An individual's physique is associated with the length of the reconstruction route via the retrosternal approach.

We hypothesized that an individual's physique is related to reconstruction length, as organs reconstructed via the retrosternal route are curved toward the ventral side. This study aimed to determine factors contributing to the reconstruction length of the retrosternal route. Fifty patients underwent subtotal esophagectomy with esophagogastric reconstruction via the posterior mediastinal route between 2010 and 2014; the esophagus-stomach and posterior mediastinal route lengths were measured to evaluate whether they could be approximated. Forty patients underwent reconstruction via the retrosternal route between 2015 and 2020; the esophagus-stomach and retrosternal route lengths were compared, and contributing factors were analyzed. Each length was measured perioperatively using three-dimensional enhanced computed tomography images. The associated factors obtained included age, sex, height, body weight, body mass index, thickness and height of the thorax, depth of the thoracic inlet space, thoracic curve, left hepatic lobe volume, and the thickness and height of the liver. The length of the esophagus-stomach could approximate that of the posterior mediastinal route [posterior mediastinal-esophagus-stomach; 0.04 (-0.5-0.6) cm, p = 0.77]. Using three-dimensional enhanced computed tomography images, the lengths of the esophagus-stomach and retrosternal routes were comparable, despite variability [retrosternal-esophagus-stomach; 0.72 (-0.1-1.8) cm, p = 0.095]. Analyzing factors associated with the length revealed a positive correlation of body weight, body mass index, and thickness of the thorax with the difference. A higher body mass index (OR = 1.7, 95% CI 1.1-2.8, p = 0.007) was associated with a longer retrosternal route in the multivariate analysis. An individual's physique is associated with the reconstruction length; particularly, the length of the retrosternal route was longer in patients with a high body mass index.

Visceral fat area is a better indicator of surgical outcomes after laparoscopic gastrectomy for cancer than the body mass index: a propensity score-matched analysis.

BACKGROUND: The number of overweight gastric cancer patients who are undergoing laparoscopic gastrectomy (LG) has increased in Japan. However, the relationship between obesity and surgical outcomes of LG remains unclear. Therefore, this study aimed to evaluate the effect of visceral fat area (VFA) on surgical outcomes of LG for gastric cancer compared to the body mass index (BMI). METHODS: This study was a retrospective, cohort study that included 587 patients who underwent LG in our institution between January 2015 and December 2019. The patients were divided into two groups according to VFA (< 100 cm2 and ≥ 100 cm2) and BMI (< 25 kg/m2 and ≥ 25 kg/m2) values, respectively. Surgical outcomes and postoperative complications were compared between the low and high groups for each VFA and BMI value. Propensity score matching was used to minimize potential selection bias. RESULTS: After propensity score matching, 144 pairs of patients in the VFA group and 82 pairs of patients in the BMI group were extracted. Operative time (p = 0.003), intraoperative blood loss (p = 0.0006), and CRP levels on postoperative day 1 (p = 0.002) and on postoperative day 3 (p = 0.004) were significantly higher in the high-VFA group than in the low-VFA group. However, these surgical outcomes were not significantly different between the high-BMI and low-BMI groups. There was no strong correlation between VFA and BMI (R2 = 0.64). There were no significant differences in postoperative complications between the high and low groups for both VFA and BMI values. On multivariate analysis, high VFA was an independent predictor of operative time, but it was not significantly associated with the incidence of postoperative complications. CONCLUSION: VFA is a better indicator of longer operative time than BMI. However, increased VFA did not affect postoperative complications.

The Association of Thymidine Phosphorylase with Gastric Cancer Prognosis.

BACKGROUND: Thymidine phosphorylase(TP)plays an important role in angiogenesis and solid tumor invasion. This study aimed to investigate TP expression in gastric cancer(GC), its correlation with clinicopathological features, and its prognostic significance. METHODS: Clinical data and tumor specimens were retrospectively collected from patients with GC in Ikeda Municipal Hospital between January 2005 and December 2006. Tumor specimens were immunohistochemically analyzed for TP expression graded as 0, 1+, 2+, or 3+ and divided into low(0/1+)and high(2+/3+)TP expression groups. To determine its potential prognostic value, any correlation between TP expression and the clinicopathological features of the patients was statistically assessed. RESULTS: Among 111 patients with GC, 33 had high TP expression(29.7%)and 78 had low TP expression(70.3%). There were significant differences in tumor size, tumor depth, venous invasion, lymphatic invasion, and clinical stage between the two groups. Analysis of the Kaplan-Meier survival curves revealed that the high TP group had significantly shorter overall survival(OS; p<0.01)and progression-free survival(PFS; p<0.01)than the low TP group. Moreover, the high TP group had significantly shorter OS(p=0.040)and a trend toward a shorter PFS(p=0.064) than the low TP group in patients with stage Ⅱ, Ⅲ, and Ⅳ cancer. Multivariate analysis revealed that high TP expression was significantly associated with tumor size, tumor type, and lymphatic invasion in patients with GC. CONCLUSIONS: Our results suggest that high TP expression might predict poor prognosis in GC.

