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Although the laparoscopic approach is accepted for the treatment of colon cancer, its value for low rectal cancer is unknown. The purpose of this study was to evaluate the influence of patient and tumor factors, particularly pelvic dimensions, on the difficulties in laparoscopic total mesorectal excision (TME) for low rectal cancer.Seventy-nine consecutive patients underwent laparoscopic TME with intracorporeal rectal transection and double stapling technique (DST) anastomosis for low rectal cancer. Gender, body mass index (BMI), tumor diameter, tumor depth, tumor distance from the anal verge, preoperative chemoradiotherapy, and 5 pelvic dimensions (pelvic inlet, pelvic outlet, length of sacrum, interspinous distance, and intertuberous distance) were analyzed as variables affecting the difficulties of laparoscopic TME. The dependent variables were pelvic operative time, which was defined as the time required for dissection of the rectum from the pelvis, intracorporeal transaction, and anastomosis. Other dependent variables were intraoperative blood loss, overall postoperative morbidity, and anastomotic leakage. Univariate and multivariate analyses were performed to determine the predictive significance of variables.Multivariate analysis showed that BMI (P.0001), tumor distance from the anal verge (P = .0003), tumor depth (P = .0021), and pelvic outlet (P = .0362) were independently predictive of pelvic operative time. Pelvic operative time was related to intraoperative blood loss (P.0001). The tumor distance from the anal verge (P = .0333, odds ratio [OR]: 1.06) was related to postoperative morbidity, and pelvic outlet was related to anastomotic leakage (P = .0305, OR: 1.13).BMI, tumor distance from the anal verge, tumor depth, and pelvic outlet were independent predictors for operative time and morbidity. These factors should be taken into account when planning laparoscopic TME.

Westernization of lifestyle and diet has resulted in an increase in overweight patients in Japan. Although the adverse effects of higher body mass index (BMI) on early surgical outcomes are known, the relationship between BMI and long-term outcome is unclear.Clinicopathological characteristics and 5-year survival rate of overweight (BMIor= 25 kg/m2; H-BMI; n = 1126) and nonoverweight (BMI25 kg/m2; N-BMI; n = 6799) patients who underwent gastrectomy with curative intent at the Cancer Institute Hospital between 1970 and 2004 were compared.Patients in the H-BMI group tended to have earlier-stage disease. The 5-year survival rate was significantly better in the H-BMI than N-BMI group (81.5% vs 74.1%, respectively; P.001). Postoperative mortality was 1% in both groups (P = .482), whereas postoperative morbidity was 22% and 19% in the H-BMI and N-BMI groups, respectively (P = .007). Multivariate analysis indicated overweight, age, gender, surgical procedure, histology, operation year, pT, and pN as independent prognostic factors. Subset analyses of pT and pN stages revealed overweight as an independent prognostic factor in patients with pT1 and pN0.The 5-year survival rate following curative gastrectomy is better in overweight than nonoverweight Japanese patients, especially for early-stage gastric cancer. Further studies are needed to determine whether these results apply to other countries where morbidity and mortality for gastric cancer are higher than in Asian countries.

Rates of postoperative morbidity, particularly infectious complications, remain high after pancreatoduodenectomy. Subjects comprised 101 patients who had undergone pancreatoduodenectomy, analyzed according to presence or absence of infectious postoperative complications. Nineteen perioperative variables were analyzed to identify risk factors associated with postoperative infectious complications. Postoperative infectious complications occurred in 56 patients (55%); among them 29 had serious infectious morbidity, including bacteremia (13%), intra-abdominal infection (18%) and pneumonia (12%). One patient (1%) died of multiple organ failure subsequent to a severe septic attack. Only body mass index (BMI) differed significantly between patients with and without serious infection. Logistic regression analysis identified BMI >25 as an independent factor for occurrence of serious postoperative infectious complications. BMI >25 was a common risk factor for individual infection, including bacteremia, intra-abdominal infection, and pneumonia. As for the influence of BMI on perioperative parameters, the high BMI significantly affected the operation time. Meanwhile preoperative biliary drainage had no influence on overall and individual infectious morbidities. This study demonstrates the need for careful postoperative monitoring in the patient with high BMI.

Background Selected cases of clinical mucosal gastric cancer can be treated endoscopically. But mucosal gastric cancer, which has a higher incidence of lymph node metastasis, should be treated by gastrectomy with lymph node dissection. Laparoscopy-assisted gastrectomy is usually indicated for the surgical treatment of mucosal gastric cancer. Study Design From April 2005 to December 2007, 148 consecutive patients with clinical mucosal gastric cancer who underwent laparoscopy-assisted gastrectomy were investigated to clarify the clinicopathologic findings in this patient group. Results Of the patients who underwent gastrectomy, 93 (63%) had tumors>20 mm in diameter and 92 (62%) had undifferentiated cancer. The frequency of lymph node metastasis was 8% (12 patients). One patient had second-compartment lymph node metastasis (station 8a). In patients with lymph node metastasis, 11 (92%) had an ulcer scar and 11 (92%) had undifferentiated tumors. None of the patients met the criteria for extended endoscopic submucosal dissection. Conclusions The incidence of lymph node metastasis in patients with mucosal gastric cancer in whom gastrectomy is indicated is higher than reported previously. More careful consideration is needed for the possibility of lymph node metastasis in this era of endoscopic submucosal dissection.

We aimed to clarify the frequency and clinicopathological characteristics of gastric stump carcinoma following proximal gastrectomy.Three-hundred and sixteen patients who had undergone curative proximal gastrectomy over a 21-year period from January 1984 through December 2004 were reviewed.Gastric stump carcinoma was observed in 17 patients (5.4%). The time interval between the initial gastrectomy and the treatment of gastric stump cancer was within 5 years in 3 patients, within 5-10 years in 8, and after 10 years in 6. Treatment included endoscopic resection (n = 4), completion total gastrectomy of the remnant stomach (n = 11), pancreatoduodenectomy (n = 1), and nonsurgical resection (n = 1). Pathologically, 9 carcinomas were differentiated and 8 were undifferentiated. In a review of reconstruction methods associated with disease stage, stage I was found in 6 of the 7 patients with esophagogastrostomy or short-segment jejunal interposition. On the other hand, stage I was found in only 3, but stage II-IV was found in 7 of the 10 patients with reconstruction by double-tract or long-segment jejunal interposition; thus, the tumor was more likely to be detected at an advanced stage after long-segment interposition (P = 0.049).Gastric stump carcinoma following proximal gastrectomy occurred at a high frequency of 5.4% of initial resections. It is necessary to select a reconstruction method that facilitates postoperative endoscopic examination, as well as to follow up the patients after proximal gastrectomy in the long term for the early detection and early treatment of gastric stump carcinoma.

