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This study developed and validated a surgical instrument motion measurement system for skill evaluation during practical laparoscopic surgery training. Owing to the various advantages of laparoscopic surgery including minimal invasiveness, this technique has been widely used. However, expert surgeons have insufficient time for providing training to beginners due to the shortage of surgeons and limited working hours. Skill transfer efficiency has to be improved for which there is an urgent need to develop objective surgical skill evaluation methods. Therefore, a simple motion capture–based surgical instrument motion measurement system that could be easily installed in an operating room for skill assessment during practical surgical training was developed. The tip positions and orientations of the instruments were calculated based on the marker positions attached to the root of the instrument. Because the patterns of these markers are individual, this system can track multiple instruments simultaneously and detect exchanges. However due to the many obstacles in the operating room, the measurement data included noise and outliers. In this study, the effect of this decrease in measurement accuracy on feature calculation was determined. Accuracy verification experiments were conducted during wet-lab training to demonstrate the capability of this system to measure the motion of surgical instruments with practical accuracy. A surgical training experiment on a cadaver was conducted, and the motions of six surgical instruments were measured in 36 cases of laparoscopic radical nephrectomy. Outlier removal and smoothing methods were also developed and applied to remove the noise and outliers in the obtained data. The questionnaire survey conducted during the experiment confirmed that the measurement system did not interfere with the surgical operation. Thus, the proposed system was capable of making reliable measurements with minimal impact on surgery. The system will facilitate surgical education by enabling the evaluation of skill transfer of surgical skills. [ABSTRACT FROM AUTHOR]

Background: Recently, minimally invasive esophagectomy and gastrectomy for esophagogastric junctional (EGJ) cancer using either thoracoscopy or laparoscopy are frequently performed. In the past decade, minimally invasive surgery with laparoscopy for splenic artery aneurysm (SAA) has also been reported. However, patients with both EGJ cancer and SAA are rare. Case presentation: A 66-year-old man, who complained of upper abdominal pain, was found to have esophagogastric junctional (EGJ) tumor. He was diagnosed as having Siewert type II adenocarcinoma. In a computed tomography (CT) scan before surgery, a 10-mm aneurysm in the splenic artery was found. Thus, we performed laparo- and thoracoscopic proximal gastrectomy and lower esophagectomy for EGJ cancer and splenic artery aneurysm (SAA) resection with spleen preservation using fluorescence imaging. We confirmed sufficient blood supply to the spleen after surgery with a postoperative CT scan. The blood supply to the spleen was suspected to be from the great pancreatic artery via the pancreas and from the omental branches of the left gastroepiploic artery via the omental artery. Conclusion: Simultaneous surgery for EGJ cancer and SAA is rare due to its potential risk, but evaluation of the blood supply for the spleen by using fluorescence imaging can be useful for this procedure. [ABSTRACT FROM AUTHOR]

Purpose: Since 2002, the Japan Surgical Society has established a board certification system for surgeons to be certified for a specialty. Surgery remains a male-dominated field in Japan. This study aimed to clarify if the Japanese surgical residency training system is equally suitable for female and male residents. Methods: The Japan Surgical Society conducted the first questionnaire survey regarding the system of surgical training for the residents in 2016. The questionnaire included the degree of satisfaction with 7 aspects of the training system, including the number and variety of cases experienced and duration and quality of instruction, and the learning level for 31 procedures. The degree of satisfaction and level of learning were compared between female and male residents. Results: The degree of satisfaction was similar for all items between female and male residents. Female residents chose breast surgery as their subspecialty more frequently than male residents and were more confident in breast surgery procedures than male residents. Conversely, fewer female residents chose gastrointestinal surgery and were less confident in gastrointestinal surgery procedures than male residents. Conclusion: Female residents were as satisfied with the current surgical training system as male residents. However, there may be room for improvement in the surgical system, considering that fewer applications for gastrointestinal surgery come from female residents than from males. [ABSTRACT FROM AUTHOR]

Background : Our aim was to build a skill assessment system, providing objective feedback to trainees based on the motion metrics of laparoscopic surgical instruments. Methods: Participants performed tissue dissection around the aorta (tissue dissection task) and renal parenchymal closure (parenchymal-suturing task), using swine organs in a box trainer under a motion capture (Mocap) system. Two experts assessed the recorded movies, according to the formula of global operative assessment of laparoscopic skills (GOALS: score range, 5–25), and the mean scores were utilized as objective variables in the regression analyses. The correlations between mean GOALS scores and Mocap metrics were evaluated, and potential Mocap metrics with a Spearman's rank correlation coefficient value exceeding 0.4 were selected for each GOALS item estimation. Four regression algorithms, support vector regression (SVR), principal component analysis (PCA)-SVR, ridge regression, and partial least squares regression, were utilized for automatic GOALS estimation. Model validation was conducted by nested and repeated k-fold cross validation, and the mean absolute error (MAE) was calculated to evaluate the accuracy of each regression model. Results: Forty-five urologic, 9 gastroenterological, and 3 gynecologic surgeons, 4 junior residents, and 9 medical students participated in the training. In both tasks, a positive correlation was observed between the speed-related parameters (e.g., velocity, velocity range, acceleration, jerk) and mean GOALS scores, with a negative correlation between the efficiency-related parameters (e.g., task time, path length, number of opening/closing operations) and mean GOALS scores. Among the 4 algorithms, SVR showed the highest accuracy in the tissue dissection task ( MAE median = 2.2352 ), and PCA-SVR in the parenchymal-suturing task ( MAE median = 1.2714 ), based on 100 iterations of the validation process of automatic GOALS estimation. Conclusion: We developed a machine learning–based GOALS scoring system in wet lab training, with an error of approximately 1–2 points for the total score, and motion metrics that were explainable to trainees. Our future challenges are the further improvement of onsite GOALS feedback, exploring the educational benefit of our model and building an efficient training program. [ABSTRACT FROM AUTHOR]

