Useful of proximal gastrectomy with double-tract reconstruction in preventing glucose spikes.

BACKGROUND: Volatile glucose levels after gastrectomy induce dumping syndrome, which adversely affects patient quality of life. This study aimed to evaluate the glycemic variability of proximal gastrectomy with double-tract reconstruction (PGDTR) as a function-preserving procedure. METHODS: This study used a continuous glucose monitoring (CGM) system to record glycemic profiles of patients who underwent PGDTR or total gastrectomy (TG) and compared them. Moreover, this study evaluated postgastrectomy syndrome, including dumping symptoms, between the PGDTR and TG groups using the 37-item Postgastrectomy Syndrome Assessment Scale (PGSAS-37) questionnaire. RESULTS: Of note, 44 patients underwent PGDTR, and 42 patients underwent TG, which included more advanced cases. CGM results showed that the SD, relative SD, and maximum drop in glucose level between 30 min and 2 h after a meal were smaller in the PGDTR group than in the TG group (14.81 vs 22.40 mg/dL [P < .001], 0.14 vs 0.20 mg/dL [P < .001], and 42.06 vs 117.67 mg/dL [P < .001], respectively). For nocturnal glucose levels, SD and percentage time below the range were smaller in the PGDTR group than in the TG group (11.76 vs 15.16 mg/dL [P = .005] and 11.25% vs 35.27% [P < .001]). The PGDTR group generally performed better than the TG group on all the PGSAS-37 questionnaire items. Patients in the PGDTR group without food inflow into the remnant stomach showed similar CGM results as those in the TG group but with stronger dumping symptoms. CONCLUSION: Food inflow into the remnant stomach is essential for PGDTR to be a function-preserving procedure as it leads to the control of dumping symptoms and lower glucose level spikes.

Feasibility of Robot-Assisted Cytoreductive Surgery With Upper-Abdominal Peritonectomy for Pseudomyxoma Peritonei With Low Peritoneal Carcinomatosis Index: A Pilot Study.

INTRODUCTION: Our study's objective was to provide the method for, and preliminary findings from, robot-assisted cytoreductive surgery (r-CRS) combined with upper-abdominal peritonectomy in pseudomyxoma peritonei (PMP) with limited peritoneal surface malignancy (PSM). MATERIALS AND METHODS: We conducted a retrospective pilot study on consecutive patients with PSM secondary to pseudomyxoma peritonei with a peritoneal cancer index (PCI) of under 10 who were indicated for r-CRS combined with upper-abdominal peritectomy. Perioperative and 30-day major morbidity and mortality characteristics were analyzed and compared with cases in which laparoscopic CRS (l-CRS) was performed under the same conditions. RESULTS: Six patients underwent r-CRS combined with an upper-abdominal partial peritonectomy. Their mean PCI was 4.83. Complete cytoreduction was achieved in all patients. The mean duration of the operation was 156.8 minutes. There was no major complication and no mortality. The mean length of hospital stay after surgery was 6.33 days. r-CRS resulted in less blood loss, a lower C-reactive protein level, and a shorter length of hospital stay that were significantly different compared with those of l-CRS. CONCLUSIONS: This is the initial technical report of a robotic approach for CRS combined with upper-abdominal peritonectomy. r-CRS with a combined upper-abdominal peritonectomy was shown to be safe and feasible for PMP with limited PSM.

Postoperative Early Body Weight Loss Is a Risk Factor for Recurrence in Patients with pStage III Gastric Cancer.

