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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.

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BACKGROUND: The drawback of the delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG) is the presence of intraoperative duodenal injury and postoperative anastomotic stenosis, which can occur due to a relatively short duodenal bulb diameter. MATERIALS AND METHODS: From June 2013 to June 2019, 35 patients with gastric cancer underwent TLDG with a modified DSG consisting of linear stapling and single-layer hand suturing in our institution. All anastomotic procedures were performed by the right hand of the operator positioned between the patient's legs. Linear stapling of the posterior walls of the remnant stomach and duodenum without creating a gap was performed using a 45-mm linear stapler, considering the prevention of intraoperative duodenal injury. The stapler entry hole was closed using a single-layer full-thickness hand suturing technique with knotted sutures and a knotless barbed suture. We described the clinical data and outcomes in the present retrospective patient series. RESULTS: No intraoperative duodenal injury occurred in any of the 35 patients. The median staple length at linear stapling of the posterior walls of the remnant stomach and duodenum was 41.7 ± 4.2 (30-45) mm, and 2 patients (5.7%) had a staple length of 30 mm. There were no incidences of postoperative anastomotic stenosis. CONCLUSIONS: We suggest that a modified DSG consisting of linear stapling and single-layer hand suturing performed by an operator positioned between the patient's legs can be one option for B-Ⅰ reconstruction following TLDG because it can aid in preventing both intraoperative duodenal injury and postoperative anastomotic stenosis.

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PURPOSE: The study was designed to evaluate the safety and efficacy of adding oxaliplatin to py (CRT) with S-1 in patients with locally advanced rectal carcinoma (LARC). We report here the final results of the study. PATIENTS AND METHODS: Patients with histopathologically confirmed LARC (cT3-T4, any N) were eligible. They received oral S-1 (80 mg/m2/day on days 1-5, 8-12, 22-26, and 29-33) and infusional oxaliplatin (60 mg/m2/day on days 1, 8, 22, 29) plus radiotherapy (1.8 Gy/day, total dose of 50.4 Gy in 28 fractions), with a chemotherapy gap in the third week of radiotherapy. Primary endpoint of the study was pathological complete response (pCR) rate. Secondary endpoints were rates of R0 resection, down-staging, cumulative 3-year local recurrence, 3-year disease-free survival (DFS), and toxicity. RESULTS: Forty-five patients were enrolled at six centers in Japan. All patients received CRT, and 44 underwent operation. The pCR rate was 27.3% (12/44). The R0 resection rate was 95.5% (42/44). T-down-staging rate was 59.1% (26/44), and N-down staging rate was 65.9% (29/44); the combined pathological down-staging rate was 79.5% (35/44). There were no grade 4 adverse events, but 11.1% of the patients had grade 3 adverse events. Cumulative 3-year local recurrence rate was 0%. However, 13 (30.0%) patients suffered from distant metastasis, and one patient suffered from secondary esophageal cancer that was unrelated to rectal cancer. Eight patients had lung metastasis, 4 had liver metastasis, and 3 patients died of the metastatic disease. The 3-year DFS rate of the 44 patients was 67.5% (median follow-up 36.3 months), and the 3-year overall survival (OS) rate was 93.0% (median follow-up 39.6 months). The patients were then divided into the pCR (12 patients) group and non pCR (32 patients) group. The 3-year rate of DFS for each group was 91.7% and 58.1% and that of OS was 100% and 90.3%, respectively. CONCLUSIONS: The study showed a high pCR rate with no severe toxicity, good follow-up results, and good loco-regional control. Therefore, addition of oxaliplatin to preoperative CRT with S-1 in patients with LARC might be feasible and lead to better local control than standard treatment.

