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Background: The incidence of rectovaginal fistula in women with Crohn's disease has been reported to be 3-10 %. Although rectovaginal fistulas can be managed medically and surgically, they have high rates of recurrence and complications. Rectal stenosis is another condition that occurs due to perianal Crohn's disease. A novel, minimally invasive procedure, dual-port laparoscopic abdominoperineal resection using a multichannel port, has been shown effective in patients with lower rectal cancer and patients with medically uncontrolled ulcerative colitis. This report describes the use of the same method for two patients with Crohn's disease-related rectovaginal fistula and rectal stenosis., Case Presentation: The first patient, a 22-year-old woman, was diagnosed with rectovaginal fistula and rectal stenosis due to perianal Crohn's disease 2 years earlier. Induction therapy with infliximab and endoscopic balloon dilatation did not improve her symptoms. The second patient, a 33-year-old woman, was also diagnosed with rectovaginal fistula and rectal stenosis due to perianal Crohn's disease, and medical treatment was also unsuccessful. Both patients underwent dual-port laparoscopic abdominoperineal resection using a multichannel port, with no perioperative and postoperative complications., Conclusion: These findings show that this reduced port method can be used to successfully treat patients with Crohn's disease-associated rectovaginal fistula and rectal stenosis.

Background: The incidence of axillary lymph node metastasis (ALNM) of colon cancer is very low, and there have been only a few reports of solitary ALNM. Neither the mechanism involved in solitary colon cancer ALNM nor the proper treatment has been elucidated. We encountered a case of solitary left ALNM after curative resection of carcinoma at the colostomy site., Case Presentation: A 53-year-old man underwent a Hartmann's operation for Hirschsprung disease during his adolescence. He complained of a mass of the descending colon and was diagnosed with colon cancer at the colostomy site with pagetoid spread to the adjacent skin. The cancer at the stoma site was resected, and a transverse colostomy was performed. Nine years later, his carbohydrate antigen (CA) 19-9 level was high during a health screening. On physical examination, adenopathy was palpated in the left axilla. Computed tomography (CT) demonstrated a lymph node in the left axillary fossa that was 33 mm in diameter, and (18)F-fluorodeoxyglucose positron emission tomography/CT showed high uptake in the lesion. We performed a curative resection of the left axillary lymph node. The lesion was pathologically diagnosed as left ALNM originating from the adenocarcinoma at the colostomy site. After lymph node resection, his serum CA19-9 level decreased compared to that observed at baseline. He has been receiving adjuvant chemotherapy (capecitabine plus oxaliplatin) without recurrence for 5 months after lymph node resection., Conclusions: The present case report shows that carcinoma at the colostomy site with pagetoid spread can metastasize to the axillary lymph nodes through superficial abdominal lymphatic pathways, and surgical resection followed by adjuvant chemotherapy may be a potent strategy to treat solitary colon cancer ALNM.

The history of clinical and research of colorectal cancer, beginning from surgery therapy, a variety of fields have evolved from there, the results have been stacked. Safety of the establishment and the usefulness of the proof of the surgery, the development of diagnostic methods, advances in chemotherapy, the discovery of hereditary colon cancer, due to the development and application of basic research to support these, research and treatment results for colorectal cancer. It has been made great strides. Advances in establishment and chemotherapy safe surgical treatment, even for colorectal cancer has been considered to unresectable ever, it has become possible to perform a surgical treatment in combination with perioperative chemotherapy. In addition, even for recurrent colon cancer, by combining the surgery therapy sure to allow timing as well as chemotherapy, likely to be observed extension of further survival are coming out Occurrence for colorectal cancer, by the elucidation of the treatment mechanism, to expect that the study of the optimization of colon cancer treatment progresses.

Purpose: To clarify the efficacy of postoperative pain management following laparoscopic gastrectomy (LG), we retrospectively compared pain assessments in patients who received fentanyl plus celecoxib with those who received epidural anesthesia., Methods: From 2011 to 2012, 55 consecutive LG patients at our institution received 48 h of epidural anesthesia for postoperative pain management (group-E). Since September 2013, epidural anesthesia was replaced with 24 h of intravenous fentanyl and 4 days of oral celecoxib. Thirty-three consecutive LG patients who received this analgesic method (group-FC) were included in this analysis. The severity of postoperative pain as assessed by the FACES Pain Rating Scale and the frequency of rescue pain medication were retrospectively compared between the two groups., Results: No significant difference in the severity of postoperative pain on postoperative day (POD) 0 or 1 was observed between the two groups. In contrast, pain was significantly lower in group-FC than group-E on PODs 2, 3, 4, and 7. The total use of rescue pain medications during the first 7 days following LG did not differ between the two groups., Conclusion: Pain management using 24 h of intravenous fentanyl and 4 days of oral celecoxib is comparable to epidural anesthesia following LG.