Lymph node metastasis (LNM) is one of the most adverse prognostic factors in extrahepatic cholangiocarcinoma (EHCC) cases. As next-generation sequencing technology has become more widely available, the genomic profile of biliary tract carcinoma has been clarified. However, whether LNMs have additional genomic alterations in patients with EHCC has not been investigated. Here, we aimed to compare the genomic alterations between primary tumors and matched LNMs in patients with EHCC. Sixteen patients with node-positive EHCCs were included. Genomic DNA was extracted from tissue samples of primary tumors and matched LNMs. Targeted amplicon sequencing of 160 cancer-related genes was performed. Among the 32 tumor samples from 16 patients, 91 genomic mutations were identified. Genomic mutations were noted in 31 genes, including TP53 , MAP3K1 , SMAD4 , APC , and ARID1A. TP53 mutations were most frequently observed (12/32; 37.5%). Genomic mutation profiles were highly concordant between primary tumors and matched LNMs (13/16; 81.3%), and an additional genomic mutation of CDK12 was observed in only one patient. Genomic mutations were highly concordant between primary tumors and matched LNMs, suggesting that genotyping of archived primary tumor samples may help predict genomic mutations of metastatic tumors in patients with EHCC. [ABSTRACT FROM AUTHOR]

Purpose: This retrospective study aimed to clarify whether the postoperative prognosis differs between right and left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma. Methods: Preoperative images of 195 patients with perihilar cholangiocarcinoma were reexamined. Patients with Bismuth type I/II perihilar cholangiocarcinoma without a difference in extraductal tumor invasion between the right and left sides of the hepatic portal region were classified into those undergoing left (L group) or right (R group) hepatectomy. Results: Twenty-three patients (11.8%) were classified into the L group and 33 (16.9%) into the R group. All eight patients with pTis/1 belonged to the L group. The L group had significantly less liver failure than the R group (p = 0.001). One patient (4.3%) in the L group and four patients (12.1%) in the R group died from postoperative complications. Among 48 patients with pT2, the L group tended to have better overall survival (median, 12.2 vs. 5.6 years; p = 0.072), but not recurrence-free survival (median, 9.1 vs. 3.6 years; p = 0.477), in comparison to the R group. Conclusions: Postoperative survival after left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma is expected to be as long as that after right hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Near-infrared (NIR) fluorescence image-guided surgery (FIGS) introduces a revolutionary new approach to address this basic challenge in minimally invasive surgery. However, current FIGS systems have some limitations – the infrared rays cannot detect and visualise thick tissues with low concentrations of the fluorescent agent. We established a novel laparoscopic fluorescence spectrum (LFS) system using indocyanine green (ICG) fluorescence to overcome these limitations. Materials and Methods: Bovine serum albumin (BSA) was conjugated to ICG, and the mixtures were serially diluted at 5 × 10−8–5 × 10−1 mg/mL. We used the LFS system and a NIR camera system (NLS; SHINKO OPTICAL CO., LTD Tokyo, Japan) to determine the optical dilution for the fluorescence detection. BSA was conjugated to ICG (5.0 × 10−2 mg/mL) and used to coat the clips. We attempted to identify the fluorescence-coated clip from the serosal side of the cadaveric porcine stomach tissues using the LFS system and the NIR camera system. We measured the depth of the cadaveric porcine stomach wall at the thickest part that could be confirmed. Results: We could not visualise fluorescence concentrations <2.5 × 10−3 mg/mL using the NIR camera system. The spectrum was detected at a concentration <2.5 × 10−3 mg/mL. We were able to identify the spectrum of ICG (829 nm) to a 13-mm depth of cadaveric porcine stomach wall by using the LFS system but could not identify the same with the NIR camera system regardless of wall thickness. Conclusions: The novel LFS system with NIR fluorescence imaging in this ex vivo and cadaveric porcine model was confirmed useful at deeper depths and lower concentrations. Based on these findings, we anticipate that the LFS system can be integrated and routinely used in minimally invasive surgery. [ABSTRACT FROM AUTHOR]

Purpose: Delirium is associated with longer hospital stays and increased medical costs and mortality. This study explored the risk factors for postoperative delirium in gastroenterological surgery and investigated the association between qualitative changes in risk factors and the incidence of postoperative delirium. Methods: A total of 418 patients > 18 years old who underwent gastroenterological surgery at our department between April 2018 and September 2019 were included. Risk factors were identified by comparing patients with and without postoperative delirium. Continuous variables were evaluated graphically using cubic spline curves. A logistic regression analysis was performed to assess independent risk factors. Results: The incidence of postoperative delirium was 6.9%. The cubic spline curve showed that the incidence of postoperative delirium began to increase at 50 years old and increased sharply at 70 years old. A multiple logistic regression analysis of patients > 50 years old identified 5 risk factors: age ≥ 70 years, preoperative serum albumin ≤ 3.8 g/dL, psychosis, sedative-hypnotics, and intensive-care unit admission. Conclusion: The risk of postoperative delirium increases progressively at 50 years old and sharply at 70 years old. Advanced age, preoperative hypoalbuminemia, psychosis, sedative-hypnotics, and intensive-care unit admission are risk factors for postoperative delirium in patients > 50 years old undergoing gastroenterological surgery. [ABSTRACT FROM AUTHOR]

Background: Our aim was to characterize the motions of multiple laparoscopic surgical instruments among participants with different levels of surgical experience in a series of wet-lab training drills, in which participants need to perform a range of surgical procedures including grasping tissue, tissue traction and dissection, applying a Hem-o-lok clip, and suturing/knotting, and digitize the level of surgical competency. Methods: Participants performed tissue dissection around the aorta, dividing encountered vessels after applying a Hem-o-lok (Task 1), and renal parenchymal closure (Task 2: suturing, Task 3: suturing and knot-tying), using swine cadaveric organs placed in a box trainer under a motion capture (Mocap) system. Motion-related metrics were compared according to participants' level of surgical experience (experts: 50 ≤ laparoscopic surgeries, intermediates: 10–49, novices: 0–9), using the Kruskal–Wallis test, and significant metrics were subjected to principal component analysis (PCA). Results: A total of 15 experts, 12 intermediates, and 18 novices participated in the training. In Task 1, a shorter path length and faster velocity/acceleration/jerk were observed using both scissors and a Hem-o-lok applier in the experts, and Hem-o-lok-related metrics markedly contributed to the 1st principal component on PCA analysis, followed by scissors-related metrics. Higher-level skills including a shorter path length and faster velocity were observed in both hands of the experts also in tasks 2 and 3. Sub-analysis showed that, in experts with 100 ≤ cases, scissors moved more frequently in the "close zone (0 ≤ to < 2.0 cm from aorta)" than those with 50–99 cases. Conclusion: Our novel Mocap system recognized significant differences in several metrics in multiple instruments according to the level of surgical experience. "Applying a Hem-o-lok clip on a pedicle" strongly reflected the level of surgical experience, and zone-metrics may be a promising tool to assess surgical expertise. Our next challenge is to give completely objective feedback to trainees on-site in the wet-lab. [ABSTRACT FROM AUTHOR]