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BACKGROUND: The drawback of intracorporeal esophagojejunostomy with the double-stapling technique (DST) using a transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA) following laparoscopic total gastrectomy (LTG) is not only the high incidence of stenosis but also the presence of intractable stenosis that is refractory to endoscopic treatments. METHODS: From November 2013 to December 2016, 24 patients with gastric cancer underwent intracorporeal circular-stapled esophagojejunostomy with the hemi-double-stapling technique (hemi-DST) using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient following LTG to prevent twisting of the esophagojejunostomy and lifted jejunum, which might cause intractable stenosis of the esophagojejunostomy. RESULTS: In this patient series, no twisting of the esophagojejunostomy and lifted jejunum was encountered intraoperatively or postoperatively. Two stenoses of the esophagojejunostomy occurred. Because neither was involved with twisting and both were localized at the anastomotic plane, endoscopic treatments including balloon dilation and electrocautery incisional therapy were successful in both cases. There were no patients with intractable stenosis in this series. CONCLUSIONS: Intracorporeal esophagojejunostomy with the hemi-DST using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient can be one option for a circular stapling technique in LTG due to its prevention of intractable stenosis of the esophagojejunostomy that is refractory to endoscopic treatments.

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We report an option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We detail a single-layer suturing technique for the endoscopic linear stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures. From June 2013 to February 2017, we performed TLDG with delta-shaped gastroduodenostomy in 20 patients with gastric cancer. The linear stapler was closed and fired to attach the posterior walls of the remnant stomach and the duodenum together. After creating a good view of the greater curvature side of the entry hole for the stapler by retracting the knotted suture on the lesser curvature side toward the ventral side, we performed single-layer entire-thickness continuous suturing of this hole using a 15-cm-long barbed suture running from the greater curvature side to the lesser curvature side. We placed the second and third stitches between the seromuscular layer of the remnant stomach and the entire-thickness layer of the duodenum while suturing the duodenal mucosa as minutely as possible. In addition, we routinely added one or two entire-thickness knotted sutures at the site near the greater curvature side. We placed similar additional knotted sutures at the site with a broad pitch. TLDG with this reconstruction technique was successfully performed in all patients with no occurrences of anastomotic leakage or intraabdominal abscess around the anastomosis. It is suggested that this method can be one option for delta-shaped gastroduodenostomy in TLDG due to its cost-effectiveness and feasibility.

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The present study aimed to evaluate whether preoperative chemoradiotherapy (CRT) has any adverse effects on laparoscopic surgery (LS) for locally advanced low rectal cancer (LARC). The study was performed at the Osaka Medical College Hospital, and included patients who were operated on between July 2006 and December 2013. The short-term outcomes in 156 patients who underwent surgery for LARC following CRT were evaluated, of whom 152 underwent LS. Among the patients who were followed for >40 months, 77 patients (the CRT group) were compared with 39 patients who underwent LS without CRT (the surgery-alone group) for long-term outcomes. The total number of patients who received sphincter-preserving surgery was 74%. No positive longitudinal resection margins were identified, and only 1.3% had identifiable positive circumferential resection margins. The complication rate was 14%, and no serious complications occurred. There were no significant differences between the CRT and the surgery-alone groups in terms of the 5-year relapse-free survival rate (70.1 vs. 61.5%; P=0.81) or the 5-year overall survival rate (88.3 vs. 69.2%; P=0.06). However, the 5-year local recurrence-free survival rate was significantly improved in the CRT group patients (96.1 vs. 79.5%; P=0.009). In conclusion, our results have demonstrated that LS with preoperative CRT appears to be feasible and safe, and may have beneficial effects on local recurrence.

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PURPOSE: This study was designed to evaluate the safety and efficacy of adding oxaliplatin to preoperative chemoradiotherapy (CRT) with S-1 in patients with locally advanced rectal carcinoma (LARC). PATIENTS AND METHODS: This was a multicenter phase II study in patients with histologically proven clinical stage T3 or T4 (any N, M0) LARC. Patients preoperatively received oral S-1 (80 mg/m(2)/day on days 1-5, 8-12, 22-27, and 29-33) and infusional oxaliplatin (60 mg/m(2) days on 1, 8, 22, and 29) plus radiotherapy (50.4 Gy), with a chemotherapy gap in the third week of radiotherapy. Pathological complete response (pCR) was the primary endpoint. Secondary endpoints included toxicity, compliance, R0 resection rate, and downstaging rate. RESULTS: A total of 45 patients were enrolled at six centers in Japan. All 45 patients received CRT, and 44 underwent operation. A pCR was achieved in 12 (27.3%) of the 44 patients who underwent surgery. Near-total tumor regression was confirmed in 47.7%. There were no grade 4 adverse events, and 11.1% of the patients had grade 3 adverse events. R0 resection was achieved in 95.5% of the patients. CONCLUSION: Preoperative CRT with S-1 plus oxaliplatin had a high pCR rate and a favorable toxicity profile.

