Masaru Hayami

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 (P < 0.001 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 (P = 0.044, < 0.001, and 0.006, respectively). Among patients who received preoperative treatment, high VS ratio correlated with poor response to preoperative treatment (P = 0.040).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 ≥ 2 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 (n = 142, 25.9%), followed by solid tumor (n = 79, 14.4%). A high CCI was significantly correlated with older age (P < 0.001), surgery alone (P = 0.020), a lower number of dissected lymph nodes (P < 0.001), lower rate of R0 resection (P = 0.048), and prolonged hospital stay (P < 0.001). 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 ≥ II 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.

Morphological and functional reconstruction of the esophago-gastric junction with a double-flap technique after laparoscopic proximal gastrectomy

Background: Esophagogastrostomy is frequently used as a reconstructive method following proximal gastrectomy, and although a safe and straightforward procedure, it may sometimes be accompanied by gastric reflux. Consequently, a standard method for reconstruction after proximal gastrectomy has yet to be established. Methods: Esophagogastrostomy with a double-door valve was performed after laparoscopic proximal gastrectomy on 50 patients in the Department of Gastroenterological Surgery at the Cancer Institute Ariake Hospital, Tokyo, Japan, from January 2013 to December 2014. This new anastomotic procedure designed to reproduce the esophago-gastric junction (EGJ) consists of two parts: (I) a hand-sewing technique to render the anastomosis soft and flexible; and (II) a double-door valve to prevent the regurgitation of gastric content. Results: The average operation time and estimated blood loss during LAPG using the described double-door technique was 388.9±10.8 min and 89.4±15.3 mL, respectively. None of the patients required conversion to open surgery, and no anastomotic leakage occurred in this study. Only one patient (2%) developed postoperative reflux-esophagitis exceeding grade B by the Los Angeles Classification, while two patients (4%) who developed stenosis of the esophagogastric anastomosis needed endoscopic balloon dilatation of an anastomotic stricture, 3 and 8 months after surgery, respectively. Conclusions: The double-flap technique after laparoscopic proximal gastrectomy was safely and feasibly performed although long operation time. Future studies are now warranted to evaluate long-term quality of life following this procedure.

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 (P < 0.001). Univariate analysis revealed that VFA was significantly associated with increased serum CRP levels on PODs 1–5 (P < 0.001 for each day), whereas multivariate analysis revealed that it was independently associated with increased serum CRP levels on PODs 1–4 (P = 0.033, 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.

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.

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.