This study aimed to investigate problems and learning curves experienced by a single surgeon performing robotic-assisted rectal surgery (RRS) for the first time. Among 62 consecutive patients who underwent RRS between May 2021 and December 2022, 30 with high anterior resection (HAR) performed by a single surgeon qualified according to the endoscopic surgical skill qualification system were retrospectively reviewed. Operative feasibility and surgical outcomes were evaluated. The cumulative sum (CUSUM) was used to visualize the learning curve of the operation time. No cases were converted to open surgery. The operative time (median, range) was 313 (163-645) min, the amount of blood loss was 5 (5-550) ml, and postoperative complications occurred in 10 (16.1%) of all 62 patients. Among 30 patients with HAR, the surgeon console time for the 10 patients in the early period was 160 (78-271) min, and that in the later period was 118 (86-234) min for 20 (P=0.03). The differences in the duration of lymph node dissection and mesorectal transection were significant between the early and later periods (P<0.01). No difference in the frequency of postoperative complications was found. RRS is a minimally invasive and safe technique even for an inexperienced surgeon according to the rectal endoscopic educational system. To shorten the learning curve, mastery of the surgical procedure of lymph node dissection and mesorectal dissection is necessary.

Brittle diabetes, malabsorption, and liver steatosis are the most common adverse consequences of total pancreatectomy （TP）. While some authors have described gastric venous congestion and bleeding, details of gastric venous drainage following TP remain incompletely known. We examined the effectiveness of our methods for avoiding gastric venous congestion in five patients who recently underwent TP. During TP, our standard practice is preservation of at least one vein providing gastric drainage. When no pancreatic vein draining the stomach can be preserved, a relatively extensive gastrectomy is added. Among five patients who underwent TP, preservation of the left gastric vein was possible in three patients, whereas the posterior and short gastric veins and the splenic vein were preserved in one patient. These four patients underwent subtotal stomach-preserving TP or TP with distal gastrectomy in two patients each. One patient requiring sacrifice of all gastric drainage veins additionally underwent TP with subtotal gastrectomy. No patient developed gastric venous congestion or bleeding; patency of drainage veins in four patients was confirmed by postoperative three-dimensional computed tomography. Postoperative body weight decreased compared with preoperative weight in three patients; however, nutritional parameters on postoperative blood tests did not significantly change compared with preoperative values. The favorable outcomes of our strategy for gastric vein preservation in TP should encourage more frequent use of TP when required.

Background & aims: Preoperative low skeletal muscle mass and obesity have been identified as poor prognostic factors after gastrectomy for cancer, but the predictive value of combined quantitation of skeletal muscle mass and obesity remains unclear. This study examined the impact of combined body compositions on outcomes after gastrectomy for cancer. Methods: 518 patients who had undergone gastric resection for cancer between 2004 and 2017 were analyzed retrospectively. Skeletal muscle mass (skeletal muscle mass index (SMI)) and visceral obesity (visceral fat area) were measured in preoperative computed tomographic images to categorize patients as outlined below. Impacts of these body compositions on outcomes after gastrectomy were investigated. Results: Body composition was classified as high SMI without obesity in 231 patients (45%), high SMI with obesity in 202 (39%), low SMI without obesity in 55 (11%), and low SMI with obesity in 30 (6%). Postoperative complications developed in 128 patients (25%). Multivariate analysis identified low SMI with obesity as an independent risk factor for postoperative complications (odds ratio, 3.27; P = 0.010). Moreover, patients with low SMI without obesity had lower 5-year overall survival rates than patients with high SMI without obesity (64.4% vs. 88.0%; P < 0.001) and worse 5-year relapse-free survival rates (61.3% vs. 81.3%; P = 0.002). Multivariate analysis identified low SMI without obesity as a significant risk factor for overall survival (hazard ratio, 3.033; P < 0.001) and relapse-free survival (hazard ratio, 2.144; P = 0.008) after gastrectomy. Conclusion: Preoperative low SMI with obesity was an independent risk factor for postoperative complications, while low SMI without obesity was an independent risk factor for overall and relapse-free survival following gastrectomy for cancer. (c) 2022 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Background Pancreatoduodenectomy including resection of the superior mesenteric vein (SMV) is increasingly performed for right-sided pancreatic ductal adenocarcinoma invading the wall of that vessel. Various venous grafts may be chosen for reconstruction. We present a woman with pancreatic cancer who underwent such a pancreatoduodenectomy with venous reconstruction using a dilated right ovarian vein. Case presentation A 71-year-old woman with cancer involving the pancreatic head, uncinate process, and SMV underwent pancreatoduodenectomy with SMV resection. Reconstruction used a portion of the right ovarian vein that was markedly dilated and had placed her at risk for pelvic congestion syndrome (PCS). Graft patency was confirmed 8 months after surgery. She now finished receiving adjuvant chemotherapy and has no symptoms of PCS. Conclusion If an ovarian vein has sufficient diameter, it can be used to reconstruct the resected segment of the SMV during pancreatoduodenectomy in suitable patients.