Background Obesity is generally considered a risk factor for postoperative morbidity following open gastrectomy. Body mass index (BMI) is widely accepted as an indicator of obesity, but does not necessarily reflect the distribution of fat. It is unclear how different types of fat may affect the operative procedure and outcome. Methods The relationship between fat area (total, visceral and subcutaneous fat, and BMI) and early surgical outcomes (bleeding, operating time, morbidity, hospital death and hospital stay) was investigated in 135 patients who had a curative gastrectomy at the Cancer Institute Hospital, Tokyo, in 2006. Results Postoperative intra-abdominal infection, which occurred in 13 patients (9·6 per cent), correlated strongly with visceral (P = 0·023) and total (P = 0·037) fat area. Visceral fat area also correlated with hospital death (P = 0·041) and a longer hospital stay (P = 0·001). Subcutaneous fat area and BMI did not correlate with these early surgical outcomes. Conclusion Patients with a high visceral fat area are more likely to develop an intra-abdominal infection after gastrectomy. Assessment of fat area, in particular visceral fat area, should alert surgeons to increased postoperative risks.

Laparoscopy-assisted distal gastrectomy (LADG) with standard D2 dissection is a complex procedure usually performed only by experienced surgeons, and the feasibility of this procedure still remains unclear.Patients who underwent LADG at the Cancer Institute Hospital between April 2006 and October 2008 were recruited for this study. Early surgical outcomes were compared between patients who underwent complete D2 dissection (complete D2 group; n = 42) and those who underwent D1 + beta dissection (D1 + beta group; n = 179) to determine the feasibility of laparoscopic D2 lymph node dissection.In complete D2 group, the operation time was longer (253 +/- 10 vs 224 +/- 4 min; P = 0.005), and the number of retrieved lymph nodes was larger (41 +/- 2 vs 35 +/- 1; P = 0.002) compared with those in D1 + beta group. The other early surgical outcomes monitored for the two groups were not different between groups.LADG with complete D2 lymph node dissection can be performed safely if the procedure is standardized and an experienced laparoscopic surgeon performs the surgery. To be accepted as a standard treatment for advanced gastric cancer, well-designed prospective trial is necessary.

In advanced gastric cancer (AGC) with duodenum invasion, the posterior pancreatic lymph nodes are susceptible to metastasis because of their proximity to the duodenum. The therapeutic value of lymph node dissection in this area for AGC with macroscopic duodenum invasion remains unclear.Patients who had undergone curative gastrectomy for lower-third AGC from 1970 to 2004 at the Cancer Institute Hospital were recruited for this study. Clinicopathological data were collected retrospectively, and compared between cases of AGC with duodenum invasion (AGC-DI group) and AGC without duodenum invasion (AGC-nDI group). In the AGC-DI group, the therapeutic value of lymph node dissection was evaluated using a therapeutic index (multiplication of the frequency of metastasis to the station by the 5-year survival rate of patients with metastasis to that station).The AGC-DI group generally had tumors of higher pathological stage, which might account for the poorer 5-year survival rate compared with that of the AGC-nDI group (50.1% versus 68.5%; P = 0.0002). The incidence of lymph node metastasis was higher in the AGC-DI group than that in the AGC-nDI group, including nodes in the posterior pancreatic head (23.9% versus 7.0%, P0.0001). In the AGC-DI group, posterior pancreatic head lymph node dissection was of therapeutic value (4.19) equivalent to dissection of second-tier lymph nodes.The dissection of posterior pancreatic head lymph nodes might be effective in AGC with macroscopic duodenum invasion since this has therapeutic value equivalent to that of second-tier lymph node dissection and might improve patients' long-term outcomes.

症例は79歳の男性で，11年前に早期胃癌に対し，噴門側胃切除ダブルトラクト再建を施行．その後，外来経過観察中であった．術後10年目の上部消化管内視鏡，腹部超音波検査など異常なく，一旦外来経過観察打ち切りとなった．ただし，間置空腸が長いため，残胃の観察はできていなかった．入院の2か月前より，嘔吐あり，前医受診．横行結腸浸潤を伴う，残胃の進行癌と診断され手術を施行した．手術所見では腹壁，肝臓，膵頭部，横行結腸への腫瘍の直接浸潤を認め，また挙上空腸も腫瘍に巻き込まれており，合併切除しなければ経口摂取不能と判断し，残胃，挙上空腸，横行結腸を合併切除した．ただし，洗浄細胞診が陽性であり，非治癒切除におわった．本症例は，初回術後，毎年経過観察していたにもかかわらず，内視鏡検査による残胃の観察ができず，早期には指摘できなかった．残胃の観察が十分できる再建法の工夫と，初回術後長期の経過観察が必要と思われた．

Background/Aims:Although laparoscopy is accepted for treatment of colorectal cancer, there is no established consensus for its use when resection of synchronous liver metastases is performed simultaneously. The purpose of this study was to evaluate whether laparoscopic colorectal resection with simultaneous resection of synchronous liver metastases was technically feasible and whether it may be a therapeutic option. Methods: Ten patients underwent laparoscopic resection for primary colorectal cancer, combined with synchronous resection of liver metastases. Results: The primary tumor location was in the sigmoid colon in 3 patients and the rectum in 7. All laparoscopic colorectal resections were successful, with no conversion to open surgery. Simultaneously, there were 7 conventional open and 3 laparoscopy-assisted liver resections. The median total operating time was 446 (range 300–745) min, including 222 (range 152–313) min for colorectal resection. The median total estimated blood loss was 175 (range 30–1,200) ml, including 10 (range 0–550) ml for colorectal resection. There was no major morbidity, except 1 patient who developed decubitus. Conclusion: This preliminary report suggests that laparoscopic resection for sigmoid colon and rectal cancer, combined with synchronous resection of liver metastases, is a safe and feasible procedure in selected patients.

Laparoscopic surgery for rectal cancer has been considered more demanding than laparoscopic colectomy due to its technical difficulties. The aim of this study was to show safety and feasibility of laparoscopic low anterior resection for lower rectal cancer reconstructed by double-stapling technique (DST). The present study reviewed 159 patients with rectal cancer undergoing laparoscopic anterior resection reconstructed by DST. They were subdivided into two groups: 98 patients with upper rectal cancer located between 75 and 150 mm from the anal verge (group A) and 61 with lower rectal cancer located within 75 mm from the anal verge (group B). Short-term results and pathological findings were compared between the two groups. There was no conversion in both groups. Operating time and intraoperative blood loss were similar in the two groups. No mortality occurred in either group. Overall morbidity rate was 10.2% in group A and 11.5% in group B (p = 0.798). Anastomotic leak rate was similar in the two groups (2.0% in group A versus 3.3% in group B; p = 0.638). Pathological examination of resected specimen showed no involvement of distal resection margin or circumferential resection margin in both groups. The present study shows that laparoscopic surgery is safe and feasible for lower rectal cancer in a very select group of patients.

