Shinji Mine

Large-Scale Investigation into Dumping Syndrome after Gastrectomy for Gastric Cancer

BACKGROUNDnThe aim of this study was to investigate early and late dumping syndromes in a large number of patients after gastrectomy for gastric cancer.nnnSTUDY DESIGNnResponses to questions on a visual analogue scale survey completed by 1,153 gastrectomy patients were analyzed for associations between clinical factors and occurrence of dumping syndrome. Types of gastrectomy included distal gastrectomy with Billroth I or with Roux-Y reconstruction, pylorus preserving gastrectomy, proximal gastrectomy, and total gastrectomy.nnnRESULTSnBased on the visual analogue scale rating of symptomatic discomfort, patients were categorized into 1 of 2 groups: symptom-free or symptomatic. Incidences of early or late dumping syndrome in all patients were 67.6% and 38.4%, respectively. Patients in whom early dumping syndrome developed were significantly more likely to experience late dumping syndrome than those in whom it did not develop (p < 0.001). According to multivariate analyses, factors that decreased the risk for developing early dumping syndrome were reduced weight loss (p < 0.01), old age (p < 0.01), pylorus preserving gastrectomy (p < 0.01), distal gastrectomy with Roux-Y reconstruction (p < 0.01), and distal gastrectomy with Billroth I (p = 0.019). In addition, factors that decreased the risk of developing late dumping syndrome were reduced weight loss (p = 0.03), being male (p < 0.01), pylorus preserving gastrectomy (p < 0.01), and distal gastrectomy with Roux-Y reconstruction (p < 0.01). No other clinical factors (lymph node dissection, vagal nerve preservation, and postoperative period) showed a substantial association with the occurrence of dumping syndrome in multivariate analyses.nnnCONCLUSIONSnSubstantially more patients suffered from early dumping syndrome than late dumping syndrome after gastrectomy. Two clinical factors, surgical procedures and amount of body weight loss, associated significantly with the occurrence of both early and late dumping syndrome.

Colon Interposition After Esophagectomy With Extended Lymphadenectomy for Esophageal Cancer

BACKGROUNDnThe purpose of this retrospective study was to investigate the feasibility of colon interposition procedures after esophagectomy with extended lymphadenectomy.nnnMETHODSnBetween 1990 and 2008, 95 consecutive patients underwent colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer in our Institution. We reviewed clinical data and long-term survival, and also investigated the association between anastomotic leakage and clinicopathologic findings.nnnRESULTSnWe applied three-field lymphadenectomy to 71 patients and two-field to 24 patients, by a right thoracotomy. Ninety-two patients underwent reconstruction by a retrosternal route, and a posterior mediastinal route was applied to only three patients. We performed hand-sewn anastomosis in the neck in all cases. Three patients required microvascular surgery. Sixty-one patients (64%) experienced postoperative morbidity, most commonly pulmonary complications. Anastomotic leakage occurred in 12 patients (13%). No colon conduit necrosis was detected. Overall mortality, including hospital mortality, was 5.3%. Dysphagia (39%) and diarrhea (38%) were common and stricture was low (6%) after discharge. The overall 5-year survival rate was 43%. During the latter period (1998 to 2008), when ileocolon grafts evolved as the primary choice for interposition, the rate of leakage decreased from 17% (1990 to 1997) to 5.4%. No mortality was recorded during the latter period.nnnCONCLUSIONSnResults from this study demonstrate that colon interposition after esophagectomy with extended lymphadenectomy is feasible and can have a favorable outcome.

Post-esophagectomy chylous leakage from a duplicated left-sided thoracic duct ligated successfully with left-sided video-assisted thoracoscopic surgery

Three months after esophagectomy for esophageal cancer, a 58-year-old man presented with fluid trapped in his upper mediastinum due to chylous leakage from a duplicated left-sided thoracic duct that remained after excision of the main thoracic duct. Classical lymphangiography using lipiodol confirmed the presence of duplicated thoracic ducts. Conservative treatments were not effective, and then we performed ligation of the left-sided thoracic duct with left-sided video-assisted thoracoscopic surgery. Anatomic variations of the thoracic duct can result in chylous leakage after thoracic surgery. Even if the patient has anomaly of the thoracic duct, classical lymphangiography is useful for detecting locations of the thoracic duct precisely, allowing for certain ligation of the duct with video-assisted thoracoscopic surgery.