Background Laparoscopic gastrectomy (LG) is performed widely, but whether LG is the optimal treatment for sarcopenic gastric cancer patients is unclear. This study aimed to determine whether LG is particularly beneficial for gastric cancer patients with sarcopenia. Methods We collected data concerning 604 consecutive patients who underwent gastrectomy for gastric cancer between January 2003 and December 2019. After adjustment using one-to-one propensity score matching, short-term and long-term outcomes were compared between LG and open gastrectomy (OG) groups among patients with sarcopenia and those without. Results Among patients with and without sarcopenia, the LG group had a significantly longer operative time but less blood loss than the OG group. The two groups showed no significant differences regarding complications. Although 5-year overall and disease-specific survival were similar between LG and OG groups among patients with and without sarcopenia, LG was associated with greater 5-year non-gastric cancer-related survival than OG among patients with sarcopenia (88.3% vs. 78.1%, P = 0.048), but not those without. Conclusion LG for resectable gastric cancer was not inferior to OG regarding complications and outcomes in patients with or without sarcopenia. No difference in overall survival was evident between these approaches, but LG may lessen mortality from conditions unrelated to gastric cancer in sarcopenic patients.

Background Day of the week when elective gastrointestinal surgery is performed may be influenced by various background and tumor-related factors. Relationships between postoperative outcome and when in the week gastrectomy is performed remain controversial. We undertook this study to evaluate whether weekday of gastrectomy influenced outcomes of gastric cancer treatment (“weekday effect”). Methods Patients who underwent curative surgery for gastric cancer between 2004 and 2017 were included in this retrospective study. To obtain 2 cohorts well balanced for variables that might influence clinical outcomes, patients whose gastrectomy was performed early in the week (EW group) were matched 1:1 with others undergoing gastrectomy later in the week (LW group) by use of propensity scores. Results Among 554 patients, 216 were selected from each group by propensity score matching. Incidence of postoperative complications classified as Clavien-Dindo grade II or higher was similar between EW and LW groups (20.4% vs. 24.1%; P = 0.418). Five-year overall and recurrence-free survival were 86.0% and 81.9% in the EW group, and 86.2% and 81.1% in the LW group (P = 0.981 and P = 0.835, respectively). Conclusions Short- and long-term outcomes were comparable between gastric cancer patients who underwent gastrectomy early and late in the week.

Purpose It is known that sarcopenia affects the overall short- and long-term outcomes of patients with gastric cancer (GC); however, the effect of muscle quality on infectious complications after gastrectomy for GC remains unclear. We investigated the associations between the preoperative quantity and quality of skeletal muscle on infectious complications following gastrectomy for GC. Methods The subjects of this retrospective study were 353 GC patients who underwent radical gastrectomy between 2009 and 2018. We examined the relationships between their clinical factors, including skeletal muscle mass index and intramuscular adipose tissue content (IMAC), and infectious complications after gastrectomy. Results Infectious complications developed in 59 patients (16.7%). The independent risk factors for infectious complications identified by multivariate analysis were male gender ( P < 0.001), prognostic nutritional index below 45 ( P = 0.006), and high IMAC ( P = 0.011). Patients with a high IMAC were older and had a higher body mass index, as well as a greater age-adjusted Charlson comorbidity index, than those with low or normal IMAC. Conclusions Low skeletal muscle quality defined by a high IMAC is a risk factor for infectious complications following gastrectomy. When feasible, preoperative nutritional intervention and rehabilitation aiming to improve muscle quality could reduce infectious complications after gastrectomy for GC.

