Kotaro Yamashita

Preoperative Glycosylated Hemoglobin Levels Predict Anastomotic Leak After Esophagectomy with Cervical Esophagogastric Anastomosis

BackgroundPatients with diabetes are considered at increased risk of delayed wound healing and infectious complications, yet the relationship between diabetes and anastomotic leak (AL) remains unclear. Given that glycosylated hemoglobin (HbA1c) is a validated indicator of the long-term glycemic state, we evaluated the relationship between preoperative HbA1c levels and AL after esophagectomy.MethodsWe assessed 300 consecutive patients who underwent esophagectomy reconstructed with cervical esophagogastric anastomosis between 2011 and 2015. HbA1c levels were measured within 90xa0days before esophagectomy. We performed comparison between the patients with and without diabetes. In addition, the predictive factors for AL, as well as the relationship between HbA1c levels and AL, were investigated.ResultsAmong the 300 patients, 35 had diabetes. The overall prevalence of AL was 11.7%, and patients with diabetes had a higher prevalence of AL than those without (pxa0=xa00.045). In univariate analysis, we identified diabetes, HbA1c level, and hand-sewn anastomosis as risk factors for AL significantly (pxa0=xa00.033, 0.009, and 0.011, respectively), but we also found previous smoking history, chronic hepatic disease, and supracarinal tumor location also showed tendencies to be risk factors (pxa0=xa00.057, 0.055, and 0.064, respectively). Multivariate logistic regression analysis indicated that chronic hepatic disease (pxa0=xa00.048), increased HbA1c level (pxa0=xa00.011), and hand-sewn anastomosis (pxa0=xa00.021) were independent risk factors for AL.ConclusionsPreoperative HbA1c level was significantly associated with the development of AL after cervical esophagogastric anastomosis. We recommend preoperative HbA1c screening for all patients scheduled to undergo esophagectomy.

Implication of visceral obesity in patients with esophageal squamous cell carcinoma

PurposeVisceral obesity is considered to be associated not only with chronic systemic inflammation but also with aggressive cancer behavior. However, the implication of visceral obesity in patients with esophageal squamous cell carcinoma (ESCC) is unclear.MethodsComputed tomography volumetry was performed in 364 patients who underwent esophagectomy for ESCC. We calculated the ratio of the visceral fat area to the subcutaneous fat area (VS ratio), which is a valuable parameter of visceral obesity. Then, the clinicopathological characteristics were compared between patients with low VS ratio and those with high VS ratio.ResultsOverall and disease-specific survivals of patients with high VS ratio were significantly worse than those with low VS ratio (Pu2009<u20090.001 in both). Patients with high VS ratio had considerably more advanced pN factor, higher prevalence of lymphatic invasion, and more number of metastatic lymph nodes than those with low VS ratio (Pu2009=u20090.044, <u20090.001, and 0.006, respectively). Among patients who received preoperative treatment, high VS ratio correlated with poor response to preoperative treatment (Pu2009=u20090.040).ConclusionsVisceral obesity was associated with lymphatic invasiveness and poor response to preoperative treatment in patients with ESCC, which may negatively influence their prognosis.

The impact of the Charlson comorbidity index on the prognosis of esophageal cancer patients who underwent esophagectomy with curative intent

PurposeThe aim of this study was to clarify the influence of Charlson comorbidity index (CCI) on treatment options, and on short- and mid-term outcomes in esophageal cancer patients who underwent esophagectomy.MethodsPatients who underwent curative-intent esophagectomy from 2009 to 2014 were classified by CCI. A CCI of ≥u20092 was defined as high, while a CCI of 0 or 1 was classified as low. Clinicopathological parameters, including overall survival (OS) and disease-specific survival (DSS), were compared between the groups.ResultsAmong 548 patients, the most frequent comorbidity was chronic obstructive pulmonary disease (nu2009=u2009142, 25.9%), followed by solid tumor (nu2009=u200979, 14.4%). A high CCI was significantly correlated with older age (Pu2009<u20090.001), surgery alone (Pu2009=u20090.020), a lower number of dissected lymph nodes (Pu2009<u20090.001), lower rate of R0 resection (Pu2009=u20090.048), and prolonged hospital stay (Pu2009<u20090.001). In the low group, OS after surgery was favorable in comparison to the the high group. Although DSS was comparable between the groups, the CCI was significantly associated with a poor prognosis in patients with stage ≥u2009II disease.ConclusionsThe CCI was significantly correlated with the prognosis of esophageal cancer patients who underwent curative-intent esophagectomy.