Proximal gastrectomy is typically indicated in early gastric cancer of the upper third of the stomach. Esophagogastrostomy (EG) and jejunum interposition (JI) are often selected as reconstruction methods, although the more appropriate method of the two is unknown. One hundred and seven patients, who underwent a proximal gastrectomy followed by either an EG or a JI, were sent a questionnaire of 33 questions about subjective symptoms. Eighty-three patients (45 in the JI group and 38 in the EG group) returned the questionnaire. Results were compared between the two groups to identify the appropriate reconstruction method after a proximal gastrectomy. Also, changes in a patient’s body weight after surgery were compared. Early and late dumping syndromes and gastroesophageal reflux associated symptoms were equally observed between the two groups. However, abdominal discomfort after meals (P = 0.008), continuous gastric fullness (P = 0.028), and hiccups between meals (P = 0.022) were often observed in the JI group. The loss of body weight was not significantly different between the two groups. EG is a better reconstruction method compared to a JI after a proximal gastrectomy when evaluating subjective symptoms. Prospective study is warranted to clarify the better reconstruction method following proximal gastrectomy in terms of both subjective and objective symptoms.

Total mesorectal excision (TME) with preoperative chemoradiation therapy is an accepted standard treatment for low rectal cancer. Although the laparoscopic approach is accepted for the treatment of colon cancer, its value for low rectal cancer is unknown. The purpose of this study was to evaluate whether preoperative chemoradiation therapy exerted an adverse influence on laparoscopic TME for low rectal cancer.We studied 125 consecutive patients who underwent laparoscopic TME for low rectal cancer. Twenty patients with preoperative chemoradiation therapy (CRT-Lap group) were compared with 105 patients without chemoradiation therapy (non-CRT-Lap group).Operating time in the CRT-Lap group (276 min, range 160-390 min) was no different from that in the non-CRT-Lap group (263 min, range 143-456 min). The CRT-Lap group had more blood loss during the operation (70 vs. 37 ml), but mean blood loss was100 ml. The distal tumor margin was longer in the CRT-Lap group (25.8 vs. 18.6 mm). The number of lymph node harvested did not differ between the groups (14.5 vs. 15.4). Conversion to open surgery was necessary only in one case in the non-CRT-Lap group. There was no anastomotic leakage in the CRT-Lap group, whereas three patients (3.1%) had anastomotic leakage in the non-CRT-Lap group.Laparoscopic TME with preoperative chemoradiation therapy is a safe procedure with reasonable operating time and does not appear to pose any threat to the surgical and oncologic outcomes.

The modified irinotecan plus bolus 5-fluorouracil/L-leucovorin (IFL) regimen (irinotecan plus bolus 5-fluorouracil/L-leucovorin) used to be one of the standard treatments for metastatic colorectal cancer until approval of oxaliplatin in Japan. We evaluated the efficacy of modified IFL therapy for Japanese patients.Forty-seven patients with metastatic colorectal cancer received irinotecan (100 mg/m(2)) and bolus 5-fluorouracil (500 mg/m(2)) plus L-leucovorin (10 mg/m(2)) on days 1 and 8 every 3 weeks until progression or unmanageable toxicity occurred. The data on toxicity and tumor response were analyzed retrospectively.All patients discontinued modified IFL therapy due to cancer progression, except for one patient who developed severe liver dysfunction. The overall response rate was 25%. The median progression-free survival time (PFS) was 8.6 [corrected] months. The median overall survival time (OS) was 27.8 [corrected] months for all patients, 30.9 [corrected] months for patients receiving subsequent oxaliplatin therapy, and 14.5 [corrected] months for patients without oxaliplatin (P = 0.0031). According to multivariate analysis results, good performance status, a normal white cell count, and absence of local recurrence were associated with a better PFS. Tumor response was a good prognostic factor for both PFS and OS. Gastrointestinal symptoms were the most common toxicities, including grade 3 diarrhea (8%) and grade 3 anorexia (10%). Grade 4 neutropenia occurred in 6% of patients. No other drug-related severe adverse events or deaths were observed.Modified IFL therapy is an effective and well-tolerated regimen for Japanese patients with metastatic colorectal cancer. Modified IFL therapy combined with biological agents might remain an option for some patients who refuse a central venous catheter.

Extracorporeal circular-stapled Billroth I (B-I) anastomosis is difficult in patients with obesity, a large body shape, or small remnant stomach, as it requires the duodenal stump to be lifted outside of the wound. The aim of this study was to evaluate the feasibility of circular-stapled B-I reconstruction for laparoscopy-assisted distal gastrectomy (LADG) with effective duodenal mobilization. Between March 2005 and December 2007, 199 patients with early gastric cancer underwent LADG with B-I reconstruction in the Department of Gastrointestinal Surgery at the Cancer Institute. The greater omentum, comprised of four membrane layers, was completely dissected for effective duodenal bulb mobilization to allow easy performance of extracorporeal end-to-end gastroduodenostomy. Several clinicopathophysiological features relating to anastomosis complications, including anastomotic leakage, stenosis, bleeding, and ulcers, were evaluated. The success rate of extracorporeal circular-stapled B-I anastomosis was 100% for the 199 patients, 24% of whom had a body mass index greater than 25. The rate of anastomosis-related postoperative complications was 2%. Anastomotic leakage was not observed in this study. Anastomotic stenosis was observed in 2 (1%) patients, anastomotic bleeding was observed in 1 (0.5%) patient, and anastomotic ulcer was diagnosed in 1 (0.5%) patient. All these complications were managed conservatively. There was no postoperative mortality. Feasible duodenal bulb mobilization by complete dissection of the greater omentum allows easy performance of extracorporeal B-I anastomosis and minimizes complications related to anastomosis in LADG.

Laparoscopy-assisted gastrectomy (LAG) is being increasingly performed in Japan. However, the indication of LAG in elderly patients who usually have preoperative morbidities and reduced functional capacities still remains unclear.Two hundred eighty-nine patients who underwent LAG at the Cancer Institute Hospital were included in this study. Among them, 240 cases were younger than 75 years old (Y-LAG group), and 49 cases were 75 years old or older (E-LAG group). Early surgical outcomes between the two groups were compared to clarify the feasibility of performing LAG in elderly patients.The E-LAG group had a higher incidence of preoperative morbidities; however, the frequency of intraoperative and postoperative complications in this group was not significantly different from the Y-LAG group (9% vs 11%). The operation time was significantly shorter, and the number of retrieved lymph nodes was significantly smaller in the E-LAG group compared to the Y-LAG group. However, other early surgical outcomes were not significantly different between two groups.LAG proved to be a feasible and safe procedure in elderly patients provided that the patients were selected carefully.

Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. This study aimed to introduce a laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection that is applicable for submucosal tumor resection independent of tumor location and size.Seven patients underwent LECS for the resection of gastric submucosal tumors. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device.In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In four of seven cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The remaining three tumors were in the posterior gastric wall. In two cases, the tumors were more than 5 cm in diameter, and one was a GIST of the remnant stomach. The mean operation time was 169 +/- 17 min, and the estimated blood loss was 7 +/- 2 ml. The postoperative course was uneventful in all cases.The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.

Pancreatoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high frequency of associated morbidity and mortality. The aim of this study was to determine the limited indication of PD for advanced gastric cancer.From January 1984 and December 2005 patient's charts were reviewed and outcomes after PD for gastric cancer were compared between two subgroups; those with a 'high' number (7or= group) of lymph node metastases and those with 'low' numbers (6or= group).PD was intraoperatively selected because of direct tumor invasion into the pancreas (52.2% of the 7or= group vs 12.5% of the 6or= group) or pancreatic lymph node infiltration (47.8% of the 7or= group vs 87.5% of the 6or= group; P = 0.058). The postoperative histological analysis showed 22 cases from 23 (95.7%) in 7or= group with T3 or T4 tumor, compared with only 4 cases (50%) in 6or= group (P = 0.014). The 5-year survival rates were significantly better in the 6or= group compared with the 7or= group (P = 0.014).The indication for PD in advanced gastric cancer should consider the degree of extensive lymph node metastases and incurable factors.

Rectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed. The important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon. Seventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%). Our standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).

Background This prospective randomized study compared the survival of patients with tumour node metastasis (TNM) stage T2 N1–2 gastric cancer treated by gastrectomy alone or gastrectomy followed by uracil–tegafur. Methods Patients were randomly assigned to surgery alone or to surgery and postoperative uracil–tegafur 360 mg per m2 per day orally for 16 months. The primary endpoint was overall survival. Relapse-free survival and site of recurrence were secondary endpoints. Results Of 190 registered patients, 95 were randomized to each group; two patients with early cancer were subsequently excluded from the chemotherapy group. The trial was terminated before the target number of patients was reached because accrual was slower than expected. Drug-related adverse effects were mild, with no treatment-related deaths. At a median follow-up of 6·2 years, overall and relapse-free survival rates were significantly higher in the chemotherapy group (hazard ratio for overall survival 0·48, P = 0·017; hazard ratio for relapse-free survival 0·44, P = 0·005), confirming the survival benefit shown in an interim analysis performed 2 years earlier. Conclusion Interim and final analyses revealed a significant survival benefit for postoperative adjuvant chemotherapy with uracil–tegafur in patients with serosa-negative, node-positive gastric cancer. Registration number: NCT00152243 (http://www.clinicaltrials.gov).

The prognosis of solitary liver metastasis involving the caudate lobe is unclear. This study analyzed the outcomes after resection of the caudate lobe for solitary colorectal liver metastasis. We reviewed the records of 114 cases in which potentially curative hepatectomy were performed for solitary colorectal liver metastasis. Solitary liver metastasis involving the caudate lobe was seen in 14 cases (Caudate group). The outcomes were compared with those of the remaining 100 cases with metastasis in a site other than the caudate lobe (Other group). No hospital deaths occurred. The 5-year survival rate for all cases was 61%. Recurrence-free and cumulative survivals were similar in the two groups, as were the intraoperative blood loss, duration of operation, and postoperative hospital stay. The distance of the surgical margin was significantly shorter in the Caudate group than in the Other group (0.6 mm vs. 6.6 mm; p = 0.001). A concomitant resection of the inferior vena cava was performed in four patients in the Caudate group but in no patients in the Other group (p < 0.001). Despite a minimal surgical margin, the resection of solitary colorectal liver metastasis offers favorable short- and long-term outcomes comparable to those for colorectal liver metastasis at other sites.

Background An aberrant left hepatic artery (ALHA) is occasionally encountered during esophagogastric surgery. However, at curative gastrectomy for gastric cancer, it is questionable as to whether the ALHA need to be divided in order to maximize lymph node clearance and the issue requires clarification. Methods We encountered 50 patients with an ALHA during curative gastrectomy for gastric cancer between 1997 and 2001. Data concerning operative feasibility, postoperative liver function and therapeutic value of nodal dissection were analyzed retrospectively. Results For 27 patients, we preserved the ALHA, and for the remaining 23 patients, we divided the ALHA at the origin of the left gastric artery (LGA). Serum levels of aspartate aminotransferase and alanine aminotransferase were statistically significant higher on postoperative day (POD) 1 ( P =0.0008 and P =0.0007), and on POD 3 ( P =0.001 and P =0.008), respectively, in the ALHA-divided group. Patients who underwent a total gastrectomy predominated in the ALHA-divided group, the total number of dissected lymph nodes being higher in the ALHA-divided group ( P =0.018). However, the total numbers of dissected lymph nodes and metastatic lymph nodes around the LGA were similar in the 2 groups ( P =0.447 and P =0.128), respectively. No significant differences were seen between the 2 groups in morbidity and mortality. The overall 5-year survival rates were also comparable. Conclusions Although a prospective study is required, this study suggested that routine division of the ALHA may not always be required for curative gastrectomy.

A 63-year-old woman with appetite loss and general fatigue underwent gastrointestinal fiberscopy, which revealed type 2 advanced gastric cancer. Multidetector-row computed tomography revealed a massive gastric cancer invading the left hepatic lobe, pancreatic head, and common hepatic artery, as well as revealing a duplicated hepatic artery in which the right hepatic artery branched directly from the celiac axis, and ran behind the splenic vein. On the other hand, the common hepatic artery ran anterior to the splenic vein. We were able to perform pancreaticoduodenectomy with common hepatic artery resection and left lobectomy as curative surgery because her duplicated hepatic artery enabled us to ligate the common hepatic artery. Her postoperative clinical course was uneventful, and she is in good health 3 years after the surgery, without recurrence. We consider that multidetector-row computed tomography is very useful for the diagnosis of vascular anomaly, preoperative staging and decision making on the appropriate surgical strategy.

T4 esophageal cancer is defined as the tumor invading adjacent structures, using tumor–node–metastasis (TNM) staging. For clinically T4 thoracic esophageal carcinoma, multimodality therapy, that is, neoadjuvant chemoradiotherapy (CRT) followed by surgery or definitive CRT, has generally been performed. However, the prognosis of patients with these tumors remains poor. Another strategy is needed to achieve curative treatment. In the present article, the treatment strategies employed to date are reviewed. Furthermore, the strategies for these malignancies are reassessed, based on our experiences. R1/2 and R0 resections are regarded as those with residual and no tumor after surgery. The present data show that patients who underwent R1/2 resection after neoadjuvant CRT experienced little survival benefit, while complete response (CR) cases after definitive CRT had comparatively better results. Therefore, curative surgery should not be attempted without down-staging, and definitive CRT should be the initial treatment. Then surgery is indicated for the eradication of residual cancer cells. Close surveillance is essential for early detection of relapse even after CR, because the operation will gradually become increasingly difficult due to post-CRT fibrosis. In conclusion, multimodality therapy consists of definitive CRT followed by R0 resection, which can be the treatment of choice for T4 esophageal carcinoma. These challenging treatments have the potential to constitute the most effective therapeutic strategy. (Cancer Sci 2007; 98: 937–942)

