Risk factors for venous thrombosis after esophagectomy.

BACKGROUND: Venous thrombosis (VT) after esophagectomy for esophageal cancer is an important complication, potentially leading to pulmonary embolism. However, there are few available information about the risk for the postsurgical VT. METHODS: This study included 271 patients who underwent esophagectomy for esophageal cancer between 2006 and 2019. Contrast-enhanced computed tomography (CT) was performed for all patients on the seventh postoperative day to survey complications, including VT. RESULTS: VT was radiologically visualized in 48 patients (17.7%), 8 of whom (16.7%) had pulmonary embolism. The thrombus disappeared in 42 patients, the thrombus size was unchanged in 5 patients, and 1 patient died. Multivariate analysis was performed on factors clinically considered to have a significant influence on thrombus formation. The analysis showed that CVC insertion via the femoral vein (odds ratio, 7.67; 95% CI, 2.64-22.27; P < 0.001), retrosternal reconstruction route (odds ratio, 3.94; 95% CI, 1.90-8.17; P < 0.001) and intraoperative fluid balance < 5 ml/kg/hr (odds ratio, 0.38; 95% CI, 0.17-0.85; P = 0.019) were independently related to VT. CONCLUSIONS: Intraoperative fluid balance < 5 ml/kg/hr, along with CVC insertion via the femoral vein and retrosternal reconstruction may be potential risk factors for VT after esophagectomy.

A feasibility study of modified docetaxel, cisplatin, and capecitabine for advanced gastric cancer followed by gastrectomy.

AIMS: To explore the feasibility of modified docetaxel, cisplatin, and capecitabine (mDCX) chemotherapy with a lower dose of docetaxel than previously reported for stage III resectable gastric cancer patients with a high risk of recurrence or for stage IV gastric cancer patients aiming for conversion surgery. METHODS: Patients with stage III resectable HER2-negative gastric cancer with large type 3 or type 4 tumors or extensive lymph node metastasis (bulky N or cN3) and those who had stage IV HER2-negative gastric cancer with distant metastasis were enrolled to receive 30 mg/m2 docetaxel and 60 mg/m2 cisplatin on day 1, followed by 2000 mg/m2 capecitabine per day for 2 weeks every 3 weeks. RESULTS: Five patients with stage III gastric cancer with a high risk of recurrence received three courses of mDCX, and four patients with stage IV gastric cancer received three or four courses of mDCX. In terms of grade 3 or worse adverse events, leukopenia was observed in one (11%) patient, neutropenia in two (22%) patients, anemia in one (11%) patient, anorexia in two (22%) patients and nausea in two (22%) patients. All six patients with measurable lesions achieved a partial response. All nine patients underwent subsequent surgeries. The histological responses of the nine patients revealed grade 3 in one (11%) patient, grade 2 in five (56%) patients, and grade 1a in three (33%) patients. Three of the nine patients survived without recurrence, and two of them survived for more than four years. CONCLUSIONS: mDCX seems to be feasible and may be helpful as neoadjuvant chemotherapy for patients at high risk of recurrence or as chemotherapy for patients who are likely to undergo conversion surgery.

Risk Factors for Muscle Loss During Neoadjuvant Therapy for Esophageal Cancer.

