Masaharu Higashida

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.

Esophageal epiphrenic diverticulum associated with diffuse esophageal spasm

Highlights • We performed diverticulectomy without myotomy for normal esophageal motility in HRM.• HRM revealed diffuse esophageal spasm of the patient, who complained of dysphagia.• The motility disorder was likely not identified at the first evaluation.• The symptoms resolved without treatment; however, longer-term follow-up is needed.

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.

Laparoscopic treatment of median arcuate ligament syndrome in a 16-year-old male

Highlights • Median Arcuate ligament(MAL) syndrome is rare disease.• MAL causes compression and stenosis of the celiac artery and lead symptoms.• 3-D CT angiography and doppler echogram is helpful for diagnosis.• Laparoscopic approach is effective and less invasive for patients.• Intraoperative doppler echogram is useful for confirmation of normal celiac arterial blood flow.

East Versus West: Differences in Surgical Management in Asia Compared with Europe and North America

In recent decades, there has been considerable worldwide progress in the treatment of gastric cancer. Gastrectomy with a modified D2 lymphadenectomy (sparing the distal pancreas and spleen) has increasingly gained acceptance as a preferable standard surgical approach among surgeons in the East and the West. Despite growing consensus significant differences still exist in surgical techniques in clinical trials and clinical practices secondary to variations in epidemiology, clinicopathologic features, and surgical outcomes among geographic regions. In addition, Western physicians tend to prefer adjuvant chemotherapy and radiotherapy after surgery instead of using S-1 chemotherapy, as is the preference in the East.

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.

Synergistic Effect of Eicosapentaenoic Acid on Antiproliferative Action of Anticancer Drugs in a Cancer Cell Line Model

Background/Aims: It has been found experimentally and clinically that eicosapentaenoic acid (EPA) exerts an anticancer effect and that it has a minimal adverse event profile relative to other anticancer drugs. Any synergy between EPA and other anticancer drugs could be of therapeutic relevance, especially in elderly or high-risk patients. Therefore, we investigated the synergism between anticancer drugs and EPA experimentally. Methods: EPA was coadministered in vitro with various anticancer drugs (paclitaxel, docetaxel, 5-fluorouracil and cis-diamminedichloridoplatinum[II]) to TE-1 cells, which were derived from human esophageal cancer tumors. Cell proliferation was measured by the water soluble tetrazolium-1 method. Result: Sub-threshold concentrations of EPA, which alone produced no anticancer effect, caused a synergistic suppressive effect on TE-1 cell proliferation when combined with other anticancer agents. Conclusion: Coadministration of EPA with other anticancer drugs may represent a new therapeutic paradigm offering a reduced side effect profile.

Repeated Combined Chemotherapy with Cisplatin Lowers Carnitine Levels in Gastric Cancer Patients

Background/Aims: Carnitine plays an important role in the metabolism of fatty acids. It has also been reported that the administration of anticancer drugs may lead to reductions in serum carnitine levels due to decreased activity of organic cation transporter novel 2, which plays a role in the reabsorption of carnitine in the tubules of the kidney. We therefore studied the change in carnitine levels when chemotherapy was administered repeatedly to patients with gastric cancer. Methods: Ten patients with upper gastrointestinal cancer were enrolled in this study between December 2014 and August 2015. All patients were administered chemotherapy consisting of TS-1 and cisplatin every 3 weeks: 3 received it as adjuvant therapy post resection, the remaining 7 received it as treatment for unresectable tumors. Before the start of each chemotherapy cycle, serum was collected. Results: The mean total carnitine level was 54.5 ± 13.7 μmol/L prior to commencing chemotherapy; it was 46.7 ± 13.5 and 41.4 ± 14.8 μmol/L at the second and third cycles respectively. The total carnitine level was decreased in a statistically significant manner (p = 0.0039). The serum level of total protein and cholinesterase was also decreased significantly (p = 0.0218 and p = 0.0418). Conclusion: Carnitine levels decreased during repeated chemotherapy in patients with gastric cancer, and they are associated with the nutritional status.

Gastroenterological Surgery: Pancreas

■ Explanation No study has compared the outcomes of LDP with that of open distal pancreatectomy (ODP) for the treatment of benign or low-grade lesions. With regard to the treatment of malignant disease, a meta-analysis shows no significant difference in the percentage of positive margin along the resection line between LDP and ODP (1). Another study of patients with benign to low-grade lesions as well as malignant disease also shows no significant difference between LDP and ODP with respect to positive margin, although the evidence level is low (2). Regarding intraoperative measures, two meta-analyses show LDP results in significantly less blood loss than ODP, with no significant difference in surgical time (1,3). These meta-analyses also show that LDP has a significantly lower incidence of all complications and a significantly shorter length of hospitalization than ODP (1,3). These intraoperative and postoperative findings suggest LDP may reduce total operative expense compared to ODP; this is corroborated by a low evidencelevel study suggesting the cost-saving potential of LDP over ODP (4). The same meta-analyses also show no significant difference in the reoperation or operational death rate between LDP and ODP (1,3). 1-2 Is postoperative recovery earlier after laparoscopic surgery than after laparotomy? Laparoscopic surgery is likely to lead to earlier resolution of wound pain, but there is no robust evidence supporting the lower invasiveness of laparoscopic pancreatectomy compared to open pancreatectomy.