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Background Oesophagectomy has a high risk of postoperative morbidity. The impact of postoperative complications on overall survival of oesophageal cancer remains unclear. This meta-analysis addressed the impact of complications on long-term survival following oesophagectomy. Methods A search of PubMed and Cochrane Library databases was undertaken for systematic review of papers published between January 1995 and August 2016 that analysed the relation between postoperative complications and long-term survival. In the meta-analysis, data were pooled. The main outcome was overall survival (OS). Secondary endpoints included disease-free (DFS) and cancer-specific (CSS) survival. Results A total of 357 citations was reviewed; 21 studies comprising 11 368 patients were included in the analyses. Overall, postoperative complications were associated with significantly decreased 5-year OS (hazard ratio (HR) 1·16, 95 per cent c.i. 1·06 to 1·26; P = 0·001) and 5-year CSS (HR 1·27, 1·09 to 1·47; P = 0·002). Pulmonary complications were associated with decreased 5-year OS (HR 1·37, 1·16 to 1·62; P < 0·001), CSS (HR 1·60, 1·35 to 1·89; P < 0·001) and 5-year DFS (HR 1·16, 1·00 to 1·33; P = 0·05). Patients with anastomotic leakage had significantly decreased 5-year OS (HR 1·20, 1·10 to 1·30; P < 0·001), 5-year CSS (HR 1·81, 1·11 to 2·95; P = 0·02) and 5-year DFS (HR 1·13, 1·02 to 1·25; P = 0·01). Conclusion Postoperative complications after oesophagectomy, including pulmonary complications and anastomotic leakage, decreased long-term survival.

Background The first systematic classification of an anatomy of bronchial arteries (BAs) is reported by Cauldwell E. W. in 1948. However, it is not suitable for recognizing anatomy of BAs for esophageal surgery since it does not contain information of relative position of BAs and esophagus. So, the aim of this study is to device a novel classification of BAswhich correlates with surgical and pathological factors of esophageal cancer. Methods Eighty-six patients that have undergone curative esophagectomy from April 2012 to March 2016 for esophageal cancer whose epicenter is located in midthoracic esophagus were enrolled. Dynamic-enhanced computed tomography imaging (dCT) and clinico-pathological factors were analyzed. The right (rt-) BA which runs along the right side of esophagus is defined as Median (M) type and rt-BA which runs along the left side of esophagus is defined as Lateral (L) type. Also, the BA which arises from right side of aortic arch and runs down aortopulmonary window is defined as Tracheal (T) type and the others are defined as Bronchial (B) type. We classified patients by combination of M/L type and T/B type. Results dCT was performed in 81 cases. The number of patients with type of MT, MB, LT and LB were 19, 46, 12 and 4, respectively. Existence of rt-2nd-BA is significantly frequent in LB type and existence of lt-2nd-BA is significantly frequent in M type (P Conclusion Classifying an anatomy of BAs by relative position to esophagus and their origin is possibly helpful in esophageal surgery. Disclosure All authors have declared no conflicts of interest.

Background Esophageal squamous cell carcinoma (ESCC) is often synchronously accompanied by pharyngeal squamous cell carcinoma (PSCC). However, the treatment strategies for these cancers have not been established. Neoadjuvant chemotherapy is the standard treatment for advanced ESCC and is also effective for PSCC patients. However, few studies have focused on the efficacy of systemic chemotherapy for patients with superficial PSCC. Methods We retrospectively examined 22 cases of superficial PSCC that occurred in 14 patients with ESCC who received neoadjuvant therapy between January 2011 and June 2017. Results Of the 14 patients, 13 (93%) were male, and the median age was 63.5 years (range: 35–74 years). The clinical stage of ESCC was II for 7, III for 5, and IVB for 2 (AJCC 8th staging system). The PSCC origin included the oropharynx in 9 lesions (40.9%) and the hypopharynx in 13 lesions (59.1%). Macroscopic type was classified as protruding (type1 or 0-I) for 2, superficial elevated (0-IIa) for 5, superficial flat (0-IIb) for 13, and superficial depressed (0-IIc) for 2. The estimated depth of invasion was EP in 12 lesions, SEP in 8 lesions, and MP in 2 lesions. FP regimen was administered to 11 patients in 15 lesions and DCF to 3 patients in 7 lesions. One patient had concurrent chemoradiotherapy. Chemotherapy for PSCC resulted in CR in 10 lesions (45.4%). In CR, 9 of 10 lesions were of superficial flat type. All non-CR lesions also had tumor regression. In the CR patients, 5 lesions(50%) had local recurrence, and the median duration until recurrence was 4 months (range: 4 to 17 months). Endoscopic resection(ER) for PSCC was performed in the 13 lesions after esophagectomy. The median duration after diagnosis was 7 months (range: 3 to 20 months). Conclusion Systemic chemotherapy of ESCC has tumor regression potential for superficial flat-type PSCC with clinical tumor invasion in EP or SEP. Although chemotherapy for PSCC results in non-CR, additional ER is quite effective. Because half of the CR lesions had recurrence, strict follow-up and observation of the pharynx are reasonable options for patients with ESCC. Disclosure All authors have declared no conflicts of interest.