Background: Postoperative pancreatic fistula is a main cause of fatal complications post-pancreatoduodenectomy. However, no universally accepted drainage management exists for clinically relevant postoperative pancreatic fistulas. We retrospectively evaluated cases in which drain contrast imaging was used to determine its utility in identifying clinically relevant postoperative pancreatic fistulas post-pancreatoduodenectomy.Methods: Between January 2014 and December 2018, 209 consecutive patients who underwent pancreatoduodenectomy in our institute were retrospectively analyzed. Drain monitoring with contrast imaging was performed in 47 of the cases. We classified drain contrast type into three categories and evaluated postoperative outcome in each group: (1) fistulous tract group-only the fistula was contrasted; (2) fluid collection group - fluid collection connected to the drain fistula; and (3) pancreatico-anastomotic fistula group-fistula connected to the digestive tract.Results: The durations of postoperative hospital stay and drainage were significantly shorter in the fistulous tract group than in the fluid collection group (31 vs. 46 days, p = 0.0026; and 12 vs. 38 days, p < 0.0001, respectively). The cost and number of drain exchanges were significantly lower in the fistulous tract group than in the fluid collection group ($163.6 vs. 467.5, p < 0.0001; and 1 vs. 5.5, p < 0.0001, respectively). Notably, no patient had grade C postoperative pancreatic fistula.Conclusion: Classification of prophylactic drain contrast type can aid in predicting outcomes of clinically relevant postoperative pancreatic fistulas and optimizing drainage management. [ABSTRACT FROM AUTHOR]

Purpose: Our aim was to develop practical training for laparoscopic surgery using Thielembalmed cadavers. Furthermore, in order to verbalize experts' motion characteristics and provide objective feedback to trainees, we initiated motion capture analyses of multiple surgical instruments simultaneously during the cadaveric trainings. In the present study, we report our preliminary results., Methods: Participants voluntarily joined the present cadaveric simulation trainings, and performed laparoscopic radical nephrectomy. After the trainings, scores for tissue similarity (face validity) and impression of educational merit (content validity) were collected from participants based on a 5-point Likert scale (tissue similarity: 5: very similar, 3: average, 1: very different; educational merit: 5: very high, 3: average, 1: very low). In addition, after the additional IRB approval, we started motion capture (Mocap) analyses of 6 surgical instruments (scissors, vessel sealing system, grasping forceps, clip applier, right-angled forceps, and suction), using an infrared trinocular camera (120-Hz location record). Mocap-metrics were compared according to the previous surgical experiences (experts: ≧50 laparoscopic surgeries, intermediates: 10-49, novices: 0-9), using the Kruskal-Wallis test., Results: A total of 9 experts, 19 intermediates, and 15 novices participated in the present study. In terms of face validity, the mean scores were higher than 3, other than for the Vena cava(mean score of 2.89). Participants agreed with the training value (usefulness for future skill improvement: mean score of 4.57). In terms of Mocap analysis, faster speed-related metrics (e.g., velocity, the distribution of tip velocity, acceleration, and jerk) in the scissors and vessel sealing system, a shorter path length of grasping forceps, and fewer dimensionless squared jerks, which indicated more purposeful motion of 4 surgical instruments (vessel sealing system, grasping forceps, clip applier and suction), were observed in the more experienced group., Conclusions: The Thiel-embalmed cadaver provides an excellent training opportunity for complex laparoscopic procedures with participants' high level of satisfaction, and may become a promising tool for a better objective understanding of surgical dexterity. In order to enrich formative feedback to trainees, we are now proceeding with Mocap analysis., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Advanced gastric cancer that has not invaded the greater curvature is a good indication for total gastrectomy (TG) with spleen-preserving suprapancreatic and splenic hilar lymph node dissection (LND). However, the suprapancreatic and splenic hilar LND increases the area of dissection of the pancreas, and prolonged pressure drainage of the pancreas is required to maintain a clear operative view. This can lead to an increased risk of postoperative pancreatic complications. To report the efficacy of our novel preemptive retropancreatic approach (PRA) for the suprapancreatic and splenic hilar LND in robotic TG (RTG). We report our experience with nine patients with gastric cancer who underwent spleen-preserving splenic hilar LND using PRA during RTG at Hokkaido University from October 2018 to November 2021. The PRA involves initial dissection of the left side of the retropancreatic space, followed by the release of the adherence between the retroperitoneum surface and the pancreas (fusion fascia), which provides a good operative field and prevents contact with the pancreas during the suprapancreatic and splenic hilar LND in RTG. The median operating time was 488 min (254-564 min). The median intraoperative bleeding was 55 mL (0-115 mL). One patient had postoperative complications (above grade II of the Clavien-Dindo classification), but there were no postoperative pancreatic complications. The spleen-preserving suprapancreatic and splenic hilar LND using PRA could help to reduce the postoperative pancreatic complications associated with RTG.Trial registration number and date of registration The Hokkaido University Hospital institutional review board approved the data collection and analysis. The trial registration number and date of registration are No. 021-0022 and July 26, retrospectively registered., (© 2024. Italian Society of Surgery (SIC).)

Background: Nivolumab with chemotherapy has been transformative for metastatic gastric cancer (GC). The potential of this regimen for local tumor control could be utilized for perioperative chemotherapy in locally advanced GC with bulky tumors or lymph node metastasis involving other organs., Case Presentation: Five patients with HER2-negative advanced GC were treated with nivolumab and oxaliplatin-based chemotherapy. All patients presented with clinical stage III or IVA GC with tumors in contact with either the pancreas or liver. Following chemotherapy, all tumors demonstrated shrinkage, allowing successful radical gastrectomies including four minimally invasive approach without postoperative complications. Four patients avoided combined resection of other organs., Conclusions: Perioperative chemotherapy with nivolumab was effective for local disease control in this case series. This regimen could be a promising treatment approach for locally advanced GC; however, its survival benefits should be evaluated in clinical trials., (© 2024. The Author(s).)

