Advantage of urological experience with both transperitoneal and retroperitoneal laparoscopy in lymph node biopsy for malignant lymphoma diagnosis.

PURPOSE: Laparoscopic urologists are familiar with both transperitoneal and retroperitoneal approaches. That experience is an advantage when devising a strategy for intra-abdominal lymph node biopsy. We report the feasibility and effectiveness of laparoscopic biopsy using a urological laparoscopic technique for the treatment of patients with clinically suspected intra-abdominal lymphoma. MATERIALS AND METHODS: From October 2010 to April 2015, a total of 22 patients underwent laparoscopic biopsy for suspected intra-abdominal lymphoma. We adopted a retroperitoneal approach for paraaortic or paracaval masses, whereas we used a transperitoneal approach for mesenteric, iliac, or obturator masses. Whenever possible, an entire node was removed; otherwise, the biopsy consisted of wedge resection sized at least 1 cm3. RESULTS: Biopsy specimens were obtained from the following lymph node sites: 10 paraaortic, 5 paracaval, 3 mesenteric, 2 obturator, 1 common iliac, and 1 perinephric fat. Laparoscopic lymph node biopsy was completed in all patients, and there were no conversions to open surgery. The median operating time was 97 minutes (range, 62-167 minutes). The estimated blood loss was <50 mL in all cases. Postoperatively, one patient (4.5%) had symptomatic chylous lymphocele that required surgical intervention. Precise diagnosis was established for all patients: malignant lymphoma in 20 patients and metastatic urothelial carcinoma and squamous cell carcinoma of unknown origin in 1 patient each. All lymphomas could be fully subclassified. CONCLUSIONS: Appropriate use of the transperitoneal or retroperitoneal approach is safe and effective for laparoscopic lymph node biopsy in patients with suspected intra-abdominal lymphoma.

[Urinary Diversion Using an Appendicovesicostomy for Idiopathic Urethral Stricture : A Case Report].

A 55-year-old woman was referred to our hospital with dysuria. We were unable to catheterize her using a nelaton catheter because of a urethral stricture, resulting in a large residual urine volume on ultrasonography. The circumference of the periurethral tissue was also thickened and the entire length of the urethra was stenotic, without apparent cause, on magnetic resonance imaging. Biopsy did not reveal malignancy. The pathological diagnosis of the periurethral tissue was simply fibrosis, and there was no definitive diagnosis. We decided to place a guidewire to attempt transurethral dilation, but it was unsuccessful because of the urethral stricture. The patient then underwent Mitrofanoff appendicovesicostomy. Three years later, there was no difficulty with catheterization through the appendix, despite her suffering from a bladder stone during the interim. We consider the Mitrofanoff appendicovesicostomy a good substitute technique for catheterization in patients with very severe urethral stricture.

Identification of frequency, severity and risk factors of complications after open gastrectomy: Retrospective analysis of prospectively collected database using the Clavien-Dindo classification.

Introduction The purpose of this study was to identify the frequency, severity, and risk factors of complications after open gastrectomy using the Clavien- Dindo classification because institution-specific criteria were mostly used in the previous articles. Materials and Methods All complication data were obtained from our prospectively collected database of open gastrectomy from January 1999 to December 2012 (n=539). Complications were classified into either major surgical complications such as pancreatic fistula, abdominal abscess, and anastomotic leakage, or others. Frequency and severity were graded retrospectively according to the Clavien- Dindo classification for subsequent analysis of risk factors. Results There were 222 events occurred in 156 patients (28.9%). Complications of grade IIIa or greater were 8.3% for major surgical complications and 10.6% for all complications. The mortality rate was 1.1%. Blood loss was the only independent risk factor for major surgical complications of grade IIIa or greater (odds ratio 1.923, 95% Confidence Interval 0.320-0.786, p=0.003). Total gastrectomy was the only independent risk factor for all complications of grade IIIa or greater (Odds ratio 2.075, 95% Confidence Interval 0.260-0.896, p=0.021). Disscussion The present study provided the objective overview regarding complications after open gastrectomy. Blood loss and total gastrectomy were revealed as the significant risk factors for complications.

