospectively evaluated 40 patients who had undergone laparoscopic local resection for GISTs near the EGJ between January 2009 and December 2019. After excluding 1 patient who had undergone right colectomy at the same time, 39 patients were classified according to distance of the GIST from the EGJ in the Near group (0–2.0 cm; n = 16) and the Far group (2.1–5.0 cm; n = 23). We found no marked differences in the operation time, blood loss, length of postoperative hospital stay, or postoperative complication rate in the two groups. Anastomotic leakage occurred with a tumor located on the EGJ. Three tumors recurred in the Near group, and all of them were located on the EGJ. Except for GISTs located on the EGJ, laparoscopic local resection for GISTs near the EGJ can be performed safely with few postoperative complications and a low risk of recurrence.

Background/aim Cancer stem cells (CSCs) contribute to resistance against neoadjuvant chemotherapy (NAC) in esophageal squamous cell carcinoma (ESCC). We conducted a retrospective observational study for the relationship between the expression levels of CSC markers in biopsy specimens prior to 5-fluorouracil plus cisplatin (FP)-NAC and the pathological responses. Patients and methods We included 171 patients with ESCC who underwent the FP-NAC followed by radical resection. Biopsy specimens prior to the FP-NAC were obtained and immunochemically stained for CD44, CD133, and CD24. Results The biopsy specimens of the non-responders had the CD44high/CD24low expression at high levels, which was found as an independent predictor of not only FP-NAC resistance but also poor overall survival by multivariate analyses. Conclusion CD44high/CD24low expression in the biopsy specimens prior to FP-NAC may be a predictor of FP-NAC resistance and poor prognosis of ESCC patients.

Despite the increasing utilization of transanal total mesorectal excision as a promising approach for low rectal cancer, the feasibility and safety of transperineal minimally invasive abdominoperineal resection (tp-APR) remain unclear. In total, 25 patients who underwent tp-APR between April 2017 and May 2020 (tp-APR group) and 27 patients who underwent conventional laparoscopic APR between May 2009 and September 2016 (lap-APR group) for low rectal cancer were enrolled in this retrospective study. Clinical outcomes were compared between the groups before and after propensity score matching. The primary outcome was the incidence of the overall postoperative complications with Clavien–Dindo grade II or above. Standardized technique of tp-APR was also demonstrated. On comparison, operative time, intraoperative blood loss, and overall postoperative complications with Clavien–Dindo grade II or above were significantly less in the tp-APR group both before and after propensity score matching. The rates of urinary disturbance and perineal wound infection were significantly less in the tp-APR group after matching. Further, postoperative hospital stay was significantly shorter in the tp-APR group both before and after matching. However, pathological outcomes did not differ between the groups before and after matching. There has been no local recurrence in the tp-APR group with a median follow-up period of 18 months. Standardized tp-APR for low rectal cancer is feasible and seems superior to conventional laparoscopic APR in terms of short-term outcomes. Further larger-scale studies with a longer follow-up period are required to evaluate oncological outcomes.

Aim The outcomes of gastrectomy for gastric cancer in patients at each severity of chronic kidney disease (CKD) remain unknown. Methods We retrospectively analyzed the outcomes of 560 patients who underwent distal or total gastrectomy for gastric cancer between 2009 and 2018. We classified the patients into four groups based on estimated glomerular filtration rate: stage 1/2 (normal to mild, n = 375), stage 3a (mild to moderate, n = 122), stage 3b (moderate to severe, n = 43), and stage 4/5 (severe to end‐stage, n = 20) CKD. The relationship between CKD stage and the incidence of postoperative morbidity was analyzed. Results CKD was a predictor of overall morbidity independent of age, gender, American Society of Anesthesiologists Performance Status, pulmonary comorbidity, extent of lymphadenectomy, and operation time in a multivariate analysis. The incidences of overall and severe morbidity were significantly increased with CKD progression (both P, Chronic kidney disease (CKD) progression increases the risk of morbidity following gastrectomy in gastric cancer patients. The risk elevates substantially at moderate CKD with an eGFR ≤ 45 ml/min/1.73 m2.

Background and Aim In 2015, the Japanese Society of Gastroenterological Surgery (JSGS) initiated data verification in the gastroenterological section of the National Clinical Database (NCD) and reported high accuracy of data entry. Remote audits were introduced for data validation on a trial basis in 2016 and formally accepted into use in 2017‐2018. The aim of this study was to audit the data quality of the NCD gastroenterological section for 2016‐2018 and to confirm the high accuracy of data in remote audits. Methods Each year, 45‐46 hospitals were selected for audit. Twenty cases were randomly selected in each hospital, and the accuracy of patient demographic and surgical outcome data (46 items) was compared with the corresponding medical records obtained by visiting the hospital (site‐visit audit) or by mailing data from the hospital to the JSGS office (remote audit). Results A total of 136 hospitals were included, of which 88 (64.7%) had a remote audit, and 124 936 items were evaluated with an overall data accuracy of 98.1%. There was no significant difference in terms of data accuracy between site‐visit audit and remote audit. Accuracy, sensitivity, and specificity of mortality were 99.7%, 89.7%, 100% for site‐visit audits and 99.8%, 97.3%, 100% for remote audits, respectively. Mean time spent on data verification per case of remote audits was shorter than that of site‐visit audits (10.0 minutes vs 13.7 minutes, P, The Japanese National Clinical Database (NCD) covers > 95% of the surgical operations carried out in Japan. The aim of this study was to audit the data quality of the NCD gastroenterological section for 2016‐2018. The audits showed that NCD data are reliable and characterized by high accuracy.

