The standard lymph node dissection for advanced gastric cancer is a D2 dissection. Although D2 laparoscopy-assisted total gastrectomy with distal pancreatosplenectomy has been reported, no studies have reported a completely intra-abdominal laparoscopic approach, because of the technical difficulty of the procedure. We successfully performed this novel procedure in two patients with advanced gastric cancer located in the upper portion of the stomach. In fact, this surgery is technically feasible, and has a potential curability comparable with that of open surgery.

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The standard lymph node dissection for advanced gastric cancer is a D2 dissection, performed in accordance with the new Japanese classification of gastric carcinoma (13th edition). Although laparoscopic D2 dissections according to the General rules for gastric cancer study (12th edition) have been reported, no studies have reported laparoscopic D2 dissections according to the revised classification for advanced gastric cancers located in the middle or lower portions of the stomach. The lack of such studies is due to the perceived technical difficulty of the procedure. However, we successfully performed this novel procedure in five patients with advanced gastric cancer located in the middle or lower portions of the stomach. In fact, this surgical procedure is technically feasible and safe.

Kelly [8], reported that this method preserved gastric emptying and prevented the Roux stasis syndrome.In Japan, the uncut Roux operation is not yet considered an alternative method. Moreover, the use of the laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy has not been reported in the English-language literature. We performed 42 laparoscopic uncut Roux-en-Y gastrojejunostomies for gastric carcinoma. Here we describe the technical details and the initial results of our surgical technique. Method Operating-room setupUnder general anesthesia, each patient was placed in the supine position with the legs apart. A 20° head-up tilt was applied in order to prevent the transverse colon or small intestine from visually compromising the operative field. The surgeon stood on the patient's right, with the first assistant on the patient's left and the camera operator between the patient's legs. Surgical techniqueAfter pneumoperitoneum was established using the open technique, five ports were placed and a flexible electrolaparoscope was introduced through the infraumbilical port.The complete uncut Roux-en-Y gastrojejunostomy is illustrated in the schema in Fig. 1. This method is a modified Billroth II operation, which is accomplished by stapling across the afferent limb of the Billroth II gastrojejunostomy in continuity just proximal to the stomach and performing a side-to-side anastomosis for 40 cm between the afferent limb and the efferent limb, which is designated a "Braun enteroenterostomy".

Perioperative use of IEEF caused a significant increase in the total lymphocyte count at 3 and 5 days after operation and caused a shift toward B cell proliferation, which may possibly be beneficial to decrease the incidence of postoperative infectious complications.

trectomies in two patients with gastric cancer. Here, we describe our surgical procedure and the postoperative courses of these two patients. Surgical procedureEach patient was placed under general anesthesia in the supine, reverse Trendelenburg position with the legs apart. The surgeon stood on the patient's right, with the assisting surgeon on the patient's left, and the camera operator stood between the patient's legs. Pneumoperitoneum was then established, using an open technique, and five working ports (each 12 mm in diameter) were then placed.Laparoscopic mobilization and transection of the stomach, and lymphadenectomy (which consisted of a limited dissection A according to the new Japanese practice guidelines for gastric cancer) were performed by the same methods as those that we reported previously ( Fig. 1) [8]. In our procedure, in order to prevent pyloric stenosis, postoperative diarrhea, and an increased risk of cholelithiasis, the vagal pyloric, celiac, and hepatic branches were preserved. Accordingly, the esophagus was not transected until after anastomosis, to allow the esophagogastrostomy to be performed safely. Side-to-side esophagogastrostomyThis anastomosis involves attaching the posterior aspect of the esophagus to the anterior wall of the gastric remnant. There must be sufficient overlap so that 5-6 cm of esophagus will lie freely over the front of the gastric remnant. Therefore, the esophagus was sufficiently mobilized to allow this. The posterior wall of the esophagus was excised, and a 1-cm stab wound was made in the anterior wall of the gastric remnant, approximately 5-6 cm from the staple lines of the stump. A 45-mm endoscopic linear stapler (ETS45; Ethicon Endo-Surgery, AbstractIn order to improve anastomotic procedures, we performed laparoscopic side-to-side esophagogastrostomy, using a linear stapler, after proximal gastrectomy in two patients with gastric cancer located in the upper third of the stomach. The patients' postoperative courses were excellent. During postoperative recovery, the patients experienced very little pain, used no analgesic medications, and never experienced reflux esophagitis. This procedure is technically feasible and is an excellent option, given the less involved anastomotic procedure and better postoperative quality of life compared with these features in end-to-side anastomosis using a circular stapler.

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While pneumatosis cystoides intestinalis (PCI) is a rare disease entity associated with a wide variety of gastrointestinal and non-gastrointestinal disorders, PCI associated with massive intra-and retroperitoneal free air is extremely uncommon, and is difficult to diagnose differentially from perforated peritonitis. We present two cases of PCI associated with massive peritoneal free air and/or retroperitoneal air that mimicked perforated peritonitis. These cases highlight the clinical importance of PCI that mimics perforated peritonitis, which requires emergency surgery. Preoperative imaging modalities and diagnostic laparoscopy are useful to make an accurate diagnosis.