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Subseasonal-to-seasonal (S2S) precipitation prediction in boreal spring and summer months, which contains a significant number of high-signal events, is scientifically challenging and prediction skill has remained poor for years. Tibetan Plateau (TP) spring observed surface ­temperatures show a lag correlation with summer precipitation in several remote regions, but current global land–atmosphere coupled models are unable to represent this behavior due to significant errors in producing observed TP surface temperatures. To address these issues, the Global Energy and Water Exchanges (GEWEX) program launched the “Impact of Initialized Land Temperature and Snowpack on Subseasonal-to-Seasonal Prediction” (LS4P) initiative as a community effort to test the impact of land temperature in high-mountain regions on S2S prediction by climate models: more than 40 institutions worldwide are participating in this project. After using an innovative new land state initialization approach based on observed surface 2-m temperature over the TP in the LS4P experiment, results from a multimodel ensemble provide evidence for a causal relationship in the observed association between the Plateau spring land temperature and summer precipitation over several regions across the world through teleconnections. The influence is underscored by an out-of-phase oscillation between the TP and Rocky Mountain surface temperatures. This study reveals for the first time that high-mountain land temperature could be a substantial source of S2S precipitation predictability, and its effect is probably as large as ocean surface temperature over global “hotspot” regions identified here; the ensemble means in some “hotspots” produce more than 40% of the observed anomalies. This LS4P approach should stimulate more follow-on explorations.

Background Retrosternal reconstruction is associated with a lower risk of mediastinitis, gastro-tracheal fistula, and hiatal hernia. Historically, traumatic manual creation of the retrosternal tunnel has been performed using one's fist. We report a novel and atraumatic laparoscopic procedure to create the retrosternal route. Methods We have laparoscopically created the retrosternal route in 25 thoracoscopic, mediastinoscopic, or robot-assisted minimally invasive esophagectomies since August 2019. Specifically, a peritoneal incision is started at the dorsal side of the xiphoid process. Through a 12-mm port inserted slightly to the right of and superior to the umbilical camera port, we dissect loose connective tissues from the caudal to the cranial side using behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route was calculated. Then, the cumulative sum (CUSUM) method and the simple moving average of five cases were used to evaluate the learning curve of this novel procedure. Operative outcomes were analyzed according to the learning curve results and also compared with 25 cases of postmediastinal reconstruction counterparts. Results Twenty-five patients were divided into the early group (six patients) and late group (19 patients) based on the peak of the CUSUM chart. The time required for route creation was 28.5 min (median) in the early and 15 min in the late group, indicating a significant difference (P = 0.038). The overall incidence of pleural injury was 20% (5 of 25 patients), with no significant difference between the groups. There was no significant difference in the incidence of perioperative complications. Also, there were no significant differences in perioperative complications or gastric conduit functions 1 year after surgery between the retrosternal and the postmediastinal reconstruction. Conclusion Laparoscopic creation of a retrosternal route for gastric conduit reconstruction is safe and feasible and has a short learning curve.

Background One of the primary treatment for resectable advanced esophageal squamous cell cancer (ESCC) is neoadjuvant chemotherapy (NAC) followed by minimally invasive esophagectomy (MIE). Because the neutrophil-to-lymphocyte ratio (NLR) is a widely reported prognostic factor in several cancers, we investigated whether the preoperative NLR is a biomarker in ESCC patients treated with NAC and MIE. Methods In this study, we investigated 174 ESCC patients who underwent MIE from January 2010 to December 2015, including 121 patients who received NAC. The cutoff value of the NLR was analyzed using the receiver operating characteristic curve. Multivariate analyses were performed to clarify independent prognostic factors for overall survival (OS). Results The cutoff value of the NLR for OS in 121 patients who received NAC was 2.5 ng/ml, and the area under the curve was 0.63026 (p = 0.0127). The 5-year OS rate was 64% in those with an NLR 415 ml were independent poor prognostic factors. Conclusions NLR is a biomarker of prognosis in ESCC patients who undergo MIE after NAC.

Whether surgical device usage in laparoscopic gastrectomy differs with respect to operator’s skill levels is unknown. Further, device usage analysis using artificial intelligence has not been reported to date. Herein, we compared the patterns of surgical device usage during laparoscopic gastrectomy for gastric cancer among surgeons at different skill levels. The data of device usage was acquired from laparoscopic video recordings using an automated surgical-instrument detection system. In total, 100 video recordings of infrapyloric lymphadenectomy and 33 of D2 suprapancreatic lymphadenectomy during laparoscopic gastrectomy for gastric cancer were analyzed in this retrospective study. The system’s accuracy was evaluated by comparing the automatic and the manual usage time. Surgical device usage patterns were compared between qualified and nonqualified surgeons of The Japan Society for Endoscopic Surgery Endoscopic Surgical Skill Qualification System. For every device, the automatic detection time and manual detection time were consistent with each other. In infrapyloric lymphadenectomy, the usage time proportions of dissector forceps and clip applier were higher among nonqualified operators than among qualified operators (dissector, 5.1% vs. 2.3%, P

