Program

Date: July 13th 2018（Fri） 11:00am～12:00pm
Hall: HALL 1 (SHIROYAMA HOTEL KAGOSHIMA Emerald)

Chair: Masaki Mori （Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University）
Speaker: Kelly M. McMasters（University of Louisville School of Medicine）

Title: Impact of the partnership between JSGS, SSO, and Annals of Surgical Oncology

Date: July 12th 2018（Thu） 10:10am～11:10am
Hall: HALL 11 (Kagoshima Prefecture Citizen's Exchange Center Medium-sized Hall)

Chair: Maski Kitajima（International University of Health and Welfare School of Medicine）
Speaker: Arnulf H. Hölscher（German Center for Esophageal- and Gastric Surgery）

Title: Current Management of Esophageal and GE junction Cancer

Date: July 12th 2018（Thu） 15:20pm～16:20pm
Hall: HALL 3 (SHIROYAMA HOTEL KAGOSHIMA Royal gardenB）

Chair: Tadahiro Takada（Teikyo University School of Medicine）
Speaker: Jakob R. Izbicki（Department of General-, Visceral- and Thoracic-Surgery University Hamburg-Eppendorf）

Title: Synchronous resections of hepatic oligometastatic pancreatic cancer: Disputing a principle in a time of safe pancreatic operations in a retrospective multicenter analysis.

Date: July 11th 2018（Wed） 8:30am～10:30am
Hall: HALL 3 (SHIROYAMA HOTEL KAGOSHIMA Royal gardenB）

Chair: Mitsuru Sasako (Department of Surgery, Hyogo College of Medicine）
Yasuhiro Kodera（Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine）
Sung Hoon Noh（Yonsei University, College of Medicine）

Speaker: Han-Kwang Yang（Department of Surgery, Seoul National University College of Medicine）
HU Xiang（Department of General Surgery, The First Affiliated Hospital,Dalian Medical University）
Jimmy B.Y. SO（National University of Singapore）
Yasuhiro Kodera（Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine）
Takahiro Kinoshita（Gastric Surgery Division, National Cancer Center Hospital East）
Yukinori Kurokawa（Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University）

Title: Gastric cancer　－from a global perspective－

In Japan, neoadjuvant chemotherapy with cisplatin and 5-fluorouracil has become a standard therapy based on the results of a randomized trial of postoperative adjuvant versus neoadjuvant chemotherapy for clinical stage II/III squamous cell carcinoma of the thoracic esophagus (JCOG 9907). However, on subgroup analysis, poor effects were observed for patients with stage III cancer. Recently, good therapeutic outcomes of new methods of radiation therapy and chemotherapy have been reported. However, it is necessary to address not only the therapeutic effect but also provide measures against adverse events, effects on postoperative complications, and improvement in prognosis. In this symposium, we would like to introduce a novel neoadjuvant therapy regimen for advanced esophageal cancer and discuss the possibility of a new treatment.

Recent advances in anticancer agents, including novel molecular targeted drugs, have helped to improve surgical resectability in patients with unresectable advanced gastric cancer. However, the selection of target cases, timing of surgical intervention, and degree of lymphadenectomy, in addition to other issues, are not known for conversion surgery. Finally, it is necessary to clarify whether conversion surgery really contributes to the improvement in prognosis. Unfortunately, currently, there is hardly any evidence supporting the use of conversion surgery. In this symposium, we would like to present the therapeutic results of conversion surgery and provide information about its current issues and future prospects.

Treatment strategies to control locally advanced rectal cancer include total mesorectal excision (TME) plus lateral lymph node dissection in Japan and neoadjuvant chemotherapy/radiation therapy (CRT) plus TME or neoadjuvant chemotherapy followed by CRT plus TME in Western countries. Recently, a watch-and-wait approach was reported for clinically complete response cases after CRT. In Japan, treatment strategies are diverse, including neoadjuvant CRT followed by TME, neoadjuvant chemotherapy followed by TME, neoadjuvant chemotherapy followed by CRT plus TME, and selective lateral lymph node dissection. In this symposium, we would like to show the short- and long-term outcomes for locally advanced rectal cancer and discuss this novel strategy to improve both local control and survival rates.

