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Background: Inguinal hernia develops as one of the common complications after robotic or laparoscopic radical prostatectomy (RP). TAPP for an inguinal hernia after RP is far from easy to perform due to postoperative severe adhesions in the preperitoneal cavity. We recently devised a high peritoneal incision approach (HPIA) in TAPP for inguinal hernia patients in whom peritoneal dissection is difficult due to severe adhesions after RP. We evaluate the safety and efficacy of TAPP with a high peritoneal incision approach for patients with an inguinal hernia after Robot-assisted radical prostatectomy. Methods Patients characteristics and surgical outcome were evaluated by a retrospective analysis. Result: From January 2014 to December 2017, 21 consecutive patients underwent TAPP for an inguinal hernia after RARP. Twenty-four lesions were the Type 3b and 3 were Type 3a according to the Nyhus classification. A conventional TAPP was performed for 10 hernia lesions in 8 patients and TAPP with HPIA was utilized for 17 lesions in 13 patients. The mean operation time for the unilateral hernia in the HPIA (137.8±20.7 min) was significantly shorter than that (182.2±42.0 min) in the conventional TAPP (p =0.038). The HPIA was complete in all patients, while the conventional TAPP was converted to IPOM in 5 patients (55.6%, p=0.008) due to dense adhesions with difficult dissection. No recurrent was observed after follow-up period of 24months in both groups. Conclusions: The TAPP with HPIA is feasible and a safe and reliable treatment of choice in patients with an inguinal hernia after RARP.

Background: We assessed the relationship between preoperative prognostic nutritional index (PNI) and short- and long-term outcomes among gastric cancer patients because the clinical significance of PNI in these patients remains controversial. Materials and Methods: We retrospectively reviewed the medical records of 434 consecutive patients who underwent curative laparoscopic gastrectomy for gastric cancer. Results: Patients with postoperative complications had a significantly poorer overall survival (OS) than those without. On multivariate analyses, postoperative complications were independently associated with PNI value and operative procedure type. In the low PNI group (n = 118), those with postoperative complications experienced significantly poorer OS than those without complications. Among the low PNI group with pTNM stage I and II disease, those with postoperative complications experienced significantly worse OS than those without complications. However, among the high PNI group and patients with stage II and III disease in the low PNI group, OS was similar with respect to postoperative complications. Conclusions: The present study confirmed that long-term prognosis was unaffected by postoperative complications in well-nourished gastric cancer patients. In addition, preoperative nutritional status and postoperative complications, may be crucial in determining the prognosis of gastric cancer, especially in early-stage cancer.

Background: Intracorporeal esophagojejunostomy in laparoscopy-assisted total or proximal gastrectomy is highly difficult. We developed ingenuity of overlap esophagojejunostomyusing a linear stapler to avoid stapler-related intraoperative complications. Methods: After lymph node dissection was completed, the esophagus was transected in the anterior-posterior direction. The jejunum was divided with a linear stapler approximately 20 cm distal to the ligament of Treitz. A small enterotomy was then created at 5 cm distal from the elevated jejunal stump to insert the linear stapler cartridge. A full-thickness incision was created with an electric knife using the tip of the nasogastric tube (NGT) pressed against the posterior wall side of the esophageal stump as a guide. Full-thickness sutures were applied on both the anterior and posterior walls of the entry hole in the esophageal stump to prevent mis-insertion of the anvil fork into the submucosal layer of esophagus. The thread on the posterior wall side was guided to the outside of the abdominal cavity through the port, into which the linear stapler was inserted to perform side-to-side anastomosis. A 45-mm cartridge fork and an anvil fork were inserted to the entry holes of the elevated jejunum and the esophageal stump, respectively. The esophageal stump was gently grasped. The thread on the posterior wall side was pulled from outside of the abdominal cavity through the port to eliminate the gap between the esophageal wall and the jejunal wall. The linear stapler was fired to create anastomosis after confirming that the anvil fork was not mis-inserted into the submucosal layer of esophagus and there was no gap between the esophagus and the elevated jejunum. The insertion hole was closed with hand-sewn sutures or linear staples to complete the esophagojejunostomy. Results:Seven patients received this procedure with no stapler-related complications. Conclusions: This method enables us to perform an easier and more stable esophagojejunostomy.