Background: Neutrophil extracellular traps (NETs) are extracellular chromatin structures composed of cytoplasmic, granular, and nuclear components of neutrophils. Recently, NETs have received much attention for their role in tumor biology; however, their impact on the postoperative prognosis of patients with extrahepatic cholangiocarcinomas (EHCCs) remains unclear. The purpose of this study was to clarify the impact of NETs identified by immunohistochemical citrullinated histone H3 (Cit-H3) staining on postoperative overall survival (OS) in patients with perihilar cholangiocarcinoma (PHCC) and distal cholangiocarcinoma (DCC)., Methods: This study included 318 patients with EHCC (PHCC, n = 192; DCC, n = 126) who underwent surgical resection with curative intent. Neutrophils and NETs were identified by immunohistochemistry using antibodies against CD15 and Cit-H3, respectively. Based on the distribution of CD15 and Cit-H3 expression in the tumor bed, the patients were classified into four groups: one negative group and three subgroups of the positive group (diffuse, intermediate, and focal subgroups)., Results: No significant difference was found in the postoperative OS rate depending on the distribution of CD15 expression in patients with PHCC or DCC. However, the three subgroups with positive Cit-H3 expression had significantly poorer OS than the negative group for both PHCC and DCC. Moreover, positive Cit-H3 was an independent OS factor in the multivariable analyses of PHCC (hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.11-2.59, P = 0.0115) and DCC (HR 2.03; 95% CI 1.21-3.42, P = 0.0057)., Conclusions: The presence of NETs in the tumor microenvironment may have adverse prognostic effects in patients with EHCCs., (© 2023. Society of Surgical Oncology.)

Purpose: Operations for malignant diseases of the bile duct, pancreas, and esophagus are the most invasive gastroenterological surgeries. The frequency of complications after these surgeries is high, which affects the postoperative course and mortality. In patients who undergo these types of surgeries, continuous monitoring of the perioperative central venous oxygen saturation (ScvO 2 ) is possible via a central venous catheter. We aimed to investigate the relationship between continuously monitored perioperative ScvO 2 values and postoperative complications., Methods: The medical records of 115 patients who underwent highly invasive gastroenterological surgeries and ScvO 2 monitoring from April 2012 to March 2014 were analyzed. Sixty patients met the inclusion criteria, and their ScvO 2 levels were continuously monitored perioperatively. The relationship between ScvO 2 levels and major postoperative complications, defined as Clavien-Dindo grade ≥ III, was examined using uni- and multivariate analysis., Results: Thirty patients developed major postoperative complications. The adequate cut-off value derived from receiver operating curves of the postoperative average ScvO 2 levels for predicting major complications was 75%. Multivariate analysis revealed that low average postoperative ScvO 2 levels ( p  = 0.016) and blood loss ≥ 1000 mL ( p  = 0.039) were significant predictors of major postoperative complications., Conclusions: Low perioperative ScvO 2 values were associated with an increased risk of major postoperative complications. Continuous ScvO 2 monitoring will help prevent postoperative complications., Competing Interests: The authors declare no conflicts of interest for this article., (© 2024 The Authors. Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.)

