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Background Malnutrition is an independent risk factor for postoperative mortality and morbidity in major gastrointestinal surgery. The aim of this study was to investigate the prevalence of malnutrition and identify the optimal preoperative nutritional support for preventing postoperative surgical site infections (SSIs) in malnourished gastric cancer patients undergoing gastrectomy. Methods We analyzed 800 patients with gastric cancer who underwent gastrectomy. Nutritional risk factors included weight loss >10 % within 6 months, body mass index <18.5 kg/m 2 , Subjective Global Assessment Grade C, and serum albumin <3.0 g/dl. Adequate energy intake was defined as receiving ≥25 kcal/kg ideal body weight per day. Optimal nutritional support was examined in terms of both duration and calorie intake. Results Overall, 152 patients (19.0 %) were classified as malnourished. The incidence of SSIs was significantly higher in malnourished patients than in well-nourished patients (35.5 vs. 14.0 %; p  < 0.0001). The incidence of SSIs in malnourished patients was significantly lower in the well-supported group receiving adequate energy support for at least 10 days than in the poorly-supported group, which received inadequate or no energy support or adequate energy support for <10 days (17.0 vs. 45.4 %; p  = 0.0006). In multivariate analysis, well-managed nutritional support was identified as an independent factor associated with fewer SSIs (odds ratio 0.14; 95 % confidence interval 0.05–0.37; p  = 0.0002). Conclusions Malnutrition, a risk factor for SSI, was prevalent in gastric cancer patients preoperatively. Well-managed preoperative nutritional support decreased the incidence of postoperative SSIs in malnourished patients.

Background Malignancy is a secondary cause of sarcopenia, which is associated with impaired cancer treatment outcomes. The aim of this study was to investigate the prevalence of preoperative sarcopenia among elderly gastric cancer patients undergoing gastrectomy and the differences in preoperative dietary intake and postoperative complications between sarcopenic and non-sarcopenic patients. Methods Ninety-nine patients over 65 years of age who underwent gastrectomy for gastric cancer were analyzed. All patients underwent gait and handgrip strength testing, and whole-body skeletal muscle mass was measured using a bioimpedance analysis technique based on the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm for the evaluation of sarcopenia before surgery. Preoperative dietary intake was assessed using a food frequency questionnaire. Results Of these patients, 21 (21.2 %) were diagnosed with sarcopenia. Sarcopenic patients consumed fewer calories and less protein preoperatively (23.9 vs. 27.8 kcal/kg ideal weight/day and 0.86 vs. 1.04 g/kg ideal weight/day; P  = 0.001 and 0.0005, respectively). Although the overall incidence of postoperative complications was similar in the two groups (57.1 % vs. 35.9 %; P  = 0.08), the incidence of severe (Clavien–Dindo grade ≥ IIIa) complications was significantly higher in the sarcopenic group than in the non-sarcopenic group (28.6 % vs. 9.0 %; P  = 0.029). In the multivariate analysis, sarcopenia alone was identified as a risk factor for severe postoperative complications (odds ratio, 4.76; 95 % confidence interval, 1.03–24.30; P  = 0.046). Conclusions Preoperative sarcopenia as defined by the EWGSOP algorithm is a risk factor for severe postoperative complications in elderly gastric cancer patients undergoing gastrectomy.

Despite advances in multimodal treatment, the long-term survival of patients with resectable pancreatic ductal adenocarcinoma (PDAC) remains poor. In Japan, neoadjuvant chemotherapy with gemcitabine and S-1 (GS) has demonstrated a survival benefit compared with upfront surgery. The addition of radiotherapy to chemotherapy may further improve outcomes by enhancing local tumor control and increasing R0 resection rates; however, no randomized trial has directly compared GS alone with GS plus radiotherapy (GS-RT) in patients with resectable PDAC. The CSGO-HBP-027 trial is a multicenter, randomized phase II/III study designed to evaluate whether neoadjuvant GS-RT improves survival compared with GS alone. This trial will enroll 200 patients with resectable PDAC, who will be randomized in a 1:1 ratio to receive either two cycles of GS or two cycles of GS with concurrent radiotherapy (50.4 Gy in 28 fractions), followed by surgery scheduled 3–8 weeks after completion of neoadjuvant therapy. The primary endpoint is overall survival, and secondary endpoints include resection rate, R0 resection rate, histological tumor response, progression-free survival, and safety. Overall survival will be compared between the two treatment arms using the stratified log-rank test, with adjusted hazard ratios estimated using the Cox proportional hazards model. This trial was registered with the Japan Registry of Clinical Trials (jRCTs051250150). The CSGO-HBP-027 trial will provide evidence on whether neoadjuvant GS-RT improves survival in patients with resectable PDAC compared with GS alone. The results of this study are expected to clarify the optimal neoadjuvant treatment strategy for resectable PDAC and to provide high-quality evidence regarding the clinical value of adding radiotherapy to GS-based neoadjuvant therapy.

