Background: Malnutrition is common among patients with cancer and has been associated with unfavorable postoperative outcomes, including higher rates of complications. This study aimed to synthesize current evidence on the relationship between malnutrition, as defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria, and postoperative outcomes after curative surgery for upper gastrointestinal (GI) cancers. Methods: We systematically searched the literature from database inception to 28 March 2026. Studies were eligible if they included adult patients with upper GI cancer who underwent surgical resection and had their nutritional status evaluated according to the GLIM criteria. We conducted a systematic review and random-effects meta-analysis. The primary outcomes were overall survival and overall postoperative complications, defined as events with a Clavien-Dindo grade ≥ II occurring within 30 days after surgery. Hazard ratios with 95% confidence intervals for overall survival and risk ratios with 95% CIs for postoperative complications were pooled. Results: Fourteen studies (17 reports) including a total of 7876 patients were eligible for both qualitative and quantitative synthesis. Compared with patients without malnutrition, those with GLIM-defined malnutrition showed poorer overall survival (hazard ratio: 1.96, 95% confidence interval: 1.57-2.45) and a higher risk of postoperative complications (risk ratio: 1.43, 95% confidence interval: 1.14-1.79). Conclusions: GLIM-defined malnutrition was associated with shorter overall survival and a higher incidence of postoperative complications in patients with upper GI cancer after surgery. However, because most included studies were observational and at low-to-moderate certainty of evidence, these associations should be interpreted with appropriate caution.

Gastric cancer (GC) often exhibits resistance to anti-programmed death-1 (PD-1) immunotherapy. Immunogenic cell death (ICD) enhances antitumor immunity, and trifluridine/tipiracil (FTD/TPI) induces ICD and modulates immunity. Radiation therapy (RT) may trigger abscopal effects. We investigated whether FTD/TPI combined with RT enhances tumor immunity in GC and its impact with PD-1 blockade. ICD induction by FTD and RT in YTN16 mouse GC cells was assessed by calreticulin, high-mobility group box 1 (HMGB1), and ATP evaluation. A dual subcutaneous YTN16 tumor model was established in C57BL/6J mice; mice were treated with FTD/TPI and RT (with irradiation of the first tumor). ICD was induced in vitro by FTD or RT and enhanced by the combination, as indicated by increased calreticulin surface expression and HMGB1 and ATP release. ICD induction in the first tumor was confirmed by HMGB1 release. FTD/TPI + RT suppressed growth of the second tumor and enhanced antitumor immunity by increasing CD8⁺ T-cell infiltration and depleting M2 macrophages. PD-1 expression on CD8⁺ T cells increased after FTD/TPI + RT; adding anti-PD-1 further suppressed the second tumor growth. Our findings support clinical trials of this triple-combination strategy in advanced GC, particularly in subgroups refractory to immune checkpoint blockade.

BACKGROUND:Robotic gastrectomy (RG) is increasingly adopted for the treatment of gastric cancer due to its technical advantages. However, specific complications such as subcutaneous emphysema (SE) and port site dilation (PSD) may arise due to pneumoperitoneum and trocar manipulation. This study aimed to investigate the incidence and risk factors of SE and PSD, with a focus on differences between robotic platforms. METHODS:This retrospective study included 126 patients who underwent RG between April 2021 and April 2025. SE was defined as subcutaneous gas extending to the anterior chest wall on postoperative day 1. PSD was evaluated using intraoperative videos and defined as a visible gap between the trocar and abdominal wall. Multivariable logistic regression was performed to identify independent predictors of SE and PSD, including robotic system type (da Vinci Xi vs. hinotori™). RESULTS:SE and PSD were observed in 20 (15.9%) and 21 (16.7%) patients, respectively. The use of the hinotori™ was independently associated with a lower incidence of SE (OR: 0.085, 95% CI: 0.01-0.70, p = 0.02) and PSD (OR: 0.089, 95% CI: 0.016-0.39, p = 0.001). No significant association was found between SE or PSD and postoperative complications of Clavien-Dindo grade ≥ II or ≥ III. CONCLUSIONS:The docking-free hinotori™ platform significantly reduced the incidence of SE and PSD compared to the da Vinci Xi. Recognizing the mechanical features of each robotic system and tailoring platform selection to patient and procedural factors may improve surgical outcomes.

