Totally laparoscopic versus laparoscopy-assisted distal gastrectomy: the KLASS-07, a randomized controlled trial.

BACKGROUNDS: Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). We performed an RCT to confirm if TLDG is different from LADG. METHODS: The XXXXX trial is a multicentre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enrolled from 21 cancer care centers in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the XXXXX trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was QoL for 1 year. This trial is registered at ClinicalTrials.gov (NCT XXXXXXXX). RESULTS: 442 patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P=0.006; and 0.5% vs. 4.3%, P=0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P<0.05). However, these QoL differences were resolved at 1 year. CONCLUSIONS: The XXXXX trial confirmed that TLDG is not different from LADG in terms of postoperative complication but has advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months.

Development and evaluation of RFID-integrated endoscopic clips for laparoscopic surgery marking.

BACKGROUND: As advancements in surgical instruments and techniques continue to evolve, minimally invasive surgery has become increasingly preferred as a means of reducing patient pain and recovery time. However, one major challenge in performing minimally invasive surgery for early gastrointestinal cancer is accurately identifying the location of the lesion. This is particularly difficult when the lesion is confined to the lumen of the intestine and cannot be visually confirmed from the outside during surgery. In such cases, surgeons must rely on CT or endoscopic imaging to locate the lesion. However, if the lesion is difficult to identify with these images or if the surgeon has less experience, it can be challenging to determine its precise location. This can result in an excessive resection margin, deviating from the goal of minimally invasive surgery. To address this challenge, researchers have been studying the development of a marker for identifying the lesion using a radio-frequency identification (RFID) system. One proposed method for clinical application of this detection system is to attach an RFID tag to an endoscopic hemostatic clip and fix it to the intended position, providing a stable marker for the inner wall of the organ. This approach has the potential to improve the accuracy and effectiveness of minimally invasive surgery for early gastrointestinal cancer. METHODS: In the development of a marker for identifying gastrointestinal lesions using a radio-frequency identification (RFID) system, the shape of the clip and suitable materials for attaching the RFID tag were determined through finite element method (FEM) analysis. A prototype of the clip was then fabricated and ex-vivo experiments were conducted using porcine intestine to evaluate the stability of the clip in relation to its position. To further evaluate the performance of the RFID-integrated clip in vivo, the clip was placed in the gastric wall of the stomach of anesthetized porcine using an endoscopic instrument. The clip was then detected using a RFID detector designed for laparoscopic approach. And later, the accuracy of detection was confirmed by incising the lesion. RESULTS: The design and fabrication of a clip with varying thicknesses using STS316 and STS304 stainless steel were accomplished using the results of finite element method analysis. The stability of the clip was evaluated through ex-vivo experiments, showing it to be a viable option. In-vivo experiments were performed on anesthetized porcine, in which the RFID-integrated clip was placed in the gastric wall and detected using a custom-made RFID detector. The resection margin, measured at about 30 mm from the detector position, was accomplished with low error. These findings indicate the feasibility and efficacy of using an RFID-integrated clip as a marker in minimally invasive surgery for the identification of gastrointestinal lesions. CONCLUSIONS: The study evaluated the feasibility of using stainless steel clips for lesion detection in endoscopic surgery using computer-aided engineering analysis and ex-vivo experimentation. Results showed that STS304 was suitable for use while STS316L was not. The ex-vivo experiments revealed that the clip holding force and tissue retention length varied depending on the location of attachment. In-vivo experiments confirmed the accuracy and usefulness of the RFID lesion detection system. However, challenges remain for its use in clinical field, such as ensuring the stability of the clip and the safe attachment of the RFID tag, which requires further research for commercialization.

The application of enhanced recovery after surgery protocol after distal gastrectomy for patients with gastric cancer: a prospective randomized clinical trial.