Purpose: To ensure the safe spread of pediatric endoscopic surgery, it is essential to build a training curriculum, and a survey of the current situation in Japan is necessary. The present study assessed an efficient training curriculum by clarifying instructor class pediatric surgeons' experiences, including autonomy when performing advanced endoscopic surgeries., Methods: An online nationwide questionnaire survey was conducted among pediatric surgeons who had Endoscopic Surgical Skill Qualification (ESSQ) and board-certified instructors who had skills comparable to ESSQ. We assessed participants' training experience, opinions concerning the ideal training curriculum, and the correlation between surgical experience and the level of autonomy. The Zwisch scale was used to assess autonomy., Results: Fifty-two participants responded to the survey (response rate: 86.7%). Only 57.7% of the respondents felt that they had received sufficient endoscopic surgery training. Most respondents considered an educational curriculum for endoscopic surgery including off-the-job training essential during the training period. Autonomy had been acquired after experiencing two to three cases for most advanced endoscopic surgeries., Conclusion: This first nationwide survey in Japan showed that instructor class pediatric surgeons acquired autonomy after experiencing two to three for most advanced endoscopic surgeries. Our findings suggest that training, especially off-the-job training, has been insufficient., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Pediatric endoscopic surgery has become an alternative to conventional techniques with the development of medical equipment. However, there is no formal, standardized curriculum for pediatric endoscopic surgery, and its requirement remains elusive. The purpose of this study is to determine the baseline knowledge of pediatric surgeons that is considered essential for pediatric laparoscopic and thoracoscopic surgery., Methods: Sixteen web-based multiple-choice questions based on the fundamental cognitive knowledge of pediatric endoscopic surgery were administered. The questions were created based on the fields covered by the Fundamentals of Laparoscopic Surgery ™ (FLS) certification examination blueprints and eight specific diseases of pediatric surgery. Pediatric surgeons and pediatric surgical trainees participated in this study voluntarily., Results: A total of 122 surgeons participated through the Japanese Society of Pediatric Surgeons. The response rate was 95% (122/128). The total mean examination score of all participants was 79.4% (77.3-81.4%). There were no significant differences in total scores between the board-certified pediatric surgeons without an endoscopic surgical skill qualification and the non-board-certified pediatric surgeons (80.4% vs. 77.1%, p = 0.12). The endoscopic surgical skill-qualified surgeons had significantly higher percentages of correct responses in specific subjects than board-certified pediatric surgeons and surgeons without pediatric board certification (94.3% vs. 82.9%, p = 0.02; 94.3% vs. 77.5%, p = 0.0002). The FLS original subjects' scores were not significantly different among them. The mean score of surgeons who had experienced more than 200 cases of endoscopic surgery, including adult cases, was 83.2% (80.4-85.9%)., Conclusions: A knowledge gap exists between surgeons, board-certified pediatric surgeons, and endoscopic surgical skill-qualified surgeons in Japan. In the field of pediatric surgery, an effective formal curriculum, such as FLS, is required to help address this vast knowledge gap for the safe conduct of endoscopic surgeries., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pancreatoduodenectomy, an advanced surgical procedure with a high complication rate, requires surgical skill in performing pancreaticojejunostomy, which correlates with operative outcomes. We aimed to analyze the correlation between pancreaticojejunostomy assessment conducted in a simulator environment and the operating room and patient clinical outcomes., Methods: We recruited 30 surgeons (with different experience levels in pancreatoduodenectomy) from 11 institutes. Three trained blinded raters assessed the videos of the pancreaticojejunostomy procedure performed in the operating room using a simulator according to an objective structured assessment of technical skill and a newly developed pancreaticojejunostomy assessment scale. The correlations between the assessment score of the pancreaticojejunostomy performed in the operating room and using the simulator and between each assessment score and patient outcomes were calculated. The participants were also surveyed regarding various aspects of the simulator as a training tool., Results: There was no correlation between the average score of the pancreaticojejunostomy performed in the operating room and that in the simulator environment (r = 0.047). Pancreaticojejunostomy scores using the simulator were significantly lower in patients with postoperative pancreatic fistula than in those without postoperative pancreatic fistula (P = .05). Multivariate analysis showed that pancreaticojejunostomy assessment scores were independent factors in postoperative pancreatic fistula (P = .09). The participants highly rated the simulator and considered that it had the potential to be used for training., Conclusion: There was no correlation between pancreaticojejunostomy surgical performance in the operating room and the simulation environment. Surgical skills evaluated in the simulation setting could predict patient surgical outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The Japanese operative-rating scale for laparoscopic distal gastrectomy (JORS-LDG) was developed through cognitive task analysis together with the Delphi method to measure intraoperative performance during laparoscopic distal gastrectomy. This study aimed to investigate the value of this rating scale as an educational tool and a surgical outcome predictor in laparoscopic distal gastrectomy., Methods: The surgical performance of laparoscopic distal gastrectomy was assessed by the first assistant, through self-evaluation in the operating room and by video raters blind to the case. We evaluated inter-rater reliability, internal consistency, and correlations between the JORS-LDG scores and the evaluation methods, patient characteristics, and surgical outcomes., Results: Fifty-four laparoscopic distal gastrectomy procedures performed by 40 surgeons at 16 institutions were evaluated in the operating room and with video recordings using the proposed rating scale. The video inter-rater reliability was > 0.8. Participating surgeons were divided into the low, intermediate, and high groups based on their total scores. The number of laparoscopic surgeries and laparoscopic gastrectomy procedures performed differed significantly among the groups according to laparoscopic distal gastrectomy skill levels. The low, intermediate, and high groups also differed in terms of median operating times (311, 266, and 229 min, respectively, P < 0.001), intraoperative complication rates (27.8, 11.8, and 0%, respectively, P = 0.01), and postoperative complication rates (22.2, 0, and 0%, respectively, P = 0.002)., Conclusions: The JORS-LDG is a reliable and valid measure for laparoscopic distal gastrectomy training and could be useful in predicting surgical outcomes., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Splenic infarction (SI) following gastrectomy is common; severe complications related to SI, such as splenic haemorrhage, abscess formation or rupture, can be fatal. To overcome these problems, we performed real-time vessel navigation using indocyanine green (ICG) fluorescence during robotic distal gastrectomy (RDG). The aim of study is to report the efficacy of robotic real-time vessel navigation for lymph node dissection (LND) along left gastroepiploic vessels (LGEVs). We treated seven patients with gastric cancer who underwent LND along the LGEVs using robotic real-time vessel navigation during RDG at our institution from January 2021 to July 2021. There were no complications (Clavien-Dindo classification II). There were no cases of post-operative SI or spleen-related complications. Robotic real-time vessel navigation using ICG for LND along LGEVs during RDG could help to reduce post-operative spleen-related complications associated with RDG., Competing Interests: None

We report the usefulness of the preemptive retropancreatic approach (PRA) in robotic distal gastrectomy (RDG) using multi-jointed forceps. Therefore, this study aimed to compare the short-term outcomes of RDG with PRA and conventional laparoscopic distal gastrectomy using the propensity score matching method. A total of 126 patients [RDG = 55; laparoscopic distal gastrectomy (LDG) = 71] were retrospectively enrolled. Patients were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, the extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Surgical results and postoperative outcomes were compared. We identified 28 propensity score-matched pairs. The median operative time and blood loss were comparable (P = 0.272 and P = 0.933, respectively). Regarding postoperative outcomes, the incidence of postoperative complications [Clavien-Dindo classification II (CD ≥ II)] was lower in the RDG group than in the LDG group (P = 0.020). No significant differences in the peak C-reactive protein value and length of hospital stay were observed between the two groups (P = 0.391 and P = 0.057, respectively). In addition, no patients had postoperative pancreas-related complications (≥ CD II) in the RDG group. RDG using PRA seems to be a safe and feasible procedure for gastric cancer because of short-term outcomes and reduction of postoperative complications (especially postoperative pancreas-related complications) as compared to conventional LDG., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Pancreatic ductal adenocarcinoma (PDA) is a fatal cancer for which even unfavorable clinicopathological factors occasionally fail to preclude long-term survival. We sought to establish a scoring system that utilizes measurable pre-intervention factors for predicting survival following surgical resection., Methods: We retrospectively analyzed 34 patients who died from short-term recurrences and 32 long-term survivors among 310 consecutively resected patients with PDA. A logistic regression model was used to define factors related to clinical parameters, molecular profiles of 18 pancreatic cancer-associated genes, and aberrant expression of major tumor suppressors., Results: Carbohydrate antigen 19-9 (CA19-9) had the best ability to classify patients with short-term recurrence and long-term survivors [odds ratio 21.04, 95% confidence interval (CI) 4.612-96.019], followed by SMAD4 and TP53 mutation scoring (odds ratio 41.322, 95% CI 3.156-541.035). Missense TP53 mutations were strongly associated with the nuclear expression of p53, whereas truncating mutations were associated with the absence of nuclear p53. The former subset was associated with a worse prognosis. The combination of aberrant SMAD4 and mutation types of TP53 exhibited a better resolution for distinguishing patients with short-term recurrences from long-term survivors (compared with the assessment of the number of mutated KRAS, CDKN2A, TP53, and SMAD4 genes). Calibration of mutation scores combined with CA19-9 in a logistic regression model setting demonstrated a practical effect in classifying long survivors and patients with early recurrence (c-statistic = 0.876)., Conclusions: Genetic information, i.e., TP53 mutation types and SMAD4 abnormalities, combined with CA19-9, will be a valuable tool for improving surgical strategies for pancreatic cancer., (© 2022. Society of Surgical Oncology.)

