Taigou Tokuhara

Comparison of three-field esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy.

Background: Thoracoscopic esophagectomy for esophageal cancer has been performed as an alternative to open surgery to reduce surgical trauma. However, its effect on pulmonary function, exercise tolerability, and quality of life is unknown. Methods: Fifty-one patients with esophageal cancer underwent thoracic esophagectomy with radical lymphadenectomy by posterolateral thoracotomy (29 cases) or thoracoscopic surgery (22 cases). Patients performed spirometry and exercise tolerance testing and completed a quality-of-life questionnaire before and 3 months after surgery. Results: Pre-to-postoperative change in vital capacity was 74.3 ± 10.6% in the thoracotomy group and 84.9 ± 10.4% in the thoracoscopy group (p = 0.021). Maximum oxygen uptake was similar, but dyspnea was the more common factor limiting exercise tolerance postoperatively in the thoracotomy group. Change in pre-to-postoperative performance status was 1.20 ± 0.62 in the thoracotomy group and 0.55 ± 0.51 in the thoracoscopy group (p = 0.0003). Conclusions: Thoracoscopic esophagectomy for esophageal cancer has better preservation of pulmonary function and quality-of-life.

Usefulness of self-expandable metallic stent with an antireflux mechanism as a palliation for malignant strictures at the gastroesophageal junction.

BACKGROUND: Patients with unresectable malignant gastroesophageal strictures often are troubled with reflux esophagitis after stent placement. METHODS: A self-expandable metallic stent (SEMS) without an antireflux mechanism was placed in seven patients with unresectable malignant gastroesophageal strictures (group A), and SEMS with an antireflux mechanism was placed in five patients (group B). After we obtained monitoring systems, two patients in group A and all the patients in group B underwent measurement of bilirubin and pH in the esophagus using a 24-h bilirubin and pH monitor. RESULTS: The mean percentage of total time less than 0.14 for use of the bilirubin absorbance unit was 12.4% in group B and 64.0% in group A. The mean percentage of total time for a pH less than 4 was 2.9% in group B and 37.8% in group A. CONCLUSION: The placement of SEMS with the antireflux mechanism can be effective not only for palliation of gastroesophageal stricture, but also for prevention of reflux.

Utility of endoscopic ultrasonography in assessing the indications for endoscopic surgery of submucosal esophageal tumors

AbstractBackground: The submucosal tumor (SMT) of the esophagus presents good indications for minimal invasive surgery, such as endoscopic or thoracoscopic resection. However, it is essential that the layer of origin be acertained. The SMT can be detected as hypoechoic lesions in the wall of the esophagus, and the intramural location can be estimated in terms of destruction or deviation of the ultrasonic layer structure of the esophagus. Methods: To test the efficacy of this approach, a series of patients were examined by an endoscopic ultrasonography (EUS). Results: In one patient, the lesion was diagnosed as located in the muscularis mucosa, and endoscopic resection was performed. In another four patients, the lesions appeared to be in the proper muscle layer, and enucleation was carried out under thoracoscopy or open surgery. Histologically, all of the lesions were leiomyomas, and the EUS diagnosis was correct in all of the patients. Conclusions: Thus, the intramural condition of SMTs can be estimated and indications for endoscopic or thoracoscopic resection assessed by this approach.

Report of a case undergone successful gastrectomy for gastric cancer in the fornix with esophageal mycosis.

76歳男性, 約10年前より糖尿病のため経口血糖降下剤を服用.72歳時に軽度の嚥下困難に対して精査を行い, 頸部食道から噴門部直上におよぶ食道真菌症と診断し, 抗真菌薬の投与にて経過観察中であった.3年後の上部消化管造影で, 胃穹窪部の隆起性病変を発見し, 生検で腺癌の診断を得た.開腹所見では腫瘍は噴門部大弯側前壁にあり, 食道胃接合部との間に約3cmの正常粘膜を有していた.そこで腫瘍の口側距離 (OW) を2cmとり, しかも食道胃接合部より1cm遠位側の胃粘膜と小腸とを吻合する胃全摘術を施行した.術後体表に創感染を認めた以外良好に経過した.食道真菌症に胃癌を合併した例 (以下本症) の報告は検索範囲ではなく, 本症に対して胃全摘術後, 真菌症罹患食道との再建術では縫合不全が危惧される.今回は幸運にも罹患食道との吻合を行わずに治癒切除しえたが, 場合により危険度の高い吻合もありえたため本症に対する再建術の2, 3の工夫を考察した.