Shirou Kuwabara

Outcomes of Extended Radical Esophagectomy for Thoracic Esophageal Cancer

BACKGROUND Great controversy exists concerning the adequate extent of esophagectomy for cure in patients with esophageal cancer. Extended radical esophagectomy combined with three-field lymphadenectomy has been performed to improve the cure rates for patients with the disease in Japan. The purposes of this study were to assess the mortality and morbidity rates after extended radical esophagectomy and to determine the oncologic indications for this procedure. STUDY DESIGN We reviewed 190 patients who underwent extended radical esophagectomy for invasive esophageal cancer. The procedures were performed prospectively between 1982 and 1996. RESULTS The 30-day mortality, in-hospital mortality, and morbidity rates were 1.6%, 4.7%, and 58.4%, respectively. The most common postoperative complication was vocal-cord paralysis (45.3%), followed by major pulmonary complications (21.6%). The overall survival rate for the 190 patients was 41.5% at 5 years, with a median followup period of 61 months. Some subgroups of patients had an extremely poor prognosis despite extended radical esophagectomy. Survival was < or = 5 years in all patients with five or more positive nodes; all patients with simultaneous metastases to the cervical, mediastinal, and abdominal lymph nodes; and all patients with cervical metastases from a lower esophageal tumor. CONCLUSIONS Extended radical esophagectomy is potentially associated with high morbidity rates although the mortality rates are acceptable, suggesting the necessity of careful patient selection. This procedure is indicated oncologically only for patients with four or fewer metastatic nodes or with metastases confined to one or two of the three anatomic compartments (neck, mediastinum, and abdomen) from upper or midesophageal tumors.

Comparison of three different operative methods of video-assisted thoracoscopic esophagectomy

BackgroundAlthough the feasibility and advantages of video-assisted thoracoscopic esophagectomy (VATS-E) for esophageal cancer are well studied, its application is limited, possibly because it is technically complex.MethodsNinety-eight patients who underwent VATS-E at our institutes were divided into three groups by the type of thoracoscope, TV monitor, and patient position used. For the first 18 patients, we used the left lateral position, a flexible thoracoscope, and a single TV monitor (method A); for the next 58 patients, the left lateral position, a 30° thoracoscope, and two TV monitors (method B); and for the last 22 patients, the prone position with 30° thoracoscope and single TV monitor (method C). We compared the area of operative field and clinical outcomes in these three approaches.ResultsOn the basis of subjective assessment, method C afforded a better operative field than methods A and B. No significant differences were noted between the three positions in operative time, duration of intubation, rate of occurrence of recurrent nerve palsy, and anastomotic leakage. However, blood loss, rate of respiratory tract complications, and length of postoperative hospital stay were decreased in the order of position. The total number of dissected lymph nodes increased in the order of position.ConclusionsVATS-E in prone position with a 30° thoracoscope and a single TV monitor appear to be superior to VATS-E in the left lateral position in terms of operative field, blood loss, respiratory tract complication, and number of lymph nodes dissected. Randomized control studies would help confirm these results.

Histogenetic heterogeneity in carcinosarcoma of the esophagus: report of a case with immunohistochemical and molecular analyses.

Carcinosarcoma is a rare esophage al tumor that shows polypoid con® gurations; it has an incidence of 0.1% ± 1.5% of all esophage al malignancie s (1). This tumor is usually composed of both invasive or in situ squamous cell carcinomas surrounding the base of the exophytic tumor and sarcomatous spindle cells forming the body of the polypoid mass. The histoge nesis of the spindle cell component has been the subje ct of debate : these spindle cells have been reported to be reactive mesenchyme (2, 3), concomitant sarcoma (4 ± 8), and a variant of poorly differentiated squamous cell carcinoma (9 ± 13) , based on the ® ndings of histological, ultrastructural, and immunohistoche mical studie s. However, none of the previous studie s have assessed the gene mutational status in this rare biphasic tumor. We herein report a case of esophage al carcinosarcoma in which the histoge netic nature of both carcinomatous and sarcomatous compone nts was studied by means of analysis of the p53 gene mutational status as well as immunohistochemical examinations.

Heterogeneity of p53 Mutational Status in Esophageal Squamous Cell Carcinoma

In esophageal squamous cell carcinoma, p53 gene mutations have been analyzed for inter‐ or intra‐patient heterogeneity but only a few studies have investigated intratumoral heterogeneity. We investigated this question within individual esophageal cancers, and also in their lymph‐node metastases in 8 cases. Analyzing the p53 gene sequence by direct sequencing of polymerase chain reaction products, we found heterogeneity for p53 mutations in the pre‐invasive area in 3 esophageal cancers. In all areas sampled in the invasive portion of each cancer, the p53 mutational status was identical in a given tumor. In heterogeneous tumors, the invasive area showed one of the p53 mutations found in the pre‐invasive area. In nodal metastases, the p53 mutation was identical to that in the invasive area of each primary tumor. These data suggest that the timing of p53 alteration is not as early as might have been expected, indicating that, in regard to p53 gene alteration, some esophageal cancers are composed of various subclones in the pre‐invasive stage with invasiveness developing in one of them, which becomes predominant through clonal selection.

