Search

Purpose: Identifying tumor location is important in colorectal tumor resection. Preoperative endoscopic India ink marking is a widespread practice, but local injection of ink is an unstable procedure. Although it is often invisible, the ink may be sprayed into the peritoneal cavity and contaminate the surgical field. At our hospital, we introduced fluorescent clip marking (FCM) using the Zeoclip FS ® , an endoscopic clip developed using near-infrared fluorescent resin. We tested the usefulness of FCM by retrospectively comparing cases in which FCM was used with cases in which conventional ink marking was used., Methods: We enrolled 305 patients with colorectal tumors who underwent colorectal surgery after preoperative marking from January 2017 to April 2022. We classified the patients into the FCM group (86 patients) and the India ink tattoo group (219 patients). Endoscopic marking was completed in the FCM group by the day before surgery, and fluorescence was evaluated during surgery with a fluorescent laparoscopic system. Patient backgrounds, marking visibility, adverse effects, and early postoperative results were retrospectively compared between groups., Results: Marking was visually confirmed in 80 patients in the FCM group (93.02%) and in 166 patients in the India ink tattoo group (75.80%) (p = 0.0006). In the group with India ink tattoos, contamination of the surgical field was observed in seven cases (3.20%). No adverse events were observed in the FCM group., Conclusion: In colorectal surgery, FCM provides better visibility than the conventional India ink tattooing method and is a simple and safe marking method., Clinical Trial Registration: Examination of fluorescence navigation for laparoscopic colorectal cancer surgery. Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf ., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background/aim: This study aimed to investigate the feasibility of a mixed reality (MR)-based hologram for intraoperative navigation in colorectal surgery. Virtual reality (VR) and MR technologies can visualize overlapping three-dimensional (3D) hologram images and real space using the wearable HoloLens2 glasses., Patients and Methods: This study comprised 13 patients with colorectal cancer. Twelve participants had hologram images created from computed tomography (CT) between August and September 2021. One patient who underwent lateral lymph node dissection (LLND) after this period was included. A 3D hologram of the arteries, veins, and tumor was downloaded to HoloLens2 with the Holoeyes MD system and used during surgery. Hologram visibility, surgical outcome, and the NASA Task Load Index (TLX) were examined., Results: A total of 2 ileocecal resections, 6 right hemicolectomies, 1 partial colectomy, 4 LLNDs, and 1 para-aortic lymph node dissection were performed safely while viewing the holograms. The mean operative duration was 421 [290-555] min, blood loss was 5 [5-15] ml, and the postoperative hospital stay was 10 [9-14] days. Regarding the TLX, the mental demand score was 30 [20-40], the physical demand score was 60 [50-67.5], the temporal demand score was 50 [40-62.5], the performance score was 15 [2.5-35], the effort score was 45 [35-62.5], the frustration score was 60 [50-65], and the weighted workload score was 34 [30.17-45.835]., Conclusion: Viewing a hologram in VR/MR can improve the understanding of the anatomy, which cannot be ascertained on a conventional two-dimensional monitor. Holographic guidance is a highly novel surgical concept that can potentially reduce the mental demand on surgeons., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Thrombomodulin™ has cytoprotective and anti-inflammatory function by interacting with G-protein coupled receptor 15 (GPR15). Recombinant TM (rTM), which comprises the extracellular regions of TM, is approved for treatment of disseminated intravascular coagulation. We investigated the anti-tumor effect of rTM for pancreatic ductal adenocarcinoma (PDAC) through GPR15., Materials and Methods: We evaluated the expression of GPR15 in human PDAC cell lines and the anti-tumor effect and signals of rTM in vitro and in vivo. To test whether GPR15 would be responsible for the inhibition of cell proliferation by rTM, we evaluated the cell viability of the GPR15 knockdown cells treated with rTM using GPR15-targeting siRNA., Results: We identified PDAC cell lines with GPR15 expression and discovered that rTM inhibited tumor growth and enhanced the effects of gemcitabine (GEM) for the PDAC cell line in a GPR15-dependent manner. Furthermore, we showed that rTM inhibited nuclear factor-kappaB (NF-[Formula: see text]B) and extracellular signal-regulated kinase (ERK) activation through interactions with GPR15., Conclusion: We demonstrated that rTM had anti-tumor effect and enhancement of cytotoxic effect of GEM for PDAC cells by inhibiting NF-[Formula: see text]B and ERK activation via GPR15 and suggest that rTM is a