BACKGROUND: This study aimed to evaluate the clinical outcomes and efficacy of enhanced recovery after surgery (ERAS) protocol in patients undergoing distal gastrectomy for gastric cancer (GC). METHODS: Patients were randomly assigned to the ERAS group (EG) and the conventional care group (CG) by stratified randomization according to age and sex. The primary endpoint was adjusted postoperative hospital stay, calculated using discharge criteria developed to evaluate recovery. Nutritional data and quality of life (QoL) (European Organisation for Research and Treatment of Cancer [EORTC] C30 and STO22) during the perioperative period were also analyzed. RESULTS: We enrolled 198 eligible patients with GC for the study between June 2017 and January 2019. A total of 147 patients were finally enrolled in this study (full analysis set) and were assigned to EG (n = 71) and CG (n = 76). First flatus was faster significantly in EG (3.6 ± 1.5 vs 4.1 ± 1.2 days, P = .019). EG showed a faster start of the sips and soft diet than CG (1.3 ± 0.7 vs 3.1 ± 0.4 days, P < .001; 2.4 ± 0.9 vs 5.2 ± 0.7 days, P < .001) according to the protocol. The recorded hospital stay was not significantly different; however, adjusted hospital stay was significantly shorter in EG than in CG (6.5 ± 3.1 vs 7.8 ± 2.1 days, P = .005). There was no difference in morbidity, and no mortality occurred in both groups. EG did not show significant superiority in nutritional outcome and QoL improvement, except for pain scale in EORTC-STO22. CONCLUSION: The application of the ERAS protocol could reduce the adjusted hospital stay without an increase in postoperative complications. There was no significant difference in long-term nutritional outcome and QoL of the 2 groups.

Diagnostic performance of F-18 FDG PET or PET/CT for detection of recurrent gastric cancer: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis investigated the diagnostic performance of F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) or PET/computed tomography (PET/CT) for the detection of disease recurrence after curative resection of gastric cancer. METHODS: The PubMed and Embase databases, from the earliest available date of indexing through November 30, 2019, were searched for studies evaluating the diagnostic performance of F-18 FDG PET or PET/CT to detect recurrent disease after gastric cancer surgery. RESULTS: Across 17 studies (1,732 patients), the pooled sensitivity for F-18 FDG PET or PET/CT was 0.82 (95% confidence interval [CI], 0.74-0.88) with heterogeneity of I2=76.5 (p<0.001), and the specificity was 0.86 (95% CI, 0.78-0.91) with heterogeneity of I2=94.2 (p<0.001). Likelihood ratio (LR) tests gave an overall positive LR of 6.0 (95% CI, 3.6-9.7) and negative LR of 0.2 (95% CI, 0.14-0.31). The pooled diagnostic odds ratio was 29 (95% CI, 13-63). The summary receiver operating characteristic curve indicates that the area under the curve was 0.91 (95% CI, 0.88-0.93). CONCLUSION: The current meta-analysis showed good sensitivity and specificity of F-18 FDG PET or PET/CT for detecting recurrent disease after curative resection of gastric cancer despite heterogeneity in ethnicity, recurrence rate, histology, and interpretation method.

Erratum: Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach.

This corrects the article on p. 3 in vol. 23, PMID: 36750993.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach.

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Laparoscopic gastric wedge resection and spleen-preserving distal pancreatectomy performed on a 6-cm gastric desmoid tumour with pancreatic invasion.

Desmoid tumours are rare tumours originating from fibroblasts, and are characterised by local infiltration and no metastasis. When complete resection is possible, surgical resection is considered a first-line treatment. In the case of large desmoid tumours, it is mainly performed by laparotomy, not laparoscopy. We report a case of a 43-year-old female patient presenting with a hypodense mass of approximately 5 cm in the posterior wall of the gastric antrum on computed tomography. There was no history of familial adenomatous polyposis, trauma or abdominal surgery. The patient underwent laparoscopic gastric wedge resection and spleen-preserving distal pancreatectomy without peri-operative complications. Pathological analysis revealed a desmoid tumour, which originated from the stomach and invaded the pancreas. Despite the large size and the locally infiltrative characteristics of these tumours, laparoscopic surgery can be an optimal treatment option due to its advantages.