BACKGROUND Rectal prolapse in young women is rare. Although laparoscopic ventral mesh rectopexy is the standard procedure because of its lower recurrence rate, postoperative infertility is a concern. Perineal rectosigmoidectomy (Altemeier procedure) is useful for these patients. However, the risk of anastomotic leakage should be considered. Recently, the usefulness of fluorescence imaging with indocyanine green (ICG) to prevent anastomotic leakage was reported. We report a case of an adolescent woman with complete rectal prolapse who underwent ICG fluorescence imaging-assisted Altemeier rectosigmoidectomy. CASE SUMMARY A 17-year-old woman who had a mental disorder was admitted to our hospital for treatment for water intoxication. The patient also suffered from rectal prolapse, approximately 3 mo before admission. She was referred to our surgical department because recurrent rectal prolapse could worsen her psychiatric disorder. Approximately 10 cm of complete rectal prolapse was observed. However, the mean maximum anal resting and constriction pressures were within normal limits on anorectal manometry. Because she had the desire to bear children in the future, she underwent Altemeier perineal rectosigmoidectomy to prevent surgery-related infertility. We performed ICG fluorescence imaging at the same time as surgery to reduce the risk of anastomotic leakage. Her postoperative course was uneventful, and the rectal prolapse was completely resolved. She continued to do well 18 mo after surgery, without recurrence of the rectal prolapse. CONCLUSION ICG fluorescence imaging-assisted Altemeier perineal rectosigmoidectomy is useful in preventing postoperative anastomotic leakage in young as well as elderly patients.

Background: Inflammation influences cancer progression by increasing catabolism and impairing nutrient absorption. We compared the prognostic ability of three inflammation-based prognostic scoring systems—the Glasgow prognostic score (GPS), modified GPS (mGPS), and high-sensitivity mGPS (HS-mGPS)—in gastric cancer patients. Materials and Methods: We retrospectively examined 434 curatively resected gastric cancer patients to evaluate the prognostic ability of scoring systems for overall survival (OS) and cancer-specific survival (CSS). Results: OS analysis identified the following independent prognostic factors: GPS model: pathological stage (pStage, p < 0.001), carcinoembryonic antigen (CEA, p = 0.004), and GPS 1 (hazard ratio [HR], 1.929; 95% confidence interval [CI], 1.152-3.228; p = 0.013); mGPS model: body mass index (BMI, p = 0.027), pStage (p < 0.001), and CEA (p < 0.001); HS-mGPS model: BMI (p = 0.029), pStage (p < 0.001), and CEA (p = 0.003). mGPS and HS-mGPS were not independent prognostic factors for OS. CSS analysis of the GPS model identified pStage (p < 0.001), CEA (p = 0.015), and GPS 1 (HR; 2.095, 95% CI; 1.025–4.283; p = 0.043) and 2 (HR, 2.812; 95% CI, 1.111–7.116; p = 0.029) as independent prognostic factors; however, mGPS and HS-mGPS were not independent prognostic factors for CSS. Log-rank tests demonstrated significant differences in OS among patients with GPS 0 vs. 1 (p < 0.001) and 0 vs. 2 (p < 0.001) and in CSS among the three GPS (0 vs. 1; p = 0.005, 0 vs. 2; p < 0.001, 1 vs. 2; p = 0.009). Conclusions: GPS most reliably predicts long-term survival of gastric cancer patients.

Highlights • Oil contrast medium caused inflammatory granuloma. • Inflammatory granuloma caused growing hernia as the contents of inguinal hernia. • Complete resection of granuloma, including hernia sac, is important to prevent recurrence., Introduction The foreign body reaction caused by oil contrast medium, Lipiodol, is rare. We present a rare case of inflammatory granuloma in the inguinal hernia sac after hysterosalpingography with lipiodol. Presentation of case A 30-year-old woman who had left inguinal growing mass for 7 months after hysterosalpingography with Lipiodol for examination of infertile. About 3 cm soft mass was palpable on the left inguinal region, and plane CT scan showed a multifocal cystic mass with metal concentration. Thus, laparoscopic herniorrhaphy was performed to repair the inguinal hernia and to confirm the contents of cystic lesion. The hernia sac filled with mucinous contents. Pathological examination revealed that inflammatory granuloma due to numerous lipid droplets and phagocytic images of leukocytes in the hernia capsule. Discussion and conclusion Although oil contrast medium is safety agent, there is rear complication which need the surgical treatment. Complete resection of granuloma, including hernia sac, is important to prevent recurrence.

