Jeong-Ho Moon

Assessment of stanniocalcin-1 as a prognostic marker in human esophageal squamous cell carcinoma.

Stanniocalcin-1 (STC1) is a secreted glycoprotein hormone and highly expressed in various types of human malignancies. Although evidence points to the role of STC1 in human cancers, the clinical significance of STC1 expression in esophageal cancer has not been well established. Quantitative reverse transcriptase-polymerase chain reaction and immunohistochemistry were performed to assess the expression of STC1 in the cancer cell line TE8 and esophageal cancer tissues from 229 esophageal squamous cell carcinomas (ESCC). Surgically-resected tissue sections were immunostained for potential regulators of STC1 expression, hypoxia-inducible factor-1α (HIF-1α) and p53. Marked increase in STC1 mRNA and protein expression was noted in TE8 cells cultured under hypoxic conditions. Overexpression of STC1 mRNA was noted in ESCC tumors compared to normal counterparts. Positive immunohistochemical staining for STC1 protein was observed in 38.9% of patients, and correlated significantly with advanced pT status (P=0.019), poor prognosis [overall survival (P<0.0006) and disease-free survival (P<0.0002) of ESCC patients who had undergone curative surgery]. Positive staining for HIF-1α and p53 proteins in ESCC did not correlate with STC1 expression. The results showed marked induction of STC1 expression under hypoxia in cultured cells and in esophageal cancer cells and that overexpression of STC1 was an independent prognostic factor in patients with esophageal cancer who had undergone curative surgery. STC1 is a potentially useful biomarker for ESCC treatment.

REGIV as a potential biomarker for peritoneal dissemination in gastric adenocarcinoma.

This study examined the clinical significance of regenerating islet‐derived family member 4 (REGIV) in surgically resected gastric tumors. The potential of REGIV as a biomarker in gastric cancer was also assessed including its predictive value for prognosis and recurrence after surgery.

Prognostic Significance of Basing Treatment Strategy on the Results of Photodynamic Diagnosis in Advanced Gastric Cancer

BackgroundWe have previously reported that use of a staging laparoscopy (SL) combined with photodynamic diagnosis using 5-aminolevulinic acid (ALA-SL) improves sensitivity in detecting peritoneal dissemination in gastric cancer (GC). The purpose of this study was to examine the clinical significance of basing treatment strategies on the results of ALA-SL in patients with advanced GC.Patients and MethodsALA-SL was performed on 113 patients with advanced GC prior to determination of their first course of treatment. According to the results of ALA-SL, patients were divided into four groups, including those classified as P0 (45%), ALA-P (12%), P1 plus P2 (23%), and P3 (20%). Patients with peritoneal metastases were subjected to chemotherapy. In addition, drug responders also received a gastrectomy. Treatment outcomes and patient characteristics stratified upon the results of ALA-SL were then analyzed.ResultsThe 3-year survival rates for patients in the P0, ALA-P, P1-2, and P3 groups were 73, 72, 49, and 6%, respectively. The survival estimates of patients classified as ALA-P via ALA-SL were very similar to those of P0 patients and were significantly better than those of P1-2 and P3 patients. Moreover, the false negative rate for ALA-SL-mediated detection of peritoneal metastasis at exploration was minimal (1/40, 2.5%), possibly due to the use of ALA.ConclusionsALA-SL may enhance the accuracy of diagnosis and contribute to therapeutic advantages in advanced GC. It should be introduced for advanced GC patients, especially females, as well as for individuals with high-stage tumors and/or tumors with diffuse-type histology.

Clinical Outcomes of Gastric Cancer Patients Who Underwent Proximal or Total Gastrectomy: A Propensity Score-Matched Analysis

BackgroundTotal gastrectomy (TG) and proximal gastrectomy (PG) are used to treat upper-third early gastric cancer. To date, no consensus has been reached regarding which procedure should be selected. The aim of this study was to validate the usefulness of preserving the stomach in early upper-third gastric cancer.MethodsBetween 2004 and 2013, 201 patients underwent PG or TG at our institution for treatment of upper-third early gastric cancer. According to the defined inclusion and exclusion criteria, 192 cases were enrolled in this study. One-to-one propensity score matching was performed to compare the outcomes between the two groups.ResultsThe operation time was shorter in the PG group. Although no significant difference was observed, the PG group had less bleeding and fewer postoperative complications. R0 resection rate was 100%, and no surgery-related deaths were observed. The frequencies of reflux symptoms and anastomotic stenosis were significantly higher in the PG group, but could be controlled by balloon dilation and drug therapy. The maintenance rates of body mass index and lean body mass were significantly higher in patients who underwent PG than TG. The total protein and serum albumin values were higher in the PG group than in the TG group and remained statistically superior.ConclusionPG group exhibited better perioperative performance. Furthermore, better nutritional results were obtained in the PG group. Although the late stenosis and reflux symptoms must be addressed, the PG is a preferable surgical procedure for the treatment of early proximal gastric cancer.

