Impact of the Preoperative C-reactive Protein to Albumin Ratio on the Long-Term Outcomes of Hepatic Resection for Intrahepatic Cholangiocarcinoma.

OBJECTIVE: The present study aimed to investigate the impact of preoperative C-reactive protein to albumin (CRP/Alb) ratio on the long-term outcomes of patients with intrahepatic cholangiocarcinoma (ICC). METHODS: 82 patients who underwent hepatic resection for mass-forming type of ICC were evaluated. The relationship between preoperative CRP/Alb ratio and survival outcomes was investigated. RESULTS: The optimal cutoff value of CRP/Alb ratio for assessing overall survival (OS) was determined as 0.089. Univariate analysis for recurrence-free survival (RFS) showed that CRP/Alb ratio >0.089, carbohydrate antigen 19-9 (CA 19-9) >37 U/mL, lymph node metastasis, vascular invasion, and multiple tumors were significantly associated with postoperative recurrence. On multivariate analysis, the independent prognostic factors identified were CRP/Alb ratio >0.089 (p < 0.001), lymph node metastasis (p = 0.006), and multiple tumors (p < 0.001). Univariate analysis for OS showed that CRP/Alb ratio >0.089, CA 19-9 >37 U/mL, lymph node metastasis, vascular invasion, multiple tumors, and positive surgical margin were significantly associated with overall death. On multivariate analysis, the independent prognostic factors identified were CRP/Alb ratio >0.089 (p < 0.001), lymph node metastasis (p = 0.01), and multiple tumors (p = 0.005). CONCLUSION: Preoperative CRP/Alb ratio may predict poor long-term outcomes after hepatic resection in patients with ICC.
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Predictive Value of the Age-Adjusted Charlson Comorbidity Index for Outcomes After Hepatic Resection of Hepatocellular Carcinoma.

BACKGROUND: This study aimed to evaluate the impact of the age-adjusted Charlson comorbidity index (ACCI) on outcomes after hepatic resection for hepatocellular carcinoma (HCC). METHODS: We assessed 763 patients who underwent hepatic resection for HCC. The ACCI scores were categorized as follows: ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7. RESULTS: A multivariate analysis showed that the odds ratios for postoperative complications in ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 0.71 (p = 0.41) and 4.15 (p < 0.001), respectively. The hazard ratios for overall survival of ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 1.52 (p = 0.023) and 2.45 (p < 0.001), respectively. The distribution of deaths due to HCC-related, liver-related, and other causes was 68.2%, 11.8%, and 20% in ACCI ≤ 5 group, 47.2%, 13.9%, and 38.9% in ACCI = 6 group, and 27.3%, 9.1%, and 63.6% in ACCI ≥ 7 group (p = 0.053; ACCI ≤ 5 vs. = 6, p = 0.19; ACCI = 6 vs. ≥ 7, p < 0.001; ACCI ≤ 5 vs. ≥ 7). In terms of the treatment for HCC recurrence in ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7 groups, adaptation rate of surgical resection was 20.1%, 7.3%, and 11.1% and the rate of palliative therapy was 4.3%, 12.2%, and 22.2%, respectively. CONCLUSIONS: The ACCI predicted the short-term and long-term outcomes after hepatic resection of HCC. These findings will help physicians establish a treatment strategy for HCC patients with comorbidities.

Giving short-term prophylactic antibiotics in patients undergoing open and laparoscopic hepatic resection.