Background This study aimed to evaluate the feasibility, safety, and efficacy of postoperative adjuvant chemotherapy with docetaxel/cisplatin/S-1 (DCS) following S-1 therapy in patients with stage III gastric cancer after curative gastrectomy. Methods Patients with stage III gastric cancer who underwent D2 gastrectomy were enrolled. Adjuvant chemotherapy was initiated within 8 weeks of gastrectomy. The first cycle of chemotherapy consisted of S-1 monotherapy (day 1–14), followed by a 7-day rest period. Cycles 2 and 3 consisted of the following: S-1 (day 1–14) administration, followed by a 14-day rest period, and an intravenous infusion of cisplatin and docetaxel on days 1 and 15. After two cycles, S-1 was administered for up to 1 year. Results Thirty patients were enrolled between 2014 and 2017. Febrile neutropenia of grade 3 or higher was the most common hematological toxicity with 4 patients (13.3%). Other hematological toxicities of grade 3 or higher were as follows: neutropenia in 3 (10.0%), leukopenia in 3 (10.0%), and anemia in 2 (6.7%) patients. Most frequent non-hematological toxicity of grade 3 was anorexia (n = 4, 13.3%) and general fatigue (n = 3, 10.0%); no grade 4 non-hematological toxicities were observed. Twenty-five patients (83.3%) completed two cycles of DCS treatment and 18 (60.0%) completed subsequent S-1 treatment for 1 year. The relative dose intensity of docetaxel and cisplatin was 0.86 and that of S-1 was 0.88. Conclusion The DCS regimen can be acceptable as an adjuvant chemotherapy and offers an effective postoperative treatment option for stage III gastric cancer patients. Trial registration number UMIN000012785. Date of registry 08/01/2014.

Background Risk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy. Methods First, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed. Results We utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases. Conclusion Our technique of NGT placement is simple, safe, and feasible.

It is now clear that cancer survival is determined not only by tumor pathology but also by host-related factors, in particular, nutritional status and systemic inflammation. It is desirable that the essential properties of any scale designed or intended to be used for the prediction of survival are simple, convenient, and objective. In this study, we retrospectively reviewed the database of patients who underwent curative surgery for esophageal cancer in our department to evaluate controlling nutritional status (CONUT) and neutrophil-lymphocyte ratio (NLR) as predictors of cancer-specific survival (CSS) after esophagectomy. We retrospectively reviewed the database of 148 consecutive patients who underwent potentially curative surgery for histologically verified esophageal squamous cell carcinoma at our institute between January 2002 and December 2014. CONUT and NLR were calculated. On multivariate analysis, pTNM stage (P < 0.0001) and CONUT (P = 0.0291) were independently associated with worse prognosis. Multivariate analysis evaluated the prognostic factors in 2 different patient groups: patients younger than 70 years (nonelderly) and those aged 70 years or more (elderly). Multivariate analysis demonstrated that pTNM stage (P = 0.0083) and CONUT (P = 0.0138) were the independent risk factors for a worse prognosis among the nonelderly group, whereas univariate analysis demonstrated that pTNM stage (P = 0.0002) was the only independent risk factor for a worse prognosis among the elderly group. CONUT was a significant predictor of CSS in patients with esophageal cancer in this study. However, pTNM stage remained a significantly more powerful predictor of CSS. Therefore, the results of this study suggested that CONUT and pTNM stage are the significant and complementary factors predicting survival in patients with esophageal cancer. But, this study failed to confirm the NLR as a significant predictor of CSS after resection for esophageal cancer.

BackgroundDespite recent improvements in early detection, progress in surgical techniques, and development of chemoradiation therapies, prognosis of esophageal cancer remains poor. The aim of the present study was to assess whether Glasgow Prognostic Score (GPS), an inflammation-based prognostic score, has prognostic value independent of conventional clinicopathological criteria in patients undergoing curative resection for esophageal cancer, even in elderly patients.MethodsWe retrospectively reviewed the database of 141 consecutive patients with histologically verified esophageal squamous cell carcinoma who underwent potentially curative surgery in our institute, between January 2006 and December 2014. GPS and neutrophil lymphocyte ratio (NLR) were calculated.ResultsOn multivariate analysis, TNM stage (p