Background Evaluating swallowing function by Videoendoscopic evaluation of swallowing (VE) and Videofluorography (VF) is vital in reintroducing oral diet to patients who underwent esophagectomy. However, performing VE and VF requires specific facility and experts. So, the aim of this study is to evaluate predictive factors for early recovery of oral intake. Methods One-hundred and thirty-six patients who underwent minimally invasive esophagectomy for thoracic esophageal cancer with three-field-lymph node dissection were enrolled. Patients’ characteristics, surgical and pathological factors, postoperative complications, duration from surgery to reintroducing oral intake, results of repetitive saliva swallowing test (RSST) and maximum phonation time (MPT) on seventh postoperative day (7POD) were analyzed. We classified patients that duration of reintroducing oral intake is shorter than 10 days into Normal-intake (N) group and patients that duration of oral intake is longer than 11 days into Delayed-intake (D) group. Results The average age of all patients was 64 ± 9 years old and average hospital stay of them was 30 ± 15 days. Three-field-lymph node dissection was performed in 96% of the cases and all patients have been performed cervical esophagogastrostomy. N group had significantly many patients who completed neoadjuvant chemo(radio)therapy (neo-C(R)Tx)) compared to D group (74% vs. 51%, P = 0.01). Also, patients in N group had significantly low level of preoperative indocyanine green test (ICG test; determined by colorimetric method at 15 minutes after injection of indocyanine green solution) and maximum postoperative serum C-reactive protein level until 7POD (max-CRP) compared to D group (P = 0.047, P = 0.001, respectively). Moreover, average time of MPT on 7POD was long in N group compared to D group (P = 0.05). In multivariate analysis, completion of neo-C(R)Tx, ICG ≤ 9, max-CRP ≤ 14.5 mg/dL was independent predictive factor of early recovery of oral intake (OR: 2.6 P = 0.023, OR: 4.6 P = 0.003, OR: 1.7 P = 0.008, respectively). Conclusion Preoperative good liver function, completion of neoadjuvant treatment and relatively low postoperative inflammation were considered to be predictive factors for early recovery of oral intake in patients who underwent curative esophagectomy for esophageal cancer. Disclosure All authors have declared no conflicts of interest.

Background Although definitive chemoradiotherapy (CRT) with salvage esophagectomy has improved overall survival (OS) for esophageal cancer, it is a more invasive approach than neoadjuvant CRT followed by surgery or surgery alone, and causes high mortality after surgery. The purpose of this study was to investigate the short and long-term outcomes of salvage esophagectomy, to determine their prognostic factors, and to create a prediction model for OS using a classification and regression tree (CART). Methods Ninety patients who had undergone CRT followed by esophagectomy for thoracic esophageal cancer at Keio University Hospital, Tokyo, Japan, between June 1994 and August 2014 were identified for this study. We divided the 90 patients into two groups—the salvage group and the neoadjuvant group—according to the dose of irradiation of CRT. Forty-four patients who underwent CRT with radiation dose less than 50 Gy, followed by planned esophagectomy, were allocated to the neoadjuvant group. Forty-six patients with salvage esophagectomy for locally recurrent or residual cancer after definitive CRT (greater than 50 Gy) were allocated to the salvage group. Results Patients from the salvage group tended to have a lower OS (median survival: Salvage, 25 months vs neoadjuvant, 50 months, P = 0.149). In the salvage group, pneumonia and age were identified as factors predictive of in-hospital mortality. OS was significantly lower in patients with postoperative pneumonia and female gender. We set the prediction model for OS in the salvage group using survival CART. The group of R1/2 resection aged ≥ 56.5 years and the group suffering from postoperative pneumonia were the groups at highest risk; the area under the curve was 0.72. Conclusion The present study demonstrates the short-term and long-term prognostic factors of salvage esophagectomy after definitive CRT for esophageal cancer. Achieving improvement in OS after salvage surgery requires increased R0 resection rates and decreased pulmonary complications. Both informed decision making in the adoption of salvage surgery and specific plans to reduce pneumonia through means such as pulmonary rehabilitation are required. Disclosure All authors have declared no conflicts of interest.

