Background Robotic gastrectomy (RG) for gastric cancer (GC) has been increasingly performed for a decade; however, evidence for its use as a standard treatment has not yet been established. The present study aimed to determine the safety, feasibility, and effectiveness of RG for GC. Methods This multi-institutional, single-arm prospective study, which included 330 patients from 15 institutions, was designed to compare morbidity rate of RG with that of a historical control (conventional laparoscopic gastrectomy, LG). This trial was approved for Advanced Medical Technology ("Senshiniryo") B. The included patients were operable patients with cStage I/II GC. The primary endpoint was morbidity (Clavien-Dindo Grade ≥ IIIa). The specific hypothesis was that RG could reduce the morbidity rate to less than half of that with LG (6.4%). A sample size of 330 was considered sufficient (one-sided alpha 0.05, power 80%). Results Among the 330 study patients, the protocol treatment was suspended in 4 patients. Thus, 326 patients fully enrolled and completed the study. The median patient age and BMI were 66 years and 22.4 kg/m 2 , respectively. Distal gastrectomy was performed in 253 (77.6%) patients. The median operative time and estimated blood loss were 313 min and 20 mL, respectively. No 30-day mortality was seen, and morbidity showed a significant reduction to 2.45% with RG (p = 0.0018). Conclusions RG for cStage I/II GC is safe and feasible. It may be effective in reducing morbidity with LG.

Background There are currently two treatment options for gastric outlet obstruction (GOO) due to gastric cancer, endoscopic stenting and surgical gastrojejunostomy. However, their therapeutic effects have not yet been established. Therefore, the present study was undertaken to examine these effects. Methods The Japanese Gastric Cancer Association invited its delegates to participate in a retrospective multicenter cohort study on patients with GOO due to gastric cancer who underwent stent therapy or gastrojejunostomy in 2015. Results We obtained data from 85 patients undergoing stent therapy and 94 undergoing gastrojejunostomy from 42 hospitals. Baseline data revealed that stent patients had lower food intake, poorer performance status, and worse prognostic indices than gastrojejunostomy patients. Postoperative food intake and survival times were worse in stent patients than in gastrojejunostomy patients. We performed propensity score matching to select pairs of patients with similar baseline characteristics in the two treatment groups. After matching, the frequency of postoperative complications was significantly less in stent patients (3%, 1/33) than in gastrojejunostomy patients (21%, 7/34; p = 0.03). A low residue or full diet was achieved by 97% of stent patients (32/33) and 97% of gastrojejunostomy patients (33/34) (p = 0.98). Median survival times were 7.8 months in stent patients and 4.0 months in gastrojejunostomy patients (p = 0.38). Conclusions Propensity score matching demonstrated that endoscopic stent placement resulted in less postoperative morbidity than and a similar food intake and equivalent survival times to gastrojejunostomy. These results suggest the utility of stent therapy.

ImportanceEvidence of implementation of laparoscopic gastrectomy for locally advanced gastric cancer is currently insufficient, as the primary end point in previous prospective studies was evaluated at a median follow-up time of 3 years. More robust evidence is necessary to verify noninferiority of laparoscopic gastrectomy.ObjectiveTo compare 5-year survival outcomes between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) with D2 lymph node dissection for locally advanced gastric cancer.Design, Setting, and ParticipantsThis was a multicenter, open-label, noninferiority, prospective randomized clinical trial. Between November 26, 2009, and July 29, 2016, eligible patients with histologically proven gastric carcinoma from 37 institutes in Japan were enrolled. Two interim analyses and final analysis were performed in October 2014, May 2018, and November 2021, respectively.InterventionsPatients were randomly assigned (1:1) to either the ODG or LADG group. The procedures were performed exclusively by qualified surgeons.Main Outcomes and MeasuresThe primary end point was 5-year relapse-free survival, and the noninferiority margin for the hazard ratio (HR) was set at 1.31. The secondary end points were 5-year overall survival and safety.ResultsA total of 502 patients were included in the full-analysis set: 254 (50.6%) in the ODG group and 248 (49.4%) in the LADG group. Patients in the ODG group had a median (IQR) age of 67 (33-80) years and included 168 males (66.1%). Patients in the LADG group had a median (IQR) age of 64 (34-80) years and included 169 males (68.1%). No significant differences were observed in severe postoperative complications between the 2 groups in the safety analysis (ODG, 4.7% [11 of 233] vs LADG, 3.5% [8 of 227]; P = .64). The median (IQR) follow-up for all patients after randomization was 67.9 (60.3-92.0) months. The 5-year relapse-free survival was 73.9% (95% CI, 68.7%-79.5%) and 75.7% (95% CI, 70.5%-81.2%) for the ODG and LADG groups, respectively, and the HR was 0.96 (90% CI, 0.72-1.26; noninferiority 1-sided P = .03). Further, no significant difference was observed in overall survival time between the 2 groups, and the HR was 0.83 (95% CI, 0.57-1.21; P = .34). The pattern of recurrence was similar between the 2 groups.Conclusions and RelevanceResults of this study show that on the basis of 5-year follow-up data, LADG with D2 lymph node dissection for locally advanced gastric cancer, when performed by qualified surgeons, was proved noninferior to ODG. This laparoscopic approach could become a standard treatment for locally advanced gastric cancer.Trial RegistrationUMIN Clinical Trial Registry: UMIN000003420