Enteroaggregative Escherichia coli (EAEC) causes acute or persistent diarrhea. The aggR gene is widely used as a marker for typical EAEC. The heterogeneity of EAEC is well known; however, there are few reports on the phylogenetic relationships of EAEC. Recently, CTX-M extended-spectrum β-lactamase (ESBL)-producing EAEC strains have been reported worldwide. To characterize EAEC strains in Japan, we investigated the population structure of EAEC. A total of 167 aggR-positive strains isolated from stool specimens from diarrheal patients in Kagoshima (139 strains) and Osaka (28 strains), Japan, between 1992 and 2010 were examined for the prevalence of EAEC virulence markers, the blaCTX-M gene, and the capacity to form biofilms. Multilocus sequence typing was also conducted. EAEC strains were widely distributed across four major E. coli phylogroups. Strains of O111:H21/clonal group 40 (CG40) (30 strains), O126:H27/CG200 (13 strains), and O86a:H27/CG3570 (11 strains) in phylogroup B1 are the historical EAEC clones in Japan, and they exhibited strong biofilm formation. Twenty-nine strains of EAEC O25:H4/CG131 were identified in phylogroup B2, 79% of which produced CTX-M-14. This clone has emerged since 2003. The clone harbored plasmid-encoded EAEC virulence genes but not chromosomal virulence genes and had lower biofilm-forming capacity than historical EAEC strains. This clone most likely emerged from a pandemic uropathogenic O25:H4/sequence type 131 clone by acquiring an EAEC virulence plasmid from canonical EAEC. Surveillance of the horizontal transfer of both virulence and ESBL genes among E. coli strains is important for preventing a worldwide increase in antimicrobial drug resistance., (Copyright © 2016, American Society for Microbiology. All Rights Reserved.)

At our institute, a non-suturing method for closure of the umbilical epidermis has been used in laparoscopic colorectal resection to prevent umbilical wound infection. We performed a retrospective evaluation of the incidence of umbilical wound infection using this technique for patients with colorectal cancer. From 2010 to 2014, 178 consecutive patients underwent elective laparoscopic resection of colorectal cancer. The umbilical fascia was closed using interrupted multifilament absorbable sutures. The skin surface of the umbilicus was compressed using a cotton ball and sealed by water vapor-permeable film. Three (1.7 %) patients required conversion from laparoscopic to open surgery. The mean surgery time was 174 ± 48 min, intraoperative blood loss was 29 ± 75 mL, and postoperative hospital stay was 10.5 ± 6.7 days. According to the Centers for Disease Control and Prevention criteria, umbilical superficial wound infection occurred in two (1.1 %) patients. The two patients recovered from their wound infections after a few days of drainage, and their hospital discharge was not delayed. Deep umbilical wound infection did not occur in any patient. Our non-suturing closure technique appeared to be effective in preventing wound infection after laparoscopic resection of colon cancer.

Immunosuppression in tumor microenvironments critically affects the success of cancer immunotherapy. Here, we focused on the role of interleukin (IL)-6/signal transducer and activator of transcription (STAT3) signaling cascade in immune regulation by human dendritic cells (DCs). IL-6-conditioned monocyte-derived DCs (MoDCs) impaired the presenting ability of cancer-related antigens. Interferon (IFN)-γ production attenuated by CD4(+) T cells co-cultured with IL-6-conditioned MoDCs corresponded with decreased DC IL-12p70 production. Human leukocyte antigen (HLA)-DR and CD86 expression was significantly reduced in CD11b(+)CD11c(+) cells obtained from peripheral blood mononuclear cells (PBMCs) of healthy donors by IL-6 treatment and was STAT3 dependent. Arginase-1 (ARG1), lysosomal protease, cathepsin L (CTSL), and cyclooxygenase-2 (COX2) were involved in the reduction of surface HLA-DR expression. Gene expressions of ARG1, CTSL, COX2, and IL6 were higher in tumor-infiltrating CD11b(+)CD11c(+) cells compared with PBMCs isolated from colorectal cancer patients. Expression of surface HLA-DR and CD86 on CD11b(+)CD11c(+) cells was down-regulated, and T cell-stimulating ability was attenuated compared with PBMCs, suggesting that an immunosuppressive phenotype might be induced by IL-6, ARG1, CTSL, and COX2 in tumor sites of colorectal cancer patients. There was a relationship between HLA-DR expression levels in tumor tissues and the size of CD4(+) T and CD8(+) T cell compartments. Our findings indicate that IL-6 causes a dysfunction in human DCs that activates cancer antigen-specific Th cells, suggesting that blocking the IL-6/STAT3 signaling pathway might be a promising strategy to improve cancer immunotherapy.