Advantages of Laparoscopic Surgery for Gastric Cancer in Elderly Patients Aged Over 80 Years: A Propensity Score Matching Analysis.

BACKGROUND: The short- and long-term efficacy of laparoscopic surgery for elderly patients with gastric cancer has not been evaluated. We aimed to use propensity score matching to clarify the efficacy of laparoscopic gastrectomy (LG) for elderly patients with gastric cancer aged ≥80 years. METHODS: We retrospectively collected data from 159 consecutive patients with gastric cancer aged ≥80 years who underwent gastrectomy with curative intent at our institution between 2004 and 2015. Propensity score matching was applied to compare the open gastrectomy (OG) and LG. Short- and long-term outcomes were evaluated between the propensity-matched groups. RESULTS: Patients' backgrounds and surgical factors were similar in both groups except for blood loss. The median time to first flatus was significantly shorter in the LG group than in the OG group (P = 0.002). The postoperative hospital stay was significantly shorter in the LG group (P = 0.014). The complication rate of Clavien-Dindo grade III or higher was significantly lower in the LG group (3% vs. 23%, P = 0.023). The 5-year overall survival and 5-year disease-specific survival rates were better in the LG group than in the OG group, but the differences were not significant (45% vs. 42% and 67% vs 57%, respectively). CONCLUSION: LG was associated with good short-term outcomes and acceptable oncologic outcomes compared with OG in these propensity-matched patients aged ≥80 years.

Esophago-bronchial fistula treated by the Over-The-Scope-Clipping (OTSC) system with argon beam electrocoagulation: A case report.

RATIONALE: An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited. PATIENT CONCERNS: A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close. DIAGNOSES: Intractable esophago-bronchial fistula associated with esophageal surgery. INTERVENTIONS AND OUTCOMES: On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case. LESSONS: We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue.

γ-H2AX as a potential indicator of radiosensitivity in colorectal cancer cells.

Preoperative radiotherapy improves local disease control and disease-free survival in patients with advanced rectal cancer; however, a reliable predictive biomarker for the effectiveness of irradiation has yet to be elucidated. Phosphorylation of H2A histone family member X (H2AX) to γ-H2AX is induced by DNA double-strand breaks and is associated with the development of colorectal cancer (CRC). The current study aimed to clarify the relationship between γ-H2AX expression and CRC radiosensitivity in vitro and in vivo. H2AX levels were analyzed in datasets obtained from cohort studies and γ-H2AX expression was investigated by performing immunohistochemistry and western blotting using clinical CRC samples from patients without any preoperative therapy. In addition, the CRC cell lines WiDr and DLD-1 were subjected to irradiation and/or small interfering RNA-H2AX, after which the protein levels of γ-H2AX were examined in samples obtained from patients undergoing preoperative chemoradiotherapy. To quantify the observable effect of treatment on cancer cells, outcomes were graded as follows: 1, mild; 2, moderate; and 3, marked, with defined signatures of cellular response. Datasets obtained from cohort studies demonstrated that H2AX mRNA levels were significantly upregulated and associated with distal metastasis and microsatellite instability in CRC tissues, in contrast to that of normal tissues. In addition, γ-H2AX was overexpressed in clinical samples. In vitro, following irradiation, γ-H2AX expression levels increased and cell viability decreased in a time-dependent manner. Combined irradiation and γ-H2AX knockdown reduced the viability of each cell line when compared with irradiation or γ-H2AX knockdown alone. Furthermore, among clinical CRC samples from patients undergoing preoperative chemoradiotherapy, levels of γ-H2AX in the grade 1 group were significantly higher than those in grade 2 or grade 3. In conclusion, γ-H2AX may serve as a novel predictive marker and target for preoperative radiotherapy effectiveness in patients with CRC.

