Randomized controlled trial on efficacy of oligomeric formula (HINE E-GEL®) versus polymeric formula (MEIN®) enteral nutrition after esophagectomy for esophageal cancer with gastric tube reconstruction.

The efficacy of early enteral nutrition after esophageal cancer surgery has been reported. However, the choice of formula and management of diarrhea are important to achieve the goal of enhanced recovery after surgery. The aim of this study is to assess the frequency of diarrhea/completion rate of enteral nutrition regimen as primary endpoints and the postoperative nutritional status/body composition analysis/operative morbidity as secondary endpoints was compared between the two nutrition groups. Among the 122 patients who underwent esophagectomy for esophageal cancer between December 2015 and September 2017, 67 patients who met the eligibility criteria were randomly assigned to receive enteral nutrition with either HINE E-GEL® (HINE group; n = 33) or MEIN® (MEIN group; n = 34). The incidence of diarrhea was significantly lower in the HINE group (18.2 % vs. 64.7 %, P < 0.001). The score of Bristol scale of POD 6/7 was significantly lower in the HINE group (P = 0.019/P = 0.006, respectively). The completion rate of enteral nutrition regimen was significantly higher in the HINE group (97.4 % vs. 86.6 %, P = 0.002). The Controlling Nutritional Status scores and total protein levels at 6 months after surgery were significantly better in the HINE group (P = 0.030 and P = 0.023, respectively), indicating improved tendency in nutritional status in the HINE group. However, there were no significant differences in Prognostic Nutritional Index values, blood test results, rapid turnover proteins, body mass index, or body composition between the two groups. HINE E-GEL compared with MEIN may reduce the frequency of diarrhea, enabling patients to adhere to the scheduled enteral nutrition plan. Also, maintenance of nutritional status with HINE E-GEL was comparable or potentially better in some nutrition components to that with MEIN, indicating that HINE E-GEL can be an option for enteral nutrition following esophageal surgery to achieve the goal of successful completion of scheduled enteral nutrition and smooth transition to the normal diet.

Labor induction using modified metreurynters plus oxytocin at an institution in Japan: a retrospective study.

OBJECTIVE: The authors evaluated the effectiveness and safety of "neo-metoro" or 'mini-metoro" metreurynters plus oxytocin for labor induction and assessed differences in parturition outcomes, according to the metreurynter used at induction initiation. MATERIALS AND METHODS: The authors retrospectively reviewed 146 consecutive women with live singleton pregnancies, and who underwent induction. Parturition outcomes were vaginal delivery achieved within the planned schedule (VDPS), vaginal delivery finally achieved (VDF), and induction-to-delivery interval (IDI). Women were divided into neo-metoro, mini-metoro, and without metreurynter groups based on metreurynter use at induction initiation. The authors examined the relationships of metreurynter groups with factors, parturition outcomes, and adverse events. In 113 women who underwent two-day induction, the authors calculated IDI and adjusted odds ratio (AOR) for achieving delivery per unit time. RESULTS: VDPS rates were 65% in nulliparous and 81% in multiparous women. VDF rates were 78% in nulliparous and 96% in multiparous women. AORs for VDPS were 0.30 in nulliparous women and 0.18 in Bishop score (BS) 1-3 class. AORs for VDF were 0.04 in BS1-3 class and 0.14 in BS4-5 class. In 113 women undergoing two-day induction, AORs for achieving delivery per unit time were 0.45 in nulliparous women, 0.46 in obese women, and 0.48 in BS1-3 class. Neo-metoro use at induction initiation tended to reduce IDI. CONCLUSIONS: Labor induction using these metreurynters plus oxytocin is safe and effective. The advantages of neo-metoro over mini-metoro use at induction initiation remain unclear; neo-metoro use at induction initiation may reduce IDI.

[Surgery for esophageal cancer complicate with cardiovascular disease].

