High abundance of Lachnospiraceae in the human gut microbiome is related to high immunoscores in advanced colorectal cancer.

INTRODUCTION: The tumor microenvironment (TME) in colorectal cancer (CRC) includes the gut microbiome, immune cells, angiogenic factors, and fibroblasts and plays a major role in cancer progression. The Immunoscore (IS) is based on tumor infiltration by immune cells that are known prognostic biomarkers for CRC. However, the interrelation between the IS, microbiome, and other TME factors in human CRC remains unclear. PATIENTS AND METHODS: A cohort of 94 patients with CRC was examined at the Shiga University of Medical Science Hospital in Japan. The expression levels of CD3, CD8, CD31, and alpha-smooth muscle actin (α-SMA) in the primary tumor were evaluated by immunohistochemistry. The IS was calculated based on the results of the CD3 and CD8 staining assays. Microbiomes in patients with CRC were examined by amplicon sequencing. RESULTS: The expression levels of α-SMA and tumor-infiltrating lymphocytes in patients with CRC were negatively correlated (P = 0.006). A high IS was associated with high abundance of Lachnospiraceae in the microbiomes of patients with CRC. CONCLUSION: Lymphocyte infiltration into the primary tumor was marked by reduced density of cancer-associated fibroblasts and enrichment of the Lachnospiraceae family in the gut microbiome, which may influence CRC progression.

Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty.

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

The Comparison of Fecal Microbiota in Left-Side and Right-Side Human Colorectal Cancer.

INTRODUCTION: Microbiomes play a vital role in the development and progression of cancer. The clinical status, including prognosis, genetic mutations, and sensitivity to chemotherapy, differs depending on the location of colorectal cancer (CRC); however, the association between gut microbiota and the location of CRC is not entirely understood. This study was conducted to evaluate the differences in the gut microbiota in patients with CRC according to the location of the tumor. METHODS: Fifty-six patients who underwent surgery for CRC between August 2018 and November 2019 were included in the study. Three patients who had received neoadjuvant therapy or antibiotic treatment within 1 month before surgery were excluded. The metagenomes of microbiota in preoperative feces were assessed using the V3-V4 region of 16s rRNA amplicon sequences. RESULTS: The beta diversity of the Bray-Curtis distance was significantly higher in left-sided than in right-sided CRC. Fusobacterium predominated in left-sided CRC according to the linear discriminant analysis effect size method. Blautia, Eryspelotrichales, Holdemanella, Faecalibacterium, Subdoligranulum, and Dorea constituted the dominant intestinal flora in right-sided CRC. Pathway analysis revealed that L-lysine fermentation and cob(II)yrinate a,c-diamide biosynthesis I were predominant in left-sided CRC. DISCUSSION: This study demonstrated that fecal microbiota in left-sided CRC constitutionally and functionally differ from those in right-side CRC. These results will help to elucidate the biological differences according to tumor location and develop treatments for human CRC.

Cancer-derived Exosomes Activate Immune Surveillance and Suppress Peritoneal Metastasis of Murine Colonic Cancer.

BACKGROUND: Colonic cancer is associated with a low incidence of peritoneal metastasis compared with gastric cancer; however, the reason for this remains unclear. In this study, a model of peritoneal dissemination using the CT26 murine colon cancer cell line was used to analyze the physiological roles of cancer-derived exosomes. MATERIALS AND METHODS: Exosomes were collected from the supernatant of CT26 cell culture by ultracentrifugation. The number of peritoneal disseminations in two mouse models of colonic cancer pre-administered exosomes or phosphate-buffered saline were compared. RESULTS: Cancer-derived exosomes suppressed peritoneal dissemination compared to phosphate-buffered saline. After administration of exosomes, the number of intraperitoneal macrophages and the expression of inducible nitric oxide synthase increased. Furthermore, cancer-derived exosomes increased activated natural killer cells and interferon-γ expression. CONCLUSION: Tumor-derived exosomes from colonic cancer may suppress peritoneal metastasis via an immunological mechanism.

Superior perianastomotic fluid collection in the early postoperative period affects pseudoaneurysm occurrence after pancreaticoduodenectomy.