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BACKGROUND: The objective of this phase I study was to determine the maximum tolerated dose (MTD) and recommended dose (RD) of preoperative chemoradiotherapy (CRT) with S-1 plus oxaliplatin in patients with locally advanced rectal cancer. METHODS: Patients received radiotherapy in a total dose of 50.4 Gy in 28 fractions. Concurrent chemotherapy consisted of a fixed oral dose of S-1 (80 mg/m(2)/day) on days 1-5, 8-12, 22-27, and 29-33, plus escalated doses of oxaliplatin as an intravenous infusion on days 1, 8, 22, and 29. Oxaliplatin was initially given in a dose of 40 mg/m(2)/week to three patients. The dose was then increased in a stepwise fashion to 50 mg/m(2)/week and the highest dose level of 60 mg/m(2)/week until the MTD was attained. RESULTS: Thirteen patients were enrolled, and 12 received CRT. Dose-limiting toxicity (DLT) occurred in two of six patients (persistent grade 2 neutropenia, delaying oxaliplatin treatment by more than 3 days) at dose level 3; there were no grade 3 or 4 adverse events defined as DLT. The RD was 60 mg/m(2)/week of oxaliplatin on days 1, 8, 22, and 29. Twelve patients underwent histologically confirmed R0 resections, and two out of six patients (33%) given dose level 3 had pathological complete responses. CONCLUSIONS: The RD for further studies is 80 mg/m(2) of S-1 5 days per week plus 60 mg/m(2) of oxaliplatin on days 1, 8, 22, and 29 and concurrent radiotherapy. Although our results are preliminary, this new regimen for neoadjuvant chemoradiotherapy is considered safe and active. TRIAL REGISTRATION: This trial was registered with Clinicaltrials.gov (identifier: NCT01227239 ).

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Laparoscopic surgery is widespread and is safe and effective for the management of patients with colorectal cancer. However, surgical site infection (SSI) remains an unresolved complication. The present study investigated the comparative effect of supraumbilical incision versus transumbilical incision (TU) on the incidence of SSI in patients undergoing laparoscopic surgery for colon cancer. Medical records from patients with colorectal cancer who underwent laparoscopic sigmoid and rectosigmoid colon surgeries with either supraumbilical incision (n = 150) or TU (n = 150) were retrospectively reviewed. There was no difference in demographics, comorbidities, or operative variables between the two groups. The transumbilical group and the supraumbilical group were comparable with regards to overall SSI (6.0% vs 4.0%; P = 0.4062), superficial SSI (6.0% vs 3.3%; P = 0.2704), and deep SSI (0% vs 0.7%; P = 0.2385). SSI developed after laparoscopic sigmoid and rectosigmoid colon cancer surgery in 15 (5.0%) of the 300 patients. Of these superficial SSI, all wounds were in the left lower quadrant incision, and the transumbilical port sites did not become infected. Univariate analysis failed to identify any risk factors for SSI. Avoidance of the umbilicus offers no benefit with regard to SSI compared with TU.

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The role of laparoscopic surgery for transverse and descending colon cancer remains controversial. The aim of the present study was to characterize the learning curve for laparoscopic left hemicolectomy including the splenic flexure and to identify factors that influence this learning curve. Data from 120 consecutive patients undergoing laparoscopic left hemicolectomy for transverse and descending colon cancer including the splenic flexure between December 1996 and December 2009 were analyzed. Patients undergoing resection combined with cholecystectomy, hepatectomy, hysterectomy, or gastrectomy were excluded. Operative time was analyzed using the moving average method. The operative time, conversion rate, and postoperative complication rate were evaluated among four groups based on the number of cases required for analysis of operative time. In addition, risk factors that influenced conversion to open surgery were analyzed. Operative time for left hemicolectomy decreased with increasing case number with stabilization at 30 cases. There was no significant difference in the conversion rate or postoperative complications over time. Significant factors for conversion to open surgery were T stage (odds ratio [OR], 5.56; 95% confidence interval [CI], 1.5 to 27.4) and previous abdominal surgery (OR, 5.38; 95% CI, 1.6 to 20.2). The learning curve for laparoscopic left hemicolectomy is steep. Thus, surgeons in the early part of this curve should carefully select patients to allow them to build experience in a stepwise manner. Laparoscopic surgery may become the gold standard for management of colon cancer regardless of stage or tumor location.