Standard laparoscopic colorectal surgery requires additional incision or enlargement of the trocar incision for the retrieval of the surgical specimen. A natural orifice specimen extraction （NOSE） procedure, in which the specimen is retrieved through the anus or vagina without any additional skin incision, requires purse-string suture （PSS） of the rostral intestinal segment in order to fix the anvil head of the stapler and perform extracorporeal mechanical anastomosis. Colorectal surgery has a limited NOSE in cases where the end of the rostral segment could be pulled through the anus. Broader application of NOSE depends on intracorporeal PSS. We developed a new forceps for intracorporeal PSS during NOSE and evaluated its efficacy. The PSS instrument was refined to pass through a 12-mm trocar in an intracorporeal PSS and achieve anastomosis using double stapling. In trials utilizing an endoscopic practice box, regular spacing of stitches during PSS were consistent （n＝10）, and tight intracorporeal anastomosis of the porcine colon was successfully performed （n＝2）. We then confirmed efficacy through an operation on a pig. Our novel PSS device will help us perform NOSE not only in laparoscopic colorectal surgery but also in any operation requiring intracorporeal PSS, which should contribute to further advances in endoscopic digestive surgery.

背景: サルコペニアは胃癌をはじめ各種悪性腫瘍の短期・長期成績に関与するが, 骨格筋の質を表す脂肪化と術後感染性合併症 (IC) の関連性は明らかでない. 目的: 腹腔鏡下胃切除 (LG) を施行した胃癌症例における骨格筋脂肪化と術後ICとの関連を明らかにする. 方法: 2009年から2018年までのLG施行早期胃癌173例を対象とした. 周術期諸因子と術後ICの関連を後方視的に検討した. 骨格筋脂肪化は術前CT画像によるIntramuscular adipose tissue content (IMAC) で評価した. 結果: 術後ICは20例 (11.6％) に認めた. 多変量解析による術後ICの独立危険因子は男性 (P＝0.003) , Prognostic nutritional index低値 (P＝0.008) , IMAC高値 (P＝0.020) であった. IMAC高値群は低値群に比較し高齢 (P＝0.001) で高Body mass inedx (P＝0.027) であり糖尿病並存例 (P＝0.021) が多かった. 結語: 骨格筋脂肪化はLG後の術後IC発生の危険因子であった. 適切な術前栄養・運動療法の介入が術後IC制御に寄与する可能性がある.

BACKGROUND:Portal vein thrombosis (PVT) is a life-threatening complication after hepatectomy. However, the relationship between postoperative PVT and morphometric features of the PV has not been fully elucidated yet.PATIENTS AND METHODS:A total of 81 patients who underwent hepatectomy for perihilar cholangio-carcinoma (PHCC) were studied. We investigated the diameters and angles of PV using pre- and postoperative computed tomography (CT) reconstructed by SYNAPSE VINCENT®.RESULTS:The incidence of PVT after hepatectomy was 11.1%. There were significant differences with respect to the remnant liver PV diameter (p=0.015), the diameter ratio (p=0.001), and the postoperative PV angle (p=0.001) between patients with and without PVT. Multivariate analysis revealed that a postoperative PV angle of less than 90° (p=0.008) and a diameter ratio of less than 45% (p=0.041) were independent risk factors for PVT.CONCLUSION:A postoperative PV angle of less than 90° and diameter ratio of less than 45% eventually lead to PVT after hepatectomy for PHCC.

Background Surgeons sometimes must plan pancreatoduodenectomy (PD) for patients with a variant common hepatic artery (CHA) branching from the superior mesenteric artery (SMA) penetrating the pancreatic parenchyma, known as a transpancreatic CHA (tp-CHA). Case presentation A 67-year-old man was admitted to our hospital because of liver dysfunction. A duodenal tumor was identified by gastrointestinal endoscopy, and a biopsy revealed a neuroendocrine tumor. Computed tomography showed multiple metastases in the left three sections of the liver. As an anatomical variant, the CHA branched from the SMA and passed through the parenchyma of the pancreatic head, and all hepatic arteries branched from the CHA. Furthermore, the arcade between the left and right gastric artery (RGA) was detected, and the RGA branched from the root of the left hepatic artery. PD and left trisectionectomy of the liver were performed. The tp-CHA was resected with the pancreatic head, and the gastric arterial arcade was preserved to maintain the right posterior hepatic arterial flow. Postoperatively, there were no signs of hepatic ischemia. Conclusions When planning PD, including hepatopancreatoduodenectomy, for patients with a tp-CHA, surgeons should simulate various situations for maintaining the hepatic arterial flow. The preservation of the gastric arterial arcade is an option for maintaining the hepatic arterial flow to avoid arterial reconstruction.

A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revascularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD.