Purpose: This study evaluated the short-term outcomes and prognosis after laparoscopic total gastrectomy (LTG) in elderly patients aged ≥ 80 years in a multicenter retrospective cohort study using propensity score matching., Methods: We retrospectively enrolled 440 patients who underwent curative LTG for gastric cancer at six institutions between January 2004 and December 2018. Patients were categorized into an elderly patient group (EG; age ≥ 80 years) and non-elderly patient group (non-EG; age < 80 years). Patients were matched using the following propensity score covariates: sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Short-term outcomes and prognoses were compared., Results: We identified 37 propensity score-matched pairs. The median operative time was significantly shorter, and postoperative stay was longer in the EG. In terms of postoperative outcomes, the rates of all complications were comparable. The median follow-up period of the EG and non-EG was 11.5 (1-106.4) months and 35.7 (1-110.0) months, respectively; there were significant differences in 5-year overall survival between the two groups (EG, 58.5% vs. non-EG, 91.5%; P = 0.031). However, there were no significant differences in 5-year disease-specific survival (EG, 62.1% vs. non-EG, 91.5%; P = 0.068) or 5-year disease-free survival (EG, 52.9% vs. non-EG, 60.8%; P = 0.132)., Conclusions: LTG seems to be safe and feasible in elderly patients. LTG had a limited effect on morbidity, disease recurrence, and survival in elderly patients. Therefore, age should not prevent elderly patients from benefitting from LTG., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Telesimulation, whereby learners telecommunicate and use simulator resources to receive education at an off-site location, has been used to educate surgical trainees about how to perform basic surgical procedures. However, it has not yet been used for advanced surgical procedures. We aimed to develop a telesimulation curriculum to teach a common laparoscopic procedure called transabdominal preperitoneal (TAPP) repair and to explore the feasibility of its use., Methods: Learning objectives were created to develop a telesimulation curriculum that included didactic telelecture and telesimulation training. Pre-tests and post-tests to assess the didactic materials were developed and assessed among surgeons with various experiences. We assessed the feasibility of the telelecture and telesimulation separately. Pre-tests, post-tests, and questionnaires were used to assess the telelectures. We created a TAPP repair telesimulation system and checked for problems during training. Trainees were assessed to determine their skill improvement using previously published assessment tools and questionnaires., Results: A didactic telelecture was developed based on the learning objectives using an expert consensus and pilot-tested among five participants. After the lecture, their test scores improved and they expressed positive opinions about the usefulness of telelectures. The TAPP repair telesimulation training was pilot-tested among three trainees. No technical problems occurred during training. All trainees improved their skills after the telesimulation training and agreed that the training was useful for learning the TAPP repair procedure., Conclusions: We systematically developed a telesimulation curriculum for the TAPP repair procedure and demonstrated its feasibility among learners., Competing Interests: Conflict of interestOn behalf of all authors, the corresponding author states that there is no conflict of interest., (© The Author(s), under exclusive licence to Association for Surgical Education 2022, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

A considerable percentage of morbidity and mortality after oesophagectomy is due to leakage of oesophagogastrostomy, which is mainly caused by ischaemia of the gastric tube. Therefore, we performed laparoscopic real-time vessel navigation (LRTVN) using indocyanine green fluorescence (ICG) during laparoscopy-assisted gastric tube reconstruction (LAGR) to evaluate gastric tube blood flow and avoid vascular injury. This study included five oesophageal cancer patients who underwent video-assisted thoracoscopic oesophagectomy and LAGR. We confirmed the presence of the left gastroepiploic artery (LGEA) in all cases, and no findings such as post-operative gastric tube ischaemia were observed. In all cases, no vascular injury was observed, and the vascularization of LGEA was confirmed. This report is the first to consider the usefulness of LRTVN using ICG during LAGR. LRTVN using ICG during LAGR was considered to be useful for evaluating gastric tube blood flow and avoiding vascular injury around the splenic hiatus., Competing Interests: None

Purpose: There is no standard program for laparoscopic surgery training in Japan, and competency in these procedures does not require the acquisition of board certification. The purpose of this survey was to investigate the current status of laparoscopic surgery training in Japan., Methods: A questionnaire survey was mailed to 2296 members of the Japan Society for Endoscopic Surgery who were between postgraduate year 3 and 10. The questionnaire inquired about laparoscopic surgical training conditions, operation case numbers, and autonomy in eight laparoscopic procedures., Results: The total response rate was 28.1%. The number of cases required to perform procedures independently was demonstrated. Most participants felt confident in performing laparoscopic appendectomy and cholecystectomy; however, they felt less confident about performing laparoscopic colectomy and gastrectomy., Conclusions: The information from this survey may be useful for surgical educators, surgical societies, and the board certification council for rebuilding the surgical training system in Japan., (© 2021. Springer Nature Singapore Pte Ltd.)

Background: The aim of this study was to evaluate the long-term nutritional state of patients with gastric cancer who underwent laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DTR) using oblique jejunogastrostomy method (OJG)., Methods: Medical records of 38 patients who underwent LPG-DTR using OJG (21 patients) or laparoscopic total gastrectomy with Roux-en-Y reconstruction (LTG-RY) (17 patients) between October 2011 and March 2018 were retrospectively reviewed. In these patients, clinicopathologic variables were analyzed using propensity score matching for age, sex, body mass index, American Society of Anesthesiologists physical state, clinical stage, and lymph node dissection. Operative outcomes and postoperative nutritional status were compared between the 2 groups., Results: A total of 16 patients were matched to analyze the LPG-DTR and LTG-RY groups. The serum hemoglobin, total protein, and albumin levels at 12 months postoperatively (P=0.008, 0.034, and 0.049) and serum hemoglobin level at 24 months (P=0.025) in the LPG-DTR group was significantly superior to those in the LTG-RY group., Conclusions: The postoperative nutritional status as long-term outcomes of patients who underwent LPG-DTR using OJG was significantly superior to those who underwent LTG-RY. The results hereby presented suggest that LPG-DTR using OJG for gastric cancer produces better postoperative nutritional status., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Laparoscopic-Warshaw technique (lap-WT) may be selected as a function-preserving operation for malignant border lesions in the tail region of the pancreas. However, previous reports showed that there are complications such as infection and abscess formation due to lack of blood flow to the spleen after surgery. To overcome the problems, we have performed real-time vessel navigation by using indocyanine green (ICG) fluorescence during lap-WT., Materials and Methods: We report our experience of three patients with pancreatic tumour who underwent real-time vessel navigation during lap-WT at Hokkaido University from May 2017 to September 2018., Results: The median operating time was 339 min (174-420). The median intraoperative bleeding was 150 ml (0-480). There were no incidences of complications. There were no cases with post-operative spleen ischaemia or abscess formation and varices formation., Conclusion: We believe that laparoscopic real-time vessel navigation using indocyanine green fluorescence during lap-WT could contribute in reducing the post-operative spleen-related complications., Competing Interests: None

