Background and Objectives:There is no standardized method of reconstruction in laparoscopic proximal gastrectomy (LPG). We present a novel technique of reconstruction with a long, narrow gastric tube in LPG for early gastric cancer (EGC).Methods:During the laparoscopic procedure, the upper part of the stomach is fully mobilized with perigastric and suprapancreatic lymphadenectomy, and then the abdominal esophagus is transected. After a minilaparotomy is created, the entire stomach is pulled outside. A long, narrow gastric tube (20 cm long, 3 cm wide) is created with a linear stapler. The proximal part of the gastric tube is formed into a cobra head shape for esophagogastric tube anastomosis, which is then performed with a 45-mm linear stapler under laparoscopic view. The end of the esophagus is fixed on the gastric tube to prevent postoperative esophageal reflux.Results:Thirteen patients with early proximal gastric cancer underwent the procedure. The mean operative time was 283 min, and median blood loss was 63 ml. There were no conversions to open surgery, and no intraoperative complications.Conclusion:This new technique of reconstruction after LPG is simple and feasible. The procedure has the potential of becoming a standard reconstruction technique after LPG for proximal EGC.

Background: An esophageal diverticulum is rare and is frequently associated with esophageal motility disorders. Jackhammer esophagus is also rare, is characterized by esophageal hypercontraction, and comprises 4.1% of esophageal motility disorders. Here, we report a case of a patient successfully treated by laparoscopic transhiatal surgery for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus diagnosed with highresolution manometry (HRM). Case presentation: The patient was a 78-year-old man who presented to the hospital with dysphagia. A diverticulum was detected in the lower part of his esophagus by upper gastrointestinal endoscopy. HRM was performed to investigate esophageal motility disorders. His integrated relaxation pressure was normal at 25.9 (< 26) mmHg, but his distal contractile integral (DCI) was very high at 21,464 (1500-13,000) mmHg s cm. Esophageal peristalsis was preserved. Therefore, the patient was diagnosed as having an epiphrenic esophageal diverticulum derived from a jackhammer esophagus for which laparoscopic transhiatal diverticulectomy and Heller-Dor procedure were performed. The postoperative course was uneventful. His symptoms improved, and the level of DCI also returned to a normal level of 3867 mmHg s cm at 2 months after the operation. Conclusion: Laparoscopic transhiatal diverticulectomy and esophagomyotomy can be useful procedures for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus due to their lower invasiveness.

With the assistance of a DVD, high success rates of IC acquisition were obtained for an RCT of laparoscopic versus open surgery for stage II/III colon cancers. To obtain such a rate, investigators should make efforts to inform patients, their relatives, and referring doctors about the medical contributions a surgical RCT can make.

Background: Bilateral adrenalectomy is performed in cases with infantile-onset Cushing syndrome due to bilateral adrenal hyperplasia in McCune-Albright syndrome (MAS) because severe Cushing syndrome with heart failure and liver dysfunction can have a lethal outcome. This procedure can completely ameliorate hypercortisolism, although lifetime steroid replacement therapy and steps to prevent adrenal crisis are necessary. Recently, the efficacy of unilateral adrenalectomy has been reported in adult cases of bilateral macronodular adrenal hyperplasia, but there is no consensus regarding the appropriate surgical treatment for bilateral adrenal hyperplasia in MAS. Objective: A 6-month-old girl presented with café-au-lait spots, short stature, central obesity, a moon face, and hypertension. Endocrinological tests and imaging studies led to the diagnosis of ACTH-independent Cushing syndrome due to bilateral adrenal hyperplasia induced by MAS. “Three-quarters adrenalectomy”, namely right-sided total adrenalectomy and left-sided half adrenalectomy, was carried out. An activating mutation of the GNAS1 gene (p.Arg201Cys) was identified in the adrenal tissues. Since the operation, our patient has been in a state of clinical remission for more than 2 years. Conclusion: Our original surgical intervention, three-quarters adrenalectomy, may be a new treatment option for Cushing syndrome associated with MAS.

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