Diagnostic peritoneal lavage for diagnosing blunt hollow visceral injury: The accuracy of two different criteria and their combination

PurposeTo test the usefulness of diagnostic peritoneal lavage (DPL) for identifying blunt hollow visceral injury with two different sets of criteria or a combination of the two.MethodsFifty victims with physical examinations and/or computed tomography findings equivocal for blunt hollow visceral injury underwent DPL. Whether or not to perform surgery was determined based on Otomos DPL criteria [lavage white blood cell counts (L-WBC) over lavage red blood cell counts (L-RBC) divided by 150 (L-WBC ≥ L-RBC/150) in the presence of hemoperitoneum, or L-WBC over 500/mm3 (L-WBC ≥ 500) in the absence of hemoperitoneum]. The cell count ratio, a comparison of L-WBC, L-RBC, peripheral WBC (P-WBC), and peripheral RBC (P-RBC) [(L-WBC/L-RBC)/(P-WBC/P-RBC) ≥ 1] were all calculated retrospectively.ResultsThere were one and two false-positive cases based on Otomos criteria and the cell count ratio, respectively, with corresponding accuracies of 97.8% and 95.7%, respectively. There were no false-positive or -negative cases according to the combined use of Otomos criteria and cell count ratio, yielding an accuracy of 100%.ConclusionAlthough each criterion alone is very accurate in predicting the presence of blunt hollow visceral injury, the combined use of the two would further improve the accuracy of the diagnosis and thereby reduce the number of unnecessary celiotomies.

ESOPHAGEAL INTRAMURAL METASTASIS FROM AN ADENOCARCINOMA OF THE GASTRIC CARDIA : REPORT OF A CASE

We report herein the rare case of a 65-year-old man found to have esophageal intramural metastasis from cancer of the gastric cardia. Endoscopic examination initially revealed an infiltrating ulcerative tumor of the gastric cardia involving the esophagogastric junction, as well as a submucosal tumor of the lower esophagus. A total thoracic esophagogastrectomy with lower mediastinal lymphadenectomy was performed, and the resected specimen demonstrated that both the cardia and esophageal tumors were adenocarcinomas with the same cellular differentiation. As lymphatic invasion and metastases to the paracardial and mediastinal lymph nodes were observed, the esophageal submucosal tumor was considered to be an intramural metastasis from the carcinoma of the gastric cardia resulting from extensive lymphatic spread. The patient died of recurrent disease 9 months after the resection. This case report serves to demonstrate that intramural metastasis may be a local indicator of the systemic spread of disease in patients with gastric carcinoma, as it is in esophageal carcinoma.

Bile duct stone formation around a nylon suture after gastrectomy: A case report

BackgroundMany cases of choledocholiths formed around sutures and clips used during cholecystectomy have been reported. We describe a case of gallstone formation around a nylon suture after non-biliary surgery. To the best of our knowledge, this is the first report of such a case.Case presentationA 75-year-old Japanese man, who had undergone distal gastrectomy for gastric cancer and reconstruction with the Billroth II method 8 years earlier, presented with gastric discomfort. Abdominal ultrasonography was conducted and we diagnosed cholecysto-choledocholithiasis with dilatation of the intrahepatic bile duct. He underwent cholecystectomy and cholangioduodenostomy for choledocholith removal. Gallstones, which had formed around a nylon suture used during the previous gastrectomy, were found in the bile duct. Sutures of the same material had also been placed on the duodenum. Chemical analysis revealed that the stones were composed of calcium bilirubinate. The patient was discharged on postoperative day 19, and choledocholithiasis has not recurred thus far.ConclusionThe findings from this case suggest that standard, non-resorbable sutures used in gastrectomy may be associated with the formation of bile duct stones; therefore, absorbable suture material may be required to avert gallstone formation even in the case of gastrectomy.

Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy

The purpose of this study was to evaluate the safety and efficacy of a novel continuous incision technique for the cystic duct and the bile duct over the orifice for laparoscopic transcystic choledocholithotomy (LTCL).

Use of indocyanine green fluorescence imaging to determine the area of bowel resection in non-occlusive mesenteric ischemia: A case report

Highlights • In cases of NOMI, it is difficult to determine the area of bowel resection.• Using ICG fluorescence imaging, we can evaluate ischemia of the intestine.• We adeptly resected the ischemic intestine in NOMI using ICG fluorescence imaging.

Phlegmonous esophagitis treated by endoscopic drainage

Phlegmonous esophagitis is a rare and sometimes fatal condition. Cases surgically treated have been reported previously; however, surgical approaches may be risky in the elderly. An 86-year-old woman presented with a sore throat and high fever after eating fish. She was first diagnosed with a deep cervical abscess, and conservative treatment was initially selected. However, her respiratory failure worsened, so emergent tracheostomy and surgical drainage were performed. Computed tomography showed intramural low-density lesions along the entire length of the esophagus and she was diagnosed with phlegmonous esophagitis. To avoid surgical intervention, endoscopic drainage was first attempted. Mucosal incision was made on the lower esophagus guided by endoscopic ultrasonography, using the insulated-tip electrosurgical knife. After the endoscopic drainage, her general health status improved, and the esophageal wall thickness was reduced. While some cases have recovered with conservative treatment, endoscopic drainage may be useful in certain patients.