Korean practice guidelines for gastric cancer 2022: an evidence-based, multidisciplinary approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Exploring ideal operative time for best outcomes in gastric cancer surgery: A multi-institutional study based on KLASS-07 database.

Objective: While a rushed operation can omit essential procedures, prolonged operative time results in higher morbidity. Nevertheless, the optimal operative time range remains uncertain. This study aimed to estimate the ideal operative time range and evaluate its applicability in laparoscopic cancer surgery. Methods: A prospectively collected multicenter database of 397 patients who underwent laparoscopic distal gastrectomy were retrospectively reviewed. The ideal operative time range was statistically calculated by separately analyzing the operative time of uneventful surgeries. Finally, intraoperative and postoperative outcomes were compared among the shorter, ideal, and longer operative time groups. Results: The statistically calculated ideal operative time was 135.4-165.4 min. The longer operative time (LOT) group had a lower rate of uneventful, perfect surgery than the ideal or shorter operative time (IOT/SOT) group (2.8% vs. 8.8% and 2.2% vs. 13.4%, all P<0.05). Longer operative time increased bleeding, postoperative morbidities, and delayed diet and discharge (all P<0.05). Particularly, an uneventful, perfect surgery could not be achieved when the operative time exceeded 240 min. Regardless of ideal time range, SOT group achieved the highest percentage of uneventful surgery (13.4%), which was possible by surgeon's ability to retrieve a higher number of lymph nodes and perform ≥150 gastrectomies annually. Conclusions: Operative time longer than the ideal time range (especially ≥240 min) should be avoided. If the essential operative procedure were faithfully conducted without compromising oncological safety, an operative time shorter than the ideal range leaded to a better prognosis. Efforts to minimize operative time should be attempted with sufficient surgical experience.

Machine learning-based survival rate prediction of Korean hepatocellular carcinoma patients using multi-center data.

AIM: To predict survival time of Korean hepatocellular carcinoma (HCC) patients using multi-center data as a foundation for the development of a predictive artificial intelligence model according to treatment methods based on machine learning. METHODS: Data of patients who underwent treatment for HCC from 2008 to 2015 was provided by Korean Liver Cancer Study Group and Korea Central Cancer Registry. A total of 10,742 patients with HCC were divided into two groups, with Group I (2920 patients) confirmed on biopsy and Group II (5562 patients) diagnosed as HCC according to HCC diagnostic criteria as outlined in Korean Liver Cancer Association guidelines. The data were modeled according to features of patient clinical characteristics. Features effective in predicting survival rate were analyzed retrospectively. Various machine learning methods were used. RESULTS: Target was overall survival time, which divided into approximately 60 months (= /< 60 m, > 60 m). Target distribution in Group I (total 514 samples) was 28.8%: (148 samples) less than 60 months, 71.2% (366 samples) greater than 60 months, and in Group II (total 757 samples) was 66.6% (504 samples) less than 60 months, 33.4% (253 samples) greater than 60 months. Using NG Boost method, its accuracy was 83%, precision 84%, sensitivity 95%, and F1 score 89% for more than 60 months survival time in Group I with surgical resection. Moreover, its accuracy was 79%, precision 82%, sensitivity 87%, and F1 score 84% for less than 60 months survival time in Group II with TACE. The feature importance with gain criterion indicated that pathology, portal vein invasion, surgery, metastasis, and needle biopsy features could be explained as important factors for prediction in case of biopsy (Group I). CONCLUSION: By developing a predictive model using machine learning algorithms to predict prognosis of HCC patients, it is possible to project optimized treatment by case according to liver function and tumor status.

Clinical features of internal hernia after gastrectomy for gastric cancer.

