Takayuki Nishi

Clinical analysis of reflux esophagitis following esophagectomy with gastric tube reconstruction

BackgroundRecently, the rate of postoperative long-term survival has increased in cases of esophageal cancer. We report on our analysis of postoperative reflux esophagitis (RE) at Tokai University.MethodsWe enrolled 48 patients who underwent gastric tube reconstruction after esophagectomy. The diagnosis of RE was confirmed by endoscopy.ResultsOf the 48 patients, 28 (58.3%) were found to have RE. Among the 28 patients with RE, only four (14.3%) reported symptoms. The distribution of the severity of RE according to the Los Angeles classification in the patients was as follows: grade M, 1 (3.6%); grade A, 2 (7.1%); grade B, 6 (21.4%); grade C, 17 (60.7%); and grade D, 2 cases (7.1%). Barretts epithelium was detected in 9 of the 28 patients (31%) with RE and in 3 of the 20 (15%) patients with no evidence of RE.ConclusionsTo detect the presence of RE as well as monitor for recurrence and development of metachronous cancer, we consider it important to perform endoscopy regularly over the long term. As Barretts epithelium is frequently encountered, care should be exercised to detect the specialized columnar epithelium showing dysplastic changes.

Endoscopic Criteria for Invasive Depth of Superficial Esophageal Cancer

Abstract: The therapeutic strategy for superficial esophageal cancer should be determined by the depth of invasion. Therefore, we endeavored to develop reliable criteria for endoscopic evaluation of the invasive depth of superficial esophageal cancer. Two hundred and fifty nine superficial squamous cell carcinoma cases were enrolled in this study, designed to investigate the relationship between endoscopic classification and the depth of invasion, and also between lesion size and depth of invasion. Almost all 0‐1, 0‐1+0‐llc, O‐llc+0‐lla and 0‐111 lesions invaded the submucosal layer, although 0‐lla and O‐llb lesions were limited to the mucosal layer. The 0‐llc type of lesion showed a wide range of invasive depths from M1 to SM3; in M1 cases with minimal depression the surface appears entirely smooth; in M2 cases the depressed surface is uniformly granular; and M3 cases have slightly larger granules. With submucosal cancer, the depressed surface showed some irregularity and variability in granule size. In the 0‐llc type, 100% of lesions under 10 mm and 80% of those under 30 mm in greatest dimension were mucosal cancer. The accuracy of our criteria for endo‐scopically evaluating the depth of invasion was 80.2%. The accuracy rate, in terms of assignment to group Ml and M2, M3 and SM1, or SM2 and SM3, was 90.6%.

Histopathology of gastrointestinal neuroendocrine neoplasms

Gastrointestinal neuroendocrine neoplasms (GI-NENs) arise from neuroendocrine cells distributed mainly in the mucosa and submucosa of the gastrointestinal tract. In 2010, the World Health Organization (WHO) classification of NENs of the digestive system was changed, categorizing these tumors as grade 1 neuroendocrine tumor (NET), grade-2NET, neuroendocrine carcinoma (large- or small-cell type), or mixed adenoneuroendocrine carcinoma (MANEC). Such a classification is based on the Ki-67 index and mitotic count in histological material. For the accurate pathological diagnosis and grading of NENs, it is important to clearly recognize the characteristic histological features of GI-NENs and to understand the correct method of counting Ki-67 and mitoses. In this review, we focus on the histopathological features of GI-NENs, particularly regarding biopsy and cytological diagnoses, neuroendocrine markers, genetic and molecular features, and the evaluation of the Ki-67 index and mitotic count. In addition, we will address the histological features of GI-NEN in specific organs.

