Evaluation of the blood flow in reconstructed gastric tube and its relation to anastomosis leakage.

OBJECTIVES: Anastomotic leakage in esophageal cancer surgery may be reduced by evaluating the blood flow to the reconstructed organ, but quantitative evaluation of arterial and venous blood flow is difficult. This study aimed to quantitatively assess blood flow using a new technique, as well as determine the relationship between the blood flow in the gastric tube and anastomotic leakage using near-infrared spectroscopy. METHODS: This single-center, observational study included 50 patients aged 51-82 years who underwent radical esophagectomy with gastric tube reconstruction for esophageal cancer between June 2022 and January 2023. Regional tissue oxygen saturation was measured at the antrum (point X), the anastomotic point (point Z), and the midpoint between points X and Z (point Y) before and after gastric tube formation. These three points of oxygen saturation were investigated in relation to anastomotic leakage. RESULTS: When comparing the presence of leakage to its absence, regional tissue oxygen saturation at points X and Z after gastric tube formation was significantly lower (X: p = 0.03, Z: p = 0.02), with the decreasing rate significantly higher at point Z (p = 0.01). There was no significant difference in the decreasing rate of regional tissue oxygen saturation between points X and Y (X: p = 0.052, Y: p = 0.83). CONCLUSION: Regional tissue oxygen saturation levels may be useful for measuring blood flow and could be a predictor of anastomotic leakage.

Remnant gastritis in gastric cancer patients causes loss of muscle mass 6 months after gastrectomy: a retrospective cohort study of Helicobacter pylori infection.

PURPOSE: In this study, we assessed the relationship between remnant gastritis and muscle mass loss and then investigated the potential relationship between Helicobacter pylori (HP) infection and remnant gastritis and muscle loss. METHODS: We reviewed the medical records of 463 patients who underwent distal gastrectomy between January 2017 and March 2020. Of these patients, 100 with pStage I after laparoscopic surgery were included in this analysis. RESULTS: A multivariate analysis showed that the total Residue, Gastritis, Bile (RGB) classification score, which indicates the degree of gastritis, was significantly associated with the rate of change (rate of decrease) in the psoas muscle area (PMA) during the first 6 months after surgery (p = 0.014). Propensity score matching was performed according to HP infection, and the rate of change in the PMA and the degree of remnant gastritis in 56 patients were compared. Neither was significantly associated with HP infection. CONCLUSIONS: Remnant gastritis did contribute to psoas muscle mass loss during the initial 6 months after gastrectomy, and HP infection was not significantly associated with either remnant gastritis or psoas muscle mass loss. Nevertheless, the potential for HP eradication to prevent muscle loss and improve the survival prognosis for gastrectomy patients merits further research.

[ESSENSE Concept and Perioperative Management in Esophageal Cancer Treatment].

The actual operation based on the philosophy of ESsential Strategy for Early Normalization after Surgery with patient's Excellent satisfaction (ESSENSE) in radical thoracic esophageal cancer surgery is described. ESSENSE, which is proposed by the Japanese Society of Surgical Metabolism and Nutrition to promote postoperative recovery, consists of four principles:reduction of invasive reactions, early independence of physical activity, early independence of nutrition intake, and perioperative anxiety reduction and motivation for recovery. Here, we describe the actual operation based on the ESSENSE philosophy in radical thoracic esophageal cancer surgery, which is classified as one of the highly invasive esophageal cancer surgeries. We have been performing perioperative management using the above protocol since April 2012. The outcomes of 334 patients up to April 2020 are described. Preoperative chemotherapy was administered in 74% of patients, 70% underwent thoracoscopic surgery, 50% had Clavien- DindoⅡ or higher postoperative complications, and 14% had postoperative pneumonia. The mean postoperative bed rest was 1.6 days. This contributed to a shorter hospital stay and fewer pulmonary complications compared with previous management. The four principles of ESSENSE are useful for early recovery programs in Japan. The ESSENSE should be implemented from this perspective according to the disease, medical facility, community, and family situation.

Efficacy and safety of patient-controlled thoracic epidural analgesia alone versus patient-controlled intravenous analgesia with acetaminophen after laparoscopic distal gastrectomy for gastric cancer: a propensity score-matched analysis.