The technical innovation of preoperative simulation based on multidetector CT was remarkable, and estimating the remnant liver volume after hepatectomy or the area of hepatic vein drainage correctly became possible. However, problems during operation and postoperative complications due to surgical methods are still reported. Moreover, liver resection methods have been used by insurance adaptation of laparoscopic liver resection, and cases that cannot be judged by conventional evaluation of hepatic reserve, e.g., Child-Pugh grading or ICG retention test, are encountered. Technetium-99m-galactosyl human serum albumin scintigraphy is widely used as another evaluation method of hepatic reserve, and new evaluation methods, e.g., ALBI grading, are also recently reported. I will present the new criteria of surgery for liver cancer via innovation of image analysis and evaluation of hepatic reserve.

In Japan, more than 20 years have passed since the first thoracoscopic esophagectomy was performed for esophageal cancer. Owing to magnifying visual effects and technological innovations such as devices, the adaptation has also expanded to advanced cancer and salvage surgery. Using a nationwide database in Japan, minimally invasive esophagectomy (MIE) was particularly beneficial in reducing postoperative respiratory complications but may be associated with higher reoperation rates. MIE did not necessarily contribute to invasive alleviation. A non-thoracotomy surgery using a mediastinoscope has attracted attention for minimally invasive surgery. However, there is no evidence supporting the use of this technique. In this video symposium, I have described each adaptation, surgical technique, treatment outcome, task, and future prospects of thoracotomy, thoracoscopic surgery, mediastinoscopic surgery.

Currently, there is little evidence regarding the surgical strategy for advanced esophagogastric junction cancer. A randomized controlled trial (RCT) is being conducted in Japan, the results of which are strongly awaited. In this video symposium, the extent of esophagogastric resection, adequate lymphadenectomy, and type of reconstruction are introduced for each type of approach.

Medical treatment, such as diet and exercise therapy, is the basic treatment method for metabolic syndrome including "obesity," which continues to increase worldwide. However, due to advances in laparoscopic surgical techniques and devices, the use of bariatric surgery has spread worldwide. In Japan, laparoscopic sleeve gastrectomy has been covered by insurance since April 2014. Since patients with metabolic syndrome have many complications such as diabetes and cardiovascular diseases, preoperative management is important to establish safe surgical procedures. We would like to discuss the surgical techniques, preoperative management, and surgical outcomes.

According to the 85th Colorectal Cancer Research questionnaire survey, the percentage of laparoscopic surgery in colon cancer was 70.4%, which means that it is routinely performed in many facilities. Recently, advancements in CT angiography and camera equipment contribute to the understanding of surgical anatomy and precise surgery. However, lymph node dissection around the surgical trunk is still one of the most difficult procedures due to variations of the venous tributaries and middle colic arteries, pancreas, duodenum, and transverse colon mesentery. In this video symposium, we discuss the point of lymph node dissection around the surgical trunk and the ways to avoid accidental injuries during the medial and cranial approaches and their combination.

Laparoscopic anatomical resection of the liver beyond subsegmentectomy has been covered by insurance since 2016, and laparoscope liver resection is now a commonly performed procedure. After that, the preoperative registry system for the National Clinical Database of JSGS has also begun. While laparoscopic anatomical resection of the liver is widely performed in many facilities as well as high volume centers, the standardization of laparoscopic surgery is important in the performance of a safe and certain surgery. I will present videos that show the standardization of laparoscopic right or left hemihepatectomy in each facility, and I hope that these discussions will help to promote laparoscopic anatomical liver resection.