INTRODUCTION: Primary parahiatal hernias are rare in adults. We report the case of a young woman with a parahiatal hernia without obvious predisposing factors that resulted in gastric fundus necrosis. CASE PRESENTATION: A 34-year-old woman had experienced intermittent chest pain for 2 months but had not sought medical attention. She developed sudden-onset left chest pain without a history of trauma, with the pain worsening on inspiration. Her previous physician suspected a left lung abscess and referred her to our facility. Contrast-enhanced CT revealed a cavity with internal air above the diaphragm in the left thoracic cavity, which was continuous with the stomach in the abdominal cavity. We diagnosed an incarcerated diaphragmatic hernia with gastric ischemia and proceeded with emergency laparoscopic surgery. Intraoperatively, the gastric fundus was found to be incarcerated in the left diaphragm, and the hernial orifice was located just to the left of the esophageal hiatus. A diagnosis of parahiatal hernia was confirmed. The incarcerated gastric fundus was repositioned into the abdominal cavity. The hernial orifice was closed using nonabsorbable barbed sutures, and the necrotic gastric fundus was resected. The postoperative course was uneventful, and the patient was discharged on POD 13. CT at the 1-month follow-up revealed no recurrence of the parahiatal hernia. CONCLUSIONS: Parahiatal hernia is extremely rare but may be life-threatening if diagnosed late. In this case, laparoscopic repair and resection of the necrotic gastric fundus were successfully performed.

Purpose Postoperative pulmonary complications (PPCs) in patients with colorectal cancer worsen long-term survival, making preoperative prediction and prevention critically important. However, the association between the preoperative respiratory function and PPCs in colorectal cancer surgery remains unclear. This study aimed to clarify the association between respiratory function and the occurrence of PPCs after colorectal cancer surgery. Methods This retrospective study included patients who underwent colorectal cancer surgery and preoperative respiratory tests at Kanazawa University Hospital between November 2006 and May 2025. Normal respiratory function was defined as forced expiratory volume in one second/forced vital capacity ratio (FEV 1 /FVC) ≥ 70%, and low respiratory function was defined as FEV 1 /FVC < 70%. The primary outcome was PPC incidence, including pneumonia and atelectasis. We performed propensity score matching to adjust for patient backgrounds and used a logistic regression model to identify factors associated with PPCs. Statistical significance was set at P < 0.05. Results Of the 1164 patients, 839 (72.1%) had normal and 325 (27.9%) had low respiratory function. After matching, 166 patients were included in each group. No statistically significant difference in PPC incidence was found between the two groups (P = 0.283). In a multivariate analysis, low respiratory function was not a significant risk factor for PPCs (odds ratio: 1.070, 95% confidence interval: 0.448–2.540). Conclusion Preoperative respiratory function may not be associated with PPC incidence after colorectal cancer surgery. Large-scale, multicenter prospective studies are required to demonstrate the validity of the association between preoperative respiratory function and the incidence of PPCs.

Artificial intelligence (AI)–based anatomical recognition has emerged to support intraoperative cognition; however, its clinical utility beyond education remains limited. This study aimed to develop an AI model for suprapancreatic lymph node dissection during robotic distal gastrectomy (RDG) and evaluate its utility for intraoperative decision-making by surgeons. We developed a deep learning model using 67 RDG videos (54 for training and 13 for testing) to recognize the pancreas, common hepatic artery (CHA), left gastric artery (LGA), and left gastric vein (LGV). Model performance was evaluated using Intersection over Union (IoU). Twenty surgeons participated in two experiments: experiment 1 assessed peritoneal incision line selection, rated by three experts on a 5-point scale, and experiment 2 assessed the time to CHA identification in a crossover design. The IoU values for the pancreas, CHA, LGA, and LGV were 0.66, 0.28, 0.216, and 0.232, respectively. In mixed-effects models, experiment 1 showed that AI assistance reduced the proportion of unsafe peritoneal incision lines (scores 1–2) compared with no assistance (odds ratio, 0.25; 95

