Intracorporeal gastrojejunostomy in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy: A case report.

The drawback of intracorporeal gastrojejunostomy using only endoscopic linear staplers in antecolic Roux-en-Y (R-Y) reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy (TLDG) is the occurrence of anastomotic failure, even though this reconstruction system is assumed to prevent intraoperative and postoperative twisting of the gastrojejunostomy and lifted jejunum. This case report presents two patients with gastric cancer who underwent intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG to prevent anastomotic failure of the gastrojejunostomy. After the sacrificed jejunum was created, linear stapling of the greater curvature of the remnant stomach and the lifted jejunum without dividing the jejunum was performed. After removing the sacrificed jejunum and creating a good view of the posterior side of the stapler entry hole, the stapler entry hole was closed from the posterior side to the anterior side, using a single-layer full-thickness and serosubmucosal hand suturing technique with knotted sutures and a knotless barbed suture. No anastomotic failure of the gastrojejunostomy occurred in either patient. Intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing could be an option for gastrojejunostomy in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG because it can aid in the prevention of anastomotic failure.

Laparoscopic Technique and Initial Experiences of Choledocholithotomy Closure With Knotless Unidirectional Barbed Sutures After Surgery for Biliary Stone Disease.

BACKGROUND AND AIM: Between January 2012 and June 2013, we performed laparoscopic choledocholithotomy on 10 cases of common bile duct stone disease. Laparoscopic surgery for common duct stone disease is technically demanding. Particularly, laparoscopic intracorporeal suturing and knot tying for repair of choledochotomy are the most difficult skills in this operative procedures. Barbed sutures has recently been proposed to facilitate laparoscopic suturing. This is the first report demonstrating that the barbed suture could potentially improve the efficacy of the intracorporeal repair of choledochotomy following extirpation of biliary tract stones with less time needed to suture. METHODS: Consecutive 10 patients with common bile duct stones who underwent laparoscopic choledocholithotomy were enrolled in this study. Choledochotomy was closed with V-Loc sutures (15 cm V-Loc 180 sutures) for 7 patients, and a V-20 needle (26 mm, tapered) for 3 patients. RESULTS: The mean choledochotomy closure time was significantly shorter in the V-Loc group (15.2 ± 1.6 min) than in the Vicryl group (23.5 ± 1.5 min). The unidirectional barbed sutures allowed surgeons to use both their hands effectively and to focus exclusively on the placement of the subsequent stitches, without the need to maintain tension on preceding stitches to prevent slippage. And also the unidirectional barbed sutures were able to distribute tension evenly along the suture line, allowing good tissue apposition. CONCLUSION: The knotless unidirectional barbed sutures are a safe and effective tool for choledochotomy repair during surgery for common bile duct stones.

Delta-like 3 is silenced by methylation and induces apoptosis in human hepatocellular carcinoma.

The genetic and epigenetic events of hepato-carcinogenesis are relatively poorly understood. By analyzing genes from human hepatocellular carcinoma (HCC) with restriction landmark genomic scanning, several aberrantly methylated genes, including Delta-like 3 (DLL3), have been isolated. In this study, we investigated the function of DLL3 in hepatocarcinogenesis. Methylation of the DLL3 gene in HCC cell lines was investigated with methylation-specific PCR and expression of DLL3 mRNA in HCC cells was examined by RT-PCR. Reactivation of DLL3 expression by treatment with a demethylating agent was examined in methylation-silenced HuH2 cells. Human DLL3 cDNA was cloned and DLL3 function was examined by restoring DLL3 expression in HuH2 cells. The effects of DLL3 on cell growth were evaluated by colony formation assay. Induction of cell death by overexpression of DLL3 was examined by flow cytometric assay using Annexin V and PI. Apoptotic cells were detected by TUNEL staining and the amount of single-stranded DNA was measured by ELISA. As a result, the promoter region of the DLL3 gene was methylated in four of ten HCC cell lines. This aberrant methyl-ation correlated well with the suppression of RNA expression and a demethylating agent reactivated DLL3 expression in methylation-silenced HCC cells. Interestingly, the restoration of DLL3 in the methylation-silenced HuH2 cells led to growth suppression on colony formation assay. Flow cytometric assay with Annexin V and PI showed that this growth suppression by DLL3 expression is associated with the induction of apoptosis. Furthermore, these apoptotic effects were confirmed by TUNEL staining and measurement of single-stranded DNA. These results suggest that DLL3 was silenced by methylation in human HCC and that it negatively regulates the growth of HCC cells.

Benefits of intracorporeal gastrointestinal anastomosis following laparoscopic distal gastrectomy.

BACKGROUND: Laparoscopic gastrectomy has recently been gaining popularity as a treatment for cancer; however, little is known about the benefits of intracorporeal (IC) gastrointestinal anastomosis with pure laparoscopic distal gastrectomy (LDG) compared with extracorporeal (EC) anastomosis with laparoscopy-assisted distal gastrectomy (LADG). METHODS: Between June 2000 and December 2011, we assessed 449 consecutive patients with early-stage gastric cancer who underwent LDG. The patients were classified into three groups according to the method of reconstruction LADG followed by EC hand-sewn anastomosis (LADG + EC) (n = 73), using any of three anastomosis methods (Billroth-I (B-I), Billroth-II (B-II) or Roux-en-Y (R-Y); LDG followed by IC B-I anastomosis (LDG + B-I) (n = 248); or LDG followed by IC R-Y anastomosis (LDG + R-Y) (n = 128)). The analyzed parameters included patient and tumor characteristics, operation details, and post-operative outcomes. RESULTS: The tumor location was significantly more proximal in the LDG + R-Y group than in the LDG + B-I group (P < 0.01). Mean operation time, intra-operative blood loss, and the length of post-operative hospital stay were all shortest in the LDG + B-I group (P < 0.05). Regarding post-operative morbidities, anastomosis-related complications occurred significantly less frequently in with the LDG + B-I group than in the LADG + EC group (P < 0.01), whereas there were no differences in the other parameters of patients' characteristics. CONCLUSIONS: Intracorporeal mechanical anastomosis by either the B-I or R-Y method following LDG has several advantages over at the LADG + EC, including small wound size, reduced invasiveness, and safe anastomosis. Although additional randomized control studies are warranted to confirm these findings, we consider that pure LDG is a useful technique for patients with early gastric cancer.