BACKGROUND/AIM: In patients with esophageal cancer, muscle loss induced by neoadjuvant therapy before esophagectomy is correlated with poor prognosis. However, little is known about the causes of muscle loss. Thus, the purpose of this retrospective study was to clarify the risk factors for muscle loss during neoadjuvant therapy. PATIENTS AND METHODS: Patients with esophageal cancer who underwent neoadjuvant therapy before esophagectomy between 2009 and 2020 were investigated (n=132). The patients received either cisplatin plus 5-fluorouracil (CF); docetaxel, cisplatin plus 5-fluorouracil (DCF); or CF with radiotherapy as neoadjuvant therapy. The cross-sectional areas of the bilateral psoas muscles were measured at the level of the third lumbar vertebra using CT, before and after neoadjuvant therapy, and psoas muscle loss was calculated. The patients were divided into the high muscle loss group with 5% or more muscle loss or the low muscle loss group with less than 5% loss. Correlations between muscle loss and clinical factors were evaluated. RESULTS: The median value of psoas muscle loss was 5.30%. Psoas muscle loss was significantly correlated with a poor 3-year overall survival rate (p=0.034). Multivariate analysis showed that the independent factors associated with muscle loss were age ≥70 years [odds ratio (OR)=2.43, p=0.022], treatment with DCF (OR=3.47, p=0.034), and a poor response to neoadjuvant therapy (OR=2.68, p=0.028). CONCLUSION: A regimen of DCF was a major trigger of muscle loss during neoadjuvant therapy.

A desmoid tumor with fluorodeoxyglucose accumulation arising from the anastomotic site of postoperative gastric cancer: a case report.

BACKGROUND: Desmoid tumors are extremely rare borderline benign and malignant tumors that do not exhibit accumulation on fluorodeoxyglucose positron emission tomography-computed tomography. In the present study, we report a rare case of a desmoid tumor with fluorodeoxyglucose accumulation at the anastomotic postoperative gastric cancer site. CASE PRESENTATION: A 68-year-old Japanese man underwent robot-assisted laparoscopic distal gastrectomy for early-stage gastric cancer in 2019. The pathological diagnosis was stage IA cancer, and no adjuvant chemotherapy was administered. Two years after surgery, a soft mass appeared on the greater curvature side of the anastomosis on computed tomography. Fluorodeoxyglucose positron emission tomography-computed tomography revealed fluorodeoxyglucose accumulation, which suggested a malignancy; therefore, surgery was performed for diagnostic treatment. The histopathological findings led to the diagnosis of a desmoid tumor. The patient has not experienced recurrence to date. CONCLUSIONS: In the present study, we encountered a desmoid tumor arising from the anastomotic site of a postoperative gastric cancer. This case is rare as fluorodeoxyglucose positron emission tomography-computed tomography showed fluorodeoxyglucose accumulation in the desmoid tumor, and a preoperative diagnosis could not be reached. We hope that further studies will improve the accuracy of preoperative diagnosis.

A long-term survivor of advanced retroperitoneal dedifferentiated liposarcoma: a successful multimodal approach with extended resection and chemotherapy.

Surgical resection is the mainstay of treatment for retroperitoneal liposarcoma (RPLS). Herein, we describe a case of dedifferentiated RPLS successfully treated with an extended surgical approach with adjuvant chemotherapy. A 61-year-old male was referred to our hospital with a chief complaint of chest tightness. Abdominal computed tomography revealed a large retroperitoneal tumor, 11 cm in diameter, extensively invading the surrounding organs: the celiac axis, the splenic artery, the pancreatic body and tail, the lesser curvature of the stomach and the left adrenal gland. Endoscopic ultrasound-guided fine-needle aspiration biopsy confirmed dedifferentiated liposarcoma, suggesting aggressive tumor biology. We performed total gastrectomy combined with distal pancreatectomy with celiac axis and left adrenal gland resection with a curative intent. The postoperative course was almost uneventful. As the pathological findings indicated a positive margin with a well-differentiated liposarcoma component, we added adjuvant chemotherapy with four cycles of doxorubicin and ifosfamide (AI). Five years after primary surgery, regular follow-up CT demonstrated a pulmonary hilar lymph node enlargement and a tumor at paraesophageal locations. After downsizing chemotherapy with eribulin followed by pazopanib, he underwent partial esophagectomy with dissection of the paraesophageal tumor. The pathological findings indicated recurrence of dedifferentiated liposarcoma with a tumor-free surgical margin. He is currently alive without any evidence of recurrence almost 7 years after the first surgery and 15 months after the second surgery. The long-term survival gained in this patient indicates that extended resections and adjuvant chemotherapy could prolong survival in patients even with RPLS with dedifferentiated tumor histology.