Introduction: Reduced-port laparoscopic surgery is a novel minimally invasive surgery. However, reduced-port surgery for ulcerative colitis (UC) remains controversial. Here, we describe the clinical outcomes of single-incision plus one port laparoscopic surgery (SILS + 1) for medically uncontrolled UC., Methods: Between May 2011 and September 2014, 10 UC patients underwent SILS + 1 port surgery. All procedures were performed with the use of a SILS port and either a 5-mm or a 12-mm port placed at the planned ileostomy site., Results: The median age of patients was 32 years (range, 22-53 years). Six patients underwent two-stage SILS + 1 port restorative proctocolectomy with ileal pouch-anal anastomosis, two patients underwent SILS + 1 total proctocolectomy, and the remaining two patients underwent SILS + 1 subtotal colectomy with subsequent three-stage SILS + 1 ileal pouch-anal anastomosis. The median operative time was 363.1 min (range, 253-465 min) and the median estimated blood loss was 29 mL (range, 0-100 mL). There were no conversions or additional ports required. Two patients previously underwent SILS + 1 subtotal colectomy, and in one of those patients, SILS + 1 ileal pouch-anal anastomosis was performed successfully 6 months after the previous surgery. There were no intra-abdominal adhesions, and no extra wounds were necessary because the previous stoma site had been used to access the SILS port. The median postoperative period was 24 months, during which five patients had their ileostomies closed. No patients reported occasional minor daily soiling or the need to wear a pad., Conclusion: Reduced-port laparoscopic surgery for medically uncontrolled UC is a feasible and safe procedure when performed by skilled surgeons., (© 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of orthopedic surgical site infections (SSIs). The aim of this study was to evaluate the effect of a bundle approach in the prevention of orthopedic MRSA SSIs., Material and Methods: MRSA active surveillance and decolonization were performed preoperatively at our institution from July 2004 until 2007. In January 2008, a bundle approach comprising contact precautions for MRSA-positive patients and cefazolin-based antimicrobial prophylaxis (AMP) stewardship was implemented. Data on the prevalence of MRSA SSIs, antimicrobial use density, duration of AMP, and the use of an alcohol antiseptic agent (L/1,000 patient-days) were evaluated during 2 periods: July 2004-December 2007 (period A) and January 2008-December 2012 (period B)., Results and Discussion: The MRSA SSI rate during period B (0.97%; 19 out of 1,966) was significantly lower than that during period A (2.17%; 29 out of 1,333; P = .003). The infection rate correlated negatively with both the cefazolin antimicrobial use density (r = -0.76; P = .0002) and the use of an alcohol antiseptic agent (r = -0.68; P = .002)., Conclusions: An infection-prevention bundle consisting of contact precautions for carriers and AMP stewardship in addition to active surveillance was associated with a significant decrease in the incidence of orthopedic MRSA SSIs., (Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Although most patients achieve favorable results following bipolar hip hemiarthroplasty (BHA), some experience rapid migration of the prosthesis. We retrospectively reviewed 18 patients with BHA that necessitated revision., Methods: We examined soft tissues obtained from periprosthetic lesions. In total, 18 patients with pain and acetabular migration of the BHA prosthesis were included. The patients were divided into a polymorphonuclear leukocyte (PMN)-positive (≥5 PMNs per high-power field [HPF]) and PMN-negative (<5 PMNs/HPF) group., Results: Pathological findings showed that 11 patients were PMN-positive, which was indicative of infection. All patients in the PMN-positive group showed no polyethylene particles or foreign body giant cells, while all patients in the PMN-negative group showed polyethylene debris or foreign body giant cells (p < 0.001). BHA survival, C-reactive protein (CRP) levels, and the Japanese Orthopaedic Association (JOA) hip score were significantly different between the PMN-positive and PMN-negative group (p < 0.01). A BHA survival cut-off value of 3270 days was diagnostic for PMN positivity (sensitivity: 100%; specificity: 100%). The cut-off values for CRP and the JOA hip score were 0.43 mg/dl and 56 points, respectively. Four of 11 PMN-positive patients showed no clinical symptoms of infection (asymptomatic PMN-positive group). BHA survival, CRP levels, and JOA hip scores were significantly different between the asymptomatic PMN-positive and PMN-negative group (p < 0.05). A BHA survival cut-off of 3270 days was diagnostic for asymptomatic PMN positivity (sensitivity: 100%; specificity: 100%). The cut-off values for CRP and the JOA hip score were 0.43 mg/dl and 57 points, respectively., Conclusion: Our findings suggest that some portion of rapid BHA prosthesis migration is caused by mild infection. Careful pathological examination should be performed to identify infection before removal of the BHA prosthesis in patients who develop migration within 9 years.

We describe a novel minimally invasive procedure: dual-port laparoscopic abdominoperineal resection using a SILS port, and report our experience of using this to treat ten patients with lower rectal cancer. A SILS port was placed in the left lower quadrant at the intended colostomy site. A 5-mm trocar was inserted at the umbilicus at the subsequent drain site. Via a standard laparoscopic medial-to-lateral approach, the inferior mesenteric artery and vein were ligated and total mesorectal excision was performed. Via a perineal approach, the specimen was retrieved from the perineal wound, and a sigmoid colostomy was created at the site of the SILS port. Ten consecutive patients with lower rectal cancer at clinical stage T3 or lower underwent the procedure at our institution. The procedure was completed successfully in all patients, without any intraoperative problems and all postoperative outcomes were satisfactory. Thus, dual-port laparoscopic abdominoperineal resection can be performed safely and feasibly in selected patients.

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.