Spectral image analysis of mutual illumination between florescent objects.

This paper proposes a method for modeling and component estimation of the spectral images of the mutual illumination phenomenon between two fluorescent objects. First, we briefly describe the bispectral characteristics of a single fluorescent object, which are summarized as a Donaldson matrix. We suppose that two fluorescent objects with different bispectral characteristics are located close together under a uniform illumination. Second, we model the mutual illumination between two objects. It is shown that the spectral composition of the mutual illumination is summarized with four components: (1) diffuse reflection, (2) diffuse-diffuse interreflection, (3) fluorescent self-luminescence, and (4) interreflection by mutual fluorescent illumination. Third, we develop algorithms for estimating the spectral image components from the observed images influenced by the mutual illumination. When the exact Donaldson matrices caused by the mutual illumination influence are unknown, we have to solve a non-linear estimation problem to estimate both the spectral functions and the location weights. An iterative algorithm is then proposed to solve the problem based on the alternate estimation of the spectral functions and the location weights. In our experiments, the feasibility of the proposed method is shown in three cases: the known Donaldson matrices, weak interreflection, and strong interreflection.

Gastric carcinoma: Evaluation with diffusion-tensor MR imaging and tractography ex vivo.

PURPOSE: To determine the feasibility of diffusion-tensor imaging (DTI) and tractography as means of evaluating the depth of mural invasion by gastric carcinomas. MATERIALS AND METHODS: This study was approved by our institutional review board, and written informed consent was obtained from each patient. Twenty gastric specimens containing a carcinoma were studied with a 7.0-T MR imaging system equipped with a four-channel phased-array surface coil. DTI was performed by using a field of view of 50-60 mm × 25-30 mm, matrix of 256 × 128, section thickness of 1mm, b value of 1000 s/mm2, and motion-probing gradients in seven noncollinear directions. The MR images were compared with the histopathologic findings as the reference standard. RESULTS: In all 20 carcinomas (100%) the diffusion-weighted images, apparent diffusion coefficient (ADC) maps, fractional anisotropy (FA) maps, λ1 maps, and direction-encoded color FA maps made it possible to identify the same depth of tumor invasion of the gastric wall as observed during histopathologic examination. The λ1 maps provided the best contrast between the carcinomas and the layers of the gastric wall. The carcinomas also had lower ADC values and lower FA values than the normal gastric wall; thus, the carcinomas were clearly demarcated from the normal gastric wall. Tractography images were also useful for determining the depth of tumor invasion of the gastric wall. CONCLUSIONS: DTI and tractography are feasible means of evaluating gastric specimens and provide excellent diagnostic accuracy for evaluating mural invasion by gastric carcinomas.

q-space MR imaging of gastric carcinoma ex vivo: Correlation with histopathologic findings.

PURPOSE: The purpose of this study was to establish the feasibility of q-space imaging (QSI) as a method of assessing the depth of mural invasion, histologic grade, and the presence of lymph node metastasis in gastric carcinomas. METHODS: A 7.0 Tesla MR imaging system was used to investigate 20 gastric specimens containing a carcinoma. QSI was performed by using the following parameters: 50-60 mm × 25-30 mm field of view, 2-mm section thickness, 256 × 128 matrix, 10 b values in the 0-7163 s/mm(2) range, which corresponded to q values of 0-1026/cm, and motion-probing gradients perpendicular to the gastric wall. The MR images and the histopathologic findings were then compared. RESULTS: The depth of tumor invasion of the gastric wall in all 20 carcinomas (100%) was established by using mean displacement, zero-displacement probability, and kurtosis maps. The QSI parameters were significantly correlated with the histologic grades of the gastric carcinomas (all P < 0.001). The QSI parameters made it possible to differentiate between metastatic and nonmetastatic lymph nodes (all P = 0.001). CONCLUSION: Ex vivo QSI facilitates excellent diagnostics for evaluating gastric carcinomas in terms of mural invasion, histologic grade, and the presence of lymph node metastasis. Magn Reson Med 76:602-612, 2016. © 2015 Wiley Periodicals, Inc.