A risk of cardiac complications is one of the most significant risks to patient undergoing major surgery. Especially, for the patients with cancer, the preoperative management can be complex. The direct effect of cancer and side effect of prior chemotherapy or radiation therapy should be considered. The 2007 American College of Cardiology/American Heart Association( ACC/AHA) guidelines on perioperative cardiovascular evaluation for noncardiac surgery concluded that 3 elements must be assessed to determine the risk of cardiac event. The preoperative risk in a patient is initially assessed by the presence or absence of clinical predictors of increased perioperative cardiovascular risk, the patient's level of cardiac function, and the underlying risk of the surgical procedure. Here we will provide an overview of issue that are relevant to patients with esophageal cancer.

Influence of preoperative chemotherapy for advanced thoracic oesophageal squamous cell carcinoma on perioperative complications.

BACKGROUND: The Japan Clinical Oncology Group (JCOG) 9907 trial has changed the standard of care for advanced thoracic oesophageal cancer in Japan from postoperative chemotherapy to preoperative chemotherapy. The impact of preoperative chemotherapy on the risk of developing postoperative complications remains controversial. This article reports the safety analysis of JCOG9907, focusing on risk factors for postoperative complications. METHODS: Patients with potentially resectable advanced thoracic oesophageal squamous cell carcinoma were randomized to either postoperative or preoperative chemotherapy followed by transthoracic oesophagectomy with D2-3 lymphadenectomy. Chemotherapy consisted of two cycles of cisplatin and 5-fluorouracil. Clinical baseline data, intraoperative complications, postoperative complications and in-hospital mortality, collected on the case report forms in a predetermined format, were analysed. Univariable and multivariable analyses were used to explore the risk of postoperative complications in relation to treatment group, age, sex, tumour depth, nodal metastasis, stage and location. RESULTS: Of 330 patients randomized, 166 were assigned to receive postoperative chemotherapy and 164 preoperative chemotherapy; 162 and 154 patients respectively underwent surgery. The incidence of intraoperative complications, postoperative complications and in-hospital mortality was similarly low in both groups. Multivariable analysis showed that age, sex and tumour location were independently associated with an increase in postoperative complications, but preoperative chemotherapy was not. CONCLUSION: Preoperative chemotherapy does not increase the risk of complications or hospital mortality after surgery for advanced thoracic oesophageal cancer.

Development of double density whole brain fNIRS with EEG system for brain machine interface.

Brain-machine interfaces (BMI) are expected as new man-machine interfaces. Non-invasive BMI have the potential to improve the quality of life of many disabled individuals with safer operation. The non-invasive BMI using the functional functional near-infrared spectroscopy (fNIRS) with the electroencephalogram (EEG) has potential applicability beyond the restoration of lost movement and rehabilitation in paraplegics and would enable normal individuals to have direct brain control of external devices in their daily lives. To shift stage of the non-invasive BMI from laboratory to clinical, the key factor is to develop high-accuracy signal decoding technology and highly restrictive of the measurement area. In this article, we present the development of a high-accuracy brain activity measurement system by combining fNIRS and EEG. The new fNIRS had high performances with high spatial resolution using double density technique and a large number of measurement channels to cover a whole human brain.

[Basic technique for reconstruction after esophagectomy].

The stomach as a conduit after esophagectomy is preferred to the colon because it is much simpler to prepare and involves only 1 anastomosis. The following principles should be followed in preparing the stomach as an esophageal substitute: the complete removal of lymphatics within the left gastric area, and careful preservation of the gastric intramural vascular network. The line of resection, where the vessels of the left gastric area enter the gastric wall, should be cautiously decided. Border between the left and right gastric area of the lesser curvature is identified by the courses of these arteries. The 1st GIA should be inserted slightly toward the caudal side, and the 2nd GIA should be fired along the resection-line. The final GIA should be advanced to the highest point. The space beneath the sternum in the anterior mediastinum is easily created with minimal blood loss. The space is initially created by blunt finger dissection through the abdominal and cervical incisions, and further developed by insertion of a flat malleable intestinal retractor with a hole on 1 side, which is useful for elevating the esophageal substitute without a twist.

Genetic analysis of interspecific incompatibility in Brassica rapa.