INTRODUCTION: The goal of this study was to determine whether postoperative early body weight loss (EWL) after radical gastrectomy is a risk factor for recurrence in patients with pathological stage III (pStage III) gastric cancer who received postoperative adjuvant chemotherapy, which included tegafur/gimeracil/oteracil (S-1). METHODS: Patients who underwent gastrectomy for gastric cancer were identified from a prospectively managed gastric cancer database. We analyzed 58 consecutive patients who underwent radical gastrectomy with D2 lymph node dissection for confirmed pStage III gastric cancer treated postoperatively with adjuvant chemotherapy including S-1 between 2010 and 2019. Clinical and pathologic characteristics, baseline body mass index (BMI), and postoperative weights were extracted. Weight changes were evaluated from the preoperative period to the start of adjuvant chemotherapy. EWL was defined as % BMI change = (preoperative BMI - postoperative BMI at the start of adjuvant chemotherapy) × 100/preoperative BMI. RESULTS: Of the 58 consecutive patients who underwent radical resection for gastric cancer, 72.4% were male, with a mean age of 65.5 years, and a mean preoperative BMI of 21.2 (range: 15.4-29.1) kg/m2. The degree of EWL was found to be closely correlated to compliance with adjuvant chemotherapy. Multivariate analysis by Cox proportional hazard analysis revealed that EWL was an independent factor for relapse-free survival (RFS), and patients with an EWL of 15.9% or more severe had poorer RFS. CONCLUSION: EWL above a certain rate at the start of adjuvant chemotherapy was a predictor of poor compliance with adjuvant chemotherapy and a high risk of disease recurrence in patients with pStage III gastric cancer.

Indocyanine Green Tracer-Guided Radical Robotic Distal Gastrectomy Using the Firefly™ System Improves the Quality of Lymph Node Dissection in Patients with Gastric Cancer.

BACKGROUND: This study investigated indocyanine green (ICG) as an intraoperative tool for improving lymph node dissection quality in radical robotic distal gastrectomy (RDG) for gastric cancer by comparing the rate of lymph node (LN) noncompliance with or without use of the Firefly™ system. METHODS: Patients with potentially resectable gastric cancer including cT1-T4a, N0/ + , M0 were registered in a prospective nonrandomized cohort study at our institution between March 2019 and December 2022. Patients were assigned to the da Vinci surgical system with Firefly system (F group) or that without Firefly system (non-F group). F group patients received endoscopic peritumoral injection of ICG to the submucosa one day before surgery. Rate of LN noncompliance, number of harvested LNs, and short-term outcomes were compared. RESULTS: Of the 94 patients in this study, 55 underwent Firefly system-guided RDG and 39 underwent conventional RDG. The mean [SD] total number of harvested lymph nodes in F group, 31.2 [10.2], was significantly higher than that harvested in non-F group (25.6 [12.6]; p = 0.026). The LN noncompliance rate in F group was lower than that in non-F group (32.7% vs. 61.5%, p = 0.006). The mean number of LNs harvested in F group was significantly higher than that harvested in non-F group (31.2 [10.2] vs. 25.7 [12.6], p = 0.02). Significant differences were found between the F vs. non-F groups in blood loss and postoperative hospital stay (83.9 [75.1] vs. 301.9 [766.7] mL; p = 0.003 and 13.4 vs. 17.4 days, p = 0.049). CONCLUSION: The Firefly system-assisted ICG tracer improved LN dissection quality without compromising safety.

Hybrid esophagogastric tube anastomosis after minimally invasive McKeown esophagectomy to prevent stenosis in patients with esophageal cancer.

PURPOSE: The use of a small circular stapler has been reported to increase the incidence of benign anastomotic stenosis in reconstruction. In circular stapling anastomosis after esophagectomy, the anastomotic lumen is dependent on the size of the esophagus and the replacement organ. We developed a new and foolproof method to prevent stenosis in esophagogastric tube anastomosis for patients with esophageal cancer that is not dependent on operator skill. METHODS: Seven patients with esophageal squamous cell carcinoma underwent minimally invasive McKeown esophagectomy in our hospital. Esophagogastric tube anastomosis was tried for all patients using the novel "hybrid esophagogastric tube anastomosis" technique. A 21-mm circular stapler was applied to perform an end-to-side anastomosis between the cervical esophagus and the posterior wall of the gastric tube. Then, a 30-mm linear stapler was positioned in the esophagogastric anastomosis formed by the 21-mm circular stapler with the anvil fork inserted into the esophagus and the cartridge fork inserted into the gastric tube. A supplementary side-to-side anastomosis of appropriately 15 mm was created. Afterward, the entry hole was closed with a linear stapler. RESULTS: The hybrid esophagogastric tube anastomosis was successful in all seven patients receiving it between June 2020 and March 2022. No postoperative complications related to this anastomosis were observed in any of the patients. Five patients underwent follow-up gastrointestinal endoscopy at 6 months after esophagectomy. No patient had an anastomotic stenosis. CONCLUSIONS: Hybrid esophagogastric tube anastomosis can be performed easily and safely and can reduce the complications associated with anastomosis.