Purpose: Internal hernia after gastrectomy is a rare but potentially life-threatening condition without surgical intervention. Clinical risk factors of internal hernia should, hence, be reviewed after gastrectomy. From 2008 to 2018, patients who underwent gastrectomy for gastric cancer were investigated. Methods: Abdominal computed tomography (CT) was used to screen for internal hernia, and surgical exploration was performed to confirm the diagnosis. Using retrospective statistical analysis, the incidence, characteristics, and risk factors were identified, and the characteristics of the internal hernia group were reviewed. Results: The overall incidence of internal hernia was 0.9%. From statistical analysis, it was found that laparoscopic surgery was almost five times riskier than open gastrectomy (odds ratio [OR], 4.947; 95% confidence interval [CI], 1.308-18.710; p = 0.019). Body mass index < 25 kg/m2 (OR, 4.596; 95% CI, 1.056-20.004; p = 0.042) and proximal gastrectomy (OR, 4.238; 95% CI, 1.072-16.751; p = 0.039) were also associated with internal hernia. Among 20 patients with internal hernia, 12 underwent laparotomy, and five had their bowels removed due to ischemia. All patients with bowel resected had suffered from short bowel syndrome. Conclusion: Suspecting an internal hernia should be an important step when a patient with a history of laparoscopic gastrectomy visits for medical care. When suspected, emergent screening through CT scan and surgical intervention should be considered as soon as possible to prevent lifetime complications accordingly.

Potential Therapeutic Approaches for the Intussusception Through a Side-to-Side Jejunojejunal Anastomosis After Laparoscopic Gastrectomy.

We reviewed our experience with the management of intussusception presenting as a complication of laparoscopic gastrectomy (LG) and studied the feasibility of a laparoscopic intervention to treat or prevent this condition. We retrospectively analyzed the data of 12 patients diagnosed with intussusception, following gastrectomy, from 2008 to 2017, including clinical manifestations, incidence, post-LG time-interval before diagnosis, and treatment. Totally, 12/2300 gastrectomy patients (0.52%) developed intussusception. All 12 had undergone laparoscopic distal gastrectomy for gastric cancer (12/1250, 0.96%) and presented with intussusception through a side-to-side jejunojejunal anastomosis. The mean latency period was 423.8 (range: 86 to 1500) days. Four patients underwent emergent laparoscopic reduction of the efferent loop without bowel resection, along with fixation of the reduced jejunum to the afferent loop and the small bowel mesentery, to prevent a recurrence. One patient required open surgery with manual reduction and segmental resection of the gangrenous small bowel portion. All operated patients recovered without any complications. Intussusception resolved spontaneously in the remaining 7/12 patients. We found that a laparoscopic approach can be used for preventing or managing post-LG intussusception. We found that recurrence can be prevented or treated by anchoring and fixing the (reduced) efferent loop to the afferent loop and the small bowel mesentery.

A ruptured jejunal gastrointestinal stromal tumor with hemoperitoneum mimicking ovarian carcinoma.

BACKGROUND: Gastrointestinal stromal tumor (GIST) of the small bowel is a rare malignancy and accounts for only 0.1-3% of all gastrointestinal neoplasms. GISTs may mimic gynecologic tumors. The authors present an unusual case of ruptured jejunal GIST with hemoperitoneum mimicking ovarian carcinoma. CASE PRESENTATION: A 57-year-old postmenopausal woman presented with progressive, generalized low abdominal pain for 3 months. Computed tomography (CT) imaging depicted a 9.6 cm-sized, complex and solid mass on the left pelvic cavity and a 3.7 cm-sized heterogeneous, enhancing mass on the right adnexa, suspicious for ovarian cancer accompanied by hemoperitoneum. There was no active bleeding. Laboratory examination revealed a low level of serum hemoglobin (6.7 g/dL), and a raised serum level of CA-125 (107.0 U/mL). Based on CT imaging findings and an elevated serum level of CA-125, bilateral ovarian cancer was suspected. The patient underwent exploratory laparotomy, and frozen section of the excised mass indicated malignancy originating from the small bowel jejunum. Consequently, small bowel segmental resection with mesenteric resection was done, and a debulking operation including hysterectomy, BSO, BPLD, omentectomy, and excision of multiple metastatic masses in the peritoneum was performed. Subsequent histopathologic examination confirmed the final diagnosis of high risk GISTs of the primary small bowel jejunum. The patient's postoperative course was uneventful, and adjuvant Imatinib was administered. CONCLUSION: The authors report an unusual case of ruptured jejunal GIST with hemoperitoneum mimicking ovarian carcinoma. Therefore, GIST, in addition to ovarian cancer, should be considered in patients with an increased serum level of CA-125 and an abdominopelvic mass.

