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We present a case of 63-year-old male patient who underwent subtotal stomach-preserving pancreaticoduodenectomy for pancreatic neuroendocrine tumor (NET) G2. He had been followed up for three years and had no signs of recurrence postoperatively. Five years after surgery, he had abdominal pain. Upper gastrointestinal endoscopy showed a gastric tumor. Laparoscopic distal gastrectomy was performed without postoperative complications. The histopathological findings of the resected specimen were consistent with mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN). The immunohistochemical characteristics of the gastric MiNEN lesion were different from those of the pancreatic NET lesion resected five years ago, suggesting that those lesions were heterochronous.

Background: Circulating tumor cells (CTCs) have been shown to be heterogeneous. Focusing on the epithelial-mesenchymal transition and perioperative kinetics, we evaluated CTCs with mesenchymal phenotypes as a potential prognostic biomarker for patients with gastric cancer., Methods: Peripheral blood was collected from 54 patients with gastric cancer before surgery and at 1 week and 1 month after surgery. CTCs were enriched using density-gradient centrifugation and magnetic-activated cell sorting (negative selection). Cell suspensions were characterized by multi-immunofluorescence staining against cytokeratin and N-cadherin, and by 4',6'-diamidino-2-phenyldole staining., Results: CTCs were detected in five patients (17%) with early cancer and 14 patients (56%) with advanced cancer (p < 0.05). In our system, N-cadherin, but not cytokeratin, was expressed in the CTCs of 90% (19/21) of patients. Postoperative recurrence was detected in 10 patients, all of whom had N-cadherin+/cytokeratin-/CD45- CTCs preoperatively. Regarding perioperative kinetics, we divided patients into three risk groups: a high-risk group, with one or more preoperative CTCs and increased CTCs postoperatively; an intermediate-risk group, with one or more preoperative CTCs and decreased CTCs postoperatively; and a low-risk group, with no preoperative CTCs. Recurrence rates were 57% (4/7), 33% (4/12), and 6% (2/35), respectively. The relapse-free survival rate was lower in patients at high risk versus those at intermediate or low risk, for all patients (p = 0.00024) and in patients with advanced cancer (p = 0.00103)., Conclusions: N-cadherin is a highly useful marker to detect CTCs lacking cytokeratin, and the perioperative kinetics of CTC numbers is beneficial in risk stratification for survival in patients with gastric cancer.

Introduction: To investigate the oncological feasibility and technical safety of laparoscopic gastrectomy with D2 lymphadenectomy for advanced gastric cancer., Methods: A total of 186 advanced gastric cancer patients treated by gastrectomy with D2 lymphadenectomy were eligible for inclusion including those with invasion into the muscularis propria, subserosa, and serosa without involvement of other organs, and stages N0-2 and M0. We retrospectively compared the short-term and long-term outcomes between laparoscopic gastrectomy and open gastrectomy., Results: We analyzed short-term outcomes by comparing distal with total gastrectomy results. We found no significant difference for distal gastrectomy for postoperative morbidity [laparoscopic vs. open: n=4 (4.6%) vs. n=1 (3.6%); P=1.00]. We also found no significant difference in postoperative morbidity for total gastrectomy [laparoscopic vs. open: n=2 (4.0%) vs. n=1 (4.0%); P=1.00]. No deaths occurred in any group.The entire cohort analysis revealed no statistically significant differences in overall-free or recurrence-free survival between the laparoscopic and open groups. For overall survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.29 and 0.27, respectively), and for pathologic stage II or III (P=0.88 and 0.86, respectively). For recurrence-free survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.63 and 0.60, respectively), and for pathologic stage II or III (P=0.98 and 0.72, respectively)., Conclusion: Laparscopic gastrectomy for advanced gastric cancer compared favorably with open gastrectomy regarding short-term and long-term outcomes.

Situs inversus totalis (SIT) is a rare congenital anomaly. Generally, laparoscopic surgery is difficult to perform in patients with SIT because of both the potential challenges associated with unexpected vascular anomalies and the lack of standardized strategy for handling such cases. This is the first report of laparoscopic total gastrectomy with lymph node dissection for advanced gastric cancer in a patient with SIT. A 79-year-old man with SIT was diagnosed with advanced gastric cancer. We performed laparoscopic total gastrectomy with modified D2 lymph node dissection (D2 without splenectomy) and esophagojejunal anastomosis using an overlap method involving retrocolic Roux-en-Y reconstruction. The total operating time was 232 min, and blood loss was 110 mL. There were no postoperative complications. In summary, laparoscopic total gastrectomy for gastric cancer can be performed safely, even in a patient with SIT., (© 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Laparoscopic partial gastrectomy is the standard surgical treatment for gastric gastrointestinal stromal tumor (GIST). However, to reduce gastric deformation, the tumor margins should be secured so as to minimize the size of the resection as much as possible. This is the report on the 3 laparoscopic resection techniques for gastric GIST depending upon the growth pattern and location of the tumor, and their results. We performed laparoscopic partial gastrectomy for 41 gastric GISTs between 2004 and 2012. Simple resection was used on exophytic or small GISTs. Seromuscular resection was used on exoendophytic (intramural) and relatively small endophytic tumors. Transgastric resection was used in cases of large endophytic tumors. We performed simple resection on 24 lesions (58.5%), seromuscular resection on 14 lesions (34.1%), and transgastric resection on 3 lesions (7.3%). There were no intraoperative complications. Postoperative complications included 1 case (2.5%) of bleeding from the staple line.

