Postoperative aggressive diuresis prevents postoperative tissue edema and complications in patients undergoing distal pancreatectomy

PURPOSE

Intraoperative fluid restriction is reported to be associated with reduced postoperative tissue edema and decreased incidence of postoperative pancreatic fistula (POPF) in pancreatic surgery. However, there is limited information regarding the postoperative approach to prevent postoperative tissue edema and reduce POPF.

METHODS

Patients undergoing distal pancreatectomy from 2013 to 2018 in our institute were retrospectively enrolled (n = 128). The patients were classified into the two groups: an early diuresis group (ED group: patients administered diuretic agents on postoperative day 2 or earlier between 2016 and 2018, n = 69) and a conventional diuresis group (CD group: patients administered diuretic agents on postoperative day 3 or later between 2013 and 2015, n = 59). Postoperative tissue edema assessed by CT imaging and the incidence of clinically relevant POPF (CR-PF; grade B or C) were compared.

RESULTS

Postoperative tissue edema was significantly reduced in the ED group (p < 0.0001). The incidence of CR-PF was lower in the ED group (19% vs. 32%, p = 0.082), especially in patients with postoperative diuresis on POD 1 (12%, p = 0.044).

CONCLUSION

Early and aggressive postoperative diuresis potentially reduced postoperative visceral tissue edema. This postoperative approach to prevent tissue edema may reduce the incidence of CR-PF in pancreatic surgery.

Clinical importance of carcinoembryonic antigen messenger RNA level in peritoneal lavage fluids measured by transcription-reverse transcription concerted reaction for advanced gastric cancer in laparoscopic surgery

BACKGROUND

Transcription-reverse transcription concerted reaction (TRC) is recognized as a useful method for detecting free cancer cells in the peritoneal cavity and predicting peritoneal recurrence in patients with gastric cancer. Nonetheless, the clinical significance of TRC in laparoscopic surgery remains unclear. This study aimed to evaluate the clinical importance of carcinoembryonic antigen (CEA) messenger RNA (mRNA) level in peritoneal lavage fluids measured by TRC in laparoscopic surgery for locally advanced gastric cancer.

METHODS

We enrolled patients with locally advanced gastric cancer who underwent laparoscopic gastrectomy. Peritoneal lavage fluids were collected prior to gastrectomy, and the TRC method was employed to quantify CEA mRNA in peritoneal washes. Overall survival (OS), recurrence-free survival (RFS), and peritoneal recurrence-free survival (PRFS) were analyzed using the Kaplan-Meier method and compared using the log-rank test. Adjusted Cox proportional hazards regression models were used to calculate the hazard ratios (HRs) for CEA mRNA positivity.

RESULTS

A total of 100 patients were analyzed in this study. Overall, 22 patients (22%) exhibited CEA mRNA positivity in peritoneal lavage fluids, as measured by TRC. No significant association between CEA mRNA levels and clinicopathological characteristics was observed. Patients who were CEA mRNA-positive in peritoneal lavage fluids had significantly worse OS, RFS, and PRFS than those who were CEA mRNA-negative (p = 0.0059, p < 0.0001, and p = 0.0022, respectively). In the univariate Cox model, the HR for all-cause mortality in CEA mRNA-positive versus CEA mRNA-negative patients was 3.60 (95% CI, 1.33-9.55; p = 0.0129). Multivariate analysis revealed that CEA mRNA positivity was a significant independent factor for recurrence.

CONCLUSIONS

TRC enables the detection of free cancer cells in the peritoneal cavity and CEA mRNA levels can help predict the prognosis, even in laparoscopic gastrectomy.

Clinical Outcome of Additional Esophagectomy After Endoscopic Treatment for Superficial Esophageal Cancer

BACKGROUND

Endoscopic treatment is one of the options for superficial esophageal cancer, but additional therapy such as esophagectomy or chemoradiotherapy (CRT) is sometimes needed due to noncurative resection. However, the outcome of additional therapy after endoscopic treatment has not been fully evaluated.

METHODS

In 160 patients with superficial esophageal cancer, including 37 patients who underwent esophagectomy and 123 patients who underwent CRT after noncurative endoscopic resection, outcomes were investigated.