potential therapeutic option for PDAC., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: In complete laparoscopic distal gastrectomy, the gastric resection line is difficult to determine due to a lack of tactile sensation. The use of intraoperative gastroscopy and intraoperative radiography has been reported, but the burden on personnel and technical complexity present impediments. In our department, based on lesion extent determined with preoperative gastroscopy, a fluorescent clip is used to mark the oral side of the lesion, which is resected after confirmation with a fluorescent laparoscopic system. In this study, we investigated the efficacy of fluorescent clip marking (FCM) in achieving an accurate resection line and reducing the operative time., Methods: Fifty-six patients with gastric cancer who underwent complete laparoscopic distal gastrectomy from January 2018 to March 2021 were divided into two groups: the FCM group (n = 32) and the conventional metal clip marking and intraoperative gastroscopy (MCMG) group (n = 24). Short-term outcomes, including the resection margins, gastric resection time, and operative time, were compared and examined., Results: The fluorescent clips were visible in all cases, and all stumps were negative according to permanent preparations. The operative times for FCM and MCMG were 350 (216-533) vs. 373.5 (258-651) min, respectively, with no significant difference (p = 0.316), while the gastric resection times were 636.5 (321-2572) vs. 1457.5 (843-4973) s, respectively, and were significantly shorter in the FCM group (p < 0.0001)., Conclusions: FCM shortened the gastric resection time and could possibly shorten the operative time. FCM is feasible and safe and can potentially be used as a tumor-marking agent to determine accurate surgical resection lines., Clinical Trial Registration: Examination of Gastric Cancer, Research Ethics Committee of the Kawaguchi Municipal Medical Centre (Saitama, Japan), approval number: 2019-33. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf., (© 2022. The Society for Surgery of the Alimentary Tract.)

Purpose: In surgery for strangulated bowel obstruction, intestinal blood flow (IBF) is usually evaluated by observing bowel colour, peristalsis, intestinal temperature and arterial pulsations in the mesentery. We investigated whether indocyanine green (ICG) fluorescence angiography (ICG-FA) is an effective alternative to palpation., Methods: Thirty-eight patients who underwent emergency surgery for strangulated bowel obstruction from January 2017 to April 2021 were divided into two groups: (i) the ICG + group, in which ICG was used during laparoscopic surgery (n = 16), and (ii) the ICG - group, in which palpation without ICG was used during open surgery (n = 22). Starting in July 2019, ICG and laparoscopic surgery were applied in all cases except emergency cases when the fluorescence laparoscope was not ready. Surgical outcomes and patient characteristics were compared., Results: Patient characteristics, the operative duration and postoperative hospitalization duration did not significantly differ between the groups. Bowel resection was performed in 4 cases (25%) among ICG + patients and 11 cases (50%) among ICG - patients. The ratios of pathological findings (ischaemia:mucosal necrosis:transmural necrosis) were 0:2:2 and 1:6:4 in the two groups, respectively. Blood loss was measured with gauze and suction tubes and was 1 (0-5) mL in the ICG + group and 12.5 (0-73) mL in the ICG - group (p = 0.002). Postoperative complications occurred in 1 case (6.3%) in the ICG + group and 9 cases (40.9%) in the ICG - group (p = 0.025)., Conclusion: Although there were few intestinal resections in the ICG + group, the rate of pathological necrosis tended to be high, and no complications due to ineligibility were noted in the intestinal preservation group. During laparoscopic surgery, ICG-FA is useful as a substitute for palpation and has the potential to improve surgical outcomes., Clinical Trial Registration: Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2019-40., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Approximately 15% of patients with colorectal cancer present with locally advanced tumors (T4 stage). Laparoscopic surgery for stage T4 disease has not yet been established. The near-infrared ray catheter fluorescent ureteral catheter (NIRFUC) is a new device that uses near-infrared fluorescence resin. We examined the utility of fluorescence ureteral navigation (FUN) with the NIRFUC during laparoscopic surgery for stage T4 colorectal cancer., Materials and Methods: Patients with stage T4 colorectal cancer (n = 143, from January 2017 to March 2021) were divided into a T4FUN + group, in which the NIRFUC was used (n = 21), and a T4FUN- group, in which the NIRFUC was not used (n = 122). Short-term outcomes were compared between the groups. Next, the laparoscopic surgery rate and incidence of ureteral injury from January 2017 