Nobuhiko Tanigawa

Benefits of intracorporeal gastrointestinal anastomosis following laparoscopic distal gastrectomy

BackgroundLaparoscopic gastrectomy has recently been gaining popularity as a treatment for cancer; however, little is known about the benefits of intracorporeal (IC) gastrointestinal anastomosis with pure laparoscopic distal gastrectomy (LDG) compared with extracorporeal (EC) anastomosis with laparoscopy-assisted distal gastrectomy (LADG).MethodsBetween June 2000 and December 2011, we assessed 449 consecutive patients with early-stage gastric cancer who underwent LDG. The patients were classified into three groups according to the method of reconstruction LADG followed by EC hand-sewn anastomosis (LADGu2009+u2009EC) (nu2009=u200973), using any of three anastomosis methods (Billroth-I (B-I), Billroth-II (B-II) or Roux-en-Y (R-Y); LDG followed by IC B-I anastomosis (LDGu2009+u2009B-I) (nu2009=u2009248); or LDG followed by IC R-Y anastomosis (LDGu2009+u2009R-Y) (nu2009=u2009128)). The analyzed parameters included patient and tumor characteristics, operation details, and post-operative outcomes.ResultsThe tumor location was significantly more proximal in the LDGu2009+u2009R-Y group than in the LDGu2009+u2009B-I group (Pu2009<u20090.01). Mean operation time, intra-operative blood loss, and the length of post-operative hospital stay were all shortest in the LDGu2009+u2009B-I group (Pu2009<u20090.05). Regarding post-operative morbidities, anastomosis-related complications occurred significantly less frequently in with the LDGu2009+u2009B-I group than in the LADGu2009+u2009EC group (Pu2009<u20090.01), whereas there were no differences in the other parameters of patients’ characteristics.ConclusionsIntracorporeal mechanical anastomosis by either the B-I or R-Y method following LDG has several advantages over at the LADGu2009+u2009EC, including small wound size, reduced invasiveness, and safe anastomosis. Although additional randomized control studies are warranted to confirm these findings, we consider that pure LDG is a useful technique for patients with early gastric cancer.

Exploratory phase II trial in a multicenter setting to evaluate the clinical value of a chemosensitivity test in patients with gastric cancer (JACCRO-GC 04, Kubota memorial trial)

BackgroundAlthough postoperative adjuvant chemotherapy with S-1, an oral fluoropyrimidine, has become a standard of care for gastric cancer in Japan, nonresponders may suffer from the cost and adverse reactions without clinical benefit. This multicenter exploratory phase II trial was conducted to see whether a chemosensitivity test, the collagen gel droplet embedded culture drug sensitivity test (CD-DST), can adequately select patients for chemotherapy.MethodsThe CD-DST using four different concentrations of 5-fluorouracil was conducted with resected specimens from preregistered patients who underwent gastrectomy withxa0D2 or more extensive lymphadenectomy. Patients who were histopathologically confirmed to havexa0stage II or greater disease without distant metastasis were eligible for final enrollment. All patients underwent protocol-specified adjuvant chemotherapy with S-1. Three-year relapse-free survival was compared between patients determined as sensitive by the CD-DST (responders) and those deemed insensitive (nonresponders). Appropriate cutoff values for in vitro growth inhibition were defined when the hazard ratio for relapse in responders and the log-rank P values were at their minimum.ResultsOf the 311 patients enrolled, 14 were ineligible and 27 failed to start the protocol treatment. The CD-DST failed in 64 other patients, and survival analyses were conducted with the remaining 206 patients (39 stage II disease, 155 stage III disease, and 12 stage IV disease). The outcome of patients who were determined to be responders was significantly superior to that of nonresponders regardless of the 5-fluorouracil concentrations, although no differences in clinicopathologic characteristics were observed between the two groups, except for age.ConclusionsThe CD-DST identified those who benefit from adjuvant chemotherapy. It deserves further evaluation in the setting of a prospective randomized trial.ClinicalTrials.gov identifier: NCT00287755

Laparoscopy-Assisted Total Gastrectomy

The patient is positioned supine on a Maquet operating table (Maquet, Germany), with the right arm adducted and the left arm abducted to 90°. Pneumatic compressors are attached, and legs are bandaged to the lower limb supports, which are abducted and hyperextended to make space for the primary surgeon who stands in between the patient’s legs. The patient is tilted head-up in a reverse-Trendelenburg position. Cardiac monitor electrodes are placed away from the ventral abdomen so that they don’t get in the way of the ports. Two seats are placed on either side of the patient for the assistants. Two video monitors are positioned on either side of the patient’s head facing inward toward the primary operator.