BACKGROUND/OBJECTIVE:Evaluating the response to neoadjuvant chemotherapy in esophageal squamous cell carcinoma (ESCC) is challenging because primary tumors are often classified as non-measurable under the RECIST criteria. This study investigated whether two-dimensional computed tomography (CT) measurements predict pathological response and prognosis after neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy in ESCC. METHODS:We retrospectively analyzed 123 patients who underwent radical esophagectomy following DCF therapy at two institutions (April 2011-March 2024). Changes in the short-axis, long-axis, and short-axis × long-axis diameters of the primary tumor after preoperative chemotherapy were measured on contrast-enhanced CT, and the reduction rate for each parameter was assessed. Based on the optimal cutoff values, univariate and multivariate analyses were conducted to identify significant predictors of pathological response. RESULTS:The short-axis × long-axis diameter reduction rate (SLRR) demonstrated the highest area under the curve (0.901), with a cutoff value of 0.55 for predicting pathological response, and it was the only independent predictor in the multivariate analysis (odds ratio, 6.27; p = 0.048). In group comparisons using the SLRR cutoff value, patients with a high SLRR had significantly better 3-year recurrence-free survival (67.8% vs. 29.4%, p < 0.001) and overall survival (79.5% vs. 46.6%, p < 0.001) than those with a low SLRR. CONCLUSIONS:The CT-based SLRR independently predicts both pathological response and prognosis after neoadjuvant DCF therapy in ESCC.

We report 2 cases in which skin grafting was avoided by utilizing thoracoepigastric following mastectomy with extensive skin defects due to advanced breast cancer extensively involving the breast.Case 1: A 53-year-old woman was diagnosed with right breast cancer extending to the midline of the chest.She underwent total mastectomy of the right breast, resection of the midline chest skin, and sentinel lymph node biopsy.Intraoperative frozen section analysis revealed positive sentinel nodes, prompting additional axillary lymph node dissection.Due to the extensive skin defect caused by resection of the midline chest skin, a thoracoepigastric flap was created to achieve wound closure.The postoperative course was uneventful.Case 2: A 64-year-old woman developed an intramammary recurrence of right breast cancer during follow-up after prior surgery.The recurrent tumor had extensively spread throughout the breast, with widespread erythema noted on the overlying skin.Multiple axillary lymph node metastases were also present, and neoadjuvant chemotherapy was initiated.Following chemotherapy, she underwent right total mastectomy and axillary lymph node dissection.A thoracoepigastric flap was used for wound closure.Her postoperative course was free of complications.

Background/Objectives: First-line therapy for advanced gastric cancer (AGC) has evolved from cytotoxic chemotherapy to HER2-targeted and immune checkpoint inhibitor (ICI)-based regimens, yet conversion surgery (CS) outcomes across these strategies remain poorly characterized. We describe CS outcomes and prognostic factors by first-line strategy at a single center. Methods: We retrospectively reviewed 187 patients with AGC who began first-line therapy from 2011, grouped as cytotoxic (CTX, n = 127), HER2-targeted (trastuzumab, n = 21), or ICI (n = 39). CS was defined as resection after response, including an extended oligometastatic definition (n = 74). Overall survival (OS) was measured from chemotherapy initiation, and prognostic factors were assessed by Cox regression. Results: Median OS was 14.8, 18.9, and 20.9 months for CTX, trastuzumab, and ICI, respectively (p = 0.048). CS rates were comparable (41%, 33%, and 38%; p = 0.794). Pathological response was more pronounced after trastuzumab/ICI (grade 3 and ypStage 0/1; both p < 0.001). Among CS cases, R0 resection (hazard ratio [HR] 0.31) and trastuzumab/ICI therapy (HR 0.37) were independent favorable factors, whereas high inflammatory-nutritional indices (NLR, CAR) were independent poor prognostic factors. OS was comparable between oligometastatic and conventional CS (p = 0.324). Conclusions: In this hypothesis-generating study, response depth tracked tumor biology, whereas survival was determined by R0 resection, targeted/ICI therapy, and host inflammatory-nutritional status-two largely dissociable axes informing biology- and host-based selection of CS candidates for prospective testing.

Metaplastic breast carcinoma, a rare subtype(<1% of breast cancers), is typically triple-negative with a poor prognosis. The KEYNOTE-522 trial established pembrolizumab plus chemotherapy as a standard treatment for early-stage, high-risk triple-negative breast cancer. We report a case of metaplastic carcinoma with squamous differentiation achieving pathological complete response after neoadjuvant pembrolizumab-based chemoimmunotherapy. This case suggests that pembrolizumab-based chemoimmunotherapy may be a promising option for chemoresistant metaplastic carcinoma.