RESULTS

The CRT group included more elderly patients than the surgery group, although there were no significant differences in tumor depth or lymphovascular invasion between the two groups. Overall survival was significantly better in the surgery group than in the CRT group (5-year overall survival: 94.3% vs. 79.9%; p = 0.039). Two (5.4%) patients in the surgery group who developed lymph node recurrence achieved complete response by chemotherapy or CRT, and 9 of 16 patients (13.0%) in the CRT group who developed recurrence underwent salvage esophagectomy or lymphadenectomy. As a result, the 5-year cause-specific survival was 100% in the surgery group and 92.8% in the CRT group. SM2 invasion (≥ SM2) was significantly associated with recurrence after CRT, while lymphatic invasion was associated with lymph node metastasis in the surgery group.

CONCLUSION

Endoscopic treatment combined with esophagectomy or CRT can be a curative treatment option in patients with superficial esophageal cancer. However, esophagectomy rather than CRT should be recommended for patients with massive submucosal tumor invasion due to the risk of recurrence after CRT.

A phase II study of the safety of olanzapine for oxaliplatin based chemotherapy in coloraectal patients

Olanzapine has exhibited efficacy as an antiemetic agent when used with 5-HT₃ receptor antagonists, dexamethasone, and NK₁ receptor antagonists for patients receiving highly emetogenic chemotherapy. In addition, several studies have reported the efficacy or safety of olanzapine in patients receiving moderately emetogenic chemotherapy, including carboplatin, irinotecan, and oxaliplatin. However, no reports of olanzapine use have focused on patients receiving oxaliplatin-based chemotherapy. Therefore, we analyzed the safety of antiemetic therapy using olanzapine, palonosetron, aprepitant, and dexamethasone in colorectal cancer patients undergoing oxaliplatin-based chemotherapy. This study was a prospective phase II single-institution study of 40 patients (median age 60 years, 23 patients were male). The primary endpoint was the incidence of adverse events, and the exploratory endpoints were the rate of chemotherapy-induced nausea and vomiting. Almost all patients (90%) had a performance status of 0. All patients received the scheduled antiemetic therapy. The most common adverse event was somnolence (n = 7 patients, 17.5%). All adverse events were grade 1. Thirty-six patients were included in the exploratory analysis of efficacy. No patients experienced vomiting during the first 120 h after chemotherapy, and complete response and complete control were both 86.1%. The rate of total control was 55.6% during the same time period. Olanzapine use with 5-HT₃ receptor antagonists, dexamethasone, and NK₁ receptor antagonists was safe for colorectal cancer patients receiving oxaliplatin-based chemotherapy.

Laparoscopic-assisted disinvagination and polypectomy for multiple intussusceptions induced by small intestinal polyps in patients with Peutz-Jeghers syndrome: a case report

Background

Peutz–Jeghers syndrome (PJS) is a very rare autosomal dominant genetic disorder characterized by hamartomatous polyps in the gastrointestinal tract and hyperpigmentation of the lips, hands, and feet. The hamartomatous polyps in the small intestine often cause intussusception and bleeding.

Case presentation

A 62-year-old male was hospitalized for treatment of deep vein thrombosis and pulmonary embolism. In the small intestine, computed tomography showed three small polyps with intussusceptions. Since the patient had gastrointestinal polyposis and pigmentation of his lips, fingers, and toes, he was diagnosed with PJS. After an inferior vena cava filter was placed, he underwent laparoscopic-assisted surgery. The polyps causing intussusception were resected as far as possible without intestinal resection, since they had caused progressive anemia and might cause intestinal obstruction in the future. The patient was discharged from the hospital on postoperative day 9 without complications.

Conclusions

Laparoscopic-assisted disinvagination and polypectomy is a useful, minimally invasive treatment for multiple intussusceptions caused by small intestinal polyps in patients with PJS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02133-5.

A Novel Valvuloplastic Esophagogastrostomy Technique for Laparoscopic Transhiatal Lower Esophagectomy and Proximal Gastrectomy for Siewert Type II Esophagogastric Junction Carcinoma-the Tri Double-Flap Hybrid Method

We developed a novel technique for valvuloplastic esophagogastrostomy, named tri double-flap hybrid method (TDF). TDF is shown to be simple and useful for Siewert type II esophagogastric junction carcinoma.