Background Two main therapeutic approaches are currently used for locally advanced pancreatic cancer (LAPC): chemoradiotherapy and systemic chemotherapy. It remains unclear which approach may be more promising, or whether these strategies should be considered alternative or complementary therapeutic options in the management of LAPC. Clinical outcomes and safety were assessed for S-1 plus concurrent radiotherapy (S-1 + RT) and gemcitabine plus nab-paclitaxel (GnP) in patients with LAPC. Methods We conducted a pooled exploratory analysis of individual patient data derived from two multi-institutional randomized phase II trials conducted by the Japan Clinical Oncology Group (JCOG1106 and JCOG1407). JCOG1106 evaluated S-1 + RT with or without induction chemotherapy. JCOG1407 compared GnP with modified FOLFIRINOX. Based on the results of these trials, S-1 + RT and GnP were selected as promising regimens for chemoradiotherapy and systemic chemotherapy, respectively. The primary endpoint of this study was progression-free survival (PFS). Inverse probability of treatment weighting (IPTW) with stabilized weights was applied based on the propensity score to account for baseline imbalances between the two groups. Results A total of 113 patients were included. After adjustment for patient characteristics, Kaplan–Meier curves showed median PFS, overall survival (OS), and distant metastasis-free survival (DMFS) of 10.2 vs. 9.3 (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.60–1.30), 19.1 vs. 21.2 (HR, 0.73; 95% CI, 0.48–1.11), and 11.5 vs. 13.1 months (HR, 0.73; 95% CI, 0.49–1.08) for S-1 + RT and GnP, respectively. Treatment received after protocol therapy differed substantially: 77.5% in the S-1 + RT group received single-agent chemotherapy, whereas 50.0% in the GnP group, received more intensive regimens, including multi-agent chemotherapy or chemoradiotherapy. Conclusions GnP may offer advantages in suppressing micrometastatic disease, whereas S-1 + RT may provide benefits in local disease control. These findings suggest that both approaches represent important and complementary therapeutic options for LAPC. Prospective randomized studies are warranted to determine the optimal initial strategy.

Purpose To evaluate the efficacy and safety of the enhanced recovery after surgery (ERAS) protocol and quantify the impact of each ERAS item on postoperative outcomes. Methods We used a generalized linear model to compare 289 colorectal cancer patients treated with the ERAS protocol between June, 2015 and April, 2021, with 99 colorectal cancer patients treated with the conventional colorectal surgery pathway between April, 2014 and June, 2015. Results The median length of hospital stay (LOHS) was significantly shorter in the ERAS group, at 9 days (range 3–104 days) vs. 14 days (range 4–44 days) ( p  < 0.001), but the complication rates (Clavien–Dindo grade 2 or more) were similar (16.6% vs. 22.2%; p  = 0.227). However, in the ERAS group, the higher the compliance with ERAS items, the lower the complication rate and LOHS (both p  < 0.001). Multiple regression analysis demonstrated that \"Discontinuation of continuous intravenous infusion on POD1\" and \"Avoidance of fluid overload\" were significantly associated with the LOHS ( p  < 0.001 and p  = 0.008). Conclusion The ERAS protocol is safe and effective for elective colorectal cancer surgery, and compliance with the ERAS protocol contributes to shorter LOHS and fewer complications. Items related to perioperative fluid management had a crucial impact on these outcomes.

Esophageal sarcoma is an extremely rare tumor, and a recommended treatment strategy remains unestablished. The present report describes, to the best of our knowledge, the first reported case of unresectable esophageal sarcoma treated with chemoradiotherapy (CRT) followed by salvage robot-assisted minimally invasive esophagectomy (RAMIE). An 82-year-old man presented with dysphagia for solid foods. An esophagogastroduodenoscopy revealed an elevated tumor in the middle thoracic esophagus at a distance of 30-35 cm from the incisors, with preserved endoscopic passage and no additional lesions in the stomach or duodenum. A biopsy demonstrated sarcoma. Enhanced computed tomography showed a middle thoracic esophageal mass, with bulky mediastinal lymph nodes (nos. 101R and 106recR) invading the trachea. No distant metastases were detected, and tumor marker levels remained within normal limits. The patient was diagnosed with esophageal sarcoma with mediastinal lymph node metastases. As the metastatic nodes demonstrated airway invasion, definitive CRT (dCRT) was selected. The regimen consisted of radiotherapy (50.4 Gy in 28 fractions) and fluorouracil plus cisplatin. Following dCRT, the tumor and lymph nodes decreased in size, and a partial response was achieved, making the tumor resectable. Salvage RAMIE with two-field lymphadenectomy, including cervical lymph node dissection of stations 101R and 101L and upper mediastinal dissection, including station 106recR, was subsequently performed, followed by gastric tube reconstruction via the posterior mediastinal route. Pathological examination of the resected specimen revealed no residual tumor. Although a therapeutic effect was observed, a limitation remains in that a definitive diagnosis could not be fully established. A total of 14 months have passed since the initiation of treatment, with no evidence of recurrence. In conclusion, this patient with unresectable locally advanced esophageal sarcoma achieved a complete pathological response after multidisciplinary treatment, with no recurrence observed during the short-term follow-up period.

