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Background Recently, indocyanine green (ICG) fluorescence imaging has been used to visualize the blood supply when anastomosis is performed in vascular surgery. We have reported the three blood supply routes to the reconstructed stomach using ICG fluorescence imaging for reconstruction during esophagectomy. Blood flow routes in the 33 patients with esophageal cancer were classified into categories on the basis of ICG imaging findings: the gastric wall route, the greater curvature route, and the omentum and splenic hiatal route. The gastric wall route was found in 13 patients and characterized by large blood vessels in the gastric wall. The greater curvature route was present in 11 patients and characterized by blood vessels in the greater omentum. The omentum and beside splenic hilum route was found in 22 patients. Blood vessels ran in the greater omentum beside the splenic hilum. a photodynamic eye (PDE) showed blood flow from right gastroepiploic artery, omentum vessels, left gastroepiploic artery, splenic hiatal vessels, short gastric artery, and gastric wall vessels to the top of the reconstructed stomach. The ‘splenic hiatal route’ was present in 66.7% of the patients and was formed by large vessels or networks of small vessels. We rechecked the ‘splenic hiatal route’ cases and recognize that the branch parted from the right gastroepiploic artery. We tried preservation of the ‘splenic hiatal route’. Methods Since January 2017, we have preserved the ‘splenic hiatal route’ and performed ICG fluorescence imaging in 5 patients with thoracic esophageal cancer who underwent thoracic esophagectomy. After pulling up the reconstructed stomach, 2.5 mg of ICG was injected as a bolus. ICG fluorescence imaging was performed with a near-infrared camera, and the images were recorded. Results ICG fluorescence was easily detected in all patients 1 min after injection. Vascular networks were well visualized in the gastric wall and omentum. The blood supply route was visualized the ‘splenic hiatal route’ in all patients. Conclusion On ICG fluorescence imaging, the splenic hiatal vessels would be the major blood supply for the anastomosis in most patients. Disclosure All authors have declared no conflicts of interest.

93 Background: Neoadjuvant chemotherapy is promising to improve the survival of resectable gastric cancer. Cisplatin/S-1 (CS) and docetaxel/cisplatin/S-1 (DCS) are both active for metastatic gastric cancer. Methods: We conducted a randomized phase II trial to compare two and four courses of neoadjuvant S-1/cisplatin (SC) and docetaxel/cisplatin/S-1 (DCS) using a two-by-two factorial design for locally resectable advanced gastric cancer. Patients with M0 and either T4 or T3 in case of junctional cancer or schirrhous type received two or four courses of cisplatin (60 mg/m2 at day 8)/S-1 (80 mg/m2 for 21 days with 1 week rest) or docetaxel (40 mg/m2 at day 1)/cisplatin (60 mg/m2 at day 1)/S-1 (80 mg/m2 for 14 days with 2 weeks rest) as neoadjuvant chemotherapy. Then, patients underwent D2 gastrectomy and adjuvant S-1 chemotherapy for 1 year. The primary endpoint was 3-year overall survival. The planned sample size was 120 eligible patients in total so that the treatment group with the superior observed 3-year OS rate by more than 60% as compared with 50% of the control group was to be selected with a probability of 85% or higher. Results: Between October 2011 and September 2014, 132 patients were assigned to CS (n = 66; 33 in 2-courses and 33 in 4-courses) and DCS (n = 66; 33 in 2-courses and 33 in 4-courses). The 3-year OS was 58.1% (95% CI, 45.8-70.3%) in CS and 60.0% (95% CI, 48.0-71.9%) in DCS with hazard ratio of 0796 (95% CI, 0.475-1.335), while that was 53.1% (95% CI, 40.9-65.4%) in the two courses and 65.0% (95% CI, 53.2-76.8%) in the four courses with hazard ratio of 0.722 (95% CI, 0.429-1.216). In the survival analysis by duration in each regimen, the 3-year OS was 58.1% (95% CI, 45.8-70.3%) both for two and four courses in CS, while that was 48.5% (95% CI, 31.4-65.5%) for two courses of DCS and was 71.9% (95% CI, 56.3-87.5%) for four courses of DCS. Conclusions: Considering high 3-year OS, four courses DCS has a value to be tested in a future phase III study to confirm superiority of neoadjuvant chemotherapy for locally advanced gastric cancer. Clinical trial information: UMIN000006378.