Laparoscopic gastrectomy has the advantage of early recovery at the initial phase after surgery. However, there are only few reports of mid- or long-term observations of patients' quality of life. In all, 254 Stage IA or IB [laparoscopy-assisted distal gastrectomy (LADG): 177, open distal gastrectomy (ODG): 77] patients were enrolled. Heart burn, diarrhea, abdominal pain, amount of food intake, and body weight of each patient were investigated at 1 month, 3 months, 6 months, and 1 year after surgery. Recovery of the amount of oral intake for the LADG group occurred earlier than for the ODG group; significant differences were seen at months 1 and 6 postoperatively. A significantly lower incidence of diarrhea was observed in the LADG group at months 6 and 12 postoperatively. Early recovery of the amount of food intake and fewer incidences of diarrhea were shown to have mid-term merits for postgastrectomy symptoms.

We successfully executed laparoscopic distal gastrectomy in two patients who had previously undergone coronary artery bypass grafting using the right gastroepiploic artery (RGEA). A laparoscopic distal gastrectomy preserving the RGEA graft with Roux-en-Y reconstruction was performed on two men, one 69 years of age and one 73 years of age. In both cases, the RGEA was used during coronary artery bypass grafting for the posterior descending branch. The laparoscopic approach helped avoid injury to the RGEA associated with laparotomy and retractor placement. In addition, the locations of ports necessary for laparoscopy were situated away from the RGEA graft and from adhesions resulting from bypass. Using typical laparoscopic settings, we were able to easily identify the grafted RGEA. Thus, laparoscopic distal gastrectomy is not only less invasive than open gastrectomy procedures, but it is also associated with a lower risk of injury to the RGEA graft., (© 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

Reduced port surgery (RPS), in which fewer ports are used than that in a conventional laparoscopic procedure, is becoming increasingly popular for various surgeries. However, the application of RPS to the field of gastrectomy is still underdeveloped. We started laparoscopy-assisted total gastrectomy through an umbilical port plus another 5 mm port (dual port laparoscopy-assisted total gastrectomy: DP-LATG) as an RPS for laparoscopy-assisted total gastrectomy (LATG). A SILS™ port was inserted into an umbilical incision, while another 5 mm port was inserted at the right flank region. We performed DP-LATG on ten early gastric cancer cases consecutively from May 2011 onwards, with the surgeries all performed by a single surgeon. The results of DP-LATG were compared with the resuls of ten conventional LATGs (C-LATGs) that were performed between March 2010 and April 2011. There were no significant differences in the mean operation time (DP-LATG, 253.0 ± 26.8 min; C-LATG, 235.5 ± 20.6 min; p = 0.119), mean blood loss (33.4 ± 23.7, 39.8 ± 60.4 mL, p = 0.759), and number of lymph nodes dissected (31.6 ± 12.3, 40.9 ± 18.7, p = 0.205). There were no intraoperative complications, there was no need for additional ports, and there were no conversions to open surgery nor postoperative complications in the DP-LATG cases. We successfully and safely performed DP-LATG without incurring any notable differences from C-LATG in terms of operation time, blood loss, and number of lymph nodes dissected.

Introduction: We investigated potential advantages of laparoscopy-assisted distal gastrectomy (LADG) in high-risk gastric cancer patients. We examined the differences among various risk groups by comparing the incidence of postoperative complications and invasiveness of LADG with those of open distal gastrectomy (ODG) based on the American Society of Anesthesiologists (ASA) criteria., Methods: A total of 639 patients with stage IA or IB gastric cancer were included in this study. ODG was performed between 2003 and 2005, and LADG was performed between 2006 and 2011., Results: The incidence of postoperative complications in the LADG group (ASA1, 5.6%; ASA2, 3.8%; and ASA3, 5.7%) was significantly lower than that in the ODG group in all the ASA classes (ASA1, 16.9%; ASA2, 12.5%; and ASA3, 20%). Changes in the pain scores, body temperatures and blood analyses revealed that LADG was less invasive than ODG in all ASA classes. However, as the ASA class increased, the less invasive nature of LADG decreased., Conclusion: LADG may be less invasive than ODG, even in ASA3 patients. Hence, LADG may reduce the incidence of postoperative complications in ASA1, ASA2, and ASA3 patients., (© 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.)