The usefulness of intraoperative neurological monitoring for esophageal cancer with double aortic arch; a case report.

BACKGROUND: Double aortic arch (DAA) is a congenital anomaly of the aorta. Esophageal cancer with DAA is rare, and consequently, the appropriate surgical approach has not been standardized. Herein, we report the utilization of intraoperative neurological monitoring (IONM) system to preserve the function of the recurrent laryngeal nerve. CASE PRESENTATION: A 79-year-old man with esophageal cancer was diagnosed with DAA incidentally. The descending aorta was located on the right side of the thoracic vertebrae. Safe dissection of the mediastinal lymph nodes was difficult using the right transthoracic approach because of the anatomical abnormalities. During surgery, we used cervical mediastinoscopy combined with the IONM system to preserve the bilateral recurrent laryngeal nerves. Severe complications, including recurrent nerve palsy, were not observed postoperatively. CONCLUSION: IONM may be useful for evaluation of the function of the recurrent laryngeal nerve, and it would be suitable for atypical cases of esophageal cancer.

Gastrointestinal Neurons Expressing HCN4 Regulate Retrograde Peristalsis.

Peristalsis is indispensable for physiological function of the gut. The enteric nervous system (ENS) plays an important role in regulating peristalsis. While the neural network regulating anterograde peristalsis, which migrates from the oral end to the anal end, is characterized to some extent, retrograde peristalsis remains unresolved with regards to its neural regulation. Using forward genetics in zebrafish, we reveal that a population of neurons expressing a hyperpolarization-activated nucleotide-gated channel HCN4 specifically regulates retrograde peristalsis. When HCN4 channels are blocked by an HCN channel inhibitor or morpholinos blocking the protein expression, retrograde peristalsis is specifically attenuated. Conversely, when HCN4(+) neurons expressing channelrhodopsin are activated by illumination, retrograde peristalsis is enhanced while anterograde peristalsis remains unchanged. We propose that HCN4(+) neurons in the ENS forward activating signals toward the oral end and simultaneously stimulate local circuits regulating the circular muscle.

Combined Intraoperative Identification and Monitoring of Recurrent Laryngeal Nerve Paresis during Minimally Invasive Esophagectomy: Surgical Technique Using Nerve Integrity Monitoring for Esophageal Carcinoma.

Recurrent laryngeal palsy occurs after No. 106 rec RL lymphadenectomy procedure, which is assumed to cause postoperative respiratory complications. A 71-year-old Japanese man with T1b N0 M0 stage 1 esophageal cancer was scheduled for thoracoscopic esophagectomy with two-field lymph node dissection using nerve integrity monitoring (NIM). The patient demonstrated an uneventful postoperative course with 56 days remission. Under general anesthesia conditions, a single-lumen intubation tube was inserted for NIM. The automatic periodic stimulation electrode was placed on the bilateral vagus nerves on the left and right, respectively. The NIM had set and enabled the identification of the nerve accurately and continuous intraoperative nerve monitoring using impulses from the stimulation probe. The postoperative outcomes and comparison of the potential amplitudes of electromyography were observed while no postoperative vocal cord paresis was present. Combined intraoperative identification and monitoring of recurrent laryngeal nerve significantly changes the quality of the lymphadenectomy procedure and is a promising optical imaging technique. It has gained recognition for being able to reduce or prevent recurrent laryngeal nerve paralysis. It was considered a reasonable method, but it has been superseded by NIM, which is a novel technology.

Endoscopic Evaluation of Neoadjuvant Chemotherapeutic Efficacy in Gastric Cancer before Gastrectomy Might be as Useful as Histological Assessment after Gastrectomy.