A lthough blunt abdominal trauma is common, injury to the celiac axis (CA) is a rare occurrence, but with significant mortality. This report describes and discusses the presentation and management of one patient with an isolated CA injury in context with the literature. CASE REPORTA 39-year-old, previously healthy, man with no history of trauma was transferred from a referring institution after suffering direct compression from the tailgate of a cargo truck. On presentation to the emergency department, the patient complained of severe epigastric pain but no superficial injury was observed. A physical examination revealed a heart rate of 70 beats per minute, a systolic blood pressure of 92 mm Hg, severe epigastric tenderness with muscle guarding and an absence of bowel sounds. Laboratory findings on admission revealed an elevated white blood cell count of 24.2 ϫ 10 3 L aspartate aminotransferase of 347 lU/L, alanine aminotransferase of 347 IU/L, and lactate dehydrogenase of 1035 IU/L. There was no anemia or elevation of serum amylase level observed.Computed tomography revealed a large midline retroperitoneal hematoma in the supramesocolic area. The superior mesenteric artery could be visualized. However, CA could not be visualized from its origin despite extravasation around the CA. Therefore, a CA injury was suspected (Fig. 1). Subsequent abdominal angiography demonstrated that the CA terminated abruptly after its origin and celiac branches were visualized via superior mesenteric artery's collaterals (Fig. 2). As no other active bleeding was observed, an isolated CA injury was diagnosed. This finding suggested an intimal injury of the CA by blunt injury. An intra-aortic balloon occlusive catheter (AISIN SEIKI Co., Ltd., Aichi, Japan) was inserted via the right femoral artery and the balloon was placed above the CA without inflation, in case of re-bleeding during the subsequent surgery.During surgery, the left femoral artery and vein were initially exposed and taped in preparation for the possible need of extracorporeal circulation. This procedure was performed to preserve the infra-celiac aortic circulation in case cross clamping of the abdominal aorta during subsequent surgery become necessary. Fortunately, we did not need to inflate the intra-aortic balloon or to place the patient on extracorporeal circulation thereafter.A left-side thoracotomy and transection of the left diaphragm and upper laparotomy was performed. The aortic hiatus of the diaphragm was also transected to obtain sufficient exposure of the proximal aorta of the CA. At this time, medial mobilization of all left-sided intra-abdominal viscera was performed for visualization of the entire abdominal aorta. After that, the aorta was isolated and tapes were placed around the distal and proximal sides of the CA, in preparation for the cross clamping of the aorta. After removal of the hematoma, a careful dissection of the dense plexus of neural tissues and lymphatics was performed. A minor tear of the celiac trunk was visualized and the celiac trunk wa...

Background. Although the feasibility and advantages of video-assisted thoracoscopic esophagectomy (VATS-E) for esophageal cancer are well studied, its application is limited, possibly because it is technically complex. Methods. Ninety-eight patients who underwent VATS-E at our institutes were divided into three groups by the type of thoracoscope, TV monitor, and patient position used. For the fi rst 18 patients, we used the left lateral position, a fl exible thoracoscope, and a single TV monitor (method A); for the next 58 patients, the left lateral position, a 30° thoracoscope, and two TV monitors (method B); and for the last 22 patients, the prone position with 30° thoracoscope and single TV monitor (method C). We compared the area of operative fi eld and clinical outcomes in these three approaches.Results. On the basis of subjective assessment, method C afforded a better operative fi eld than methods A and B. No signifi cant differences were noted between the three positions in operative time, duration of intubation, rate of occurrence of recurrent nerve palsy, and anastomotic leakage. However, blood loss, rate of respiratory tract complications, and length of postoperative hospital stay were decreased in the order of position. The total number of dissected lymph nodes increased in the order of position. Conclusions. VATS-E in prone position with a 30° thoracoscope and a single TV monitor appear to be superior to VATS-E in the left lateral position in terms of operative fi eld, blood loss, respiratory tract complication, and number of lymph nodes dissected. Randomized control studies would help confi rm these results.