It is unknown whether reduced-port gastrectomy has a less invasive nature than conventional laparoscopy-assisted distal gastrectomy (C-LADG). So we compared 30 cases of dual-port laparoscopy-assisted distal gastrectomy (DP-LADG; using an umbilical port plus a right flank 5-mm port) as a reduced-port gastrectomy with 30 cases of C-LADG alternately performed by a single surgeon. No significant differences were observed in blood loss, intraoperative complications, the number of dissected lymph nodes, postoperative complications, the day of first defecation, analgesic agents required, changes in body temperature, heart rate, white blood cell count, serum albumin level, or lymphocyte count between the 2 groups. The amounts of oral intake in the DP-LADG group were significantly higher on postoperative days 9 and 10. We concluded that the amount of oral intake in the DP-LADG group was superior to that in the C-LADG group; however, no other evidence of DP-LADG being less invasive than C-LADG was obtained.

Purpose: We performed laparoscopic gastrectomy using an umbilical port in addition with one other port (dual-ports laparoscopy-assisted distal gastrectomy, DP-LADG) since December 2009. We describe a retrospective study to evaluate the possibility of DP-LADG compared with conventional LADG (C-LADG)., Methods: The indication for DP-LADG was preoperative clinical Stage IA gastric cancer. We compared 20 patients who underwent DP-LADG with 24 patients of clinical Stage IA patients who underwent C-LADG., Results: The mean operation time was significantly longer for DP-LADG (250.5 min) than for C-LADG (197.5 min); however, the mean operation time for the last 5 patients undergoing DP-LADG (209 ± 31.1 min) was almost the same as that for C-LADG. There were no significant differences between DP-LADG and C-LADG in terms of blood loss, number of lymph nodes dissected, rates of conversion to open surgery, postoperative complications, and length of postoperative hospital stay., Conclusions: DP-LADG is technically feasible.

Purpose: To compare the effects of obesity on laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG)., Methods: A retrospective study was conducted on 249 patients, who underwent LADG and 224 patients who underwent ODG., Results: The regression coefficient of the primary regression equation between operative time and body mass index (BMI) for LADG was greater than ODG; and between blood loss and BMI for LADG was almost the same as ODG. In overweight patients (BMI ≥25), no significant difference was seen between LADG and ODG regarding postoperative complications, and the benefits of the less-invasive nature of LADG were also seen in some parameters., Conclusion: Obesity-associated difficulties are more while performing LADG than during ODG; however, the influence of obesity on LADG decreases with surgical experience. Moreover, even in overweight patients, the benefits of the less-invasive nature of LADG still remain, but the degree of the benefits is smaller than that in nonobese patients.

Background: There have been few case reports of 3rd-line chemotherapy for gastric cancer. So we reported the results of CPT-11 therapy as the 3rd-line chemotherapy for gastric cancer., Patients and Methods: 549 cases underwent gastrectomy from Jan. 2004 to Aug. 2007 in our hospital. In 76 of these cases, which underwent non-curative resection or evidenced a recurrence until July 2009, were analyzed in this study. CPT -11 3rd-line chemotherapy was administered to 11 cases., Results: The mean survival time of non-curative or recurrent cases was 16.9 months. Mean survival times of the non-chemotherapy group, the group administered only 1st-line chemotherapy, the group administered until 3rd-line chemotherapy, the group administered 3rd-line chemotherapy were 7.9 , 11.3 , 21.4 and 28.9 months, respectively(p=0.000 ). Adverse effects occurred in 90.9% of 3rd-line CPT-11, however, all cases were categorized in GradeI., Conclusion: The group administered 3rd-line chemotherapy survived the longest. It is probably correct to administer 3rd-line chemotherapy, if the patient maintains a good performance status.

Purpose: This study assessed the acceptability of laparoscopy-assisted gastrectomy (LAG) for patients with previous intra-abdominal surgery (PIS)., Methods: Sixteen patients with PIS had undergone LAG; 9 of laparoscopy-assisted distal gastrectomy, 2 of laparoscopy-assisted total gastrectomy and 5 of laparoscopy-assisted remnant gastrectomy (LARG). Difficulty, safety, and accuracy of LAG were compared between patients with PIS and with no previous intra-abdominal surgery. An independent group of 11 cases with open remnant gastrectomy (ORG) was used for comparing with LARG., Results: No significant difference was observed in conversion rate, intraoperative complication, operation time, blood loss, dissected lymph nodes, postoperative complications and hospital stay between PIS, and no PIS. There was no significant difference in operative time, dissected lymph nodes, and postoperative complications between LARG and ORG. Blood loss was lesser and postoperative hospital stay was shorter in LARG than in ORG., Conclusion: LAG for patients with PIS is acceptable.