Early volume loss of skeletal muscle after esophagectomy: a risk for late-onset postoperative pneumonia.

Late-onset postoperative pneumonia (LOPP) after esophagectomy is poorly understood. This study was designed to clarify the features and risk factors for this event. Patients who underwent esophagectomy for esophageal cancer between 2006 and 2016 were included. LOPP was defined as radiologically proven pneumonia that occurred over 3 months after surgery, and clinically relevant late-onset postoperative pneumonia (CR-LOPP) was defined as LOPP that required administration of oxygen and antibiotics in the hospital and/or more intensive treatment. The total psoas muscle area (TPA) was measured using preoperative and postoperative (at 3 months after surgery) computed tomography scan images. Potential risk factors for CR-LOPP were investigated. Among 175 study patients, 46 (26.3%) had LOPP, 29 (16.6%) of whom exhibited CR-LOPP with a cumulative incidence of 15.6% at 3 years and 22.4% at 5 years. Four (13.8%) of these patients died of LOPP. Univariable analysis showed that clinical stage ≥III (P = 0.005), preoperative prognostic nutritional index (PNI) <45 (P = 0.035), arrhythmia (P = 0.014), postoperative hospital stay ≥40 days (P = 0.003), and percent decrease of TPA more than 5% (P < 0.001) were associated with CR-LOPP but not early onset postoperative pneumonia. Multivariable analysis revealed that clinical stage ≥III (hazard ratio [HR] 3.01, P = 0.004), postoperative hospital stay ≥40 days (HR 2.51, P = 0.015), and percent decrease of TPA >5% (HR 9.93, P < 0.001) were independent risk factors for CR-LOPP. CR-LOPP occurred in over 20% of patients at 5 years, and early postoperative loss of TPA was a potential trigger for this delayed complication.

Trefoil factor 1 inhibits the development of esophageal adenocarcinoma from Barrett's epithelium.

Trefoil factor family 1 (TFF1) is one of three members of the trefoil factor family that are abundantly expressed in the gastrointestinal mucosal epithelium. Recent studies have shown that TFF1 acts as a tumor suppressor in gastric, pancreatic and hepatocellular carcinogenesis; however, little is known about its function in esophageal carcinogenesis, especially in esophageal adenocarcinoma (EAC). Barrett's epithelium is the metaplastic columnar epithelium of the esophagus and a known premalignant lesion of EAC. To investigate the role of TFF1 in EAC development, a mouse model of Barrett's epithelium was employed, and human specimens of EAC were assessed by immunohistochemistry (IHC) and methylation-specific PCR. Wild-type (WT) mice underwent gastrojejunostomy on the forestomach, resulting in the development of Barrett's epithelium-like (BE-like) epithelium adjacent to the anastomotic site. BE-like epithelium in these mice expressed TFF1, indicating the association of TFF1 with esophageal adenocarcinoma. TFF1-knockout (TFF1KO) mice underwent the same procedure as well, revealing that a deficiency in TFF1 resulted in the development of adenocarcinoma in the anastomotic site, presumably from BE-like epithelium. IHC of human samples revealed strong TFF1 expression in Barrett's epithelium, which was lost in some EACs, confirming the association between TFF1 and EAC development. Aberrant DNA hypermethylation in TFF1 promoter lesions was detected in TFF1-negative human EAC samples, further confirming not only the role of TFF1 in EAC but also the underlying mechanisms of TFF1 regulation. In addition, IHC revealed the nuclear translocation of ß-catenin in human and mouse EAC, suggesting that activation of the Wnt/ß-catenin pathway was induced by the loss of TFF1. In conclusion, these results indicate that TFF1 functions as a tumor suppressor to inhibit the development of esophageal carcinogenesis from Barrett's epithelium.

