Naomi Morita

Cervical approach by lifting the superior sternum for mediastinal parathyroid adenoma.

We report our experience with sternum lifting method in 5 patients with a retrosternal large parathyroid gland around an innominate vein. There were 2 men and 3 women aged 35 to 81 years. All patients showed a retrosternal large parathyroid gland around an innominate vein. Under general anesthesia, the patient is placed in a supine position with the neck extended. About 3 to 4 cm cervical incision is made above the sternal notch. Two hooks are placed at both sternoclavicular junctions. After the sternum is retracted upward, the anterior mediastinum can now be well visualized with the surgeon at the head of the table. When the direct vision is not clear, using the video imaging provides the physician with a clear, magnified view of the area under deep sternum. All patients underwent complete cervical excision using our method without any complications. The average operative time was 61 minutes and blood loss was minimal. Excellent postoperative outcomes were observed. The patients had no pain or other complications. All patients were discharged 4 days after the surgery. We believe that cervical excision using our method is a better alternative in those patients with anterior mediastinal parathyroid glands around an innominate vein.

Replacement of a feeding tube through the gastric tube in patients after esophagectomy with retrosternal reconstruction.

Introduction We present our technique of endoscopic replacement of the jejunostomy through the stomach conduit in patients after esophagectomy with retrosternal reconstruction. Methods After an upper gastrointestinal tract endoscopy was performed, the stomach conduit was sufficiently inflated with air and the site of the previously removed gastric tube was confirmed by the puncture using 23 G needle. After an approximately 6-mm incision was made under local anesthesia, a 4-mm peel-off introducer sheath was advanced into the stomach conduit under endoscopic control. A 3-mm jejunostomy tube was inserted through the sheath and placed into the jejunum using the endoscopic guidance. Using endoscopy, the jejunostomy tube was confirmed to be placed without bending. Results Between 1998 and 2006, subtotal esophagectomy with retrosternal cervical esophagogastrostomy was performed in 48 patients. All patients were inserted with at least either jejunostomy tube or decompression tube through the stomach conduit. Among them, 11 patients (23%) were performed percutaneous replacement jejunostomy through the stomach conduit. There were 9 men and 2 women whose mean age was 67 years (range: 59 to 76 y). Replacement of the jejunostomy tube was successful in all patients. The procedure required about 30 minutes. There were no deaths and no procedural complications. After 24 hours, the tube was used for enteral feeding. No late complication occurred in our cases. Conclusions We believe that the endoscopic percutaneous approach described in this report is safe and effective in patients after esophagectomy with retrosternal reconstruction.

Esophageal skip metastasis from an adenocarcinoma of the gastric cardia

Although diffuse‐type gastric carcinomas sometimes spread within the esophageal mucosa, a distant skip metastasis from a gastric carcinoma to the esophagus wall has rarely been reported. We herein report the case of a patient found to have a carcinoma of the gastric cardia with a skip metastasis to the esophagus, approximately 10 cm distant from the esophagogastric junction. A 53‐year‐old man was admitted to our department suffering from a sudden hematemesis. An upper gastrointestinal endoscopic study revealed an infiltrative ulcerating tumor of the gastric cardia and a small, reddish, elevated submucosal tumor on the middle third of the esophagus, apart from the tumor on the cardia. A histological study of the biopsy specimens from both tumors showed poorly differentiated adenocarcinomas. The patient underwent total thoracic esophagectomy and proximal gastrectomy combined with a splenectomy through a cervicoabdominal approach. The resected specimen contained a tumor of the cardia, 7.4 × 5.1 cm in area, that had infiltrated the submucosal layers of the lower esophagus up to 2.0 cm from the esophagogastric junction. The skip metastases were located 0.5, 4 and 7.2 cm from the oral side of the main tumor.