Purpose: Although noninvasive and highly informative, transabdominal ultrasonography (US) is not yet an accepted means of staging colorectal cancer preoperatively. This prospective study evaluated the diagnostic accuracy of US in preoperative staging of patients with resectable colon cancers., Methods: A total of 98 patients with primary colon cancer diagnosed by colonoscopy at our institute between January, 2011 and June, 2014 underwent preoperative ultrasonographic tumor staging. Depth of tumor infiltration (T-stage) was assessed by standard means (i.e., extent of mural involvement), analyzing agreement in US and histopathology determinations., Results: All but two colon cancers (at splenic flexure) were detected by US (98%, 96/98). Compared with histopathology, overall accuracy of US in determining T-stage was 64% (61/96), indicating moderate reproducibility (κ coefficient 0.48; 95% CI 0.35-0.62; p < 0.001). Using a three-tier approach of graded muscularis propria (MP) involvement (Tis/T1, below MP; T2, within MP; and T3/T4, beyond MP), diagnostic agreement increased to 89% (85/96), with good agreement (κ coefficient 0.77; 95% CI 0.64-0.90; p < 0.001). No tumor characteristics or patient demographics influenced diagnostic agreement at any site in the colon., Conclusions: Given the potential to yield valuable information while limiting patient discomfort, US should be reconsidered as a means of assessing colon cancer.

Background: To effectively treat orthopaedic infections by methicillin-resistant strains, an early diagnosis is necessary. Bacterial cultures and real-time polymerase chain reaction (PCR) have been used to define methicillin-resistant staphylococci. However, even when patients display clinical signs of infections, bacterial culture and real-time PCR often cannot confirm infection. The aim of this study was to prospectively compare the utility of real-time PCR for the mecA gene detection following centrifugation of human samples with suspected orthopaedic infections., Results: In addition to the conventional real-time PCR method, we performed real-time PCR following centrifugation of the sample at 4,830×g for 10 min in a modified real-time PCR (M-PCR) method. We suspended cultured methicillin-resistant Staphylococcus aureus and generated standard dilution series for in vitro experiments. The in vitro detection sensitivity of the M-PCR method was approximately 5.06 times higher than that of the conventional real-time PCR method. We performed bacterial culture, pathological examination, real-time PCR, and M-PCR to examine the infectious fluids and tissues obtained from 36 surgical patients at our hospital. Of these, 20 patients who had undergone primary total hip arthroplasty were enrolled as negative controls. In addition, 15 patients were examined who were clinically confirmed to have an infection, including periprosthetic joint infection (eight patients), pyogenic spondylitis (two patients), infectious pseudoarthrosis (two patients), and after spine surgery (three patients). In one sample from a patient who developed infectious pseudoarthrosis and two samples from surgical site infections after spine surgery, the mecA gene was detected only by the M-PCR method. In one patient with infectious pseudoarthrosis, one patient with infection after arthroplasty, and two patients with purulent spondylitis, the detection sensitivity of the M-PCR method was increased compared with PCR (clinical sample average: 411.6 times)., Conclusions: These findings suggest that the M-PCR method is useful to detect methicillin-resistant strains infections. In addition, the centrifugation process only takes 10 min longer than conventional real-time PCR methods. We believe that the M-PCR method could be clinically useful to detect orthopaedic infections caused by methicillin-resistant strains.

Purposes: Sepsis caused by Gram-negative bacilli (GNB) is the most serious catheter-related bloodstream infection. However, the cause(s) of GNB propagation on the skin around needle or catheter insertion sites remain unclear. This observational study aimed to assess the differences in the microbial growth among various types of dressings used to cover injection sites, with a particular focus on GNB., Methods: We analyzed the bacterial populations on three types of surgical dressings; Tegaderm I.V. (semi-permeable, 27 sheets), IV3000 (highly permeable, 34 sheets) and Tegaderm CHG (chlorhexidine-impregnated, 26 sheets). The peripheral catheter site dressing was replaced every 3 days or when there was leakage or pain at the catheter site., Results: Bacterial growth was observed in all Tegaderm I.V. and IV3000 sheets and in only one (3.8%) Tegaderm CHG sheet. The GNB detection rate was significantly lower in the IV3000 group (2.9%) than in the Tegaderm I.V. group (63.0%). No GNB growth was identified in the Tegaderm CHG group., Conclusions: Semi-permeable dressings were insufficient to prevent GNB infections, whereas highly permeable or chlorhexidine-impregnated dressings could prevent GNB infections. Chlorhexidine-impregnated dressings can control almost all bacterial growth.

Background: Reduced-port laparoscopic surgery is the latest innovation in minimally invasive surgery. We performed single-incision plus one additional port laparoscopy-assisted anterior resection (SILS + 1-AR) starting in August 2010. This study aimed at evaluating the feasibility of SILS + 1-AR and comparing it with that of conventional laparoscopy-assisted anterior resection (C-AR)., Methods: Patients with preoperative clinical stage 0 to stage III rectal cancer were included. Demographic, intraoperative, and pathological examination data, as well as short-term outcome data, of 20 patients who underwent SILS + 1-AR were retrospectively compared with that of 20 patients who underwent C-AR. Invasiveness of the two procedures was also evaluated through a vital signs diary and hematological examination on postoperative days (POD) 1, 3, and 7., Results: Operating time, mean estimated blood loss, the number of lymph nodes dissected, the number of lymph node metastases, and the mean distal resection margin length were not significantly different. However, postoperative neutrophil counts in the SILS + 1-AR group were lower than those in the C-AR group (P = 0.085). A significant difference in body temperature was observed in the SILS + 1-AR group on POD 1 (P = 0.028). No significant differences were observed in perioperative and overall morbidity between the two groups. Conversion to open surgery was required in 2 (10 %) of the 20 patients in the SILS + 1-AR group. The mean postoperative length of stay and recurrence rates were similar in the two groups., Conclusion: SILS + 1-AR for rectal cancer is similar to C-AR in safety, feasibility, and provision of oncological radicality.