Background Esophagectomy with lymphadenectomy is the principal treatment for localized esophageal cancer. Conventional minimally invasive esophagectomy (C-MIE) in prone position has spread worldwide as it is less invasive. However, its efficacy remains controversial. Robot-assisted MIE (RAMIE) can have more advantages than C-MIE. Therefore, the current study aimed to validate whether RAMIE is associated with lower incidence of left recurrent laryngeal nerve (RLN) palsy compared with C-MIE in prone position. Patients and Methods In total, 404 patients with esophageal carcinoma underwent MIE (353 C-MIEs and 51 RAMIEs) in prone position at Kobe University between 2010 and 2020. Then, propensity score matching was performed, and results showed that 51 patients should be included in each group. Thereafter, the perioperative outcomes between the two groups were compared. Results The RAMIE group had a significantly longer operative time than the C-MIE group (P < 0.0001). However, the number of lymph nodes resected along the left RLN was similar in both groups. Moreover, the incidence of left RLN palsy was significantly lower in the RAMIE group than in the C-MIE [Clavien-Dindo classification grade II; 0 (0%) versus 32 (9%), P = 0.022 in entire cohort, and 0 (0%) versus 5 (10%), P = 0.022 in matched cohort. Esophagectomy Complications Consensus Group definitions type I; 8 (16%) versus 101 (29%), P = 0.041 in entire cohort and 8 (16%) versus 18 (35%) in matched cohort, P = 0.023]. Conclusion RAMIE is superior to C-MIE in prone position in decreasing the incidence of left RLN palsy.

INTRODUCTION Although lateral pelvic lymph node dissection is considered as a treatment option for advanced rectal cancer, it is technically demanding. Recently, the transanal approach for total mesorectal excision has become increasingly used. In this Technical Note, we describe lateral pelvic lymph node dissection using a 2-team method that was assisted by the transanal approach. TECHNIQUE First, the lateral pelvic area was entered from the anal side by dissection between the S4 sacral splanchnic nerve and levator ani muscle. Then, the fatty tissues including the obturator compartment and the distal part of the internal iliac compartment were separated from the inferior and superior vesical vessels and the bladder wall. Next, the fatty tissues were separated from the lateral pelvic wall. The obturator nerve was isolated and preserved, whereas the obturator vessels were resected at their peripheral end. Then, the fatty tissues were dissected from the bottom plane. Finally, the fatty tissues were dissected from the ventral bladder wall and were completely isolated from the obturator nerve in cooperation with the transabdominal team. RESULTS The 2-team method shortened the operative time dramatically and decreased mental and physical burden on the operators during lateral dissection. Assistance with the transanal approach helped with a secure and effective dissection, especially of the most distal parts, such as around the internal pudendal and inferior vesical arteries, because substantial skill is required for the transabdominal approach alone. CONCLUSIONS This procedure is useful for the safe and effective performance of lateral pelvic lymph node dissection for patients with rectal cancer.

Background/aim Cancer stem cells (CSCs) contribute to resistance against neoadjuvant chemotherapy (NAC) in esophageal squamous cell carcinoma (ESCC). We conducted a retrospective observational study for the relationship between the expression levels of CSC markers in biopsy specimens prior to 5-fluorouracil plus cisplatin (FP)-NAC and the pathological responses. Patients and methods We included 171 patients with ESCC who underwent the FP-NAC followed by radical resection. Biopsy specimens prior to the FP-NAC were obtained and immunochemically stained for CD44, CD133, and CD24. Results The biopsy specimens of the non-responders had the CD44high/CD24low expression at high levels, which was found as an independent predictor of not only FP-NAC resistance but also poor overall survival by multivariate analyses. Conclusion CD44high/CD24low expression in the biopsy specimens prior to FP-NAC may be a predictor of FP-NAC resistance and poor prognosis of ESCC patients.

Despite the increasing utilization of transanal total mesorectal excision as a promising approach for low rectal cancer, the feasibility and safety of transperineal minimally invasive abdominoperineal resection (tp-APR) remain unclear. In total, 25 patients who underwent tp-APR between April 2017 and May 2020 (tp-APR group) and 27 patients who underwent conventional laparoscopic APR between May 2009 and September 2016 (lap-APR group) for low rectal cancer were enrolled in this retrospective study. Clinical outcomes were compared between the groups before and after propensity score matching. The primary outcome was the incidence of the overall postoperative complications with Clavien–Dindo grade II or above. Standardized technique of tp-APR was also demonstrated. On comparison, operative time, intraoperative blood loss, and overall postoperative complications with Clavien–Dindo grade II or above were significantly less in the tp-APR group both before and after propensity score matching. The rates of urinary disturbance and perineal wound infection were significantly less in the tp-APR group after matching. Further, postoperative hospital stay was significantly shorter in the tp-APR group both before and after matching. However, pathological outcomes did not differ between the groups before and after matching. There has been no local recurrence in the tp-APR group with a median follow-up period of 18 months. Standardized tp-APR for low rectal cancer is feasible and seems superior to conventional laparoscopic APR in terms of short-term outcomes. Further larger-scale studies with a longer follow-up period are required to evaluate oncological outcomes.