Curative resection often requires major vessel reconstruction in hepatobiliary pancreatic surgery. The development of an imaging simulation enabled accurate resection and reconstruction of blood vessels. Herein, the safe vessel reconstruction method, pitfalls, and tips of troubleshooting are shown via a video presentation. Furthermore, the indication and significance of concomitant major vessel resection have been shown considering the viewpoint of postoperative outcomes.

The development of laparoscopic surgery is remarkable, but it is difficult to perform in cases of complicated operations. In order to compensate for such difficulties, robotic-assisted surgery has been established and is still in the process of development since the pharmaceutical approval of the da Vinci Surgical System in 2009 in Japan. Although this operation is said to be a high-potential surgical technique due to the excellent field of view, three-dimensional high-vision system, multi-joint forceps, and computer-controlled operability, the benefit corresponding to the expensive equipment is still limited. In this video symposium, we would like to present the current status of robotic-assisted surgery in each organ by using videos and discuss future challenges of the procedure.

Laparoscopic surgery is used for precise manipulation based on magnifying visual effects and is performed for various early gastrointestinal cancers. Furthermore, the indications for laparoscopic surgery have been expanded, and it has been performed for patients with serosal invasion, lymph node metastasis, and residual gastric cancer. However, there are various pitfalls of laparoscopic surgery. To date, many investigators have reported intraoperative problems and postoperative complications associated with these pitfalls. In this video symposium, we would like to present the anatomical or technical pitfalls and discuss troubleshooting.

Accurate clinical evaluation of lymph node metastasis is crucial for deciding the appropriate treatment strategy for esophageal cancer. Some modalities or their combination are used for the assessment of lymph node metastasis; however, their accuracy is insufficient. In this workshop, diagnostic accuracy of the types of modalities for preoperative lymph node metastasis will be discussed; furthermore, latest or testing establishment for the diagnosis of lymph node metastasis is introduced.

Since medical examination including screening is widely prevalent in Japan, patients with early GIST undergo minimally invasive surgery by LECS. In addition, preoperative chemotherapy has been attempted in patients with a high risk of disease recurrence. However, the clinical impact of preoperative chemotherapy remains unclear in these patients. Moreover, resistance to antitumor drugs such as imatinib, sunitinib, and regorafenib is a clinical problem in patients with unresectable and recurrent GIST. In this session, we would like to discuss the therapeutic strategies that improve the prognosis in these patients.

To date, many investigators have demonstrated the clinical usefulness of adjuvant or neoadjuvant chemotherapy in patients with gastric cancer. Since it is clinically difficult to predict tumor response and monitor disease status, the clinical significance of the optimal chemotherapeutic regimen and surgical intervention remains unclear. Sensitivity tests for anticancer agents have been conventionally used in clinical management. However, studies regarding biomarkers for predicting therapeutic effects have been reported owing to the recent progress in molecular techniques. In this session, we would like to discuss the therapeutic biomarkers for chemotherapy in patients with gastric cancer.

Total mesorectal excision (TME) is a standard technique for the treatment of rectal cancer. In recent years, transanal TME (taTME) has been introduced internationally as a revolutionary approach, and a multicenter, randomized trial has begun to verify the superiority of taTME over laparoscopic surgery. In this workshop, please present the ingenuity and problems of taTME conducted at each facility and discuss future prospects of this approach.

In Japan, live-donor liver transplantations remain the mainstream surgery, and ensuring safety throughout donor surgeries is considered an extremely important issue. Surgical techniques developed through liver transplantations are widely utilized in gastroenterological surgeries and have long contributed to their development. There are 27 liver transplantation facilities registered nationwide, under the Japan Organ Transplant Network; however most liver surgeons are not involved in transplantation therapy. This section presents surgical techniques, anatomical features, perioperative management, pitfalls, and surgical planning of hepatectomies from the experience of liver transplantation surgeons, as well as educational considerations for general liver surgeons.

