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In esophageal squamous cell cancer (SCC), lymphadenectomy along the right recurrent laryngeal nerve (RLN) is important for disease control. The metastatic rate was 33% and the 5-year overall survival rate of these patients was 33.3%,1 but the risk of RLN palsy increases.2 We reported a reliable new method ('Pincers Maneuver')3 for lymphadenectomy along the right RLN during thoracoscopic esophagectomy in the prone position (TEP), and hereby present our video, aimed at providing a complete and safe dissection.The 'Pincers Maneuver' is performed for all resectable clinical stage IA-III lower, middle, or upper thoracic esophageal SCCs. Patients above clinical stage IB were treated with neoadjuvant chemotherapy. The concept of this procedure is to first exfoliate the two-dimensional membrane (lateral pedicle), which includes the right RLN, lymph nodes, and the primary esophageal artery, from the right side of the trachea toward the neck. Improved mobility of the lateral pedicle, gained by closing in from its inner and outer sides, enables easy lymphadenectomy along the right RLN toward the right inferior thyroid artery.Using this method, we performed 31 TEPs in 2016 at Kobe University Hospital. Median body mass index was 23 kg/mOur method for lymphadenectomy along the right RLN during TEP is safe and practical. It provides sufficient lymph node dissection, and no right RLN palsy has been observed.

e14577 Background: In recent years, immune checkpoint inhibitors have attracted attention and a lot of studies on PD-L1 (Programmed death-ligand 1) have been reported, but their anti-tumor effects are limited to colorectal cancer in which the expression of PD-L1 is infrequent. On the other hand, radiation therapy has been suggested to be closely related to the antitumor effect derived from the immune response. So we report the histological and clinicopathological examination about the relationship between the expression of PD-L1 and CD8 and irradiation in rectal cancer cases in which operation was performed after preoperative chemoradiotherapy (neoadjuvant chemoradiotherapy, NACRT) to clarify the indication for immune checkpoint inhibitors. Methods: Immunohistochemical staining of PD-L1, CD8 as immune related factors was performed on 34 cases in which operation was performed after NACRT(UFT/LV:300mg/m2/day and 75mg/body/day, respectively +RT(45Gy)) was done for locally advanced rectal cancer from January 2005 to December 2014, and we evaluated their preoperative biopsy specimens and resected specimens to examine the relationship between their evaluations and clinicopathological factors. Results: The 5-year survival rate and relapse-free survival rate of 34 patients were 84.4% and 65.5%, respectively, and there were 4 pathological CR cases. In 30 patients excluding CR cases, the expression of PD-L1 in tumor cells was enhanced or emerged in 5 cases(16.7%) and the infiltration of CD8+TIL(tumor infiltrating lymphocyte) was also enhanced in 13 cases(43.7%) after NACRT. Also, patients with PD-L1 expression had significantly poor prognosis (p = 0.0023) than others, and the prognosis tended to be further poor in CD8+TIL noninvasive cases. Conclusions: NACRT for locally advanced rectal cancer induced PD-L1 expression in tumor cells and also induced the infiltration of CD8+TIL.

Although acute appendicitis is a common disease, retroperitoneal abscesses are rarely observed. Here, we report a case consisting of a psoas abscess and cutaneous fistula caused by appendicitis. The patient was a 56-year-old male who was introduced to our institution due to an intractable right psoas abscess. Imaging tests had been performed over the previous 3 years; however, clinicians could not find the origin of the abscess and failed to resolve the problem. A successful operation was performed via a laparoscopic approach, and 17 mo have passed without recurrence. The advantage of laparoscopic surgery is well understood in cases of appendicitis with abscesses. However, the indication for laparoscopic approach is not clear for retroperitoneal abscesses. From our experience, we can conclude that appendicitis with retroperitoneal abscesses can be managed and treated using a laparoscopic approach.

Our purpose was to evaluate the perioperative safety of laparoscopic-assisted distal gastrectomy (LADG) in elderly patients with clinical stage I gastric cancer. From 527 consecutive patients who underwent distal gastrectomy for gastric cancer from 2000 to 2011, 38 elderly patients (aged 75 years or older) with clinical stage I disease who underwent LADG were compared with 28 elderly patients who underwent open distal gastrectomy (ODG) and with 41 nonelderly patients (younger than aged 65 years) who underwent LADG. Intraoperative cardiopulmonary changes following pneumoperitoneum and surgical outcomes were analyzed. A significant elevation in mean blood pressure (MAP) (by 44 %) and slight increase in heart rate (HR) (by 13 %) were observed 5 min after the beginning of pneumoperitoneum in the elderly LADG group, although they tended to remain stable since 30 min. The elevation of end-tidal CO2 (ETCO2) in the elderly LADG group remained at 8 % and did not differ from that in the nonelderly LADG group who were 20.5 years (median) younger, whereas percutaneous oxygen saturation (SpO2) did not worsen. Compared with the elderly ODG group, the elderly LADG group did not increase intraoperative cardiopulmonary impairment or complication, had lower incidence of postoperative medical complication (7.9 vs. 32.1 %, p = 0.012) and shortened postoperative recovery course (25 vs. 15 days, p

