Hideharu Yamanaka

Risk factors in relation to postoperative complications in patients undergoing esophagectomy or gastrectomy for cancer.

To clarify the risk factors contributing to postoperative complications in the elderly patients (over 70 years) undergoing esophagectomy and/or gastrectomy, 364 patients with primary cancer seen were evaluated. As a result, some characteristic patterns of stress response in the elderly could be detected as follows: the disorders of the vital organs were more important indices for the development of postoperative complications rather than age, and a reduction in the maximum response of the stress hormones to surgical procedures in aged patients was noted; moreover, the functional variability of target organ in the aged group was confirmed. Studies on the hormonal response to surgery suggest that the restriction of fluid replacement is advisable until the third postoperative day, maintaining the host on the dry side, to prevent cardiopulmonary complications. As the nutritional status in the patients with esophageal and gastric cancer goes from bad to worse with the advancing clinical stages, adequate perioperative nutrition is imperative to prevent complications such as anastomotic leakage, wound dehiscence, and/or infections. For the treatment of anastomotic leaks after esophagectomy and esophagogastrectomy, more than 45 kcal/kg/d must be provided, and the serum albumin level must be restored to 3.5 g/dL in order to achieve spontaneous healing of small anastomotic leakages.

Preoperative nutritional assessment to predict postoperative complication in gastric cancer patients

The correlation between preoperative nutritional parameters and postoperative complications in 440 patients with gastric cancer were analyzed. All the nutritional parameters reflected a significant deterioration as the stages of cancer progressed, and the frequency of postoperative complications was highest in patients with stage IV gastric cancer. The incidence of anastomotic leaks was increased in patients undergoing total gastrectomy with no relation to the clinical stage or nutritional status. However, there was a close relationship between nutritional status and immunocompetence, lung complications, and infection. The nutritional indices which reliably predicted preoperatively the nutritional status of cancer patients were the serum protein concentrations including the serum albumin (Alb) and prealbumin (PA). The indices predicting postoperative complications were the Alb, PA, and total lymphocyte count. These results suggest that preoperative nutritional assessment can be beneficial for the prediction of postoperative complications.

Surgical treatment for poor-risk patients with carcinoma of the esophagus

During the period between 1979 and 1988, 145 patients with cancer of the esophagus were admitted to our department. They were examined for the preoperative risk factors associated with multiple organ function and classified into three groups according to the risk score. Special attention was paid to postoperative pulmonary complications, mortality and the long term results of surgery in the poor-risk patients and the findings analyzed in reference to the operative procedures. The resection rate for the poor-risk group was 41 per cent, however, esophagectomy was only able to be combined with a right thoracotomy and abdominal approach in 26 per cent of the patients in this group. Postoperative pulmonary complications developed in 64 per cent of the poor-risk patients who underwent a transthoracic esophagectomy and in only 25 per cent of those who received a transhiatal esophagectomy, although there was no significant difference in the overall survival rate beteeen these two subgroups. The present observations therefore raised the possibility that transhiatal esophagectomy may improve the results of surgical treatment for poor-risk patients with esophageal cancer.

NEDAPLATIN AND 5-FU COMBINED WITH RADIATION IN THE TREATMENT FOR ESOPHAGEAL CANCER

A series of patients with esophageal cancer was treated with chemotherapeutic regimens of the new antitumor platinum preparation nedaplatin plus 5-FU in combination with radiation therapy, and the therapeutic responses, side effects, and complications were clinically assessed. There were 2 patients with a complete response and 11 patients with a partial response, hence, a response rate of 76.5%. Major adverse reactions were those of hematological toxicity and included leukopenia (13 patients, 76.5%), thrombocytopenia (8 patients, 47.1%), and lowered serum hemoglobin concentration (9 patients, 52.9%). The leukopenia and thrombocytopenia, though of a grade 3 severity in 3 and 2 patients, respectively, subsided spontaneously in all affected cases. Gastrointestinal adverse reactions were mild and included appetite loss in 7 patients (41.2%) and nausea in 2 patients (11.8%). The only abnormality in renal function observed was a slight elevation of serum creatinine in one patient. The combined therapy of chemotherapy with nedaplatin and 5-FU plus radiation produced a high response rate in the treatment of carcinoma of the esophagus and was associated with reduced gastrointestinal and renal toxicity. The results indicate the combined therapy with nedaplatin to be clinically useful.

Immunohistochemical Study of the Expression of HLA-DR Antigen and Lymphocyte Infiltration in Human Esophageal Carcinoma

The major histocompatibility complex (MHC) class II antigen HLA-DR is known to be present on many types of immunocompetent cells, involved in a variety of immune functions, and can be found in various kinds of cancer cells of the gastrointestinal tract. It is also reported that HLA-DR is associated with tumor invasion, tumor metastasis, and patient survival [1].