BACKGROUND: Laparoscopic gastrectomy is a common procedure for early gastric cancer treatment. Improving postoperative pain control enhances patient recovery after surgery. The use of multimodal analgesia can potentially enhance the analgesic effect, minimize side effects, and change the postoperative management. The purpose of this study was to evaluate and compare the efficacies of the use of patient-controlled intravenous analgesia with regular acetaminophen (PCIA + Ace) and patient-controlled thoracic epidural analgesia (PCEA) for postoperative pain control. METHODS: We retrospectively collected the data of 226 patients who underwent laparoscopic distal gastrectomy (LDG) with delta-shaped anastomosis between 2016 and 2019. After 1:1 propensity-score matching, we compared 83 patients who used PCEA alone (PCEA group) with 83 patients who used PCIA + Ace (PCIA + Ace group). Postoperative pain was assessed using a numeric rating scale (NRS) with scores ranging from 0 to 10. An NRS score ≥ 4 was considered the threshold for additional intravenous rescue medication administration. RESULTS: Although NRS scores at rest were comparable between the PCEA and PCIA + Ace groups, NRS scores of patients in the PCIA + Ace group during coughing or movement were significantly better than those of patients in the PCEA group on postoperative days 2 and 3. The frequency of additional rescue analgesic use was significantly lower in the PCIA + Ace group than in the PCEA group (1.1 vs. 2.7, respectively, p < 0.001). The rate of reduction or interruption of the patient-controlled analgesic dose was higher in the PCEA group than in the PCIA + Ace group (74.6% vs. 95.1%, respectively, p = 0.0002), mainly due to hypotension occurrence in the PCEA group. Physical recovery time, postoperative complication occurrence, and liver enzyme elevation incidence were not significantly different between groups. CONCLUSIONS: PCIA + Ace can be safely applied without an increase in complications or deterioration in gastrointestinal function; moreover, PCIA + Ace use may provide better pain control than PCEA use in patients following LDG.

Relative dose intensity and 1-year psoas muscle index reduction rate as prognostic factors in gastric cancer patients with postoperative adjuvant chemotherapy.

BACKGROUND: Higher relative dose intensity (RDI) of chemotherapy improves the clinical outcomes of various cancers. The psoas muscle index (PMI) is related to sarcopenia, and patients with low PMI have worse prognoses. However, few studies have demonstrated its clinical relevance in gastric cancer. METHODS: This retrospective study included 188 stage II/III gastric cancer patients who had undergone curative gastrectomy between January 2013 and March 2017, 124 of whom had received postoperative S-1 adjuvant chemotherapy. RESULTS: Per receiver operating characteristic analysis, patients were divided into high and low RDI groups, between which relapse-free survival differed marginally significantly and disease-specific survival differed significantly. In patients who received adjuvant chemotherapy, multivariate analysis found that high RDI and low PMI reduction rate 1 year after surgery were significantly associated with better relapse-free survival. Low RDI can be predicted by a combination of low preoperative PMI and non-distal gastrectomy, whereas high PMI reduction rate at 1 year can be affected by non-distal gastrectomy. CONCLUSION: High RDI with preserved psoas muscle up to 1 year after gastrectomy may be associated with prognoses in gastric cancer requiring postoperative adjuvant chemotherapy. Since RDI and PMI reduction rate can be predicted preoperatively, respectively, interventional consideration is possible for optimal adjuvant therapy in gastric cancer.

Dismal prognosis of elderly gastric cancer patients who underwent gastrectomy with American Society of Anesthesiologists (ASA) 3.

BACKGROUND: Although the American Society of Anesthesiologists (ASA) score of 3 is relatively common in elderly patients, there have been few debates on the indications for gastrectomy in elderly gastric cancer (GC) patients with ASA3. Therefore, this study aimed to investigate gastrectomy's clinical relevance in elderly patients with GC and ASA3. METHODS: We retrospectively analyzed 228 consecutive elderly GC patients (aged ≥ 75 years) without prior treatments who underwent curative gastrectomy between 2013 and 2017. RESULTS: Thirty-three patients with ASA3 showed significantly poorer prognosis than those with ASA1 and 2 (p = 0.004). The multivariate Cox proportional hazards model showed that ASA3 (p = 0.021) and pStage (p = 0.007) were independent prognostic factors, respectively. Elderly GC patients with pStage III and ASA3 exhibited uniquely dismal prognosis (p < 0.001); however, several survivors were still confirmed. Postoperative complications (PCs) were only the final remnant independent prognostic factor (p = 0.020) among the 33 elderly GC patients with ASA3, where dead patients included cancer-specific and other deaths, especially pneumonia. PCs were independently associated with prognostic nutritional index (PNI) (< 42.7) in elderly GC patients, and the most frequent complication was pneumonia, which was significantly associated with ASA3 and marginally associated with PNI in a multivariate analysis. CONCLUSIONS: ASA3 has a dismal prognosis after curative gastrectomy in the elderly GC patients, but the number of survivors was confirmed. Curative gastrectomy is not considered contraindicated even in elderly GC with ASA3. Preoperative malnutrition is associated with PCs, which proposing preoperative nutritional intervention in the context of treatment strategy for the elderly GC patients with ASA3.