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OBJECTIVE: The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colectomy was retrospectively investigated. DESIGN: This retrospective cohort study was conducted from December 1996 through December 2009. SETTING: This study was conducted at Osaka Medical College Hospital. PATIENTS: A total of 1701 consecutive patients who had undergone laparoscopic resection of the colon and rectum were classified as not having previous abdominal surgery (n = 1121) or as having previous abdominal surgery (n = 580). MAIN OUTCOME MEASURES: Short-term outcomes were recorded, and risk factors for conversion to open surgery were analyzed. RESULTS: There were no significant differences in operative time, blood loss, number of lymph nodes removed, or conversion rate between the groups. The rate of inadvertent enterotomy was significantly higher in the previous abdominal surgery group than in the not having previous abdominal surgery group (0.9% versus 0.1%; p = 0.03), and the postoperative recovery time was significantly longer in the previous abdominal surgery group than in the not having previous abdominal surgery group. Ileus was more frequent in the previous abdominal surgery group than in the not having previous abdominal surgery group (3.8% versus 2.1%; p = 0.04). Significant risk factors for conversion to open surgery were T stage ≥3 (OR, 2.81; 95% CI, 1.89-3.75), median incision (OR, 4.34; 95% CI, 1.23-9.41), upper median incision (OR, 2.78; 95% CI, 1.29-5.42), lower median incision (OR, 1.82; 95% CI, 1.09-3.12), and transverse colectomy (OR, 1.76; 95% CI, 1.29-2.41). CONCLUSION: The incidence of successfully completed laparoscopic colectomy after previous abdominal surgery remains high, and the short-term outcomes are acceptable.

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We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy to the lesser omental cleft in a 61-year-old female. We performed laparoscopic-assisted partial resection of the transverse colon to treat transverse colon cancer. Three years and 6 months after the operation, the patient developed a bowel obstruction requiring surgical intervention. When we observed the intraperitoneal space under laparoscopy, we determined that the small intestine had passed into the bursa omentalis through the mesenteric defect. Additionally, an abnormal opening of the lesser omentum was present with a portion of the small intestine escaping into the space inferior to the liver. We performed reintegration of the escaped bowel and closed the mesenteric defect laparoscopically. This is the first case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy that we have experienced out of more than 2400 cases. Further research is needed to identify the patients who would benefit from the closure of mesenteric defects during laparoscopic-assisted colectomy.

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BACKGROUND: The role of laparoscopic surgery in management of transverse and descending colon cancer remains controversial. The aim of the present study is to investigate the short-term and oncologic long-term outcomes associated with laparoscopic surgery for transverse and descending colon cancer. METHODS: This cohort study analyzed 245 patients (stage II disease, n = 70; stage III disease, n = 63) who underwent resection of transverse and descending colon cancers, including 200 laparoscopic surgeries (LAC) and 45 conventional open surgeries (OC) from December 1996 to December 2010. Short-term and oncologic long-term outcomes were recorded. RESULTS: The operative time was longer in the LAC group than in the OC group. However, intraoperative blood loss was significantly lower and postoperative recovery time was significantly shorter in the LAC group than in the OC group. The 5-year overall and disease-free survival rates for patients with stage II were 84.9% and 84.9% in the OC group and 93.7% and 90.0% in the LAC group, respectively. The 5-year overall and disease-free survival rates for patients with stage III disease were 63.4% and 54.6% in the OC group and 66.7% and 56.9% in the LAC group, respectively. CONCLUSION: Use of laparoscopic surgery resulted in acceptable short-term and oncologic outcomes in patients with advanced transverse and descending colon cancer.