107 Background: Several reports revealed that preoperative presence of sarcopenia was related with poor prognosis for esophageal cancer. However, the influence of muscle mass loss during perioperative period on prognosis is unknown. The alternation of muscle mass during perioperative period is attractive topic as surgeon have chance to intervene for maintaining muscle mass in perioperative care. The aim of this study was to assess the influence of loss of muscle after esophagectomy to discharge on prognosis. Methods: This study retrospectively analyzed 150 consecutive patients with esophageal and gastroesophageal junction cancer, who underwent the open right thoraco−abdominal approach esophagectomy, pathologically diagnosed as squamous cell carcinoma or adenocarcinoma, between September 2011 and June 2015. Patients who had pathologically diagnosed as T4 or stageⅣ according to the UICC 7th edition TNM classification were excluded. This study investigated the influence of muscle mass loss after esophagectomy to discharge on prognosis. Body composition was analyzed using the Tanita MC−190EM bioelectrical impedance analyzer, evaluated within 1 week before surgery and at discharge. The primary end−point is over−all survival after esophagectomy. Results: The median % muscle mass loss was 4.38% (range −3.3 to +18.8). Patients were divided into two groups based on the % muscle mass loss by cut−off 4.38 (group A: less % muscle mass loss, group B: more % muscle mass loss). N stage (0/1/2/3) was 39/28/6/2 in group A, and 26/23/19/7 in group B. The rate of 2/3 was significantly higher in group B. Postoperative complication rate was 31% (23/75) in group A, and 48% (36/75) in group B. The complication rate was significantly higher in group B. The 3−years survival rate was 89.2% in group A, and 70.9% in group B. Group B was significantly worse for over−all survival than group A (p = 0.033). Multivariate Cox regression analysis showed that the patients who had % muscle mass loss over 4.38 (p = 0.045; HR 2.008; HR 95% CI 1.014−3.977), T2/3 (p = 0.001; HR 3.649; HR 95% CI 1.660−8.019) associated with worse over−all survival. Conclusions: Our study found correlation between loss of muscle after esophagectomy to discharge and worse outcomes.

Summary: Background: Body weight loss (BWL) is frequently observed in gastric cancer patients who undergo gastrectomy for gastric cancer. The risk factors for severe BWL after gastrectomy remain unclear. Methods: The present study retrospectively examined patients who underwent curative gastrectomy for gastric cancer between January 2012 and June 2014 at Kanagawa Cancer Center. All patients received perioperative care based on the enhanced recovery after surgery protocol. The %BWL value was calculated based on the percentage of body weight at 1 month after surgery in comparison to the preoperative body weight. Severe BWL was defined as %BWL > 10%. The risk factors for severe BWL were determined by both univariate and multivariate logistic regression analyses. Results: There were 278 patients examined. The median age of the patients was 68 years. The operative procedures included total gastrectomy [n=97; open (n=61) and laparoscopic {n=36)] and distal gastrectomy (n=181). Surgical complications of grade ≥ 2 (as defined by the Clavien–Dindo classification) were observed in 37 patients, these included: pancreatic fistula (n=9), anastomotic leakage (n=5), and abdominal abscess (n=3). There were no cases of surgery-associated mortality. Both univariate and multivariate logistic analyses demonstrated that surgical complications, and total gastrectomy were significant risk factors for severe BWL. Conclusions: Surgical complications and total gastrectomy were identified as being significant risk factors for severe BWL in the 1st month after gastrectomy. To maintain body weight after gastrectomy, physicians should pay careful attention to patients who undergo total gastrectomy and those who develop surgical complications. : Synopsis: This report demonstrates for the first time that the type of gastrectomy and surgical complications were significant independent risk factors for severe body weight loss in patients who received perioperative care using an enhanced recovery after surgery program after gastrectomy. Keywords: body weight loss, gastrectomy, gastric cancer

We previously demonstrated that body weight loss (BWL) at one month after gastrectomy, a common finding after surgery for gastric cancer, was an independent risk factor for the continuation of adjuvant chemotherapy with S-1. However, it is unclear whether BWL after gastrectomy leads to poor survival through poor compliance to adjuvant chemotherapy with S-1. We conducted this follow-up study in the same cohort as our previous study. Overall survival (OS) and recurrence-free survival (RFS) were examined in 103 patients who underwent curative D2 surgery and were pathologically diagnosed with stage II or III gastric cancer, and who received postoperative adjuvant chemotherapy with S-1 between June 2002 and December 2011. The median follow-up period was 64.3 months. The 5-year OS rate in the patients with a BWL of