Situs inversus totalis (SIT) is a rare condition in which the internal organ's position is a mirror image of normal anatomy. Although several investigators reported laparoscopic surgery for colorectal cancer in patients with SIT, it is considered difficult even for an experienced surgeon because of the mirror position. We show a case report of laparoscopic sigmoidectomy with the splenic flexure mobilization (SFM) procedure in SIT. A 79-year-old woman with SIT was referred to our hospital for a locally advanced sigmoid cancer (cT3N1M0, cStageIIIB). We safely performed the laparoscopic sigmoidectomy with SFM, as shown in detail below. No postoperative complication occurred, and the patient is in good health with no recurrences 30 months after surgery, as of the writing this report. We propose three critical points; checking the CT angiography to understand the anatomy; using flip-horizontal video of "normal" laparoscopic sigmoidectomy to confirm an unfamiliar situation; adding the epigastric trocar to make SFM procedures safe and comfortable.

Given the worldwide popularization of conventional minimally invasive esophagectomy (C-MIE), robot-assisted MIE (RAMIE) can be expected to provide a finer procedure. However, controversy remains regarding whether RAMIE is superior to C-MIE in preventing recurrent laryngeal nerve (RLN) palsy. Considering the shallow learning curve for RAMIE, a novel procedure for lymphadenectomy along the RLN during RAMIE is needed. Based on a logical and simple understanding of the left upper mediastinum anatomy, the authors developed a novel “modified bascule method” for RAMIE that could simplify lymphadenectomy along the left RLN and prevent it from being touched and stretched. Between 2018 and 2020, 46 patients with esophageal carcinoma underwent RAMIE using this method at Kobe University. The modified bascule method was used to perform RAMIE for 29 men and 17 women with a median age of 67 years (range, 49–82 years). The median thoracoscopic procedure time was 438 min (range, 344–625 min), and the median console time was 351 min (range 273–518 min). The study harvested a median of 24 (range, 8–34) lymph nodes from the thoracic portion and 4 (range, 0–10) lymph nodes from along the left RLN. The mortality rate was 0%. Postoperative left RLN palsy classified as Clavien–Dindo (C–D) grade 1 or higher was observed for 9 patients (19%), whereas grade 2 or higher was not seen (0%). Pneumonia and anastomotic leakage rates higher than C–D grade 2 were respectively 13% and 19%. The novel modified bascule method for RAMIE can promote feasible lymphadenectomy along the left RLN even when performed during the learning period.

BACKGROUND/AIM The safety of neoadjuvant chemoradiotherapy (NACRT) combined with total mesorectal excision (TME) and selective lateral pelvic lymph node dissection (LLND) is unclear in elderly patients with locally advanced rectal cancer (LARC). PATIENTS AND METHODS Forty-two patients with LARC underwent TME and selective LLND following NACRT at Kobe University Hospital. The clinical outcomes were retrospectively compared between the elderly (aged ≥70 years, n=13) and non-elderly patients (aged

Esophageal squamous cell cancer (ESCC) is one of the deadliest cancers in the world. Esophagectomy remains the principal treatment, and minimally invasive esophagectomy (MIE) has been performed worldwide. This study aimed to clarify whether the lymph node ratio (LNR), defined as the ratio of metastatic lymph nodes (LNs) to examined, is a prognostic factor for ESCC after MIE. This study included 327 MIEs with the patient in the prone position at two institutions from 2010 to 2015. Cox proportional hazards regression analyses using clinicopathologic characteristics and the LNR were performed for the pN1 patients and the whole cohort. In the multivariate analysis for all stages, independent prognostic factors were depth of tumor invasion (P

Purpose Minimally invasive esophagectomy (MIE) has been increasingly used, but many reports have stated that recurrent laryngeal nerve (RLN) palsy after MIE is a major complication associated with postoperative pneumonia. Prevention of RLN palsy clearly has been a challenging task. The study aim was to determine if a three-dimensional (3-D) stereoscopic vision system can reduce the RLN palsy rate after MIE. Methods This was a retrospective study of MIE (McKeown esophagectomy) using a 3-D or 2-D stereoscopic vision system to treat 358 patients in the prone position between April 2010 and March 2019. The patients who underwent 3-D MIE (3-D group) or 2-D MIE (2-D group) were matched by using propensity score matching. After matching, the perioperative outcomes were compared between the groups. Results After propensity score matching, 154 patients were analyzed (77 patients, 3-D group; 77 patients, 2-D group). There were no significant differences in the patients’baseline characteristics in the matched cohort. There were no significant differences in the rates of pneumonia (Clavien–Dindo (C–D) grade ≥ II, 3-D vs. 2-D, 11 (14%) vs. 12 (16%)), anastomotic leakage (C–D grade ≥ II, 10 (13%) vs. 18 (23%)) and mortality. The rates of left RLN palsy (C–D grade ≥ IIIa, 1 (1.3%) vs. 7 (9.1%), P = 0.029), right RLN palsy (C–D grade ≥ I, 2 (3%) vs. 8 (10%), P = 0.049), comprehensive complication index (CCI®) (8.5 vs. 14.3, P = 0.011), and postoperative hospital stay period (median: 25 vs. 30 days, P = 0.034) were significantly lower in the 3-D group than in the 2-D group, respectively. Conclusions In MIE, the 3-D viewing system was one of the factors that reduced postoperative morbidities such as the rates of each RLN palsy and CCI®, leading to shorter postoperative hospital stay.

