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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.

Summary: Background: Billroth Ⅰ (BⅠ) reconstruction and Roux-en-Y (RY) reconstruction are both commonly performed after distal gastrectomy (DG). We conducted a retrospective study to evaluate which is the better option. Methods: Included in our study were 162 patients who, between April 2011 and October 2015, underwent DG followed by BⅠ reconstruction (n = 93) or RY reconstruction (n = 69). All patients were followed up for at least 1 year. We compared perioperative outcomes, postoperative complications, gastrointestinal (GI) symptoms, endoscopic findings, and nutritional status between the 2 groups of patients. Results: Patient characteristics did not differ between the 2 groups, with the exception of the incidence of gastric body tumors, which was significantly higher in the RY group (73.9% vs. 19.4%; p

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.

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...

Magnetoencephalographic (MEG) studies have revealed enhancement of neural activity of the N1m response of auditory evoked fields in long-term trained musicians, reflecting neuroplastic modification of the representation of the auditory cortex. In contrast, the amplitude of the P2 response of auditory evoked potentials is modified by musical experience, with no alteration of N1. Here, we performed a comprehensive MEG study using stimulation of successive musical-instrument tones to examine how the neural activities of different MEG responses are modified in long-term experienced musicians who commenced musical lessons at ages of ∼5 years and had continued to practice. The dipole moment of the P2m response occurring at 160–180 ms was significantly enlarged in musicians compared with that in individuals who had not received musical lessons. The enlargement was found for the dipole moment of N1m occurring at 100–120 ms in a restricted condition but not for the moment of P1m at 50–60 ms. Furthermore, the dipole moment of P2m for successive stimuli, normalized by the moment for the first stimulus, was significantly larger for chord tones than single tones and was significantly larger in the musicians than controls. These results suggest that the P2m response is susceptible to be modified by musical training in a period of neural maturation, with a short refractory period of neural activity for the auditory input of composite tones. The P2m activity may be specialized to the processing of multifrequency sounds, such as musical timbre consisting of abundant harmonics.