A Novel Technique of Anti-reflux Esophagogastrostomy Following Left Thoracoabdominal Esophagectomy for Carcinoma of the Esophagogastric Junction

We developed an anti-reflux technique of intrathoracic esophagogastrostomy, based on the “Kamikawa procedure” or “Double flap technique”, which is sometimes used in Japan after open proximal gastrectomy for early upper gastric cancer. We applied this technique to four patients with tumors of the esophagogastric junction. All four patients underwent lower esophagectomy and proximal gastrectomy via a left thoraco-abdominal approach. This procedure includes four steps. Firstly, “double door” seromuscular flaps were created at the anterior wall of the gastric tube. Secondly, the inferior end of the mucosal “window” was opened. Thirdly, suturing was performed between the esophagus and the gastric mucosal “window”. Finally, the anastomosis was covered by the seromuscular flaps. No patient experienced post-operative morbidity, or suffered from reflux, even in the Trendelenburg position, dysphagia, or belching. Although this procedure has only been applied to a limited number of patients, we consider that this anastomosis surgical technique is a promising approach to the prevention of reflux after esophagogastrostomy.

Thoracic lymph node involvement in adenocarcinoma of the esophagogastric junction and lower esophageal squamous cell carcinoma relative to the location of the proximal end of the tumor.

BackgroundIt is difficult to determine preoperatively whether upper/middle thoracic lymphadenectomy is necessary in patients with adenocarcinoma of the esophagogastric junction (AEG) or lower esophageal squamous cell carcinoma (ESCC). Here, we investigated whether stratification based on the location of the proximal end of the tumor, as assessed using preoperative computed tomography (CT) images, would be useful for predicting upper/middle thoracic lymph node involvement for AEG and lower ESCC.MethodsA total of 142 patients with AEG and lower ESCC treated by R0–1 surgical resection via a thoracotomy was retrospectively investigated. The location of the proximal end of the tumor in comparison with the vena cava foramen (VCF) was decided by inspecting preoperative CT images and then correlated with upper/middle thoracic lymph node involvement.ResultsThe incidence of upper/middle thoracic lymph node involvement was low in AEG and ESCC tumors having proximal ends below the VCF (0xa0%, 0 of 13, and 5.9xa0%, 1 of 17, for AEG and ESCC, respectively). In contrast, when the tumors’ proximal ends were above the VCF, patients had higher frequencies of upper/middle thoracic lymph node involvement (36.4xa0%, 8 of 22, and 37.8xa0%, 34 of 90, for AEG and ESCC, respectively). Multivariate analysis showed that the location of the proximal end of the tumor is an independent risk factor related to upper/middle thoracic lymph node involvement (odds ratio 14.3, 95xa0% confidence interval 1.76–111, pxa0=xa00.013), whereas other clinical factors (cT, cN, tumor length, and histologic types) are not.ConclusionsThis manner of stratification using preoperative CT images could be useful in deciding the extent of thoracic lymphadenectomy in both AEG and ESCC.

Modified Dor fundoplication technique following diverticulectomy and myotomy for epiphrenic diverticulum combined with esophageal motility disorders: prevention of esophageal leak at the diverticulectomy staple line

Surgery is the standard treatment for patients with pulmonary or incapacitating symptoms related to an epiphrenic diverticulum combined with esophageal motility disorders. Leakage from the staple line at the diverticulectomy site is a severe complication because of the lack of proper esophageal muscle. When the staple line that lacks the proper muscle is wider than expected, interrupted suturing may cause the muscle to tear because of the lack of adventitia of the esophagus, or esophageal stenosis may occur as the result of a tight suture. We propose that an antireflux wrap should be used to cover over the staple line to prevent esophageal leaks. Even if a staple line leak occurred, a major leak and mediastinitis can be avoided when the muscle defect is completely covered by a fundus.