A congenital anomaly of the right aortic arch (RAA) is rare, and esophageal cancer associated with the vascular ring is even more rare. In such cases, it is very important to understand the anatomical situation in the upper mediastinum in order to perform a safe and curative operation. A 52-year-old man who presented with odynophagia was admitted to our department after a diagnosis of advanced esophageal cancer. Chest computed tomography revealed an RAA with an aberrant subclavian artery and showed that the esophagus was completely encircled by the RAA, aortic diverticulum, and pulmonary artery. By the thoracoscopic view with the patient in the prone position, we were able to easily and safely identify the anatomical location of the upper mediastinum and successfully perform thoracoscopic esophagectomy. To the best of our knowledge, this is the first report of a patient undergoing total thoracoscopic esophagectomy in the prone position without thoracotomy.

Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis has been introduced to achieve safer anastomosis with good vision, and a small wound. However, little is known about the surgical outcomes of newly introduced TLDG compared with established procedures of laparoscopy-assisted gastrectomy (LADG) with extracorporeal anastomosis. This retrospective study included 114 patients who underwent laparoscopic distal gastrectomy (LDG) between January 2010 and September 2012. The patients were classified into two groups according to the approach of reconstruction (LADG group: n = 74; TLDG group: n = 40). The parameters analyzed included patients, operation details, and operative outcomes. No complication was observed in the TLDG group. Surgical outcomes of the TLDG group, such as mean operation time, estimated blood loss, and rate of conversion to laparotomy were not inferior to the LADG group. Furthermore, postoperative hospital stay of the TLDG group was significantly shorter than the LADG group (p

Background: The pN classification of gastric cancer (GC) in the Japanese system (Japanese Gastric Cancer Association; JGCA) is based on the site and distance of metastatic nodes from the primary tumour. Union International Contra Cancer (UICC) has recently proposed a classification system based on the number of nodes involved (TNM-1997). The aim of the present study is to assess which classification system is more suitable for providing a prognosis in advanced GC with lymph node metastasis. Methods: A total of 224 patients who underwent curative gastrectomy (R0: UICC−TNM and Resection A and B: JGCA) and D2 lymphadenectomy between 1990 and 1999, and diagnosed as pT2, pT3 and pT4 GC were enrolled. Patients were followed until the end of 2002. The disease-free survival rates of patients were compared between the two-stage systems (UICC−TNM and JGCA). Results: Using the JGCA system, there was a significant difference between the two survival curves (pN0 and pN1, P = 0.025; pN1 and pN2, P

It is very important to achieve a sufficient field and space in laparoscopic assisted distal gastrectomy (LADG) for a less-experienced surgeon. In this study, the usefulness of a novel surgical technique to lift the liver was evaluated in LADG.Fifty-four patients who underwent standardized LADG for gastric cancer using the novel technique of lifting the liver were retrospectively evaluated based on video records. Patient characteristics, the time required to lift the liver and for gastrectomy, total operation time, blood loss and complications were analyzed.The mean time necessary to lift the liver using this novel technique was 240.1±86.1 seconds and that for gastrectomy was 167.6±50.4 minutes. Blood loss was 72.5±59.6mL. The morbidity rate was 4/54 (7.4%).Standardized LADG using this novel technique is feasible and possible in a period of time.

The patient is a 55-year-old woman who has biliary tract cancer with peritoneal dissemination (T3N1P2M0, Stage IV b). Since a curative operation was deemed impossible, we conducted chemotherapy using S-1. S-1 (120 mg/day) was administered for 2 weeks and then chemotherapy was discontinued for 1 week, which was regarded as one course. After 2 courses of the chemotherapy, CT scan showed that the metastatic lymph node and tumor of peritoneal dissemination were reduced in size, and that there was no ascites. Left lobectomy of the liver, cholecystectomy, and partial resection of omentum were carried out. The pathological diagnosis was also curative (pT1, pN0, pP0, Stage I). We think this case shows the possibility of S-1 for patients with unresectable biliary tract cancer.

A sixties-man had complained of melena. Colonoscopy revealed type 2 tumor at rectum. Computed tomography (CT)demonstrated lymph node metastasis in front of sacrum and two low density areas which were suspected metastases in the liver. The patient was diagnosed stageIV rectal cancer and resected primary focus and lymph node metastasis.[ Ra-RS, ant, type 2, moderately differentiated adenocarcinoma, ly1, v3, pSE, pN2, sH1(Grade C), sP0, pM1(No. 270)]without liver resection. It was due to high level of CEA and remote lymph node metastasis. The patient was treated with mFOLFOX6 and bevacizumab after the operation. The level of CEA decreased to normal level and CT revealed a partial response after 4 cycles of systemic chemotherapy. Liver resection was performed safely. Histological response was Grade 2 at liver metastases.