Prognostic impact of postoperative pulmonary complications following salvage esophagectomy after definitive chemoradiotherapy

Postoperative complications after esophagectomy for esophageal cancer have a negative effect on patients’ survival. Although postoperative complications are more frequently observed after salvage esophagectomy than after planned esophagectomy, the effects of postoperative complications on long‐term oncologic outcomes after salvage esophagectomy remain unclear.

Cervicothoracoscopic Approach in Esophagectomy

BackgroundsEsophageal cancer frequently metastasizes to lymph nodes along the recurrent laryngeal nerve (RLN).1 Therefore, it is essential to dissect RLN nodes for curative esophagectomy. Complete RLN node dissection without injury to the organs at the cervicothoracic junction requires experienced techniques. This report describes the cervicothoracoscopic approach, whereby the complete dissection can be safely performed.MethodsWith this approach, both cervical and laparoscopic procedures are performed in the open-leg supine position before the thoracoscopic procedure is performed in the prone position. For RLN node dissection, the paratracheal lymphatic chain is detached from RLNs at the cervicothoracic junction in the cervical operation field, and the detached tissue is retrieved together with the mediastinal RLN lymph nodes via thoracoscopy. This approach was applied to all squamous cell carcinoma patients and to patients with Siewert type 1 tumors of stage 2 or more, except for patients with clinically suspected T4 tumors.ResultsOf 91 patients, 27 (29.7%) experienced RLN palsy and 15 (16.5%) experienced postoperative pneumonia. Hoarseness due to RLN palsy was improved in almost all the patients within 6 postoperative months, and persistent paralysis was seldom observed. Within 30 days, neither a reoperation nor a hospital mortality occurred.ConclusionsThe cervicothoracoscopic approach enables complete en bloc dissection of the lymphatic chain that lies along RLN in the cervicothoracic junction. Also, with this approach, RLNs can be identified easily because RLNs are already exposed at the upper mediastinum by the cervical procedure. Therefore, this approach may contribute to improving the surgical curability and preventing RLN injury.

Glycemic Status and Prognosis of Patients with Squamous Cell Carcinoma of the Esophagus

BackgroundThe impact of glycemic status on esophageal squamous cell carcinoma (ESCC) prognosis is unclear.MethodsA total of 623 patients who underwent curative subtotal esophagectomy for ESCC were evaluated. Diabetes was defined as a prior diagnosis of diabetes under treatment or newly diagnosed diabetes based on preoperative glycosylated hemoglobin (HbA1c) levels. Poor glycemic control was defined as HbA1cxa0≥xa07.0%, whereas good glycemic control was defined as HbA1cxa0<xa07.0%. The impact of glycemic status on long-term survival after esophagectomy was evaluated.ResultsAmong the 623 patients, 64 (10.3%) had diabetes including 30 (4.8%) with poor glycemic control. Although diabetes did not influence patient survival, patients with poor glycemic control had worse overall and disease-specific survival compared with those with good glycemic control (Pxa0=xa00.011 and 0.039, respectively). Comparing poor glycemic control with good glycemic control, the hazard ratios (HRs) for overall and disease-specific mortality were 1.91 (1.15–3.18) and 1.89 (1.02–3.49) in univariate analysis. After multivariate adjustment, poor glycemic control also had increased risk of overall and disease-specific mortality [HR 1.72 (95% CI 1.02–2.88) and 1.65 (95% CI 0.89–3.08), respectively]. Poor glycemic control did not increase the risk of overall or disease-specific mortality in patients with stages 0–II disease but significantly increased this risk in those with stages III–IV disease [HR 2.05 (1.14–3.69) and 1.95 (1.01–3.80), respectively].ConclusionsPoor glycemic control is an independent risk factor for overall and disease-specific mortality after esophagectomy for advanced-stage ESCC.

Relationship Between Visceral Obesity and Postoperative Inflammatory Response Following Minimally Invasive Esophagectomy

BackgroundEsophagectomy for esophageal cancer is one of the most invasive surgeries. However, the factors influencing postoperative systemic inflammatory response following esophagectomy have not been elucidated. Recently, visceral fat has been shown to play an important role in both chronic and acute inflammation. In this study, we assessed the relationship between visceral obesity and postoperative inflammatory response following minimally invasive esophagectomy (MIE).MethodsVisceral fat area (VFA) was measured using computed tomography in 152 patients undergoing MIE for esophageal cancer. We assessed perioperative serum C-reactive protein (CRP) levels preoperatively and on postoperative days (PODs) 1–5 and analyzed the relationship between VFA and perioperative serum CRP levels.ResultsVFA was positively associated with preoperative serum CRP level (Pu2009<u20090.001). Univariate analysis revealed that VFA was significantly associated with increased serum CRP levels on PODs 1–5 (Pu2009<u20090.001 for each day), whereas multivariate analysis revealed that it was independently associated with increased serum CRP levels on PODs 1–4 (Pu2009=u20090.033, 0.035, 0.001, and 0.006, respectively). Similar results were observed in patients who did not have postoperative infectious complications, such as pneumonia, anastomotic leak, and surgical site infection. VFA was not an independent risk factor for the occurrence of these postoperative infectious complications.ConclusionsVisceral obesity might be associated with chronic inflammation in patients with esophageal cancer and promote postoperative inflammatory response following MIE.