Although transanal total mesorectal excision (ta-TME) is adopted for rectal cancer surgery by an increasing number of surgeons, it is still technically challenging. We have employed a lateral-first approach for ta-TME to overcome technical difficulties. However, its outcomes and advantage over conventional laparoscopic TME remain unclear. Thirty-five consecutive patients who underwent ta-TME using a lateral-first approach (the ta-TME group) and 53 consecutive patients who underwent conventional laparoscopic TME (the lap-TME group) for low rectal cancer were included. Propensity score matching (PSM) was used to create balanced cohorts of ta-TME (n = 28) and lap-TME (n = 28). Their clinical outcomes were compared after PSM. The operative time and intraoperative blood loss were significantly lower in the ta-TME group than in the lap-TME group (P = 0.042 and P

Esophageal cancer has a poor prognosis despite the fact that surgical techniques have been advanced and optimized, and systemic multimodality approaches have progressed recently. Adding chemotherapy, radiotherapy, and immunotherapy to the basic surgical approach have been shown to have therapeutic benefit for esophageal cancer. This review describes the latest development of chemoradiotherapy, chemotherapy, and immunotherapy, which have contributed to the reduction in esophageal cancer growth and improved the survival of patients. Chemoradiation is a treatment option for resectable esophageal cancer to preserve the esophagus for patients who cannot tolerate surgery. Moreover, a combination of chemoradiotherapy and salvage surgery could extend the survival of patients. The effects of a triplet chemotherapy regimen are currently being verified in some Phase III studies for unresectable advanced/recurrent esophageal cancer. In addition, with the great promise of immune checkpoint inhibitors, strategies that incorporate the use of immunotherapy may shift from the metastatic setting to the neoadjuvant/adjuvant setting as a result of clinical trials. More precise comprehension of the molecular biology of esophageal cancer is expected to further control disease progression using multimodality treatments in the future.

Objectives: Dissection of the No. 11p lymph nodes is technically challenging because of variations in anatomical landmarks. This study aimed to determine the accuracy and efficacy of predicting the dorsal landmark of No. 11p lymph node using three-dimensional computed tomography simulation. Methods: Laparoscopic gastrectomy with No. 11p lymph node dissection with preoperative simulation using three-dimensional computed tomography was performed in 24 patients at our institution from October 2016 to May 2018. Initially, preoperative three-dimensional computed tomography findings with operative videos in these 24 patients were compared. The dorsal landmark was defined as an anatomical structure behind the splenic artery on preoperative three-dimensional computed tomography and operative videos. The dorsal landmark of No. 11p lymph node was divided into four types: (1) splenic vein type, (2) splenic vein and pancreas type, (3) pancreas type, and (4) unclear type. Then, to investigate the efficacy of three-dimensional computed tomography, we compared the clinical and pathological features and surgical outcomes of nine patients who underwent preoperative three-dimensional computed tomography simulation (three-dimensional computed tomography group) and 23 patients who did not undergo three-dimensional computed tomography simulation from August 2014 to September 2016 (non-three-dimensional computed tomography group). All procedures were performed by one surgeon certified by the Endoscopic Surgical Skill Qualification System in Japan. Results: The concordance rate between three-dimensional computed tomography and operative videos of the dorsal landmark using three-dimensional computed tomography was 79% (19/24). The operative time of No. 11p lymph node dissection was significantly shorter in the three-dimensional computed tomography group than in the non-three-dimensional computed tomography group (7.7 versus 15.8 min, P = 0.044). Conclusion: The accuracy of predicting the dorsal landmark of No. 11p lymph node using three-dimensional computed tomography was extremely high. Preoperative simulation with three-dimensional computed tomography was useful in shortening the operative time of No. 11p lymph node dissection.

This study was conducted to determine whether establishing the proximal resection line using India ink tattooing can ensure safe resection margins during totally laparoscopic distal gastrectomy. This retrospective study included 81 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer on the lower two-thirds of the stomach. The proximal resection margins were analyzed with respect to the macroscopic type and clinical T stage, and the intraoperative appearance of the stain on the serosa was classified by reviewing surgical videos. R0 resection was performed in all patients. The rates of the intended margins were 89.2% in patients without a frozen section diagnosis and 84.2% in patients with differentiated type lesions who underwent a frozen section diagnosis; however, most patients with undifferentiated advanced lesions failed to achieve the intended resection margins. Intraoperative appearance revealed that 85.2% of patients had localized type stains, whereas 11.1% had widespread-type stains. Our procedure to determine the proximal resection line in totally laparoscopic distal gastrectomy is oncologically safe. However, careful observation of the resected specimen and a frozen section analysis should be performed for undifferentiated advanced lesions.

Objective Laparoscopic endoscopic cooperative surgery for duodenal tumors (D-LECS) has been developed to prevent duodenal leakage by reinforcing the endoscopic submucosal dissection site. However, there has been no prospective trial showing the feasibility of D-LECS. Herein, we conducted a single-arm confirmatory trial to evaluate the safety of D-LECS for non-ampullary superficial duodenal neoplasms. Methods This prospective single-center single-arm confirmatory trial analyzed patients with non-ampullary superficial duodenal neoplasms who underwent D-LECS. The primary endpoint was the incidence of any postoperative leakage occurring on the duodenal wall within 1 month postoperatively. The planned sample size was 20 patients, considering a threshold of 28% and one-sided alpha value of 5%. Results Between January 2015 and September 2018, 20 eligible patients were enrolled. Sixteen tumors were located in the second portion, three in the first portion, and one in the third portion of the duodenal region. The median operative time was 225 (134-361) min and the median blood loss was 0 (0-150) mL. Curative resection (R0) with negative margins was achieved in 19 cases. One case of postoperative leakage and one case of bleeding of grade 2 according to the Clavien-Dindo classification were observed in this series. The median duration of postoperative hospital stay was 9 (5-12) days. No local recurrence was observed in any patient during the median follow-up of 15.0 (12.0-38.0) months. Conclusions This trial confirmed the safety and feasibility of D-LECS for non-ampullary superficial duodenal neoplasms with respect to the low incidence of postoperative duodenal leakage.