BACKGROUND: Neoadjuvant chemotherapy for advanced gastric cancer is expected to improve prognoses. However, as there is no method to evaluate neoadjuvant chemotherapeutic efficacy before gastrectomy, some patients at high risk for a poor prognosis undergo gastrectomy. The aim of the present study was to investigate whether endoscopy could be useful for assessing the efficacy of neoadjuvant chemotherapy. METHODS: In this retrospective study, we analyzed the data of 41 patients who received neoadjuvant chemotherapy followed by gastrectomy at our institution to investigate whether responsiveness to neoadjuvant chemotherapy, as assessed with endoscopy, can serve as a surrogate marker for histological grades 1b or higher in the Japanese Classification of Gastric Carcinoma (JCGC) scheme. RESULTS: There were 32 (78.0%) responders and 9 (22.0%) nonresponders to neoadjuvant chemotherapy, as observed in endoscopic evaluations. Among the endoscopic responders, 24 (75.0%) had cancer of histological grade 1b or higher, and 15 (46.9%) had cancer of grade 2 or higher. Among the endoscopic nonresponders, 1 (11.1%) patient had histological grade 1b cancer. Compared with endoscopic nonresponders, endoscopic responders were more likely to show a histological response (chi-square test: p = 0.0005 for JCGC grade 1b or higher; p = 0.0099 for JCGC grade 2 or higher). CONCLUSIONS: Most endoscopic responders showed JCGC histological responses. Evaluation of neoadjuvant chemotherapeutic efficacy by endoscopy in gastric cancer may be useful before gastrectomy. As this was a retrospective study, further investigations are required. The protocol was approved by the ethics review committee at Osaka Medical College (No. 2422) and was registered in the University Hospital Medical Information Network Clinical Trial Registry (UMIN000033088).

Functional Evaluation for Various Methods of Gastrectomy and Reconstruction for Gastric Cancer.

OBJECTIVE: This study of 45 patients aimed to retrospectively examine whether the relationships among the postoperative to preoperative body weight ratio (BWR), meal intake as a good indicator of quality of l ife (QOL), and absorptive kinetics from the small intestine could be expressed by the acetaminophen (AAP) concentration. METHODS: The postoperative/preoperative BWR and meal intake ratio (MIR) were evaluated in 30 patients who underwent open distal gastrectomy for advanced gastric cancer (ODG group) and 15 patients who underwent laparoscopic proximal gastrectomy for early gastric cancer (LPG group). In addition, all patients underwent functional evaluation using the AAP method. Correlation coefficients of the BWR and MIR with the plasma AAP concentration after meal intake were evaluated. RESULTS: There was a negative correlation between the AAP concentration at 15 min and the BWR in all patients (r = -0.438, P = 0.00259, n = 45) and a weak negative correlation between the AAP concentration at 15 min and the MIR (r = -0.309, P = 0.0368, n = 45). CONCLUSIONS: There were some relationships between slow intestinal absorption in the early postprandial phase and the maintenance of postoperative body weight and meal intake. Namely, operative methods that maintained preoperative slow intestinal absorption were thought to be better for maintaining postoperative QOL.

Analysis of Extracellular Vesicles in Gastric Juice from Gastric Cancer Patients.

Extracellular vesicles (EVs) are secretory membrane vesicles containing lipids, proteins, and nucleic acids; they function in intercellular transport by delivering their components to recipient cells. EVs are observed in various body fluids, i.e., blood, saliva, urine, amniotic fluid, and ascites. EVs secreted from cancer cells play important roles in the formation of their environment, including fibrosis, angiogenesis, evasion of immune surveillance, and even metastasis. However, EVs in gastric juice (GJ-EVs) have been largely unexplored. In this study, we sought to clarify the existence of GJ-EVs derived from gastric cancer patients. GJ-EVs were isolated by the ultracentrifuge method combined with our own preprocessing from gastric cancer (GC) patients. We verified GJ-EVs by morphological experiments, i.e., nanoparticle tracking system analysis and electron microscopy. In addition, protein and microRNA markers of EVs were examined by Western blotting analysis, Bioanalyzer, or quantitative reverse transcription polymerase chain reaction. GJ-EVs were found to promote the proliferation of normal fibroblast cells. Our findings suggest that isolates from the GJ of GC patients contain EVs and imply that GJ-EVs partially affect their microenvironments and that analysis using GJ-EVs from GC patients will help to clarify the pathophysiology of GC.

Functional evaluations comparing the double-tract method and the jejunal interposition method following laparoscopic proximal gastrectomy for gastric cancer: an investigation including laparoscopic total gastrectomy.

