Manabu Okuyama

Hand-Sewn Cervical Anastomosis Versus Stapled Intrathoracic Anastomosis After Esophagectomy for Middle or Lower Thoracic Esophageal Cancer: A Prospective Randomized Controlled Study

PurposeThe type of anastomosis and its outcome can affect postoperative morbidity, mortality, and quality of life after esophagectomy. We compared the outcomes of cervical hand-sewn anastomosis (CHS) and intrathoracic stapled anastomosis (ITS) performed after esophagectomy and gastric reconstruction.MethodsThirty-two patients with middle or lower thoracic esophageal cancer were prospectively randomized to undergo CHS (n = 18) or ITS (n = 14) after esophagectomy. We compared clinical data, postoperative symptoms, and long-term survival in the two groups.ResultsThe rates of anastomotic leak and stricture in the CHS and ITS groups were 16.7% versus 7.1% and 0% versus 14.2%, respectively, which do not represent significant differences. The respective rates of recurrent laryngeal nerve palsy were 38.8% versus 7.1% (P < 0.05), and proximal esophageal resection was 15 mm longer (P < 0.05) in the CHS group. There were no significant differences in symptoms 6 months after surgery, or in the overall 5-year survival rates (72.2% and 85.7%, respectively).ConclusionsThe two methods of anastomosis yielded similar anastomotic outcomes. Although the incidence of recurrent laryngeal nerve injury was higher after CHS, and proximal esophageal resection was longer, this had little impact on postoperative symptoms and long-term survival.

Outcome and Treatment Strategy for Mid- and Lower-Thoracic Esophageal Cancer Recurring Locally in the Lymph Nodes of the Neck

The aim of the present study was to assess the outcome of treatment for patients with recurrent mid- and lower-thoracic esophageal cancers in whom recurrence was localized to the lymph nodes of the neck, and to determine the best strategy for further treatment. Between 1989 and 2001, 270 patients with mid- and lower-thoracic esophageal cancer underwent curative esophagectomy; 90 of those patients had a cancer recurrence. Our focus was on lymph node recurrence, especially when the recurrent cancers were localized to the lymph nodes in the neck. The outcomes of those patients and the efficacy of the strategies used to treat the recurrent cancers were determined. In 43 patients (48%), recurrent cancer initially appeared in the lymph nodes. Among the 43 patients, 15 (35%) had localized neck recurrence. The time between tumor recurrence and death among the 15 patients with localized neck recurrence was significantly longer than among the 28 patients with other recurrence patterns. In addition, 15 patients underwent lymph node resection, while 28 patients were treated non-surgically. The time between tumor recurrence and death was significantly longer in patients treated surgically. Of the 15 patients in whom recurrence affected the neck lymph nodes only, 10 (67%) were treated surgically; their 2-year survival rate after recurrence was 45%. The outcomes of recurrent esophageal cancers localized to the lymph nodes of the neck were better than those seen with other recurrence patterns, and salvage resection followed by chemoradiation therapy would seem to be indicated for those patients.

Proton Pump Inhibitors Relieve and Prevent Symptoms Related to Gastric Acidity after Esophagectomy

BackgroundDenervated stomach used as an esophageal substitute after esophagectomy often retains or spontaneously recovers acid production. The aims of the present study were to assess the relationship between esophageal acid exposure or gastric acidity and reflux-related symptoms after esophagectomy, and to assess the ability of proton pump inhibitors (PPIs) to relieve gastroesophageal reflux-related symptoms.MethodsForty-four patients underwent esophageal and gastric 24-h pH monitoring early after esophagectomy with gastric reconstruction. Initially, patients with both gastric acidity and reflux symptoms were treated with PPIs (Treatment group), then all patients with gastric acidity, whether symptomatic or not, were treated (Prevention group). Reflux-related symptoms were correlated with esophageal acid exposure and postoperative gastric acidity. Gastric acidity was then correlated with serum anti-Helicobacter pylori immunoglobulin G (IgG) titers and preoperative endoscopic findingsResultsSixteen patients (36.4%) reporting reflux and showing gastric acid production were treated with PPIs, which provided relief to 13 (81.3%). Although symptoms did not correlate with the esophageal acid exposure, postoperative gastric acidity was significantly greater among patients who were symptomatic than among those who were not. Overall, acid production was lower in older patients (> 64 years of age), although older patients who were H. pylori-negative and without chronic atrophic gastritis also showed high levels of gastric acidity.ConclusionsProton pump inhibitors should be administered prophylactically early after esophagectomy to relieve and prevent reflux-related symptoms. Candidates for preventive therapy include those less than 64 years of age or older patients who are H. pylori-negative and without chronic atrophic gastritis.