Assessment of Serum Copper State after Gastrectomy with Roux-en-Y Reconstruction for Gastric Cancer.

BACKGROUND: Some recent reports have noted that copper deficiency can occur in obese patients who have undergone bariatric surgery, such as Roux-en-Y (RY) gastric bypass or biliopancreatic diversion, or in patients who receive enteral nutrition through a jejunostomy. No reports appear to have assessed the serum copper state of patients following gastrectomy with RY reconstruction for gastric cancer. METHODS: A cross-sectional study was conducted from June 2013 to December 2014. Serum copper levels (SCLs) in 242 out-clinic patients who underwent curative gastrectomy were obtained. Patients were classified into an RY group (n = 208) and a non-RY group (n = 34). RESULTS: Hypocupremia was identified in 3 patients in the RY group (1.4%), and 2 patients in the non-RY group (5.9%; p = 0.146), but none experienced any symptoms caused by hypocupremia. No significant difference in the mean SCL was seen between the RY group (105.8 ± 21.2 µg/dl) and non-RY group (107.9 ± 22.7 µg/dl; p = 0.499). In the RY group, the mean SCL was significantly lower in younger patients, patients with follow-up period <3 years, and male patients. CONCLUSION: Some patients developed hypocupremia after gastrectomy with RY reconstruction, but the number is acceptably low, and physical symptoms were unusual.

Gastric Carcinoma: Ex Vivo MR Imaging at 7.0 T-Correlation with Histopathologic Findings.

PURPOSE: To determine the imaging detail and diagnostic information that can be obtained at 7.0-T magnetic resonance (MR) imaging with a voxel volume of 9.5-14.0 nL as a means of evaluating the depth of mural invasion by gastric carcinomas ex vivo. MATERIALS AND METHODS: This study was approved by the institutional review board, and written informed consent was obtained from each patient. Twenty gastric specimens containing 20 carcinomas were studied with a 7.0-T MR imaging system equipped with a four-channel surface coil. MR images were obtained with a 50-60 × 25-30 mm field of view, a 512 × 256 matrix, and a 1.0-mm section thickness, resulting in a voxel volume of 0.0095-0.0140 mm(3) (9.5-14.0 nL). The signal intensity of the gastric wall layers, tumor tissue, and fibrosis was described as low, intermediate, or high by comparing it with the signal intensity of the muscularis propria. Depth of invasion initially was assessed by two reviewers independently and then by the two reviewers in consensus. MR images were compared with histopathologic findings. RESULTS: The 7.0-T T2-weighted MR images clearly depicted the normal gastric wall in all 20 specimens (100%) as consisting of seven layers, which clearly corresponded to the tissue layers of the gastric wall. These MR images enabled clear differentiation between tumor tissue and fibrosis. Reviewers disagreed on the depth of invasion at the initial reading in three (15%) of 20 specimens (between mucosa and submucosa in two specimens and between muscularis propria and subserosa and serosa in one specimen); however, in all 20 gastric carcinomas, the depth of invasion could be accurately determined on T2-weighted images after consensus interpretation. CONCLUSION: Ex vivo 7.0-T MR imaging enables clear delineation of the gastric wall layers and clear differentiation of tumor tissue from fibrosis and allows one to assess the depth of mural invasion by gastric carcinomas.

[A Case of Long-Term Survival in a Patient with Colorectal Liver Metastasis Treated with Multidisciplinary Therapy].