We report a 35 month-old boy with acute renal failure caused by an obstructive ureteral stone associated with norovirus gastroenteritis. He visited his family physician because of fever, abdominal pain and vomiting. He was diagnosed as acute gastroenteritis. The symptoms relieved once, but abdominal pain and vomiting recurred two days after the visit and the volume of urine decreased. He was diagnosed as norovirus gastoenteritis and acute renal failure which was unresponsive to fluid replacement. Ultrasound study of the abdomen showed a solitary kidney with mild hydronephrosis. He was then admitted to our hospital. He was finally diagnosed as acute postrenal failure due to obstructive ureteral stone with left solitary kidney by abdominal computer tomography (CT). We performed transurethral catheterization immediately. The creatinine and blood urea nitrogen returned to normal level in 2 days. The CT performed on the 28th day post operation showed disappearance of the stone after uric alkalization. Recently, some cases of postrenal failure due to bilateral obstructive ureteral stones, mainly ammonium acid urate stones, associated with viral gastroenteritis were reported. As clinical features, they are common in boys three years or younger after an episode of rotavirus gastroenteritis with high uric acid concentration. By far, the most common cause of acute renal failure in patients with severe gastroenteritis is prerenal failure resulting from hypovolemia. But postrenal cause due to bilateral obstructive stones should be taken in a consideration.

We report four patients with SRY-positive 46,XX testicular disorders of sex development (46,XX-TDSD) (cases 1-4). Case 1 exhibited underdeveloped external genitalia with hypospadias, case 2 manifested micropenis and cases 3 and 4 showed normal external genitalia. The Xp;Yp translocations occurred between the X- and the Y-differential regions in case 1, between PRKX and inverted PRKY in case 2 and between the X-chromosomal short arm pseudoautosomal region and the Y-differential regions in cases 3 and 4. The distance of the Yp breakpoint from SRY was ~0.75 Mb in case 1, ~6.5 Mb in case 2, ~2.3 Mb in case 3 and ~72 kb in case 4. The Xp;Yp translocation occurred within an 87-bp homologous segment of PRKX and PRKY in case 2, and between non-homologous regions with addition of an 18-bp sequence of unknown origin in case 4. X-inactivation analysis revealed random inactivation in cases 1-4. The results argue against the notion that undermasculinization in 46,XX-TDSD is prone to occur when translocated Yp materials are small (<100 kb of the Y-differential region), and imply that the Xp;Yp translocations result from several mechanisms including non-allelic homologous recombination and non-homologous end joining.

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.)

Background: Standard treatment for acute cholecystitis (AC) in patients receiving antithrombotic drugs has not been established. We evaluated the safety of percutaneous transhepatic gallbladder drainage (PTGBD) followed by elective laparoscopic cholecystectomy (LC) in patients with moderate AC who were receiving antithrombotics., Methods: Seventy-five patients received PTGBD from January 2006 to March 2013 followed by elective LC for moderate AC. Patients were divided into Group A, which consisted of patients receiving antithrombotic therapy (n = 23), and Group B, which included the remaining patients (n = 52). We analyzed clinical outcomes and perioperative complications between groups., Results: No hemorrhagic events occurred during PTGBD insertion regardless of antithrombotic treatment. The open conversion rate was not significantly different between the two groups. Postoperative complications were found in 10 patients (13.3%). The rate of postoperative complications in Group A was slightly higher than that in Group B, but the difference was not significant (21.7% vs. 9.6%; P = 0.15). Complications associated with PTGBD occurred in six patients (8%). There were no significant differences in the incidence of these complications, operation time, intraoperative blood loss, or length of postoperative hospital stay., Conclusions: Percutaneous transhepatic gallbladder drainage followed by elective LC may be an effective therapeutic strategy for moderate AC in patients receiving antithrombotic therapy., (© 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

The antimicrobial agents vancomycin and metronidazole have been used to treat Clostridium difficile infections (CDIs). However, it remains unclear why patients are at risk of treatment failure and recurrence. Therefore, this study retrospectively examined 98 patients with CDIs who were diagnosed based on the detection of toxin-positive C. difficile to determine the risk factors affecting drug treatment responses and the recurrence of CDI. No significant difference was observed in the cure rate or dosage between the vancomycin and metronidazole groups. The 90-d mortality rate and total number of drugs associated with CDIs, including antiinfective agents used within 2 months before the detection of toxin-positive C. difficile, were significantly lower in the treatment success group than in the failure group. The total number of antiinfective agents and gastric acid-suppressive agents used during CDI therapy was also significantly lower in the success group than in the failure group. The period from the completion of CDI therapy to restarting the administration of anticancer agents and steroids was significantly longer in patients without than in patients with recurrence. These results indicate that the total number of drugs associated with CDIs should be minimized to reduce the risk of CDIs, that not only antibiotics but also gastric acid-suppressive agents should be discontinued during CDI therapy to increase therapeutic efficacy, and that the use of anticancer agents and steroids should be delayed as long as possible after patients are cured by CDI therapy to prevent recurrence.