Preoperative docetaxel, cisplatin, and fluorouracil treatment with pegfilgrastim on day 7 for patients with esophageal cancer: A phase II study.

AIMS: The docetaxel and cisplatin plus 5-fluorouracil (5-FU) (DCF) regimen is expected to be superior to cisplatin plus 5-FU for the preoperative treatment of esophageal cancer. However, a high risk of adverse effects, including febrile neutropenia (FN), has been reported. To evaluate the effectiveness and safety of DCF with prophylactic pegfilgrastim, we conducted a phase II study. METHODS: The regimen consisted of intravenous administration of docetaxel (70 mg/m2 per day) and cisplatin (70 mg/m2 per day) on day 1 and a continuous infusion of 5-FU (750 mg/m2 per day) on days 1-5. A single 3.6-mg dose of pegfilgrastim was given as a subcutaneous injection on day 7 of each cycle. This regimen was repeated every 3 weeks for a maximum of three cycles. The primary endpoint was the grade-2/3 histopathological response rate. RESULTS: Thirty-seven eligible patients were enrolled and received DCF. Thirty-four patients underwent esophagectomy. Two patients received chemoradiotherapy or radiotherapy without surgery. One patient withdrew consent and ended his hospital visit. One patient received additional radiotherapy before surgery. Histopathological responses of grade 3, grade 2, grade 1b, and grade 1a were observed in two (5.4%), 14 (37.8%), 10 (27.0%), and seven (18.9%) patients, respectively, and the primary endpoint was met. Of the 37 eligible patients, 11 (29.7%) developed FN in the first cycle. CONCLUSIONS: Since the histopathological responses were as expected, DCF with prophylactic pegfilgrastim is considered to be effective as preoperative chemotherapy. However, the prophylactic use of pegfilgrastim on day 7 was insufficient to prevent FN.

Impact of synbiotics treatment on bacteremia induced during neoadjuvant chemotherapy for esophageal cancer: A randomised controlled trial.

BACKGROUND & AIMS: To elucidate the impact of synbiotics on bacterial translocation and subsequent bacteremia during neoadjuvant chemotherapy for esophageal cancer. METHODS: Patients requiring neoadjuvant chemotherapy for esophageal cancer were randomized to receive synbiotics (synbiotics group) or no synbiotics (control group) during chemotherapy. Blood and fecal samples were taken before and after every chemotherapy cycle, and 1 day before surgery. Mesenteric lymph nodes (MLNs) were harvested at laparotomy (MLN-1) and after resection of the tumor (MLN-2). Bacteria in each sample were detected. Fecal microbiota and organic acid concentrations were also determined. The primary endpoint was the detection of bacteria in the blood samples, as well as the incidence of side effects during chemotherapy. The secondary endpoint was the detection rate of bacteria in the MLN samples collected during surgery. RESULTS: The study recruited a total of 42 patients (22 in the control group, 20 in the synbiotics group). Bacteria were detected in 16 of 101 blood samples in the control group, whereas those were detected only 2 of 100 blood samples in the synbiotics group (p < 0.001) during neoadjuvant chemotherapy. Additionally, bacteria were detected in 12 of 34 MLN samples in the control group, whereas no bacteria were detected in 38 MLN samples in the synbiotics group (p < 0.001). Suppression of bacterial translocation was at least partly associated with an increased fecal acetic acid concentration as well as a lowered fecal pH by synbiotics. The incidence rate of grade 3 gastrointestinal toxicity during chemotherapy was lower in the synbiotics group compared to the control group (8/22 vs. 1/20, p = 0.022). CONCLUSIONS: Neoadjuvant chemotherapy for esophageal cancer may induce bacterial translocation and subsequent bacteremia, which can be prevented by synbiotics administration. TRIAL REGISTRATION: The University Hospital Medical Information Network (http://www.umin.ac.jp; registration number ID 000007651).

Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis.