623PEXPLORATORY PHASE II TRIAL ASSESSING RELEVANCE OF IN VITRO CHEMOSENSITIVITY TEST AS A PREDICTOR OF SURVIVAL IN GASTRIC CANCER UNDERGOING ADJUVANT CHEMOTHERAPY (JACCRO-GC04)

ABSTRACT Aim: Postoperative S-1 (a 5-FU derivative) monotherapy has become the standard for Stage II/III gastric cancer in Japan following a phase III trial designated ACTS-GC, which implies that S-1 is also given to the patients whose tumors may not be sensitive to 5-FU. A nationwide clinical trial, JACCRO-GC04, was conducted to explore whether individualization of the treatment is possible through chemosensitivity testing. Methods: Using surgically resected specimens, the collagen gel droplet-embedded drug sensitivity test was performed at 5-FU concentrations (conc) of 0.2, 0.4, 1.0 and 2.0 µg/ml. Patients who underwent R0 resection for histologically proven stage II ∼ IV gastric cancer and for whom the chemosensitivity test was successful were eligible. All eligible patients were to receive adjuvant treatment with S-1 for 1 year at a dose of 80u2003mg/m2 bid for 4 weeks followed by 2 weeks rest. Optimal cut-off values at each 5-FU conc to decide on the chemosensitivity were to be sought within the study. Ultimate objective of the study was to prove the hypothesis that a significant difference in 3-year relapse-free survival (RFS), the primary endpoint, is observed between the responder (Res) and non-responder (Non). Results: Between 2005 and 2013, 311 patients were enrolled, of which 206 were eligible. Hazard ratios (HR) for relapse in Res as compared with Non were calculated at various cut-off values of in vitro growth inhibition rates from 10% to 90% with an increment of 10%. The appropriate cut-off values could be defined based on HR Conclusions: The appropriate cut-off values classifying patients as Res or Non were found. The low HR for relapse indicates the in vitro drug sensitivity predicts efficacy of the postoperative S-1 treatment. Disclosure: M. Fujii: Advisory board; Taiho Honarium; Taiho Travel Grant; JACCRO. All other authors have declared no conflicts of interest.

Role of Robotic Surgery in Laparoscopy-Assisted Distal Gastrectomy

The robotic surgery system was introduced to overcome the demerits of laparoscopic surgery [1, 2]. The early impact of robotic surgery was that it may make it possible to perform complex procedures by minimally invasive surgery, such as surgery for prostate cancer and mitral valve surgery [3–6].

Surgical Skills Qualification System for Laparoscopic Gastrectomy in Japan

Laparoscopic surgery is increasingly popular as a less invasive alternative to conventional open surgery. There are, however, drawbacks to the laparoscopic approach such as the lack of tactile feedback through long instruments and the two-dimensional display of the operative field. This means that laparoscopic surgery is technically more demanding than open surgery.

Clinical Characteristics and Immunohistochemical Examination of Gastric Adenosquamous Carcinoma. Expression of Proliferating Cell Nuclear Antigen(PCNA), Apoptotic Cell, p53, CD44 and Intratumoral Microvessel Density(CD34).

胃腺扁平上皮癌 (以下, 本症) の特徴を検索する目的で, 本症を対象として一般型進行胃癌症例 (以下, 一般型) と比較検討した. まず両者を臨床的に比較し, PCNA, Apoptotic cell, p53, CD44, CD34の発現状態を免疫組織化学的に検討した. 臨床的に本症では肝転移率が高く, Stageの高い症例の多いことが特徴であり, その予後は一般型に比べて有意に不良であった. 本症のPCNA陽性細胞率は一般型に比べて有意に高値であり, Apoptotic Indexは一般型より有意に低率であった. p53, CD44発現陽性率は本症ではいずれも一般型に比べて有意に高率であり, 発現陽性例では両癌成分ともに同等に発現していた. さらに, 腫瘍内血管密度の検索では, 本症は一般型に比べて有意に高値であった. 今回の検討から, 本症は増殖活性が高く, p53などの遺伝子異常が蓄積され, アポトーシス活性が低く, 進展過程で豊富な新生血管が生じて癌細胞が転移しやすい状況を形成している可能性が示唆された.