Background/aim To investigate the outcomes of laparoscopic surgery in colorectal cancer patients with dialysis. Patients and methods Fourteen dialysis (dialysis group) and 567 non-dialysis (non-dialysis group) patients who underwent laparoscopic and open surgery for colorectal cancer between April 2008 and December 2015 were included. Short-term and long-term outcomes were compared between the groups. A 1:2 propensity score matching was performed to compare long-term outcomes. Results All the dialysis patients underwent laparoscopic surgery. There were no significant differences in operative outcomes and postoperative short-term outcomes between the two groups. In the whole cohort, overall survival of dialysis patients was shorter than that in the non-dialysis ones (p=0.020), while disease-free survival did not differ between the two groups. After matching, there was no significant difference between the groups in overall or disease-free survival. Conclusion Laparoscopic colorectal cancer surgery for dialysis patients seems safe and feasible and associates with comparable short-term outcome and recurrence rate to non-dialysis patients.

Background: With the aging population, more patients are expected to receive antithrombotic treatment. Although many studies have investigated the perioperative management of antithrombotic therapy, few have targeted gastrectomy. Hence, the safety of gastrectomy for patients receiving antithrombotic agents remains unclear. This retrospective cohort study sought to compare outcomes between patients who did and did not receive antithrombotic agents.Methods: This single-center retrospective cohort study included 548 patients who underwent gastrectomy for primary gastric adenocarcinoma from January 2011 to December 2019. Patients were subsequently classified into two groups according to whether they received antithrombotic therapy (n = 121) or not (n = 427), after which surgical outcomes were compared. Propensity score analysis was performed based on age, sex, body mass index, open versus laparoscopic surgery, and total versus distal gastrectomy. After propensity score matching, 121 patients were included in each group.Results: Among the entire cohort, receiving antithrombotic therapy group was significantly older than those who did not (age ≥ 75 years, 48% vs. 33%; p ≤ 0.0001). Those receiving antithrombotic therapy had significantly higher postoperative complication rates than those who did not (33.1% vs. 23.9%; p = 0.046). After matching, no significant difference in the postoperative complication rate was observed between both groups.Conclusion: Despite having a high risk for postoperative complications, patients receiving antithrombotic therapy can safely undergo gastric resection.

Background Lateral pelvic lymph node metastasis impairs the oncological outcomes of patients with rectal cancer. Although lateral pelvic lymph node dissection (LLND) might be an effective procedure for such patients, the associated risk factors for postoperative complications are unknown. Patients and methods The operative outcomes of 21 patients undergoing unilateral LLND and 26 patients undergoing bilateral LLND for rectal cancer were compared. The risk factors for complications were evaluated using a logistic regression model. Results Univariate and multivariate analyses revealed that a longer operative time (≥480 min) was the most important risk factor for grade II or more postoperative complications according to the Clavien-Dindo classification (odds ratio=6.58; 95% confidence interval=1.35-32.1; p=0.020). A bilateral procedure was not a significant risk factor for postoperative complications. Conclusion Surgeons should make efforts to shorten the operative time to reduce the risk of postoperative complications.

Recent advances in treatment for esophageal cancer have improved prognosis after esophagectomy, but they have led to an increased incidence of gastric conduit cancer. In most gastric conduit cancer patients who underwent retrosternal reconstruction, median sternotomy is performed, which is associated with a risk of postoperative bleeding and osteomyelitis; pain often negatively affects respiration. To avoid these problems, we developed thoracoscopic retrosternal gastric conduit resection in the supine position (TRGR-S) as new procedure. Methods We performed the first case of TRGR-S for a 75-year-old male with retrosternal gastric conduit cancer. He was placed in the supine position. Four ports were placed in the left chest wall. The gastric conduit was separated from the epicardium, sternum, and left brachiocephalic vein. Due to adhesions between the gastric tube and the right pleura, combined resection of the right pleura was performed. Next, pediculated jejunal reconstruction via the presternal route was performed. Results Because there were few adhesions in the left thoracic cavity, this approach provided safety and a good surgical view, and it was easy to recognize the landmark including epicardium, sternum, and left brachiocephalic vein leading to appropriate resection of the tissue. Furthermore, there were few restrictions on the operative angle for the forceps and operability was quite ergonomic. Moreover, the lungs can be noninvasively contracted via an artificial pneumothorax. The pathological diagnosis was signet ring cell carcinoma (pT1b, pN0, M0, pStage I), indicating R0 resection. There were no post-operative complications. Conclusion This approach does not require sternotomy, so it has less risk of postoperative bleeding and osteomyelitis. Due to fewer adhesions, this approach is safe and provides a good surgical view. TRGR-S is a safe, ergonomic, and reliable procedure for resection of retrosternal gastric conduit cancer. Video This is the video of the operation ‘TRGR-S’, which is the new procedure for the gastric conduit cancer. https://www.dropbox.com/s/2whnekgp73hw1lz/video%20for%20ISDE2020.mov?dl=0.