A-71-year-old man underwent right hemicolectomy combined with partial resection of the small intestine and duodenum for an ascending colon carcinoma in July 2009. He presented with a liver metastasis adjacent to the inferior vena cava in November 2009. He received 6 courses of FOLFOX4, but the therapeutic effect was SD, so he underwent an extended posterior sectionectomy combined with partial S8 resection, inferior vena cava resection, and cholecystectomy. He developed remnant liver recurrence in February 2011 and another partial S8 resection was performed. He presented with remnant liver recurrence in October 2011, and radiofrequency ablation and systemic chemotherapy were performed, but were not effective. In June 2013, we performed an extended S8 segmentectomy combined with median hepatic vein and diaphragm resection. He is alive 2 years after the third hepatectomy without any recurrence. Although non-anatomical resection is often performed in repeat liver resections for colorectal liver metastases, sometimes detection of recurrent lesions in the same segment indicates Glisson invasion; therefore, anatomic resection may prolong long-term survival.

[Hepatocellular Carcinoma with Vp3 Tumor Thrombosis Treated with Multidisciplinary Treatment--Report of Two Cases].

Hepatic resection of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) at the bifurcation of the portal has the potential to cure the disease. Herein, we report 2 cases of HCC with Vp3 treated with a multidisciplinary approach that might include preoperative transcatheter arterial chemoembolization (TACE) or postoperative hepatic arterial infusion chemotherapy (HAIC). Case 1: A 73-year-old man was diagnosed with HCC with Vp3 located in segment 1 during follow up that was treated by performing a left hepatectomy with removal of the tumor thrombus. After surgery, the patient underwent HAIC, and he was alive without disease recurrence 2 years and 2 months after surgery. Case 2: A 77-year-old man with cirrhotic nonalcoholic steatohepatitis underwent liver resection followed by TACE. However, recurrent HCC with Vp3 was detected in segments 2 and 5, so we performed a repeat liver resection. The patient was alive without disease recurrence 1 year and 8 months after surgery without having received postoperative adjuvant chemotherapy. In select patients diagnosed with HCC with PVTT (Vp3/4), long-term survival can be obtained with multidisciplinary treatment such as surgery and preoperative TACE or postoperative HAIC.

Long-term outcomes of laparoscopic gastrectomy for gastric cancer.

BACKGROUND: Laparoscopic gastrectomy (LG) has been established as a procedure for the treatment of gastric cancer. However, there have been few reports on the long-term outcomes of LG for gastric cancer. The aim of this study is to investigate the long-term outcomes of LG for gastric cancer. METHODS: A total of 278 consecutive patients who underwent LG in our unit between January 1999 and December 2006 were included in this study. Survival, recurrence, and late gastrointestinal complications were analyzed. RESULTS: The median follow-up period was 73.7 mo (6-165 mo). Distal gastrectomy was performed in 229 patients, total gastrectomy in 23 patients, proximal gastrectomy in 15 patients, and pylorus-preserving gastrectomy in 11 patients. Five-year overall and disease-specific survival rates were 91% and 99% for stage IA, 75% and 91% for stage IB, 72% and 88% for stage II, and 40% and 50% for stage III, respectively. Recurrences were detected in 15 (5.4%) patients, including 5 distant lymph node, 5 peritoneal, 4 hematogenous, and 1 locoregional recurrences. Bowel obstruction occurred in 4 (1.4%) patients, and gallstones developed in 37 (15%) patients. CONCLUSIONS: This follow-up investigation suggested that LG for gastric cancer is a feasible procedure from the standpoint of long-term oncological outcome and postoperative complications.

Erythropoietin-Producing Hepatocellular A1 is an Independent Prognostic Factor for Gastric Cancer.