Background: The differences between perihilar cholangiocarcinoma (PHCC) and distal cholangiocarcinoma (DCC) regarding recurrence and the factors that affect recurrence after surgery are unclear. This study aims to investigate the differences in recurrence patterns between patients with PHCC and those with DCC after surgical resection with curative intent. It also investigates the risk factors associated with recurrence and survival thereafter., Patients and Methods: The postoperative courses of 366 patients with extrahepatic cholangiocarcinomas (EHCCs), including 236 with PHCC and 130 with DCC, who underwent surgical resections were investigated retrospectively., Results: During follow-up, tumors recurred in 143 (60.6%) patients with PHCC and in 72 (55.4%) patients with DCC. Overall survival (OS) after surgery, recurrence-free survival (RFS), and OS after recurrence were similar for the patients with PHCC and those with DCC. The cumulative probability of recurrence declined 3 years after surgery in the patients with PHCC and those with DCC. A multivariable analysis determined that, among the patients with PHCC and those with DCC, regional lymph node metastasis was a significant risk factor associated with RFS. Ten patients with PHCC and eight patients with DCC with two or fewer sites of recurrence in a single organ underwent resections. A multivariable analysis determined that recurrent tumor resection was an independent prognostic factor associated with OS after recurrence in the patients with PHCC and those with DCC., Conclusions: Postoperative survival did not differ between the patients with PHCC and those with DCC. Frequent surveillances for recurrence are needed for 3 years after surgical resection of EHCCs. In selected patients, surgery for recurrent EHCCs might be associated with improved outcomes.

Purpose: This study aimed to evaluate the relationship between the body mass index (BMI) and the short-term outcomes of laparoscopic total gastrectomy (LTG)., Subjects and Methods: Data of patients who underwent LTG for gastric cancer at six institutions between 2004 and 2018 were retrospectively collected. The patients were classified into three groups: low BMI (<18.5 kg/m 2 ), normal BMI (≥18.5 and <25 kg/m 2 ) and high BMI (≥25 kg/m 2 ). In these patients, clinicopathological variables were analysed using propensity score matching for age, sex, the American Society of Anaesthesiologists physical state, clinical stage, surgical method, D2 lymph node dissection, combined resection of other organs, anastomosis method and jejunal pouch reconstruction. The surgical results and post-operative outcomes were compared among the three groups., Results: A total of 82 patients were matched in the analysis of the low BMI and normal BMI groups. There were no differences in operative time (P = 0.693), blood loss (P = 0.150), post-operative complication (P = 0.762) and post-operative hospital stay (P = 0.448). In the analysis of the normal BMI and high BMI groups, 208 patients were matched. There were also no differences in blood loss (P = 0.377), post-operative complication (P = 0.249) and post-operative hospital stay (P = 0.676). However, the operative time was significantly longer in the high BMI group (P = 0.023)., Conclusions: Despite the association with a longer operative time in the high BMI group, BMI had no significant effect on the surgical outcomes of LTG. LTG could be performed safely regardless of BMI., Competing Interests: None

Background: Lymphangioma is a benign malformation of the lymphatic system and is often found in the neck and axilla, the orbit, the mediastinum, etc. However, isolated splenic lymphangioma is a rare disease in young women, and its treatment is controversial. We report a case of laparoscopic partial splenectomy for isolated splenic lymphangioma in a young woman., Case Presentation: An 18-year-old woman with mild epigastralgia was admitted to a nearby hospital. Abdominal ultrasound detected a 6-cm mass confined to the upper pole of the spleen; thereafter, she was referred to our department for surgical treatment. Although a benign tumor, we decided to resect it because of her symptoms. To preserve part of the normal spleen, laparoscopic partial splenectomy was performed with a co-axial approach using four ports and a liver retractor in the lithotomy position. After dissection around the spleen hilum, we identified that the tumor was being fed from the splenic vessels of the upper pole and severed the branch. Postoperatively, the patient showed no complications and was discharged on postoperative day 8 without symptoms. Pathological examination revealed splenic lymphangioma, which is rare in young women. No recurrence was seen 1 year after surgery, and a computed tomography scan showed no problems with the remaining spleen., Conclusions: In our experience of laparoscopic partial splenectomy for a young woman with an isolated splenic lymphangioma, we determined that laparoscopic partial splenectomy is a safe, effective, and valuable option for the treatment of benign splenic tumors.

Background: Rectal neuroendocrine neoplasms (NENs) are rare, but their incidence has increased in recent years. The metastasis rate is low in cases of a tumor diameter < 1 cm or depth of invasion lower than the submucosa; therefore, the European Neuroendocrine Tumor Society (ENETS) and the North American Neuroendocrine Tumor Society (NANETS) consensus guidelines recommend endoscopic resection. Since little has been reported on the long-term prognosis of endoscopic resection for rectal NEN, consensus is lacking regarding the follow-up period after endoscopic resection., Case Presentation: Here, we report three cases of metachronous liver metastasis after long-term follow-up of endoscopic mucosal resection (EMR) for rectal NEN. The pathological findings indicated a depth lower than the submucosa and complete radical resection in all cases and lymphovascular invasion in only one case. All three cases showed metachronous multiple liver metastases after 9-13 years of follow-up for EMR, despite achieving complete resection and without muscular invasion., Conclusions: Metachronous liver metastases may occur after long interval following endoscopic resection; thus, long-term follow-up is necessary after endoscopic resection for rectal NEN.