to March 2021 were compared between the T4FUN- group and the non-stage T4FUN- group (n = 434, from January 2017 to March 2021), in which fluorescence ureter navigation was not used., Results: Rectal cancer, stage T4b disease, and invasion into the urinary tract were observed more often in the T4FUN + group than in the T4FUN- group. In the comparisons of the T4FUN + versus T4FUN- groups, the operative time was 398 (161-1090) vs. 256 (93-839) minutes, the blood loss was 10 (1-710) vs. 25 (0-1360) ml, and the ratio of laparoscopic surgery to open surgery was 21:0 vs. 79:43. Postoperative complications (Clavien-Dindo grade ≥ III) were present in 2 (10%; 0 ureteral injury) patients in the T4FUN + group and 13 (11%; 2 ureteral injury) patients in the T4FUN- group. In the T4FUN + group, the operative time was longer (p < 0.0001), but the laparoscopic ratio was higher (p = 0.0002), and the blood loss volume and incidence of ureteral injury tended to be lower. In the comparisons of the T4FUN- versus non-stage T4FUN- groups, the ratio of laparoscopic surgery to open surgery was 79:43 vs. 384:50, the incidence of open conversion was 8 (6.6%) vs. 15 (3.5%), and the incidence of ureteral injury was 2 (1.6%) vs. 0 (0%). In the T4FUN- group, the open surgery rate (<0.0001), open conversion rate (p = 0.0205) and incidence of ureteral injury (p = 0.0478) were high, with a significant difference observed between the groups., Conclusion: Patients with stage T4 disease have an increased risk of ureteral injury and are more likely to be converted to open surgery. FUN can help to safely increase the laparoscopic surgery rate while safely visualizing the ureter. FUN is recommended for laparoscopic surgery in patients with stage T4 colorectal cancer., Clinical Trial Registration: Examination of fluorescence navigation for laparoscopic colorectal cancer surgery; Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinical research-r02.pdf., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Lateral lymph node metastasis in lower rectal cancer is considered a local disease in Japan, and guidelines suggest lateral lymph node dissection (LLND). However, laparoscopic procedures are relatively difficult. The ureter and hypogastric fascia must be dissected from the vesicohypogastric fascia to preserve the autonomic nerve and ureter. Additionally, lymph node dissection around the internal iliac artery is complex because many patterns of branching from the internal iliac artery exist. We investigated the utility of fluorescence ureter and vessel navigation using a near-infrared ray fluorescent ureteral catheter (NIRFUC) and indocyanine green (ICG)., Methods: Fourteen patients who underwent laparoscopic LLND using fluorescence navigation were included. Eleven patients had rectal cancer, 1 had anal cancer, and 2 exhibited recurrence of rectal cancer. Eleven patients underwent NIRFUC insertion before surgery. Fluorescence vessel navigation (FVN) was performed with intraoperative ICG injections in 14 patients, with a total of 18 sides. The outcome measures were ureter navigation visibility, detection of the branch form from the internal iliac artery with FVN, differences between the fluorescence findings and anatomy of the internal iliac artery determined after LLND, and the surgical outcome., Results: In all 11 patients, the ureters were clearly identified as fluorescent before dissection around the ureter. FVN revealed the internal iliac, umbilical, and superior vesical arteries in all patients. The branch from the internal iliac artery according to the Adachi classification was revealed on 16 sides (89%). The time from intravenous ICG injection to fluorescence of the internal iliac artery was 38 (17-57) s. The time from intravenous injection to when the vessels were observed as fluorescent was 113 (65-661) s. No ureteral or vessel injuries occurred., Conclusions: Fluorescence navigation of vessels and the ureter is feasible in laparoscopic LLND and has the potential to increase safety., Clinical Trial Registration: Examination of fluorescence navigation for laparoscopic colorectal cancer surgery Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

A 40-year-old man visited the hospital for a refractory urinary tract infection. A sigmoidovesical fistula resulting from a sigmoidovesical diverticulum was diagnosed, and laparoscopic surgery was performed. To avoid ureteral injury during surgery for highly advanced cancer and inflammatory diseases, a ureteral stent is generally placed before the procedure. However, in this case, surgery was performed using a near-infrared ray catheter (NIRC), which emits fluorescence when irradiated with near-infrared light. By clearly observing the pathway of the ureter via near-infrared light, the integrity of the ureter could be preserved, and sigmoidectomy was safely performed. The visual navigation of the ureter with NIRC was especially useful during surgery for a colovesical fistula with marked