Surgical site infection (SSI) has not been extensively studied in musculoskeletal tumors (MST) owing to the rarity of the disease. We analyzed incidence and risk factors of SSI in MST. SSI incidence was evaluated in consecutive 457 MST cases (benign, 310 cases and malignant, 147 cases) treated at our institution. A detailed analysis of the clinical background of the patients, pre- and postoperative hematological data, and other factors that might be associated with SSI incidence was performed for malignant MST cases. SSI occurred in 0.32% and 12.2% of benign and malignant MST cases, respectively. The duration of the surgery (P = 0.0002) and intraoperative blood loss (P = 0.0005) was significantly more in the SSI group than in the non-SSI group. We established the musculoskeletal oncological surgery invasiveness (MOSI) index by combining 4 risk factors (blood loss, operation duration, preoperative chemotherapy, and the use of artificial materials). The MOSI index (0-4 points) score significantly correlated with the risk of SSI, as demonstrated by an SSI incidence of 38.5% in the group with a high score (3-4 points). The MOSI index score and laboratory data at 1 week after surgery could facilitate risk evaluation and prompt diagnosis of SSI.

Introduction: An association between bullous pemphigoid (BP) and internal malignancy has been suggested. However, no reports have documented a dramatic improvement in BP after surgery for gastric cancer., Presentation of Case: An 82-year-old Japanese woman was admitted to a local hospital for severe fatigue. On examination, she was diagnosed with BP and gastric cancer. Her BP was resistant to steroid treatment; however, it improved dramatically after surgery for gastric cancer., Discussion: In this case, a strong relationship appeared to exist between BP and gastric cancer., Conclusion: This is the first report of a dramatic improvement in BP after surgery for gastric cancer., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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.

Goblet cell carcinoid (GCC) tumor of the appendix is rare, and the prognosis is considered poor compared to classical carcinoid tumor. We present a case of a 60-year old woman who underwent appendectomy for acute appendicitis. Histopathological studies revealed a GCC tumor with submucosal invasion. Based on the malignancy of this tumor and the possible risk of regional lymph node metastases, we performed laparoscopic ileocecectomy with lymph node dissection. Histologically, no residual tumor or lymph node metastases were found. The patient remains well without any sign of recurrence.

After gastrectomy, a longer period of intravenous alimentation is required than for other digestive surgeries, portending a higher risk of catheter-related bloodstream infection (CRBSI). From assessment of CRBSI occurring between 2004 and 2007 (preintervention group), the duration of intravenous infusion between 2008 and 2010 (postintervention group) was changed to shorter-term (6-day) infusion. To verify the effect of changes in injection schedule on the incidence of CRBSI, the occurrence of CRBSI was studied comparatively among preintervention and postintervention cases, excluding cases requiring intravenous infusion preoperatively, and cases requiring long-term intravenous infusion postoperatively due to postoperative complications. The rate of CRBSI in the postintervention group (0%; 0 of 298) was significantly lower than that in the preintervention group (1.7%; 8 of 477; P = 0.026). There was no significant difference between preintervention and postintervention groups in postoperative complications. Six-day infusion decreased the incidence of CRBSI after gastrectomy significantly, without increasing postoperative complications.

Background: The aim of this study is to demonstrate a shaft formation of forceps and scope which provides higher degree of freedom of motion for single-port laparoscopic surgery (SPLS). The key to smoothly performing SPLS lies in understanding the formation in which the shaft conflict is minimized. However, there have been no reported studies on conflict reduction in SPLS from a shaft formation perspective., Methods: When performing SPLS, 3 instruments are passed into a narrow space, only 2 patterns of shaft formation can be obtained: a formation in which the 3 instruments rotate clockwise or counterclockwise (rotation formation) or a formation in which 1 instrument passes between the other 2 (cross formation). So motion spaces of the instruments in rotation formation compared with that in cross formation were tested using engineering methods. The range of the forceps' motion was assumed to be the space covered by the forceps till collision occurred between the moving forceps and either the other fixed forceps or the fixed scope. Examination of the range of movement of the scope was conducted in the same manner. The motion space with the area on the x-y horizontal is evaluated, as viewed from the peritoneal umbilicus port entry area., Results: The motion area of each instrument in rotation formation is 1.9 to 2.6 times wider than that in cross formation., Conclusions: Rotation formation provides high degree of freedom of motion for SPLS.