BACKGROUND

Research has found valvuloplastic esophagogastrostomy using the conventional hand-sutured double-flap (CDF) technique to be a useful anti-reflux procedure after proximal gastrectomy. However, no study has focused on this reconstruction procedure after laparoscopic transhiatal lower esophagectomy and proximal gastrectomy (LEPG) for esophagogastric junction carcinoma primarily because of its profound difficulty. Thus, we devised a novel technique for valvuloplastic esophagogastrostomy comprising triangular linear-stapled esophagogastrostomy and hand-sutured flap closure, which we term the tri double-flap hybrid (TDF) method.

METHODS

After reviewing our institution's prospective gastric cancer database, 59 consecutive patients with Siewert type II esophagogastric junction carcinoma who underwent LEPG with valvuloplastic esophagogastrostomy from January 2014 to August 2018 were analyzed. Short- and mid-term surgical outcomes were then compared between the LEPG-TDF and LEPG-CDF groups to evaluate the efficacy of the TDF method.

RESULTS

The median operative time was 316 min (184-613 min) and blood loss was 22.5 ml (0-180 ml). In comparison between the two groups, the LEPG-TDF group had a significantly shorter operative time (298 vs. 336 min, p = 0.041) and significantly lower postoperative anastomotic leak/stenosis rates (0 vs. 14.2%, p = 0.045), compared to the LEPG-CDF group. No patient suffered from severe gastroesophageal reflux symptoms (Visick score ≥ III).

CONCLUSIONS

This study showed that double-flap valvuloplastic esophagogastrostomy is safe and feasible for reconstruction after LEPG for Siewert type II esophagogastric junction carcinoma. Moreover, the TDF method is a simple and useful technique that offers a shorter operative time and lower morbidity compared to the CDF technique.

A randomized controlled trial of single-port versus multi-port laparoscopic distal gastrectomy for gastric cancer

OBJECTIVE

This prospective randomized trial compared the invasiveness of laparoscopic gastrectomy using a single-port approach with that of a conventional multi-port approach in the treatment of gastric cancer. The benefit of single-port laparoscopic gastrectomy (SLG) over multi-port laparoscopic gastrectomy (MLG) has yet to be confirmed in a well-designed study.

METHODS

One hundred and one patients who were scheduled to undergo laparoscopic distal gastrectomy for histologically confirmed clinical stage I gastric cancer between April 2016 and September 2018 were randomly allocated to SLG (n = 50) or MLG (n = 51). The primary endpoints were the postoperative visual analog scale pain scores. Secondary endpoints were frequency of use of analgesia, short-term outcomes, such as operating time, intraoperative blood loss, inflammatory reactions, postoperative morbidity, and 90-day mortality.

RESULTS

The postoperative pain score was significantly lower in the SLG group than in the MLG group (p < 0.001) on the operative day and the postoperative day 1-7. Analgesics were administered significantly less often in the SLG group than in the MLG group (1 vs. 3 days, p = 0.0078) and the duration of use of analgesics was significantly shorter in the SLG group (2 vs. 3 days, p = 0.0171). The operating time was significantly shorter in the SLG group than in the MLG group (169 vs. 182 min, p = 0.0399). Other surgical outcomes were comparable between the study groups.

CONCLUSIONS

SLG was shown to be safe and feasible in the treatment of gastric cancer with better short-term results in terms of less severe pain and may be suitable for treatment of cStage I gastric cancer.

CLINICAL TRIAL REGISTRATION

UMIN000022218.

Clinical implications of the serum CA19-9 level in "biological borderline resectability" and "biological downstaging" in the setting of preoperative chemoradiation therapy for pancreatic cancer

BACKGROUND

Biological factors are emphasized in borderline resectable pancreatic cancer (BRPC), and CA19-9 is an important factor for biological borderline resectability (b-BR). The aim of this study was to investigate the cut-off value of CA19-9 for biological borderline resectability and "biological downstaging" in chemoradiation therapy (CRT) for pancreatic cancer (PC).