Survival Advantage of Using Autologous Blood Transfusion During Surgery for Esophageal Cancer

Abstract.Purpose: There is evidence that blood transfusion is associated with an increased rate of tumor recurrence. This study was conducted to assess the survival advantage of giving autologous blood instead of allogeneic blood during surgery for esophageal cancer. Methods: We retrospectively analyzed 62 patients who underwent esophagectomy for thoracic esophageal cancer between January 1991 and February 1995 and received allogeneic blood transfusion, and 61 patients operated on between March 1995 and February 1998, who received autologous blood transfusion. The clinicopathological factors and survival rates were compared between the two groups. Results: The clinicopathological factors that influenced prognosis were similar in the two groups; however, a definite survival advantage was evident in the autologous blood transfusion group. According to multivariate analyses, the transfusion of allogeneic blood was an independent prognostic factor (P = 0.0222), as was the presence of metastatic lymph nodes. Patients who received allogeneic blood transfusions perioperatively had more than a twofold greater risk (Hazard ration 2.406) of death over patients who received autologous blood transfusions. Conclusion: Autologous blood transfusion appears to be an independent prognostic factor for the survival of patients with esophageal cancer.

Histological confirmation of healing of gastrobronchial fistula using a muscle flap

We report a case of gastrobronchial fistula that developed after esophagectomy for esophageal cancer. The fistula was repaired successfully by transposing a pectoralis major muscle flap. Complete healing was confirmed histologically by epithelialization of the fistula site and at autopsy 12 months after surgery. Muscle flap transposition effectively repairs gastrobronchial fistula.

Laparoscopic Long Esophagomyotomy with Dor's Fundoplication Using a Transhiatal Approach for an Epiphrenic Esophageal Diverticulum

The conventional treatment for an epiphrenic diverticulum consists of diverticulectomy with or without myotomy via a left thoracic approach. We describe the resection of an epiphrenic esophageal diverticulum using a laparoscopic transhiatal approach after observing its rate of enlargement on routine chest X-rays done over a number of years. This approach eliminates the need for thoracotomy and pleural drainage, and permits a complete laparoscopic procedure, including diverticulectomy, myotomy, and antireflex surgery.

Methylprednisolone-induced Expression Of Mitochondrial Heat Shock Protein 60 Protects Mitochondrial Membrane Potential In The Hypoxic Rat Liver

This study investigated the contribution made by mitochondrial heat shock protein (hsp) 60 to methylprednisolone-mediated protection against mitochondrial membrane depolarization under hypoxic conditions. A low-flow hypoxia model was generated in isolated male, fasted, pathogen-free Sprague-Dawley rat livers by reducing perfusate inflow pressure from 10 to 2.5 cm H2O for 2 h. The effects of methylprednisolone on mitochondrial membrane potential and expression of mitochondrial hsp 60 protein and mRNA were determined. We measured mitochondrial membrane potential by imaging rhodamine 123 fluorescence. Induction of mitochondrial hsp 60 was detected using two different anti-hsp 60 antibodies: one against the N-terminal signal sequence, which reacted exclusively with cytoplasmic hsp 60, and one against a different epitope, which reacted with cytoplasmic and mitochondrial hsp 60. In addition, the distribution of hsp 60 mRNA was examined using in situ hybridization. We found that under hypoxic conditions, there was a significant decline in mitochondrial membrane potential that was accompanied by a mild decline in the level of mitochondrial hsp 60, and that cytosolic hsp 60 was translocated into mitochondria. Pretreatment with methylprednisolone inhibited the declines in mitochondrial membrane potential and hsp 60 protein, as well as the translocation of cytosolic hsp 60. This raises the possibility that one way in which methylprednisolone protects the mitochondrial membrane potential under hypoxic conditions is to induce expression of mitochondrial hsp 60.