Previous studies have shown that signal intensity variations in the gallbladder wall on magnetic resonance imaging (MRI) are associated with necrosis and fibrosis in the gallbladder of acute cholecystitis (AC). However, the association between MRI findings and operative outcomes remains unclear. We retrospectively identified 321 patients who underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and early laparoscopic cholecystectomy (LC) for AC. Based on the gallbladder wall signal intensity on MRI, these patients were divided into high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI) groups. Comparisons of bailout procedure rates (open conversion and laparoscopic subtotal cholecystectomy) and operating times were performed. The recorded bailout procedure rates were 6.8% (7/103 cases), 26.7% (31/116 cases), and 40.2% (41/102 cases), and the median operating times were 95, 110, and 138 minutes in the HSI, ISI, and LSI groups, respectively (both p < 0.001). During the multivariate analysis, the LSI of the gallbladder wall was an independent predictor of both the bailout procedure (odds ratio [OR] 5.30; 95% CI 2.11-13.30; p < 0.001) and prolonged surgery (≥144 min) (OR 6.10, 95% CI 2.74-13.60, p < 0.001). Preoperative MRCP/MRI assessment could be a novel method for predicting surgical difficulty during LC for AC.

Clinical importance of "occult-bacterial translocation" in patients undergoing highly invasive gastrointestinal surgery: A review.

In the clinical setting, mild bacteremia cannot be detected by conventional culture methods, only by a highly sensitive bacterial detection system. One of the major causes of mild bacteremia is bacterial translocation (BT) induced by a dysregulated intestinal microenvironment and increased intestinal epithelial permeability. This condition is called "occult-bacterial translocation (O-BT)"; however, the concept of O-BT is not yet fully recognized. In our previous studies, done using a highly sensitive bacterial detection system such as bacterium-specific ribosomal RNA-targeted reverse transcriptase quantitative polymerase chain reaction (RT-qPCR), O-BT was commonly observed in patients who underwent highly invasive surgery. We collected blood and mesenteric lymph node (MLN) samples from patients undergoing esophagectomy for esophageal cancer, before and after they were subjected to surgical stress. The detection rate of bacteria in these samples increased from approximately 20% before surgical stress to more than 50% after surgical stress. Moreover, positivity for bacteria in the blood or MLN samples was associated with the incidence of postoperative infectious complications (POICs). Using the RT-qPCR system, it is possible to detect the specific bacteria that cause O-BT immediately after surgery. This may allow us to select the exact antibiotic that targets possible pathogenic bacteria of POICs.

Repair of gastro-tracheobronchial fistula after esophagectomy for esophageal cancer using intercostal muscle and latissimus dorsi muscle flaps: a case report.

BACKGROUND: Gastro-tracheobronchial fistula after esophagectomy is a rare but life-threatening complication associated with high mortality. Several authors reported postoperative management of tracheobronchial fistula. However, treatment is demanding and challenging, and the strategy is still controversial. CASE PRESENTATION: A 64-year-old man underwent thoracoscopic esophagectomy with two-field lymph node dissection and gastric conduit reconstruction by an intrathoracic anastomosis for esophageal cancer at a local hospital in June 2013. After surgery, a gastro-tracheal fistula and a gastro-bronchial fistula of the left main bronchus were diagnosed, and the patient was referred to our hospital for the management of the gastro-tracheobronchial fistula. CT and bronchoscopy and esophagogastroduodenoscopy performed at our hospital revealed that the gastro-bronchial fistula of the left main bronchus was cured by packing with the omentum from the gastric conduit and the gastro-tracheal fistula located 3 cm above the carina remained open. We concluded that the fistula would not resolve without further surgical procedure. However, such an operation was expected to be difficult and to need much time due to severe adhesion among the gastric conduit and/or trachea, bronchus, lung, and chest wall. Therefore, a two-stage operation was planned for safety and outcome certainty. The first operation was performed to close the fistula in October 2013. The gastric conduit was separated from the trachea and resected; then, the fistula was sutured and covered by intercostal muscle and latissimus dorsi muscle flaps. A month after the first operation, reconstruction with pedunculated jejunum was performed via the percutaneous route. The patient's postoperative course was uneventful. CONCLUSION: If the omentum is not observed between the gastric conduit and the tracheobronchus when a gastro-tracheobronchial fistula occurs after esophagectomy, surgeons should perform surgical treatment because conservative treatment is unlikely to cure. During surgery, the use of two types of muscle flaps, such as the intercostal muscle and the latissimus dorsi muscle flaps, is helpful for the closure of gastro-tracheobronchial fistulas.