Aim The outcomes of gastrectomy for gastric cancer in patients at each severity of chronic kidney disease (CKD) remain unknown. Methods We retrospectively analyzed the outcomes of 560 patients who underwent distal or total gastrectomy for gastric cancer between 2009 and 2018. We classified the patients into four groups based on estimated glomerular filtration rate: stage 1/2 (normal to mild, n = 375), stage 3a (mild to moderate, n = 122), stage 3b (moderate to severe, n = 43), and stage 4/5 (severe to end‐stage, n = 20) CKD. The relationship between CKD stage and the incidence of postoperative morbidity was analyzed. Results CKD was a predictor of overall morbidity independent of age, gender, American Society of Anesthesiologists Performance Status, pulmonary comorbidity, extent of lymphadenectomy, and operation time in a multivariate analysis. The incidences of overall and severe morbidity were significantly increased with CKD progression (both P, Chronic kidney disease (CKD) progression increases the risk of morbidity following gastrectomy in gastric cancer patients. The risk elevates substantially at moderate CKD with an eGFR ≤ 45 ml/min/1.73 m2.

Given the worldwide popularization of conventional minimally invasive esophagectomy (C-MIE), robot-assisted MIE (RAMIE) can be expected to provide a finer procedure. However, controversy remains regarding whether RAMIE is superior to C-MIE in preventing recurrent laryngeal nerve (RLN) palsy. Considering the shallow learning curve for RAMIE, a novel procedure for lymphadenectomy along the RLN during RAMIE is needed. Based on a logical and simple understanding of the left upper mediastinum anatomy, the authors developed a novel “modified bascule method” for RAMIE that could simplify lymphadenectomy along the left RLN and prevent it from being touched and stretched. Between 2018 and 2020, 46 patients with esophageal carcinoma underwent RAMIE using this method at Kobe University. The modified bascule method was used to perform RAMIE for 29 men and 17 women with a median age of 67 years (range, 49–82 years). The median thoracoscopic procedure time was 438 min (range, 344–625 min), and the median console time was 351 min (range 273–518 min). The study harvested a median of 24 (range, 8–34) lymph nodes from the thoracic portion and 4 (range, 0–10) lymph nodes from along the left RLN. The mortality rate was 0%. Postoperative left RLN palsy classified as Clavien–Dindo (C–D) grade 1 or higher was observed for 9 patients (19%), whereas grade 2 or higher was not seen (0%). Pneumonia and anastomotic leakage rates higher than C–D grade 2 were respectively 13% and 19%. The novel modified bascule method for RAMIE can promote feasible lymphadenectomy along the left RLN even when performed during the learning period.

BACKGROUND/AIM The safety of neoadjuvant chemoradiotherapy (NACRT) combined with total mesorectal excision (TME) and selective lateral pelvic lymph node dissection (LLND) is unclear in elderly patients with locally advanced rectal cancer (LARC). PATIENTS AND METHODS Forty-two patients with LARC underwent TME and selective LLND following NACRT at Kobe University Hospital. The clinical outcomes were retrospectively compared between the elderly (aged ≥70 years, n=13) and non-elderly patients (aged

Esophageal squamous cell cancer (ESCC) is one of the deadliest cancers in the world. Esophagectomy remains the principal treatment, and minimally invasive esophagectomy (MIE) has been performed worldwide. This study aimed to clarify whether the lymph node ratio (LNR), defined as the ratio of metastatic lymph nodes (LNs) to examined, is a prognostic factor for ESCC after MIE. This study included 327 MIEs with the patient in the prone position at two institutions from 2010 to 2015. Cox proportional hazards regression analyses using clinicopathologic characteristics and the LNR were performed for the pN1 patients and the whole cohort. In the multivariate analysis for all stages, independent prognostic factors were depth of tumor invasion (P

Summertime temperatures in marginal seas are, in general, colder than on the surrounding continent because of the large contrast in heat capacity between the land and the ocean. The Okhotsk Sea, which is covered by sea ice until early summer, is much colder than the surrounding continent in summer. The Okhotsk Sea is thus located in an area with one of the largest temperature contrasts of all the marginal seas in summertime midlatitudes. Cooled air over the Okhotsk Sea may have an impact on remote summer climates, such as by serving as the source of cold-air advection that results in a poor crop harvest in Japan. Here, we examine the role of the Okhotsk Sea on the early summer climate of the western part of the North Pacific through an ideal numerical experiment by artificially changing the model’s default oceanic condition in the Okhotsk Sea to a condition of land cover. Simulation results reveal that the presence of the Okhotsk Sea increases precipitation of the baiu/mei-yu front through strengthening of the northward moisture flux at the western edge of an intensified North Pacific subtropical high. The Okhotsk influence farther extends toward western North America to which the strengthened jet stream with a storm track extends. This remote influence is achievable through feedback from a transient eddy anomaly that is activated by the surface temperature gradient between the cold Okhotsk Sea and the warm Pacific Ocean. The findings imply that the existence of the Okhotsk Sea strengthens the East Asian summer monsoons.