BACKGROUND:The optimal reconstruction route after esophagectomy remains controversial. The retrosternal route has the advantage of a lower risk of fatal complications. However, the blind maneuver to create a retrosternal route may cause bleeding and pleural injury. Herein, we report a novel robotic technique for creating a retrosternal route. METHODS:This study included 43 consecutive patients with esophageal cancer who underwent robot-assisted minimally invasive esophagectomy with robotic retrosternal route reconstruction between April 2021 and December 2023. Clinicopathological findings and perioperative outcomes, including the time required to create the retrosternal route, were retrospectively analyzed. The creation times were also compared among surgeons. RESULTS:The median age and body mass index of the patients were 68 years (range: 46-80) and 21.4 kg/m2 (range: 16.6-30.2 kg/m2), respectively. Twenty-six patients (60%) received neoadjuvant chemotherapy. The median time to create the retrosternal route was nine minutes (range, 5-14 min). No cases showed pleural injury or postoperative hemorrhage associated with this procedure. There was no significant difference in the time taken to create the retrosternal route between the four surgeons (p = 0.434). CONCLUSIONS:Robotic creation of a retrosternal route for gastric conduit reconstruction is simple, easy to learn, and results in a safe and feasible procedure.

BACKGROUND:The occurrence of a gastrointestinal-airway fistula after esophageal cancer surgery is a serious and fatal complication that can cause severe respiratory complications. It is a pathological condition requiring prompt intervention to avoid a fatal course. Conventionally, highly invasive surgical treatment has been selected for the treatment for gastrointestinal-airway fistula, but its difficulty and mortality risk cannot be neglected. Esophageal stent placement is useful as a nonoperative management for gastrointestinal-airway fistulas, but the success rate of fistula closure is not that high. Hence, an effective method that can solve technical problems to avoid intervention-related complications and increases the success rate of fistula closure by stent placement needs to be developed. We have achieved better results with our unique ingenuity for the management of esophageal stent placement; thus, we aimed to describe the details of the management methods. METHODS:Our technique used in stent placement included endoscopic insertion of the self-expandable metallic stent and the fixation of the stent with a nylon thread and a transnasal catheter on the face. With this ingenuity, it becomes possible to reduce stent migration, and an easy and quick adjustment of its position in case of stent migration can be possible. RESULTS:We have experienced successfully cured cases with our novel technique [five of seven cases (71.4%)] with a minimum indwelling period. CONCLUSIONS:Our technique is feasible for use in the management of gastrointestinal-airway fistula after esophageal cancer surgery.

BACKGROUND:Thoracic epidural analgesia (TEA) is widely used for postoperative pain control in abdominal surgery, but its role in minimally invasive procedures remains unclear. This pragmatic multicentre open-label randomized non-inferiority trial evaluated whether scheduled intravenous acetaminophen combined with local wound infiltration provides non-inferior analgesia to TEA following minimally invasive gastrectomy. METHODS:Adults with gastric adenocarcinoma categorized as clinical stage I-III (according to the Japanese classification of gastric carcinoma) who were undergoing laparoscopic or robot-assisted gastrectomy were randomized 1 : 1 to TEA or scheduled intravenous acetaminophen (1 g every 6 hours (h) for 72 h). All patients received wound infiltration with ropivacaine. Participants and clinicians were not blinded to the randomization; statisticians were masked. The primary endpoint in the study was the proportion of patients with a numerical rating scale (NRS) pain score ≥ 4 at rest 24 h after surgery, with a prespecified non-inferiority margin of 20 percentage points. Analyses used the modified intention-to-treat population. RESULTS:Between June 2020 and May 2024, 140 patients were randomized and 135 were analysed (TEA 68, acetaminophen 67). At 24 h after surgery, 27.9% of patients in the TEA group and 23.9% in the acetaminophen group had an NRS score ≥ 4 at rest (risk difference -4.1%; 95% confidence interval -24.3 to 16.6), confirming non-inferiority. Pain trajectories, rescue analgesic use, patient satisfaction, and recovery were comparable between the two groups. No patient required rescue opioids, and there were no serious catheter- or acetaminophen-related adverse events. CONCLUSION:Scheduled intravenous acetaminophen with wound infiltration was non-inferior to TEA for postoperative pain after minimally invasive gastrectomy and provided safe, effective, and opioid-sparing analgesia consistent with enhanced recovery principles. Registration number: UMIN000039505 (https://www.umin.ac.jp/english/).