Successful two-stage operation for esophageal necrosis due to proton beam therapy followed by sorafenib in a case of large hepatocellular carcinoma.

BACKGROUND: Locally advanced hepatocellular carcinoma (HCC), which is unsuitable for standard locoregional therapies, remains a challenge to manage. Among the recently developed treatments, proton beam therapy (PBT) has been reported to achieve good local control. However, in patients with large HCC adjacent to the esophagus, high-dose PBT may rarely lead to radiation-induced esophageal necrosis or perforation. Furthermore, the optimal strategy to safely treat these fatal complications remains unclear. CASE PRESENTATION: A 49-year-old man who was diagnosed with a large (16 cm) HCC in the right lobe with tumor thrombosis in the main trunk of the portal vein (PVTT) received high-dose hypofractionated PBT in another hospital. A total dose of 66 GyE in 10 fractions was administered to the primary tumor and the PVTT. After 5 months, a 1-cm solitary nodule was noted in the upper lobe of the right lung. Therefore, sorafenib was started. About 6 months after the PBT, lower esophageal mucosal inflammation that progressed to an ulcer was noted. About 7 months after the PBT, the lower esophagus developed full-thickness necrosis. Therefore, emergency thoracoscopic esophagectomy was performed, followed by two-stage reconstruction 2 months later. The operation and postoperative clinical course were mostly uneventful, except for a minor anastomotic leakage. The outcome of the primary HCC, including the PVTT, was graded as a complete response, which has been maintained for 51 months after the PBT. CONCLUSION: PBT is a promising option for patients with locally advanced HCC; however, for large tumors adjacent to the esophagus, ischemic esophageal necrosis due to antiangiogenic effects may occur, particularly with the combined use of PBT and sorafenib. In such a life-threatening condition, the thoracoscopic esophagectomy and the two-stage reconstruction are a safe option that can prevent critical postoperative complications due to the poor general condition, effects of PBT on the remnant gastric conduit, and use of sorafenib.

Scheduled intravenous acetaminophen versus nonsteroidal anti-inflammatory drugs (NSAIDs) for better short-term outcomes after esophagectomy for esophageal cancer.

PURPOSE: To evaluate the effect of scheduled intravenous acetaminophen administration versus nonsteroidal anti-inflammatory drugs on postoperative pain and short-term outcomes after esophagectomy. METHODS: The subjects of this study were 150 consecutive patients who underwent esophagectomy for esophageal cancer. Seventy-seven patients received scheduled intravenous acetaminophen and the other 73 received NSAIDs enterally for postoperative pain management. We compared the postoperative pain and short-term outcomes between the groups. Inverse probability of treatment weighting (IPTW) based on propensity scores was used to control for selection bias. RESULTS: The visual analog scale (VAS) of postoperative pain was lower in the acetaminophen group than in the NSAIDs group, based on the mean values of chest VAS on postoperative days (PODs) 0, 4, 5, and 6 and the mean values of abdomen VAS on PODs 4, 5, and 6. The incidence of anastomotic leakage and postoperative delirium was lower in the acetaminophen group than in the NSAIDs group (anastomotic leakage, odds ratio (OR) 0.3, p = 0.01; postoperative delirium, OR 0.19, p < 0.01). CONCLUSION: Scheduled intravenous acetaminophen administration is effective and feasible for the postoperative pain management of patients undergoing esophagectomy and may be associated with a lower incidence of anastomotic leakage and postoperative delirium.

