Ayako Shimada

Clinical outcome of transthoracic esophagectomy with thoracic duct resection Number of dissected lymph node and distribution of lymph node metastasis around the thoracic duct

AbstractThe number of dissected lymph nodes (LNs), surgical outcomes, and postoperative recurrence-free survival (RFS) were compared between thoracic duct (TD)-preserved and TD-resected groups. The distribution of metastasis in LNs around TD (TDLN) was reviewed. Transthoracic esophagectomy (TTE) with TD resection for esophageal cancer patients has been one of the standard procedures. Because the adipose tissue surrounding the TD contains LNs, TD resection might be necessary for radical LN dissection. However, few studies have investigated the oncological outcome of TTE with TD resection. Two hundred fifty-six consecutive patients who underwent TTE between 2004 and 2015 were retrospectively reviewed and classified into TD-preserved or TD-resected groups. The number of dissected LNs for each LN station and surgical outcomes were compared. RFS was analyzed in 155 patients who underwent TTE before December 2012. Since 2013, the TDLN number was prospectively examined, independent of the regional LNs (n = 72). Of these, the TDLN number for each location (TDLN-Ut/Mt/Lt) was investigated and the correlation between TDLN metastasis and clinicopathological factors was analyzed. The TD was preserved in 89 patients and resected in 167 patients. Patients with TD resection showed significant advanced stage. There was no significant difference in the incidence of postoperative complications, including pneumonia, anastomotic leakage, and chylothorax. The number of dissected mediastinal LNs was significantly increased in the TD-resected group. The 5-year RFS rate of cStage I patients was 67.3% in the TD-preserved group against 90.3% in the TD-resected group, showing a tendency towards RFS extension that did not quite reach statistical significance (P = 0.055). The mean TDLN-Ut/Mt/Lt numbers were 0.89/0.56/0.44, respectively. Eight of 72 (11%) patients displayed TDLN metastasis. Metastatic TDLNs were observed on the same or cranial level of the primary lesion in 7 of 8 patients. Transthoracic esophagectomy with TD resection could increase the number of dissected mediastinal LNs without increase of postoperative complication. TDLN metastasis was observed in patients with advanced disease. A prospective trial, investigating the survival between TD-preserved and TD-resected groups, should be conducted to clarify if TD should be resected in TTE.

Risk factors for complications after pharyngolaryngectomy with total esophagectomy

BackgroundPharyngolaryngectomy with total esophagectomy (PLTE) is an effective surgical treatment for synchronous or metachronous hypopharyngeal or laryngeal cancer and thoracic esophageal cancer, although it is more invasive than esophagectomy and total pharyngolaryngectomy. The aim of this study was to identify risk factors for complications after PLTE.MethodsFrom November 2002 to December 2014, a total of 8 patients underwent PLTE at the Shizuoka Cancer Center Hospital, Shizuoka, Japan. We investigated the clinicopathological characteristics, surgical procedures, and postoperative complications of these patients.ResultsOf the 8 patients, 5 underwent one-stage PLTE and 3 underwent staged PLTE. There was no mortality in this study. Two cases of tracheal necrosis, two of anastomotic leakage, and one of ileus were observed as postoperative complications. Two patients who underwent one-stage PLTE with standard mediastinal lymph node dissection developed tracheal necrosis and severe anastomotic leakage.ConclusionOne-stage PLTE and standard mediastinal lymph node dissection were identified as the risk factors for severe postoperative complications. Staged PLTE or transhiatal esophagectomy should be considered when PLTE is performed and standard mediastinal lymph node dissection should be avoided when one-stage PLTE is performed with transthoracic esophagectomy.

Risk factors for lymph node metastasis in non-sentinel node basins in early gastric cancer: sentinel node concept

BackgroundSentinel node (SN) concept is being applied to early gastric cancer. However, when SNs are positive for metastasis, it is unclear how often LNs in other LN basins show metastasis. We aimed to investigate LN metastasis possibility in LN basins without SNs (non-SN basins). We determined risk factors for metastasis in non-SN basins and identified a prediction model for non-SN basin metastasis using classification and regression tree (CART) analysis.MethodsWe enrolled 550 patients who were diagnosed with cT1N0M0 or cT2N0M0 gastric cancer with a single lesion and underwent SN mapping. We adopted a dual-tracer method using a radioactive colloid and blue dye to detect SNs.ResultsOf all, 45 (8.2%) patients had SN metastasis; we divided them into two groups: LN metastasis positive and LN metastasis negative in non-SN basins. Univariate analysis showed that the groups differed significantly regarding lymphatic invasion (p = 0.007), number of identified SNs (p = 0.032), and macrometastasis in SN basins (p = 0.005). The CART decision tree for predicting LN metastasis in non-SN basins had area under the curve value of 0.86. Moreover, there were significantly differences in cancer-specific survival (CSS) between the two groups (p = 0.028).ConclusionsMacrometastasis in SN basins, lymphatic invasion, and number of identified SNs ≥ 5 are risk factors for LN metastasis in non-SN basins among gastric cancer patients. We identified a prediction model with CART analysis; patients with macrometastasis in SN basins and lymphatic invasion were considered to be at the highest risk for LN metastasis.

Reply to: Preventive role of ramelteon and suvorexant for postoperative delirium after pharyngolaryngectomy with esophagectomy

We would like to express our appreciation to Dr. Kawada for his attention and comments. We totally agree with his comments. We also had the same concern as he expressed in his letter. However, we thought the results might interest the readers and might be of some use to those who were engaged in the management of postoperative delirium. Therefore, in spite of the incompleteness in statistical treatment, we thought it worth to report the results of this small research. We also think the results should be validated by randomized control trial procedure. We reported the results of the multivariable logistic regression analysis based on only 9 events in 65 patients, because this study was conducted as an effort of our team therapy to prevent postoperative complications of esophagectomy and the objective was to understand the preventive effect of the combination of ramelteon and suvorexant to postoperative delirium using the available data. As pointed out by the letter, there is some incompleteness in the statistical treatment. Especially, based on the one in ten rule, we should have included more than 20 events in the analysis. We think that we should have displayed some statistical information such as confidence interval, sample size, event size and so on. We also should have included some statistical limitations in the article, so that the readers could interpret the results properly without confusion. Regarding individual data, retrospective single institute researches may have some kind of biases, but all patients’ charts were systematically assessed by two psychiatrists to minimize them. Regarding the recommendation to include minor tranquilizer as one of the variables, we did it as shown in Table 2. This retrospective study led to the conclusion that ramelteon with or without suvorexant was more effective than minor tranquilizer. We hope the above could be a good explanation to the comments in Dr. Kawada’s letter. This reply refers to the article available at https ://doi.org/10.1007/ s1038 8-018-0603-2.