Granulocyte-colony stimulating factor (G-CSF) producing tumor is one type of growth factor producing tumor that induces leukocytosis. On the other hand, adenocarcinoma with enteroblastic differentiation disease is known as α-fetprotein (AFP), glypican3, and Sal-like protein 4 (SALL4) producing tumor. We report a first case of G-CSF producing esophageal cancer with enteroblastic differentiation which has never been reported in the world. Methods [Case presentation]: A fifty-six year-old man was admitted to our hospital to treat esophageal carcinoma. His body temperature was elevated. Blood biochemistry tests showed leukocytosis (WBC 14000/μl). Gastroscopy revealed a 10-cm diameter, superficial elevated lesion in the lower thoracic esophagus. Biopsy findings indicated a diagnosis of adenocarcinoma. No distant metastasis, but right subclavian and para esophageal lymph nodes swelling were identified via computed tomography. Thus, we planned neo adjuvant chemotherapy (NAC) (5-FU 800 mg/m2 plus Cisplatin 80 mg/m2) before surgical resection. The patient’s hyperthermia and leukocytosis improved by not antibiotics but NAC. Therefore, we suspected G-CSF producing tumor. Results The serum level of G-CSF was markedly elevated at 133 pg/ml (normal range, Additionally, PET/CT showed abnormally high uptake of (18) F-FDG not only by the tumor itself, but also diffusely throughout the bone marrow. The patient underwent minimally invasive esophagectomy in the prone position with two-field lymph node dissection. Immunohistochemical studies showed G-CSF producing adenocarcinoma with enteroblastic differentiation (AFP negative, glypican3 and SALL4 positive). Pathological stage was pT2N0M0, stageII. After resection, improvement of hyperthermia, leukocytosis, and serum level of G-CSF can be seen. Findings of (18) F-FDG throughout the bone marrow were also disappeared. Conclusion We experienced an extremely rare case of G-CSF producing, esophageal adenocarcinoma with enteroblastic differentiation.

Procedure of minimally invasive esophagectomy in prone position (Conventional prone-MIE) is standardized leading to feasible short outcomes. On the other hand, robot assisted MIE (Robotic MIE) was approved as Japanese health insurance treatment since 2018. Especially, reduction of recurrent laryngeal nerve (RLN) palsy leading to aspiration pneumonia is expected for Robotic MIE. The purpose of this study is to clarify the potential of Robotic MIE for improvement of short outcomes. Methods Twenty-four Robotic MIEs in introduction period since 2018 and 128 Conventional prone-MIEs in established period since 2015 from all of the 375 cases were compared using propensity score matching. Results Operative times in both entire and thoracic procedures were significantly longer in Robotic MIE. There were no significant differences between two groups in the number of harvested lymph nodes, amount of the blood loss, left RLN palsy rate (13% vs 14%, > Clavien-Dindo classification: C-D grade I), right RLN palsy rate (4% vs 8%, > C-D grade I), and pneumonia rate (7% vs 7%, > C-D grade II). Conclusion Short outcomes of Robotic MIE in introduction period were not inferior to those of Conventional prone-MIE in established period. More improvement is expected for Robotic MIE via learning curve. In conclusion, Robotic MIE has hidden potential to outstrip Conventional prone-MIE in outcomes. Video https://www.dropbox.com/s/7byc8nsqupgetsp/2020%20ISDE%20movie%20for%20submission.wmv?dl=0.

Reconstruction routes after esophagectomy include posterior mediastinal, retrosternal, and subcutaneous route. We have performed posterior mediastinal reconstruction, but this route has higher risks of gastro-tracheal fistula and hiatal hernia. To avoid these complications, now we take the retrosternal route as our first choice by creating the route laparoscopically before pulling-up gastric conduit. We report the successful and safe procedure. Methods We performed laparoscopic creation of retrosternal route in 13 thoracoscopic/robot-assisted minimally invasive esophagectomies since August 2019. In practice, a peritoneal incision at the dorsal side of the xiphoid process is started. Then, via 12 mm port on the surgeon's right hand inserted slightly to the right and cranial side of the umbilical camera port, we dissect loose connective tissues from the caudal side to the cranial side behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route and pleural injury rate during the procedure was examined. Results Thirteen cases were divided into two groups as early period group (seven cases) and later period group (six cases) respectively. The time required for route creation was 31.3 minutes(average) in the early period group, and 16.7 minutes in the later period group. There is tendency towards faster in later period group than in earlier one. The overall pleural injury rate was 15% (2 of 13 cases). Although it was difficult to determine the amount of bleeding, it was visually observed that the bleeding during the route creation was lower in the later period group than in the early period group. Conclusion The entire laparoscopic procedure to create retrosternal route makes it easier to observe and preserve the pleura and internal thoracic vessels compared to blind blunt dissection. As a conclusion, laparoscopic creation of retrosternal route for gastric conduit reconstruction is safe and feasible with good learning curve. Video https://www.dropbox.com/sh/p0wc3x46n33jp23/AADwiWHYIEUNUX6qZsERVIOga?dl=0.

Introduction Recently, sarcopenia has been reported to be associated with poor postoperative outcomes in various cancers. However, its clinical significance for rectal cancer patients undergoing neoadjuvant chemoradiotherapy (NACRT) followed by surgery remains unknown. Materials and methods This study included 46 patients with locally advanced rectal cancer who underwent curative surgery after NACRT. Sarcopenia was assessed by measuring the cross-sectional psoas muscle area (PA) at L3 and total bilateral psoas muscle volume (PV). Patients with a lower PV or PA value than the median were assigned to the sarcopenia group while others were assigned to the non-sarcopenia group. Clinical outcomes were then compared between groups. Results The sarcopenia group included 22 patients. The rate of overall postoperative complications did not differ between groups. Five-year relapse-free survival (RFS) was significantly lower in the sarcopenia group when sarcopenia was assessed by PV after NACRT (44.0% vs. 82.6%, P = 0.00494). In contrast, RFS did not differ between groups when sarcopenia was assessed by PA. Multivariable analysis identified PV after NACRT as the most significant risk factor for RFS (hazard ratio 4.00; 95% CI 1.27–12.66, P = 0.018). Conclusion Sarcopenia assessed by total PV after NACRT may be an accurate and reliable predictor of poor oncological outcomes in rectal cancer patients.