We report a case of advanced esophageal and gastric cancer that was successfully treated via multimodal therapy. A 65- year-old man with hoarseness was referred to our hospital. He was diagnosed with clinical T4aN2M0, Stage IV esophageal squamous cell carcinoma and clinical T3N1M0, Stage II B gastric adenocarcinoma. He was treated with 3 courses of chemotherapy, administered over 4weeks, with S-1(80mg/m / / 2: day 1-14), cisplatin(60mg/m2: day 1), and docetaxel(40mg/m2: day 1). Computed tomography(CT)revealed shrinkage of the primary esophageal tumor, gastric tumor, and lymph node metastases. Next, we selected definitive radiation chemotherapy(CRT), because lymph node metastases remained around the bilateral recurrent laryngeal nerves. After CRT with a total 60 Gy plus administration of 5-fluorouracil and cisplatin, CT showed that the primary esophageal tumor and lymph node metastases had disappeared. Then, distal gastrectomy was performed for the remaining gastric cancer, as part of the multimodal therapy. After gastrectomy, no systemic chemotherapy was performed. At a follow-up examination 5 years and 6 months after the start of chemotherapy, the patient is alive without recurrence.

A30 -year-old woman underwent total gastrectomy with D2 lymph node dissection after being diagnosed with clinical T3, N2, M0, Stage III B gastric cancer. The postoperative pathological findings revealed a T3(SE), N2, M0, Stage III B tumor. Headache, dizziness, and vomiting occurred during chemotherapy for peritoneal recurrence, using weekly paclitaxel on days 1, 8, and 15. Head CT showed a solitary tumor with a diameter of 28mm in the cerebellum, as well as cerebellar swelling and hydrocephalus. She underwent an emergency craniotomy and tumor enucleation. Pathological examination revealed a metastatic brain tumor from the gastric cancer. She received 12 courses of CPT-11 plus cisplatin until discontinuation because of an adverse event. The patient is alive 6 years after the diagnosis of the cerebellar metastasis without recurrence.

Complete surgical resection is essential for a cure for most gastric cancer. Recently it was reported that surgical Apgar score (SAS) can predict postoperative complication and that postoperative complication is associated with poor long-term survival. The aim of this study is to assess whether SAS can predict overall survival (OS) after surgery for gastric cancer. We retrospectively compared clinicopathological characteristics and survival between high and low SAS score groups in patients who underwent gastrectomy for gastric cancer. Low-scored SAS group (group L) was significantly more common among ASA-PS 2, open approach, total gastrectomy, D2 lymph node dissection, postoperative complication grade 2–4, deep tumor invasion, lymph node metastases, and advanced pathological TNM stage than high-scored SAS group (group H). The 5-year OS of group H and group L were 81.6 and 55.9 %, respectively (p

Previous studies comparing survival between gastric cancer (GC) patients from the West and the East were based on the assumption that background factors and prognostic factors were identical. The aim of the current study was to compare the survival of GC patients from the UK and Japan using weighted propensity score analysis after identifying all different background factors. Data from 464 patients from the Leeds Teaching Hospital NHS Trust, Leeds, UK (LTHT), and 465 patients from the Kanagawa Cancer Center Hospital, Yokohama, Japan (KCCH), who had surgery for GC were analyzed. Prognostic factors for overall survival (OS) and cancer-specific survival (CSS) were identified by univariate and multivariate analyses. Survival was compared by propensity score weighting after adjusting for all significantly different background factors. Most background factors were different between LTHT and KCCH patients. Unadjusted stage-specific OS and CSS were significantly better in KCCH. Independent prognostic factors for unadjusted OS and CSS were pT and pN in KCCH and in addition tumor location, pancreatectomy, resection margin status and number of examined lymph nodes in LTHT. Even after adjusting for all background characteristics, survival remained better in KCCH. These results suggest that differences in background factors are unable to fully explain the survival difference of GC patients between UK and Japan. Comprehensive studies into the biology of GC and/or host factors are needed to fully understand the survival difference.