METHODS

A total of 407 patients with anatomically resectable PC (a-R) and BRPC (a-BR) received preoperative gemcitabine-based CRT. The b-BR was determined, according to the CA19-9 value prior to preoperative CRT (pre-CA19-9), as the subgroup of a-R cases in which the survival was comparable with that in a-BR cases. "Biological downstaging" was determined based on prognostic analyses regarding the CA19-9 value after preoperative CRT (post-CA19-9) in association with the survival of R cases (a-R cases without the b-BR factor).

RESULTS

The 5-year survival of a-R patients with pre-CA19-9 > 120 U/mL was comparable with that of a-BR patients (44% vs 34%, p = 0.082). The survival of b-BR patients with post-CRT CA19-9 ≤ 37 U/mL (normalized) was comparably favorable with that of R patients (56% vs 65%, p = 0.369). The incidence of distant recurrence was higher in b-BR patients without post-CA19-9 normalization than in those with post-CA19-9 normalization (70% vs 50%, p = 0.003), while the incidence of local recurrence was comparable between these two groups (12% vs 13%, p = 0.986).

CONCLUSIONS

Biological BRPC was determined to be an anatomically resectable disease with pre-CA19-9 > 120 U/mL, and post-CA19-9 normalization indicated "biological downstaging" in b-BR in the preoperative CRT strategy.

Minimally invasive surgery is feasible after preoperative chemotherapy for stage IV gastric cancer

AIM

To elucidate the safety and feasibility of minimally invasive surgery (MIS) as conversion surgery after chemotherapy for stage IV gastric cancer, we compared the background characteristics and clinical courses of patients who underwent open conversion surgery (open group) versus MIS (MIS group).

METHODS

We included 94 consecutive patients with stage IV gastric cancer who received chemotherapy followed by conversion surgery gastric resection from January 2011 to October 2019 at the Osaka International Cancer Institute in this analysis.

RESULTS

The open group included more patients who had macroscopic peritoneal metastasis and required splenectomy. However, other background characteristics, including preoperative chemotherapy duration, were comparable. The MIS group had significantly longer operative time (266 vs 339 minutes, P = .0039) and less operative blood loss (520 vs 10 mL, P < .0001). The incidence of postoperative complication of Clavien-Dindo grade II or higher was non-significantly lower (24.5% vs 9.8%, P = .058) and length of postoperative hospital stay was significantly shorter in the MIS group (12 vs 8 days, P < .0001). Even though the open group included more patients with more advanced (ypT4a or higher, or N3) disease, the MIS group had better recurrence free survival and overall survival (OS). Multivariate analysis revealed that N status (hazard ratio [HR], 4.39; 95% confidence interval [CI], 2.18-12.26; P < .0001) and T status (2.11; 1.05-4.36; P = .036) were independent prognostic factors for OS. MIS was not a negative prognostic factor for OS (HR, 0.44; 95% CI, 0.15-1.10; P = .081).

CONCLUSION

MIS can be safely performed as conversion surgery following chemotherapy for stage IV gastric cancer.

Prognostic Implication of Postoperative Weight Loss After Esophagectomy for Esophageal Squamous Cell Cancer

BACKGROUND

Preoperative weight loss in esophageal cancer is reported to be associated with a poor prognosis. However, the impact of postoperative weight loss on the prognosis of patients with esophageal cancer remains unclear.

METHODS

This study included 186 patients with esophageal squamous cell carcinoma who underwent surgery between January 2012 and January 2015. The relationship between weight loss 6 months after esophagectomy as well as the clinical factors and prognosis of patients was investigated.

RESULTS

The mean weight loss rate for all the patients was 9.3% at 3 months, 10.8% at 6 months, 11.1% at 12 months, and 11.4% at 24 months after surgery. The patients with severe weight loss 6 months after surgery (≥ 12%) exhibited lower serum albumin levels and a lower prognostic nutrition index 6 months after esophagectomy than the patients with moderate weight loss (< 12%; p = 0.011 and 0.009, respectively). Although overall survival did not differ significantly between the two groups, for all the patients, severe weight loss was significantly associated with shortened overall survival for the cStages 3 and 4 patients (3-year overall survival rate, 76.6% in the moderate group vs 54.5% in the severe group; p = 0.042). The multivariate analyses identified only severe weight loss as an independent factor associated with worse overall survival for the cStages 3 and 4 patients (p = 0.034).