Purpose Minimally invasive esophagectomy (MIE) has been increasingly used, but many reports have stated that recurrent laryngeal nerve (RLN) palsy after MIE is a major complication associated with postoperative pneumonia. Prevention of RLN palsy clearly has been a challenging task. The study aim was to determine if a three-dimensional (3-D) stereoscopic vision system can reduce the RLN palsy rate after MIE. Methods This was a retrospective study of MIE (McKeown esophagectomy) using a 3-D or 2-D stereoscopic vision system to treat 358 patients in the prone position between April 2010 and March 2019. The patients who underwent 3-D MIE (3-D group) or 2-D MIE (2-D group) were matched by using propensity score matching. After matching, the perioperative outcomes were compared between the groups. Results After propensity score matching, 154 patients were analyzed (77 patients, 3-D group; 77 patients, 2-D group). There were no significant differences in the patients’baseline characteristics in the matched cohort. There were no significant differences in the rates of pneumonia (Clavien–Dindo (C–D) grade ≥ II, 3-D vs. 2-D, 11 (14%) vs. 12 (16%)), anastomotic leakage (C–D grade ≥ II, 10 (13%) vs. 18 (23%)) and mortality. The rates of left RLN palsy (C–D grade ≥ IIIa, 1 (1.3%) vs. 7 (9.1%), P = 0.029), right RLN palsy (C–D grade ≥ I, 2 (3%) vs. 8 (10%), P = 0.049), comprehensive complication index (CCI®) (8.5 vs. 14.3, P = 0.011), and postoperative hospital stay period (median: 25 vs. 30 days, P = 0.034) were significantly lower in the 3-D group than in the 2-D group, respectively. Conclusions In MIE, the 3-D viewing system was one of the factors that reduced postoperative morbidities such as the rates of each RLN palsy and CCI®, leading to shorter postoperative hospital stay.

Although transanal total mesorectal excision (ta-TME) is adopted for rectal cancer surgery by an increasing number of surgeons, it is still technically challenging. We have employed a lateral-first approach for ta-TME to overcome technical difficulties. However, its outcomes and advantage over conventional laparoscopic TME remain unclear. Thirty-five consecutive patients who underwent ta-TME using a lateral-first approach (the ta-TME group) and 53 consecutive patients who underwent conventional laparoscopic TME (the lap-TME group) for low rectal cancer were included. Propensity score matching (PSM) was used to create balanced cohorts of ta-TME (n = 28) and lap-TME (n = 28). Their clinical outcomes were compared after PSM. The operative time and intraoperative blood loss were significantly lower in the ta-TME group than in the lap-TME group (P = 0.042 and P

Esophageal cancer has a poor prognosis despite the fact that surgical techniques have been advanced and optimized, and systemic multimodality approaches have progressed recently. Adding chemotherapy, radiotherapy, and immunotherapy to the basic surgical approach have been shown to have therapeutic benefit for esophageal cancer. This review describes the latest development of chemoradiotherapy, chemotherapy, and immunotherapy, which have contributed to the reduction in esophageal cancer growth and improved the survival of patients. Chemoradiation is a treatment option for resectable esophageal cancer to preserve the esophagus for patients who cannot tolerate surgery. Moreover, a combination of chemoradiotherapy and salvage surgery could extend the survival of patients. The effects of a triplet chemotherapy regimen are currently being verified in some Phase III studies for unresectable advanced/recurrent esophageal cancer. In addition, with the great promise of immune checkpoint inhibitors, strategies that incorporate the use of immunotherapy may shift from the metastatic setting to the neoadjuvant/adjuvant setting as a result of clinical trials. More precise comprehension of the molecular biology of esophageal cancer is expected to further control disease progression using multimodality treatments in the future.

Objectives: Dissection of the No. 11p lymph nodes is technically challenging because of variations in anatomical landmarks. This study aimed to determine the accuracy and efficacy of predicting the dorsal landmark of No. 11p lymph node using three-dimensional computed tomography simulation. Methods: Laparoscopic gastrectomy with No. 11p lymph node dissection with preoperative simulation using three-dimensional computed tomography was performed in 24 patients at our institution from October 2016 to May 2018. Initially, preoperative three-dimensional computed tomography findings with operative videos in these 24 patients were compared. The dorsal landmark was defined as an anatomical structure behind the splenic artery on preoperative three-dimensional computed tomography and operative videos. The dorsal landmark of No. 11p lymph node was divided into four types: (1) splenic vein type, (2) splenic vein and pancreas type, (3) pancreas type, and (4) unclear type. Then, to investigate the efficacy of three-dimensional computed tomography, we compared the clinical and pathological features and surgical outcomes of nine patients who underwent preoperative three-dimensional computed tomography simulation (three-dimensional computed tomography group) and 23 patients who did not undergo three-dimensional computed tomography simulation from August 2014 to September 2016 (non-three-dimensional computed tomography group). All procedures were performed by one surgeon certified by the Endoscopic Surgical Skill Qualification System in Japan. Results: The concordance rate between three-dimensional computed tomography and operative videos of the dorsal landmark using three-dimensional computed tomography was 79% (19/24). The operative time of No. 11p lymph node dissection was significantly shorter in the three-dimensional computed tomography group than in the non-three-dimensional computed tomography group (7.7 versus 15.8 min, P = 0.044). Conclusion: The accuracy of predicting the dorsal landmark of No. 11p lymph node using three-dimensional computed tomography was extremely high. Preoperative simulation with three-dimensional computed tomography was useful in shortening the operative time of No. 11p lymph node dissection.