PURPOSE: Pseudoaneurysm (PA) after pancreaticoduodenectomy (PD) is a harmful complication due to postoperative pancreatic fistula. However, the preventive method for PA is unclear. This study aimed to assess the risk factors for PA after PD and to evaluate the clinical features of patients with PA. METHODS: Medical records of 54 patients who underwent PD and developed clinically relevant postoperative pancreatic fistula (POPF) were retrospectively reviewed. We evaluated postoperative computed tomography (CT) findings, including the perianastomotic fluid collection (PFC) location on postoperative day 4. Perioperative findings and postoperative CT findings were compared between patients with and without PA after PD. RESULTS: The PA group included nine patients (17%). The median postoperative day of diagnosis of PA was 17 (range, 7-33). The PA locations were the gastroduodenal artery stump (n = 3), dorsal pancreatic artery (DPA) stump from the common hepatic artery (n = 4), DPA stump from the replaced right hepatic artery (n = 1), and inferior pancreaticoduodenal artery stump (n = 1). The prevalence of falciform ligament wrap to the hepatic artery was lower (33% vs. 78%, p = 0.014) and superior PFC prevalence was higher (100% vs. 58%, p = 0.019) in the PA group than in the non-PA group. Superior PFC reached the dorsal part of the caudate lobe of the liver in all patients with PA. Furthermore, all PAs occurred at the arteries that could not be wrapped by the falciform ligament. CONCLUSION: Prevention of superior PFC and falciform ligament wrapping may reduce PA occurrence after PD with clinically relevant POPF.

Estimated functional remnant pancreatic volume predicts nonalcoholic fatty liver disease after pancreaticoduodenectomy: use of computed tomography attenuation value of the pancreas.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a late complication of pancreaticoduodenectomy (PD). However, this complication is difficult to predict preoperatively. This study aimed to assess the association between NAFLD and preoperative computed tomography (CT) findings. METHODS: Medical records of 112 patients who had undergone PD and had CT scans preoperatively and 6 months postoperatively were retrospectively reviewed. We evaluated several CT findings, including the CT attenuation value of the remnant pancreas, remnant pancreatic volume (RPV), and the estimated functional remnant pancreatic volume (eFRPV) on preoperative CT. The variables, including the CT findings and histopathological findings, were compared between the patients with and without NAFLD after PD. RESULTS: The NAFLD group included 21 patients (18.8%). The CT attenuation value of the remnant pancreas was correlated with the pancreatic acinar cell density (r = 0.537), and was lower in the NAFLD group than in the non-NAFLD group (p = 0.007). The eFRPV was lower in the NAFLD group than in the non-NAFLD group (p = 0.002). An eFRPV ≤47 mL·HU was an independent predictive factor for NAFLD (p = 0.007; odds ratio: 6.73; 95% confidence interval: 1.70-26.70). CONCLUSION: The eFRPV can be used to preoperatively predict NAFLD after PD.

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults.

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

The location of perianastomotic fluid collection predicts postoperative complications after pancreaticoduodenectomy.

PURPOSE: Perianastomotic fluid collection (PFC) is one of the postoperative complications of pancreaticoduodenectomy (PD). However, no studies have investigated the clinical significance of PFC location and volume during the early postoperative period. This study aimed to assess the association between PFC during the early postoperative period and postoperative complications. METHODS: Medical records of 148 patients who had undergone PD and computed tomography (CT) on postoperative day 4 were retrospectively reviewed. The location-superior, inferior, ventral, dorsal, or splenic hilum-and PFC index, which is the estimated volume of fluid collection, were determined using CT. The associations between postoperative complication and the presence of PFC, and PFC index according to the location, were assessed. RESULTS: The PFC group included 102 patients (69%). Postoperative pancreatic fistula (POPF) and organ/space surgical site infection (SSI) were more frequent in the PFC group (42% vs 9%, p < 0.001 and 29% vs 11%, p = 0.020, respectively). Additionally, the PFC index was larger in patients who developed POPF, organ/space SSI, or pseudoaneurysm (81 cm3 vs 19 cm3, p < 0.001; 75 cm3 vs 30 cm3, p = 0.001; and 185 cm3 vs 31 cm3, p < 0.001, respectively). Furthermore, superior and ventral PFCs were associated with pseudoaneurysm (11% vs 0%, p = 0.006 and 14% vs 1%, p = 0.002, respectively), whereas inferior and dorsal PFCs were associated with deep incisional SSI (9% vs 0%, p = 0.027 and 8% vs 1%, p = 0.034, respectively). CONCLUSION: The PFC location during the early postoperative period is associated with postoperative complications. Our findings may help determine the optimal location of prophylactic drains.

The effect of preoperative synbiotic treatment to prevent surgical-site infection in hepatic resection.