Development of an artificial portal vein using bioabsorbable polymers.

PURPOSE: During surgical resection of malignant tumors in the hepatobiliary pancreatic region, portal vein resection and reconstruction may be needed. However, there is no alternative to the portal vein. We therefore developed an artificial portal vein that could be used in the abdominal cavity. METHODS: In the experiments, hybrid pigs (n = 8) were included. An artificial portal vein was created using a bioabsorbable polymer sheet (BAPS). Subsequently, the portal vein's anterior wall was excised into an elliptical shape. A BAPS in the form of a patch was implanted at the same site. At 2 weeks (n = 3) and 3 months (n = 5) after the implantation, the BAPS implantation site was resected and evaluated macroscopically and histopathologically. RESULTS: Immediately after the implantation, blood leakage was not detected. Two weeks after implantation, the BAPS remained, and endothelial cells were observed. Thrombus formation was not observed. Three months after implantation, the BAPS had been completely absorbed and was indistinguishable from the surrounding portal vein. Stenosis and aneurysms were not observed. CONCLUSIONS: BAPS can replace a defective portal vein from the early stage of implantation to BAPS absorption. These results suggest that it can be an alternative material to the portal vein in surgical reconstruction.

[A Case of Long-Term Survival Achieved by Multimodal Treatments for Postoperative Lung Metastasis and Mediastinal Lymph Node Metastasis after Surgery for Ascending Colon Cancer].

A 52-year-old male patient with Stage Ⅲc ascending colon cancer underwent laparoscopic right hemicolectomy with D3 lymph node dissection. Adjuvant chemotherapy was administered for 6 months, and no recurrence was observed during the follow-up period. Left lung metastasis was detected and surgically removed 7 years after the initial surgery. He underwent open partial small bowel resection with lymph node dissection when mesenteric lymph node metastasis was identified 2 years later. Although chemotherapy was conducted on the identification of mediastinal lymph node metastasis 2 years later, the mediastinal lymph nodes increased. Although attempted, lymph node dissection was impossible because of the strong adhesion to the trachea. Subsequently, chemotherapy and radiation therapy were administered. However, an infiltration of the mediastinal lymph nodes into the trachea was observed. The patient underwent bronchoscopic laser tumor ablation. The patient died 4 months after the resumption of chemotherapy(18 years after the initial surgery). Mediastinal lymph node recurrence after curative resection for colon cancer is a rare clinical condition. Nevertheless, long-term survival could be achieved by multimodal treatments in such patients.

[A Case of pagetoid Carcinoma of the Breast with Pathological Complete Response by Neoadjuvant Chemotherapy].

We herein report a 63-year-old woman who presented with about 20 mm-sized mass in the right breast and the right nipple with erosion. Preoperative examinations revealed a diagnosis of HER2-type pagetoid carcinoma with axillary lymph node metastasis. After neoadjuvant chemotherapy(pertuzumab, trastuzumab, and docetaxel, followed by adriamycin and cyclophosphamide), a pathological complete response was achieved. The patient was treated with anti-HER2 therapy without recurrence.

[A Case of Robotic Abdominoperineal Resection for Rectal Cancer with Leriche Syndrome].

We report a case of robotic abdominoperineal resection for rectal cancer with Leriche syndrome. Case: A 75-year-old male. Colonoscopy, which was performed due to persistent diarrhea, revealed type 2 lower rectal circumferential tumor. Pathological examination revealed adenocarcinoma. Computed tomography revealed no distant metastasis, and incidentally complete occlusion from the abdominal aorta to both common iliac arteries. He was diagnosed to rectal cancer(RbRaP, cT3N0M0, cStage Ⅱa)with Leriche syndrome. Therefore, robotic abdominoperineal resection(D3 dissection)was performed. There was no complication, and he was discharged 15 days after surgery. Postoperative pathological examination revealed pT3N1asM0, pStage Ⅲb.

[A Case of Perforated Rectal Cancer with Laparoscopic Low Anterior Resection].