This study was conducted to determine whether establishing the proximal resection line using India ink tattooing can ensure safe resection margins during totally laparoscopic distal gastrectomy. This retrospective study included 81 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer on the lower two-thirds of the stomach. The proximal resection margins were analyzed with respect to the macroscopic type and clinical T stage, and the intraoperative appearance of the stain on the serosa was classified by reviewing surgical videos. R0 resection was performed in all patients. The rates of the intended margins were 89.2% in patients without a frozen section diagnosis and 84.2% in patients with differentiated type lesions who underwent a frozen section diagnosis; however, most patients with undifferentiated advanced lesions failed to achieve the intended resection margins. Intraoperative appearance revealed that 85.2% of patients had localized type stains, whereas 11.1% had widespread-type stains. Our procedure to determine the proximal resection line in totally laparoscopic distal gastrectomy is oncologically safe. However, careful observation of the resected specimen and a frozen section analysis should be performed for undifferentiated advanced lesions.

Objective Laparoscopic endoscopic cooperative surgery for duodenal tumors (D-LECS) has been developed to prevent duodenal leakage by reinforcing the endoscopic submucosal dissection site. However, there has been no prospective trial showing the feasibility of D-LECS. Herein, we conducted a single-arm confirmatory trial to evaluate the safety of D-LECS for non-ampullary superficial duodenal neoplasms. Methods This prospective single-center single-arm confirmatory trial analyzed patients with non-ampullary superficial duodenal neoplasms who underwent D-LECS. The primary endpoint was the incidence of any postoperative leakage occurring on the duodenal wall within 1 month postoperatively. The planned sample size was 20 patients, considering a threshold of 28% and one-sided alpha value of 5%. Results Between January 2015 and September 2018, 20 eligible patients were enrolled. Sixteen tumors were located in the second portion, three in the first portion, and one in the third portion of the duodenal region. The median operative time was 225 (134-361) min and the median blood loss was 0 (0-150) mL. Curative resection (R0) with negative margins was achieved in 19 cases. One case of postoperative leakage and one case of bleeding of grade 2 according to the Clavien-Dindo classification were observed in this series. The median duration of postoperative hospital stay was 9 (5-12) days. No local recurrence was observed in any patient during the median follow-up of 15.0 (12.0-38.0) months. Conclusions This trial confirmed the safety and feasibility of D-LECS for non-ampullary superficial duodenal neoplasms with respect to the low incidence of postoperative duodenal leakage.

The influence of anastomotic leakage on long-term survival in patients with rectal cancer is debatable. The aim of this study was to evaluate relationships between anastomotic leakage and long-term survival. In this multicenter retrospective cohort study, 395 consecutive stage I to III rectal cancer patients underwent anterior resection between 2007 and 2012. Five-year overall survival, 5-year disease-free survival, and 5-year local recurrence-free survival were compared between patients with leakage (Leakage (+)) and patients without leakage (Leakage (−)). Of 395 patients, 50 (12.7%) had anastomotic leakage. Of these 50, 34 (68.0%) required urgent surgery and 16 (32.0%) could be managed by watchful waiting or with percutaneous drainage. The median follow-up period was 62.6 months. Five-year overall survival did not differ between the two groups (Leakage (+) 93.8% vs. Leakage (−) 89.0%, P = 0.121). Five-year disease-free survival also did not differ between the two groups (81.6% vs. 80.3%, P = 0.731), and neither did 5-year local recurrence-free survival (91.9% vs. 86.1%, P = 0.206). In a multivariable Cox regression model, BMI > 25, preoperative CA19-9 > 37, pathological T stage, pathological N stage, and circumferential resection margin (CRM) positive were independent predictors of disease-free survival. Moreover, pathological T stage, pathological N stage, and CRM positive were the only independent predictors of overall survival and local recurrence-free survival. Anastomotic leakage was not a risk factor for overall survival, disease-free survival, or local recurrence-free survival. Anastomotic leakage is not associated with a significant decrease in long-term survival in rectal cancer patients.

Background/aim To investigate the outcomes of laparoscopic surgery in colorectal cancer patients with dialysis. Patients and methods Fourteen dialysis (dialysis group) and 567 non-dialysis (non-dialysis group) patients who underwent laparoscopic and open surgery for colorectal cancer between April 2008 and December 2015 were included. Short-term and long-term outcomes were compared between the groups. A 1:2 propensity score matching was performed to compare long-term outcomes. Results All the dialysis patients underwent laparoscopic surgery. There were no significant differences in operative outcomes and postoperative short-term outcomes between the two groups. In the whole cohort, overall survival of dialysis patients was shorter than that in the non-dialysis ones (p=0.020), while disease-free survival did not differ between the two groups. After matching, there was no significant difference between the groups in overall or disease-free survival. Conclusion Laparoscopic colorectal cancer surgery for dialysis patients seems safe and feasible and associates with comparable short-term outcome and recurrence rate to non-dialysis patients.

