Haruaki Murakami

Safe esophageal reconstruction by ileocolic interposition

Many techniques have been proposed for esophageal reconstruction after esophagectomy when a gastric tube cannot be employed. There are two essential criteria for such a substitute: substitute length and sufficient blood supply. We propose ileocolic interposition as an easy and safe option. Two technical aspects contributing to the high success rate of this method are the preservation of an intact arterial network allowing normal blood flow to the ileocolic area, and the ability to quantify blood flow using a Doppler pulse flow meter in six cases. These are enabled by a long (up to 20cm) ileocolic segment. The preservation of the right colic artery is important, because its interruption would reduce blood supply to the long ileum segment. Between July 2003 and October 2008, we used this method in six patients in whom a gastric tube was not an option. We assessed perioperative morbidity and swallowing difficulties in each patient, quantifying dysphagia on scale of 0 to 4. There was no mortality and no anastomotic leak. There was one wound infection, and in one patient, recurrent nerve paralysis was observed. The postoperative hospital stay was 29.5 ± 10.8 days. The average dysphagia score for the six patients was 0.17 ± 0.41 after the operation. All patients can eat normally, without any dietary limitations. Ileocolonic interposition after esophagectomy requires careful assessment of the vascular supply. In this small series, morbidity was low and there was no perioperative mortality. We believe that this is an easy and safe method of reconstruction after esophagectomy in cases in whom a gastric tube cannot be used as a substitute.

Prognosis Prediction for Postoperative Esophageal Cancer Patients Using Onodera's Prognostic Nutritional Index

ABSTRACT Purpose: Preoperative nutritional status may impact surgical outcome and prognosis. We evaluated the predictive value of Onoderas prognostic nutritional index (Os-PNI) of surgical outcome following esophagectomy in esophageal cancer patients. Patients and methods: In total, 144 patients undergoing esophagectomy for esophageal cancer from April 2010 to May 2015 were evaluated, retrospectively. Eighty-four patients were enrolled in this study. Os-PNIs were calculated before surgery, discharge, and 1, 2, and 6 mo after discharge. The relationship between Os-PNI and occurrence of complications as classified by the Clavien–Dindo (C–D) classification, length of hospital stay, and survival time was investigated. Results: The mean Os-PNI for patients with complications of more than Grade 2 by the C–D classification was 37.4, which was significantly lower than that for Grades 0 or 1 (40.5, P = 0.0094). A negative correlation was obtained between Os-PNI and hospital stay length (P = 0.0006), whereas a positive correlation was obtained for Os-PNI at 6 mo postsurgery and overall survival (P = 0.0171, P = 0.0201). Conclusion: Os-PNI may represent a useful indicator of the occurrence of complications and length of hospital stay, and may influence overall survival at 6 mo postsurgery. Nutritional management during the perioperative period could therefore contribute to satisfactory outcomes following esophagectomy in esophageal cancer patients.

A case of a gastrobronchial fistula after esophageal reconstruction successfully closed with an intercostal muscle flap

A 63-year-old man with esophageal cancer underwent a subtotal esophagectomy via the thoracolaparotomy approach. Two years after the operation, a gastrobronchial fistula unexpectedly occurred in the right bronchus. After admission, medication including omeprazole and nutritional support administered through an enteral tube improved his general condition, and the gastrobronchial fistula was successfully closed with the seventh intercostal muscle flap. After the operation, sputa were aspirated with a bronchofiberscope through a tracheal incision rather than blindly with a catheter. He was in good condition 10 months after the operation.

High-Resolution Manometry Reveals Normal Esophageal Motility, Including Lower Esophageal Sphincter Function, After Vagus Nerve-PreservingGastrectomy

Objective: We developed two new methods to preserve lower esophageal sphincter (LES) function and the vagus nerve in performing total gastrectomy (TG) and partial cardiectomy (PC) for patients with early-stage gastric cancer. We used two methods compared to standard TG and evaluated outcomes using high-resolution manometry (HRM) to analyze esophageal function. Methods: We used HRM to evaluate 38 patients who underwent gastrectomy between April 2012 and September 2015. Nine, 13, and 16 patients underwent standard TG (Group A), LES and vagus nerve-preserving (LES-VNP) TG (Group B), and LES-VNP-PC (Group C), respectively. The differences among the mean values of DCI, IRP, CFV, and LESP were evaluated using Student’s ttest. In addition, post-hoc sample analysis was performed. Results: LES function and normal peristalsis of the esophagus were observed in 9 of 13 patients in Group B. LES pressure (LESP) was observed in all but 1 patient, and 6 in Group C exhibited normal LESP. Normal peristalsis was observed in 11 patients, although weak or failed contraction was observed in 5 patients each, respectively. In contrast, 1 of the 9 patients in Group A exhibited normal LESP. Normal peristalsis of the esophagus was observed in 6 patients, although the distal contractile interval was less than the normal range. Furthermore, in 3 patients each, weak or no contraction of the esophagus was observed. The LESP in Group B and Group C was significantly higher compared with that in Group A (p= 0.0275, 0.007, respectively). There were no significant differences in the values of the other variables between groups. In post hoc analysis, there were no significant differences between Group A and Group B only in CFV (p=0.0345). Conclusion: Our new technique shows promise for preserving LES function as well as esophageal peristalsis.

A case of secondary achalasia caused by scar tissue formation after distal gastrectomy

A 64-year-old man underwent distal gastrectomy for gastric cancer. His postoperative recovery was uneventful until he suddenly started complaining of difficulty swallowing. Fluoroscopy revealed narrowing of the abdominal esophagus into a spindle-like shape. Endoscopic esophageal balloon dilatation was performed with no improvement in his condition. We concluded that the patient could not eat because of mechanical stenosis of the gastroesophageal junction. Reoperation was performed via laparotomy. The abdominal esophagus and gastroesophageal junction were found to have become stiff with adhesions, probably as a result of surgical scarring. We incised the esophageal muscle layer and dissected adhesions around the abdominal esophagus to relieve esophageal stenosis. After reoperation, the patient was able to eat. We recommend that in cases of sudden onset dysphagia after distal gastrectomy, the possibility of secondary achalasia because of scar tissue formation should be considered.

A case of spontaneous submucosal dissection of the esophagus

We report a case of spontaneous submucosal dissection of the esophagus of a 58-year-old patient. In September 2005, he complained of chest pain followed by vomiting. Endoscopy showed an ulcerative lesion in the entire circumference of the middle esophagus. No malignant cells were observed in biopsy specimen. The patient received therapy with hyperalimentation, a proton pump inhibitor, and Alloid G. The lesion healed under conservative treatment with a good clinical course and without the development of stenosis. One year later, we performed 24-h pH monitoring and esophageal manometry to clarify the pathogenesis of submucosal dissection in this patient. There was no gastroesophageal reflux, but the manometry test revealed decreased amplitude in the portion of the esophageal lesion that was considered to be caused by fibrosis resulting from inflammation. Two years later, the patient had no complaint of dysphagia. Further follow-up is needed for such a case.