In interspecific pollination of Brassica rapa stigmas with Brassica oleracea pollen grains, pollen tubes cannot penetrate stigma tissues. This trait, called interspecific incompatibility, is similar to self-incompatibility in pollen tube behaviors of rejected pollen grains. Since some B. rapa lines have no interspecific incompatibility, genetic analysis of interspecific incompatibility was performed using two F(2) populations. Analysis with an F(2) population between an interspecific-incompatible line and a self-compatible cultivar 'Yellow sarson' having non-functional alleles of S-locus genes and MLPK, the stigmas of which are compatible with B. oleracea pollen grains, revealed no involvement of the S locus and MLPK in the difference of their interspecific incompatibility phenotypes. In QTL analysis of the strength of interspecific incompatibility, three peaks of LOD scores were found, but their LOD scores were as high as the threshold value, and the variance explained by each QTL was small. QTL analysis using another F(2) population derived from selected parents having the highest and lowest levels of interspecific incompatibility revealed five QTLs with high LOD scores, which did not correspond to those found in the former population. The QTL having the highest LOD score was found in linkage group A02. The effect of this QTL on interspecific incompatibility was confirmed by analyzing backcrossed progeny. Based on synteny of this QTL region with Arabidopsis thaliana chromosome 5, a possible candidate gene, which might be involved in interspecific incompatibility, is discussed.

[Which tube is better for esophagectomy?].

We performed differential lung ventilation for thoracoscopic esophagectomy. There are 2 tools available for differential lung ventilation: double lumen tube (DLT) and endbronchial blocker tube (blocker). We reviewed the best tube by studying esophageal cancer perioperative findings in thoracoscopic esophagectomy. We examined 85 esophagectomy cases from 2007, in which we used a blocker combined with a spiral tracheal tube or DLT. An average of 1.5 times displacement of the blocker occurred in blocker cases and resulted in ventilation inability requiring a surgical interruption. Because bronchial displacement was present, 2 cases had to block it in an intermediate bronchial trunk. In DLT cases, tube movement was not seen and we could maintain good ventilation. However, lymph node dissection (LND) was difficult in DLT cases and DLT required exchange via a spiral tube for cervical LND. Next, we compared 4 DLTs, and found that the phi con DLT tube was the best because of its pliability. We concluded that the best tube for esophagectomy is a phi con DLT because it allows easy control of the differential lung ventilation and this tube does not interfere with surgery.

Surgical repair of refractory strictures of esophagogastric anastomoses caused by leakage following esophagectomy.

Refractory strictures of esophagogastric anastomosis caused by leakage following an esophagectomy are a severe complication, for which either repeated balloon dilations or bougies are not necessarily effective. In such a case, surgical repair is quite difficult because the esophageal substitute such as the stomach or colon is usually located in the mediastinum and severely adhesive to the neighboring organs. Furthermore, in case the resected stricture is too long for direct re-anastomosis to be performed, a free jejunal graft or a new esophageal substitute should be prepared. This paper proposes a procedure for the re-reconstruction of refractory stricture in the case of a retrosternal reconstruction with a gastric conduit, which frequently employs pull-up route. The anterior plate of the manubrium was divided medially from the notch to the symphysis with the sternal saw. The manubrium is then removed, bite by bite, like breaking up rocks, with a bone rongeur forceps, starting with the anterior plate, then the posterior plate, from upper median part to the lower and lateral part of the sternum until it reaches the symphysis and the sternoclavicular and the sternocostal joints. It is safer to destroy the manubrium little by little from the anterior side so that the posterior periosteum, which is likely to adhere tightly to the gastric conduit, can be preserved. After the manubrium is almost completely resected and the posterior periosteum of the manubrium is preserved, a median longitudinal incision is carefully made on the periosteum so as not to damage the gastric conduit that may be adhesive to the periosteum. The periosteum was gradually opened bilaterally separating the periostium and the gastric conduit. Although gastroenterological surgeons may hesitate to remove the manubrium, removing the manubrium and preserving the posterior periosteum make it possible to avoid injuring the gastric conduit and to provide a wide view around the stenosis for safely resecting the anastomotic stricture. Furthermore, this procedure allows direct re-anastomosis between the cervical esophagus and the gastric conduit without a complicated reconstruction such as a free jejunal graft. This procedure is strongly recommended as an alternative option so that a second reconstruction can be performed both safely and steadily.