The aim of this study was to determine the long-term post-resection outcomes for cirrhotic patients with early-stage hepatocellular carcinoma (HCC).A total of 217or = 65-year-old cirrhotic patients who underwent hepatic resection were divided into four groups in accordance with the Milan criteria: Group 1, those who met the Milan criteria (n = 130); Group 2A, those with a solitary tumor5 cm in size (n = 12); Group 2B, those with 2 or 3 tumors3 cm in size (n = 35); and Group 2C, those withor = 4 tumors (n = 33). Overall and recurrence-free survival were compared between the groups.At 1, 3, 5 and 10 years, overall survival rates were 91, 67, 45 and 12%, and recurrence-free survival rates were 62, 26, 16 and 0%, respectively. Independent prognostic factors for overall survival were age, blood transfusion, tumor number, tumor size and microscopic vascular invasion; and for recurrence they were hepatitis C infection, tumor number, tumor size, microscopic vascular invasion and histological tumor grade. Group 1 patients had significantly better survival (5-year survival rate, 56%) than those of other groups (5-year survival rate, around 30%). The median tumor-free survival time was significantly shorter in Groups 2B and 2C (0.7 years and 0.6 years, respectively) than in Groups 1 and 2A.Hepatic resection can confer a considerable overall survival benefit for cirrhotic patients with HCC who meet the Milan criteria. For patients with HCC who do not meet the criteria, however, hepatic resection has limited efficacy. We suggest that application of non-surgical therapy or expansion of the indications for liver transplantation may be warranted for such patient subsets.

肝・膵手術における特殊縫合糸の使用実態を明らかにするために多施設調査を行い, 経済的な観点から考察を行った. 2005年4月～2006年12月の任意の連続した3カ月間に全国10の協力施設で手術ごとに使用した特殊縫合糸を品番別にパッケージ単位でカウントした. 診療報酬点数表の全種類の肝切除術, 肝移植に関する手術, 膵頭部腫瘍切除術で特殊縫合糸の平均使用金額が50,000円以上であった. 手術料に占める特殊縫合糸平均使用金額の割合は生体部分肝移植で27%, 肝部分切除術と周辺臓器の合併切除を伴う膵頭部腫瘍切除術で24%, 肝区域切除術が23%を示した. 本調査により肝胆膵外科・移植外科領域での合成吸収糸等の特殊縫合糸の使用状況が明らかになった. その費用は手術料に包括できる範囲を超えており, 手術の種類や個々の患者の状態で使用量が大きく変動することから手術料とは別に保険償還することが合理的であると考えられた.

Background Owing to its relative rarity, the characteristics of gastric stump cancer (GSC) have not been fully understood. In this study, we clarified the detailed characteristics from a large cohort of GSC patients. Patients and methods For this retrospective cohort study from 1 hospital in Japan, we recruited 262 GSC patients who underwent surgery for GSC between 1984 and 2012. GSC was defined in accordance with Japanese Gastric Cancer Association. Stage was categorized in accordance with the 7th TNM classification for primary gastric cancer. Results Although the time interval between the primary and second operations differed significantly depending on the primary disease (34.3 years for benign vs 9.9 years for malignant on average), it did not influence survival. The 5-year overall survival rates of patients with N0, N1, N2, and N3 were 70.4%, 27.7%, 21.8%, and 6.4%, respectively, whereas the rates for those with stage I, II, III, and IV were 77.8%, 37.4%, 18.6%, and 10.5%, respectively. Recurrence in the peritoneum was the most common pattern, followed by recurrence in the local region or lymph nodes. The Cox proportional hazard model demonstrated that age > 65, T stage, N stage, and tumor histology were significant independent prognostic factors for survival, whereas neither primary disease nor primary anastomosis type significantly impacted survival. Conclusion Neither primary disease nor anastomosis type affected survival significantly, despite significant differences in their characteristics. In addition, the time interval between the primary and second surgery did not impact survival.

Studies have demonstrated a relationship between clinical outcomes after curative resection for colorectal cancer (CRC) and gene mutations of the EGFR pathway; however, no studies have examined metastatic CRC (mCRC) patients with metastasectomy. The aim of this study was to evaluate the relationship between gene mutations of EGFR pathway and clinical outcomes after metastasectomy in mCRC patients. A total of 1,053 patients histopathologically confirmed CRC received a genotyping test for the EGFR pathway from February 2012 to October 2013. Detailed information was obtained through review of medical records. Gene mutations of EGFR pathway were analyzed by Luminex assay. Overall survival (OS) and recurrence free survival were estimated by the Kaplan-Meier method and the log-rank test was used to compare the survival outcomes by gene mutation status. A total of 132 patients received metastasectomy. The frequencies of KRAS exon 2, KRAS exon 3.4, NRAS, BRAF, and PIK3CA mutations were 38.6% (51/132), 3.6% (5/132), 5.1% (7/132), 5.1% (7/132), and 8.7% (12/132), respectively. With a median follow-up of 84.1 months (57.2-NA) for a survivor, the 4-year OS rate was 65.6% for mCRC with RAS mutation, and 81.3% for mCRC with wild-type RAS (p 0.05). We observed a statistically significant correlation for only the RAS mutation and OS. In multivariate analysis, RAS mutation and liver metastasis were independent factors for shorter OS. There were no significant differences between gene mutations of EGFR pathway and recurrence free survival. RAS mutation in mCRC metastasectomy patients was associated with shorter overall survival.

Background: Capecitabine plus oxaliplatin (CapeOx) ± bevacizumab therapy is associated with a high incidence of hand-foot skin reaction (HFSR), hindering treatment. However, timing of onset and risk factors remain unclear. Objective: This study examined the development of HFSR and risk factors for its exacerbation to a serious condition in CapeOx ± bevacizumab therapy. Methods: We retrospectively examined patients with colorectal cancer receiving CapeOx ± bevacizumab therapy between October 1, 2009, and March 31, 2012. The observation period was defined as lasting until completion of 8 cycles. The relationship between cumulative dose of capecitabine and cumulative proportion of patients developing HFSR was evaluated by Kaplan-Meier methods. Risk factors for exacerbation of HFSR to a serious condition were assessed by multiple logistic regression. Results: Data for 203 patients were analyzed. For patients treated at cumulative capecitabine doses of 100 000 mg/m2 and 200 000 mg/m2, Grade 1 HFSR occurred in ≥80% and ≥90%, respectively, and moderate-to-severe HFSR (Grade 2+) occurred in ≥10% and ≥20%, respectively. Multivariate analysis showed significant associations with diabetes (odds ratio [OR] = 4.79; 95% confidence interval [CI] = 1.86-12.34; P = 0.001), concomitant use of bevacizumab (OR = 6.01; 95% CI = 2.20-16.41; P = 0.001), history of fluorinated pyrimidine administration (OR = 2.42; 95% CI = 1.10-5.33; P = 0.027), and early onset (within 21 days) of Grade 1 HFSR (OR = 3.78; 95% CI = 1.64-8.70; P = 0.001). Conclusions: HFSR in CapeOx therapy is a cumulative toxicity and risk of exacerbation to a serious condition increases with diabetes, concomitant use of bevacizumab, history of fluorinated pyrimidine administration, and onset of Grade 1 HFSR within 21 days.