We report a case of perforated rectal cancer with laparoscopic low anterior resection. Case: A 60-year-old man was transported to the hospital with a chief complaint of sudden lower abdominal pain. Computed tomography revealed wall thickening of the upper rectum and free air localized around the rectum and fecal mass in the mesorectum. He was diagnosed with perforated rectal cancer. Because of the early onset, young age, and ascites confined to the pelvic floor, we decided to perform laparoscopic low anterior resection(D3 dissection). Intraabdominal observation revealed tumor in the upper rectum with a large rectal perforation 3 cm proximal to the tumor. By using gauze and suction, we were able to complete the surgery with ingenuity laparoscopically. The postoperative course was good, and he was discharged 9 days after surgery. Postoperative pathological examination revealed pT4apN0sM0, pStage Ⅱb. Adjuvant chemotherapy of 8 courses of capecitabine was performed. There has been no recurrence 3 years after surgery.

Ruptured ileocolic artery pseudoaneurysm after laparoscopic appendectomy for acute appendicitis.

BACKGROUND: A pseudoaneurysm of the splanchnic vessels is considered to be rare, and in particular, very few cases of pseudoaneurysm in the ileocolic artery are reported. Here, we report a case of rupture of a pseudoaneurysm of the appendicular branch of the ileocolic artery after laparoscopic appendectomy. CASE PRESENTATION: A 52-year-old man was diagnosed as having phlegmonous appendicitis, and an emergency laparoscopic appendectomy was performed. Bleeding from the inter-appendicular ligament during detachment of adhesions was stopped by white coagulation and Z-suture, and the inter-appendicular ligament was treated. The postoperative course was uneventful, and there were no adverse events or findings suggestive of abscess formation. On postoperative day 30, he presented with a ruptured pseudoaneurysm of the appendicular branch of the ileocolic artery. A definitive diagnosis was made by computed tomography, and emergency interventional radiology was performed with hemostasis achieved by coiling. The patient's postprocedure course was favorable, and he was discharged with no adverse events, such as intestinal ischemia. CONCLUSIONS: We experienced a case of delayed pseudoaneurysm rupture after laparoscopic appendectomy. Care must be taken when handling the appendicular artery during the procedure, and the potential for pseudoaneurysm formation should be considered at postoperative follow-up.

Validity and safety of laparoscopic gastrectomy with D1+ lymphadenectomy for very elderly advanced gastric cancer patients; retrospective cohort study.

BACKGROUND: It remains unclear whether laparoscopic gastrectomy with optimal lymphadenectomy is appropriate for very elderly patients with advanced gastric cancer. This study aimed to assess the validity of laparoscopic gastrectomy with D1+ lymphadenectomy performed for advanced gastric cancer in patients aged 80 years or more. METHODS: Included in this retrospective study were 122 patients who underwent curative laparoscopic gastrectomy for advanced gastric cancer between 2013 and 2018. All patients over 80 years old underwent laparoscopic gastrectomy with D1+ lymphadenectomy. We divided patients by age between those who were very elderly (age ≥ 80 years; very elderly group [n = 57]) and those who were non-very elderly (age < 80 years; control group [n = 65]), and we compared patient and clinicopathological characteristics, intraoperative outcomes, and short- and long-term outcomes between the two groups. We also performed multivariate analyses to identify predictors of postoperative prognosis. RESULTS: Eastern Cooperative Oncology Group Performance Status of grade 2 or higher and mean Charlson comorbidity index score and body mass index were significantly different between the very elderly group and the control group. Adjuvant chemotherapy was used in relatively few very elderly group patients. Operation time, blood loss volume, and postoperative morbidity and mortality did not differ between the two groups. The overall survival and disease-specific survival rate of very elderly group patients with the Charlson comorbidity index score of <3 was not significantly different from that of the control group patients. CONCLUSION: The treatment of advanced gastric cancer by laparoscopic gastrectomy with D1+ lymphadenectomy to be both safe and effective in the very elderly group patients with the Charlson comorbidity index score of <3.

Evaluating the burden of the COVID-19 pandemic on patients with colorectal cancer.