Background: Because only a few studies have been performed to date on the invasiveness of laparoscopy-assisted total gastrectomy (LATG) compared with open total gastrectomy (OTG), the minimal invasiveness of LATG has been unclear., Methods: The OTG cohort contained 35 cases, which were performed from April 2003 to October 2005. The LATG cohort contained 46 cases, which were performed from November 2005 to November 2008. Postoperative changes over time in various parameters relating to minimal invasiveness were evaluated. We used the Wong-Baker FACES Pain Rating Scale to evaluate pain. Vital signs and a face scale were analyzed using daily maximum values on postoperative days (POD) 1-7. A hematological examination was performed on the preoperative day and POD 1, 4, 7, and 10. The number of days until oxygen saturation level (SaO2) was 95% or more in room air was used to evaluate respiratory function., Results: Significantly lower pain scores were obtained in the LATG group on POD 1, 4, 5, and 7. There was a significantly lower body temperature in the LATG group on POD 7. A significantly lower white blood cell count was revealed for LATG patients on POD 10, and for C-reactive protein on POD 1. Significantly higher serum total protein values were observed in the LATG group on POD 1, 4, and 7. Significantly lower blood sugar level was found in the LATG group on POD 4 and 7. The number of days until SaO2 was 95% or more in room air was significantly fewer in the LATG group., Conclusions: LATG seems to be a less invasive procedure than OTG.

Background: There is a consensus on the indication of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer that needs D1 + alpha or D1 + beta lymph node dissection. However, many gastrointestinal surgeons consider D2 lymph node dissection in LADG to be difficult, therefore, only a few medical institutions have performed D2 lymph node dissection in LADG. We examined the safety and accuracy of D2 dissection in LADG by comparing with open distal gastrectomy (ODG), as the first step to operate on advanced gastric cancer., Methods: The study population comprised 53 and 67 patients who underwent D2 dissection in LADG or ODG, respectively; with the diagnosis of preoperative depth grade SM, between 2004 and 2006. In D2 lymph node dissection, difficult points are dissections of lymph node along the superior mesenteric vein (No. 14v), along the hepatic artery (No. 12a), and along the proximal splenic artery (No. 11p). We performed these lymph nodes dissection in a fixed process, which was achieved through all improvements., Results: No significant difference was observed in age, sex, American Society of Anesthesiology (ASA) classification, body mass index (BMI), and operative time between two groups. Bleeding volume was significantly lower in LADG (96.5 +/- 126.3 ml) than in ODG (221.9 +/- 174.8 ml). There was no significant difference in number of dissected lymph nodes between ODG (44.8 +/- 15.6) and LADG (49.2 +/- 16.1), with no significant difference in degree of pathological stage. The postoperative complication rate was 16.4% for ODG and 5.7% for LADG, and postoperative hospital stay was significantly shorter for LADG (16.7 +/- 5.6 days) than for ODG (21 +/- 11.4 days)., Conclusions: D2 dissection in LADG can be performed without problems with safety and accuracy, if the surgical team is skilled in the procedures of LADG.

Background: Since only a few extensive reports are available on the less invasive nature of laparoscopic gastrectomy, we compared postoperative changes over time in vital signs and hematological parameters between this surgery and laparotomic gastrectomy., Methods: Of 188 patients who underwent distal gastrectomy for preoperatively diagnosed early gastric cancer between January 2004 and September 2006, 87 underwent laparoscopy-assisted distal gastrectomy (LADG) and 101 underwent laparotomic distal gastrectomy (DG). The invasiveness of the two procedures was evaluated in 164 patients with no postoperative complications (82 cases of LADG and 82 cases of DG by measuing vital signs daily and performing hematological examination on postoperative days (POD) 1, 4, 7, and 10., Results: For body temperature, heart rate, and blood pressure, significantly lower values were obtained with LADG on 3 and 4 POD, 4 POD, and 3 and 4 POD, respectively. For white blood cell counts (WBC) and C-reactive protein (CRP), significantly lower values were obtained with LADG on 7 and 10 POD, and 10 POD, respectively. For serum protein levels and lymphocyte counts, significantly higher values were obtained with LADG on 1, 4, 7, and 10 POD, and 4 and 10 POD, respectively. Body temperature, WBC, and CRP showed no significant difference immediately after surgery but earlier recovery occurred with LADG. For protein levels and lymphocyte counts, higher values were obtained immediately after surgery. There seemed to be two patterns of less invasiveness in the parameters: the early recovery found for body temperature, WBC and CRP, and the smaller shift immediately after surgery in protein level and lymphocyte count, and probably, heart rate and blood pressure. The complication rate was 18.8% for DG and 5.7% for LADG., Conclusions: LADG is a less-invasive surgical procedure as it produces early normalization or smaller shifts in various parameters and exhibits a low prevalence of complications.