PURPOSE: Functional outcomes were prospectively compared between two types of reconstruction [double tract (L-DT; n = 15) and jejunal interposition (L-JIP; n = 15)] following laparoscopic half-proximal gastrectomy (LPG), including laparoscopic total gastrectomy (L-TG; n = 30) as a control group, at 1 year after surgery. METHODS: Clinical investigations were performed in each patient, and functional evaluations, involving the swallowing of an alimentary liquid containing acetaminophen (AAP), followed by measurements of the concentrations of AAP and hormones in the sitting (n = 5) and in the supine positions (n = 5), were carried out in each group. RESULTS: The post-/preoperative body weight ratios were significantly higher in the L-DT and L-JIP groups than in the L-TG group. The AAP levels were significantly lower in the LPG group than in the LTG group. The AAP, insulin, and gastrin levels in the L-JIP group were markedly increased in the sitting position compared with the supine position, while those in the L-DT and L-TG groups were stable in both positions. CONCLUSIONS: L-JIP and L-DT are procedures that maintain gradual intestinal absorption and help improve the quality of life. Intestinal absorption and hormonal secretion were relatively unaffected by the posture of the meal intake after L-DT, so L-DT might be the procedure providing the most stable results.

The crossover technique for intracorporeal esophagojejunostomy following laparoscopic total gastrectomy: a simple and safe technique using a linear stapler and two barbed sutures.

BACKGROUND: Totally laparoscopic gastrectomy (LG) is preferred over open gastrectomy because it allows safe anastomosis, a small wound, and early bowel recovery. However, esophagojejunostomy (EJS) following laparoscopic total gastrectomy (LTG) remains technically challenging. To popularize LTG, a secure method of reconstruction must be developed. We present a simple and safe technique for intracorporeal EJS following LTG. METHODS: Our modified technique for intracorporeal EJS as a part of Roux-en-Y reconstruction following LTG incorporates an isoperistaltic stapled EJS with closure of the entry hole using two unidirectional barbed sutures. First, a side-to-side isoperistaltic EJS is created between the dorsal and left side of the esophagus and the jejunal arm. Second, the opening for the stapler is closed with a two-layer continuous suture using two 15-cm 3-0 V-Loc suture devices. The full-thickness inner layer closure commences from the sides of the staple lines and progresses toward the center of the enterotomy. During suturing, the remaining thread is utilized to apply tension and lift the enterotomy. Once the full-thickness layer closure is complete at the center of the enterotomy, suturing of the second seromuscular layer is started in the forward direction toward each corner to give a crossover-shaped suturing line. RESULTS: From February 2012 to October 2017, 27 patients with gastric cancer underwent LTG with intracorporeal stapled EJS as a part of Roux-en-Y reconstruction. All procedures were successfully performed without any intra- or postoperative anastomosis-related complications. No conversion to other procedures was required. The mean suturing time was 19.1 ± 9.5 min. The mean postoperative time to tolerating a liquid diet was 3.3 days, and the mean hospital stay was 12.1 days. CONCLUSIONS: We herein report our procedure for intracorporeal EJS using a linear stapler and barbed sutures. This technique is simple and feasible and has acceptable morbidity.

Nogo-B (Reticulon-4B) functions as a negative regulator of the apoptotic pathway through the interaction with c-FLIP in colorectal cancer cells.

Nogo-B is a member of the Nogo/Reticulon-4 family and has been reported to be an inducer of apoptosis in certain types of cancer cells. However, the role of Nogo-B in human cancer remains less understood. Here, we demonstrated the functions of Nogo-B in colorectal cancer cells. In clinical colorectal cancer specimens, Nogo-B was obviously overexpressed, as determined by immunohistochemistry; and Western blot analysis showed its expression level to be significantly up-regulated. Furthermore, knockdown of Nogo-B in two colorectal cancer cell lines, SW480 and DLD-1, by transfection with si-RNA (siR) resulted in significantly reduced cell viability and a dramatic increase in apoptosis with insistent overexpression of cleaved caspase-8 and cleaved PARP. The transfection with Nogo-B plasmid cancelled that apoptosis induced by siRNogoB in SW480 cells. Besides, combinatory treatment with siR-Nogo-B/staurosporine (STS) or siR-Nogo-B/Fas ligand (FasL) synergistically reduced cell viability and increased the expression of apoptotic signaling proteins in colorectal cancer cells. These results strongly support our contention that Nogo-B most likely played an oncogenic role in colorectal cancer cells, mainly by negatively regulating the extrinsic apoptotic pathway in them. Finally, we revealed that suppression of Nogo-B caused down-regulation of c-FLIP, known as a major anti-apoptotic protein, and activation of caspase-8 in the death receptor pathway. Interaction between Nogo-B and c-FLIP was shown by immunoprecipitation and immunofluorescence studies. In conclusion, Nogo-B was shown to play an important negative role in apoptotic signaling through its interaction with c-FLIP in colorectal cancer cells, and may thus become a novel therapeutic target for colorectal cancer.