CONCLUSION

This study showed that postoperative weight loss negatively affected the prognosis for patients with advanced esophageal cancer, indicating the necessity of administering nutritional interventions to these patients to prevent postoperative weight loss.

Lymph Node Metastasis and Recurrences from Esophageal Squamous Cell Carcinoma in Patients with Previous Gastrectomy

BACKGROUND

Esophageal cancer patients sometimes have a history of previous gastrectomy. To determine whether we should resect or preserve the remnant stomach, we need to understand the frequency and sites of abdominal lymph node (LN) metastasis from esophageal cancer after gastrectomy.

PATIENTS AND METHODS

In 46 patients with thoracic esophageal squamous cell carcinoma (ESCC) who had a history of previous gastrectomy due to gastric cancer (n = 20) or benign disease (n = 26), the frequency and sites of any LN metastasis including LN metastasis at surgery and LN recurrence were investigated. The factors associated with abdominal LN metastasis were also examined.

RESULTS

The incidence of metastasis to cervical, mediastinal, and abdominal LNs at surgery was 10.8%, 30.4%, and 30.4%, respectively. The incidence of abdominal LN recurrence was 6.5%. Of 46 patients, 16 patients (34.8%) had any abdominal LN metastasis, including abdominal LN metastasis at surgery or abdominal LN recurrence. There was no significant difference in the incidence of any abdominal LN metastasis between the gastric cancer group and the benign disease group (25.0% vs. 42.3%, p = 0.222). Clinically, nodal status was identified as the only independent factor associated with the occurrence of any abdominal LN metastasis, although neither tumor location nor the reason for gastrectomy was.

CONCLUSIONS

The present study showed that the incidence of abdominal LN metastasis from ESCC after gastrectomy was not necessarily low, regardless of the tumor location and the reason for previous gastrectomy. This result suggests that gastrectomy should not be omitted easily in ESCC patients after previous gastrectomy.

Decreased CT-number in the pancreatic parenchyma is a reliable imaging biomarker of the presence of malignancies in patients with high-risk intraductal papillary mucinous neoplasm

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) is a premalignant cystic neoplasm of the pancreas and is frequently detected in imaging investigations. A proportion of the patients with IPMN develop malignancies including high-grade dysplasia and invasive carcinoma. To predict the presence of malignancies in IPMN, constant imaging follow-up is usually required. Pancreatic steatosis (PS) has been recently identified as a facilitating factor for pancreatic cancer, and can be predicted through computed tomography (CT). We hypothesized that the CT-number of the pancreatic parenchyma could be a new reliable imaging biomarker for IPMN patients.

METHODS

Eighty-six patients undergoing pancreatectomy for IPMN were investigated. Using preoperative CT, the pancreatic index (PI) was calculated by dividing the CT-number of the pancreas by that of the spleen.

RESULTS

Malignancies were pathologically detected in 63 cases (73.3%). Patients were divided into two cohorts according to the presence of malignancies and were compared for various factors including the PI scores. The comparison of the two cohorts detected significant differences in two parameters (CA19-9 and PI score), and the PI score was the most sensitive biomarker to predict the presence of malignancies in patients showing high-risk stigmata of IPMN.

CONCLUSIONS

Pancreatic CT-number is an additional reliable imaging biomarker in distinguishing patients with IPMN having malignancies when investigating the patients showing high-risk stigmata.

Prognostic Impact of Postoperative Complications following Salvage Esophagectomy for Esophageal Cancer after Definitive Chemoradiotherapy

BACKGROUND

Recent studies have reported that the occurrence of postoperative complications after esophagectomy for esophageal cancer has a negative impact on long-term survival. Although salvage esophagectomy is associated with higher rates of morbidity and mortality, the impact of postoperative complications on long-term survival following salvage esophagectomy has not been fully investigated.

METHODS

We retrospectively analyzed 73 patients with thoracic esophageal cancer who underwent salvage esophagectomy between January 1997 and December 2017 after definitive chemoradiotherapy. We investigated the clinical impact of postoperative complications on long-term survival after salvage esophagectomy.