Hypothyroidism is one of the side-effects caused by regorafenib. In the Japanese subset of the CORRECT study, hypothyroidism developed in 1.5% of the patients, but was not grade 3 or higher in any patient. Regorafenib is an oral multi-kinase inhibitor that has the same mechanism of action as sunitinb. However, the reported incidence of sunitinb-related hypothyroidism varies widely, ranging from 16.0% in clinical trials to 35.4% in post-marketing surveillance studies. In general, symptoms of hypothyroidism include fatigue and dysphonia. Hyperthyroidism must, therefore, be appropriately managed in order to maintain patient quality of life and avoid a critical level of hypothyroidism. During the first cycle of treatment with regorafenib, the incidence of abnormal thyroid-stimulating hormone (TSH) elevation was 31.4%. Our results suggest that thyroid function tests should be performed from day 1 of treatment with regorafenib. It would be prudent to consider routine monitoring of thyroid function in all patients who receive regorafenib and to recommend endocrinological consultation as necessary.

Surgery is the only potentially curative strategy for patients who have Stage IV colorectal cancer (CRC) with resectable metastases, but relapse is common. Randomized trials of adjuvant 5-FU-based systemic chemotherapy have not demonstrated any benefit after resection of liver metastases. We evaluated the efficacy, safety, and tolerability of oxaliplatin-based adjuvant chemotherapy after curative resection of hepatic or extrahepatic metastases of CRC. We retrospectively studied data for 88 consecutive patients with Stage IV CRC who underwent curative resection of metastases followed by oxaliplatin-based adjuvant chemotherapy between March 2007 and June 2013. The 3-year relapse-free survival (RFS) rate was 54.0 %. There was no significant difference in 3-year RFS between patients with metastases confined to the liver (52.7 %) and patients with extrahepatic metastases (57.2 %). Multivariate analysis revealed that the site of the primary tumor (right-sided colon or left-sided colon/rectum) and the number of metastases (solitary or multiple) were predictors of RFS. Scheduled courses were completed in 80.7 % of the patients. Except for neutropenia (47.7 %), severe adverse events were observed in

The objectives of this study were to evaluate the incidence of and the risk factors for readmission after gastrectomy. Our hypothesis was that early discharge may be related to an increase in the incidence of readmission. This was a retrospective, single-center, observational study of 1442 patients who underwent gastrectomy for stage I gastric cancer. The main outcome was the incidence of early readmission after gastrectomy, which was defined as an admission within 6 months after the first discharge day. A stepwise logistic regression analysis was conducted to identify the risk factors for readmission after gastrectomy. The surgical procedures performed were total gastrectomy in 217 patients (15.0 %), distal gastrectomy in 845 patients (58.6 %), pylorus-preserving gastrectomy in 342 patients (23.7 %), and proximal gastrectomy in 37 patients (2.6 %). The median hospital stay was 11 days, and there were 63 readmissions for a total of 56 patients (3.8 %). The main reasons for readmission were poor food intake in 14 patients (22.2 %), anastomotic stricture in nine patients (14.3 %), small bowel obstruction in eight patients (12.7 %), and an abdominal distension in seven patients (11.1 %). Endoscopic balloon dilation was performed for the nine patients with anastomotic stricture, drainage was needed for the four patients with an intra-abdominal abscess, and laparotomy was performed for one patient with adhesion-associated bowel obstruction. The long hospitalization during the primary admission and patients who underwent total gastrectomy were risk factors for readmission. Patients with a long hospital stay after gastrectomy are at an increased risk of early readmission, which was likely related to the incidence of severe sequelae specific to gastrectomy.

Background The Maastricht, Asia-Pacific consensus guidelines strongly recommend eradication of Helicobacter pylori in patients who have a history of gastric cancer. This open-label, single-center, randomized controlled trial was conducted to investigate the appropriate timing of eradication for patients undergoing gastrectomy. Study Design One hundred and fifty patients scheduled to undergo gastrectomy were allocated to either a preoperative or a postoperative group. The eradication regimen was a common triple therapy: lansoprazole, amoxicillin, and clarithromycin. Patients in the preoperative group were treated with the regimen, followed by surgery, and patients in the postoperative group were treated after postoperative day 8. The primary end point was the proportion of patients achieving successful eradication in the remnant stomach. The definition of successful eradication was negativity in both the C13 urea breath test and for the antigen in feces at 6 months after surgery. Results Eight patients were excluded, and the remaining one hundred and forty-two, 70 in the preoperative group and 72 in the postoperative group, were included on an intention to treat basis. The procedures used were gastrectomy with Billroth I, Roux-en-Y, and pylorus-preserving gastrectomy in 18, 70, and 57 patients, respectively. The proportion of patients showing successful eradication hardly differed between the 2 groups, 68.6% vs 69.4% (p = 1.000) in the pre- and postoperative groups, respectively. Subgroup analysis also demonstrated no significant difference among the reconstruction methods used. Conclusions Preoperative H pylori eradication therapy for gastric cancer patients scheduled for gastrectomy is not necessary, regardless of the planned reconstruction procedure.

Mitsukuni Suenaga, Nobuyuki Mizunuma, Eiji Shinozaki, Satoshi Matsusaka, Masato Ozaka, Mariko Ogura, Keisho Chin, Toshiharu Yamaguchi Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan Background: Doppler ultrasound imaging is useful for management of venous thromboembolism associated with a subclavicular implantable central venous access system in patients receiving bevacizumab (Bev). We investigated the efficacy and safety of our anticoagulant regimen based on Doppler findings.Methods: Patients aged ≤75 years with metastatic colorectal cancer, no history of thromboembolism, and no prior use of Bev received chemotherapy plus Bev. Doppler ultrasound imaging of the deep venous system to detect thrombosis was performed after the first course of Bev and repeated after the third course in patients with asymptomatic thrombosis. Indications for anticoagulant therapy in patients with asymptomatic thrombosis were as follows: enlarging thrombus (E), thrombus >40 mm in diameter (S), thrombus involving the superior vena cava (C), and decreased blood flow (V).Results: Among 79 patients enrolled in this study, asymptomatic thrombosis was detected in 56 patients (70.9%) by Doppler ultrasound imaging after the first course of Bev and there was no thrombus in 23 patients (29.1%). Of these 56 patients, 11 (19.6%) received anticoagulant therapy with warfarin, including eight after the first course and three after follow-up imaging. S + V was observed in four of 11 patients (36.4%), as well as V in two (18.2%), S + V + C in one (9.1%), E + S + V in one (9.1%), E + C in one (9.1%), E in one (9.1%), and C in one (9.1%). All patients resumed chemotherapy, including seven who resumed Bev. Improvement or stabilization of thrombi was achieved in ten patients (90.9%). Only one patient had symptomatic thromboembolism. Mild bleeding due to anticoagulant therapy occurred in six patients (54.5%), but there were no treatment-related severe adverse events or deaths. Severe thromboembolism was not observed in the other 68 patients.Conclusion: Our anticoagulant protocol for asymptomatic thrombosis detected by Doppler ultrasound imaging was effective at preventing severe thromboembolism during continued treatment with Bev. Keywords: venous thromboembolism, Bev, anticoagulant therapy, colorectal cancer