Minimally invasive esophagectomy attenuates the postoperative inflammatory response and improves survival compared with open esophagectomy in patients with esophageal cancer: a propensity score matched analysis

BackgroundMinimally invasive esophagectomy (MIE) for patients with esophageal cancer has recently spread worldwide. However, whether MIE is less invasive has not yet been fully evaluated.MethodsWe retrospectively analyzed data from 551 patients who underwent curative esophagectomy for esophageal cancer from 2005 to 2014: 145 patients underwent minimally invasive esophagectomy (MIE) and 406 patients underwent open transthoracic esophagectomy (OE). We compared postoperative CRP levels with propensity score matching. In addition, long-term outcomes were also compared between the groups.ResultsOperative time was significantly longer, and intraoperative blood loss was significantly less in the MIE group compared with the OE group. Although the incidence of postoperative complications was similar between the 2 groups, postoperative serum CRP levels during the first 3 and 5xa0postoperative days and peak postoperative CRP levels were significantly lower after MIE versus OE (MIE vs. OE, median, 15.21 vs. 19.50xa0mg/dl; Pu2009<u20090.001). The MIE group had significantly more favorable disease-free survival (DFS) and overall survival (OS) rates than the OE group (3-year DFS rate, 81.7 vs. 69.3%, log-rank Pu2009=u20090.021; 3-year OS rate, 89.9 vs. 79.2%, log-rank Pu2009=u20090.007). MIE was an independent prognostic factor for patients with esophageal cancer. The incidence of regional lymph node recurrence was lower in the MIE group.ConclusionsMIE significantly attenuated postoperative serum CRP levels compared with OE. MIE could contribute to improved survival.

Recent progress in perioperative management of patients undergoing esophagectomy for esophageal cancer

Esophagectomy remains the mainstay of curative intent treatment for esophageal cancer. Oncologic esophagectomy is a highly invasive surgery and both morbidity and mortality rates still remain high. Recently, it has been revealed that multidisciplinary perioperative management can decrease the postoperative complications after esophagectomy. In this review, we summarized the recent progress in each component of multidisciplinary perioperative care bundle, including oral hygiene, cessation of smoking and alcohol, respiratory training, measurement of physical fitness, swallowing evaluation and rehabilitation, nutritional support, pain control and management of delirium. The accumulation of evidence and the popularization of knowledge will increase safety of esophagectomy and thus improve the outcome of patients with esophageal cancer.

Surgical team proficiency in minimally invasive esophagectomy is related to case volume and improves patient outcomes

BackgroundMinimally invasive esophagectomy (MIE) is being increasingly performed; however, it is still associated with high morbidity and mortality. The correlation between surgical team proficiency and patient load lacks clarity. This study evaluates surgical outcomes during the first 3-year period after establishment of a new surgical team.MethodsA new surgical team was established in September 2013 by two expert surgeons having experience of performing more than 100 MIEs. We assessed 237 consecutive patients who underwent MIE for esophageal cancer and evaluated the impact of surgical team proficiency on postoperative outcomes, as well as the team learning curve.ResultsIn the cumulative sum analysis, a point of downward inflection for operative time and blood loss was observed in case 175. After 175 cases, both operative time and blood loss significantly decreased (Pxa0<xa00.001 and Pxa0<xa00.001, respectively), and postoperative incidence of pneumonia significantly decreased from 18.9 to 6.5% (Pxa0=xa00.024). Median postoperative hospital stay also decreased from 20 to 18xa0days (Pxa0=xa00.022). Additionally, serum CRP levels on postoperative day 1 showed a significant, but weak inverse association with the number of cases (Pxa0=xa00.024).ConclusionsAfter 175 cases, both operative time and blood loss significantly decreased. In addition, the incidence of pneumonia decreased significantly. Additionally, surgical team proficiency may decrease serum CRP levels immediately after MIE. Surgical team proficiency based on team experience had beneficial effects on patients undergoing MIE.