RESULTS

Postoperative complications, pulmonary complications, and anastomotic leakage occurred in 34 (47%), 14 (13%), and 14 (19%) of the patients, respectively. Patients with complications had significantly poorer survival than patients who did not have complications (HR [hazard ratio], 2.06; p = 0.017), but there were no significant differences in overall survival between patients with and those without pulmonary complications or anastomotic leakage (HR, 1.48, p = 0.318, and HR, 1.37, p = 0.377, respectively). Multivariate analysis revealed that pathological T3-4 disease (HR, 4.63; p = 0.001), residual disease (HR, 5.09; p = 0.001), and postoperative complications (HR, 3.85; p = 0.001) were significant independent prognostic factors. In particular, the frequency of death from other diseases among patients with postoperative complications was nonsignificantly higher than among patients without postoperative complications (26 vs. 10%; p = 0.071).

CONCLUSION

The occurrence of complications leads to a poor prognosis for patients with esophageal cancer after salvage esophagectomy. Prevention of postoperative complications and long-term postoperative general supportive care might be important for improving patients' prognosis.

A case of esophagojejunal varices rupture after proximal gastrectomy with double-tract reconstruction

BACKGROUND

The varices after proximal or total gastrectomy are uncommon because the supplying vessels are all divided. Emergent upper gastrointestinal endoscopy is the cornerstone of first-line management for the diagnosis and treatment of esophageal varices. However, there is no widely accepted standard strategy for esophagojejunal varices. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration.

CASE PRESENTATION

A 50-year-old man who had undergone proximal gastrectomy with double-tract reconstruction for esophagogastric junctional cancer 3 months before was admitted to the hospital due to gastrointestinal perforation. We performed emergency surgery and abdominal symptoms and inflammatory response improved postoperative. However, on POD3, he had eruptive bleeding at the just anal side of esophagojejunal anastomosis. Endoscopic clipping was unsuccessful because the mucosa was fragile and easily lacerated. Contrast-enhanced CT scan revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb. Therefore, he was diagnosed as esophagojejunal varices rupture and percutaneous transhepatic obliteration (PTO) was tried for hemostasis. The portal and superior mesenteric veins were catheterized with the percutaneous transhepatic approach. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices. The microcatheter was inserted into the variceal blood supply branch and 10 mL of 5% ethanolamine oleate with iopamidol was injected. After obliteration therapy, the superior mesenteric venogram showed complete occlusion of the variceal supply branch. The patient was discharged from the hospital without any complications after 14 days.

CONCLUSION

PTO can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites.

The Anatomical Pattern of the Proximal Jejunal Vein as a Prognostic Factor in Patients With Pancreatic Head Cancer Treated With Preoperative Chemoradiation Therapy

BACKGROUND/AIM

The significance of the anatomical variations of proximal jejunal vein [the so-called 1st jejunal vein (J1v)] has been reported from a technical standpoint. The aim of this study was to retrospectively investigate the prognostic impact of the anatomical variations of J1v in the surgical treatment of resectable pancreatic cancer (PC).

PATIENTS AND METHODS

A total of 49 patients with resectable PC located in the uncinate process were included in this study. The J1v converging pattern was divided into 2 groups in terms of its relation to the SMA (i.e., the J1v status): i) group D: the J1v travels posterior to the SMA; ii) group V: the J1v travels anterior to the SMA. The associations between the J1v status and surgical outcome were assessed.

RESULTS

The 5-year survival rate after resection in group V (35%) was significantly lower than that in group D (70%) (p=0.029), and the J1v status of group V was the only independent negative prognostic factor (HR=5.49; 95% CI=1.69-19.3; p=0.005).

CONCLUSION

The J1v converging pattern is a significant prognostic variable in patients with PC located in the uncinate process: the J1v status of group V was significantly associated with impaired survival.

Clinical features of metastasis from superficial squamous cell carcinoma of the thoracic esophagus

BACKGROUND

It is important to understand the sites and the frequency of metastasis to perform less invasive treatments for superficial esophageal cancer, such as minimized or focused lymphadenectomy, endoscopic resection, and chemoradiotherapy. The distribution pattern and frequency of metastases from superficial esophageal cancer, however, have not been well elucidated.