AIM: The 2016 guidelines of the Japan Society for Surgical Infection and the Japan Society of Chemotherapy advocate giving prophylactic antibiotics 1 hour before surgery and until 24 hours after surgery in patients undergoing elective hepatic resection. However, the efficacy of short-term antimicrobial prophylaxis has not been evaluated according to surgical approach. We evaluated the efficacy of giving prophylactic antibiotics in patients undergoing open or laparoscopic hepatic resection. METHODS: The study comprised 218 and 185 patients undergoing open and pure laparoscopic hepatic resection, respectively. Incidence rates of postoperative infectious complications were compared between patients who received flomoxef sodium as the prophylactic antibiotic before and until 24 hours after surgery (short-term group) and those who received flomoxef sodium until 72 hours after surgery (long-term group) among patients undergoing open or laparoscopic hepatic resection. Propensity score matching analysis was carried out to adjust for confounding factors between the short- and long-term groups. RESULTS: There was no significant difference in the postoperative infectious complication incidence between the short- and long-term groups among patients undergoing open (18.9% vs 12.2%; P = 0.36) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection after propensity score matching. Incidence rate of surgical site infections was comparable between the short- and long-term groups among patients undergoing open (13.5% vs 10.8%; P = 0.80) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection. CONCLUSION: Giving short-term prophylactic antibiotics might be sufficient in preventing postoperative infectious complications in patients undergoing open and laparoscopic hepatic resection.

[The Effect of Ninjinyoeito for Patients Undergoing Chemotherapy].

The effect of Ninjinyoeito on reducing adverse reactions during chemotherapy for gastrointestinalcancer was investigated. Patients suffering from "fatigue"after undergoing chemotherapy for gastrointestinalcancer between January and April 2017 were investigated. The subjects were divided into two groups; Ninjinyoeito(treatment group)and a controlgroup. Patients were examined at the initiation of treatment and 12 weeks after treatment, and then subsequently evaluated in the form of an interview sheet to establish physicalsymptoms and CTCAE v4.0. Treatment and controlgroup comprised 24 and 9 cases, respectively. Cases where both the score of "fatigue"and proportion of patients with a score of over 2 improved were found only in the treatment group. Although numbness of hands and feet deteriorated, there was no significant difference in the proportion of patients with a score of over 2. In the assessment of CTCAE v4.0, only cases in the treatment group showed improvement of "fatigue"and proportion of patients with a score of over 2 before and after treatment. Although there was no significant difference in "peripheralneuropathy"between the two groups, patients with a score of over 2 in the treatment group showed an improvement. Our results show Ninjinyoeito helps to alleviate the symptoms of patients who had undergone chemotherapy for gastrointestinalcancer. Thus, treatment with Ninjinyoeito may contribute to enhancing the continuity of medicalcare and improving the prognosis of chemotherapy.

Outcomes of Hepatic Resection in Intrahepatic Cholangiocarcinoma Patients with Diabetes, Hypertension, and Dyslipidemia: Significance of Routine Follow-Up.

BACKGROUND: The outcomes of hepatic resection in intrahepatic cholangiocarcinoma (ICC) patients with diabetes mellitus (DM), hypertension (HT), and dyslipidemia (DL) (metabolic components) remain unclear. METHODS: The outcomes of 43 ICC patients without known risk factors for ICC who underwent hepatic resection were retrospectively reviewed. These patients were divided into three groups: those followed-up for metabolic components at least every 6 months (follow-up group, n=16), those not followed-up for metabolic components (no follow-up group, n=14), and those without metabolic components (control group, n=13). RESULTS: In the follow-up group, 13 (81%) patients were further examined for ICC during follow-up because of abnormal screening results, such as elevated serum gamma-glutamyl transpeptidase and carbohydrate antigen 19-9 (CA19-9) concentrations or detection of hepatic tumor on ultrasonography and/or computed tomography, whereas most patients in the other two groups exhibited ICC-related symptoms. No patient in the follow-up group exhibited lymph node metastasis, whereas 43% of those in the no follow-up group and 46% in the control group had lymph node metastasis (p=0.005 and 0.004 vs. the follow-up group, respectively). All 16 patients in the follow-up group were diagnosed as International Union Against Cancer pathologic stage I or II (early stage). There were no significant differences in the incidence of postoperative recurrence between the three groups; however, the incidence of extrahepatic recurrence was lower in the follow-up group than in the no follow-up group and the control group (13% vs. 78% vs. 63%, p=0.0232). The 1-, 3-, and 5-year overall survivalrates in the follow-up group were better than those in the no follow-up and control groups (93/93/66% vs. 77/34/34% and 85/24/0%, p=0.034 and 0.001, respectively). CONCLUSIONS: Routine measurement of serum gamma-glutamyl transpeptidase and/or CA19-9 levels and imaging examinations every 12 months (or 6 months, if possible) are recommended during follow-up for DM, HT, and DL to detect ICC at an early stage.