BACKGROUND: Erythropoietin-producing hepatocellular (Eph) receptors are the largest subfamily of receptor tyrosine kinases that have been investigated as a possible target for molecular targeted therapy of various cancers. METHODS: Patients (n = 222) who underwent gastrectomy for primary gastric cancer were enrolled in this study. Tumor protein expression of EphA1 and EphB6 in surgically resected specimen was investigated using immunohistochemistry. The associations between expression of EphA1 and EphB6 and clinicopathological factors and prognosis were analyzed. RESULTS: High expression of EphA1 was associated with undifferentiated histology (P = 0.002), depth of tumor (P < 0.001), lymph node metastasis (P = 0.001), venous invasion (P = 0.015), stage (P = 0.001), and remote metastasis or recurrence (P < 0.001). In univariate analysis, patients with high expression of EphA1 had significantly poorer overall survival and relapse-free survival compared with patients with low EphA1 expression. The expression level of EphB6 was not associated with any clinicopathological factors and patient survival. Multivariate analysis indicated that depth of tumor [hazard ratio (HR) 9.26, 95 % confidence interval (CI) 0.03-0.46, P = 0.003], lymph node metastasis (HR 9.26, 95 % CI 0.07-0.39, P < 0.001), and high expression of EphA1 (HR 1.86, 95 % CI 0.29-0.99, P = 0.048) are independent prognostic factors for relapse-free survival. CONCLUSIONS: EphA1 is a possible target of molecular targeted therapy of gastric cancer.

Clinical significance of platelet derived growth factor-C and -D in gastric cancer.

Platelet-derived growth factor (PDGF)-C and PDGF-D are frequently upregulated in human cancers and play important roles in tumor progression, angiogenesis and metastasis. However, the distribution, frequency and prognostic value of PDGF-C and PDGF-D expression in gastric cancer have not been clarified. The present study evaluated the association between expression of PDGF-C and PDGF-D, clinicopathological factors and outcomes, in patients with gastric cancer. Gastric adenocarcinoma tumor samples were obtained from 204 patients who underwent curative gastrectomy between 2003 and 2007. The expression of PDGF-C and PDGF-D was analyzed by immunohistochemical staining. High expression of PDGF-C and PDGF-D was detected in 114 (56%) and 151 (74%) tumors, respectively. PDGF-D expression was significantly associated with tumor depth (P=0.039), histopathology (P<0.01), tumor stage (P=0.01) and recurrence (P<0.01), whereas PDGF-C expression correlated only with histopathology (P=0.05). High PDGF-D expression was also associated with significantly shorter relapse-free survival (RFS) time (P<0.01), whilst high PDGF-C expression was associated with marginally, but not significantly, shorter RFS (P=0.10). On multivariate analysis, high PDGF-D expression was determined to be an independent prognostic factor (hazard ratio, 3.3; 95% confidence interval, 1.20-9.4; P=0.02). These findings indicate that high PDGF-D expression is strongly associated with tumor progression, recurrence, distant metastasis and poor outcomes in patients with gastric cancer. PDGF-D may therefore be an independent prognostic factor and a novel therapeutic target.

[Laparoscopic Radical Cystectomy in the Elderly Patients].

We compared the perioperative and oncological outcomes of laparoscopic radical cystectomy (LRC) between elderly patients over 75 years old and younger patients. Fifty-three patients underwent LRC between 2003 and 2014 at Tenriyorozu Hospital. Eighteen patients were classified as elderly (over 75) and the other 35 patients were considered young. The median operating time (434 vs 465 min, p＝0.35), estimated bloodloss (534 vs 525 g, p＝0.74), time to recommencing foodintake (7 vs 6 days, p＝1.00), and hospital stay (35 vs 32 days, p＝0.81) were not significantly different between the groups. Perioperative pyelonephritis was significantly more frequent in the elderly group (50% vs 20%, p＝0.02), while other complications were not significantly different between the two groups. The perioperative mortality rate was 0% in both groups. There were no significant differences between the elderly and young groups with respect to 2-year overall survival (74. 4% vs 91. 6%), cancer-specific survival (74. 4% vs 91. 6%), and recurrence-free survival (70.2% vs 81. 8%). LRC is a safe andefficient procedure for selected elderly patients.