We aimed to clarify the influence of preoperative synbiotic therapy on surgical-site infections (SSIs) after hepatic resection. Between January 2011 and December 2017, 284 patients who underwent hepatic resection without biliary tract reconstruction and resection of other organs were included. We prospectively administered Clostridium butyricum and partially hydrolyzed guar gum before hepatic resection between April 2016 and December 2017 (synbiotic group). One-hundred-fifteen patients of the synbiotic group and 169 patients (conventional group) treated between January 2011 and the end of March 2016 were compared using propensity score matching. The frequency of laparoscopic resection was significantly larger in the synbiotic group (conventional group; 28% vs synbiotic group; 55%, p<0.001) and the amount of intraoperative bleeding was significantly smaller in the synbiotic group (median; conventional group, 700 ml vs synbiotic group, 200 ml; p<0.001). The postoperative SSI was significantly lower in the synbiotic group of six patients (5.2%) than in the conventional group of 30 patients (17.8%) (p = 0.002). Sixty patients in each group remained after propensity score matching. There was no significant difference in the incidence of SSI between the groups (conventional group, 15% vs synbiotic group, 6.7%; p = 0.239). In conclusion, preoperative synbiotic treatment did not reduce SSIs after hepatic resection.

Vimentin Expression in Tumor Microenvironment Predicts Survival in Pancreatic Ductal Adenocarcinoma: Heterogeneity in Fibroblast Population.

BACKGROUND: The tumor microenvironment, including cancer-associated fibroblasts (CAFs), plays various clinical roles in cancer growth. CAFs are a heterogeneous population and express a variety of mesenchymal markers. However, the clinical roles for CAFs expressing different markers in pancreatic ductal adenocarcinoma (PDAC) remain unknown. METHODS: We reviewed 67 resected PDAC patients who had not received preoperative therapy. Each primary tumor was analyzed for vimentin and α-smooth muscle actin (α-SMA) expression by immunohistochemical and dual immunofluorescence staining. RESULTS: There was no correlation between the percentage of cells expressing vimentin and α-SMA in the tumor stroma (Pearson's correlation coefficient: r = 0.171). Higher vimentin expression (p = 0.018) was associated with significantly shorter overall survival in PDAC patients. Using dual immunofluorescence staining, vimentin-positive CAFs were divided into two subpopulations: co-expression of α-SMA, and no co-expression of α-SMA. In PDAC, the level of co-expression had no effect on survival using univariate analysis (median survival time, 33.3 months for low co-expression vs. 18.2 months for high co-expression; log-rank, p = 0.143). However, multivariate analysis clarified that CAFs expressing vimentin alone was an independent predictor of poor survival (p = 0.014; hazard ratio, 2.305; 95% confidence interval, 1.181-4.497). CONCLUSIONS: Vimentin-positive CAFs without co-expression of α-SMA were associated with poor survival in PDAC, and CAFs possessed molecular and functional heterogeneity in this disease.

Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports.

BACKGROUND: Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess. This refractory complication can be fatal; therefore, intensive treatment is important. Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis, and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL. We also discuss our institutional protocol for CLL for postoperative pancreatic fistula. CASE SUMMARY: The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy, and pancreatic leakage was observed postoperatively. Intractable pancreatic fistula led to intraperitoneal abscess, and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8. The abscess resolved after 7 d of CLL. The second patient underwent distal pancreatectomy. Pancreatic leakage was observed, and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump. CLL was instituted from POD 9, and the abscess resolved after 4 d of CLL. The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma. Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula; however, intraperitoneal abscess was detected on POD 59. We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult. CLL was instituted from POD 63, and the abscess resolved after 1 wk of CLL. CONCLUSION: CLL has therapeutic potential for postoperative pancreatic fistula.

Aggressive Graphic/Surgical R0 Resection and Jejunal Interposition with Preservation of Mesojejunal Autonomic Nerves in Patients with Stage IV Esophagogastric Junction Adenocarcinoma: A Report of 3 Cases.

BACKGROUND Three patients with stage IV esophagogastric junction cancer (EGJC) underwent extended resection to achieve a graphic/surgical R0 status (no visible remnant of viable tumor in imaging/surgical findings) and adjuvant chemotherapy from the early postoperative period. We also introduced use of our digestive reconstruction technique in these patients. CASE REPORT We used jejunal interposition for digestive reconstruction, which involved end-to-end jejunojejunostomy with a biofragmentable anastomosis ring. The mesojejunal autonomic nerves of the lifted jejunum were preserved. The first adenocarcinoma involved the perilesional lymph nodes (LNs). Graphic/surgical R0 resection was completed by para-aortic LN dissection. The diagnosis (Japanese Classification of Gastric Carcinoma) was stage IV [pM1(LYM)]. Adjuvant chemotherapy began on postoperative day (POD) 11. The second adenocarcinoma was accompanied by a solitary lung metastasis. Intraoperative cytology of ascitic fluid was positive, and cisplatin was intraperitoneally administered. Adjuvant chemotherapy began on POD 10. The solitary lung metastasis was then resected, and graphic/surgical R0 resection was achieved. The diagnosis was stage IV [pM1(PUL) and CY1]. The third adenocarcinoma was accompanied by multiple liver metastases and metastatic regional LNs. The diagnosis was stage IV [H1]. Systemic chemotherapy was repeated. Only a solitary liver metastasis remained and was treated by radiofrequency ablation. Conversion surgery was conducted, achieving graphic/surgical R0 resection. Systemic chemotherapy was continued from POD 10. CONCLUSIONS For patients with stage IV EGJC, extended resection to achieve a graphic/surgical R0 status is still controversial, and systemic chemotherapy is important. The results of the present study suggest that our physiological reconstruction technique does not affect the efficacy of other therapies, such as adjuvant chemotherapy.

