A young child with VACTERL association who refused oral intake and had relied on gastric tube feeding for almost all of her nutritional intake since birth was initially managed with nutritional guidance based on the assumption that refusal was due to oral hypersensitivity. However, no improvement was observed in the refusal of oral intake, and her inherent developmental delay and bilateral hearing loss prevented the continuation of nutritional guidance. A speech-language-hearing therapist was then consulted to assess the patient’s swallowing function, and the diagnosis was that the lack of experience of oral intake itself and the dependence on tube feeding were more likely causes of the refusal than oral hypersensitivity. We therefore decided to use the approach proposed by Tazumi et al. for stepwise management of eating disorders requiring tube feeding in young children. This allowed us to create a step-bystep management plan toward achieving oral intake, resulting in gradual but significant changes in the patient's eating behavior. Although oral intake has not been achieved as of the time of writing, we are continuing to manage the patient with this trial-and-error approach.

Purpose: The incidence of early gastric cancer is increasing in older patients alongside life expectancy. For early gastric cancer of the upper third of the stomach, laparoscopic functionpreserving gastrectomy (LFPG), including laparoscopic proximal gastrectomy (LPG) and laparoscopic subtotal gastrectomy (LSTG), is expected to be an alternative to laparoscopic total gastrectomy (LTG). However, whether LFPG has advantages over LTG in older patients remains unknown. Materials and Methods: We retrospectively analyzed data of consecutive patients aged ≥75 years who underwent LTG, LPG, or LSTG for cT1N0M0 gastric cancer between 2005 and 2019. Surgical and nutritional outcomes, including blood parameters, percentage body weight (%BW) and percentage skeletal muscle index (%SMI) were compared between LTG and LPG or LSTG. Survival outcomes were also compared between LTG and LFPG groups. Results: A total of 111 patients who underwent LTG (n=39), LPG (n=48), and LSTG (n=24) were enrolled in this study. To match the surgical indications, LTG was further categorized into “LTG for LPG” (LTG-P) and “LTG for LSTG” (LTG-S). No significant differences were identified in the incidence of postoperative complications among the procedures. Postoperative nutritional parameters, %BW and %SMI were better after LPG and LSTG than after LTG-P and LTG-S, respectively. The survival outcomes of LFPG were better than those of LTG. Conclusions LFPG is safe for older patients and has advantages over LTG in terms of postoperative nutritional parameters, body weight, skeletal muscle-sparing, and survival.Therefore, LFPG for upper early gastric cancer should be considered in older patients.