Bacteriological study of autologous cryoprecipitate-derived fibrin glue as the operative sealant.

Fibrin glue (FG) is frequently used to seal and cover the anastomoses in many operations such as cardiovascular surgery or orthopaedic surgery. However, in case of gastrointestinal surgery, anastomoses are potentially contaminated, and FG may promote bacterial growth, increasing the risk of leakage. The purpose of this study was to examine the effect of cryoprecipitate-derived FG (CryoFG) on bacterial growth. Bacterial growth on the CryoFG and on the commercial FG (Beriplast P) was evaluated and compared with that on control medium. In addition, the complement activities were evaluated by heat inactivation or addition of guinea-pig complement to the experimental settings. The CryoFG inhibited the growth of Escherichia coli, whereas the commercial FG had no effect. Heat inactivation of the CryoFG inhibited the bactericidal effect of CryoFG. Addition of guinea-pig complement to the heat-inactivated CryoFG could almost restore the bactericidal activity, suggesting the important role of complement. This study showed that the CryoFG preserved the complement activity, which inhibited the in vitro growth of E. coli. Therefore, we concluded that the application of the CryoFG for gastrointestinal surgical anastomoses not only would be safe but also has the advantage of reducing bacterial infection.

Esophageal carcinoma with tracheal stenosis due to tumor invasion and long survival after chemoradiotherapy.

For patients who have esophageal carcinoma with tracheal invasion surgery is usually not indicated because operative complications are considerable and the prognosis is poor. We experienced complete regression of a large esophageal carcinoma with tracheal stenosis due to tumor invasion without tracheo-esophageal fistula. Irradiation of 68 Gy was delivered to a long T field from the neck to the lower thoracic esophagus, and was combined with chemotherapy using cisplatin and 5-fluorouracil. The tumor decreased markedly in size and the tracheal stenosis resolved. The patient has survived for 4 years, although second primary early esophageal carcinoma and hypopharyngeal carcinoma were detected 2 years after his initial chemoradiotherapy. Although the prognosis of advanced esophageal carcinoma with invasion of other organs is usually poor, the effect of chemoradiotherapy can sometimes be dramatic and a good result can be achieved in such patients.

Histopathologic effects of neoadjuvant therapies for advanced squamous cell carcinoma of the esophagus: multivariate analysis of predictive factors and p53 overexpression.

In 97 patients (60, chemotherapy; 22, chemoradiotherapy; 15, radiotherapy), histopathologic effects were evaluated microscopically, and histologic response rates were compared among three neoadjuvant treatment modalities. Predictive factors for neoadjuvant therapies were analyzed by logistic regression, including the results of p53 immunohistochemical staining. In the chemoradiotherapy group, the pathologic response rate was 86.4%, and was significantly higher than that for chemotherapy (P < 0.0001) or for radiotherapy (P = 0.0031). In patients with normal p53 protein expression, the histopathologic response rate to chemotherapy was 20.0%, a higher rate than that for patients with abnormal p53 overexpression. In the chemoradiotherapy or radiotherapy group, however, the response rates were almost the same, irrespective of p53 oncoprotein status. From multivariate analysis, the neoadjuvant treatment modality itself was identified as the most powerful predictive factor for the effect. Chemoradiotherapy had the most powerful effect on advanced esophageal cancer, and p53 status did not influence the clinical outcome in this group.

Surgical treatment of esophageal cancer: Tokyo experience of the three-field technique.