The prognostic significance of tumor laterality in patients with esophageal squamous cell carcinoma

It has been shown that part of the lymph fluid from the right/dorsal side of the esophagus drains directly into the thoracic duct, whereas the lymph fluid from the left/ventral side has to pass through lymph nodes before entering the duct. We hypothesized that patients with right/dorsal tumors have a poorer prognosis than those with left/ventral tumors because cancer cells from the right/dorsal quadrant may easily enter the systemic circulation.

A commentary on “Ten-year follow-up results of a randomized clinical trial comparing left thoracoabdominal and abdominal transhiatal approaches to total gastrectomy for adenocarcinoma of the oesophagogastric junction or gastric cardia”

Kurokawa and other authors published 10-year outcomes of a Japanese randomized clinical trial comparing left thoracoabdominal approaches (LTA) with abdominal transhiatal approaches (TH) for adenocarcinoma of the esophagogastric junction (AEG) (JCOG9502) (1). That study demonstrated that LTA was not superior to TH regarding AEG patients’ survival, but had a higher incidence of morbidity than TH (2). Moreover, the authors stratified patients into Siewert type II or type III and showed that LTA should be avoided especially for the latter.

Surgical treatment of superficial esophageal cancer, its result and perspective

BackgroundOur objective was to review the results of surgical treatment for superficial esophageal cancer to obtain the proper indications for the recently proposed esophagus-preserving strategies.MethodsThe clinicopathological data of 290 consecutive patients with superficial thoracic or abdominal esophageal cancer who underwent esophagectomy with radical lymph node dissection without preoperative adjuvant treatment from 1984 to 2005 were examined in terms of tumor depth (ep, lpm, mm, sm1, sm2, sm3) and TNM pStage. The category sm1 was subclassified into sm1(0–200): lesions with 200 μm or less vertical tumor invasion depth in the submucosal layer, and sm1(200-): deeper sm1, to make our results referable to endoscopically resected lesions.ResultsAbout 8% of the patients with mm or deeper tumors were classified as TNM pStage IV. Around 20% of mm and sm1(0–200) tumors were associated with lymph node involvement. The 5-year survival rate of the 211sm cancers was 74.8% ± 3.3%; the mean survival time was 11.47 ± 0.68 years. The survival of TNM pStage IV patients was no worse than that of pStage IIB patients.ConclusionsEndoscopic mucosal resection/endoscopic submucosal dissection (EMR/ESD) is definitely indicated for ep or lpm lesions. Any tumors with deeper invasion including mm and sm1(0–200) should be regarded as potentially lymph node positive, and the most reliable treatment is still radical esophagectomy. Recent attempts to treat superficial esophageal cancer while preserving the esophagus should be performed with caution and with informed consent. A randomized controlled trial is necessary to compare the results of the recent esophagus-preserving strategies to the results of radical esophagectomy.

Safety and efficacy of preoperative chemotherapy followed by esophagectomy versus upfront surgery for resectable esophageal squamous cell carcinoma

PurposeNeoadjuvant chemotherapy (NAC) followed by esophagectomy has become a standard treatment for esophageal squamous cancer (ESCC) in Japan. We used propensity-matching analysis to clarify the safety and efficacy of NAC in daily clinical practice.MethodsWe reviewed the medical records of 335 patients with clinical Stage II/III ESCC diagnosed between 2007 and 2012, including 191 who received preoperative NAC (NAC group) and 144 treated by upfront surgery (US group). After propensity score matching, there were 118 patients in each group. We compared the postoperative complications and long-term outcomes between the groups.ResultsSeven patients in the NAC group underwent replacement therapy. Complications occurred in 76 (68.5%) and 76 (64.4%) patients in NAC and US groups, respectively (pu2009=u20090.51), and severe complications occurred in 17 (22.4%) and 30 (39.5%) patients, respectively (pu2009=u20090.057). One (0.8%) and three patients (2.5%) from the US group died within 30xa0days and 90xa0days after surgery, respectively, but none of the patients from the NAC group died within the same period. The 5-year survival rate was 54.9% in the NAC group and 41.2% in the US group (pu2009=u20090.024).ConclusionsNAC is a safe and effective treatment to improve prognosis in the clinical setting.