Purpose: Despite annual endoscopy, patients with metachronous remnant gastric cancer (MRGC) following proximal gastrectomy (PG) are at times ineligible for endoscopic resection (ER). This study aimed to clarify the clinical risk factors for ER inapplicability. Materials and Methods: We reviewed the records of 203 patients who underwent PG for cT1 gastric cancer between 2006 and 2015. The remnant stomach was categorized as a pseudofornix, corpus, or antrum. Results: Thirty-two MRGCs were identified in the 29 patients. Twenty MRGCs were classified as ER (ER group, 62.5%), whereas 12 were not (non-ER group, 37.5%). MRGCs were located in the pseudo-fornix in 1, corpus in 5, and antrum in 14 in the ER group, and in the pseudofornix in 6, corpus in 4, and antrum in 2 in the non-ER group (P=0.019). Multivariate analysis revealed that the pseudo-fornix was an independent risk factor for non-ER (P=0.014). In the non-ER group, MRGCs at the pseudo-fornix (n=6) had more frequent undifferentiated-type histology (4/6 vs. 0/6), deeper (≥pT1b2; 6/6 vs. 2/6) and nodal metastasis (3/6 vs. 0/6) than non-pseudo-fornix lesions (n=6). We examined the visibility of the region developing MRGC on an annual follow-up endoscopy one year before MRGC detection. In seven lesions at the pseudofornix, visibility was only secured in two (28.6%) because of food residues. Of the 25 lesions in the non-pseudo-fornix, visibility was secured in 21 lesions (84%; P=0.010). Conclusions Endoscopic visibility increases the chances of ER applicability. Special preparation is required to ensure the complete clearance of food residues in the pseudo-fornix.

Background/Aims: The accurate assessment of the depth of invasion of early gastric cancer (EGC) is critical to determine the most appropriate treatment option. However, it is difficult to distinguish shallow submucosal (SM1) invasion from deeper submucosal (SM2) invasion. We investigated the diagnostic performance of endoscopic ultrasonography (EUS) using a miniature probe for EGC with suspected SM invasion. Methods: From April 2008 to June 2018, EGCs with suspected SM invasion were analyzed retrospectively. The EGCs examined by a 20 MHz high-frequency miniature probe was included in our study. Esophago-gastric junction cancers and patients treated by chemotherapy before resection were excluded. The sensitivity and specificity for the detection of SM2 invasion by EUS were compared with those of white light imaging (WLI).Additionally, factors related to depth underestimation or overestimation were investigated using multivariate analysis. Results: A total of 278 EGCs in 259 patients were included in the final analysis. The sensitivity and specificity for SM2 or deeper by EUS were 73.7% (87/118) and 74.4% (119/160), respectively. The sensitivity and specificity by WLI were 47.5% (56/118) and 68.1% (109/160), respectively. The sensitivity of EUS was significantly superior to that of conventional endoscopy (p<0.01). Multivariate analysis revealed that an anterior location of the EGC was an independent risk factor for underestimation by EUS (odds ratio, 3.3; 95% confidence interval, 1.1 to 9.8; p=0.03). Conclusions The depth diagnostic performance for EGCs with suspected SM invasion using EUS was satisfactory and superior to that of conventional endoscopy. Additionally, it is important to recognize factors that may lead to misdiagnosis in thoselesions.

PURPOSE: To evaluate the status of number 3b lymph node (LN) station in patients with adenocarcinoma of the esophagogastric junction (AEG) and to investigate the optimal indications for radical proximal gastrectomy (PG) for AEG. MATERIALS AND METHODS: Data of 51 patients with clinically advanced Siewert types II and III AEG who underwent total gastrectomy (TG) between April 2010 and July 2017 were reviewed. The proportion of metastatic LNs at each LN station was examined. Number 3 LN station was separately classified into number 3a and number 3b. The risk factors for number 3b LN metastasis and the clinicopathological features of number 3b-positive AEG patients were investigated. RESULTS: The incidences of LN metastasis were the highest in number 1 (47.1%), followed by number 2 (23.5%), number 3a (39.2%), and number 7 (23.5%) LN stations. LN metastasis in number 3b LN station was detected in 4 patients (7.8%). A gastric invasion length of more than 40 mm was a significant risk factor for number 3b LN metastasis. All 4 patients with number 3b-positive AEG had advanced cancer with a gastric invasion length of more than 40 mm. The 5-year survival rate of patients with a gastric invasion length of more than 40 mm was 50.0%. CONCLUSIONS: Radical PG may be indicated for patients with AEG with gastric invasion length of less than 40 mm.
Adenocarcinoma* ; Esophagogastric Junction* ; Gastrectomy* ; Humans ; Incidence ; Lymph Nodes ; Neoplasm Metastasis ; Risk Factors ; Survival Rate