Refractory gastroesophageal reflux disease can develop after proximal gastrectomy and esophagogastrostomy. We introduce a new method that combines distal gastrectomy and Roux-en-Y reconstruction to treat refractory reflux esophagitis in patients who have undergone proximal gastrectomy and esophagogastric anastomosis reconstruction. This novel method may be useful not only for alleviating the symptoms of gastroesophageal reflux disease but also for preventing future esophageal malignancies arising from long-term reflux esophagitis.

Background Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease, and multimodal strategies, such as surgery plus neoadjuvant chemotherapy (NAC)/adjuvant chemotherapy, have been attempted to improve survival in patients with localized PDAC. To date, there is one prospective study providing evidence for the superiority of a neoadjuvant strategy over upfront surgery for localized PDAC. However, which NAC regimen is optimal remains unclear. Methods A randomized, exploratory trial is performed to examine the clinical benefits of two chemotherapy regimens, gemcitabine plus S-1 (GS) and gemcitabine plus nab-paclitaxel (GA), as NAC for patients with planned PDAC resection. Patients are enrolled after the diagnosis of resectable or borderline resectable PDAC. They are randomly assigned to either NAC regimen. Adjuvant chemotherapy after curative resection is highly recommended for 6 months in both arms. The primary endpoint is tumor progression-free survival time, and secondary endpoints include the rate of curative resection, the completion rate of protocol therapy, the recurrence type, the overall survival time, and safety. The target sample size is set as at least 100. Discussion This study is the first randomized phase II study comparing GS combination therapy with GA combination therapy as NAC for localized pancreatic cancer. Trial registration UMIN Clinical Trials Registry UMIN000021484 . This trial began in April 2016.

Biliary tract cancer (BTC) has a generally poor prognosis. Furthermore, it is difficult to distinguish BTC from benign biliary disease (BBD) with commonly used modalities. Therefore, a novel biomarker to facilitate cancer detection is highly desirable. Recent studies have reported the use of circulating microRNAs (miRNAs) as biomarkers for cancers. The purpose of this study was to evaluate whether circulating miRNA‐21 (miR‐21) could be used as a biomarker for BTC. Plasma samples were obtained from 94 BTC patients, 50 healthy volunteers (HVs), and 23 BBD patients. miR‐21 levels in the samples were measured by qRT‐PCR. Plasma miR‐21 levels in patients with BTC were significantly higher than in HVs or in patients with BBD (P < 0.0001 for both). Receiver–operator curve (ROC) curve analysis in differentiating BTC patients from HVs indicated that area under the curve (AUC), optimal sensitivity and specificity was 0.93, 85.1% and 100%, respectively, and those in differentiating BTC patients from BBD patients was 0.83, 72.3%, 91.3%, respectively. Validation of these results indicated that the negative predictive value, positive predictive value, sensitivity, specificity, and accuracy in differentiating BTC patients from HVs was 76.6%, 98.6%, 84.0%, 98.0%, and 88.9%, respectively, and those in differentiating BTC patients from BBD patients was 42.2%, 93.0%, 71.2%, 82.6%, and 72.6%, respectively. These sets of values were improved by combining miR‐21 and CA19‐9 measurements. Plasma miR‐21 is a novel diagnostic biomarker for BTC, and may be useful in distinguishing between BTC and BBD patients. In the present study, we evaluated the usefulness of plasma miR‐21 as a diagnostic biomarker for biliary tract cancer (BTC). Judging solely by CA19‐9 levels, many BTC patients were within the normal range. More BTC patients could be diagnosed by miR‐21 levels. (Black circle, BTC patients; blue circle, HVs; red circle, BBD patients).

Background Laugier’s hernia is a very rare atypical femoral hernia and is challenging to diagnose preoperatively. Herein, we report a rare case of inguinal and Laugier’s hernias treated with laparoscopic transabdominal preperitoneal repair. Case presentation A 63-year-old man was admitted to our hospital with right groin swelling for 4 years. Computed tomography revealed an indirect inguinal hernia with protrusion of the small intestine. The preoperative diagnosis was right indirect inguinal hernia; Laugier’s hernia was unknown. The patient underwent laparoscopic transabdominal preperitoneal repair. During the surgery, part of the perivesical adipose tissue penetrated the lacunar ligament. It was located medial to the typical site of a femoral hernia. Thus, Laugier's hernia was diagnosed. Finally, laparoscopic transabdominal preperitoneal repair was performed for Laugier's hernia and inguinal hernia. The postoperative course was good, without recurrence. Conclusions To our knowledge, this is the first reported case of inguinal and Laugier’s hernia treated with laparoscopic transabdominal preperitoneal repair. Surgeons should be mindful that inguinal hernias can occur concurrently with other types of hernias, such as femoral hernias, including atypical variants like Laugier's hernia. Additionally, they should actively consider laparoscopic approaches such as transabdominal preperitoneal for femoral hernias. These approaches are beneficial for precise diagnosis, confirming the presence of other hernias, and simultaneously treating all coexisting inguinal hernias.