A novel liver retraction method in laparoscopic gastrectomy for gastric cancer

BackgroundRetracting the lateral liver segment during laparoscopic distal gastrectomy is important for achieving an optimal surgical field. However, excessive force may injure the liver, causing temporary abnormalities of liver function tests after laparoscopic surgery. We developed a new liver retraction method and assessed its safety and utility.Patients and methodsWe retrospectively analyzed records in our surgical database of consecutive surgical patients who underwent laparoscopic distal gastrectomy for early gastric cancer. We divided the 229 patients into two groups based on the liver retraction method used, either flexible liver retraction with clipping and suturing (FLICS) or the Nathanson retractor (NR). One-to-one propensity score matching was performed to match patients, resulting in the records of 53 pairs of cases extracted from the database. Operative and postoperative outcomes were assessed, including following the values of serum liver enzymes, total bilirubin, and C-reactive protein until postoperative day 30.ResultsThere were no significant differences in patient characteristics or preoperative data in the two groups. The retraction method was not changed intraoperatively for any patients. The operative time was significantly shorter in the FLICS group, but the amount of bleeding did not differ. Liver injury was not observed as a result of liver retraction during surgery. In both groups, serum liver enzymes temporarily increased after surgery but improved rapidly thereafter. The postoperative increases in aspartate transaminase, alanine transaminase, and C-reactive protein levels were significantly lower in the FLICS than in the NR group. No serious complications associated with liver retraction were observed in either group.ConclusionsOur new liver retraction technique provided an optimal surgical field without inducing liver dysfunction. It is a simple, safe, and effective liver retraction technique.

The Feasibility and Safety of Preoperative Fluorescence Marking with Indocyanine Green (ICG) in Laparoscopic Gastrectomy for Gastric Cancer

BackgroundSecuring the surgical margin is the most essential and important task in curative surgery. However, it is difficult to accurately identify the tumor location during laparoscopic surgery for gastric cancer, and existing methods, such as preoperative endoscopic marking with tattooing and clipping, have multiple disadvantages.AimsWe investigated the feasibility and safety of indocyanine green (ICG) fluorescence marking for determining the tumor location during laparoscopic gastrectomy.MethodsWe retrospectively analyzed preoperative and perioperative data from consecutive patients with gastric cancer undergoing planned laparoscopic distal gastrectomy. Data was maintained in a prospectively compiled surgical database, and patients were categorized into ICG (n = 84) or non-ICG (n = 174) groups based on whether they underwent preoperative endoscopic mucosal ICG injection. One-to-one propensity score matching (PSM) was performed to compare outcomes between the two groups.ResultsWe included 84 patient pairs after PSM, and there were no significant differences in preoperative patient characteristics. The ICG group had shorter procedure time (p < 0.001), lower estimated blood loss (p = 0.005), and significantly shorter postoperative hospital stay (p < 0.001). Positive resection margins were confirmed in five cases (6.0%) in the non-ICG group, whereas there were none in the ICG group (p = 0.008). Real-time confirmation was possible during laparoscopy, and the injected ICG did not affect the surgical procedure or result in adverse events.ConclusionICG fluorescence imaging is feasible and safe and can potentially be used as a tumor-marking agent for determining the surgical resection line.

A modified efficient purse-string stapling technique (mEST) that uses a new metal rod for intracorporeal esophagojejunostomy in laparoscopic total gastrectomy

Intracorporeal esophagojejunostomy after laparoscopic total gastrectomy is technically difficult because this procedure should be performed in a narrow surgical field in the upper abdomen even when completely laparoscopic approaches are used. The placement of the anvil of a circular stapling device into the esophagus and connection the instrument to the anvil are extremely difficult steps in this surgery. Therefore, we developed a simple technique for intracorporeal esophagojejunostomy using hemi-double stapling technique; we named this technique the efficient purse-string stapling technique (EST). More recently, we have developed a modified EST (mEST) that utilizes a new stainless steel anvil rod instead of a plastic rod. Relative to the plastic rod, the steel rod is reusable and shorter; thus, it was easier to perform anvil placement into the esophagus with the steel rod. Anvil preparation for mEST: a stainless steel rod is attached to the shaft of the anvil, and the needle and thread are sutured to the tip of the rod. After complete insertion of the anvil into the esophageal cavity, the needle and thread are used to penetrate the anterior esophageal wall, and the esophagus is then clamped using a linear stapler just distal to the site penetrated by the thread. The linear stapler is fired, and anvil placement in the esophagus is simultaneously accomplished. After the rod is removed from the anvil, the instrument is intracorporeally connected to the anvil and then fired to complete the gastrojejunostomy. This technique is simple and facilitates intracorporeal reconstruction procedures in laparoscopic total gastrectomy.

Pure single-port laparoscopic proximal gastrectomy using a novel double-flap technique

We developed a novel double-flap technique as an anti-reflux procedure following sin-gle-port laparoscopic proximal gastrectomy. After performing laparoscopic proximal gas-trectomy, an H-shaped seromuscular flap is created on the anterior wall of the gastric remnant and then reconstruction procedure is started. First, the posterior esophageal wall is fixed to the stomach at the cranial edge of the submucosal window. Second, the posterior wall of the esophagus and the gastric mucosa are sutured and layer-to-layer suturing is then performed between the anterior esophagus and stomach to complete the esophagogas-trostomy. Finally, the anastomotic site and distal esophagus are covered with the sero-muscular flap. All steps were performed using continuous barbed sutures to facilitate anastomotic procedures. The above mentioned procedure is safe and feasible for the treatment of gastric cancer with acceptable short- and mid-term results. Thus, this pro-cedure may be an attractive surgical option as a minimally invasive surgery.