Although neoadjuvant chemotherapy for borderline resectable pancreatic cancer invading to artery (BR-A PDAC) has took recent consensus, the efficacy of this therapy requires further studies against resectable (R-PDAC) or borderline resectable pancreatic cancer invading to portal vein (BR-PV PDAC). Especially, R-PDAC can be cured by surgery followed by adjuvant chemotherapy, and as such, there may not be need for neoadjuvant chemotherapy. Furthermore, many facilities select surgery followed by adjuvant chemotherapy, even in cases of BR-PV PDAC, because of better results and the possibility of losing future surgery opportunities due to tumor progression during neoadjuvant chemotherapy. In this workshop, we would like to discuss strategies of preoperative therapy for pancreatic cancer, including indications, results, and latest standards.

In a speech in January 2015, US President Obama announced the "Precision Medicine Initiative," which is drawing attention. The background of precision medicine is the development of new drugs that are different from conventional anticancer drugs and the gene information analysis individual patients through the development of biotechnology. Detailed analyses of environmental factors, such as living environment and lifestyle, that affect treatment have been performed, and such analyses have enabled us to lead effective cancer preventions and treatments, on individual bases. In Japan, precision medicine efforts have just begun, however we would like to announce the role of surgical treatments and issues about the prevention and treatment of gastrointestinal cancer based on the "Precision Medicine Initiative."

Conventionally, serum tumor markers such as CEA and CA 19-9 have been used as blood biomarkers for clinical diagnosis and therapeutic monitoring. In recent years, liquid biopsy using blood and cerebrospinal fluid has attracted attention, and many investigators have reported molecular studies using liquid biopsy to predict tumor progression and prognosis. Translational research using liquid biopsy is extremely important for the further development of clinical management methods for patients with gastrointestinal cancer. In this workshop, we will report how liquid biopsy can be applied for the clinical treatment of patients with gastrointestinal cancer.

Patients with peritoneal dissemination from gastric cancer have a poor prognosis, and pathological diagnosis in the majority of cases is confirmed by staging laparoscopy. The standard treatment for peritoneal dissemination has not yet been established. Basic and clinical studies are very important in improving the diagnosis and treatment of patients with peritoneal dissemination. In this session, we would like to report the latest knowledge on the diagnosis and treatment of peritoneal dissemination.

Surgical simulation technology using three-dimensional image analysis has advanced rapidly and is greatly utilized in information sharing within surgical teams for the accurate grasp of anatomy and coaching of surgical interns. In addition, in the area of endoscopic surgeries, trials of projecting simulation images on surgical monitors, as well as research on navigation technology using position sensors and projection mapping, are in progress. However, the extent to which real-time navigation technology will advance in the field of gastroenterology, where organ forms change depending on conditions, remains unknown. This section explains the navigation technology and preclinical studies performed at various facilities, regardless of organ type, and discusses future developments.

To date, immunotherapy such as cancer vaccine and dendritic cell therapy has been extensively studied in patients with gastrointestinal cancer. Recently, immune checkpoint molecules have been identified, and this signaling pathway is the focus of attention as a promising immune target in patients with various malignancies. Moreover, these molecules play an important role in the escape mechanism of tumors from immune surveillance. Large-scale clinical trials have demonstrated the clinical utility of immunotherapy using immune checkpoint inhibitors. In this workshop, we will discuss the clinical value of immunotherapy, its therapeutic effect, and biomarker research for predicting tumor response.

To date, immunotherapy such as cancer vaccine and dendritic cell therapy has been extensively studied in patients with gastrointestinal cancer. Recently, immune checkpoint molecules have been identified, and this signaling pathway is the focus of attention as a promising immune target in patients with various malignancies. Moreover, these molecules play an important role in the escape mechanism of tumors from immune surveillance. Large-scale clinical trials have demonstrated the clinical utility of immunotherapy using immune checkpoint inhibitors. In this workshop, we will discuss the clinical value of immunotherapy, its therapeutic effect, and biomarker research for predicting tumor response.