BACKGROUND: The objective of this study was to investigate whether the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer TNM classification (TNM7) had superior discriminatory ability over the sixth edition of the TNM classification (TNM6) in patients with gastric cancer regardless of their country of origin. METHODS: In total, 538 patients from the Kanagawa Cancer Center Hospital (Yokohama, Japan) (KCCH) and 519 patients from the Leeds Teaching Hospitals National Health Service Trust (Leeds, United Kingdom) (LTHT) who underwent surgery for gastric cancer were selected. Overall survival was used for statistical analysis. Hazard ratios (HRs) were estimated with disease stage as a continuous variable to evaluate the discriminatory ability of the TNM stage groups. The estimates of log HRs (logHRs) for the TNM6 and the TNM7 stage groups were compared. RESULTS: In the KCCH cohort, 82 patients (15%) were upstaged, and 26 patients (5%) were downstaged between TNM6 and TNM7 compared with 253 patients (49%) and 53 patients (10%), respectively, in the LTHT cohort. The logHRs for a 1-stage increase within TNM6 and TNM7 were 1.06 and 1.16, respectively, in the KCCH cohort and 0.57 and 0.79, respectively, in the LTHT cohort. The differences in logHRs between TNM6 and TNM7 were significant in each cohort (KCCH: logHR, 0.11; P ¼ .024; LTHT: logHR, 0.21; P ¼ .0002) and between the 2 cohorts. CONCLUSIONS: TNM7 had superior discriminatory ability compared with TNM6 in both cohorts. The improved ability to discriminate patients with different survival probability when using TNM7 was greater in the LTHT cohort. The current findings indicated that the discriminatory ability of the TNM stage groups may depend on the baseline survival characteristics of the patient cohort. Cancer 2013;000:000–000. V C 2013 American Cancer Society.

The aim of this study is to clarify whether TNM-EC or TNM-GC is better for classifying patients with AEG types II/III. The patients who had AEG types II/III and received D1 or more radical lymphadenectomy were selected. The patients were staged both by seventh edition of TNM-EC and TNM-GC. The distribution of the patients, the hazard ratio (HR) of each stage, and the separation of the survival were compared. A total of 163 patients were enrolled in this study. TNM-EC and TNM-GC classified 25 (20 and 5) and 32 (20 and 12) patients to stage I (IA and IB), 15 (4 and 11), and 33 (11 and 22) to stage II (IIA and IIB), 88 (24, 3, and 61) and 63 (14, 26, and 23) to stage III (IIIA, IIIB, and IIIC), and 35 and 35 to stage IV, respectively. The distribution of the patients was substantially deviated to stage IIIC in TNM-EC but was almost even in TNM-GC. A stepwise increase of HR was observed in TNM-GC, but not in TNM-EC. The survival curves between stages II and III were significantly separated in TNM-GC (P = 0.019), but not in TNM-EC (P = 0.204). The 5-year survival rates of stages IIIA, IIIB, and IIIC were 69.0, 100, and 38.9 % in TNM-EC and were 52.0, 43.4, and 33.9 % in TNM-GC, respectively. TNM-GC is better for classifying patients with AEG types II/III than TNM-EC is. These results could impact the next TNM revision for AEG.

Laparoscopic esophagojejunostomy using a circular stapler is associated with technical difficulties in the purse-string sutures used to insert the anvil head and in obtaining an adequate visual field to prevent rolling the mesentery and the wall of the jejunum on the mesenteric side into the anastomosis. To overcome these difficulties, we used the EndoStitch to create the purse-string suture and the ENDOCAMELEON to create the visual field to stretch the jejunum. After resecting the esophagus, purse-string sutures were placed using the EndoStitch. A total of five to six needle deliveries were performed. Next, the anvil head was inserted into the esophagus. The main unit of the EEA was inserted from the end of the resected jejunum. Then, the scope was changed to the ENDOCAMELEON. The main unit was slowly moved toward the anvil head. After making sure that the mesentery and the wall of the jejunum on the mesenteric side were not rolled into the anastomosis under the visual field created by the ENDOCAMELEON, the main unit was then fired. Thereafter, esophagojejunostomy was successfully completed. This technique was applied in 20 patients between April 2010 and May 2012. Laparoscopic esophagojejunostomy after total gastrectomy for gastric cancer was completed in all 20 patients. No case required conversion to open surgery. Neither anastomotic leakage nor stenosis was observed. This method is simple and useful for laparoscopic esophagojejunostomy after total gastrectomy for gastric cancer.