Impact of loss of skeletal muscle mass within 6-12 months after gastrectomy and S1 adjuvant chemotherapy on the survival prognosis of elderly patients with gastric cancer.

BACKGROUND AND PURPOSE: We investigated the impact of postoperative changes in the psoas muscle mass index (PMI) after gastrectomy and S1 adjuvant chemotherapy (AC) on the long-term outcomes of elderly patients with gastric cancer. METHODS: We reviewed the medical records of 228 patients aged over 75 years, who underwent distal, proximal, or total gastrectomy between January, 2013 and March 2017. Among these patients, 78 with pStage IIA-IIIC who survived for at least 1 year without recurrence after gastrectomy were the subjects of this analysis. RESULTS: The log-rank test using the cut-off value from the rate of change in PMI from 6 to 12 months after gastrectomy (late rate of decrease) showed significantly poorer prognosis for the group above the cut-off value for both overall survival (OS) and recurrence-free survival (RFS) (RFS: PMI decrease ≥ 1.55%, p < 0.001; OS: PMI decrease ≥ 1.55%, p < 0.001). Patients with a relative dose intensity of S1 below 68.7% and a late rate of decrease in PMI above 1.55% were found to have a poor prognosis. CONCLUSION: It is necessary to prevent decline in the PMI of elderly patients from 6 months after gastrectomy and to administer adjuvant chemotherapy with about two-thirds or more RDI of S1 to improve their survival prognosis.

Impact of the first era of the coronavirus disease 2019 pandemic on gastric cancer patients: a single-institutional analysis in Japan.

BACKGROUND: Little is known about the disadvantages of the coronavirus disease 2019 (COVID-19) pandemic in patients with gastric cancer. This study aimed to examine the negative impact of the COVID-19 pandemic on patients with gastric cancer in the first era in Japan. METHODS: This retrospective study included 725 patients diagnosed with gastric cancer who visited our hospital between April 2019 and March 2021. The number of patients and their characteristics before and during the COVID-19 pandemic were compared. RESULTS: The number of patients diagnosed with gastric cancer during the COVID-19 pandemic decreased by 26.2% (from 417 to 308; p = 0.013) compared to that before the COVID-19 pandemic. There was a significant decrease in cStage I cancer and an increase in cStage III cancer (p = 0.004). Patients were often symptomatic (p = 0.029), especially those with stenosis-related symptoms (p < 0.001) and longer symptom duration (p < 0.001). The number of endoscopic resections was decreased by 34.8% (p = 0.005). The number of total gastrectomy was higher than that of partial gastrectomy (p = 0.021). The median time to treatment was significantly shorter (p < 0.001). CONCLUSIONS: In Japan, delays diagnosing patients with gastric cancer, probably due to refraining from consultation, may have resulted in an increase in the diagnosis of advanced-stage cancer. Moreover, an increasing proportion of patients required more invasive gastrectomy. Therefore, it may be necessary to educate patients not to refrain from consultation, even during the COVID-19 pandemic, as it can have a negative impact on treatment, policy decision, and prognosis of gastric cancer.

Impact of the coronavirus disease 2019 pandemic on first-visit patients with oesophageal cancer in the first infection wave in Saitama prefecture near Tokyo: a single-centre retrospective study.

BACKGROUND: Although the novel coronavirus disease 2019 did not lead to a serious medical collapse in Japan, its impact on treatment of oesophageal cancer has rarely been investigated. This study aimed to investigate the influence of the pandemic on consultation status and initial treatment in patients with primary oesophageal cancer. METHODS: A retrospective study was conducted among 546 patients with oesophageal cancer who visited our hospital from April 2018 to March 2021. Pre-pandemic and pandemic data were compared with the clinical features, oncological factors and initial treatment as outcome measures. RESULTS: Diagnoses of oesophageal cancer decreased during the early phase of the pandemic from April to June (P = 0.048); however, there was no significant difference between the pre-pandemic and pandemic periods throughout the year. The proportion of patients diagnosed with distant metastases significantly increased during the pandemic (P = 0.026), while the proportion of those who underwent initial radical treatment decreased (P = 0.044). The rate of definitive chemoradiotherapy decreased by 58.6% relative to pre-pandemic levels (P = 0.001). CONCLUSIONS: Patients may have refrained from consultation during the early phase of the coronavirus disease 2019 pandemic. The resultant delay in diagnosis may have led to an increase in the number of patients who were not indicated for radical treatment, as well as a decrease in the number of those who underwent definitive chemoradiotherapy. Our findings highlight the need to maintain the health care system and raise awareness on the importance of consultation.