There are cases of recurrence even after curative resection in early gastric cancer.Seven hundred and sixty-five patients with early gastric cancer who underwent curative gastrectomy were analyzed to identify the prognostic factor. Micrometastases within lymph nodes were determined by immunohistochemistry using anti-cytokeratin antibody in node-negative early gastric cancer patients with recurrence.The recurrence was observed in 17 patients. Hematogenous recurrence was observed most frequently (47.1%), followed by peritoneal recurrence (23.5%). Of 17 patients with recurrence, 6 (35.3%) patients died more than 5 years after operation. The prognosis was poorer when the patients were older, and the depth of invasion was greater, lymph node metastasis, lymphatic involvement, and vascular involvement were present, and lymph node dissection was limited. The independent prognostic factors were lymph node metastasis, lymph node dissection, and age by multivariate analysis using Cox proportional hazards. Micrometastases within lymph nodes were confirmed in 3 of 6 node-negative patients with recurrence.When patients have lymph node metastases or are older, close and long-term follow-up and careful planning of postoperative adjuvant therapy might be necessary to avoid recurrence. The detection of micrometastases by anti-cytokeratin antibody might be useful for predicting the possibility of recurrence in early gastric cancer.

Yasunori Otowa, Kimihiro Yamashita, Kiyonori Kanemitsu, Yasuo Sumi, Masashi Yamamoto, Shingo Kanaji, Tatsuya Imanishi, Tetsu Nakamura, Satoshi Suzuki, Kenichi Tanaka, Yoshihiro Kakeji Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Abstract: Preoperative chemoradiotherapy (CRT) and lateral pelvic lymph node (LPLN) dissection (LPLD) based on pretreatment imaging are performed to improve oncological outcomes at our institution. However, the advantage of LPLD following preoperative CRT in advanced rectal cancer remains unclear. The objective of the present study was to assess the validity of this approach. Thirty-two patients with advanced rectal cancer were included in the study. All patients were treated with preoperative CRT and curative operation. Of these, 16patients who were treated between August 2005 and June 2008 underwent LPLD on both sides (LPLD group). Sixteen patients who were treated between July 2008 and January 2013 underwent LPLD only on the side with suspected LPLN metastasis determined by pretreatment imaging; in cases without LPLN metastasis, only total mesorectal excision was performed (limited-LPLD group). The overall survival and relapse-free survival between the LPLD and the limited-LPLD groups were compared. Preoperative CRT was able to lower clinical lymph node status in 50% of the cases. In addition, pathological lymph node status did not exceed the pretreatment clinical lymph node status stage in the LPLD group. There were no differences in the overall survival and relapse-free survival between the two groups (P=0.729 and P=0.874, respectively). We conclude that multi-imaging studies have a very low risk of overlooking pathologically positive LPLN metastases. Therefore, limited LPLD is a feasible strategy for patients with advanced rectal cancer and suspicious LPLN metastases based on pretreatment imaging. Keywords: neoadjuvant treatment, rectal cancer, chemoradiotherapy, lateral pelvic lymph node, MRI, CT

Background Robotic gastric surgery has been introduced and is being performed in many Japanese facilities. There are some limitations of devices capable to be used in the robotic arms in the da Vinci Surgical System. We have reviewed our first ten cases with early gastric cancer who underwent robot-assisted gastrectomy and have compared the operative time between cases who underwent the operation only with an electric cautery device and those in whom laparoscopic coagulating shears (LCS) through an assistant port were used. Findings We used an electric cautery device only in cases 1–3, and LCS in cases 4–10 except case 9. The mean operative time was 454 min in cases where only robotic devices were used and 414 min in those with LCS assist. The mean console time of 251 min in those with LCS assist was significantly shorter than that of 306 min in cases where only robotic devices were used. The number of dissected lymph nodes was satisfactory, and the estimated blood loss was small. Postoperative complications in two cases were slight and transient with short hospital stay. Conclusion Assistant use of ultrasonic shears is useful to shorten the console time in robotic gastrectomy.

Objective: To assess the prognostic value of polo-like kinase 1 (PLK1), an important regulator of cell cycle progression, in patients with gastric carcinoma. Methods: PLK1 expression was determined in 160 gastric carcinoma patients by immunohistochemistry and compared with p53 expression and the proliferating cell nuclear antigen-labeling index (PCNA-LI) to evaluate the effect of PLK1 on tumor progression. Furthermore, PLK mRNA expression was determined in 26 advanced gastric cancer patients by reverse transcription-polymerase chain reaction (RT-PCR). Results: PLK mRNA expression was detected in 25 (96.2%) patients by RT-PCR. Immunohistochemical staining revealed PLK1 expression in 84 (52.5%) patients. There were no significant relationships between PLK1 expression and various clinicopathological factors. PLK1 expression was significantly correlated with the PCNA-LI, but not p53 expression. The prognosis of patients with PLK1-positive tumors was significantly worse than that of patients with PLK1-negative tumors (p < 0.05). Moreover, multivariate analysis revealed that PLK1 expression was an independent prognostic factor. Patients with PLK1-positive and high PCNA-LI tumors showed a significantly poorer prognosis than patients with PLK1-negative and/or low PCNA-LI tumors. Furthermore, the prognosis of patients with PLK1- and p53-positive tumors was significantly worse than that of patients with PLK1- and p53-negative or PLK1-negative and p53-positive tumors. Conclusion: PLK1 expression may be a critical indicator of a poor prognosis in patients with gastric carcinoma.