INTRODUCTION:The onset of colorectal cancer during pregnancy is rare, and no standard treatment has been established. In this report, we present the case of a woman with clinical stage II rectal cancer diagnosed in the second trimester, in which neoadjuvant chemotherapy was administered, followed by delivery once fetal development was sufficiently advanced, and surgery was performed afterward. CASE PRESENTATION:The patient was a 36-year-old woman at 22 weeks of gestation. Sigmoidoscopy was performed for hematochezia, which revealed a semicircular type 2 tumor in the rectum. A biopsy confirmed the presence of adenocarcinoma. A thorough systemic examination revealed no lymph nodes or distant metastases. After discussing the risks and benefits with the patient, her family, a pediatrician, and an obstetrician, we decided to administer neoadjuvant chemotherapy. The plan was to deliver the fetus after it had adequately developed and then perform radical surgery for rectal cancer after delivery. Neoadjuvant chemotherapy comprised 4 courses of the modified FOLFOX6 regimen, including leucovorin calcium (folinic acid), fluorouracil, and oxaliplatin. The patient had a vaginal delivery at 35 weeks and 5 days of gestation, 23 days after the last chemotherapy dose. The newborn was healthy with no congenital anomalies. On the 27th day after delivery, a robot-assisted low anterior resection of the rectum was performed. The pathological findings revealed rectal cancer located above the peritoneal reflection, ypT2N0M0, and ypStage I. The patient recovered well and was discharged 12 days after surgery. At the time of writing, both the mother and child are doing well, with no evidence of recurrence 6 months after surgery. CONCLUSIONS:In cases of colorectal cancer during pregnancy, it is important to select a treatment plan that considers the site and stage of the tumor, number of weeks of pregnancy, and conditions of the fetus and mother. Even in cases of clinical stage II colorectal cancer diagnosed during the second trimester, where immediate surgery is not feasible, neoadjuvant chemotherapy can be considered a viable treatment option.

Single-incision laparoscopic surgery (SILS) and needle forceps have been introduced to enhance cosmetic outcomes and reduce postoperative pain. However, in demanding procedures like total gastrectomy, these approaches can be technically challenging due to limited triangulation and lack of assistant support. We report the case of a 31-year-old woman with gastric cancer who requested a cosmetically favorable procedure. A total gastrectomy with D2 lymphadenectomy was performed using a SILS approach with one 3-mm needle forceps. To maintain adequate exposure without an assistant port, we utilized an adjustable organ retractor that allows multidirectional traction by repositioning external sutures. This technique provided stable visualization and facilitated a safe, oncologically appropriate dissection. The patient was discharged uneventfully without major complications and remains recurrence-free at 3 years. We report a technical modification that enabled the safe performance of SILS total gastrectomy using a needle forceps in combination with an adjustable organ retractor.

Double-tract reconstruction is commonly performed after proximal gastrectomy to prevent gastroesophageal reflux and ensure adequate nutrition. We developed a modified double-tract reconstruction intervention, denominated the NI method, in which the anastomosis between the remnant stomach and jejunum was strategically configured to optimize food passage and suppress gastroesophageal reflux. This retrospective study included patients with upper-third gastric cancer and adenocarcinoma of the esophagogastric junction who underwent proximal gastrectomy with either conventional or NI-modified double-tract reconstruction at two institutions. Postoperative outcomes, including body weight loss and incidence of reflux esophagitis, were compared. In total, 115 patients underwent proximal gastrectomy with double-tract reconstruction, including 35 with the NI method and 110 using the conventional method. No significant differences were observed in the baseline characteristics between the two groups. The incidence of reflux esophagitis was significantly lower in the NI group (0

The malignancy risk has increased following improvements in the long-term survival rates after liver transplantation. Reports show a 23.4-fold increase in the risk of de novo esophageal cancer after liver transplantation compared to the general population. We report the case of a 47-year-old female diagnosed with early esophageal cancer after liver transplantation. Endoscopic submucosal dissection was performed; however, due to it being a noncurative resection, additional treatment was required. Total robot-assisted minimally invasive esophagectomy (RAMIE) was performed using a robot for thoracic and abdominal procedures. Although extensive adhesions were observed after liver transplantation, precise surgery using the robot did not damage any vital organs, such as the graft blood vessels. The patient was discharged without postoperative complications. Total RAMIE for esophageal cancer after liver transplantation is a feasible and safe option following careful evaluation of the patient's condition, and expands the possibilities of successful complex posttransplant surgeries through robotic precision.