Previously it has reported that the incidence of internal hernia can be decreased by closing Petersen's defect, but the perfect closure method, in fact, has not been discovered yet. In this study we have developed an easy and reliable method for closing Petersen's defect in the Roux-en-Y reconstruction after a laparoscopic distal gastrectomy.We performed intracorporeal Roux-en-Y reconstruction after laparoscopic distal gastrectomy with antiperistaltic gastrojejunostomy. The greater omentum is placed on the cranial side of the transverse colon through the defect between the elevated jejunum and the transverse mesocolon. Anastomosis is performed of the transverse mesocolon attached to the transverse colon, the greater omentum is passed through the Petersen's defect, and the stump of the mesojejunum is attached to the elevated jejunum by an interrupted suture. Petersen's defect is spread and straightened to stabilize the visual field. The thread is inserted first at the base of the stump of the elevated mesojejunum, next to the greater omentum, which has passed through Petersen's defect, and then to the transverse mesocolon to set the starting point of continuous suture. The stitches of continuous suture are sewn toward the transverse colon. Petersen's defect is closed completely.We performed this technique in 37 patients. All procedures were completed without intraoperative complication or conversion to laparotomy. During the follow-up period, none of the patients developed complications related to the internal hernia, such as Petersen's hernia.We have indicated a novel, easy, and secure closure procedure of Petersen's defect following laparoscopic distal gastrectomy with Roux-en-Y reconstruction.

Early superior mesenteric artery (SMA) dissection from behind the head of the pancreas using an “artery-first approach” has been considered a safe and efficient technique in performing a pancreaticoduodenectomy for pancreatic cancer when SMA involvement is suspected. The goal of this approach for the resection of pancreatic head cancer is complete surgical removal of the tumor, ie, a no-residual-tumor (R0) resection, because the prognostic significance of complete tumor clearance at the resection margins has been demonstrated. Meanwhile, the preoperative diagnostic accuracy of various imaging studies in detecting vascular invasion, especially in borderline resectable pancreatic cancers, is unsatisfactory. For example, the specificity of a CT scan ranges from 67% to 91% due to difficulties in exact differentiation between cancer infiltration and fibrosis or tumor-mimicking adhesions. Therefore, surgical exploration is usually carried out in patients who are categorized as having borderline resectable disease because of the suspicion of arterial infiltration on the basis of imaging criteria. The biggest advantage of the artery-first approach is that it allows surgeons to make a final decision regarding resectability before reaching the “point of no return” during surgery. Many studies have therefore focused on this technique in performing a pancreaticoduodenectomy for cancers of the head of the pancreas, but its significance in pancreatosplenectomy has not been fully discussed. In 2003, Strasberg and colleagues demonstrated a new surgical procedure for cancers of the body and tail of

Background Unnecessary intra-abdominal drain insertion must be avoided, but little is known about the value of prophylactic drainage following laparoscopic distal gastrectomy (LDG). In this study, we investigated the significance of prophylactic drain placement after LDG for gastric cancer. Methods Seventy-eight consecutive patients with gastric cancer who underwent LDG in our department were retrospectively analyzed. The patients were divided into two groups according to the insertion of a prophylactic intra-abdominal drain following LDG. The ‘drain group’ comprised 45 patients with routine use of a prophylactic intra-abdominal drain, and the ‘no-drain group’ comprised 33 patients who did not undergo placement of an intra-abdominal drain. Results There were no significant differences in terms of the mean age of the patients, male/female ratio, body mass index, and concurrent diseases between the drain group and the no-drain group. In addition, there were no significant differences in the tumor location, tumor diameter, depth of the tumor, nodal metastasis, and tumor stage between the two groups. All patients in each group were successfully treated with R0 surgery, and no patient required conversion to open surgery. Surgery-related factors, including lymph node dissection and operative time, were similar in the drain group and the no-drain group. A comparison of the amount of intraoperative blood loss between patients with and without postoperative complications revealed that patients who experienced postoperative complications had a significantly larger amount of blood loss than those without postoperative complications. A comparison of operative times between patients with and without surgery-related postoperative local complications revealed that patients who experienced surgery-related postoperative local complications had a significantly longer operative time than those without surgery-related postoperative local complications. Analysis of operative times in each group revealed that patients with surgery-related postoperative local complications had a significantly longer operative time than those without surgery-related postoperative local complications in the no-drain group. Conclusions Intraoperative factors such as the operative time and the amount of intraoperative blood loss affected the occurrence of postoperative complications following LDG. A prophylactic drain may thus be useful in patients at higher risk and in those with a longer operative time or massive intraoperative bleeding.