Mucosal Congestion on the First Day Following Endoscopy Predicts Anastomotic Stricture After Esophagectomy.

BACKGROUND: Anastomotic stricture is a relatively common postoperative complication after esophagectomy. Previous studies have indicated that impaired perioperative blood perfusion at the anastomosis is associated with the occurrence of stricture. Therefore, we analyzed the association between endoscopically assessed blood perfusion during the early postoperative period and anastomotic stricture. METHODS: This retrospective study evaluated patients who underwent esophagectomy at Tokyo Medical and Dental University between 2010 and 2015. The patients had undergone nasal endoscopy on the 1st and 8th postoperative days. The findings were used to evaluate blood perfusion at the anastomosis and gastric tube, which was classified based on mucosal color as ischemia (white) or congestion (blue or black). Univariate and multivariable logistic regression analyses were performed to identify risk factors for anastomotic stricture. RESULTS: The study included 197 patients and anastomotic stricture was observed in 60 patients (30.4%). The multivariable analysis revealed that postoperative gastric tube congestion was a risk factor for stricture (odds ratio [OR]: 6.440, 95% confidence interval [CI]: 2.660-15.600; p < 0.001). Lower risks of anastomotic stricture were associated with pathological stage III-IV disease (OR: 0.325, 95% CI: 0.161-0.656; p = 0.002). CONCLUSION: This study revealed that endoscopically detected congestion at the anastomosis on the first postoperative day was a risk factor for anastomotic stricture.

A feasibility study of mediastinoscopic radical esophagectomy for thoracic esophageal cancer from the viewpoint of the dissected mediastinal lymph nodes validated with thoracoscopic procedure: a prospective clinical trial.

PURPOSE: A prospective trial evaluated the feasibility and safety of "mediastinoscopic esophagectomy with lymph node dissection" (MELD). METHODS: Eligible patients had thoracic esophageal squamous cell carcinoma, excluding T4, a bulky primary lesion or distant metastasis. Ten patients were enrolled and treated between September 2015 and March 2018. Additionally, to verify the integrity of the mediastinal lymph node dissection, thoracoscopic observation and lymph node dissection were followed. The primary end point was the integrity of mediastinal lymph node dissection. The secondary end points were the short-term outcomes, including mortality and morbidity. RESULTS: The median number of dissected lymph nodes in the upper mediastinal to cervical region and middle to lower mediastinal region by mediastinoscopy/thoracoscopy was 27/0.5 and 11.5/0, respectively. The median total operation time was 615 min, the median bleeding amount was 476 ml, and the median postoperative hospital stay was 15.5 days. Regarding complications of more than grade III according to the Clavien-Dindo classification, four had sputum excretion difficulty, one had pneumothorax and one had bilateral recurrent nerve palsy, but none required conversion to thoracotomy, and no operative deaths occurred. CONCLUSION: Although the rate of recurrent nerve palsy still should be reduced, our mediastinoscopic lymphadenectomy technique is closely similar to radical esophagectomy.

Detection of Second Primary Malignancies of the Esophagus and Hypophraynx in Oral Squamous Cell Carcinoma Patients.

OBJECTIVE: To assess the usefulness of modified esophagogastroduodenoscopy (EGD) for the detection of second primary malignancies of the esophagus or hypopharynx in patients with oral squamous cell carcinoma and determine the association between the oral lesion subsite and esophageal or hypopharyngeal lesion occurrence. STUDY DESIGN: Retrospective review. METHODS: In total, 166 patients with oral squamous cell carcinoma without any established symptoms of esophageal or hypopharyngeal squamous cell carcinoma underwent modified EGD based on the Valsalva maneuver and U-turn method, image-enhanced endoscopy, and chromoendoscopy using Lugol's iodine for diagnosis. All suspected lesions were biopsied to determine the clinical stages and duplication rates. Odds ratios for the occurrence of duplicate lesions according to the oral lesion subsite were determined. RESULTS: In total, 37 esophageal and 16 hypopharyngeal lesions were detected. According to the Union for International Cancer Control/American Joint Committee on Cancer classification (2009), 75.7% and 5.4% esophageal lesions were classified as stage IA and IB, respectively, and 50% and 18.8% hypopharyngeal lesions as stage II and stage I, respectively. Approximately 59.1% and 50% esophageal and hypopharyngeal lesions, respectively, were successfully treated by endoscopic resection. Oral lesions involving the floor of the mouth were more frequently accompanied by second primary malignancies of the esophagus or hypopharynx. CONCLUSIONS: Modified EGD is an effective noninvasive technique for early diagnosis and treatment of second primary malignancies of the esophagus and hypopharynx in patients with oral squamous cell carcinoma. In particular, patients with floor of the mouth lesions need close monitoring for hypopharyngeal and esophageal lesions. LEVEL OF EVIDENCE: 3b.

Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum.