Impact of comorbidities on postoperative complications in patients undergoing laparoscopy-assisted gastrectomy for gastric cancer.

BACKGROUND: Comorbidity is a predictor of postoperative complications (PCs) in gastrectomy. However, it remains unclear which comorbidities are predictors of PCs in patients who undergo laparoscopy-assisted gastrectomy (LAG). Clinically, insufficient lymphadenectomy (LND) is sometimes performed in high-risk patients, although the impact on PCs and outcomes remains unclear. METHODS: We retrospectively studied 529 patients with gastric cancer (GC) who underwent LAG. PCs were defined as grade 2 or higher events according to the Clavien-Dindo classification. We evaluated various comorbidities as risk factors for PCs and examined the impact of insufficient LND on PCs in patients with risky comorbidities. RESULT: A total of 87 (16.4%) patients had PCs. There was no PC-related death. On univariate analysis, heart disease, central nervous system (CNS) disease, liver disease, renal dysfunction, and restrictive pulmonary dysfunction were significantly associated with PCs. Both liver disease and heart disease were significant independent risk factors for PCs on multivariate analysis (odds ratio [OR] = 3.25, p = 0.022; OR = 2.36, p = 0.017, respectively). In patients with one or more risky comorbidity, insufficient LND did not significantly decrease PCs (p = 0.42) or shorten GC-specific survival (p = 0.25). CONCLUSION: In patients who undergo LAG for GC, the presence of heart disease or liver disease is an independent risk factor for PC. Insufficient LND (for example, D1+ for advanced GC) might be permissible in high-risk patients, because although it did not reduce PCs, it had no negative impact on GC-specific survival.

Prognostic significance of the co-overexpression of fibroblast growth factor receptors 1, 2 and 4 in gastric cancer.

The overexpression of fibroblast growth factor receptor (FGFR) 2 is an established prognostic factor and treatment target in gastric cancer. However, the roles of other FGFRs have not been fully elucidated. In this study, we investigated the correlations of the expression of FGFR1-4 with clinicopathological characteristics and outcomes in gastric cancer. Tumor samples were obtained from 222 patients with gastric adenocarcinoma who underwent gastrectomy between 2003 and 2007. The expression of each FGFR was measured in the tumors by immunohistochemical analysis. The overexpression of FGFR1, FGFR2 or FGFR4 was found to be significantly associated with tumor progression, including depth of invasion, lymph node metastasis, pathological stage and distant metastasis or recurrent disease. Patients exhibiting overexpression of FGFR1, FGFR2 or FGFR4 had a significantly poorer disease-specific survival (DSS; P<0.001, P=0.008 and P<0.001, respectively). Moreover, the co-overexpression of all three FGFRs was significantly associated with a poorer DSS compared to the expression of none or only one of the FGFRs (P<0.001 and P=0.001, respectively) and it was found to be an independent prognostic factor (HR=1.71, 95% CI: 1.02-2.85, P=0.041). In conclusion, high expression of FGFR1, FGFR2 or FGFR4 was associated with tumor progression and poor survival in patients with gastric cancer. Similar to FGFR2, FGFR1 and FGFR4 may be considered as prognostic factors and treatment targets in gastric cancer.

Risk factors for post-operative pulmonary complications after gastrectomy for gastric cancer.