Effectiveness and safety of a newly introduced multidisciplinary perioperative enhanced recovery after surgery protocol for thoracic esophageal cancer surgery.

OBJECTIVE: Data are sparse regarding the multidisciplinary perioperative enhanced recovery after surgery protocol (E-P) for thoracic esophageal cancer surgery that was newly used at another institution. Therefore, this study aimed to retrospectively evaluate the effectiveness and safety of the protocol. METHODS: We enrolled 101 patients who underwent transthoracic esophagectomy for E-P at the Shizuoka Cancer Center Hospital (SCC). The outcomes obtained at the SCC were compared with the outcomes of 140 patients treated with E-P at the Saitama Medical University International Medical Center (SMU). At the SMU, we compared the results before and after the introduction of E-P. RESULTS: The rates of morbidity, pulmonary complications, and postoperative pneumonia were 44%, 31%, and 6.9% at the SCC and 44%, 27%, and 6.5% at the SMU (P = 0.91, 0.55, and 0.88, respectively). The mean time to walk was 1.1 and 1.5 days at the SCC and SMU, respectively (P < 0.001). The median length of hospital stay was longer at the SMU than at the SCC (24.0 versus 20.8 days; P = 0.004). In the comparative study before and after the introduction of E-P, the rate of postoperative pneumonia was 16% in the conventional management group and 6.5% in the E-P group (P = 0.02). CONCLUSION: Postoperative pneumonia was reduced before and after introduction of E-P. As similar short-term postoperative outcomes were promising (except for the time to walk and postoperative hospital stay), the same E-P that was safely performed at the SMU can be implemented as a standard practice.

Laparoscopic plug removal for femoral nerve colic pain after mesh & plug hernioplasty.

BACKGROUND: Inguinal hernias account for 75% of abdominal wall hernias, with a lifetime risk of 27% in men and 3% in women. Major complications are recurrence, chronic pain, and surgical site infection, but their frequency is low. Few studies have reported a calcified mesh causing neuropathy by chronic compression of the femoral nerve after mesh & plug inguinal hernia repair. This is the first report of laparoscopic plug removal for femoral colic due to femoral nerve irritation cause by a calcified plug after mesh & plug inguinal hernia repair. CASE PRESENTATION: In July 2013, a 53-year-old man presented to our hospital with a chief complaint of colic pain in the left lower limb while walking. The patient had undergone left inguinal hernia repair about 10 years earlier and reported no chronic pain after the operation. Physical examination revealed a colic pain exacerbated by left thigh movement, especially during flexion, but the patient was pain-free at rest and had no sensory loss. Axial computed tomography and magnetic resonance imaging showed that the inward-projecting plug was extremely close to the femoral nerve. Because of the radicular symptoms and the absence of orthopedic and urological disease, we strongly suspected that the neuralgia was associated with the previous hernia operation and advised exploratory laparotomy, which revealed the plug bulging inward into the abdominal cavity. Moreover, the tip of the plug was firmly calcified and compressing the femoral nerve, which lay just beneath the plug, especially during hip flexion. We explanted the plug and his pain resolved after the operation. The patient remains pain free after 20 months of follow up. CONCLUSION: In this study, laparoscopic hernioplasty proved useful for plug removal because laparoscopic instruments can easily grasp perilesional tissue, and laparoscopic approach has the benefit of isolating the plug for removal while preserving the onlay patch, and helpful for restoring peritoneal defects. Laparoscopic plug removal effectively resolved colic pain in the left thigh due to compression of the femoral nerve by a calcified plug.

Spontaneous perforation of primary gastric malignant lymphoma: a case report and review of the literature.

BACKGROUND AND AIMS: Spontaneous gastric perforation in the absence of chemotherapy is extremely rare. The authors encountered a case of spontaneous perforation of primary gastric lymphoma. CASE PRESENTATION: A 58-year-old man visited the authors' hospital with acute severe epigastralgia. A large amount of free gas and a fluid collection around the stomach were noted on an abdominal computed tomography scan. The results of imaging studies indicated a perforated gastric ulcer, and a distal gastrectomy was performed. There was a large perforation about 50 mm in diameter in the anterior wall of the middle part of the stomach body. Microscopically, the full thickness of the gastric wall was diffusely infiltrated by a population of large atypical lymphoid cells. The lymphoid nature of these cells was indicated by the strongly positive immunohistochemical staining for CD20 and CD10. This confirmed the diagnosis of a germinal center B-cell-like type of diffuse large B cell lymphoma. Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone were administered after the operation. RESULTS AND CONCLUSION: Gastrectomy should be considered if a giant ulcer with necrotic matter on the ulcer floor is seen on upper gastrointestinal endoscopy because of the possibility of gastric perforation. If upper gastrointestinal endoscopy shows a finding similar to the abovementioned one during chemotherapy, dose reduction of chemotherapy or gastrectomy should be considered.

Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer.

We herein report a case of bronchial bleeding after radical esophagectomy that was treated with lobectomy. A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis. After the esophagectomy, bilateral vocal cord paralysis was observed, and the patient suffered from repeated episodes of aspiration pneumonia. Bronchoscopy revealed hemosputum in the right middle lobe bronchus, and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus. Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis, the procedures were unsuccessful. Right middle lobectomy was therefore performed via video-assisted thoracic surgery. Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen. The patient recovered uneventfully and was discharged on postoperative day 14.

Benign esophageal stricture after thermal injury treated with esophagectomy and ileocolon interposition.

Thermal injuries of the esophagus are rare causes of benign esophageal stricture, and all published cases were successfully treated with conservative management. A 28-year-old Japanese man with a thermal esophageal injury caused by drinking a cup of hot coffee six months earlier was referred to our hospital. The hot coffee was consumed in a single gulp at a party. Although the patient had been treated conservatively at another hospital, his symptoms of dysphagia gradually worsened after discharge. An upper gastrointestinal endoscopy and computed tomography revealed a pin-hole like area of stricture located 19 cm distally from the incisors to the esophagogastric junction, as well as circumferential stenosis with notable wall thickness at the same site. The patient underwent a thoracoscopic esophageal resection with reconstruction using ileocolon interposition. The pathological findings revealed wall thickening along the entire length of the esophagus, with massive fibrosis extending to the muscularis propria and adventitia at almost all levels. Treatment with balloon dilation for long areas of stricture is generally difficult, and stent placement in patients with benign esophageal stricture, particularly young patients, is not yet widely accepted due to the incidence of late adverse events. Considering the curability and quality-of-life associated with a long expected prognosis, we determined that surgery was the best treatment option for this young patient. In this case, we decided to perform an esophagectomy and reconstruction with ileocolon interposition in order to preserve the reservoir function of the stomach and to avoid any problems related to the reflux of gastric contents. In conclusion, resection of the esophagus is a treatment option in patients with benign esophageal injury, especially in cases involving young patients with refractory esophageal stricture. In addition, ileocolon interposition may help to improve the quality-of-life of patients.

Right hepatectomy for giant cavernous hemangioma with diffuse hemangiomatosis around Glisson's capsule.

Diffuse liver hemangiomatosis with giant cavernous hemangioma in adult is extremely rare. A 35 year-old woman presented to hospital with main complaint of epigastric pain and abdominal fullness. An enhanced computed tomography scan revealed a massive liver tumor in right lobe about 150 mm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. She underwent right hepatectomy. Histologically, it was diagnosed as a cavernous hemangioma. And also, hemangiomatous lesions were scattered around the Glisson's capsule on the back ground liver. These hemangiomatous lesions were not recognized preoperatively. Even if we couldn't diagnose hemangiomatosis around the main giant hemangioma preoperatively, we need to take enough surgical margins because the giant hemangioma has the potential to have small hemangiomatous lesions around the tumor. We reported right hepatectomy for giant cavernous hemangioma with diffuse hepatic hemangiomatosis without an extrahepatic lesion in an adult.

Mixed adeno(neuro)endocrine carcinoma arising from the ectopic gastric mucosa of the upper thoracic esophagus.

We report a case of mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. A 64-year-old man who had been diagnosed with an esophageal tumor on the basis of esophagoscopy was referred to our hospital. Upper gastrointestinal endoscopy revealed the presence of ectopic gastric mucosa and an adjacent pedunculated lesion located on the posterior wall of the upper thoracic esophagus. Subtotal esophagectomy with three-field lymph node dissection was performed. A microscopic examination revealed that there was a partially intermingling component of neuroendocrine carcinoma adjacent to a tubular adenocarcinoma which was conterminous with the area of the ectopic gastric mucosa. Although the tubular adenocarcinoma was confined to the mucosa and submucosa, the neuroendocrine carcinoma had invaded the submucosaand there was vascular permeation. Each component accounted for 30% or more of the tumor, so the final histopathological diagnosis was mixed adenoendocrine carcinoma of the upper thoracic esophagus arising from ectopic gastric mucosa. Adjuvant chemotherapy was not performed, because the postoperative tumor stage was IA. The patient was well and had no evidence of recurrence 16 months after surgery.