The factors that affect the 6-month continuation of adjuvant chemotherapy with S-1 have not been fully evaluated. The objective of this retrospective study was to clarify the risk factors for 6-month continuation of S-1 adjuvant chemotherapy.The study selected patients who underwent curative D2 surgery for gastric cancer, were diagnosed with stage 2 or 3 disease, had a serum creatinine level of ≤ 1.2 mg/dl, and received adjuvant S-1 between June 2002 and March 2011.One hundred of these patients were eligible for the present study. A comparison of 6-month continuation of S-1 stratified by various clinical factors, using the log-rank test, revealed a marginally significant difference in creatinine clearance (CCr) between those patients who continued for 6 months and those who did not. A CCr of 60 ml/min was regarded as the critical point. Uni- and multivariate Cox's proportional hazard analyses demonstrated that CCr was the only significant independent factor for the prediction of 6-month continuation. The 6-month continuation rate was 72.9 % in the patients with CCr ≥ 60 ml/min, and 40.0 % in patients with CCr60 ml/min (P = 0.015). Adverse events occurred more frequently and earlier in the patients with CCr60 ml/min than in those with CCr ≥ 60 ml/min.CCr60 ml/min was a significant risk factor for 6-month continuation of S-1 adjuvant chemotherapy, even though the renal function was judged as normal by the serum creatinine level. Careful attention is therefore required for S-1 continuation in patients with CCr60 ml/min.

The peritoneum is still the most frequent site of recurrence in stage II/III gastric cancer patients, although the survival rate was improved by the introduction of S-1 adjuvant chemotherapy. The objective of this retrospective study was to clarify the risk factors for peritoneal recurrence in patients who received S-1 adjuvant chemotherapy.Peritoneal recurrence-free survival was examined in 100 gastric cancer patients who underwent curative D2 surgery, which were diagnosed with stage II or III disease pathologically, and received adjuvant S-1 between June 2002 and March 2011. The univariate and multivariate analyses were performed to identify risk factors by a Cox proportional hazards analysis.The P-RFS was 64.3% at 3 years and 58.8% at 5 years. A total of 18 patients were diagnosed with peritoneal recurrence. The macroscopic tumor diameter, depth of tumor invasion, and lymph node metastasis were the significant factors identified by the univariate analysis, while the tumor diameter and lymph node metastasis were the only significant independent risk factors identified by the multivariate analysis.The macroscopic tumor diameter and presence of lymph node metastasis were the most important risk factors for peritoneal recurrence. When patients had these risk factors, S-1 was not sufficient to inhibit peritoneal recurrence. A novel adjuvant chemotherapeutic agent targeting peritoneal metastasis in these patients should be developed.

The safety and feasibility of administering S-1 adjuvant chemotherapy for gastric cancer has not been fully evaluated in elderly patients.This retrospective study selected patients who underwent curative D2 surgery for gastric cancer, were diagnosed with stage II or III disease, and received adjuvant S-1 at our institution. Patients were categorized into two groups; non-elderly patients (age70 years: group A) and elderly patients (age ≥70 years: group B). The toxicity and S-1 continuation rates in the two groups were compared.A total of 75 patients were evaluated in the study. There were no grade 4 toxicities. The incidences of grade 3 hematological and non-hematological toxicities were5% in both groups, and the differences were not significant. The continuation rate at 6 months was 69% in group A and 70% in group B, and this difference was also not significant.These results suggest that S-1 adjuvant chemotherapy for gastric cancer is safe and feasible, regardless of the age of the patient; especially for elderly patients who could be candidates for clinical trials.

Radical gastrectomy for gastric cancer is among the most invasive procedures in gastrointestinal surgery. Several studies have found that an enhanced recovery after surgery (ERAS) protocol is useful in patients who undergo colorectal surgery, but its value in gastric surgery remains uncertain. The aim of this study was to assess the usefulness of an ERAS protocol for gastric surgery. We studied the clinical characteristics, oncological factors, surgical factors, and outcomes in patients who underwent elective radical gastrectomy for gastric cancer before and after the introduction of an ERAS protocol. The first days of oral intake, oral intake recovery, flatus, and defecation were significantly earlier in the ERAS group (n = 91) than in the conventional care (CONV) group (n = 100). Maximum pain evaluated on a visual analog scale and the number of additional analgesics on demand were significantly less in the ERAS group than in the CONV group. The ratio of the postoperative body weight at 1 week to the preoperative body weight was significantly higher in the ERAS group than in the CONV group (0.95 vs. 0.94, respectively, P = 0.01). Our results suggest that the ERAS protocol is useful in patients who undergo elective radical gastrectomy.