A prospective trial to evaluate treatment effects of a ß-hydroxy-ß-methylbutyrate containing nutrient for leakage at the anastomotic site after esophagectomy.

Anastomotic leakage after esophagectomy is associated with prolonged hospitalization and increased medical cost. Additionally, it sometimes leads to a fatal condition and impaired postoperative quality of life. During the process of wound healing, ß-hydroxy-ß-methylbutyrate (HMB) is important for collagen biosynthesis. An open-label prospective intervention trial has been designed to evaluate the treatment effect of an enteral nutrient containing HMB with arginine and glutamine (Abound, Abbott Japan Co., Ltd.) for leakage at the anastomotic site after esophagectomy. Patients in whom leakage at the anastomotic site developed within 14 days after esophagectomy are eligible and Abound (24 g) is administered for 14 days through an enteral feeding tube. The target sample size is 10. The primary endpoint is duration between diagnosis and cure of leakage. Surgical procedure, safety, length of fasting, drainage placement and hospital stay, and nutritional status are determined as secondary endpoints. A historical control consisting of 20 patients who had leakage at the anastomotic site after esophagectomy between 2005 and 2018 at Nagoya University Hospital is compared with enrolled patients.

Esophageal reconstruction using a pedicled jejunum following esophagectomy for metastatic esophageal stricture from breast cancer in a patient with previous pancreatoduodenectomy.

A 71-year-old woman with dysphagia was diagnosed with thoracic esophageal squamous cell carcinoma by endoscopic biopsy at another hospital. She had previously undergone partial breast excision with axillary lymph node dissection for right breast cancer eleven years earlier and subtotal stomach-preserving pancreatoduodenectomy with Child's reconstruction for ampullary cancer ten years earlier. Gastrointestinal endoscopy showed a stricture due to a bulging submucosal tumor in the mid-thoracic esophagus. The tumor was diagnosed as an esophageal metastasis from breast cancer by endoscopic ultrasound-guided fine-needle aspiration biopsy. After six courses of fulvestrant, the tumor progressed, completely impeding her ability to swallow. An esophagectomy was planned in a one-stage operation because of the expectation of a prolonged survival and her strong hope of regaining oral intake. Unfortunately, she underwent emergent omental patch repair for perforation of the gastrojejunostomy site due to an anastomotic ulcer one day before the scheduled operation. Due to postoperative impairment of her performance status, she subsequently underwent a two-stage esophageal operation. In the first surgical stage, prone position thoracoscopic esophagectomy and cervical esophagostomy were performed and she was discharged with enteral nutrition on postoperative day 15. Sixty-one days after the first surgical stage, esophageal reconstruction was performed using a pedicled jejunum with microvascular anastomosis via the subcutaneous route. She was discharged without any complications 20 days after the second operation.

Repeated episodes of thoracic empyema after spontaneous esophageal rupture.

A 52-year-old man with a cough, high fever, and inappetence was diagnosed with thoracic empyema on computed tomography at a local hospital. He had undergone continuous thoracic drainage for a spontaneous esophageal rupture that occurred 17 years earlier. He developed left thoracic empyema 2, 14 and 17 years following the initial esophageal rupture that improved with conservative therapy each time. The most recent episode of thoracic empyema also resolved with conservative therapy. However, he was referred to our hospital for further examination and more complete surgical treatment for recurrent thoracic empyema. Gastrointestinal endoscopy showed a scar from the previous esophageal rupture in the lower esophagus. We considered that recurrent esophageal rupture may have caused repeated episodes of thoracic empyema based on endoscopic findings and his past history and elected to perform subtotal esophagectomy to provide a complete cure. A left transthoracic esophagectomy with a left lower lung lobectomy and gastric tube reconstruction via a retrosternal route were performed. A latissimus dorsi muscle flap was used to eliminate the dead space after lower lung lobectomy to prevent recurrent thoracic empyema. The bronchial stump was covered with a pedicled intercostal muscle flap to prevent leakage from the stump. Minor leakage from the esophagogastrostomy site developed during the postoperative course but resolved with conservative therapy. The patient was transferred to the previous hospital on the 36th postoperative day. Four years after surgery, he had good oral intake and nutritional status without any evidence of recurrent thoracic empyema.