METHODS

In 342 patients with superficial esophageal squamous cell carcinoma who underwent esophagectomy, the sites and frequency of any metastasis, including lymph node metastasis at the time of esophagectomy, lymph node recurrence, and hematologic metastases were investigated. Factors associated with the likelihood of metastasis and prognosis were also examined.

RESULTS

The incidence of lymph node metastasis increased with tumor depth (m2 = 7%; m3 = 17%; sm1 = 29%; sm2 = 41%; and sm3 = 42%). Lymph node metastases were observed most frequently in upper mediastinal lymph nodes, such as upper paratracheal lymph nodes, and in perigastric lymph nodes, such as paracardial lymph nodes and the left gastric lymph nodes. Lymph node metastases were also observed across a broad range of lymph nodes, including cervical, mediastinal, and abdominal lymph node regions, irrespective of tumor location. The 5-year overall survival and disease-specific survival rates were 78% and 89%, respectively. Submucosal invasion and lymphatic invasion were identified as independent factors associated with metastasis. Lymphatic invasion was also identified as an independent factor associated with disease-specific survival.

CONCLUSION

The present study shows that metastasis can occur in a wide range of lymph node stations even in superficial esophageal squamous cell carcinoma. Together with the finding that lymphatic invasion is an independent prognostic factor, this study may help determine the treatment strategy for superficial esophageal squamous cell carcinoma.

Clinical Implications of Conversion Surgery After Induction Therapy for T4b Thoracic Esophageal Squamous Cell Carcinoma

BACKGROUND

Definitive chemoradiation therapy or chemotherapy alone is generally recommended for patients with unresectable cT4b esophageal cancer. However, conversion surgery has emerged as a therapeutic option when downstaging is achieved by induction therapy.

METHODS

We studied 169 patients with cT4 esophageal cancer who underwent induction therapy. Survival and prognostic factors were examined.

RESULTS

Of 169 patients, 25 who achieved a clinical complete response (cCR) underwent surveillance, 72 patients underwent conversion surgery, while another 72 patients whose tumors were regarded as unresectable after induction therapy did not undergo surgery. Among 169 patients, the 3- and 5-year survival rates were 31.0% and 25.9%, respectively. Sixty-four patients who underwent curative resection showed better survival comparable with survival of 25 patients who achieved cCR (3- and 5-year survival; 56.8% and 48.6% versus 64.0% and 52.0%, respectively). However, the survival of eight patients who underwent noncurative resection was as dismal as that of patients who did not undergo conversion surgery. Multivariate analysis in 169 patients identified female sex and achieving cCR or R0 resection as independent prognostic factors. Multivariate analysis in 72 patients who underwent conversion surgery identified sex, lymph node status, and R0 resection as independent prognostic factors in patients with cT4b esophageal cancer.

CONCLUSIONS

The present study showed that conversion surgery after induction therapy can be a potentially curative treatment option for select patients with cT4b esophageal cancer. An important issue for further research is to establish a method for more accurately diagnosing tumor resectability after induction therapy for cT4b esophageal cancer.

Sarcopenia Is Associated With Impaired Overall Survival After Gastrectomy for Elderly Gastric Cancer

BACKGROUND/AIM

The aim of this study was to evaluate the impact of sarcopenia diagnosed by the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm on long-term outcome after gastrectomy.

PATIENTS AND METHODS

A total of 90 elderly gastric cancer patients without distant metastasis aged 65 years or older who underwent gastrectomy at the Osaka National Hospital between July 2012 and January 2015 were included in the current analysis.

RESULTS

The sarcopenic group (n=19) had a poorer overall survival (OS) (p<0.0001) compared to the non-sarcopenic group (n=79). OS after recurrence was also worse in the sarcopenic group. Multivariate analysis indicated that sarcopenia was an independent risk factor for worse OS after gastrectomy (hazard ratio(HR)=2.92; 95% confidence interval(CI)=1.15-7.75; p=0.025), along with N stage ≥2, age ≥75 years, and presence of severe postoperative complications.