Over the past 30 years, the therapeutic outcome for pancreatic ductal adenocarcinoma (PDAC) has remained stagnant due to the lack of effective treatments. We performed a genome-wide analysis to identify novel therapeutic targets for PDAC. Our analysis showed that Homo sapiens chromosome 16 open reading frame 74 (C16orf74) was upregulated in most patients with PDAC and associated with poor prognosis. Previously, we demonstrated that C16orf74 interacts with the catalytic subunit alpha of protein phosphatase 3 and plays an important role in PDAC invasion. However, the pathophysiologic function of C16orf74 is still unclear. In this study, through the analysis of C16orf74 interaction, we demonstrate a new strategy to inhibit the growth and invasion of PDAC. C16orf74 exists in the homodimer form under the cell membrane and binds integrin αVβ3 and is also involved in invasion by activating Rho family (Rac1) and MMP2. Considering that this dimeric form was found to be involved in the function of C16orf74, we designed an 11R-DB (dimer block) cell-permeable dominant-negative peptide that inhibits the dimer form of C16orf74. 11R-DB suppressed invasion and proliferation of PDAC cell lines by inhibiting phosphorylation of Akt and mTOR and also by inactivation of MMP2. 11R-DB also showed antitumor effects in an orthotopic xenograft model and peritoneal metastasis model. Thus, this study demonstrates that dimerized C16orf74, present in the cell membrane, is involved in pancreatic cancer invasion and proliferation. In addition, the C16orf74 dimer block cell-permeable peptide (11R-DB) has a potent therapeutic effect on PDAC in vitro and in vivo ., (©2019 American Association for Cancer Research.)

Background: Virtual reality simulators allow trainees to perform repeated practice and provide objective dexterity metrics regarding their performance, which means that virtual reality-based surgical training is becoming a vital part of initial learning of basic laparoscopic surgical skills. However, its educational role in learning advanced procedures remains undetermined. We evaluated the validity of the laparoscopic radical nephrectomy module of the LapVision virtual reality simulator., Methods: Urologists, medical students, and a junior resident voluntarily participated in the present study, and they performed training with a laparoscopic left radical nephrectomy module. For construct validation, dexterity metrics calculated in the simulator and the mean score of Global Operative Assessment of Laparoscopic Skills evaluated by 2 experts' video review were compared according to the certification of Japanese Endoscopic Surgical Skill Qualification or previous surgical experience., Results: Ten experts (≥ 50 laparoscopic surgeries), 9 intermediates (11-49), and 14 novices (0-10) voluntarily participated in the present study. Regarding the construct validity, there was a significant difference in the total number of errors, blood loss, and Global Operative Assessment of Laparoscopic Skills score among the groups for both the Endoscopic Surgical Skill Qualification status and previous surgical experience., Conclusion: The present study demonstrated good construct validity for the LapVision nephrectomy module. Furthermore, global skill assessment was possible by experts' reviews, which indicates the usefulness of the virtual reality procedural module as a skill assessment tool. Virtual reality-based procedural simulation has marked potential to become a vital part of integrated laparoscopic training programs., (© 2019 The Authors.)

This report describes a rare case of hilar cholangiocarcinoma with intratumoral calcification that mimicked hepatolithiasis. A 73-year-old man presented to a local hospital with a calcified lesion in the hepatic hilum. At first, hepatolithiasis was diagnosed, and he underwent endoscopic stone extraction via the trans-papillary route. This treatment strategy failed due to biliary stricture. He was referred to our hospital, and further examination suggested the existence of cholangiocarcinoma. He underwent left hepatectomy with caudate lobectomy and extrahepatic bile duct resection. Pathological examination revealed hilar cholangiocarcinoma with intratumoral calcification, while no stones were found. To the best of our knowledge, only one case of calcified hilar cholangiocarcinoma has been previously reported in the literature. Here, we report a rare case of calcified hilar cholangiocarcinoma and reveal its clinicopathologic features.

Background/aims: Advanced pancreatic body carcinoma frequently accompany extra-pancreatic nerve plexus (PL) invasion, one of the poor indicator of patient prognosis. The present study aimed to reveal the progress of the PL invasion from cancer of the pancreas body toward the root of the celiac artery (CA) and superior mesenteric artery (SMA) followed by investigation of the relevance of diagnostic accuracy., Methodology: Resected specimens from 50 consecutive patients who underwent distal pancreatectomy with en bloc celiac axis resection (DP-CAR) were pathologically analyzed for the direction of PL invasion. Diagnostic accuracy on CT imaging were also investigated., Results: Thirty seven of the 50 patients (74%) were positive for PL invasion around the CHA, SPA, CA and SMA. In terms of the diagnostic accuracy, positive predictive values for the PL invasion were 35%, 36%, 43% and 81% for the SPA, CHA, CA and SMA, respectively. Among 21 patients and 23 patients with PL invasion around CHA and SPA, 13 and 6 patients also accompanied PL invasion around CA, respectively., Conclusions: Carcinoma of the pancreatic body is found to frequently accompany PL invasion around CA. Under the limitation of low diagnostic accuracy, DP-CAR might be feasible operation that increases the possibility of R0 resection.

Infection with Helicobacter pylori cagA-positive strains causes gastritis and peptic ulceration and is associated with gastric adenocarcinoma. The cagA gene product CagA is delivered into gastric epithelial cells, where it undergoes tyrosine phosphorylation by Src family kinases at the C-terminal EPIYA-repeat region. Tyrosine-phosphorylated CagA specifically binds and activates SHP-2 tyrosine phosphatase, causing cell morphological transformation known as the hummingbird phenotype. CagA also destabilizes the E-cadherin/beta-catenin complex to elicit aberrant activation of the beta-catenin signal that underlies intestinal metaplasia. Here we show that translocalization of membranous beta-catenin and subsequent activation of the beta-catenin signal by CagA requires the EPIYA-repeat region, which is characterized by structural variation between CagA of H. pylori isolated in Western countries (Western CagA) and that of East Asian H. pylori isolates (East Asian CagA), but is independent of CagA tyrosine phosphorylation. Detailed analysis using a series of Western and East Asian CagA mutants revealed that deregulation of beta-catenin requires residues 1009-1086 and residues 908-1012 of ABCCC Western CagA and ABD East Asian CagA, respectively, and is mediated by the 16-amino-acid CagA multimerization sequence that is conserved between the 2 geographically distinct H. pylori CagA species. Our results indicate that aberrant activation of the beta-catenin signal, which promotes precancerous intestinal metaplasia, is an inherent and fundamental CagA activity that is independent of the structural polymorphism of CagA., ((c) 2007 Wiley-Liss, Inc.)