Some patients experience a recurrence of cancer even after curative D2 gastrectomy followed by adjuvant S-1 chemotherapy. The objective of this retrospective study was to clarify the survival and prognosticators in these patients.The study selected patients who underwent curative D2 surgery, were diagnosed with stage II, IIIA, or IIIB cancer, received adjuvant S-1 for more than 4 weeks, and experienced recurrence confirmed by an imaging study.A total of 34 patients were evaluated. The median overall survival (OS) was significantly longer in the 26 patients who received palliative chemotherapy than that in the 8 who did not (8.5 vs. 2.5 months, P = 0.002). Only 1 patient received S-1, 21 received taxane-containing regimens, and 4 received irinotecan plus cisplatin as the first-line chemotherapy. Univariate and multivariate analyses showed that the histological type was only independent significant prognosticator.These results suggested that the survival did not reach the level expected for first-line chemotherapy. The histological type was a significant prognosticator in patients who experienced recurrence after adjuvant S-1 therapy and thereafter received palliative chemotherapy.

e16012Background: During preoperative chemotherapy, appropriate nutritional support is necessary. Especially advanced esophageal cancer patients sometimes have a difficulty of oral ingestion. In Ja...

e16036Background: Some of gastric cancers show hepatoid or fetal gut-like differentiation, and these cancers are previously reported as adenocarcinomas with primitive features morphology similar to...

In this report, we describe our traction suture technique of the pericardium for suspension of the heart without hemodynamic instability to obtain excellent exposure in the abdominal-transhiatal approach (TH). Our technique is an application of deep pericardium stitches for off-pump coronary artery bypass surgery. In detail, the left hepatic lobe is detached at its triangular ligament from the diaphragm and is deflected to the right. Then, the tendinous portion of the diaphragm arching over the esophagus is incised upward in the midline until the pericardium is exposed. Pericardial fatty tissue was dissected. Three U-shaped sutures reinforced with a felt pledget are placed on the posterior aspect of the pericardium and diaphragm. A 15 Fr. flexible catheter is placed over both ends of the suture to avoid damage of the adjacent organs. Finally, the sutures are fixed to the drape of anterior wall of the patient to maintain good exposure.

Background We have previousy reported on a Phase II study of S-1 monotherapy as a first line, combination therapy of S-1 plus cisplatin as a second line, and weekly paclitaxel monotherapy as a third line therapy in patients with advanced gastric carcinomas. The median survival time (MST) of patients over the whole course of treatment was not previously calculated because 12 out of 19 patients had not yet succumbed. Since then, we have calculated the MST for this study and herein report our findings. Patients and Methods Between 2002 and 2005, 19 patients were enrolled in this study. Chemotherapy consisted of either 60 mg/m2 of S-1 for 4 weeks at 6-week intervals, a combination of 60 mg/m2 S-1 for 3 weeks and 60 mg/m2 cisplatin on day 8 at 5-week intervals, or 60 mg/m2 paclitaxel at days 1, 8, and 15, at 4-week intervals. The regimens were repeated until the occurrence of unacceptable toxicities, disease progression, or patient noncompliance. The primary end point was the overall survival. Results The median survival time was 774 days. The response rates were 33.3% (3/9), 12.5% (1/8), and 0% (0/4) after the first, second, and third line chemotherapies, respectively. The major adverse hematological toxicity was leukopenia, which reached grades 3–4 in all lines of chemotherapy investigated. In addition, the major adverse non-hematological toxicity was anorexia, which reached grade 3–4 in second line chemotherapy, and no deaths were attributable to the adverse effects of the drugs. Conclusion This sequential therapy was an effective treatment for advanced gastric cancer with acceptable toxic side-effects. We considered this therapy to be effective because of the smooth transition to the next regimen.