BACKGROUND: The structure of the fascia in upper mediastinum has already been reported from gross anatomical viewpoints by Sarrazin. But it is necessary to understand meticulous anatomy for thoracoscopic or mediastinoscopic surgery. So herein, we investigate histologically the thin membranous structure made of dense connective tissues. METHODS: Semi-sequential transverse sections of the mediastinum were obtained from three cadavers. Hematoxylin and eosin staining, Elastica van Gieson staining, and Masson trichrome staining were performed to identify the presence and location of the thin membranous structure made of dense connective tissues. RESULTS: The "visceral sheath" and "vascular sheath," as previously described by Sarrazin, were observed histologically. These two thin membranous structures do not surround the esophagus and trachea cylindrically. In addition, the "visceral sheath" on the right side of the upper mediastinum was unclear in comparison to the left side. The "visceral sheath" (on the left side) gradually became unclear, and seemed to almost disappear; the esophagus was found to be very close to the thoracic duct on the caudal side of the bifurcation of the trachea. Although the left recurrent nerve was located inside the "visceral sheath" in all cadavers, the left recurrent nerve lymph nodes were located inside the "visceral sheath" in cadaver 1 and between the "visceral sheath" and "vascular sheath" in cadaver 3. CONCLUSION: The "visceral sheath" around the esophagus in the upper mediastinum was histologically demonstrated; however, the findings were not constant.

Visualization Method for Proprioceptive Drift on a 2D Plane Using Support Vector Machine.

Proprioceptive drift, which is a perceptual shift in body-part position from the unseen real body to a visible body-like image, has been measured as the behavioral correlate for the sense of ownership. Previously, the estimation of proprioceptive drift was limited to one spatial dimension, such as height, width, or depth. As the hand can move freely in 3D, measuring proprioceptive drift in only one dimension is not sufficient for the estimation of the drift in real life situations. In this article, we provide a novel method to estimate proprioceptive drift on a 2D plane using the mirror illusion by combining an objective behavioral measurement (hand position tracking) and subjective, phenomenological assessment (subjective assessment of hand position and questionnaire) with a sophisticated machine learning approach. This technique permits not only an investigation of the underlying mechanisms of the sense of ownership and agency but also assists in the rehabilitation of a missing or paralyzed limb and in the design rules of real-time control systems with a self-body-like usability, in which the operator controls the system as if it were part of his/her own body.

[Evaluation of Bevacizumab in Combination with Weekly Paclitaxel for Locally Advanced Breast Cancer].

Locally advanced breast cancer that exhibits bleeding, has a foul odor, and expresses an exudate often reduces the quality of life(QOL). Bevacizumab(Bv)in combination with weekly paclitaxel(PTX)therapy has a high response rate. To date, we have used this combination for 8 cases of locally advanced breast cancer in our hospital. The patients' mean age was 62.1 years. The tumors were T4b in 6 cases, T4c in 1 case and T4d in 1 case. The clinical stage was Stage III B in 1 case and Stage IV in 7 cases. The subtype was Luminal A in 2 cases, Luminal B in 4 cases, and triple negative in 2 cases. The mean dosage duration was 5.8 months. Five cases underwent local control operations after chemotherapy. One case showed a complete response, 4 cases had a partial response, 2 cases had a stable disease and 1 case had progressive disease. Four cases with Grade 2-3 hypertension and 4 cases with Grade 2 neutropenia were identified. Bvin combination with weekly PTX therapy had a high response rate, and 5 patients were able to undergo surgery. As QOL improved after treatment and the safety did not have any problem, Bv in combination with weekly PTX therapy is one of the effective treatments for locally advanced breast cancer.

The mirror illusion: does proprioceptive drift go hand in hand with sense of agency?

Vection can be regarded as the illusion of "whole-body" position perception. In contrast, the mirror illusion is that of "body-part" position perception. When participants viewed their left hands in a mirror positioned along the midsaggital axis while moving both hands synchronously, they hardly noticed the spatial offset between the hand in the mirror and the obscured real right hand. This illusion encompasses two phenomena: proprioceptive drift and sense of agency. Proprioceptive drift represented a perceptual change in the position of the obscured hand relative to that of the hand in the mirror. Sense of agency referred to the participants' subjective sense of controlling body image as they would their own bodies. We examined the spatial offset between these two phenomena. Participants responded to a two-alternative forced choice (2AFC) question regarding the subjective position of their right hands and questionnaires regarding sense of agency at various positions of the right hand. We analyzed the 2AFC data using a support vector machine and compared its classification result and the questionnaire results. Our data analysis suggested that the two phenomena were observed in concentric space, but the estimated range of the proprioceptive drift was slightly narrower than the range of agency. Although this outcome can be attributed to differences in measurement or analysis, to our knowledge, this is the first report to suggest that proprioceptive drift and sense of agency are concentric and almost overlap.