Esophageal cancer can metastasize to the lymph nodes at a very early stage of the disease, and spread occurs both upwards and downwards. We have developed the 'three-field lymphadenectomy' (3-FD) technique, in which more than 100 lymph nodes are completely dissected from the lower neck, mediastinum, and upper abdomen. More than 700 patients have undergone 3-FD since 1984. Three-field lymphadenectomy is associated with considerable morbidity, although efforts have been made to reduce this by preserving tracheobronchial circulation and innervation. The mortality associated with 3-FD is acceptable (5-year survival rate of 53.8% for patients treated with curative surgery). We believe that 3-FD is a suitable standard operation for the treatment of thoracic esophageal cancer. Further trials are now under way with the aim of improving the results of the technique and also extending the applications of limited surgery and non-surgical therapy.

Outcomes of extended lymph node dissection for squamous cell carcinoma of the thoracic esophagus.

Patients with thoracic esophageal carcinoma who underwent extended lymph node (LN) dissection were studied to assess the state of LN metastasis and evaluate its outcome in terms of a prognostic benefit. Pertaining to LN metastasis, it was found that depending on the location of a primary tumor, the area of choice, in which metastasis tends to develop predominantly, showed some variation. However, irrespective of the location of the tumor, the predominant growth of positive nodes was found to locate among three fields, namely the neck, mediastinum and abdomen even in patients with a single metastatic node. This suggests that extended LN dissection including the neck, mediastinum and abdomen should be considered mandatory, if a complete removal of the tumors for carcinoma of the thoracic esophagus is to be desired. Multivariate analysis revealed importance of LN dissection as a prognostic factor. A cumulative survival rate in the patients with lymphadenectomy through right thoracotomy was statistically better than that in the patients who underwent blunt extraction of the esophagus without lymphadenectomy. Furthermore, extensiveness of LN dissection could effectively serve as a prognostic factor. Consequently, three-field LN dissection yields a prognostic benefit to improve a long term survival in patients with carcinoma of the thoracic esophagus.

ST-segment elevation in leads I and aVL predicts short-term prognosis in acute anterior wall myocardial infarction.

Our study demonstrates that ST-segment elevation in both leads I and aVL noted on admission for an anterior acute myocardial infarction does portend a worse short-term survival. Independent predictors of short-term prognosis in an anterior acute myocardial infarction include ST elevation in both leads I and aVL, advanced age, female gender, left ventricular failure, and malignant arrhythmias.

Pulmonary thromboembolism after surgery for esophageal cancer: its features and prophylaxis.

We attempt to clarify the problems of pulmonary thromboembolism (PTE), which occurs less frequently in Japan than in the West, regarding its special perioperative management and prophylaxis for PTE after esophagectomy. We studied 26 patients with PTE following esophagectomy among 1023 patients with esophageal cancer between 1984 and 1997. The presence of embolism was confirmed by pulmonary perfusion scintigraphy. The incidence, diagnosis, and other issues of PTE were all reviewed. The incidence of PTE was 2.5%, with patients showing a biphasic early and late onset. The main symptoms were dyspnea in 19 patients and tachycardia in 17. Scintigraphy demonstrated 154 lesions, 35.7% of which were located in the left lower lobe and 25.3% in the right lower lobe. Treatment mainly consisted of the administration of heparin and urokinase. Four of the 26 patients died. Intermittent pneumatic compression (IPC) with the administration of heparin has been used in our department since 1994 to prevent PTE and this has also helped to decrease the incidence from 3.2% to 0.7%. Because the incidence of PTE following esophagectomy is higher than expected, PTE should be considered whenever hypoxemia of some unknown cause is found. Both early diagnosis and treatment are essential. It is also important to prevent PTE by the use of IPC.

Severity of residual stenosis of infarct-related lesion and left ventricular function after single-vessel anterior wall myocardial infarction: implication of ST-segment elevation in lead aVL of the admission electrocardiograms.