After the emergence of the coronavirus disease 2019 (COVID-19) pandemic, individuals needing medical help preferred to not go to the hospital to avoid the risk of severe acute respiratory syndrome coronavirus 2 infection. The present study investigated the influence of the COVID-19 pandemic on patients with colorectal cancer. Patients with colorectal cancer treated between January and December 2019 were classified as the pre-pandemic group (pre-group) and those treated between April 2020 and March 2021 as the post-pandemic group (pandemic group). The clinicopathologic features of patients who underwent surgery for colorectal cancer in the two groups were retrospectively compared. A total of 161 patients were enrolled: 79 In the pre-group and 82 in the pandemic group. Although no significant differences were observed in tumor location and surgical procedure between the two groups, circumferential lesions (P<0.001), colorectal stenting (P=0.016) and Stage IV classification (P=0.019) had a higher frequency in the pandemic group compared with the pre-group; additionally, surgical curability was significantly lower (P=0.036) in the pandemic group. The spread of COVID-19 has increased the incidence of patients with advanced colorectal cancer. To reduce this incidence, healthcare professionals should inform the general public not only about the risk of COVID-19, but also about the increased incidence of advanced colorectal cancer after the pandemic.

Double tract-like gastric tube reconstruction decreases the incidences of delayed gastric emptying and bile reflux after esophagectomy: results of a pilot study of an experimental technique.

PURPOSE: Esophagectomy with gastric tube reconstruction is often complicated postoperatively by duodenogastric reflux and/or delayed gastric emptying and the accompanying symptoms, leading to patients being dissatisfied with their quality of life (QOL). Medical interventions to relieve patients of their symptoms are rarely effective. We began, in 2018, performing double tract-like gastric tube reconstruction, and, in a pilot study, we compared postoperative QOL between patients in whom this experimental reconstruction was performed and those in whom conventional reconstruction was performed. METHODS: Included in the study were 33 patients who underwent thoracoscopic McKeown esophagectomy with two- or three-field lymph node dissection for thoracic esophageal cancer between April 2015 and March 2020. A gastric tube about 4 cm in width was created in all patients, and in 14 of the patients (DT group), a double tract was appended by anastomosing the elevated jejunum to the anterior wall of the gastric tube, QOL was assessed 10-14 months later by means of the DAUGS-32 questionnaire, and bile reflux and the presence or absence of food residue were assessed by upper gastrointestinal endoscopy. RESULTS: DAUGS-32 food passage dysfunction, nausea and vomiting, and reflux symptoms scores were significantly lower in the DT group than in the conventional reconstruction group. There was no significant between-group difference in the incidence of postoperative complications. No food residue was seen in DT patients' gastric tube, and no reflux esophagitis was observed. CONCLUSION: Double tract-like gastric tube reconstruction shows promise as an effective means of improving patients' post-esophagectomy QOL.

[A Case in Which a Laparotomy Transition, in a Patient with Sigmoid Colon Cancer, Prevented Peritoneal Metastasis from Being Missed].

We report a case of laparoscopic sigmoidectomy for sigmoid colon cancer where a laparotomy transition prevented peritoneal metastasis from being missed. Case: A 64-year-old woman was diagnosed with sigmoid colon cancer. Computed tomography revealed a large bowel obstruction and a 12 mm wide basal bulge in the gallbladder. A laparoscopic sigmoidectomy( D3 dissection)was first performed, and intra-abdominal observation revealed no disseminated nodules. A laparoscopic cholecystectomy was performed continuously but, due to strong adhesions, a laparotomy was administered. Three disseminated nodules were observed in the omentum during the laparotomy and a postoperative pathological examination revealed pT4aN1b(2/23)M1c1(P2), pStage Ⅳc. Adjuvant chemotherapy of 8 courses of CAPOX was performed and there has been no recurrence 20 months after surgery.

[A Case of Locally Advanced Rectal Cancer Treated Successfully with TNT].

Local control is important in the treatment of locally advanced rectal cancer(LARC). In Western countries, the standard therapy for LARC is preoperative chemoradiotherapy(CRT)followed by total mesorectal excision. Recently, addition of intensive chemotherapy to CRT known as total neoadjuvant therapy(TNT)is increasing. We herein report a 69-year-old woman who developed LARC(cT3N3M0, cStage Ⅲc). She was diagnosed as clinical complete response after TNT, and she chose"watch and wait". She did not have a recurrence for 16 months.

[A Case of Rectal Cancer with Bladder Invasion Performed with Robot-Assisted Low Anterior Resection after TNT].