BACKGROUND: Post-operative pulmonary complications (PPCs) negatively affect patients' quality of life and can be life-threatening. Predictors of PPCs have been evaluated in patients who underwent various operations, but few studies have specifically focused on gastrectomy. METHODS: We retrospectively studied 1,053 patients with gastric adenocarcinoma who underwent radical gastrectomy with lymphadenectomy in our hospital between 1999 and 2011. Post-operative pulmonary complications were defined as conditions such as pneumonia, macroscopic atelectasis, pneumothorax, and acute respiratory distress syndrome that developed within 30 d after surgery. We evaluated the relations between PPCs and pre-operative or intra-operative factors and assessed risk factors for PPCs after gastrectomy. RESULT: A total of 49 (4.7%) patients had PPCs. On univariate analysis, PPCs were significantly associated with male gender (p=0.024), predicted vital capacity (VC) (p=0.020), a lower pre-operative serum albumin concentration (p=0.023), open surgery (p=0.007), total gastrectomy (p<0.001), combined resection of another organ (p=0.001), extended operating time (p<0.001), higher operative bleeding volume (p<0.001), intra-operative or post-operative blood transfusion (p=0.009), and pathologic tumor stage (p=0.003). On multivariable analysis, extended operating time (odds ratio [OR], 3.21, 95% confidence interval [CI] 1.46-7.07; p=0.004), total gastrectomy (OR, 2.65, 95% CI 1.25-5.59; p=0.011) and predicted VC (OR, 2.42, 95% CI 1.01-5.85; p=0.049) were independent risk factors. These three factors also were independent risk factors for post-operative pneumonia (total gastrectomy OR, 2.64, 95% CI 1.32-5.30; p=0.006); extended operating time OR, 2.54, 95% CI 1.24-5.19; p=0.011; and predicted VC OR, 2.41, 95% CI 1.01-5.75; p=0.048). CONCLUSION: Extended operating time, total gastrectomy, and predicted VC were independent predictors of PPCs, particularly pneumonia, in patients with gastric cancer who underwent gastrectomy. In patients with restrictive pulmonary dysfunction who are scheduled to undergo total gastrectomy, reduced lymphadenectomy or the avoidance of combined resection should be considered to shorten the operating time.

[A case of adrenal metastasectomy in renal cell carcinoma after neoadjuvant therapy with sunitinib].

A 58-year-old man had undergone laparoscopic radical nephrectomy for right renal cell carcinoma. The histopathological diagnosis was clear cell carcinoma, grade 2＞3, pT1b. Two years and 10 months postoperatively, computed tomography scans demonstrated an enhanced mass on the right adrenal gland. As we could not detect other metastatic lesions, it was diagnosed as solitary adrenal metastasis of renal cell carcinoma. Albeit metastasectomy was planned with curative intent, right hemihepatectomy was also required for surgical removal because the tumor was adherent to the right lobe of the liver broadly and had indistinct margins. So we started neoadjuvant therapy with sunitinib. Eight courses of treatment shrunk the metastatic tumor enough to allow it to be removed completely without partial hepatectomy. Neoadjuvant therapy with the molecular targeted drugs may provide an effective option for metastasectomy in renal cell carcinoma regarding increased curability and decreased the risk of an operation.

ß-Shaped intracorporeal Roux-en-Y reconstruction after totally laparoscopic distal gastrectomy.

BACKGROUND: The use of laparoscopic gastrectomy for the treatment of gastric cancer has been increasing. Roux-en-Y (R-Y) reconstruction after laparoscopy-assisted distal gastrectomy is now widely used to decrease leakage and prevent reflux. Owing to the need for a less invasive technique, we have developed a new technique for intracorporeal R-Y reconstruction (ß reconstruction) after totally laparoscopic distal gastrectomy (TLDG). METHODS: In this report, we describe the ß reconstruction technique and short-term outcomes of the initial 105 patients who underwent ß reconstruction from December 2008 to March 2012. RESULTS: The operative and ß reconstruction times were 330 ± 61.3 and 29 ± 5.6 min (mean ± SD), respectively. Anastomotic leakage after gastrojejunostomy occurred in one patient (0.9 %), requiring reoperation. Four cases (3.8 %) of anastomotic stenosis required endoscopic balloon dilation. However, R-Y stasis was not noted. CONCLUSIONS: We have indicated a technical description as well as the usefulness of ß-shaped intracorporeal R-Y reconstruction after TLDG.