Brachial plexus paralysis after thoracoscopic esophagectomy for esophageal cancer in the prone position: A thought-provoking case report of an unexpected complication.

INTRODUCTION: During prone esophagectomy, placement of a port in the third intercostal space for upper mediastinal dissection requires adequate axillary expansion. To facilitate this, the right arm is elevated cranially and simultaneously turned outward. Brachial plexus paralysis associated with esophagectomy in the prone position has not been documented. PRESENTATION OF CASE: A 58-year-old man diagnosed with middle intrathoracic esophageal cancer was referred to our department. Thoracoscopic esophagectomy in the prone position was performed following neoadjuvant chemotherapy. After surgery, he complained of difficulty moving his right arm. Physical examination revealed perceptual dysfunction and movement disorder in the territory of cervical spinal nerve 6. Magnetic resonance imaging indicated the injury in the right posterior cord of the brachial plexus at the costoclavicular space. Therefore, we diagnosed the patient with right brachial plexus injury caused by the intraoperative position. The postoperative course was uneventful other than the brachial plexus paralysis, and he was discharged on postoperative day 23. He underwent continuous rehabilitation as an outpatient, and the right brachial plexus paralysis had completely disappeared by 2 months after surgery. DISCUSSION: This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. In prone esophagectomy, managing the patient's position, especially the head and arm positions, is so important to avoid brachial plexus injury due to intraoperative positioning. CONCLUSION: The clinicians should consider managing the patient's position with anatomical familiarity to avoid brachial plexus injury due to intraoperative positioning.

Safety and feasibility of laparoscopic gastrectomy accompanied by D1+ lymph node dissection for early gastric cancer in elderly patients.

INTRODUCTION: The age of patients with gastric cancer has increased worldwide. The aim of this study was to investigate the safety and feasibility of laparoscopic gastrectomy (LG) for early gastric cancer in elderly patients. METHODS: We retrospectively investigated 221 consecutive patients who underwent LG for early gastric cancer during a 5-year period (January 2010 to December 2014). We divided the patients into two groups: elderly patients (≥75 years old) and younger patients (<75 years old). We compared these two groups with respect to clinical characteristics, histopathological findings, intraoperative factors, and postoperative outcomes. RESULTS: The preoperative characteristics were similar in both groups. Except for the number of harvested lymph nodes (42.0 vs 34.9; P = 0.0016), the short-term operative outcomes, including postoperative complications and histopathological findings, were comparable between the two groups. Although significantly fewer lymph nodes were harvested in the elderly group, the overall survival and relapse-free survival rates did not significantly differ between the groups. Postoperative complications, such as acute cholecystitis and internal hernia, occurred during the long-term postoperative period after LG, and these unexpected complications were more frequently observed in elderly patients. All elderly patients required additional emergent surgeries for delayed complications. CONCLUSION: The outcomes of LG for early gastric cancer in elderly patients seem to be reasonable. Aggressive lymph node dissection may be omissible in elderly patients with acceptable results. LG can be a safe and feasible procedure in elderly patients. However, the higher rate of delayed but urgent complications during the long-term postoperative period must be considered.

Trans-perineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer.