Association Between Preoperative Muscle Mass and Intraoperative Bacterial Translocation in Patients Undergoing Hepatectomy, Pancreatoduodenectomy, and Esophagectomy.

PURPOSE: This study investigated the correlation between the fecal profile and muscle mass, which has not been elucidated before. METHODS: This study included patients who underwent hepatectomy, pancreatoduodenectomy, or esophagectomy and had fecal samples collected preoperatively and mesenteric lymph nodes (MLNs) harvested intraoperatively to determine the fecal profile and presence of bacteria in the MLNs. Total psoas area (TPA) was measured at the third lumbar vertebra using preoperative computed tomography images. TPA was standardized by body surface area (BSA) using the following equation: standardized TPA (mm2/m2) (stTPA) = TPA (mm2)/BSA (m2). The fecal concentrations of representative microorganisms and organic acids also were measured. RESULTS: A total of 127 patients undergoing hepatectomy (n = 48), pancreatoduodenectomy (n = 44), and esophagectomy (n = 35) were included. The fecal levels of predominant obligate anaerobes showed a positive correlation with stTPA, whereas that of pathogenic microorganisms showed a negative correlation with stTPA. The fecal concentrations of total short chain fatty acids (the sum of acetic acid, propionic acid, and butyric acid) also showed a positive correlation with stTPA. The stTPA was significantly lower in patients with positive microorganisms in the MLNs (patients with bacterial translocation) compared to those without microorganisms in the MLNs (p = 0.047). CONCLUSIONS: This study was the first to demonstrate the association between muscle mass and the fecal profile, as well as their association with bacterial translocation.

The impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux after intrathoracic esophagogastrostomy following transthoracic esophagectomy.

PURPOSE: The aim of this study was to evaluate the impact of cervical lymph node dissection on acid reflux and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy. METHODS: Thirty-one patients receiving transthoracic esophagectomy with gastric tube reconstruction by intrathoracic esophagogastrostomy were divided into the following two groups: a two-field lymph node dissection group (2F group) and a three-field lymph node dissection group (3F group). All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy at 1 year after surgery. The 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were compared between the 2 groups. RESULTS: No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) patients in the 3F group (p = 0.007). DGER was found in 2 patients (13%) in the 2F group and in 8 (53%) in the 3F group (p = 0.023). Four patients (25%) in the 2F group and 9 (60%) in the 3F group (p = 0.048) had reflux esophagitis. CONCLUSION: Cervical lymph node dissection increases acid reflux and DGER and can lead to an increase in the incidence of reflux esophagitis in patients undergoing intrathoracic esophagogastrostomy.

Retrosternal salvage reconstruction of esophageal discontinuity for a necrotic gastric tube after esophagectomy: A novel procedure.

In patients with esophageal cancer, esophageal conduit necrosis is a catastrophic complication of esophagectomy that requires surgical restoration. Because such patients are generally fatigued, less-invasive surgery is encouraged whenever possible. Therefore, we trim the sternum minimally above the healthy part of the gastric conduit, expose its surface, and then make anastomoses between the remnant esophagus and the exposed gastric conduit using a free jejunal graft through a retrosternal-subcutaneous route. The risk involved with this procedure is low, because we avoid manipulation of the heavily inflamed lesion due to mediastinitis. J. Med. Invest. 65:296-298, August, 2018.