Aim To assess the risk of gastric cancer in a Japanese patient population with the disease by stratification with histology, age, tumour location and the association with family history of gastric or non-gastric tumours. Methods A retrospective analysis of 1400 consecutive patients with gastric cancer and 13,467 age- and gender-matched controls from a pre-recorded database using conditional logistic regression models. Results Young patients (≤43 years of age) with gastric cancer of intestinal type had a strong association with family history of gastric cancer in first degree-relatives (OR = 12.5). Moreover, when a history of gastric cancer was observed in both parents, there was an increased risk of gastric cancer intestinal type (OR = 7.8), more commonly in the proximal and mid-stomach. In contrast, there was an increased risk of diffuse-type cancer when both parents suffered non-gastric cancers (OR = 2.1). Conclusion These data suggest that the degree of familial clustering differ in gastric cancer subgroups stratified by histology, age, and stomach location in this Japanese population.

Background Surgical resection has been the first choice for treatment of pulmonary metastases from colorectal cancer; however, indications for surgery have yet to be adequately clarified. In considering strategies for the treatment of pulmonary metastases from colorectal carcinoma, determination of disease status as either systemic or pre-systemic is of primary importance. The aim of this study is to define the characteristics of those patients who are most likely to benefit from surgical resection. Methods Fifty-eight patients who underwent pulmonary resection for colorectal metastases were retrospectively reviewed and examined for clinicopathological factors. Results Overall, 5-year survival rates were 29%, with a median survival time (MST) of 27 months. Multivariate analysis identified four factors that indicate independent and favourable prognostic impact: three or less tumours, metachronous metastasis, negative hilar and/or mediastinal lymph node metastasis and normal prethoracotomy serum carcinoembryonic antigen level. The 5-year survival rate for 16 patients who satisfied all of these favourable characteristics was 62% (MST = 86 months), which was significantly better than those patients lacking these characteristics. The 5-year survival rate for 13 patients who underwent repeated metastasectomy was 37% (MST = 32 months). Conclusions The four factors selected in our multivariate analysis appear to be favourable factors for the practical identification of those patients who are most likely to benefit from surgical resection. Repeated pulmonary resection for lung-only recurrence may benefit carefully selected patients.

The goal of the present study was to evaluate the efficacy of the novel LigaSure Vessel Sealing System (Valleylab, Boulder, CO) when used for liver resection.Sixty patients (n = 30 in each group) with liver pathology from a single center were randomized to undergo liver resection with either the LigaSure system or with conventional clamping methods. Patients were stratified according to tumor size (5 or5 cm), type of hepatectomy (minor or major), and liver damage (normal or injured). Estimated blood loss during liver transection was used as the primary end point, whereas liver transection speed and morbidity rate were used as secondary end points.There were no hospital deaths. The median blood loss during liver transection was less in the LigaSure than in the conventional group (200 vs 322 mL; P = .185). The amount of blood loss during minor hepatectomy was significantly less in the LigaSure than in the conventional group (186 vs 412 mL, P = .012). The liver transection speed was significantly faster in the LigaSure than in the conventional group (2.3 vs 1.6 cm(2)/min, P.001. The number of ties required during liver transection was significantly less in the LigaSure than in the conventional group (6 vs 69 ties, P.001). The morbidity rate was similar when comparing the 2 groups, indicating that the LigaSure sealing device and conventional methods had comparable efficacy in sealing the bile duct in the portal triad. Postoperative bile leak was observed in 1 patient (3%) in the LigaSure group and in 3 patients (9%) in the conventional group (P = .301).The LigaSure system is an effective and safe tool for decreasing liver resection time.

Imatinib mesylate (imatinib, STI571, Gleevec; Novartis Pharma) is an orally administered competitive inhibitor of BCR-ABL tyrosine kinase that has demonstrated significant efficacy in chronic myelogenous leukemia (CML). Imatinib is also a potent inhibitor of the receptor-type KIT tyrosine kinase with demonstrated benefits in KIT-expressing gastrointestinal stromal tumors (GISTs). This article presents the case of a patient with simultaneous occurrence of CML and GIST who was treated with the single agent imatinib. To our knowledge, this is the first report of simultaneous occurrence of these two malignancies and of the efficacy of imatinib in concurrent treatment of both neoplasms in a single patient.

Background Reflux oesophagitis is commonly encountered in the surgical treatment of cancer of the upper third of the stomach. The aim of this study was to describe a novel surgical technique and evaluate the clinical outcome of high segmental gastrectomy for early-stage proximal gastric cancer. Methods Thirty consecutive patients with early gastric cancer located in the upper third of the stomach were included, of whom 12 underwent high segmental gastrectomy and 18 underwent proximal gastrectomy with jejunal interposition. The incidence of reflux oesophagitis and nutritional parameters were compared between the two groups at 1 year after operation. Results One patient had mild reflux symptoms and two had endoscopic evidence of oesophagitis 1 year after high segmental gastrectomy. Half of the patients who had proximal gastrectomy had reflux symptoms of varying severity and 14 had endoscopic evidence of oesophageal changes at 1 year after surgery. There were significant differences between groups in the incidence of reflux symptoms (P = 0·016) and endoscopically detected gastro-oesophagitis (P < 0·001). There were no adverse events in either group, and the survival rate after high segmental gastrectomy appeared favourable. Conclusion Selected patients with early-stage proximal gastric cancer benefit from high segmental gastrectomy in terms of reduced reflex oesophagitis, without jeopardizing curability.

比較的稀な, Adachi VI型の血管走行破格を伴う胃癌手術を5例経験したので報告する. Adachi分類は腹腔動脈の分岐様式の分類で, VI型28群に分類される. Adachi VI型は膵上縁,門脈前面に総肝動脈がみられない型で,頻度は約2%とされる. Adachi VI型に対する胃癌手術では, No.8aリンパ節郭清の際に総肝動脈を認識することができず,しばしば問題となる.われわれは,進行胃癌症例においては,術前にMDCT, 3D-amgio-graphyを積極的に行い,詳細な血管走行の把握に努めている.その結果,過去20カ月間で経験したAdachi VI型の症例全てで術前診断が可能であり, D2郭清を伴う胃癌手術を安全に遂行可能であった. Adachi VI型をはじめとする血管走行の破格は少なからず存在し,術前に診断することで,術中合併症を回避できる可能性がある.また,術前に詳細な血管走行を理解する上で, MDCT, 3D-angiographyは極めて有用であると考えられた.