BACKGROUND: Laparoscopic abdominoperineal resection (APR) for low rectal cancer (LRC) is performed worldwide. However, APR involves technical difficulties and often causes intractable perineal complications. Therefore, a novel and secure technique during APR is required to overcome these critical issues. Although the usefulness of the endoscopic trans-anal approach has been documented, no series of the endoscopic trans-perineal approach during laparoscopic APR for LRC has been reported. METHODS: Trans-perineal minimally invasive surgery (TpMIS) has been used during laparoscopic APR in our institution since April 2014. TpMIS is defined as an endoscopic trans-perineal approach using a single-port device and laparoscopic instruments. In this study, we retrospectively evaluated 50 consecutive patients with LRC who underwent laparoscopic APR at our institution from February 2011 to June 2017 and compared the outcomes of the patients who underwent TpMIS [trans-perineal APR (TpAPR) group, n = 21] versus the conventional trans-perineal approach (conventional group, n = 29). We investigated our experiences with TpMIS in detail and evaluated the safety and utility of TpMIS for patients with LRC. Moreover, major features and difficulties of TpMIS were examined from a surgical viewpoint. RESULTS: Intraoperative blood loss (median (range) 55 (10-600) vs. 120 (20-1650) ml) and severe perineal wound infection (Clavien-Dindo grade 3, 0 vs. 5 cases) were significantly lower in the TpAPR than conventional group. TpMIS led to a shortened hospital stay (median (range), 14 (10-74) vs. 23 (10-84) days), and neither mortality nor conversion to open surgery occurred in the TpAPR group. CONCLUSIONS: Magnified visualization via endoscopy provided more accurate dissection and less blood loss during surgery. Minimal skin incisions enabled a reduction in postoperative perineal complications, and consequently shortened the hospital stay. TpMIS during laparoscopic APR is safe and beneficial for patients with LRC.

Internal Hernia Associated with Colostomy After Laparoscopic Surgery for Rectal Malignancy: A Report of 3 Thought-Provoking Cases.

BACKGROUND Colostomy creation via intraperitoneal route is often performed during laparoscopic Hartmann's operation or abdominoperineal resection (APR). Herein, we report 3 rare cases of internal hernia associated with colostomy (IHAC). CASE REPORT The first case involved a 70-year-old man with IHAC after laparoscopic APR. Laparoscopy revealed the small intestine passed through a defect between the lifted sigmoid colon and left lateral abdominal wall in a cranial-to-caudal direction. The dislocated bowel with ischemic change was restored to its normal position and the lateral defect was covered with lateral peritoneum and greater omentum. The second case involved a 75-year-old man with IHAC after laparoscopic APR. Intraperitoneal findings were similar to those in the first case, except for the size of the lateral defect. This defect was too large for primary closure or patching; therefore, no surgical repair was performed. Unfortunately, this led to IHAC recurrence and creation of a new colostomy via extraperitoneal route. The third case involved an 85-year-old man with acute peritonitis resulting from IHAC after laparoscopic Hartmann's operation. Surgery revealed incarcerated bowels forming a closed loop and a perforation in the lifted sigmoid colon. The perforated colon was compressed by the dilated herniated bowel. The resected sigmoid colon showed perforation at the ulcer, which was shown on pathology to be caused by ischemia. CONCLUSIONS IHAC can lead not only to ischemia of strangulated bowel, but also to secondary damage to the lifted colon. During laparoscopic Hartmann's operation or APR, the colostomy should be created via extraperitoneal route to avoid IHAC.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits.

Laparoscopic and endoscopic cooperative surgery (LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors (GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to avoid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according to the concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Overlap Anastomosis for Digestive Reconstruction during Laparoscopic Distal Gastrectomy with Intensive Regional Lymph Node Dissection: Physiological Impact of Preserving the Mesenteric Autonomic Nerves in the Lifted Jejunal Limb.

Laparoscopic gastrectomy is a treatment for gastric cancer, and isoperistaltic side-to-side reconstruction is called "overlap anastomosis." The physiological advantages of preserving the autonomic nerves in the jejunal limb for digestive reconstruction are well known. Here, we focused on overlap anastomosis with autonomic nerve-preserved mesojejunum of the lifted jejunal limb for laparoscopic distal gastrectomy with intentional lymph node dissection. Our surgical techniques and technical pitfalls were described in detail. The jejunum was partially sacrificed to preserve the autonomic nerves in the lifted jejunal limb. The length of the staple line was 35 - 40 mm. The endostapler entry was carefully closed to avoid even subtle stenosis. Twelve patients were retrospectively evaluated with a follow-up of 5.0 ± 0.6 years. Histological findings according to the Japanese classification were stage IA or IB. Dietary intake and postoperative ambulation occurred at 3.3 ± 1.0 and 1.3 ± 0.5 days after surgery, respectively. Postoperative complications according to Clavien-Dindo classification were one each of grade I and grade II. Postoperative hospital stay was 6.7 ± 1.6 days. Five patients were medication-free at final follow-up, with no recurrence in any patient. Overlap anastomosis with autonomic nerve-preserved jejunal limb was safe and feasible for laparoscopic distal gastrectomy with lymph node dissection.