INTRODUCTION Laparoscopic surgery has become popular for colorectal cancer treatment in recent years. However, its success rate even among high-risk patients remains debatable. The present study aims to compare the short- and long-term outcomes between laparoscopic and open surgeries in the American Society of Anesthesiologists (ASA) classes 3 and 4 patients with colorectal cancer. METHODS This was a single-center, retrospective, cohort study performed at a university hospital, with 78 patients suffering from colorectal cancer who underwent surgery in ASA classes 3 and 4 as respondents. Patient and tumor characteristics, operative outcomes, and prognoses were factors compared between the open and laparoscopic groups. RESULTS Compared with the open group, laparoscopic group had longer operation time (median 287.5 vs 204.5 minutes, P = .001), less operative blood loss (median 40 vs 240 mL, P = .020), and fewer postoperative complications (24% vs 55%, P = .011). In addition, operative approach (open vs laparoscopic) served as an independent factor for the occurrence of postoperative complications [HR = 3.963 (1.344-12.269), P = .013]. In terms of overall survival and recurrence-free survival (P = .171 and .087, respectively), no significant difference was found between the two groups. CONCLUSION Laparoscopic surgery is thus associated with more favorable short-time outcomes and could be adopted as treatment even for colorectal cancer ASA class 3 and 4 patients.

Skeletal muscle loss after gastrectomy can worsen patients’ quality of life and prognosis. Laparoscopic gastrectomy is less invasive than open gastrectomy and has become commonly performed. However, the degree of skeletal muscle loss after laparoscopic procedures remains unclear. We herein report the degree and risk factors of psoas muscle loss after laparoscopic gastrectomy for gastric cancer. The total psoas area (TPA) on computed tomography of 50 consecutive patients who underwent laparoscopic total gastrectomy (LTG) and 167 consecutive patients who underwent laparoscopic distal gastrectomy (LDG) for gastric cancer was retrospectively evaluated at one postoperative year. The TPA loss was compared between LDG and LTG and univariate and multivariate analyses were performed to identify the risk factors for TPA loss > 10%. The median TPA decrease rate was 5.9% in the LDG group and 15.6% in the LTG group. LTG and postoperative respiratory complications were independent factors associated with a severe TPA loss of > 10%. In the LTG group, no independent factors were identified in a multivariate analysis. In the LDG group, postoperative complications were identified as an independent risk factor for TPA loss > 10%. Laparoscopic gastrectomy leads to postoperative TPA loss, especially in patients who underwent LTG and had postoperative respiratory complications. Postoperative complications after LDG were also a risk factor for TPA loss.

Three-dimensional (3-D) high-definition (HD) stereovision and two-dimensional (2-D) ultra-high-resolution (4K) monitors have recently become available for laparoscopic surgery. The aim of this study was to compare laparoscopic performance between inexperienced participants using 3-D/HD and 2-D/4K monitors and those using conventional 2-D/HD monitors.The study enrolled 66 participants with no previous surgical experience or medical training. They were randomly divided into three equal groups, each using a different type of monitor (2-D/HD, 2-D/4K, or 3-D/HD), to perform three phantom tasks using a laparoscopic simulator: Task 1, touching markers on a non-flat surface; Task 2, bimanual peg transfer; and Task 3, passing a straight rod through a loop. Each task was performed three times. The performance scores (operative time, path length of the forceps, and technical errors) were compared for each monitor type and by age group ( 30 vs. 30 years).For all three tasks, scores using the 3-D monitor were significantly better than those using either 2-D monitor, with no difference between the 2-D/4K and 2-D/HD monitors. Using the 2-D monitors, the performance of Task 3 by the participants 30 years was worse than that by the younger participants; however, there was no difference between the age groups when using the 3-D monitor.Participants with no prior experience using a 3-D monitor showed better laparoscopic performance than those using 2-D monitors, even with 4K resolution. This improvement was more marked in older participants, suggesting a greater loss of depth perception in a 2-D environment.

Oral health is associated with various diseases, including cancer. Tooth loss is a simple and objective index of oral health. The purpose of this study was to investigate the association between preoperative tooth loss and esophageal cancer prognosis after esophagectomy. This study included 191 patients who underwent esophagectomy for esophageal cancer after perioperative dental evaluation and oral care at Kobe University Hospital from April 2011 to March 2016. Patients were divided into two groups: Group A (tooth loss

Introduction Recent advances in the treatment for esophageal cancer have improved the prognosis after esophagectomy, but they have led to an increased incidence of gastric tube cancer. In most patients who underwent retrosternal reconstruction, median sternotomy is performed; it is associated with a risk of postoperative bleeding and osteomyelitis, and pain often negatively affects respiration. Here, we report the first case of thoracoscopic retrosternal gastric conduit resection in the supine position (TRGR-S). Materials and surgical technique A 75-year-old male patient was placed in the supine position. Four ports were placed in the left chest wall. The gastric tube was separated from the epicardium, sternum, and left brachiocephalic vein. Because of adhesions between the gastric tube and the right pleura, combined resection of the right pleura was performed. The dorsal side of the gastric tube was dissected before the ventral side, enabling the gastric tube to be suspended from the back of the sternum and, thus, making it easier to expose the surgical field. Next, pedicled jejunal reconstruction via the presternal route was performed. There were no postoperative complications. The pathological diagnosis was signet ring cell carcinoma (pT1b, pN0, M0, pStage I), indicating R0 resection. Discussion TRGR-S does not require sternotomy, reducing the risk of postoperative bleeding and osteomyelitis. In the presence of adhesions, TRGR-S is safe and provides a good surgical view. It is also reliable procedure for resection of retrosternal gastric tube cancer, and it is ergonomic for surgeons.