Recent advances in treatment for esophageal cancer have improved prognosis after esophagectomy, but they have led to an increased incidence of gastric conduit cancer. In most gastric conduit cancer patients who underwent retrosternal reconstruction, median sternotomy is performed, which is associated with a risk of postoperative bleeding and osteomyelitis; pain often negatively affects respiration. To avoid these problems, we developed thoracoscopic retrosternal gastric conduit resection in the supine position (TRGR-S) as new procedure. Methods We performed the first case of TRGR-S for a 75-year-old male with retrosternal gastric conduit cancer. He was placed in the supine position. Four ports were placed in the left chest wall. The gastric conduit was separated from the epicardium, sternum, and left brachiocephalic vein. Due to adhesions between the gastric tube and the right pleura, combined resection of the right pleura was performed. Next, pediculated jejunal reconstruction via the presternal route was performed. Results Because there were few adhesions in the left thoracic cavity, this approach provided safety and a good surgical view, and it was easy to recognize the landmark including epicardium, sternum, and left brachiocephalic vein leading to appropriate resection of the tissue. Furthermore, there were few restrictions on the operative angle for the forceps and operability was quite ergonomic. Moreover, the lungs can be noninvasively contracted via an artificial pneumothorax. The pathological diagnosis was signet ring cell carcinoma (pT1b, pN0, M0, pStage I), indicating R0 resection. There were no post-operative complications. Conclusion This approach does not require sternotomy, so it has less risk of postoperative bleeding and osteomyelitis. Due to fewer adhesions, this approach is safe and provides a good surgical view. TRGR-S is a safe, ergonomic, and reliable procedure for resection of retrosternal gastric conduit cancer. Video This is the video of the operation ‘TRGR-S’, which is the new procedure for the gastric conduit cancer. https://www.dropbox.com/s/2whnekgp73hw1lz/video%20for%20ISDE2020.mov?dl=0.

Thoracoscopic esophagectomy in the prone position (TEP) for esophageal cancer is reported to have superiority in preserving postoperative respiratory function and reducing postoperative respiratory complications. In Japan, the majority of patients with esophageal cancer are smokers and have obstructive ventilation disorders. But, the feasibirity and safety of TEP for patients with low respiratory function is unclear. Objectives To clarify the feasibirity and safety of TEP for esophageal cancer patients with obstructive respiratory function. Methods The 95 patients with obstructive respiratory disorder who underwent TEP and gastric tube reconstruction via posterior mediastinal route for esophageal cancer from January 2016 to April 2019 were divided into the two groups, low respiratory function (LRF) group and the control group. Short-term outcomes were compared between two groups. Results The control group was 73 cases, and the LRF group was 22 cases. Propensity score matching using age, gender, cT, and cN as covariates was used to identify matched patients (22 per group) in both groups. There were no differences in operation time of overall and intrathoracic part, or blood loss in each group. In the postoperative complications, pneumonia (13.6% vs. 9.1%), recurrent laryngeal palsy (18.2% vs. 22.7%), anastomotic leakage (13.6% vs. 13.6%) and hospital stay (36.3 days vs 27.5 days) were no differences in both groups. Conclusion TEP can be feasible and safe for the patients with obstructive ventilation disorder and low respiratory function.

Granulocyte-colony stimulating factor (G-CSF) producing tumor is one type of growth factor producing tumor that induces leukocytosis. On the other hand, adenocarcinoma with enteroblastic differentiation disease is known as α-fetprotein (AFP), glypican3, and Sal-like protein 4 (SALL4) producing tumor. We report a first case of G-CSF producing esophageal cancer with enteroblastic differentiation which has never been reported in the world. Methods [Case presentation]: A fifty-six year-old man was admitted to our hospital to treat esophageal carcinoma. His body temperature was elevated. Blood biochemistry tests showed leukocytosis (WBC 14000/μl). Gastroscopy revealed a 10-cm diameter, superficial elevated lesion in the lower thoracic esophagus. Biopsy findings indicated a diagnosis of adenocarcinoma. No distant metastasis, but right subclavian and para esophageal lymph nodes swelling were identified via computed tomography. Thus, we planned neo adjuvant chemotherapy (NAC) (5-FU 800 mg/m2 plus Cisplatin 80 mg/m2) before surgical resection. The patient’s hyperthermia and leukocytosis improved by not antibiotics but NAC. Therefore, we suspected G-CSF producing tumor. Results The serum level of G-CSF was markedly elevated at 133 pg/ml (normal range, Additionally, PET/CT showed abnormally high uptake of (18) F-FDG not only by the tumor itself, but also diffusely throughout the bone marrow. The patient underwent minimally invasive esophagectomy in the prone position with two-field lymph node dissection. Immunohistochemical studies showed G-CSF producing adenocarcinoma with enteroblastic differentiation (AFP negative, glypican3 and SALL4 positive). Pathological stage was pT2N0M0, stageII. After resection, improvement of hyperthermia, leukocytosis, and serum level of G-CSF can be seen. Findings of (18) F-FDG throughout the bone marrow were also disappeared. Conclusion We experienced an extremely rare case of G-CSF producing, esophageal adenocarcinoma with enteroblastic differentiation.