The association between non-alcoholic steatohepatitis and intrahepatic cholangiocarcinoma: A hospital based case-control study.

BACKGROUND: This study aimed to investigate the association between non-alcoholic steatohepatitis (NASH) and intrahepatic cholangiocarcinoma (ICC). METHODS: This was a case control study of patients who underwent surgical resection either for ICC or for a metastatic liver tumor (the control group). We assessed their clinical characteristics, pathological findings, and the prevalence of known ICC risk factors. For patients without known risk factors, we compared other factors including the prevalence of NASH. RESULTS: In the patients without known risk factors, 15 of 34 patients in the ICC group and 13 of 69 patients in the control group were diagnosed with NASH. Univariate analysis showed significantly higher values in the ICC group for age (P = 0.0478), prevalence of obesity (P = 0.0365) and NASH (P = 0.0078), and serum levels of albumin (P = 0.0051), and gamma-glutamyl transpeptidase (γ-GTP) (P = 0.0006) compared with the control group. Multivariate analysis showed that age and serum levels of γ-GTP and NASH were independent risk factors for ICC. In patients with NASH, the proportion of patients with hepatic fibrosis was significantly higher in the ICC group than in the control group (P = 0.0014). CONCLUSION: NASH is a possible risk factor for ICC development. J. Surg. Oncol. 2016;113:779-783. © 2016 Wiley Periodicals, Inc.

Outcomes of laparoscopic hepatic resection versus percutaneous radiofrequency ablation for hepatocellular carcinoma located at the liver surface: A case-control study with propensity score matching.

AIM: Percutaneous radiofrequency ablation (P-RFA) therapy is a widely applied treatment for small hepatocellular carcinoma (HCC); however, local recurrence is a major issue of HCC located at the surface of the liver (surface HCC). The aim of this study was to compare the outcome of laparoscopic hepatic resection (LH) and P-RFA for surface HCC in case-control patient groups using the propensity score. METHODS: Between 2011 and 2013, 40 and 52 patients underwent LH and P-RFA for surface HCC (≤3 cm, 1-3 nodules). To correct the difference in clinicopathological factors between the two groups, propensity score matching was used at a 1:1 ratio, which resulted in a comparison of 27 patients/group. We compared outcomes between the two groups, with special reference to local recurrence. RESULTS: Clinicopathological variables were well balanced between the two groups. One patient in the LH group was converted to open surgery due to adhesion. The incidence of complications was 0% in the P-RFA group and 15% (four patients) in the LH group (P = 0.11); however, none of these four patients in the LH group sustained severe complications. The duration of hospitalization following treatment was longer in the LH group than in the P-RFA group (12.6 vs 7.6 days, P < 0.01). The incidence of local recurrence was lower in the LH group (0%) than in the P-RFA group (eight patients [30%], P = 0.004). CONCLUSION: LH is an effective treatment for surface HCC with regard to control of local recurrence.

Screening and surveillance for occupational cholangiocarcinoma in workers exposed to organic solvents.