A 73-year-old woman was admitted with a chief complaint of weight loss. Colonoscopy revealed rectal cancer. After the placement of a colonic stent, the patient was referred to our department. Computed tomography, magnetic resonance imaging, and cystoscopy indicated extensive invasion of the bladder. Since total pelvic exenteration was necessary at the first diagnosis, total neoadjuvant therapy(TNT)was conducted. The diagnosis after TNT was ycT4bycN0ycM0. Low anterior resection with partial resection of the bladder and a diverting ileostomy were performed. The patient was discharged on the 16th day post-surgery with a good postoperative course. The pathological examination revealed a complete response, ypT0ypN0.

Alimentary tract obstruction attributed to use of barbed suture for double tract reconstruction after robot-assisted proximal gastrectomy: a case report.

BACKGROUND: Anastomotic stenosis following esophagojejunostomy reconstruction by the overlap method with absorbable barbed sutures occurs only rarely in patients who have undergone laparoscopic surgery. We report anastomotic stenosis by the overlap method that we attributed to the lack of tactile sensation during robot-assisted surgery. CASE PRESENTATION: An 83-year-old man underwent robot-assisted laparoscopic proximal gastrectomy and lymph node dissection at our hospital for treatment of gastric cancer. Double tract reconstruction followed with side-to-side esophagojejunostomy (overlap method) performed with an endoscopic linear stapler. On completion of the anastomosis, the enterotomy was closed under robotic assistance with absorbable barbed suture. Once solid foods were introduced, the patient had difficulty swallowing and felt as though his digestive tract was stopped up. When upper gastrointestinal endoscopy was performed, we found the anastomotic lumen to be coated with food residue. After rinsing off the residue with water, we could see barbed suture protruding into the anastomotic lumen that had become entangled upon itself, which explained how the food residue had accumulated. We cut the entangled suture under endoscopic visualization using a loop cutter. CONCLUSION: This case highlights a stricture caused by insufficiently tensioning barbed suture, which subsequently protruded into the anastomotic lumen and became entangled upon itself. We believe this occurrence was associated with the lack of tactile sensation in robot-assisted surgery.

Intraoperative neuromonitoring during prone thoracoscopic esophagectomy for esophageal cancer reduces the incidence of recurrent laryngeal nerve palsy: a single-center study.

The incidence of recurrent laryngeal nerve palsy (RLNP) following minimally invasive esophagectomy has yet to be satisfactorily reduced. Use of intraoperative neuromonitoring (IONM), specifically of the RLN, during thyroidectomy has been reported to reduce the incidence of RLN injury. We now apply IONM during curative prone thoracoscopic esophagectomy, and we conducted a retrospective study to evaluate the feasibility and efficacy of intermittent monitoring of the RLN during the surgery. The study involved 32 consecutive patients who underwent esophagectomy with radical lymph node dissection for esophageal cancer. The patients were of two groups: an IONM group (n = 17) and a non-IONM group (n = 15). We chiefly strip around the esophagus preserving the membranous structure, which contains the tracheoesophageal artery, lymph nodes, and RLN. In the IONM group patients, we stimulated the RLN and measured the electromyography (EMG) amplitude after dissection, at the dissection starting point and dissection end point on both sides. For the purpose of the study, we compared outcomes between the two groups of patients. IONM was carried out successfully in all 17 patients in the IONM group. The incidence of RLNP was significantly reduced in this group. We found that both RLNs can be identified by mean of IONM easily, immediately, and safely and that the EMG amplitude attenuation rate is particularly useful for predicting RLNP.

[A Case of Advanced Rectal Cancer with Left Hydronephrosis Treated with Left Ureter-Sparing Laparoscopic High Anterior Resection after Chemotherapy].

A 47-year-old woman with a complaint of weight loss for the past 5 months was referred to our hospital. Colonoscopy revealed advanced rectal cancer 20 cm from the anal verge. The patient had left hydronephrosis caused by ureteral invasion. Firstly, we performed transverse colostomy and left nephrostomy. After 8 courses of capecitabine, oxaliplatin plus bevacizumab( CAPOX plus Bmab)therapy, colonoscopy and computed tomography revealed shrinkage of both the primary and metastatic lesions. Laparoscopic high anterior resection was performed, and the left ureter was successfully preserved. The patient received chemotherapy after surgery. Neither local recurrence nor enlargement of metastases has been observed 8 months after surgery.