Purpose Completion gastrectomy (CG) is a common procedure for remnant gastric cancer (RGC). However, partial gastrectomy for gastric cancer has several benefits compared to total gastrectomy in terms of the quality of life. In this study, we evaluated the feasibility and advantage of subtotal resection of the remnant stomach (SR) for clinical stage IA RGC. Methods A total of 43 patients who underwent gastrectomy for clinical stage IA RGC were included. CG and SR were performed on 27 (62.8%) and 16 patients (37.2%), respectively. The short- and long-term outcomes, including the nutritional status, after CG and SR for clinical stage IA RGC were compared between the two groups. Results There were no significant differences in pathological stage or incidence of postoperative complications between the two groups. The decrease in body weight, body mass index, and serum albumin level was significantly lower in the SR group than in the CG group (P

Retroperitoneal cellular angiofibroma (RCA) is very rare, and the optimal treatment for RCA has not been established. We report the case of RCA in a 58-year-old man who underwent curative laparoscopy-assisted resection. Preoperative computed tomography showed heterogeneous enhancement of the 7 cm diameter tumor in the pelvis. A smaller (2.3 cm) mass was also detected in the small intestine. The preoperative diagnosis was peritoneal metastasis of the gastrointestinal tumor of the small intestine. The pelvic tumor was laparoscopically mobilized from the rectum, the left ureter, and the left internal iliac vessels. The tumor was excised by detachment from the urinary bladder in laparotomy. The pathological diagnosis was RCA. The tumor had not recurred by the 1-year follow-up. The laparoscopic approach thus might be useful for resection of RCA.

Purpose: The surgical indication of laparoscopic surgery for pT4 colon cancer remains to be established because only a few studies have investigated the short- and long-term outcomes of laparoscopic surgery for them to date. Therefore, we aimed to elucidate the validity of laparoscopic surgery for them. Methods: We retrospectively analyzed 81 patients with pT4 colon cancer who underwent surgical resection with a curative intent at Kobe University Hospital from January 2007 to December 2015. The short- and long-term outcomes were compared between the propensity score–matched patients who underwent laparoscopic colectomy (LAP group, n = 25) and those who underwent open colectomy (OP group, n = 25). Results: Intraoperative blood loss was significantly less in the LAP group than in the OP group (p = 0.029). Operative time, R0 resection rate, and morbidity did not significantly differ between the two groups. The 5-year overall survival (OS) and the 5-year recurrence-free survival (RFS) did not significantly differ between the propensity score–matched groups. Univariate and multivariate analyses of the entire cohort showed the surgical approach (LAP vs OP) selected was not a significant prognostic factor for OS or RFS. Conclusions: The short and the long-term outcomes were similar between the LAP and OP groups. Laparoscopic surgery might be a safe and feasible option for pT4 colon cancer patients.

Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal cancer. However, it is one of the most invasive procedures with high morbidity. To reduce invasiveness, minimally invasive esophagectomy (MIE), which includes thoracoscopic, laparoscopic, mediastinoscopic, and robotic surgery, is becoming popular worldwide. Thoracoscopic esophagectomy in the prone position is ergonomic for the surgeon and has better perioperative arterial oxygen pressure/fraction of inspired oxygen (P/F) ratio. Thoracoscopic esophagectomy in the left decubitus position is easy to introduce because it is similar to standard right posterolateral open esophagectomy (OE) in position. It has a relatively short operative time. Laparoscopic approach could potentially have a substantial effect on pneumonia prevention under the condition of thoracotomy. Mediastinoscopic surgery has the potential to reduce pulmonary complications because it can avoid a transthoracic procedure. In robotic surgery, in the future, less recurrent laryngeal nerve palsy will be expected as a result of polyarticular fine maneuvering without human tremors. In studies comparing MIE with OE, mediastinoscopic surgery and robotic surgery are usually not included; these studies show that MIE has a longer operative time and less blood loss than OE. MIE is particularly beneficial in reducing postoperative respiratory complications such as atelectasis, despite no dramatic decrease in pneumonia. Reoperation might occur more frequently with MIE. There is no significant difference in mortality rate between MIE and OE. It is important to recognize that the advantages of MIE, particularly “less invasiveness”, can be of benefit at facilities with experienced medical personnel.

There has been an increase in the percentage of elderly patients with colorectal cancer (CRC). However, few studies have reported the short- and long-term outcomes of laparoscopic surgery for elderly patients with CRC aged over 80 years. This study included 529 patients who underwent laparoscopic resection for clinical stage 0–III CRC at Kobe University Hospital between January 2010 and December 2018. Propensity score matching (PSM) was used to create balanced cohorts of the elderly (aged ≥ 80, n = 113) and the non-elderly (aged