BACKGROUND: The relationship between the severity of chronic-phase stenosis of infarct-related lesions (IRLs) and chronic left ventricular function in anterior acute myocardial infarctions (AMI) has not been adequately investigated. HYPOTHESIS: This study investigated whether ST elevation in lead aVL of admission electrocardiogram (ECG) would be a determinant factor of the relationship between the severity of stenosis of the IRL and chronic left ventricular function after anterior wall AMI. METHODS: One month after AMI, the IRL was evaluated by coronary angiography in 98 patients with anterior AMI, and left ventricular ejection fraction (LVEF) was determined using multigated radionuclide angiocardiography. Patients were classified according to the severity of the IRL: patients with 100% occlusion (Group O), patients with 90 to 99% stenosis (Group H), and patients with < or =75% stenosis (Group L). Patients with ST elevation > or =0.1 mV in the aVL lead on their admission ECG were included in the ST-elevation group, and those with ST elevation <0.1 mV were included in the non-ST-elevation group. RESULTS: The LVEF was greater in the non-ST-elevation group than in the ST-elevation group (p<0.0001), and the LVEF in a whole group as follows: Group L LVEF>Group H LVEF>Group O LVEF (p = 0.0160). In the ST-elevation group, LVEF was higher in Group L than in the other groups (p = 0.0251). There were three independent predictors of a reduced LVEF: ST-elevation in aVL [odds ratio (OR): 3.38, p = 0.0044], IRL stenosis > or =90% (OR: 2.90, p = 0.0044), and the IRL occurring in the left anterior descending artery proximal to the first diagonal branch (OR: 6.31, p = 0.0024). CONCLUSION: Left ventricular function was preserved, regardless of the severity of residual stenosis, in patients without ST elevation in aVL if the IRL was not totally occluded. In patients with ST elevation in aVL, LVEF was lower in patients with more severe stenosis, even if the IRL was patent.

Usefulness of autologous blood transfusion for avoiding allogenic transfusion and infectious complications after esophageal cancer resection.

BACKGROUND: A retrospective investigation was conducted to determine whether autologous blood collection could reduce allogenic transfusion after resection of esophageal cancer and whether allogenic transfusion influenced postoperative infection. METHODS: Patients (n = 100) who met the criteria for hemoglobin, age, body weight, and serum protein donated 800 mL of autologous blood from May 1994 to December 1997. The control group (n = 248) was selected from patients who met the same criteria and did not donate autologous blood over the 10 years before the start of autologous blood collection. RESULTS: Only three patients (3%) from the autologous group required allogenic transfusion versus 84 patients (33.7%) from the control group. Sixteen of the 26 patients who received more than 4 units of allogenic blood contracted postoperative infections compared with 25 of 165 patients who did not (P < .0001). Autologous blood transfusion significantly increased the probability of avoiding allogenic transfusion (odds ratio, 27.58), and allogenic transfusion was significantly related to postoperative infection (odds ratio, 1.19), according to logistic regression analysis. CONCLUSIONS: Autologous blood collection reduces the need for allogenic transfusion in patients undergoing resection of esophageal cancer, and avoidance of allogenic transfusion may reduce the risk of postoperative infection.

Cardiac rupture and admission electrocardiography in acute anterior myocardial infarction: implication of ST elevation in aVL.

This study determines the usefulness of electrocardiography in the emergency room for assessing the risk of cardiac rupture after acute anterior myocardial infarction (MI). The presence of ST segment elevation on the admission 12-lead electrocardiography was evaluated in 325 consecutive anterior MI patients. A forward-stepwise logistic regression analysis for cardiac rupture was performed with the covariates of age, gender, hypertension, history of MI, reperfusion therapy by coronary angioplasty, and ST segment elevations in leads I, aVL, V1-V6. Cardiac rupture occurred in 16 patients, including 7 with left ventricular free wall rupture (FWR) and 9 with ventricular septal perforation (VSP). For FWR, ST elevation in lead aVL was the only independent predictor (odds ratio = 12.1, P = .0215). For VSP, female gender (odds ratio = 5.32, P = .0201) was the independent predictor. In conclusion, in patients with acute anterior MI, ST segment elevation in lead aVL on the admission electrocardiography is a significant risk factor for left ventricular FWR.

Prognosis of aortic intramural hemorrhage compared with classic aortic dissection.

Aortic intramural hemorrhage occurs fairly frequently among patients with aortic dissection, and may not have a poor prognosis if it is Stanford type B. In patients with type A aortic dissection, cardiac tamponade should be ruled out during observation.