PURPOSE: This study aimed to establish an efficient strategy for screening and surveillance for occupational cholangiocarcinoma. METHODS: We evaluated the consecutive changes in laboratory findings during regular health examinations and in abdominal ultrasonography findings before the diagnosis of occupational cholangiocarcinoma in nine patients. The results of laboratory tests and abdominal ultrasonography at the time of diagnosis were also examined. RESULTS: In all patients, the serum γ-glutamyl transpeptidase (γ-GTP) activity increased several years before the diagnosis of cholangiocarcinoma. The serum alanine aminotransferase (ALT) activity also increased several years before the diagnosis, following an increase in the serum aspartate aminotransferase (AST) activity in most patients. Abdominal ultrasonography before the diagnosis revealed regional dilatation of the bile ducts, which continued to enlarge. At the time of diagnosis, the γ-GTP, AST, and ALT activities were increased in nine, seven, and seven patients, respectively. The regional dilatation of bile ducts without tumor-induced stenosis, dilated bile ducts due to tumor-induced stenosis, space-occupying lesions, and/or lymph node swelling were observed. The serum concentrations of carbohydrate antigen 19-9 (CA 19-9) and/or carcinoembryonic antigen (CEA) were increased in all patients. CONCLUSIONS: Regular health examinations with a combination of ultrasonography and laboratory tests including the γ-GTP, AST, ALT, CA 19-9, and CEA levels are useful for screening and surveillance for occupational cholangiocarcinoma.

Outcomes of Pure Laparoscopic versus Open Hepatic Resection for Hepatocellular Carcinoma in Cirrhotic Patients: A Case-Control Study with Propensity Score Matching.

BACKGROUND/PURPOSE: Laparoscopic hepatic resection (LH) for hepatocellular carcinoma (HCC) has gradually gained ground as a safe and minimally invasive treatment, although LH for cirrhotic patients remains challenging. METHODS: Between January 2007 and August 2014, 28 and 57 patients with histologically proven cirrhosis (histological activity index, fibrosis score 4) underwent pure LH and open hepatic resection (OH; less than segmentectomy), respectively, for peripheral HCC ≤5 cm. To correct the difference in clinicopathological factors, including difficulty scores, between the two groups, propensity score matching was used at a 1:1 ratio, which resulted in a comparison of 20 patients per group. We compared the short- and long-term outcomes of LH and OH to investigate the efficacy of LH. RESULTS: Clinicopathological variables, including difficulty scores, were well balanced between the two groups. The incidence of complications and mean intraoperative blood loss were lower in the LH group than the OH group (0 vs. 45% and 180 vs. 440 ml, p = 0.001 and 0.04, respectively). The 3-year disease-free survival rate was 42% in the LH group and 30% in the OH group (p = 0.533), whereas the 5-year overall survival rates were 46 and 60%, respectively (p = 0.606). CONCLUSIONS: LH is a safe and effective treatment option for cirrhotic patients with HCC in terms of intraoperative blood loss and morbidity.

Management of hepatitis B virus infection during treatment for hepatitis B virus-related hepatocellular carcinoma.

Although liver resection is considered the most effective treatment for hepatocellular carcinoma (HCC), treatment outcomes are unsatisfactory because of the high rate of HCC recurrence. Since we reported hepatitis B e-antigen positivity and high serum hepatitis B virus (HBV) DNA concentrations are strong risk factors for HCC recurrence after curative resection of HBV-related HCC in the early 2000s, many investigators have demonstrated the effects of viral status on HCC recurrence and post-treatment outcomes. These findings suggest controlling viral status is important to prevent HCC recurrence and improve survival after curative treatment for HBV-related HCC. Antiviral therapy after curative treatment aims to improve prognosis by preventing HCC recurrence and maintaining liver function. Therapy with interferon and nucleos(t)ide analogs may be useful for preventing HCC recurrence and improving overall survival in patients who have undergone curative resection for HBV-related HCC. In addition, reactivation of viral replication can occur after liver resection for HBV-related HCC. Antiviral therapy can be recommended for patients to prevent HBV reactivation. Nevertheless, further studies are required to establish treatment guidelines for patients with HBV-related HCC.