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Laparoscopic colorectal resection has been applied to advanced colorectal cancer. Synchronous liver metastasis of colorectal cancer would be treated safely and effectively by simultaneous laparoscopic colorectal and hepatic resection. Seven patients with colorectal cancer and synchronous liver metastasis treated by simultaneous laparoscopic resection were analyzed retrospectively. Three patients received a hybrid operation using a small skin incision, 2 patients underwent hand-assisted laparoscopic surgery using a small incision produced for colonic anastomosis, and 2 patients were treated with pure laparoscopic resection. The mean total operation duration was 407 minutes, and mean blood loss was 207 mL. Negative surgical margins were achieved in all cases. Mean postoperative hospital stay was 16.4 days. No recurrence at the surgical margin was observed in the liver. For selected patients with synchronous liver metastasis of colorectal cancer, simultaneous laparoscopic resection is useful for minimizing operative invasiveness while maintaining safety and curability, with satisfying short- and long-term results.

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BACKGROUND: Laparoscopic low anterior resection for rectal cancer is considered to be more technically demanding than laparoscopic colectomy. This study aimed to analyze the learning curve for laparoscopic low anterior resection and to identify the factors that influence this learning curve. METHODS: Data from 250 consecutive patients undergoing laparoscopic low anterior resection for rectal cancer, excluding patients with a combined resection such as cholecystectomy, hepatectomy, hysterectomy, or gastrectomy, between December 1996 and April 2010 were analyzed. For operative time, the learning curve was analyzed using the moving average method. The conversion rate and the postoperative complication rate were evaluated in five groups of up to 50 patients each based on the number of cases required for analysis of operative time. In addition, risk factors that influenced conversion to open surgery and postoperative complications were analyzed. RESULTS: The learning curve analysis for operative time using the moving average method showed stabilization at 50 cases. The conversion rate decreased significantly by group 4 (151-200 cases). The postoperative complication rate decreased significantly by group 5 (201-250 cases). The significant factors for conversion to open surgery were male sex (odds ratio [OR], 2.6094; 95% confidence interval [CI], 1.1-6.4) and T stage (OR, 2.4793; 95% CI, 1.1-5.8). For postoperative complications, male sex (OR, 3.8590; 95% CI, 1.9-3.8) was significant. In addition, the risk factors for anastomotic leakage were male sex (OR, 15.7659, 95% CI, 3.2-284.8) and multiple firing (2 or more cartridges for rectal transection) (OR, 3.0589; 95% CI, 1.1-9.5). CONCLUSIONS: The risk factors affecting the learning curve for laparoscopic low anterior resection were T stage and male sex. In laparoscopic low anterior resection, rectal transection in particular can be technically difficult, and standardization for accurate performance of the same technique for expanded indications is very important.

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BACKGROUND AND OBJECTIVES: Chymase is expressed in mast cells and induces angiogenesis via activation of angiotensin II and matrix metalloproteinase-9. However, it has been unclear whether chymase is involved in the pathophysiology of angiogenesis in gastric cancer. To clarify the contribution of chymase to angiogenesis in gastric cancer, we assessed the relationship between chymase-positive cells and tumor angiogenesis. METHODS: We evaluated chymase-positive cells and microvessels using anti-human chymase and anti-CD34 antibodies in 168 cases of gastric cancer, respectively. RESULTS: Chymase-positive cells in gastric tumor region were significantly higher than the cells in normal region. The number of chymase-positive cells in the undifferentiated type of gastric tumor region was significantly higher than the one in the differentiated type. Specimens from patients with advanced histological stages of disease had more chymase-positive cells than those with early-stage disease. There was a significant positive correlation between chymase-positive cells and microvessels in gastric cancer specimens. Postoperative survival curves revealed that patients with a high number of chymase-positive cells had a poor prognosis. CONCLUSIONS: These results suggest that accumulation of chymase-positive cells in gastric cancer may lead to an increase of tumor angiogenesis, and may contribute to tumor growth and progression.

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