Treatment of esophageal cancer in patients over 80 years old

A total of 828 patients with esophageal cancer were treated at the Second Department of Surgery of Tokai University in the 20-year period from 1975 to June 1994, including 45 patients over 80 years old. We reviewed these elderly patients to assess the optimum therapeutic approach for such individuals. In recent years, the number of elderly patients with esophageal cancer has steadily been increasing. Advanced cancer is more common among this group, but early cancer has also been detected more frequently in recent years. Of the 45 elderly patients (80%) in our series, 36 were encountered in the last 10 years. As 28.9% of the patients had multiple cancers, a careful workup was necessary preoperatively. Since most patients (88.9%) had complications and were also in a poor general condition, limited surgery was recommended in consideration of the postoperative quality of life. The indications for endoscopic mucosal resection (EMR) may be able to be extended to submucosall (sml) cancer without lymph node swelling. Postoperative complications occurred in 60% of those undergoing surgical resection or esophageal bypass, although death only resulted in 1 case. The 5-year survival rate after surgical resection was 30.8%. These results therefore support the use of surgical treatment for selected elderly patients with esophageal cancer.

Technique of the double-channel ESD method performed with an EEMR tube

Endoscopic submucosal dissection (ESD) recently has been aggressively performed to treat superficial esophageal cancer; however, it is difficult to secure a good field of view for mucosal dissection, and the technique requires considerable skill. We have developed a double-channel ESD method using an endoscopic esophageal mucosal resection (EEMR) tube that makes it possible to perform the submucosal dissection with a good field of view while applying countertraction. Countertraction is achieved by maneuvering a fine grasping forceps inserted through the side channel of the EEMR tube, and the field of view of the submucosal dissection layer can be easily exposed. This technique can be performed while constantly observing the submucosal dissection layer with a stable field of view, and it is also easy to handle the blood vessels. Moreover, there is no disturbance of the field of view by the dissected mucosa.

Basaloid squamous carcinoma of the esophagus developed from achalasia: report of a case

A 57-year-old man, who had been diagnosed as having flask type, grade II achalasia of the esophagus at the age of 26, underwent Heller’s esophagomyectomy in a nearby hospital in 1971. A type 0-Is lesion measuring 2 cm in size was found on the middle thoracic esophagus in September 2002. A protruding tumor with a central depression, not stained with iodine, was detected by endoscopic examination. Standard subtotal esophagectomy with three-field lymph node dissection was performed. By histopathological examination, the esophageal lesion was classified as basaloid squamous carcinoma, extending to the middle part of the submucosa (T1b; sm2), without lymph node metastasis. The majority of the invasive carcinoma was composed of basaloid carcinoma, while a part showed as squamous cell carcinoma at the mucosal site. Achalasia of the esophagus is considered as a risk factor for squamous cell carcinoma by persistent mucosal inflammation caused by chronic stasis and food retention. Most of the reported carcinomas developing from esophageal achalasia are squamous cell carcinoma histologically. An extremely rare case of superficial basaloid squamous carcinoma with achalasia is presented.

Clinicopathological significance of laminin-5γ2 chain expression in superficial esophageal cancer

The glycoprotein laminin 5γ2 chain (LN-5γ2) has recently become a focus of increased interest and investigation as a marker of invasion in gastrointestinal malignancies. We investigated the significance of LN-5γ2 expression as a prognostic factor in superficial esophageal cancer. The study population consisted of 87 patients who had undergone a transthoracic esophagectomy and three-field lymphadenectomy for the treatment of superficial esophageal cancer at Tokai University Hospital. Formalin-fixed, paraffin-embedded sections of the resected specimens were examined using immunohistochemical staining and hematoxylin and eosin staining to assess the correlations between the LN-5γ2 expression pattern and the clinicopathological factors (age, sex, T-factor, N-factor, ly-factor, v-factor, degree of differentiation, infiltrative growth pattern, tumor node metastasis classification of malignant tumors [TNM] stage, etc.) and the patient outcome. The expression pattern of LN-5γ2 was classified into an extracellular type (E type), characterized by the staining of extracellular matrix such as the basement membrane and the stroma (31 cases, 35.6%), and a cytoplasmic type (C type), characterized by the staining of the cytoplasm in the cancer cells (56 cases, 64.6%). The expression pattern was not correlated with any of the clinicopathological factors that were assessed. However, univariate analyses of the survival analysis data showed that the N-factor (P = 0.011), TNM stage (P = 0.011), and LN-5γ2 C type (P = 0.017) were prognostic factors. A multivariate analysis revealed that the N-factor (P = 0.049) and LN-5γ2 C type (P = 0.048) were prognostic factors. In the survival analysis, a univariate analysis of the 75 T1b cases also showed that the N-factor (P = 0.048), TNM stage (P = 0.048), and LN-5γ2 C type (P = 0.029) were prognostic factors, while a multivariate analysis showed that the LN-5γ2 C type (P = 0.035) was a prognostic factor. The C type expression of LN-5γ2, i.e. confined to the cytoplasm, was correlated with an unfavorable outcome among the patients with superficial esophageal cancer in the present series. Observation of the LN-5γ2 expression pattern may be useful for the diagnosis of highly malignant tumors.