Recent Status of Laparoscopic Distal Gastrectomy in Korea: A Multicenter Retrospective Cohort Study (Pre-study Survey of KLASS-07 Trial).

Purpose: To analyze the surgical trend and brief postoperative results of laparoscopic distal gastrectomy (LDG) in Korea on the basis of a multicenter cohort. Materials and Methods: Data of 812 patients who underwent LDG between January and December 2016 were collected from 14 surgeons at 7 institutions. Patients were divided into laparoscopy-assisted distal gastrectomy (LADG) group and totally laparoscopic distal gastrectomy (TLDG) group. Perioperative and clinicopathologic outcomes were compared retrospectively. Results: Among the patients [n = 222 (27.3%) LADG; n = 590 (72.7%) TLDG], there are no significant differences in patient's demographics (sex, age, body mass index, and American Society of Anesthesiologists score). Billroth-I anastomosis (84.7%) was most performed in the LADG group, but Billroth-II anastomosis (59.0%) in the TLDG group (p < 0.001). The mean operative time was longer in the TLDG group (197.3 ± 44.4 min vs. 222.0 ± 60.2 min, p < 0.001), and there was no statistical difference in the hospital stay between the two groups (9.6 ± 4.8 days vs. 8.9 ± 7.1 days, p = 0.149). There were no significant differences in morbidity and mortality between the two groups. The length of proximal margin was longer in the TLDG group (4.3 ± 3.1 cm vs. 6.0 ± 3.4 cm, p < 0.001), but the distal margin was longer in the LADG group (6.5 ± 3.7 cm vs. 5.5 ± 3.1 cm, p < 0.001). The distribution of operations among each institution was shown very heterogeneously. Conclusion: There was no significant difference related to surgical outcome between LADG and TLDG in pre-study survey prior to KLASS-07 trial. Therefore, to obtain more reliable data, well designed prospective randomized controlled study is needed.

Reduction rate of C-reactive protein as an early predictor of postoperative complications and a reliable discharge indicator after gastrectomy for gastric cancer.

PURPOSE: Postoperative complications (PCs) after gastrectomy are associated with readmission and longer hospital stay. This study aimed to determine the role of CRP as an early predictor of PCs and a reliable discharge indicator after gastrectomy. METHODS: Clinicopathologic data and PCs of 613 patients who underwent gastrectomy for gastric cancer in 2015-2016 were retrospectively analyzed, including consecutive blood samples for CRP obtained preoperatively, at the operative day, and postoperatively. Following the Clavien-Dindo classification, the patients were divided into a group with major PCs and a group with minor/no PCs. Diagnostic accuracy was determined by the area under the receiver operating characteristic curve (AUC). Clinical factors related to major PCs were identified using univariate and multivariate logistic regression analyses. RESULTS: PCs occurred in 89 patients (14.5%). The most significant predictive factor for major PCs was a CRP concentration reduction rate of ≤38.1% (AUC, 0.82; sensitivity, 76.4%; specificity, 76.1%) between postoperative day (POD) 3 and 5 (R5), followed by ≤11.1% (AUC, 0.75; sensitivity, 73%; specificity, 76%) between POD 2 and 3 (R4). When both factors were applied (R4 ≤ 11.1% and R5 ≤ 38.1%), the specificity was 91.6%; when only one condition was satisfied (R4 ≤ 11.1% or R5 ≤ 38.1%), the sensitivity was 91%. CONCLUSION: CRP concentration reduction rates between POD 3 and 5 and between POD 2 and 3 were the best combination factors to predict PCs and indicate a safe discharge after gastrectomy for gastric cancer.