The Japanese National Clinical Database (NCD) started its data registration since 2011, has grown up to a large nationwide database covering more than 95% of the surgeries performed by regular surgeons in Japan. The NCD grew rapidly harvesting over 11 million cases data between 2011 and 2018 from more than 5,000 facilities. Methods In this period, the surgeries of the esophagus were performed for 70,528 cases. In 2018, 93.8% of surgeries were performed at certified institutions, and 94.7% did with the participation of the board-certified surgeon. The board-certified surgeons operated 75.2% of the surgeries. Results Esophagectomy was performed for 47,055 patients in eight years. In 2018, 23.3% of the cases were 75 years old or more. Postoperative complications of Clavien Dindo classification grade III or higher occurred in 22.9% of all. As the patients have been getting older, the morbidities have been increasing. However, the mortalities have been kept at a low level. Postoperative 30-day and 90-day mortalities were 0.9% and 1.9%, respectively. The rates of endoscopic surgery have been increasing year by year, especially high in esophagectomy, which was 61.0% in 2018. Conclusion A risk-adjusted analysis based on nationwide data allows personnel to establish and provide feedback on the risks that patients face before undergoing a procedure. The risk calculator for eight main procedures are available on the websites of the hospitals that are a part of NCD. Nationwide this database is surely expecting to ensure the quality of board certification system and surgical outcomes in gastroenterological surgery.

Procedure of minimally invasive esophagectomy in prone position (Conventional prone-MIE) is standardized leading to feasible short outcomes. On the other hand, robot assisted MIE (Robotic MIE) was approved as Japanese health insurance treatment since 2018. Especially, reduction of recurrent laryngeal nerve (RLN) palsy leading to aspiration pneumonia is expected for Robotic MIE. The purpose of this study is to clarify the potential of Robotic MIE for improvement of short outcomes. Methods Twenty-four Robotic MIEs in introduction period since 2018 and 128 Conventional prone-MIEs in established period since 2015 from all of the 375 cases were compared using propensity score matching. Results Operative times in both entire and thoracic procedures were significantly longer in Robotic MIE. There were no significant differences between two groups in the number of harvested lymph nodes, amount of the blood loss, left RLN palsy rate (13% vs 14%, > Clavien-Dindo classification: C-D grade I), right RLN palsy rate (4% vs 8%, > C-D grade I), and pneumonia rate (7% vs 7%, > C-D grade II). Conclusion Short outcomes of Robotic MIE in introduction period were not inferior to those of Conventional prone-MIE in established period. More improvement is expected for Robotic MIE via learning curve. In conclusion, Robotic MIE has hidden potential to outstrip Conventional prone-MIE in outcomes. Video https://www.dropbox.com/s/7byc8nsqupgetsp/2020%20ISDE%20movie%20for%20submission.wmv?dl=0.

Reconstruction routes after esophagectomy include posterior mediastinal, retrosternal, and subcutaneous route. We have performed posterior mediastinal reconstruction, but this route has higher risks of gastro-tracheal fistula and hiatal hernia. To avoid these complications, now we take the retrosternal route as our first choice by creating the route laparoscopically before pulling-up gastric conduit. We report the successful and safe procedure. Methods We performed laparoscopic creation of retrosternal route in 13 thoracoscopic/robot-assisted minimally invasive esophagectomies since August 2019. In practice, a peritoneal incision at the dorsal side of the xiphoid process is started. Then, via 12 mm port on the surgeon's right hand inserted slightly to the right and cranial side of the umbilical camera port, we dissect loose connective tissues from the caudal side to the cranial side behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route and pleural injury rate during the procedure was examined. Results Thirteen cases were divided into two groups as early period group (seven cases) and later period group (six cases) respectively. The time required for route creation was 31.3 minutes(average) in the early period group, and 16.7 minutes in the later period group. There is tendency towards faster in later period group than in earlier one. The overall pleural injury rate was 15% (2 of 13 cases). Although it was difficult to determine the amount of bleeding, it was visually observed that the bleeding during the route creation was lower in the later period group than in the early period group. Conclusion The entire laparoscopic procedure to create retrosternal route makes it easier to observe and preserve the pleura and internal thoracic vessels compared to blind blunt dissection. As a conclusion, laparoscopic creation of retrosternal route for gastric conduit reconstruction is safe and feasible with good learning curve. Video https://www.dropbox.com/sh/p0wc3x46n33jp23/AADwiWHYIEUNUX6qZsERVIOga?dl=0.

Achalasia is a rare benign esophageal motility disease caused by the impaired relaxation of the lower esophageal sphincter, which results from nerve damage. Patients with achalasia are known to have a high risk of esophageal cancer. Here, we present the case of a patient with achalasia and esophageal cancer in whom the Lugol‐voiding areas (LVAs) could be improved by pneumatic dilation and the extending area of esophagus cancer could become clear. In achalasia patients, LVAs are modified by inflammation and appear wider than their actual size. Moreover, some parts of LVAs in achalasia patients might be reversible by treatments that improve delayed emptying. When the spread of esophagus cancer is unclear due to the detection of numerous LVAs by Lugol chromoendoscopy, the treatments that improve delayed emptying first may be effective in accurately diagnosing the extending area of esophagus cancer., In achalasia patients, Lugol‐voiding areas (LVAs) are modified by inflammation and appear wider than their actual size. Moreover, some parts of LVAs in achalasia patients might be reversible by treatments that improve delayed emptying.