Hydrogen peroxide-dependent declines in Bcl-2 induces apoptosis in hypoxic liver.

BACKGROUND Low-flow hypoxia induces xanthine oxidase-dependent hydrogen peroxide production by hepatocytes in the midzone of blood-perfused rat livers and apoptosis in sinusoidal endothelial cells (SECs). As Bcl-2 is a potent inhibitor of apoptotic cell death and is localized mainly in the inner mitochondrial membrane and crista, the purpose of this study was to determine whether cell-specific changes in mitochondrial Bcl-2 levels could account for the hypoxia-induced apoptosis in SECs. MATERIALS AND METHODS A low-flow hypoxia model was generated in isolated rat livers by reducing perfusate inflow pressure from 10 to 2.5 cmH2O for 2 h. Apoptosis was then evaluated using the TdT-mediated dUTP-digoxigenin nick end-labeling (TUNEL) method. Mitochondrial Bcl-2 protein levels were determined in hepatocytes and SECs using cryosectioning immunogold labeling electron microscopy.Results. TUNEL-positive nonparenchymal cells, identified as SECs, were observed predominantly in the midzone of low-flow hypoxic rat livers, whereas few parenchymal cells were stained. Mitochondrial Bcl-2 levels were higher in SECs than in hepatocytes under control conditions, but they declined significantly during hypoxia, though no morphological signs of apoptosis were apparent. In hepatocytes, by contrast, Bcl-2 levels were unaffected by hypoxia. Pretreatment with a specific xanthine oxidase inhibitor, sodium (-)-8-(3-methoxy-4-phenylsulfinylphenyl) pyrazolo [1,5-a]-1,3,5-triazine-4-olate monohydrate, which blocks production of hydrogen peroxide, also blocked both the hypoxia-induced apoptosis and the decline in mitochondrial Bcl-2 in SECs. CONCLUSION Hydrogen peroxide-dependent declines in Bcl-2 induce apoptosis in SECs in the hypoxic rat liver.

Does Central Venous Pressure Reflect the Circulating Blood Volume for the Decrement of Compliance Just After Esophagectomy

Abstract: This study investigates whether the pressure parameters obtained from the Swan-Ganz catheter (SGC) accurately reflect the circulating blood volume just after en bloc resection of the thoracic esophagus with regional lymph node dissection. It is well known that this operation induces severe hemodynamic changes and although the pressure parameters obtained from the SGC are an accepted means of monitoring circulating blood volume, we have often experienced a discrepancy between the SGC data and the clinical state. We examined the pressure parameters and diameter of the inferior vena cava (IVC) and left ventricle (LV), and the central venous compliance using SGC and echocardiography in ten patients who underwent esophagectomy for esophageal cancer. The central venous pressure, pulmonary arterial mean pressure, and pulmonary artery wedged pressure were significantly increased just after the operation compared with the preoperative levels, while the diameters of the IVC and LV decreased just after the operation. The compliances of the IVC decreased significantly just after the operation. The hemodynamic shift to the third space after esophagectomy induces decrement of the compliances of IVC. As the CVP does not always reflect the circulating blood volume, measuring the diameter of the IVC using echocardiography is extremely useful for monitoring circulating blood volume just after esophagectomy.

Cervical Approach for Resection of a Pedunculated Giant Atypical Lipomatous Tumor of the Esophagus

We describe how we removed a giant pedunculated atypical lipomatous tumor, arising in the cervical to upper thoracic esophagus and occupying a region extending from the cervical to the middle thoracic esophagus, through a cervical esophagotomy without thoracotomy or laparotomy. We suggest that if the base of the tumor is located in the cervical portion of the esophagus, and if the tumor is not aggressive, the cervical approach is best, irrespective of the size of the tumor.