Masami Yuda

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.

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.

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.

Supraclavicular and celiac metastases in squamous cell carcinoma of the middle thoracic esophagus

PurposeSquamous cell carcinoma of the middle thoracic esophagus (SCC-ME) often metastasizes to the neck, mediastinum, and abdomen. This study aims to assess the prognostic impact of supraclavicular (SC) and celiac (CE) lymph node (LN) metastases in patients with SCC-ME.MethodsWe examined 210 patients who underwent curative esophagectomy with three-field LN dissection for SCC-ME. The clinicopathological features and survival outcomes of patients with and without SC and/or CE metastases were compared to assess the prognostic significance of SC and/or CE metastases.ResultsWe observed metastases to SC and CE in 25 (11.9%) and 20 (9.5%) patients, respectively. Seven patients (3.3%) had both SC and CE metastases. Although the survival of patients with SC and/or CE metastases was worse compared with those without, that of patients with SC metastases but without CE metastases was comparable with that of patients with CE metastases but without SC metastases; the 5xa0year overall survival rates were 35.6% and 46.2%, respectively. However, survival of patients with both SC and CE metastases was the worst among all groups, and all patients with both SC and CE metastases experienced disease recurrence.ConclusionsThe prognosis of patients with both SC and CE metastases was extremely poor. In contrast, patients with metastasis to either one of these sites could be candidates for surgery as the main modality in a multidisciplinary strategy.

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.

Oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment for squamous cell carcinoma of the oesophagus: Oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment

Treatment of supraclavicular nodes remains controversial among patients with oesophageal squamous cell carcinoma. This study assessed the outcomes of patients who underwent oesophagectomy with or without supraclavicular lymphadenectomy after neoadjuvant treatment.

Cervicothoracoscopic Approach for Esophageal Cancer in a Patient with Right-Sided Aortic Arch

BackgroundEsophageal cancer frequently metastasizes to lymph nodes along the recurrent laryngeal nerve (RLN),1 therefore it is essential to dissect RLN nodes for curative esophagectomy.2 Right-sided aortic arch (RAA), a rare congenital anomaly, occurs in approximately 0.1% of adults.3 Because RAA forms a vascular ring encircling both the esophagus and the trachea at the cervicothoracic junction, its surgical anatomy is difficult to understand; hence, thoracoscopic dissection of RLN nodes is technically challenging. In this video, we applied the cervicothoracoscopic approach in a patient with esophageal squamous cell carcinoma and RAA, wherein the cervical operation was performed prior to the thoracoscopic operation.4MethodsA 60-year-old woman was diagnosed with stage IA esophageal squamous cell carcinoma. During preoperative evaluation, we found that she had RAA with an aberrant left subclavian artery, and therefore decided to perform esophagectomy using the cervicothoracoscopic approach. In the cervical operation, we identified the RLN and dissected the lymph node in the cervicothoracic junction. The thoracoscopic operation was then performed from the left side with the patient in the prone position.ResultsThe operation was successful. Total operative time was 548xa0min, with an estimated blood loss of 220xa0ml. There were no intraoperative and postoperative complications, and RLN palsy did not occur.ConclusionsThe vascular ring at the cervicothoracic junction in a patient with RAA made it difficult to dissect the RLN lymph nodes during oncologic esophagectomy. The cervicothoracoscopic approach enables the complete dissection of these lymph nodes and is a useful esophagectomy technique for patients with RAA.