Efficacy of prewarming prophylaxis method for intraoperative hypothermia during thoracoscopic esophagectomy.

BACKGROUND: This study was performed to elucidate the clinical efficacy of the prewarming prophylaxis method for intraoperative hypothermia during thoracoscopic esophagectomy for esophageal cancer. METHODS: We enrolled 100 consecutive patients with esophageal cancer. Two patients in the prewarming group could not undergo thoracoscopic esophagectomy because of conversion to thoracotomy. The intraoperative core temperature was measured in 50 and 48 patients classified into the control and prewarming groups, respectively. Patients in the prewarming group wore a Bair Hugger warming gown (3 M, Maplewood, MN, USA) in the ward for 30 min before entering the operation room. The primary outcome measure was the difference in the intraoperative body core temperature between the control and prewarming groups, and the secondary outcome measure was the difference in postoperative infectious complications between the control and prewarming groups. RESULTS: The intraoperative core temperature was significantly different between the two groups at each 30-min time point from the starting of operation to the ending of the thoracic procedure (P < 0.001). The incidence of infectious surgical complications was not significantly different between the control and prewarming groups (30.0% vs. 14.6%, respectively; P = 0.11). CONCLUSION: The prewarming prophylaxis method was effective for maintaining normothermia during thoracoscopic esophagectomy.

A novel device designed to improve the operability of energy devices with foot pedals in endoscopic surgery: the Foot-Site Monitor.

PURPOSE: We developed the "Foot-Site Monitor" (FSM) to permit easy identification of multiple foot pedals of energy devices in endoscopic surgery. The purpose of this study was to evaluate the effectiveness of the use of the FSM. METHODS: Using a training box, 20 surgeons performed a task consisting of pressing foot pedals with and without the FSM. The time from showing a color on a PC monitor to pressing the foot pedal that corresponded to this color (defined as the completion time), and the distance of the movement of the tip of the surgeon's forceps from the beginning to the end of the task (defined as shaking of the forceps) were measured. RESULTS: The use of the FSM was associated with significantly reduced shaking of the forceps (1.95 vs. 2.47 mm; p = 0.014), and a tendency toward a shorter completion time (1.39 vs. 1.51 s; p = 0.053). CONCLUSIONS: The use of the FSM in endoscopic surgery contributes to reduced shaking of the forceps and may shorten the operative time.

Impact of pathologically assessing extranodal extension in the thoracic field on the prognosis of esophageal squamous cell carcinoma.

BACKGROUND: This study aimed to elucidate the impact of extranodal extension, pathologically assessed according to new diagnostic criteria, on the prognosis of esophageal squamous cell carcinoma. Extranodal extension has been shown to be a prognostic indicator for head and neck cancers; however, its utility in esophageal squamous cell carcinoma has not been demonstrated. METHODS: We enrolled 174 consecutive esophageal squamous cell carcinoma patients who had undergone esophagectomy with lymph node dissection in the three fields. Extranodal extensions from all metastatic lymph nodes were pathologically classified into grades 1-3. Then, relationships between extranodal extension and clinicopathologic factors, including overall survival and recurrence-free survival were examined. Recurrence patterns in the thoracic and abdominal fields were also examined. RESULTS: Kaplan-Meier analyses showed that patients with grades 2 and 3 extranodal extension showed significantly poorer recurrence-free survival compared with those with intranodal involvement of esophageal squamous cell carcinoma cells (P = .0041 and P = .0011, respectively). Patients with pN3b (newly defined in this study as including at least one lymph node with grade 2-3 extranodal extension regardless of region or number of metastatic lymph nodes) was associated with significantly shorter overall survival and recurrence-free survival (P < .001). Moreover, multivariate analyses indicated that patients with grades 2-3 extranodal extension showed significantly reduced recurrence-free survival in the thoracic but not in the abdominal field (thoracic: P = .047; abdominal: P = .15). CONCLUSION: This study suggests that the extranodal extension grading system proposed in this study is a novel predictor of overall survival and recurrence-free survival in esophageal squamous cell carcinoma.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature.

BACKGROUND: Non-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy. CASE PRESENTATION: In case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48. In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28. CONCLUSIONS: The causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

Safety and efficacy of hydroxyethyl starch 6% 130/0.4/9 solution versus 5% human serum albumin in thoracic esophagectomy with 3-field lymph nodes dissection.

PURPOSE: We investigated the safety and efficacy of administering hydroxyethyl starch 6% 130/0.4/9 (HES130/0.4/9) versus 5% human serum albumin (HSA), perioperatively, to patients undergoing thoracic esophagectomy with 3-field lymph-node dissection for esophageal cancer. METHODS: The subjects of this study were 262 patients, scheduled to undergo thoracic esophagectomy for esophageal cancer, who were assigned to one of two groups based on the fluid replacement therapy. We compared the intraoperative and immediate postoperative hemodynamics and incidence of complications in the two groups. RESULTS: Neither group suffered any adverse events. No significant differences were observed in systolic/diastolic blood pressure, heart rate, incidence of postoperative complications, postoperative urine output, or serum creatinine levels, between the groups. A mild postoperative increase (×1.5 increase) in serum creatinine levels was seen in 9.5% and 9.5% of patients in the HSA and HES130/0.4/9 groups, respectively (p = 0.99), and a moderate postoperative increase (×2.0 increase) was seen in 4.4% and 3.1%, respectively (p = 0.84). Univariate and multivariate analyses revealed that the administration of hydroxyethyl starch was not associated with a postoperative increase in serum creatinine levels. CONCLUSION: Hydroxyethyl starch 6% 130/0.4/9 was well tolerated and comparable to albumin with respect to its effect on renal function during thoracic esophagectomy with 3-field lymph-node dissection.

A case report of postoperative VRSA enteritis: Effective management of rifampicin for vancomycin resistant Staphylococcus aureus enteritis after esophagectomy and colon reconstruction.

INTRODUCTION: Vancomycin is one of the most widely used antibiotics for the treatment of serious infectious caused by methicillin-resistant Staphylococcus aureus (MRSA). However, reduced susceptibility of S. aureus to vancomycin has been observed in recent years. We report on a case of vancomycin resistant methicillin-resistant Staphylococcus aureus (VRSA) enteritis after colon reconstruction followed by esophagectomy and completion gastrectomy, with extended lymph node dissection for esophageal squamous cell carcinoma. PRESENTATION OF CASE: A 66-year old male was referred to our hospital for esophageal carcinoma of clinical stage T3 N0 M0, Stage IIA. From the postoperative day 3, the patient reported heavy watery stools on more then 10 occasions and high fever, and was diagnosed with the methicillin-resistant Staphylococcus aureus (MRSA) enteritis. We administered vancomycin to treat the enteritis, although a subsequent stool culture indicated VRSA instead of MRSA. Rifampincin treatment was initiated and the patient's symptoms improved. DISCUSSION: In this case report, this patient underwent esophagectomy, total resection of the gastric remnant, and colon reconstruction, and it is likely that methicillin-resistant Staphylococcus aureus (MRSA) from the upper airway system, which is not exposed to gastric acid, proliferated in the interposed colon and resulted in MRSA enteritis. CONCLUSIONS: Rifampicin represents an effective treatment strategy for postoperative VRSA enteritis.