Hepatic resection for hepatocellular carcinoma in super-elderly patients aged 80 years and older in the first decade of the 21st century.

PURPOSE: We evaluated the preoperative and postoperative characteristics and prognosis of super-elderly patients with hepatocellular carcinoma (HCC). METHODS: Four hundred and thirty-one patients who underwent hepatic resection for HCC were classified into three groups according to their age at the time of surgery: super-elderly (≥80 years; n = 20), elderly (70-80 years; n = 172) and younger (<70 years; n = 239). We compared the clinical characteristics, preoperative and postoperative factors and prognosis among the groups to evaluate whether liver resection is appropriate for super-elderly patients. RESULTS: The liver function was not significantly different among the groups. The proportion of patients with preoperative cardiovascular and respiratory disease and hypertension was higher in the super-elderly group compared to the other groups. The super-elderly group had shorter operations and reduced hemorrhage rates compared to the other groups. Postoperative cardiovascular complications and delirium were more frequently observed in the super-elderly group. The overall and tumor-free survival rates were not significantly different among the groups. Super-elderly patients had a lower rate of liver or HCC-related death and a higher rate of death due to other causes than the other groups. CONCLUSIONS: Super-elderly HCC patients who are appropriately evaluated and selected might have a favorable prognosis after undergoing hepatic resection.

Characteristics of printing company workers newly diagnosed with occupational cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma has been reported in workers exposed to chlorinated organic solvents and has consequently been classified as an occupational disease (occupational cholangiocarcinoma) by the Japanese Ministry of Health, Labour and Welfare. This study aimed to identify the characteristics of nine workers newly diagnosed with occupational cholangiocarcinoma. METHODS: This study was a retrospective study conducted in 13 hospitals and three universities. Clinicopathological findings of nine occupational cholangiocarcinoma patients from seven printing companies in Japan were investigated and compared with 17 cholangiocarcinoma patients clustered in a single printing company in Osaka. RESULTS: Patient age at diagnosis was 31-57 years. Patients were exposed to 1,2-dichloropropane and/or dichloromethane. Serum γ-glutamyl transpeptidase activity was elevated in all patients. Regional dilatation of the intrahepatic bile ducts without tumor-induced obstruction was observed in two patients. Four patients developed intrahepatic cholangiocarcinoma and five developed hilar cholangiocarcinoma. Biliary intraepithelial neoplasia and/or intraductal papillary neoplasm of the bile duct was observed in four patients with available operative or autopsy specimens. CONCLUSIONS: Most of these patients with occupational cholangiocarcinoma exhibited typical findings, including high serum γ-glutamyl transpeptidase activity, regional dilatation of the bile ducts, and precancerous lesions, similar to findings previously reported in 17 occupational cholangiocarcinoma patients in Osaka.

Changes in laboratory test results and diagnostic imaging presentation before the detection of occupational cholangiocarcinoma.

OBJECTIVES: A cholangiocarcinoma outbreak among workers of an offset color proof-printing department in a printing company was recently reported. It is important to understand the clinical course leading to occupational cholangiocarcinoma development for investigation of the carcinogenesis process and for surveillance and early detection. We evaluated the changes in laboratory test results and diagnostic imaging presentation before the detection of cholangiocarcinoma. METHODS: We investigated the changes in laboratory test results and diagnostic imaging presentation before the detection of cholangiocarcinoma in 2 patients because the data were available. Results The clinical courses observed in the 2 participating patients showed persistent elevation of serum γ-glutamyl transpeptidase levels with or without elevated serum levels of alanine aminotransferase and/or aspartate aminotransferase before cholangiocarcinoma detection. Dilatation of the bile ducts without tumor-induced stenosis was observed several years before cholangiocarcinoma detection and progressed gradually in both patients. The serum concentration of carbohydrate 19-9 also increased prior to cholangiocarcinoma detection in both patients. Eventually, observation of stenosis of the bile duct and a space-occupying lesion strongly suggested cholangiocarcinoma. Pathological examination of the resected specimens showed chronic bile duct injury and neoplastic lesions, such as "biliary intraepithelial neoplasia" and "intraductal papillary neoplasm of the bile duct" in various sites of the bile ducts, particularly in the dilated bile ducts. CONCLUSIONS: The changes in laboratory test results and diagnostic imaging might be related to the development of cholangiocarcinoma. It is important to monitor diagnostic imaging presentation and laboratory test results in workers with extended exposure to organic solvents.