Background: Solid-pseudopapillary neoplasms (SPNs) of the pancreas are a relatively rare type of tumor with low-grade malignant potential. Although surgical resection provides a cure in most of cases, the safety and efficacy of surgical treatment for tumors with major arterial involvement remains unknown. Case presentation: A 30-year-old man with a preoperative diagnosis of SPN was referred to our department. Abdominal computed tomography (CT) revealed a lobulated mass located at the pancreatic body, with a maximum diameter of 11 cm. The celiac artery (CA) and splenic artery (SA) were surrounded (by approximately 270° and 360°, respectively) by an expansively growing tumor, while the common hepatic artery (CHA), superior mesenteric artery (SMA) and superior mesenteric vein (SMV) were contacted by the tumor for a distance of 26.6, 42.8, and 43.5 mm, respectively on CT. The arterial walls of the CHA and SMA were smooth without any irregularity; however, narrowing and irregularity of the SA was present. The imaging findings strongly suggested an SPN of the pancreas; the involvement of the SA, CA, SV and SMV by the tumor was suspected. Distal pancreatectomy with celiac axis resection was planned. After laparotomy, the CHA, SMA, CA, and SMV were safely preserved, and the tumor was resected by distal pancreatectomy alone. A pathological examination confirmed that the tumor was an SPN with a malignant component. Although the tumor pathologically invaded the retropancreatic tissue, splenic artery and splenic vein, the resected margin was negative. Conclusion: Although the preoperative examination delineated the gross expansion of an SPN around the CA, CHA, and PV, these vessels were safely preserved during pancreatectomy. This case suggests that the surgical resection of the SPN may occasionally be attempted; even in cases with compressed and deviated by the tumor.

【目的】早期大腸癌に対する内視鏡治療後に追加腸切除を受けた症例のリンパ節転移と遠隔転移再発の危険因子を明らかにすること.【対象と方法】2002年11月から2013年12月までの期間に,cT1大腸癌に対する内視鏡治療後に当院で外科的追加腸切除をうけた182例.臨床病理学的因子に対して単変量および多変量解析を行い,リンパ節転移と遠隔転移再発の危険因子を抽出した.【結果】多変量解析の結果,リンパ管侵襲あり(p=0.011)と癌遺残あり(p=0.001)がリンパ節転移の独立した危険因子として抽出された.遠隔転移再発に関しては,単変量解析で有意差のある因子は抽出されなかった.【結語】cT1大腸癌に対する内視鏡治療後に外科的追加腸切除をうけた症例のリンパ節転移の危険因子はリンパ管侵襲と癌遺残であった.一方,遠隔転移再発の危険因子は同定されなかった.

Skeletal muscle wasting during curative treatment is an important issue faced by esophageal cancer patients. However, it has not been clarified whether skeletal muscle change during neoadjuvant chemotherapy followed by surgery adversely affects prognosis. This study aimed to determine the relation between skeletal muscle change and survival for patients with advanced esophageal cancer who underwent neoadjuvant chemotherapy followed by surgery.

A 44-year old man with squamous cell carcinoma of the left lower lobe extending to the mucosa of the main carina, was treated with high dose rate brachytherapy prior to surgery. A significant reduction of tumor infiltration was achieved allowing a radical pneumonectomy instead of a sleeve pneumonectomy with resection of the main carina. He remains disease-free after a follow-up period of 43 months. (Chest 1992; 102:308–09)

Cholangiocarcinoma is not infrequently associated with intraepithelial spread of neoplastic biliary cells in the biliary mucosa around the main carcinoma which is called here "intraepithelial spreading neoplasm (IESN)". Herein, the pathological features and significance of IESN of intraductal papillary neoplasm of bile duct (IPNB) were examined by using 52 cases of IPNB with reference to those of IPNB itself. As a control, 23 cases of nodular sclerosing cholangiocarcinoma (NS-CCA) with IESN were used. It was found that IPNB were constantly associated with IESN, and IESN and IPNB showed the similar biological and pathological features in individual cases. Interestingly, invasive lesion(s) were found at IESN in 22 of and also at IPNB in 32 of 52 cases, and invasion was tended to be found at both lesions in the same cases. IESN of IPNB was classifiable histologically into flat (52 cases), and lower and higher micropapillary types (52 and 43 cases, respectively), while IESN(s) in NS-CCA were only classifiable into flat (23 cases) and low micropapillary (12 cases) types. Intestinal, gastric, pancreatobiliary (PB) and oncocytic phenotypes were found similarly in IPNB and IESN of IPNB, while PB type was predominant in NS-CCA and in LSIN of NS-CCA. These findings suggest that IPNB and IESN compose a unique intraepithelial neoplasm of the biliary tree with imminent potential of invasion along any place.