surrounding inflammatory changes and a high risk of ureteral damage., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background/aim: According to limited current reports, therapeutic paraaortic lymph node (PALN) dissection with intensive combined therapy for colorectal cancer improves prognosis in select patients. Laparoscopic PALN dissection is a difficult technique that has not yet been established. We applied this procedure using an intraoperative fluorescence navigation technique with a near-infrared ray catheter (NIRC™) fluorescent ureteral catheter (NIRFUC)., Patients and Methods: We evaluated the utility of laparoscopic fluorescence navigation and the short-term outcomes of 6 patients undergoing laparoscopic PALN dissection., Results: There were 3 surgeries for synchronous metastasis and 3 surgeries for recurrent metastasis. The mean surgical duration, blood loss, and postoperative hospital stay were 677 (range=518-1,090) min, 7.5 (range=3-1,600) ml, and 14 (range=9-33) days, respectively. Postoperative complications (Clavien-Dindo grade >III) occurred in 1 case., Conclusion: Dissection around the ureter was navigated with a NIRFUC. Fluorescence ureteral navigation facilitated completion of the complex laparoscopic PALN dissection procedure., Competing Interests: Shunjin Ryu MD, PhD, Keigo Hara MD, Keisuke Goto MD, Keisuke Goto MD, Atsuko Okamoto MD, Takahiro Kitagawa MD, Rui Marukuchi MD, PhD, Ryusuke Ito MD, PhD, and Yukio Nakabayashi MD, PhD have no conflicts of interest or financial ties to disclose in relation to this study., (Copyright 2021, International Institute of Anticancer Research.)

Background: Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis (CCL) and related morbidities than the general population. However, the management of common bile duct (CBD) stones with endoscopic retrograde cholangiopancreatography is challenging in patients after Roux-en-Y or Billroth II reconstruction because of the altered gastrointestinal anatomy. The aim of the current study was to evaluate the safety and efficacy of one-stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy (LTPBD+LC) in patients with previous gastrectomy for gastric cancer., Methods: This retrospective cohort study included five patients with CCL who had previously undergone gastrectomy. All five underwent LTPBD+LC between May 2015 and February 2020 at our institution. The primary end-point was complete clearance of the CBD stones., Results: Of the 311 patients who had undergone gastrectomy for gastric cancer from December 2009 to December 2018 at our institution, six (1.9%) were later diagnosed with CCL. Five of the six patients did not need emergency biliary drainage and underwent conservative therapy and subsequent elective LTPBD+LC. LTPBD+LC was successfully performed in all cases. None of the patients required conversion to open surgery. The rate of complete clearance of the CBD stones was 100%. The mean operative time of the entire procedure was 126 minutes (range, 102-144 minutes), and the mean blood loss was 12.4 mL (range, 1-50 mL). There were no major perioperative complications, and the mean length of postoperative hospital stay was 4.2 days (range, 3-7 days)., Conclusion: One-stage LTPBD+LC may be a feasible procedure for patients with CCL who have previously undergone gastrectomy for gastric cancer., (© 2020 The Authors. Asian Journal of Endoscopic Surgery published by Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Background: Placement of feeding jejunostomy (PFJ) during esophagectomy is an effective method to maintain adequate nutrition, but is associated with serious complications such as bowel obstruction and jejunal torsion. The purpose of the current study was to analyze the incidence, clinical features, and risk factors of bowel obstruction associated with feeding jejunostomy (BOFJ) after PFJ., Methods: This was a retrospective cohort study of 70 patients who underwent esophagectomy with three-field lymph node dissection for esophageal cancer and treated with PFJ between March 2013 and December 2019 in our hospital. Abdominal dissection was performed under hand-assisted laparoscopic surgery (HALS) from March 2013 to March 2015, and was changed to complete laparoscopic surgery in April 2015. We compared patients with and without BOFJ, and the incidence of BOFJ was evaluated. The primary endpoint was incidence of BOFJ after PFJ., Results: Six patients (8.5%) were diagnosed with BOFJ, all of whom were symptomatic and in the HALS group. In addition, 3 cases displayed histories of recurrent BOFJ (3, 3, and 5 times). Laparotomy was performed in all cases. Subgroup analysis of the HALS group showed a significant difference only in straight-line distance between the jejunostomy and navel as a significant pre- and perioperative factor (117 mm [101-130 mm] vs. 89 mm [51-150 mm], p < 0.001). Furthermore, dividing straight-line distance between the jejunostomy and navel into VD and HD, only VD differed significantly (107 mm [93-120 mm] vs. 79 mm [28-135 mm], p = 0.010), not HD (48 mm [40-59 mm] vs. 46 mm [22-60 mm], p = 0.199)., Conclusions: VD between the jejunostomy and navel was associated with BOFJ after PFJ with HALS esophagectomy. PFJ < 9 cm above the navel during HALS esophagectomy might effectively prevent BOFJ.