Meta-analysis and systematic review on laparoscopic-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) for gastric cancer: Preliminary study for a multicenter prospective KLASS07 trial.

BACKGROUND: The curative surgical treatment of gastric cancer in the current laparoscopic surgical era relies on the surgeon's preference, technical difficulties, and concerns regarding outcome have led to the availability of totally laparoscopic distal gastrectomy (TLDG) and laparoscopic-assisted distal gastrectomy (LADG). A consensus on which of the two procedures is preferable is necessary. Therefore, the aim of this study was to evaluate the differences between LADG and TLDG in terms of surgical outcomes, postoperative recovery, pain, and complications. METHODS: PubMed, Google Scholar, Medline, Embase, and Cochrane databases were explored up to 2017 to evaluate TLDG and LADG. Parameters including surgical outcomes, postoperative recovery, and postoperative complications were subjected to meta-analysis to calculate the odds ratio and weighted mean difference with 95% confidence intervals (c.i.). RESULTS: Twenty-five studies (24 non-RCT and 1 RCT) with a total of 4562 gastric cancer patients were included in the meta-analysis. Under reconstruction-matched analysis, overall complications and anastomotic complications were similar for TLDG and LADG. Nevertheless, short-term outcomes such as blood loss, time to first soft diet, hospital stay, analgesic use, and CRP level were favourable for TLDG, while all other surgical outcomes showed no difference. CONCLUSIONS: TLDG and LADG did not show significant differences in surgical outcomes and postoperative complications, including anastomotic-related morbidity. Therefore, decisive factors in selecting surgical procedures, which previously consisted of surgical outcomes, have been superseded by extra-surgical values such as cosmesis, economics, and patient's quality of life. These factors will be explored in a future multicentre prospective study (KLASS07 trial).

Digital image analysis-based scoring system for endoscopic ultrasonography is useful in predicting gastrointestinal stromal tumors.

BACKGROUND: When gastric mesenchymal tumors (GMTs) measuring 2-5 cm in size are found, whether to undergo further treatment or not is controversial. Endoscopic ultrasonography (EUS) is useful for the evaluation of malignant potential of GMTs, but has limitations, such as subjective interpretation of EUS images. Therefore, we aimed to develop a scoring system based on the digital image analysis of EUS images to predict gastrointestinal stromal tumors (GISTs). METHODS: We included 103 patients with histopathologically proven GIST, leiomyoma or schwannoma on surgically resected specimen who underwent EUS examination between January 2007 and June 2018. After standardization of the EUS images, brightness values, including the mean (Tmean), indicative of echogenicity, and the standard deviation (TSD), indicative of heterogeneity, in the tumors were analyzed. RESULTS: Age, Tmean, and TSD were significantly higher in GISTs than in non-GISTs. The sensitivity and specificity were almost optimized for differentiating GISTs from non-GISTs when the critical values of age, Tmean, and TSD were 57.5 years, 67.0, and 25.6, respectively. A GIST-predicting scoring system was created by assigning 3 points for Tmean ≥ 67, 2 points for age ≥ 58 years, and 1 point for TSD ≥ 26. When GMTs with 3 points or more were diagnosed as GISTs, the sensitivity, specificity, and accuracy of the scoring system were 86.5%, 75.9%, and 83.5%, respectively. CONCLUSIONS: The scoring system based on the information of digital image analysis is useful in predicting GISTs in case of GMTs that are 2-5 cm in size.