183 Background: The laparoscopic gastrectomy is becoming widespread. But acquisition of its technique is challenging. We investigated whether supervision by a technically qualified surgeon (QS) affects the feasibility and safety of laparoscopic gastrectomy performed by trainee (TR). Methods: The outcomes of laparoscopy-assisted distal gastrectomy for gastric cancer performed by QS group and TR group between 2013 and 2016 were assessed. A laparoscopic surgeon qualified by the Endoscopic Surgical Skill Qualification System (Japan Society for Endoscopic Surgery) participated in surgeries that ware performed by trainee as the teaching assistant. Results: All patient characteristics were not different between QS group and TR group, except of BMI (median BMI 23.9 vs 22.2, p = 0.01). Although operation time of TR group was longer than that of QS group (median time: 248 min. vs 285 min., p = 0.01), Blood loss and number of harvested lymph nodes were not different. One patient (0.3%) in QS group and two patients (0.4%) in TR group required conversion to open surgery (p = 0.58). Postoperative complication, that was defined by Clavien-Dindo classification grade 3 and more, occurred in four patients (11.4%) in QS group and nine patients (5.4%) in TR group (p = 0.25). Complication in QS group were anastomotic leakage (n = 2) and abdominal abscess (n = 2), whereas that in TR group were anastomotic leakage (n = 3), anastomotic stenosis (n = 2), pancreatic fistula (n = 1), bowel obstruction (n = 1), pneumothorax (n = 1), and cerebral hemorrhage (n = 1). One patient in QS group (2.9%) and four patients in TR group (2.4%) underwent reoperation (p = 1.00). Postoperative mortality occurred in one cases in TR group (0.01%). Conclusions: The laparoscopy-assisted distal gastrectomy of TR group supervised by QS was feasible and safe procedure as well as that of QS group.

42 Background: Neoadjuvant chemotherapy (NAC) followed by surgery is a standard treatment for esophageal squamous cell carcinoma (ESCC) in Japan. Efficacy of NAC on the primary tumor is clinically evaluated during NAC and before surgery and is pathologically examined after surgery. Clinical evaluation of the primary tumor is sometimes difficult because primary tumor is nonmesurable lesion and is usually evaluated subjectively, while pathological finding is objective and a gold standard to evaluate efficacy of NAC. In the present study, we tried to evaluate clinicaly efficacy objectively by calcurating tumor volume by esophagography and concordance between volume reduction rate and pathological efficacy. Methods: This retrospective study examined 53 patients who fullfilled the following criteria; (1) thoracic ESCC, (2) underwent resection following NAC between January 2011 and February 2017, and (3) T2-3N0 before surgey. Clinically, volume of the primary tumor was calculated by multiplying length and thickness in the lateral view of esophagography. Pathological efficacy was examined by the proportion of the tumor disappearance of the primary tumor and was classified as Grade 0-1 when degeneration area was < 2/3, Grade 2 when those area was > 2/3 and < 3/3, and Grade 3 when there was no residual tumor. Volume reduction rate calculrated by the difference of pre- and post-NAC was compared by stratifying pathological grade. Results: T2/T3 was 23/30, respectively. Regimen of neoadjuvant chemotherapy was 5-FU/CDDP in 50 patients,docetaxel/5-FU/CDDP in 1,and 5-FU/CDDP and Radiotherapy in 2. Overall volume reduction rate was 58.9% in median (range -127-100%). Pathological response (Grade 0-1/2/3) was 28/18/4, respectively. Median volume reduction rate (range) was 38.5% (-127-100%) in Grade 0-1, 72.2% (21.7-100%) in Grade 2, and 91.1% (75.5-100%) in Grade 3, which was significantly different (p < 0.01). Conclusions: The volume reduction rate of the primary tumor was correlated with pathological efficacy, suggesting that volume reduction rate could be a objective measure to evaluate efficacy of neoadjuvant chemotherapy for ESCC.

184 Background: Advanced esophageal cancer patients sometimes have a difficulty to swallow food. On the other hand, standard treatment for resectable advanced esophageal cancer patients is surgery after 2 course preoperative chemotherapy of CDDP-5-FU (JCOG 9907). So we usually use naso-gastric ED tube for patients with difficulty of oral intake during preoperative chemotherapy to administrate adequate nutrition. But there is no report of the safety of this trial. Methods: The aim of this study is to clarify the safety of using ED tube during preoperative chemotherapy and compare the nutritional status between using ED tube or not. From Jan 2012 to June 2017, 122 patients were undergone esophagectomy with 2 course of preoperative chemotherapy, and 14 patients were treated with ED tube for nutrition(Group A) and 108 patients without ED tube(Group B). We evaluated the changes of nutritional status and postoperative complication as an indicator of safety. Results: Changes before and after preoperative chemotherapy(GroupA/B): average of body weight: 53.1→50.8/58.1→57.0, BMI: 20.0→19.2/22.0→21.6, TP: 6.7→6.9/7.3→6.9, alb: 3.5→3.8/4.3→4.2, pre-alb: 20.1→21.7/24.8→23.4, RBP: 2.77→3.33/3.15→3.23. Adverse events during chemotherapy: 1 case of Grade 3 hematologic toxicity and 1 case of Grade 2 non-hematologic toxicity were found at Group A(14.2%), and 11 cases of Grade 3 hematologic toxicity and 8 cases of Grade 2 non-hematologic toxicity were found at Group B(17.61%)(p = 0.758). Postoperative complications (clavien-dindo classification, Grade3 or more): 2 cases were observed at Group A(14.2%), and 21 cases were observed at Group B(19.4%)(p = 0.62). Conclusions: Preoperative chemotherapy with ED tube for nutrition was safe and effective to maintain the preoperative nutritional status.