Case series of 17 patients with cholangiocarcinoma among young adult workers of a printing company in Japan.

BACKGROUND: An outbreak of cholangiocarcinoma occurred among workers in the offset color proof-printing department at a printing company in Japan. The aim of this study was to clarify the characteristics of the patients with cholangiocarcinoma. METHODS: This was a retrospective study conducted in 13 Japanese hospitals between 1996 to 2013. The clinicopathological findings of cholangiocarcinoma developed in 17 of 111 former or current workers in the department were investigated. Most workers were relatively young. RESULTS: The cholangiocarcinoma was diagnosed at 25-45 years old. They were exposed to chemicals, including dichloromethane and 1,2-dichloropropane. The serum γ-glutamyl transpeptidase activity was elevated in all patients. Dilated intrahepatic bile ducts without tumor-induced obstruction were observed in five patients. The cholangiocarcinomas arose from the large bile ducts. The precancerous or early cancerous lesions, such as biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile ducts, as well as non-specific bile duct injuries, such as fibrosis, were observed in various sites of the bile ducts in all eight patients for whom operative specimens were available. CONCLUSIONS: The present results showed that cholangiocarcinomas occurred at a high incidence in relatively young workers of a printing company, who were exposed to chemicals including chlorinated organic solvents.

[Successful treatment of a patient using mFOLFOX6 after laparoscopic surgery for rectal cancer with peritoneal dissemination].

A 58-year-old man underwent laparoscopic surgery for rectal cancer(rectal sigmoid)complicated by intestinal obstruction. He had no liver metastasis. Although many nodules suspected to have arisen from peritoneal dissemination were observed in the pelvic cavity, we performed anterior resection assuming that the primary lesion was resectable. The surgical findings were sSE, sN2, sP3, sStage IV, and histopathological findings were signet-ring cell carcinoma, pSE, pN2, pP+, pStage IV. After 8 courses of adjuvant chemotherapy with modified 5-fluorouracil/Leucovorin/oxaliplatin(mFOLFOX6), carcinoembryonic antigen( CEA)decreased to a normal level, and positron emission tomography-computed tomography(PET-CT)showed no abnormal accumulation that suggested metastasis. To evaluate the effectiveness of this procedure, laparoscopic peritoneal biopsy was performed 5 months after surgery, revealing histopathological disappearance of the peritoneal dissemination lesion. The patient has been followed up and has been receiving S-1 for 1 year after the first surgery. No evidence of recurrence has been observed.

Effect of interferon therapy on first and second recurrence after resection of hepatitis C virus-related hepatocellular carcinoma.

AIM: Several investigators have shown that interferon (IFN) therapy can suppress the recurrence of hepatocellular carcinoma (HCC) after curative treatment. We investigated the effect of IFN therapy on the first and second HCC recurrence following hepatic resection of hepatitis C virus (HCV)-related HCC. METHODS: Subjects included 166 patients who had undergone curative resection for a single HCV-related HCC. We analyzed the outcome after initial hepatic resection and risk factors of a second HCC recurrence following treatment for the first HCC recurrence. RESULTS: Using multivariate analysis, a non-sustained virological response (non-SVR) was significantly associated with a high incidence of first HCC recurrence. The rate of second HCC recurrence tended to be higher in the non-SVR group than in the SVR group. In the patients with recurrence of multiple tumors or who received non-curative treatment for recurrent HCC, the second HCC recurrence rates were significantly higher. Multivariate analysis demonstrated that non-curative treatment for first HCC recurrence was an independent risk factor for a second HCC recurrence. Among the patients who received curative treatment for their first HCC recurrence, the rates of second recurrence were significantly higher in the non-SVR group than in the SVR group. Multivariate analysis also revealed that SVR was independently associated with prevention of a second HCC recurrence. CONCLUSIONS: These results suggest that on first HCC recurrence, a curative treatment should be considered in order to prevent a second recurrence if possible. In addition, IFN therapy contributes to improved prognosis after curative treatment, even in patients with recurrent HCC.