Background: In colorectal laparoscopic surgery, accuracy of tumor marking has been an important but not fully resolved issue. The tattoo marking technique or intraoperative endoscopy have been used but they either carry the risk of accidental intestinal puncture or require either longer operation times, a skilled endoscopist and/or intraoperative colon insufflation. We supposed that tumor site marking with the near-infrared fluorescent clips, ZEOCLIP FS clips (Zeon Medical Co., Ltd., Tokyo, Japan) might overcome disadvantages of both tattoo marking and intraoperative endoscopy-based tumor localization methods. This is the first report on the case series using near-infrared fluorescent marking clip. We summarize the early results in 30 patients, who underwent colorectal laparoscopic surgery; we focus particularly on effectiveness and safety of the method., Materials and Methods: Thirty consecutive patients, who underwent laparoscopic surgery for colorectal cancer after previous endoscopic ZEOCLIP FS placement were enrolled from May 2019 till October 2019. The primary endpoint was the rate of intraoperative clip detection and the secondary endpoints were: the rate of adverse effects, percentage of slipped clips and usefulness of plain abdominal radiography to preoperatively confirm the clip retention. Locations of fluorescent clips were identified with a full-color fluorescence laparoscope. All operations and clip placements were performed by the same senior surgeon with sufficient experience in both procedures., Results: Fluorescent clips could be detected in 94.1% of tumor lesions. Three (2.1%) clips dropped before surgery. Plain abdominal radiography was sufficient to assess clip retention in all cases. No adverse effects related to either clip placement or clip detection were observed., Conclusion: The ZEOCLIP FS could be easily detected from the serosal side of the intestinal tract when placed 1-2 days before surgery. Fluorescent clip-guided laparoscopy may be considered a safe and effective method for localization of colorectal tumor sites. The Research Registry UIN: researchregistry5400., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Postoperative non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction is a rare complication. If endoscopic balloon dilation proves ineffective, patients need re-operation under general anesthesia and experience a high rate of postoperative complications. Magnetic compression anastomosis is a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. We report a case in which magnetic compression anastomosis was successfully performed to avoid re-operation for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction., Case Presentation: A 70-year-old woman was admitted to our hospital for treatment of non-anastomotic stenosis of the proximal jejunum. Open total gastrectomy and Roux-en-Y reconstruction were performed 2 years previously for advanced gastric cancer at another hospital. She complained of anorexia and obstructed passage of food. No recurrence of gastric cancer was identified. Esophagogastroduodenoscopy showed circumferential membranous stenosis of the jejunum 3 cm distal to the esophago-jejunal anastomosis. Endoscopic balloon dilation was performed three times, but proved ineffective. Magnetic compression anastomosis was planned because the stenosis existed near the esophago-jejunal anastomosis and re-operation was a highly invasive procedure requiring intrathoracic anastomosis. Endoscopic balloon dilation preceded placement of the parent magnet on the anal side of the stenosis. Confirming the improvement of stenosis, the parent magnet was placed on the anal side of the stenosis during esophagogastroduodenoscopy. The parent magnet attached to nylon thread was fixed to the cheek to prevent magnet migration. A week after placing the parent magnet, restenosis was confirmed and the daughter magnet was placed via nylon thread on the oral side of the stenosis. The two magnets were adsorbed in the end-to-end direction across the stenosis. Magnets adsorbed in the end-to-end direction moved to the anal side 11 days after placement. Wide anastomosis was confirmed by esophagogastroduodenoscopy. Endoscopic balloon dilation was regularly performed to prevent restenosis after magnetic compression anastomosis. No complications were observed postoperatively. The patient was able to eat normally and successfully reintegrated into society., Conclusions: Magnetic compression anastomosis could be a feasible procedure to avoid surgery for non-anastomotic stenosis of the proximal jejunum after gastrectomy with Roux-en-Y reconstruction.