Methicillin-resistant Staphylococcus aureus (MRSA) is highly contagious. It is spread by direct contact with MRSA-infected people or objects. Healthcare workers' hands are the most common vehicle for the transmission of healthcare-associated pathogens from patient to patient and within the healthcare environment. The present study aimed to investigate the correlation between the incidence of MRSA among Staphylococcus aureus recovered from clinical culture and the use of alcohol-based hand rub solutions or gloves and antimicrobial use density (AUD). All data were examined every 6 months between January 2005 and June 2008. The increasing use of alcohol-based hand rub solutions was correlated with a decreasing incidence of recovery of MRSA from clinical cultures (r(2) = 0.58). A statistically significant (P < 0.05) correlation (r(2) = 0.68) was observed between glove use and the incidence of MRSA. On the other hand, we did not find any correlation between the AUD of each antibiotic group and the incidence of MRSA. Thus, we suggest that it is important to use not only alcohol-based hand rubs, but also gloves, because MRSA is transmitted from patient to patient by the hands of healthcare workers.

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.

Malignant melanoma of the anorectal region is rare, and the prognosis is considered to be poor. We present a case of long-term survival in a 56-year-old patient with primary malignant melanoma in the anorectal area, who complained of anal bleeding. Barium enema showed an elevated lesion in the anorectal region. Colonoscopy revealed a 3 cm sessile tumor with focal pigmentation, and a satellite nodule, 1 cm in diameter. Based on diagnosis of malignant melanoma by biopsy, abdominoperineal resection with lateral node dissection was performed. Pathologically the tumor remained in the mucosa, and no lymph node metastasis was found. This patient refused any adjuvant chemotherapy after the operation, and remains well without any sign of recurrence for seven years.

Biofilms play a pivotal role in medical device-related infections. However, epidemiological analysis of biofilm formation and genotyping among clinical methicillin-resistant Staphylococcus aureus (MRSA) isolates from patients with orthopaedic infections has rarely been reported. A total of 168 MRSA strains were examined: 23 strains from patients with device-related infection (the device group); 55 from patients with device-non-related infection (the nondevice group); and 90 from asymptomatic nasal carriers (the colonization group). Pulsed-field gel electrophoresis analysis and five genotyping methods including agr typing were performed. Biofilm formation was quantified using a microtitre plate assay. The device group had a significantly higher incidence of agr-2 than the colonization group (78.3% vs. 34.4%, P=0.001). The biofilm index of the agr-2 (0.523 ± 0.572) strains was significantly higher than those of agr-1 (0.260 ± 0.418, P<0.0001) and agr-3 (0.379 ± 0.557, P=0.045). The prevalence of strong biofilm formers in the device group (43.5%) was significantly higher than that in the nondevice group (12.7%, P=0.003) and the colonization group (20.0%, P=0.020). agr-2 MRSA strains may be more likely to cause orthopaedic device infection because of their strong biofilm formation ability., (© 2011 Federation of European Microbiological Societies. Published by Blackwell Publishing Ltd. All rights reserved.)

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: Laparoscopic gastrectomy (LAG) is recognized as a less invasive surgery, but no advantage in terms of respiratory function recovery has been demonstrated. We investigated respiratory function recovery in the early period after LAG compared with open gastrectomy (OG) for measuring the recovery of oxygen saturation level (SaO(2))., Methods: The study population comprised 454 patients who underwent distal gastrectomy or total gastrectomy for preoperatively diagnosed T1N0 gastric cancer: 192 underwent laparoscopy-assisted distal gastrectomy (LADG), 190 underwent open distal gastrectomy (ODG), 42 underwent laparoscopy-assisted total gastrectomy (LATG), and 30 underwent open total gastrectomy (OTG)., Results: The number of days until SaO(2) reached 95% or higher in room air was significantly smaller in the LADG group (1.54 days) than in the ODG group (1.81 days; p = 0.010) and also significantly smaller in the LATG group (1.48 days) than in the OTG group (2.03 days; p = 0.043)., Conclusions: LAG patients recovered their oxygenation earlier than OG patients. The laparoscopic procedure might confer a respiratory benefit for gastrectomy patients.

This is a case of a 72-year-old male whose chest computed tomography (CT) revealed a 2.0 x 1.6 cm anterior mediastinal solid tumor during follow-up of an abnormal shadow of the lung. The tumor increased its size during preoperative follow-up, and multilocular cyst was also observed. Radical thymectomy was performed, and histopathologically the tumor was diagnosed as thymic basaloid carcinoma. Thymic basaloid carcinoma is a rare tumor and is often associated with multilocular thymic cyst. There are only 32 cases reported both locally and internationally. Surgical resection is the general treatment for this disease. Adjuvant radiotherapy can be considered in cases of incomplete resection and invasive tumor. In our case, no recurrence of the tumor was noted 12 months post-operative. Generally, the malignancy of thymic basaloid carcinomas are regarded as low-grade compared with other thymic carcinomas, however, since mortality and recurrence have been reported, careful follow-up is required.