Background There is no consensus regarding the optimal extent of lymphadenectomy for the esophagogastric junctional (EGJ) cancer. The Japanese esophagogastric cancer treatment guideline showed the tentative standard in the extent of lymphadenectomy based on the location, histology and T-categories. The purpose of this study is to identify the lymph node status in patients with pT1 EGJ adenocarcinoma. Methods From January 2000 to November 2016, we underwent radical resection with or without sentinel lymph node (SN) mapping for esophagogastric cancer at Keio University Hospital. We identified 38 patients with pT1 adenocarcinoma with its center located within 2cm of the junction. We then analyzed the lymph node status and SN distribution. Results The primary tumor that had their epicenter within the proximal of the cardia in 37%, that had their epicenter within the distal of the cardia in 63% of all patients (n = 12, 26). The surgical procedures were proximal gastrectomy (n = 30); subtotal esophagectomy (n = 4); and total gastrectomy(n = 4). Two patients (5%) had positive lymph node metastasis. Of the 2 patients with positive node, one patient had the metastatic lymph node along the short gastric vessels and the other patient had the metastatic lymph nodes along both the left gastric artery and the celiac artery. Those 2 patients with positive node had no recurrence. However, liver or local (anastomotic) recurrence occurred in 1 patients, respectively. SN was accomplished in all patients who underwent SN mapping and diagnostic accuracy based on the SN status was 100% (17/17). Conclusion Our results suggested that lower mediastinal lymphadenectomy was of limited significance in patients with pT1 EGJ adenocarcinoma. SN mapping may be contributory to the optimal extent of lymphadenectomy. Disclosure All authors have declared no conflicts of interest.

Background In our institute, we usually use gastric tube for reconstruction organ after esophagectomy. When we can’t use gastric tube, we use right hemi-colon with ante-thoracic route. Previously, we reconstructed by 1-step after esophagectomy, but from 2012, we have done by 2-step for reduce postoperative complications. Methods We enrolled 15 esophageal cancer patients who underwent esophagectomy and right hemicolon reconstruction between April 2004 and December 2016. Results The average age of 15 patients is 67.3. The reasons of using right hemicolon are as follows; post gastrectomy 13, stomach double cancer 2. The reasons of gastrectomy are as follows; gastric cancer 8, duodenum cancer 1, gastric ulcer 4. The average duration from gastrectomy to esophagectomy is 12.5 year. We reconstructed by 1-step for 5 patients, and after 2012, we reconstructed by 2-step for 10 patients. Anastomotic leakages were found in 2 cases (40.0%) in 1-step reconstruction group, and 3 cases (20.0%) in 2-step reconstruction group. In 1-step reconstruction group, 1 case occurred multiple anastomotic leakages and DIC, and another 1 case was found necrosis of reconstructive colon. In 2-step reconstruction group, we found 1 case of major leakage and 1 case of recurrent nerve paralysis and 2 cases of postoperative pneumonia. However, there were no case of tracheotomy. The incidence of pneumonia did not differ between the two groups. And the term of postoperative oral intake tend to shorter in 2-step reconstruction group (P = 0.06). 2 severe postoperative complications (Clavian-Dindo V or IVa) cases were found in 1-step reconstruction group, on the other hand, 2 cases severe complications (CD IIIa) in 2-step reconstruction group. Conclusion In the case of using right hemicolon as a reconstructive organ, 2-step reconstruction approach is useful and superior from the viewpoints of postoperative complications. Disclosure All authors have declared no conflicts of interest.

Invasive ductal adenocarcinoma (IDA) of the pancreas (IDAP) originating from the ductal gland has a poor prognosis. Noninvasive carcinomas are principally intraductal papillary mucinous carcinomas (IPMCs) and pancreatic intraepithelial neoplasms 3 (PanIN-3). Small papillary-cohesive clusters, individually well-enveloped nuclei in well-preserved cytoplasm, centrally located nuclei, small nuclei (about 10 mum), euchromatin, clearly defined cell borders, small cytoplasm without prominent anisocytosis and no cytoplasm more than 21 mum in shortest diameter, a mixture of goblet cells, and a pleomorphic aspect are common in IPMC and intraductal papillary mucinous neoplasm (IPMN), whereas malignancy in nuclei are observed only in IPMC. PanIN-3 cells have small papillary-cohesive and compact clusters, a monomorphic aspect, and small dense cytoplasm and are highly suggestive of malignancy. IDA cells have loose sheet and solid clusters, poorly preserved cytoplasm, nuclei that tend to adhere to each other, large nuclei, a combination of large nuclei (short diameter