Background: Small bowel obstruction after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction) is not a rare complication. However, patients who need re-operation for this complication have a high rate of postoperative complications. We report a case series of three patients who underwent fluoroscopic balloon dilation (FBD) for early jejunojejunostomy obstruction (JJO) after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction)., Case Presentation: Three patients were referred to our hospital for surgery for gastric cancer. Robot-assisted distal gastrectomy with D2 lymph node dissection and antecolic R-Y reconstruction were performed in two patients, and robot-assisted total gastrectomy with D1+ lymph node dissection and antecolic R-Y reconstruction was performed in one patient. The jejunojejunostomy was created as a side-to-side anastomosis using a linear 45-mm stapler. The entry hole was closed with a knotless barbed suture, and serosal-muscle layer suture reinforcement with an absorbable suture was performed at the jejunojejunostomy. Subsequently, all the patients were diagnosed with JJO by computed tomography and upper gastrointestinal series. The average time to JJO from gastrectomy was 5 days (range 2-7); initial clinical symptoms were vomiting in all three cases, with simultaneous upper abdominal pain in one case. We successfully performed FBD in all three cases after unsuccessful conservative treatment using an ileus tube. The clinical symptoms improved soon after FBD, and all the patients were able to avoid re-operation. The average period to FBD from JJO was 10 days (range 4-14). The average procedure time was 46 min (range 29-68), and the average duration to oral intake from FBD was 4 days (range 2-5). The average duration of hospital stay after FBD was 12 days (range 9-15). There were no complications in any of the cases., Conclusion: FBD might be a feasible procedure to avoid surgery for early small bowel obstruction after gastrectomy with R-Y reconstruction.

Background: Magnetic compression anastomosis (MCA) is mainly applied in the gastrointestinal and biliary tracts through a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. Magnets usually adsorb in the end-to-end direction (end-to-end anastomosis), exert a strong magnetic force and create an anastomosis according to the size of the magnets. Regular endoscopic dilation is required to prevent restenosis when the anastomotic size is small. We report a case in which MCA was successfully used to treat anastomotic stenosis of the sigmoid colon; the magnets adsorbed in the side-to-side direction rather than the end-to-end direction and generated a wide anastomosis in a short time that did not require endoscopic dilation., Case Presentation: An 81-year-old woman was admitted to our hospital to treat anastomotic stenosis of the sigmoid colon for closure of transverse colostomy. Two years prior, the Hartmann operation and drainage were performed at other hospitals due to perforated diverticulitis of the sigmoid colon. Obstruction of the sigmoid colostomy occurred, and a transverse colostomy was performed. One year after the first surgery, high anterior resection was performed, but anastomotic stenosis occurred, causing obstruction. MCA was planned because the patient had a history of multiple operations and was expected to have strong adhesions postoperatively. MCA was safely performed, but two magnets were accidently adsorbed in the side-to-side direction. The magnet position could not be changed. The two magnets were expected to move and adsorb in an end-to-end direction naturally due to bowel movements. The magnets that adsorbed in the side-to-side direction dropped from the anus 5 days after treatment, and the anastomosis was observed by colonoscopy. Three ileus tubes were placed from the transverse colostomy beyond the anastomosis to prevent restenosis. Colonoscopy showed that the anastomosis diameter was wider than expected at 14 days after treatment, and endoscopic dilation was not necessary. No complications were observed in this patient's postoperative course. Finally, closure of the patient's colostomy was successfully performed., Conclusions: MCA with side-to-side anastomosis generated a wide anastomosis in a short time.