Laparoscopic total gastrectomy (LTG) is used for early gastric cancer (EGC) in the upper stomach. However, the incidences of postoperative anastomotic complications such as leakage and stricture remain high. This study investigated whether using a single-stapling technique (SST) instead of a hemi-double-stapling technique (HDST) for intracorporeal circular-stapled esophagojejunostomy could reduce anastomotic complications after LTG. This retrospective study included 136 patients with EGC treated by LTG with intracorporeal circular-stapled esophagojejunostomy. Originally, HDST was used for esophagojejunostomy in 71 patients (original group). Thereafter, the esophagojejunostomy procedure was modified, and SST was used in a further 65 patients (modified group). The impact of the anastomotic procedure (SST or HDST) on anastomotic complications after LTG was determined by uni- and multivariate analyses. The incidence of anastomotic complications was significantly lower in the modified group (7.7 %) than in the original group (22.5 %; P = 0.017). The frequency of anastomotic leakage was lower in the modified group (3.1 %) than in the original group (9.9 %), although the difference was not statistically significant. Meanwhile, the frequency of anastomotic stricture was significantly less common in the modified group (6.2 %) than in the original group (18.3 %; P = 0.032). Multivariate analysis showed that anastomotic procedure with SST was significantly associated with a lower rate of postoperative anastomotic complications (odds ratio [OR], 0.217; 95 % confidence interval [CI], 0.063–0.631; P = 0.004), as was the operation time (OR, 0.237; 95 % CI 0.082–0.667; P = 0.007). The use of SST for intracorporeal circular-stapled esophagojejunostomy could reduce anastomotic complications after LTG.

Early-onset gastric cancer is relatively rare. To evaluate the clinicopathological features and surgical outcome of young patients with gastric cancer, this retrospective comparative study was conducted. From 2000 to 2010, 4882 patients underwent surgery for gastric adenocarcinoma in our institution. A total of 136 patients under 40 years old were enrolled as the young group, and a total of 1435 patients aged between 60 and 69 were identified as the control group for this study. The patient’s characteristics, pathological findings, surgical and clinical outcomes were reviewed, and the risk factors of recurrence were compared between the two groups. Among the young group, patients had significantly fewer comorbidities and postoperative complications. The patient proportion having 7 or more lymph node metastases was higher in the young group (25 %) than in the control group (16 %). The presence of lymph node metastasis was identified as a strong risk factor for recurrence (odds ratio = 4.31) in the young group according to the results of the step-wise logistic regression analysis. Although the disease-specific survival at stage II was relatively better in the young group (p = 0.0439) than in the control group, there were no significant differences in overall survival for all stages. Early-onset gastric cancer is likely to present lymph node metastases. The survival rate of gastric cancer in young patients was equivalent to that in patients in their 60s, which is the typical age at onset.

To evaluate the clinical value of multidetector row computed tomography (MDCT) as a pre-operative staging tool for lymph node metastasis in patients with early gastric cancer (EGC).In 278 consecutive patients with EGC, lymph node metastasis was evaluated pre-operatively with MDCT at a slice thickness of 2.5mm (n=57), 5.0mm (n=188), or 7.5mm (n=33).Overall accuracy of nodal category from N0 to N3 was 86% for MDCT and 95% for operative assessment. Regarding accuracy in detecting at least one metastatic lymph node, area under curves (AUC) of receiver operating characteristics for 2.5, 5.0, and 7.5-mm slices and assessment during surgery were 0.87, 0.67 and 0.47, and 0.70, which were significantly different (P0.0001). MDCT image with 2.5-mm could discriminate the presence of lymph node metastasis with diagnostic accuracy: sensitivity 80%; specificity 92%; positive predictive value (PPV) 50%; negative predictive value (NPV) 98%, whereas assessment during surgery was as follows: sensitivity 65%; specificity 98%; PPV 72%; and NPV 97%.These results suggest that pre-operative assessment with MDCT using thinner slices may detect at least one lymph node metastasis as accurately as assessment during surgery for patients with EGC.

This report documents the findings of two rare cases of mature cystic teratoma of the pancreas. Although they could not be diagnosed preoperatively, our retrospective report suggests that the combined diagnosis of ultrasonography (US), enhanced computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP) might allow differentiation from other cystic lesions such as mucinous cystic tumors (MCTs) and intraductal papillary-mucinous tumors (IPMTs). Since the cystic teratomas were both filled with keratinous and sebaceous material, they were echogenic, appearing as solid masses on US. Enhanced CT showed their cystic nature, with values slightly higher than water, and MRCP revealed defects of internal signals.

Background. Although the number of patients with early gastric cancer (EGC) treated by endoscopic mucosal resection (EMR) has increased, the appropriate strategy for treating those with incomplete resection has not been established. Methods. This study analyzed 726 cases of EGC in patients treated by EMR between 1991 and 2000, in order to clarify the en-bloc and complete resection rates. We classified patients with incomplete resection into four groups according to the estimated risk of residual cancer or lymph node (LN) metastasis, determined from pathological findings of EMR specimens. We then analyzed 45 patients with EGC treated surgically after incomplete EMR, with the aim of eliciting the risk of residual cancer and LN metastasis. Results. Of the 726 patients, 529 (72.9%) had an en-bloc resection, while 378 (52.1%) had a complete resection. Three hundred and nine patients were found to have mucosal cancer and lateral cut-end-positive status with no LN metastasis (group A). In this group, 18 patients (5.8%) had residual cancer, with the lesions in the majority of patients being limited to the mucosal layer. Group B consisted of 14 patients with differentiated and submucosal (sm1) depth cancers, with 1 patient having residual cancer and 2 patients having LN metastasis. Fifteen patients were classified as group C, with sm2 or greater and vertical cut end-negative status, with 2 showing residual cancer and 1 showing LN metastasis. Group D included 10 patients with vertical cut end-positive status. Four of these patients had residual cancer while 1 had LN metastasis. Conclusion. We recommend that patients in group A should have close follow-up or endoscopic treatment, while those in groups B, C, or D should be treated by gastrectomy associated with LN dissection.

Between 1988 and 2003, 38 patients underwent biliary resection for pancreaticobiliary maljunction (PBM). We reviewed the histopathologic findings for the surgically resected specimens to compare the clinical and pathologic features and assess the relationship between changes in the background biliary epithelium and the development of neoplasms.Papillary hyperplasia (PHP) seen in the biliary epithelium of patients with PBM, was classified into grades 0--III in the gallbladder and grades 0--II in the extrahepatic bile duct, according to the extent, and was assessed for links with tumors in the same specimens.The incidence of gallbladder carcinoma was 13/21 in grades I--II, versus 0/16 in grade III, while the incidence of bile duct carcinoma was 4/20 in grade I versus 0/5 in grade II. Furthermore, these incidences for patients below age 50 years and age 50 or older were 1/18 versus 12/20, and 0/14 versus 6/17, respectively.PHP of the biliary epithelium in PBM patients is an important precursor lesion, especially for gallbladder cancer, and the risk becomes greater with age, regardless of the type of pancreatobiliary junction (PBJ) and its location in the biliary tract.