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: It is predictable that since distal gastrectomy (DG) with Billroth I anastomosis involves no procedures caudal to transverse colon, the effects of the surgical wound are the main cause of adhesive obstruction. Thus, it is an appropriate operation to test the efficiency of a synthetic absorbable adhesion barrier (Seprafilm)., Methods: The subjects were 282 patients diagnosed with gastric cancer who underwent open DG with Billroth I anastomosis between 2001 and August, 2005. Seprafilm was not used in any patients operated on before April, 2003 (n = 169), but it was used in all patients operated on from May 2003 onward (n = 113). We retrospectively compared the incidences of adhesive obstruction in the Seprafilm group and the non-Seprafilm group., Results: The cumulative incidence of adhesive obstruction was significantly lower in the Seprafilm group than in the non-Seprafilm group (P = 0.021). The respective incidences of adhesive obstruction 2 years after surgery were 0.9% and 6.5%. Multivariate analysis of the occurrence of adhesive obstruction revealed no significant differences in sex, age, body mass index, operation time, blood loss, or degree of lymph-node dissection; however, it revealed a significant difference in relation to the use of Seprafilm (P = 0.049)., Conclusion: In this series, Seprafilm reduced the incidence of adhesive obstruction after DG significantly; however, a prospective randomized study will be necessary to confirm this result.

Optimal use of carbapenems is an important issue in the prevention of resistance in Pseudomonas aeruginosa. In this study, we investigated the correlation between antimicrobial use density (AUD) of carbapenems and imipenem/cilastatin (IPM/CS) or meropenem (MEPM) susceptibility of P. aeruginosa strains. The AUD of five carbapenems [IPM/CS, panipenem/betamipron, biapenem, MEPM and doripenem (DRPM)] was examined every 6 months between 2006 and 2008. The AUD was calculated using the defined daily doses methodology developed by the World Health Organisation. A minimum inhibitory concentration of IPM/CS or MEPM of < or =4 mg/L was considered to be sensitive. There was a significant negative correlation between MEPM susceptibility and the total AUD of MEPM and DRPM [r=-0.823, 95% confidence interval (CI) -0.035 to -0.980; P=0.044]. Furthermore, there was a significant correlation between MEPM susceptibility and IPM/CS susceptibility (r=0.839, 95% CI 0.084 to 0.981; P=0.037). Cross-resistance was therefore investigated and only 5.6% of MEPM-insensitive strains were susceptible to IPM/CS, although 43.3% of IPM/CS-insensitive strains were susceptible to MEPM. These results suggest that curtailing the use of MEPM and DRPM may curb the emergence not only of MEPM-resistant strains but also IPM/CS-resistant strains.

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: Laparoscopic gastrectomy is reported to cause little pain. However, only the total number of analgesics used has been studied to date. Because pain is a subjective experience, its evaluation requires indicators for the subjective assessment., Methods: Pain was evaluation for patients after open distal gastrectomy (ODG, 52 cases), laparoscopically assisted distal gastrectomy (LADG, 112 cases), open total gastrectomy (OTG, 18 cases), and laparoscopically assisted total gastrectomy (LATG, 33 cases). The patients were administered continuous epidural anesthesia for 2 days after the surgery. The Wong-Baker FACES pain rating scale was used to evaluate the differences in pain. Each patient was evaluated from postoperative day (POD) 1 to POD 7, and temporal changes in pain were studied comparatively between ODG and LADG and between OTG and LATG., Results: Peak pain scores were recorded on POD 3 for both distal and total gastrectomy. The scores decreased over time after POD 3. There was no significant difference in scores between open and laparoscopic gastrectomy up to POD 2, but lower scores were shown on PODs 3, 4, and 5 for LADG and on days 3 and 4 for LATG., Conclusions: The pain score for laparoscopic gastrectomy was low. There was no significant difference in pain between procedures while epidural anesthesia was in effect. Pain subsided earlier with laparoscopic than with open gastrectomy. The same characteristics were observed with both LADG and LATG.

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 and Aim: Conversion of data from technetium 99 m diethylenetriaminepentaacetic acid galactosyl human serum albumin (99mTc-GSA) scintigraphy to ICGR15 (indocyanin green retention at 15 min) is an easy and convenient method for obtaining parameters to determine the appropriate and safe extent of liver resection. We investigated a conversion method which also accounts for LHL15 (receptor index: uptake ratio of the liver to the liver plus heart at 15 min) and HH15 (blood clearance index: uptake ratio of the heart at 15 min to that at 3 min) characteristics., Methods: Cases included 282 patients undergoing hepatic resection following 99mTc-GSA scintigraphy and an ICG tolerance test. Degree of liver dysfunction was classified as A, B, or C according to criteria of the Liver Cancer Study Group of Japan., Results: HH15 demonstrated a larger distribution in patients with liver damage A, while LHL15 demonstrated a larger distribution in patients with liver damage B. In liver damage A, the conversion formula ICGR15 = 87.0-79.6 x LHL15 was obtained, and in liver damage B, the conversion formula ICGR15 = -23.3 + 72.4 x HH15 was obtained, and correlation with ICGR15 was higher (r = 0.61, P < 0.0001) than when the data were not segregated by liver damage severity. Furthermore, postoperative hyperbilirubinemia significantly occurred in cases where both ICGR15 and converted ICGR15 were high., Conclusions: Conversion models based on data segregated by severity of liver damage were more closely correlated with ICGR15 than conversion models not based on segregated data. By using this converted ICGR15, preoperative estimation of hepatic functional reserve can become more reliable.

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.