Real-time Vessel Navigation Using Indocyanine Green Fluorescence during Robotic or Laparoscopic Gastrectomy for Gastric Cancer

PURPOSE: Identification of the infrapyloric artery (IPA) type is a key component of pylorus-preserving gastrectomy. As the indocyanine green (ICG) fluorescence technique is known to help visualize blood vessels and flow during reconstruction, we speculated that this emerging technique would be helpful in identifying the IPA type. MATERIALS AND METHODS: From August 2015 to February 2016, 20 patients who underwent robotic or laparoscopic gastrectomy were prospectively enrolled. After intravenous injection of approximately 3 mL of ICG (2.5 mg/mL), a near-infrared fluorescence apparatus was applied. The identified shape of the IPA was confirmed by examining the actual anatomy following infrapyloric dissection. RESULTS: The mean interval time between ICG injection and visualization of the artery was 22.2 seconds (range, 14–30 seconds), and the mean duration of the arterial phase was 16.1 seconds (range, 9–30 seconds). The overall positive predictive value (PPV) of ICG fluorescence in identifying the IPA type was 80% (16/20). The IPA type was incorrectly predicted in four patients, all of whom were obese with a body mass index (BMI) of more than 25 kg/m². CONCLUSIONS: Our preliminary results indicate that intraoperative vascular imaging using the ICG fluorescence technique may be helpful for robotic or laparoscopic pylorus-preserving gastrectomy.

Case Report of an Adult Patient Who Underwent a Serial Transverse Enteroplasty Procedure for Short Bowel Syndrome Following an Esophagectomy and Total Gastrectomy

Since its introduction as an alternative intestinal lengthening technique, the serial transverse enteroplasty (STEP) procedure has been used increasingly as the surgical treatment of choice for children with short bowel syndrome (SBS). On the other hand, there are few report of its efficacy in adults with SBS, particularly those who have previously undergone a gastrectomy. This case report describes a 34-year-old woman with a short bowel after an esophagectomy and total gastrectomy due to lye ingestion followed by an extensive intestinal resection due to small bowel strangulation. The STEP procedure was performed successfully and the small intestine was lengthened from 55 to 75 cm. The patient tolerated the procedure well and was weaned off total parenteral nutrition. The frequency and characteristics of diarrhea improved, and her weight remained acceptable via management with intermittent parenteral nutritional support for 6 months postoperatively. This case suggests that the STEP procedure should be considered for gastrectomized patients with SBS.

A Novel Roux-en-Y Reconstruction Involving the Use of Two Circular Staplers after Distal Subtotal Gastrectomy for Gastric Cancer

PURPOSE: Although Roux-en-Y (R-Y) reconstruction after distal gastrectomy has several advantages, such as prevention of bile reflux into the remnant stomach, it is rarely used because of the technical difficulty. This prospective randomized clinical trial aimed to show the efficacy of a novel method of R-Y reconstruction involving the use of 2 circular staplers by comparing this novel method to Billroth-I (B-I) reconstruction. MATERIALS AND METHODS: A total of 118 patients were randomly allocated into the R-Y (59 patients) and B-I reconstruction (59 patients) groups. R-Y anastomosis was performed using two circular staplers and no hand sewing. The primary end-point of this clinical trial was the reflux of bile into the remnant stomach evaluated using endoscopic and histological findings at 6 months after surgery. RESULTS: No significant differences in clinicopathological findings were observed between the 2 groups. Although anastomosis time was significantly longer for the patients of the R-Y group (P<0.001), no difference was detected between the 2 groups in terms of the total surgery duration (P=0.112). Endoscopic findings showed a significant reduction of bile reflux in the remnant stomach in the R-Y group (P<0.001), and the histological findings showed that reflux gastritis was more significant in the B-I group than in the R-Y group (P=0.026). CONCLUSIONS: The results of this randomized controlled clinical trial showed that compared with B-I reconstruction, R-Y reconstruction using circular staplers is a safe and feasible procedure. This clinical trial study was registered at www.ClinicalTrials.gov (registration No. NCT01142271).

Brief introduction to current pharmacogenomics research tools

There is increasing interest in the application of personalized therapy to healthcare to increase the effectiveness of and reduce the adverse reactions to treatment. Pharmacogenomics is a core element in personalized therapy and pharmacogenomic research is a growing field. Understanding pharmacogenomic research tools enables better design, conduct, and analysis of pharmacogenomic studies, as well as interpretation of pharmacogenomic results. This review provides a general and brief introduction to pharmacogenomics research tools, including genotyping technology, web-based genome browsers, and software for haplotype analysis.

Can Robotic Gastrectomy Surpass Laparoscopic Gastrectomy by Acquiring Long-Term Experience? A Propensity Score Analysis of a 7-Year Experience at a Single Institution

PURPOSE: It is hypothesized that robotic gastrectomy may surpass laparoscopic gastrectomy after the operators acquire long-term experience and skills in the manipulation of robotic arms. This study aimed to evaluate the long-term learning curve of robotic distal gastrectomy (RDG) for gastric cancer compared with laparoscopic distal gastrectomy (LDG). MATERIALS AND METHODS: From October 2008 to December 2015, patients who underwent LDG (n=809) were matched to patients who underwent RDG (n=232) at a 1:1 ratio, by using a propensity score matching method after stratification for the operative year. The surgical outcomes, such as trends of operative time, blood loss, and complication rate, were compared between the two groups. RESULTS: The RDG group showed a longer operative time (171.3 minutes vs. 147.6 minutes, P<0.001) but less estimated blood loss (77.6 ml vs. 116.6 ml, P<0.001). The complication rate and postoperative recovery did not differ between the two groups. The RDG group showed a longer operative time and similar estimated blood loss compared with the LDG group after 5 years of experience (operative time: 159.2 minutes vs. 136.0 minutes in 2015, P=0.003; estimated blood loss: 72.9 ml vs. 78.1 ml in 2015, P=0.793). CONCLUSIONS: In terms of short-term surgical outcomes, RDG may not surpass LDG after a long-term experience with the technique.

Is There any Role of Visceral Fat Area for Predicting Difficulty of Laparoscopic Gastrectomy for Gastric Cancer?

PURPOSE: Obesity is associated with morbidity following gastric cancer surgery, but whether obesity influences morbidity after laparoscopic gastrectomy (LG) remains controversial. The present study evaluated whether body mass index (BMI) and visceral fat area (VFA) predict postoperative complications. MATERIALS AND METHODS: A total of 217 consecutive patients who had undergone LG for gastric cancer between May 2003 and December 2005 were included in the present study. We divided the patients into two groups ('before learning curve' and 'after learning curve') based on the learning curve effect of the surgeon. Each of these groups was sub-classified according to BMI ( or =25 kg/m2) and VFA ( or =100 cm2). Surgical outcomes, including operative time, quantity of blood loss, and postoperative complications, were compared between BMI and VFA subgroups. RESULTS: The mean operative time, length of hospital stay, and complication rate were significantly higher in the before learning curve group than in the after learning curve group. In the subgroup analysis, complication rate and length of hospital stay did not differ according to BMI or VFA; however, for the before learning curve group, mean operative time and blood loss were significantly higher in the high VFA subgroup than in the low VFA subgroup (P=0.047 and P=0.028, respectively). CONCLUSIONS: VFA may be a better predictive marker than BMI for selecting candidates for LG, which may help to get a better surgical outcome for inexperienced surgeons.