Perforated gastrointestinal stromal tumor in the small intestine: A rare case of Torricelli-Bernoulli sign

The Torricelli-Bernoulli sign is a computed tomography (CT) finding that occurs when ulceration/necrosis of a submucosal gastrointestinal tumor releases a stream of air bubbles into the intestinal lumen. A 75-year-old man developed acute abdominal pain at night and presented to a local doctor. Acute abdomen was diagnosed and he was referred to the Emergency Department at Tokai University Oiso Hospital. On CT scans, disseminated intestinal tumor-like lesions were seen in the right lower abdomen. The Torricelli-Bernoulli sign and free intraabdominal gas were observed, so perforation of an intestinal tumor was diagnosed and emergency surgery was performed. At operation, there was scanty opaque ascites in the right lower abdomen and an ileal tumor associated with nodules that suggested peritoneal dissemination. Partial resection of the ileum was performed and peritoneal lavage was conducted. The patient was discharged on postoperative day 11. Histopathological examination revealed a high risk gastrointestinal stromal tumor. The abdominal nodules were metastases, indicating that the tumor was Stage IV. The patient is currently on treatment with an oral tyrosine kinase inhibitor (imatinib).

Pulmonary artery hypoplasia associated with posterior mediastinal hematoma accompanied by a ruptured pseudoaneurysm of the esophageal branch of the left gastric artery

A 65-year-old woman with no significant medical history visited the emergency department complaining of epigastric discomfort. A computed tomography of the thorax and abdomen showed the attenuation of the pulmonary artery and a posterior mediastinal hematoma. Angiography showed a tortuous esophageal branch of the left gastric artery and a pseudoaneurysm, and during the later phase, the left lower lobe of the lung was enhanced, and finally, the left pulmonary vein was enhanced. We considered that the patient was exhibiting hypoperfusion of the left pulmonary artery arising from left pulmonary artery hypoplasia, since the left lung was supplying the systemic circulation. Transcatheter arterial embolization was performed. The patient has not experienced any recurrence of a ruptured pseudoaneurysm or epigastric discomfort. Here, we report the first documented case of pulmonary artery hypoplasia associated with posterior mediastinal hematoma accompanied by a ruptured aneurysm of the left gastric artery.

The Efficacy of Calcium Mupirocin for Esophageal Cancer Operation.

ムピロシン軟膏の使用で食道癌術後のMRSA感染症が減少するかを検討した.食道癌手術予定の患者54例全例にムピロシン軟膏を使用した.術前に1日3回, 3日間鼻前庭部に左右それぞれ30mgずつ塗布した.Historical controlとしてそれ以前の症例47例を対照とし比較検討した.対照群では47例中9例 (19.1%)にMRSAが検出された.ムピロシン使用群では54例中2例 (3.7%)にMRSAが検出され, MRSA感染症はそのうちの1例 (1.85%)であった.培養された菌の中で最も多かったのは両群とも緑膿菌であった.食道癌手術に対しムピロシン軟膏を使用することでMRSA感染は減少させることが可能である.食道癌手術に対するムピロシンの投与は非常に有用であると考えられた.