Several prospective studies on laparoscopy-assisted distal gastrectomy for early gastric cancer have been initiated, but no prospective study evaluating laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy has been completed to date. A non-randomized confirmatory trial was commenced in April 2015 to evaluate the safety of laparoscopy-assisted total gastrectomy and laparoscopy-assisted proximal gastrectomy for clinical stage I gastric cancer. A total of 245 patients will be accrued from 42 Japanese institutions over 3 years. The primary endpoint is the proportion of patients with anastomotic leakage. The secondary endpoints are overall survival, relapse-free survival, proportion of patients with completed laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy, proportion of patients with conversion to open surgery, adverse events, and short-term clinical outcomes. The UMIN Clinical Trials Registry number is UMIN000017155.
Anastomotic Leak ; Asian Continental Ancestry Group ; Conversion to Open Surgery ; Gastrectomy* ; Humans ; Japan* ; Laparoscopy ; Medical Oncology* ; Non-Randomized Controlled Trials as Topic ; Prospective Studies ; Stomach Neoplasms*

Acupuncture and moxibustion are not fully or well-utilized in the medical system, particularly in the hospitals of Japan. If they were more commonly practiced in hospitals, disorders and disease conditions that are not improved by modern Western medicine might be better treated. In addition, collaboration between acupuncturist and Western medical doctors would promote the research of acupuncture, moxibustion, and related techniques.
However, to achieve these aims, improvements in the quality of acupuncture and moxibustion education would be needed. Also, hospitals that are presently using acupuncture and moxibustion for routine treatment would have to demonstrate their usefulness and how this is contributing to patients' health.
Having acupuncture and moxibustion therapists (AMT), as a defined occupation in hospitals, was proposed in 1981, although this has not yet been realized. However, we believe that hospital AMTs would be necessary for the progress of acupuncture and moxibustion, as well as for national health care and the medical system in Japan.

Continued from the previous year's theme of our workshop, we collected various information and ideas for safer acupuncture practice. Subjects and presentations of the present workshop were as follows:
1. Literature review of papers on adverse events published between 2003and 2006
1) Papers in domestic journals (by Ishizaki and Egawa)
2) Papers in foreign journals (by Yamashita and Umeda)
2. Debate on wearing sterilized fingerstall or glove
1) Present status of the use of fingerstall in acupuncture practice (by Katai and Minowa)
2) Practical side of clinical education of acupuncture using fingerstall (by Hatakeyama and Furuya)
3) Problem of using individual fingerstalls in acupuncture practice (by Handa and Miyamoto)
We will continue to provide information and discuss solutions in order to reach a common understanding and specific methods for safer acupuncture practice.

We have been collecting various ideas on safer acupuncture practice from participants in our workshop as well as members of the committee. Subjects and presentations of the present workshop were as follows:
1. Forgotten needles
  1) Ideas of prevention based on a questionnaire survey (Egawa and Ishizaki)
  2) Effect of incident reporting system (Yamashita)
2. Cleaner method of needle insertion and Oshide (needle-supporting fingers)
  1) Merits and demerits of sterilized fingerstall and glove (Miyamoto)
  2) History of the clean needle development (Umeda)
  3) A novel clean acupuncture needle device (Imai and Ishizaki)
Although there was not enough time for discussion, we collected some useful ideas from the participants. A novel clean needle invented by Imai gave a strong impression to the audience. We should continue to discuss a diverse impact when such new devices and concepts become widespread in traditional acupuncture practices. We welcome more ideas and opinions from relevant facilities, clinics and fields in order to further improve safety of acupuncture.

We continued reviewing published evidence and information regarding the safety of acupuncture. Subjects in 2005 were as follows :
1. Safety during acupuncture stimulation
2. Quality and strength of acupuncture needle
3. Sterilization and storage of equipments
4. Hygienic handling of equipments
5. Relevant notices from the Government
6. Standards of notification regarding hygienic practice and contaminated wastes
We hope that the information here will influence the future school education, clinical practice, manual editing and research activities.

We updated safety information on acupuncture and moxibustion, focusing on adverse events. Case reports published between 1998 and 2002 were searched, using “Ichushi Web” (Web version of Japana Centra Medio Medicina) and “PubMed”. Thirtysix cases of acupunctureassociated adverse events (13 infections, 11 dermatological problems, 6 organ injuries or foreign bodies, 5 nerve injuries etc.) and nine cases of moxibustionassociated adverse events (6 dermatological problems etc.) were located. Most cases were published in academic journals in the field of modern Western medicine, which clinical acupuncturists usually do not read. Therefore, our committee should play a role of collecting safety information and performing the feedback for the acupuncturists.
We also summarize the contents of the Workshop held by our committee on June 6, 2003. The most controversial issue was determining an appropriate method of needle insertion in terms of infection control. More evidence is needed for establishing a good manual for safety acupuncture.

We reviewed case reports of bilateral pneumothorax after acupuncture treatment from the point of view of clinical acupuncture. A paper showing pathological findings based on autopsy suggests that, in more cases than we had expected, acupuncture needles penetrate the lung or the pleura. We speculate a portion of these cases develop into pneumothorax and a few of these become serious. By means of literature search, we have found that 23 cases of bilateral pneumothorax after acupuncture have been published in Japan and other countries. We must learn from these case reports. Further, we should reassess the contents of clinical acupuncture education and introduce the concept of failsafe treatment.