One-stage laparoscopic-assisted resection of gastrojejunocolic fistula after gastrojejunostomy for duodenal ulcer: a case report.

INTRODUCTION: Gastrojejunocolic fistula is a rare condition after gastrojejunostomy. It was thought to be a late complication related to stomal ulcers as a result of inadequate gastrectomy or incomplete vagotomy. We report a case of gastrojejunocolic fistula after gastrojejunostomy for peptic ulcer treated with one-stage laparoscopic resection. CASE PRESENTATION: A 41-year-old Japanese man complained of diarrhea for 10 months, as well as severe weight loss and weakness. After admission, we immediately started intravenous hyperalimentation. On performing colonoscopy and barium swallow, gastrojejunocolic fistula was observed close to the gastrojejunostomy site leading to the transverse colon. After our patient's nutritional status had improved, one-stage surgical intervention was performed laparoscopically. After the operation, our patient recovered uneventfully and his body weight increased by 5 kg within three months. CONCLUSIONS: Modern management of gastrojejunocolic fistula is a one-stage resection because of the possibility of early recovery from malnutrition using parenteral nutritional methods. Today, laparoscopic one-stage en bloc resection may be feasible for patients with gastrojejunocolic fistula due to the development of laparoscopic instruments and procedures. We describe the first case of gastrojejunocolic fistula treated laparoscopically by one-stage resection and review the literature.

A novel liver retraction technique for lateral lobe of the liver during laparoscopic surgery using silicone disk.

For safe and effective laparoscopic surgery it is important to maintain a favorable view of the operative field. However, the use of a conventional liver retractor needs an additional wound and carries a risk for liver injury during surgery. We developed a novel retraction technique for the lateral lobe of the liver using a silicone disk (Hakko Co. Ltd.) during laparoscopic surgery. We used a silicone disk that consists of a silicone rubber membrane inside a flexible ring and four monofilament threads. The disk can be inserted into the abdomen under the pneumoperitoneum through a 12-mm port and is located at the dorsal side of the lateral lobe of the liver. The threads are withdrawn through the abdominal wall, two threads close to the infraxiphoid space and the other two threads bilaterally below the costal arch. Thus, the lateral lobe of the liver is safely raised to the ventral side and covered with a silicone membrane. We introduced this technique for various laparoscopic operations, such as gastrectomy, gastroplasty, and fundoplication. There were no complications related to the procedure. This retraction technique is easy, results in less liver damage, and provides an excellent operative view around the esophageal hiatus. The silicone membrane covering the lateral lobe reduces the risk of liver injury during surgery using laparoscopic forceps to a low level.

[A case of advanced gastric cancer responding to neoadjuvant chemotherapy with S-1 and CDDP combination].

The patient is a 75-year-old woman who received 2 courses of neoadjuvant chemotherapy (NAC) with S-1/CDDP for advanced gastric cancer and para-aortic lymph node metastasis. After completion of the second course, both the primary tumor and lymph node metastases practically disappeared. Later, total gastrectomy was performed. Histopathological examination revealed cancer cells remaining in just one part of subserosa (ss), and no lymph node metastases were detected. The postoperative course was favorable, and the patient is currently attending the outpatient clinic.