24 Background: Patients with gastric cancer should receive treatment for the cure as soon as possible because cancer cells are considered to grow and metastasize quickly. However, patients sometimes have to wait for the treatment because of further examinations of comorbidity, social background, and limited medical resources. It remained unclear whether interval between diagnosis and surgery is a risk factor for the survival. Methods: This retrospective single-center study examined 801 patients who visited outpatient clinic for gastric cancer and underwent curative surgery from 2006 to 2012 at Kanagawa Cancer Center in Japan. The patients who received neoadjuvant chemotherapy were excluded. Interval was defined as the time from the date of the first visit to the date of surgery. Interval was divided by the median and was classified to the early (less than median) and the late (exceeding the median) groups. Survival was analyzed by separating clinical T1 and T2-4. Results: 461 patients had clinical T1 and 340 had clinical T2-4. Median interval was 55 days (15-269 days) in clinical T1 and 35 days (10-148 days) in clinical T2-4, respectively. In clinical T1, 5-year survival rate was 93.1% in the early group and 91.2% in the late group (p = 0.456). In clinical T2-4, 5-year survival rate was 77.8% in the early group and 78.9% in the late group (p = 0.864). In the multivariate analysis, significant independent risk factors were over 75 years of age and clinical T4, and clinical N+, over 75 years of age in clinical T1, and over 75 years of age and clinical T4 in clinical T2-4. Interval was not significant factor both in clinical T1 (HR: 1.242, 95%CI 0.641-2.407 p = 0.522) and in clinical T2-4 (HR: 1.078, 95%CI 0.672-1.729 p = 0.756). Conclusions: Interval between diagnosis and surgery did not have a negative impact on the prognosis in patients with gastric cancer. Necessary interval for the clinical practice would be acceptable.

症例は61歳の男性で，腹部の違和感と下血を主訴に来院した．腹部超音波検査および腹部CTで上行結腸に腸重積に特徴的な所見を認めた．注腸X線検査，下部消化管内視鏡検査で盲腸に約3 cmの表面にびらんを伴う硬い隆起性病変を認めた．腹腔鏡下回盲部切除術を施行し，切除標本の病理組織，および免疫組織学的検索で盲腸のgastrointestinal stromal tumor（以下，GIST），uncommitted typeと診断した．本邦において，盲腸原発GISTの報告例は2例と極めてまれであるため報告する．

症例は63歳の男性で, 心窩部痛を主訴に来院した. 腹部は軽度膨満し腹部単純X線検査で小腸ガスの貯留と鏡面形成を認め, 腹部CTでは右上腹部にtarget signを呈する腫瘤像を認め, 回腸上行結腸型の腸重積症と診断した. また, 胃壁の肥厚を認めたため上部消化管内視鏡検査を施行, 粘膜不整像と巨大皺壁を認めた. 病理組織学的検査 (胃) で悪性リンパ腫が疑われたが, 確定診断は得られなかった. 組織型の診断確定と腸重積解除目的に開腹手術を行った. 開腹時腸重積は解除されていたが, Bauhin弁から10cm口側の回腸粘膜下にポリープ様腫瘤が多発しており, 粘膜下腫瘍を切除し, 病理組織学的検査でマントル細胞リンパ腫の診断であった.胃と回腸に多発病変を有し, 回腸末端のポリポーシスを先進部として回腸上行結腸型腸重積を来していた. マントル細胞リンパ腫による成人腸重積の報告は自験例を含めて国内, 国外合計7例のみと極めてまれであり, 文献的考察を加え報告する.