Tumor localization using radio-frequency identification clip marker: experimental results of an ex vivo porcine model.

PURPOSE: With the widespread use of minimally invasive surgery, tumor detection is becoming more difficult. We present the experimental results of a radio-frequency identification (RFID) lesion detection system in an ex vivo porcine model. METHODS: The efficacy and feasibility of a newly developed RFID lesion detection system were examined. It was applied to the stomach and colon of pigs weighing 40 kg. The RFID clip was attached to the upper and lower mucosal sides of the stomach. Colon specimens with thin and thick walls were used. The clipped sites were marked on the serosa by a pin. The longest distance from the pin the RFID tag could be detected was measured 25 times in each direction. RESULTS: In the upper gastric wall, the RFID tag detection distance was 4.5 ± 0.9 mm, 5.6 ± 0.7 mm, 12.5 ± 0.7 mm, and 5.3 ± 0.5 mm in the four directions, respectively (right, left, upper, and lower). In the antrum, the RFID tag detection distance was 5.8 ± 0.7 mm, 6.9 ± 0.5 mm, 5.6 ± 0.5 mm, and 3.7 ± 0.5 mm in the four directions. In the thin colon, the RFID tag detection distance was 6.3 ± 0.5 mm, 5.0 ± 0.5 mm, 9.7 ± 0.7 mm, and 6.4 ± 0.4 mm in the four directions. In the thick colon, the RFID tag detection distance was 3.5 ± 0.8 mm, 6.6 ± 0.5 mm, 8.4 ± 0.6 mm, and 9.8 ± 0.5 mm in the four directions. The area of detection was smallest for the antrum (83.7 mm2) and similar for the other sites (150.6, 154.7 and 157.7 mm2 for the upper body, thin colon, and thick colon, respectively). CONCLUSIONS: The distance at which the RFID tag was detected was usually within 10 mm. These results indicate the feasibility of the clinical application of the add-on clip and RFID tag as a marker for identifying the location of various gastrointestinal tumors.

Multimodal treatments of right gastroepiploic arterial leiomyosarcoma with hepatic metastasis: A case report and review of the literature.

Leiomyosarcoma of an artery is very rare, and cases with hepatic metastasis are even rarer. We describe a case of a 70-year-old man who after follow up due to rectal cancer, presented with an intra-abdominal hypervascular mass and a hepatic mass. After surgical resection, it was diagnosed as a leiomyosarcoma of the right gastroepiploic artery with hepatic metastasis. Multiple metastases had recurred at the liver. He has survived more than 53 mo through multimodal treatments (three surgical resections, radiofrequency ablation, transarterial chemoembolization, chemotherapies, and targeted therapy). Multimodal treatments, including active surgical resection, may be helpful in the treatment of aggressive diseases such as arterial leiomyosarcoma with metastasis.

Atraumatic Liver Retraction Using Nelaton Catheters During Totally Laparoscopic Gastrectomy.

This study introduces a novel technique for liver retraction during laparoscopic gastrectomy and assesses its impact on postoperative recovery. This study included 139 patients in whom Nelaton catheters (n=57) or Nathanson retractors (n=82) were used for liver retraction. Serum liver enzyme levels were measured preoperatively and on the first, second, third, fifth, and seventh postoperative days. Clinicopathologic features and postoperative recovery variables between the 2 groups were compared. The aspartate aminotransferase, alanine aminotransferase, and C-reactive protein levels were significantly lower (P<0.001, P<0.001, and P=0.007, respectively), and the day of first flatus, the day of initiating a soft diet, and the length of hospital stay were shorter in the Nelaton catheter U-shaped retractor group than those seen in the Nathanson retractor group (P=0.035, P=0.002, and P=0.024, respectively). Atraumatic liver retraction with Nelaton catheters is recommended in laparoscopic gastrectomy.