Despite the recent development of chemotherapeutic agents, the prognosis of colorectal cancer (CRC) patients with peritoneal dissemination (PD) remains poor. The tumor immune microenvironment (TIME) has drawn attention as a key contributing factor of tumor progression. Of TIME components, myeloid‑derived suppressor cells (MDSCs) are considered to play a responsible role in the immunosuppressive characteristics of the TIME. MDSCs are classified into two major subsets: Monocytic MDSCs (M‑MDSCs) and polymorphonuclear MDSCs (PMN‑MDSCs). Therefore, we hypothesize that MDSCs would play important roles in the PD‑relevant TIME and PD progression. To address this hypothesis, we established PD mouse models. As the PD nodules consisted scarcely of immune cells, we focused on the peritoneal cavity, but not PD nodule, to evaluate the PD‑relevant TIME. As a result, intraperitoneal PMN‑MDSCs were found to be substantially increased in association with PD progression. Based on these results, we phenotypically and functionally verified the usefulness of CD244 for identifying PMN‑MDSCs. In addition, the concentrations of interleukin (IL)‑6 and granulocyte‑colony stimulating factor (G‑CSF) were significantly increased in the peritoneal cavity, both of which were produced by the tumors and thought to contribute to the increases in the PMN‑MDSCs. In vivo depletion of the PMN‑MDSCs by anti‑Ly6G monoclonal antibody (mAb) significantly inhibited the PD progression and reverted CD4+ and CD8+ T cells in the peritoneal cavity and the peripheral blood. Collectively, these results suggest that the targeted therapy for PMN‑MDSCs would provide not only new therapeutic value but also a novel strategy to synergize with T‑cell‑based immunotherapy for CRC‑derived PD.

INTRODUCTION The closure of the appendiceal stump is a crucial part of a laparoscopic appendectomy, and an endoloop or endostapler is generally used. The endoloop can be more cost effective than the endostapler. However, reports have shown that the endoloop has a higher postoperative abdominal abscess rate than the endostapler in complicated appendicitis. At our institution, we perform a purse-string suture after ligating by endoloop to reduce postoperative abdominal abscess risk. This study aimed to clarify whether this method could reduce the incidence of postoperative abdominal abscess compared with the endostapler. METHODS Patients with acute appendicitis were classified into the purse-string suture group (n = 149) and the endostapler group (n = 82). Postoperative outcomes were compared after propensity score matching (n = 47). RESULTS No significant difference was found between the two groups in terms of the patient characteristics and postoperative complications, including abdominal abscess. However, the purse-string suture group had more drain placement and a shorter hospital stay than the endostapler group (P = .04 and P = .02, respectively). In patients with complicated appendicitis, there was less drain placement and a shorter hospital stay in the purse-string suture group than in the endostapler group (P

We conducted a prospective clinical control study to identify the best imaging technology among three-dimensional (3-D) high-definition (HD) stereovision and two-dimensional (2-D) ultra-high-resolution (4 K) technology and confirm their effects on surgical outcomes of laparoscopic gastrectomy for gastric cancer. From April 2018 to August 2019, 50 patients were randomly classified into two groups based on the imaging technology (3-D/HD group = 25, 2-D/4 K = 25). After excluding eight patients based on laparoscopic findings, 42 patients were analyzed (3-D/HD group = 21, 2-D/4 K = 21). The primary endpoint was the operative time; the secondary endpoints were blood loss, postoperative infectious complications, and postoperative hospital stay. The patients’ backgrounds were similar (sex, age, body mass index [BMI], stage, procedure, and extent of lymph node dissection). There were no significant differences in operative time (252 vs. 238 min, P = 0.70), total blood loss, postoperative infectious complications, and postoperative hospital stay between the two groups. However, video analysis of surgeries revealed a significantly shortened median operative time (18 vs. 25 min, P = 0.04) in the suturing step with 3-D/HD; the median number of camera cleaning procedures during suprapancreatic lymph node dissection was significantly lower with 2-D/4 K than with 3-D/HD (n = 4.4 vs. 2.8, P = 0.02). 3-D/HD and 2-D/4 K laparoscopic radical gastrectomies provide similar surgical outcomes. However, the 3-D monitor reduces suturing time during reconstruction, while the 4 K monitor reduces the number of camera cleaning procedures during lymphadenectomy. Registered in the University Hospital Medical Information Network Clinical Trials Registry (identification number 000029227).

OBJECTIVE To elucidate the association between preoperative hemoglobin A1c (HbA1c) levels and short-term outcomes after oncologic esophagectomy. SUMMARY BACKGROUND DATA Although diabetes mellitus (DM) is associated with an increased risk of postoperative morbidity in several types of surgery, the association of DM with short-term outcomes after esophagectomy has shown conflicting results. METHODS We analyzed 15801 patients who underwent oncologic esophagectomy between 2015 and 2017 from the National Clinical Database. We evaluated the associations between preoperative HbA1c levels and short-term outcomes, using multivariable logistic regression and restricted cubic spline models. RESULTS The cohort included 12074, 1361, 1097, 909, and 360 patients with HbA1c levels of ≤5.9%, 6.0%-6.4%, 6.5%-6.9%, 7.0%-7.9%, and ≥8.0%, respectively. There were value-dependent associations between HbA1c values and odds ratios (ORs) for anastomotic leakage (AL), surgical site infections (SSIs), pneumonia, and composite outcomes. Compared with the HbA1c category of ≤5.9%, the categories of 7.0%-7.9% and ≥8.0% were at higher risk for AL (P

BACKGROUND Omentoplasty is sometimes used to prevent perineal wound complications after abdominoperineal resection (APR) following neoadjuvant chemoradiotherapy (NACRT). However, recent studies have raised some controversy about its clinical benefit. PATIENTS AND METHODS Outcomes for rectal cancer patients who received APR after NACRT were retrospectively compared between the groups with omentoplasty (n=28) and without omentoplasty (n=14). RESULTS The operative time was significantly longer in the omentoplasty group (575 vs. 404 min, p