CONCLUSION

Sarcopenia is a potential target for preoperative intervention in elderly gastric cancer patients to improve prognosis after gastrectomy. (UMIN-CTR: R000041532).

Indocyanine Green Fluorescence Imaging of the Tracheal Blood Flow During Esophagectomy

BACKGROUND

Tracheobronchial ischemia and necrosis are uncommon causes of pulmonary complications that can be lethal on development. Surgical manipulation considering tracheal blood flow is important in radical esophagectomy with extensive lymph node dissection. This study introduces a novel method for assessing tracheal blood perfusion using indocyanine green (ICG) fluorescence imaging.

MATERIALS AND METHODS

Twenty patients who underwent esophagectomy with lymph node dissection for esophageal cancer were prospectively enrolled in this study. Tracheal blood flow after esophagectomy was quantitatively assessed using ICG fluorescence imaging. Region-of-interest software was used, and a time-intensity curve was created for the quantitative assessment of tracheal blood flow.

RESULTS

We assessed ICG fluorescence imaging of the trachea during esophagectomy for esophageal cancer in all 20 cases. In the quantitative assessment of this pilot study, postoperative tracheal ischemic change and sputum discharge disorder tended to be associated with decreased tracheal blood flow (P = 0.084, P = 0.044). Resection of the right bronchial artery (BA) tended to be associated with decreased tracheal blood flow (P = 0.109), but the preoperative treatment, including chemotherapy and chemoradiotherapy, did not influence tracheal blood flow (P = 0.861, P = 0.435). The subgroup analysis of the preoperative chemoradiation group showed that the tracheal blood flow was significantly reduced with right BA resection compared with right BA preservation (P = 0.049).

CONCLUSIONS

We assessed ICG fluorescence imaging of the trachea during esophagectomy for esophageal cancer. Further studies are needed to explore the significance of the assessment of tracheal blood flow during esophagectomy using ICG fluorescence imaging.

[A Case of Scirrhous Gastric Carcinoma Diagnosed by Staging Laparoscopy]

We report a case of scirrhous gastric carcinoma diagnosed by staging laparoscopy and discuss some literature reviews. A 60-year-old man was referred because of a choking sensation and weight loss, and gastroendoscopy revealed thickening of the entire circumference of the wall at the gastric cardia. Scirrhous gastric carcinoma was suspected, and biopsy was performed at many points and times by endoscopic examination, but the histologic findings revealed no malignant features. We performed staging laparoscopy, peritoneal washing cytology, and biopsy of the nodules in the abdominal wall. He was diagnosed with advanced gastric cancer with peritoneal dissemination and has received chemotherapy. Staging laparoscopy is a useful method for diagnosis and determination of the management of scirrhous gastric carcinoma.

[A Case of Long-Term Survival without Recurrence following Resection of Hepatic and Pulmonary Metastases of Gastric Cancer]

We report a case of long-term survival without recurrence followingresection of hepatic and pulmonary metastases of gastric cancer. A 64-year-old man underwent distal gastrectomy for gastric cancer. Seventeen months later, he underwent partial hepatectomy for hepatic metastasis in S7. Twenty months after the partial hepatectomy, he underwent hepatectomy for right lobe resection for hepatic metastases in S6/S7 and S7. Six months after the hepatectomy, he underwent partial pulmonary resection for lungmetastasis in the right lung(S3). He has remained tumor-free for 5 years after the pulmonary resection.

[A Case of Conversion Surgery Following Combined Chemotherapy with Molecular Targeting Agent for Unresectable Colorectal Liver Metastases]

A 76-year-old woman complaining of constipation was diagnosed with advanced rectosigmoid colon cancer with unresectable liver metastases. We performed a laparoscopic high-anterior resection due to the obstruction. The patient then received a capecitabine plus oxaliplatin(CapeOX)plus cetuximab(Cmab)combination chemotherapy. After 7 cycles of CapeOX with Cmab, the multiple liver metastases had reduced remarkably in size. Therefore, a liver metastases resection was performed. The patient underwent 6 cycles of postoperative CapeOX with Cmab therapy and has survived 7 years with no recurrence after the primary surgery.