Backgrounds No confirmatory randomized controlled trials (RCTs) have evaluated the efficacy of laparoscopy-assisted distal gastrectomy (LADG) compared with open distal gastrectomy (ODG). We performed an RCT to confirm that LADG is not inferior to ODG in efficacy. Methods We conducted a multi-institutional RCT. Eligibility criteria included histologically proven gastric adenocarcinoma in the middle or lower third of the stomach, clinical stage I tumor. Patients were preoperatively randomized to ODG or LADG. This study is now in the follow-up stage. The primary endpoint is relapse-free survival (RFS) and the primary analysis is planned in 2018. Here, we compared the surgical outcomes of the two groups. This trial was registered at the UMIN Clinical Trials Registry as UMIN000003319.Results Between March 2010 and November 2013, 921 patients (LADG 462, ODG 459) were enrolled from 33 institutions. Operative time was longer in LADG than in ODG (median 278 vs. 194 min, p \ 0.001), while blood loss was smaller (median 38 vs. 115 ml, p \ 0.001). There was no difference in the overall proportion with in-hospital grade 3-4 surgical complications (3.3 %: LADG, 3.7 %: ODG). The proportion of patients with elevated serum AST/ALT was higher in LADG than in ODG (16.4 vs. 5.3 %, p \ 0.001). There was no operation-related death in either arm. Conclusions This trial confirmed that LADG was as safe as ODG in terms of adverse events and short-term clinical outcomes. LADG may be an alternative procedure in clinical IA/IB gastric cancer if the noninferiority of LADG in terms of RFS is confirmed.

Objectives: A multicenter randomized phase II study was conducted to evaluate the effects of Hochu-ekki-to (TJ-41) for reducing adverse reactions and increasing compliance with S-1 adjuvant therapy for advanced gastric cancer. Methods: The eligibility criteria were pathological stage II/III after R0 resection. Patients received adjuvant therapy with S-1 alone (group S) or S-1 with TJ-41 (group ST) for 1 year. The primary endpoint was the completion rate of S-1. Secondary endpoints were adverse events, relative dose intensity, relapse-free survival (RFS), and overall survival (OS). Results: We randomly assigned 56 patients to group ST and 57 patients to group S. The completion rates of S-1 were 54.5 and 50.9%, the median relative dose intensities were 89.2 and 71.9%, and adverse events of grade 3 or 4 occurred in 45.5 and 54.5% in groups ST and S, respectively. There was no significant difference in 3-year OS or RFS between the two groups. Conclusions: TJ-41 does not increase relative dose and completion rate of S-1 significantly. J-41 may reduce toxic effects, but our findings do not support routine use of TJ-41 after gastrectomy.

This case report describes the repair of an aortoesophageal fistula caused by a previously placed aortic arch graft. A 62-year-old man underwent total aortic arch graft replacement one year ago. He was readmitted with hematemesis and a high fever. Examination by endoscopy revealed a perforation and two swollen lesions in the mid-esophagus. With the diagnosis of aortoesophageal fistula, the patient underwent esophagectomy, cervical esophagostomy, and gastrostomy with plans for esophageal continuity. Twenty days later, the patient had the graft replacement. Left thoracotomy was performed at the fourth intercostal space and the incision was extended to a sternal transection. The old aortic arch graft was replaced with a rifampicin-bonded gelatin-sealed Dacron graft. After successful esophageal reconstruction (a cervical esophagogastrostomy with the stomach in the substernal position), he fully recovered from surgery. Aortoesophageal fistula is rare and always fatal if surgical intervention is not attempted. When homografts are unavailable, an alternative therapeutic approach is in situ replacement with a rifampicin-bonded gelatin-sealed Dacron graft.

A 69-year-old alcoholic manwith pneumonia and sepsis due to Aeromonashydrophila is presented. He died of suffocation by a copious amount of hemoptysis six hours after his first symptoms of abdominal pain, diarrhea and dyspnea. Aeromonas hydrophila was isolated from blood and bronchial secretion. A fulminant form of pneumonia could develop in patients with predisposing underlying conditions such as alcoholism with chronic hepatitis and diabetes mellitus. Aeromonas hydrophila pneumonia may be characterized by hemoptysis and rapid clinical deterioration with a high mortality rate. (Internal Medicine 35: 410-412, 1996)

Prosthetic graft infection is difficult to diagnose early, and hence, is associated with high mortality and morbidity rates. A 63-year-old man who had undergone surgical prosthetic replacement for an inflammatory thoracic aortic aneurysm 10 months previously visited our emergency room, complaining of chills, shivering, frequent vomiting, and back pain. He was diagnosed with severe sepsis, and a blood culture detected Streptococcus anginosus and Prevotella oralis. Repeated contrast-enhanced computed tomography (CT) scans of his chest revealed ectopic gas around the graft, and esophagogastroduodenoscopy revealed esophageal perforations at several sites. We therefore diagnosed him with aortic prosthetic graft infection accompanied with esophagomediastinal fistulas. He received medical treatment and three operations and recovered from the infection. This is a rare case of aortic prosthetic graft infection accompanied with esophagomediastinal fistulas, and we conclude that repeated CT is useful for identifying the primary infection site and invasion route in patients with suspected aortic prosthetic graft infection.