Background: Endoscopic biliary stenting (EBS) using a plastic stent is currently widely performed for preoperative biliary drainage for periampullary cancer. The aim of this study was to investigate the risk factors and surgical outcomes of stent dysfunction after EBS in patients who underwent pancreaticoduodenectomy (PD). Patients and Methods: The subjects were 85 patients who underwent PD after EBS using a plastic stent for malignant biliary obstruction between November 2008 and January 2019. We retrospectively investigated the relationship between perioperative patient characteristics and the incidence of stent dysfunction. Stent dysfunction was defined as insufficient biliary drainage and the presence of various symptoms, including high fever and abdominal pain, with elevated serum hepatobiliary enzyme levels or bilirubin level. Results: Stent dysfunction occurred in 38% of patients. In univariate analysis, serum total bilirubin before the initial EBS ≥15 mg/dL ( P  = .0244) and a stent diameter of 7 Fr ( P  = .0044) were significant predictors of stent dysfunction. In multivariate analysis, the only significant independent predictor of stent dysfunction was a stent diameter of 7 Fr ( P  = .0227). In the patients without stent dysfunction, duration from the initial EBS to the operation was significantly shorter than that in the patients with stent dysfunction ( P  = .0055). Operation time, intraoperative blood loss, postoperative pancreatic fistula, and bile leakage were comparable between the two groups. Conclusion: Seven French stent was the significant independent predictor of stent dysfunction after EBS in patients who underwent PD.

Background/aim: After primary resection of hepatocellular carcinoma (HCC), the impact of patient's characteristics at the initial hepatectomy, on long-term remnant liver function has not been reported. The aim of this study was to identify factors associated with the deterioration of remnant liver function among patients who developed recurrent HCC., Patients and Methods: A total of 51 patients with intrahepatic recurrence after initial hepatic resection for HCC were included. We retrospectively investigated the relation between patient characteristics and the degree of deterioration of remnant liver function upon recurrence., Results: In univariate analysis, significant predictors of deterioration of remnant liver function consisted of preoperative gastro-esophageal varices (p=0.0101), preoperative transcatheter arterial chemoembolization (p=0.0230) and hepatectomy beyond Makuuchi's criteria (p=0.0101). In multivariate analysis, the only significant independent predictor of deterioration of remnant liver function was hepatectomy beyond Makuuchi's criteria (p=0.0498)., Conclusion: Hepatectomy beyond Makuuchi's criteria at the initial hepatectomy may predict deterioration of remnant liver function upon recurrence of HCC., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Introduction: In laparoscopic surgery, marking of tumor location has been gaining importance. Tattoo marking has been often used but the technique carries the risk of accidental peritoneal scattering or other organ injury. We have been involved in the development of a novel fluorescent clip for marking tumor sites and supposed that its usage would reduce risks related to other marking methods., Case Presentation: A 52-year-old man was diagnosed with sigmoid colon cancer and polyp, and was scheduled for laparoscopic sigmoidectomy. On the day before operation, fluorescent clips (ZEOCLIP FS: Zeon Medical co, Ltd, Tokyo) were endoscopically placed around the tumor and polyp sites, 4 clips for each lesion attached every 90 degrees within the colonic lumen, respectively. During the operation, locations of the fluorescent clips were easily confirmed using a full-color fluorescent laparoscope, VISION SENSE (Medtronic Co., U.S.). Curative operation was performed accordingly with the preoperative pathological and radiological findings. The postoperative course was uneventful., Discussion: Locations of intraluminally placed fluorescent clips were clearly and easily recognized through the serosal layer of the intestinal wall using a fluorescent laparoscope. Complications related to dye scattering or intestinal wall/other organ perforation were not observed suggesting that future incorporation of this tumor site marking technique into laparoscopic surgery might be beneficial., Conclusion: The fluorescent marking clips were easily placed and recognized with a fluorescent laparoscope. This method is expected to be safe and risks of accidental puncture related to tattoo marking method can be reduced or almost eliminated., (Published by Elsevier Ltd.)