INTRODUCTION Laparoscopic surgery has become popular for colorectal cancer treatment in recent years. However, its success rate even among high-risk patients remains debatable. The present study aims to compare the short- and long-term outcomes between laparoscopic and open surgeries in the American Society of Anesthesiologists (ASA) classes 3 and 4 patients with colorectal cancer. METHODS This was a single-center, retrospective, cohort study performed at a university hospital, with 78 patients suffering from colorectal cancer who underwent surgery in ASA classes 3 and 4 as respondents. Patient and tumor characteristics, operative outcomes, and prognoses were factors compared between the open and laparoscopic groups. RESULTS Compared with the open group, laparoscopic group had longer operation time (median 287.5 vs 204.5 minutes, P = .001), less operative blood loss (median 40 vs 240 mL, P = .020), and fewer postoperative complications (24% vs 55%, P = .011). In addition, operative approach (open vs laparoscopic) served as an independent factor for the occurrence of postoperative complications [HR = 3.963 (1.344-12.269), P = .013]. In terms of overall survival and recurrence-free survival (P = .171 and .087, respectively), no significant difference was found between the two groups. CONCLUSION Laparoscopic surgery is thus associated with more favorable short-time outcomes and could be adopted as treatment even for colorectal cancer ASA class 3 and 4 patients.

Skeletal muscle loss after gastrectomy can worsen patients’ quality of life and prognosis. Laparoscopic gastrectomy is less invasive than open gastrectomy and has become commonly performed. However, the degree of skeletal muscle loss after laparoscopic procedures remains unclear. We herein report the degree and risk factors of psoas muscle loss after laparoscopic gastrectomy for gastric cancer. The total psoas area (TPA) on computed tomography of 50 consecutive patients who underwent laparoscopic total gastrectomy (LTG) and 167 consecutive patients who underwent laparoscopic distal gastrectomy (LDG) for gastric cancer was retrospectively evaluated at one postoperative year. The TPA loss was compared between LDG and LTG and univariate and multivariate analyses were performed to identify the risk factors for TPA loss > 10%. The median TPA decrease rate was 5.9% in the LDG group and 15.6% in the LTG group. LTG and postoperative respiratory complications were independent factors associated with a severe TPA loss of > 10%. In the LTG group, no independent factors were identified in a multivariate analysis. In the LDG group, postoperative complications were identified as an independent risk factor for TPA loss > 10%. Laparoscopic gastrectomy leads to postoperative TPA loss, especially in patients who underwent LTG and had postoperative respiratory complications. Postoperative complications after LDG were also a risk factor for TPA loss.

Amplified Arctic warming and its relevance to mid-latitude cooling in winter have been intensively studied. Observational evidence has shown strong connections between decreasing sea ice and cooling over the Siberian/East Asian regions. However, the robustness of such connections remains a matter of discussion because modeling studies have shown divergent and controversial results. Here, we report a set of general circulation model experiments specifically designed to extract memory effects of land processes that can amplify sea ice–climate impacts. The results show that sea ice–induced cooling anomalies over the Eurasian continent are memorized in the snow amount and soil temperature fields, and they reemerge in the following winters to enhance negative Arctic Oscillation-like anomalies. The contribution from this memory effect is similar in magnitude to the direct effect of sea ice loss. The results emphasize the essential role of land processes in understanding and evaluating the Arctic–mid-latitude climate linkage., The connection between Arctic sea ice loss and mid-latitude cooling in Eurasia has been widely debated. Here, model experiments reveal that the persistence of sea ice loss-related snow and soil temperature anomalies in Eurasia may lead to further cooling in the following winters.

Oral health is associated with various diseases, including cancer. Tooth loss is a simple and objective index of oral health. The purpose of this study was to investigate the association between preoperative tooth loss and esophageal cancer prognosis after esophagectomy. This study included 191 patients who underwent esophagectomy for esophageal cancer after perioperative dental evaluation and oral care at Kobe University Hospital from April 2011 to March 2016. Patients were divided into two groups: Group A (tooth loss

Introduction Recent advances in the treatment for esophageal cancer have improved the prognosis after esophagectomy, but they have led to an increased incidence of gastric tube cancer. In most patients who underwent retrosternal reconstruction, median sternotomy is performed; it is associated with a risk of postoperative bleeding and osteomyelitis, and pain often negatively affects respiration. Here, we report the first case of thoracoscopic retrosternal gastric conduit resection in the supine position (TRGR-S). Materials and surgical technique A 75-year-old male patient was placed in the supine position. Four ports were placed in the left chest wall. The gastric tube was separated from the epicardium, sternum, and left brachiocephalic vein. Because of adhesions between the gastric tube and the right pleura, combined resection of the right pleura was performed. The dorsal side of the gastric tube was dissected before the ventral side, enabling the gastric tube to be suspended from the back of the sternum and, thus, making it easier to expose the surgical field. Next, pedicled jejunal reconstruction via the presternal route was performed. There were no postoperative complications. The pathological diagnosis was signet ring cell carcinoma (pT1b, pN0, M0, pStage I), indicating R0 resection. Discussion TRGR-S does not require sternotomy, reducing the risk of postoperative bleeding and osteomyelitis. In the presence of adhesions, TRGR-S is safe and provides a good surgical view. It is also reliable procedure for resection of retrosternal gastric tube cancer, and it is ergonomic for surgeons.