Laparoscopic distal gastrectomy with D2 lymphadenectomy followed by intracorporeal gastroduodenostomy for advanced gastric cancer: technical guide and tips.

In 1994, Kitano and colleagues first reported laparoscopy-assisted Billroth I gastrectomy. Since then, laparoscopic gastrectomy (LG) has been associated with earlier patient recovery compared with open surgery, and has gained increasing international acceptance. Japan Society of Endoscopic Surgery biennial surveys confirm the increasing use of laparoscopic procedures for treatment of gastric cancer in Japan. Its thirteenth national survey indicates that of 31,264 patients treated at Japanese institutions in 2015, approximately 9,500 (30.3%) underwent LG, and laparoscopic distal gastrectomy (LDG) was the procedure most commonly performed. Despite evidence supporting the efficacy of LDG for gastric cancer in the short term, however, uncertainty remains concerning the efficacy of LG. Today, phase III randomized control trials on this procedure are ongoing in East Asian countries. Distal gastrectomy (DG) is the most commonly performed mode of resection, and as appropriate surgical techniques need to be acquired by gastric surgeons, here we describe a 'gold standard' method to perform total LDG.

Protocol for enhanced recovery after surgery improves short-term outcomes for patients with gastric cancer: a randomized clinical trial.

BACKGROUND: The feasibility of the use of the enhanced recovery after surgery (ERAS) protocol in patients with gastric cancer remains unclear. METHODS: This study was a single-center, prospective randomized trial involving patients with gastric cancer undergoing curative gastrectomy. The primary end point was the length of postoperative hospital stay. Secondary end points were the postoperative complication rate, admission costs, weight loss, and amount of physical activity. RESULTS: From July 2013 to June 2015, we randomized 148 patients into an ERAS protocol group (n = 73) and a conventional protocol group (n = 69); six patients withdrew from the study. The hospital stay was significantly shorter in the ERAS protocol group than in the conventional protocol group (9 days vs 10 days; P = 0.037). The ERAS protocol group had a significantly lower rate of postoperative complications of grade III or higher (4.1% vs 15.4%; P = 0.042) and reduced costs of hospitalization (JPY 1,462,766 vs JPY 1,493,930; P = 0.045). The ratio of body weight to preoperative weight at 1 week and 1 month after the operation was higher in the ERAS protocol group (0.962 vs 0.957, P = 0.020, and 0.951 vs 0.937, P = 0.021, respectively). The ERAS protocol group recorded more physical activity in the first week after surgery. CONCLUSIONS: The ERAS protocol is safe and efficient, and seems to improve the postoperative course of patients with gastric cancer.

Laparoscopic gastrointestinal anastomoses using knotless barbed absorbable sutures are safe and reproducible: a single-center experience with 242 patients.

OBJECTIVE: Intracorporeal reconstruction of the digestive tract is technically challenging. The V-Loc 180 wound closure device (Covidien) is a self-anchoring unidirectional barbed suture that obviates the need for knot tying. The aim of this prospective cohort study was to investigate the use of the novel suture in gastrointestinal enterotomy closure. METHODS: The subjects comprised patients with malignant disease who were scheduled to undergo laparoscopic gastrectomy with curative intent. The barbed suture was used to close the entry hole for the linear stapler during intracorporeal reconstruction following laparoscopic gastric resection. The primary endpoint was the proportion of patients who developed anastomotic leakage at the site where the barbed suture was applied. RESULTS: Between July 2012 and March 2015, 242 patients were enrolled. Of 362 anastomoses, the enterotomy hole at 256 sites was closed using the barbed suture. These 256 sites consisted of 95 gastroduodenostomies, 25 gastrogastrostomies, 13 gastrojejunostomies, 90 jejunojejunostomies, 17 esophagojejunostomies and 16 primary closures of the stomach following local gastric resection. There were no anastomosis-related complications, conversion to usual sutures, mechanical closure of the entry hole and reoperation due to adhesive obstructions or mortality over a median follow-up period of 17.8 months. CONCLUSIONS: The use of the unidirectional barbed absorbable suture for gastrointestinal closure is safe and effective in laparoscopic gastrectomy.