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Oral administration of cystine and theanine (CT) increases glutathione levels to modulate the inflammatory response, which has yet to be sufficiently explored for patients' recovery and early rehabilitation. We planned a randomized, double-blind, placebo-controlled trial to determine whether perioperative oral administration of CT promotes recovery after esophagectomy. Patients were randomized into either CT or placebo groups, who received preoperative and postoperative treatments for 4 and 13 days, respectively. The main outcome measures were triaxial accelerometer readings, inflammation indicators, a 6 min walk test (6MWT), and a quality of life questionnaire (QoR-40). The study involved 32 patients. Although the CT group ( n = 16) showed better patient activity across the investigated period, there was no significant difference between the two groups. However, white blood cell count on postoperative days (POD) 2 and 10, neutrophil count (POD 2, 7, and 10), and C-reactive protein level (POD 13) in the CT group were significantly lower than in the placebo group. Furthermore, 6MWT on POD 7 and QoR-40 on POD 13 were significantly higher in the CT group than those in the placebo group. This study suggests that perioperative administration of CT may contribute to early recovery and rehabilitation after esophagectomy via suppression of inflammatory response.

Background: Patients with esophageal cancer suffer from anxiety in the perioperative period surrounding esophagectomy; this may increase the risk of postoperative complications. In particular, postoperative aspiration pneumonia carries a high risk of hospital mortality. Bukuryoingohangekobokuto (BRIHK) is a traditional Japanese medicine formula used to treat anxiety, the feeling of a foreign body in the esophagus, and water brash. We hypothesize that BRIHK might be effective for both anxiety and water brash in perioperative patients with esophageal cancer. The aim of this study is to evaluate the efficacy and safety of BRIHK compared to a placebo for anxiety and water brash in perioperative esophageal cancer patients., Method/design: This will be a single-center, single blind, placebo-controlled randomized clinical trial. Twenty-four patients with esophageal cancer undergoing radical resection surgery will be registered to participate, then randomly and blindly assigned to the BRIHK treatment group or control group. Patients will be administered BRIHK or the placebo from 2 weeks before to 6 weeks after surgery. Primary outcome measures will be anxiety and depression (assessed using the Hospital Anxiety and Depression Scale), and water brash (assessed using the 10-item Eating Assessment Tool, Esophagus and Stomach Surgery Symptom Scale, and videofluoroscopy swallowing measurement). Incidences of aspiration pneumonia will be noted and abdominal gas volume, inflammatory markers, and nutrition status will be evaluated., Discussion: This investigative study will provide clinical evidence of BRIHK administration for anxiety and water brash, which might improve mental distress and reduce postoperative mortality., Trial Registration: The protocol and progress are registered on the Japan Registry of Clinical Trials (jRCT s021190001) and University Hospital Medical Information Network (UMIN000031330). The protocol was approved by the Japanese Ministry of Health, Labour and Welfare certified clinical research review board, Tohoku University (CRB2180001).

Recently, thoracoscopic esophagectomy has been widely accepted as a minimally invasive surgery and a possible standard procedure for esophageal cancer patients. Furthermore, it has an advantage for meticulous lymph node dissection by providing a magnification view and less blood loss. Mediastinal lymphadenectomy, especially upper mediastinal lymph node dissection, is a key point for esophageal cancer surgery because of its high frequency of metastasis and dissection efficacy. To avoid complications such as recurrent laryngeal nerve palsy, pneumoniae, chylothorax and unexpected injury in mediastinal lymph node dissection, detailed anatomical knowledge and careful procedures are required for surgeon. An appropriate operative procedure or technique will lead to good short- and long-term outcomes for the patients with esophageal cancer.

Background: Bezoars are rare but may cause gastrointestinal obstruction and ulcers. To the best of our knowledge, only two cases of bezoars in the reconstructed gastric conduit have been reported, but there has been no report on reconstructed gastric conduit obstruction due to bezoars., Case Presentation: A 60-year-old man presented to our clinic with abdominal pain and vomiting that occurred suddenly after dinner. Three years before presentation, he had undergone radical thoracoscopic esophagectomy followed by reconstruction of the gastric conduit through the posterior sternum, for esophageal cancer. Enhanced computed tomography scans showed distension of only the gastric conduit without ischemia and distension of the small intestine. According to our findings, we initially diagnosed the patient with postoperative intestinal obstruction caused by adhesions. After conservative treatment failed, the patient underwent an endoscopic study that showed a bezoar at the pylorus ring. We initially failed to remove the bezoar endoscopically because of its large size; hence, we attempted enzymatic dissolution. Three days after the first endoscopic study, the bezoar was disintegrated using a snare and extracted during a second endoscopy. The patient recovered uneventfully and presented with no complications during the 1-year follow-up interval., Conclusion: In cases wherein the discharge of materials in the reconstructed gastric conduit is delayed, bezoars should be considered in the differential diagnosis, and an endoscopic study should be performed to verify the cause of obstruction.

Background: Funnel chest is the most common chest deformity, occurring in 0.06-0.3% of the general population. When it occurs concomitantly with esophageal cancer, it hinders intrathoracic surgery that is necessary for treatment. Although there are a few reports of esophagectomy performed in patients with funnel chest, simultaneous treatment of esophageal cancer and funnel chest with funnel chest surgery (Nuss method) and esophagectomy has not been reported. We report the first case of advanced esophageal cancer complicated by severe funnel chest that was treated using the Nuss method and radical thoracoscopic esophagectomy., Case Presentation: A 59-year-old man was diagnosed with advanced thoracic esophageal cancer and severe funnel chest. Because his sternum was almost attached to the vertebral bone, thereby creating a narrow space in the mediastinum, esophageal surgery was expected to be complicated. After the patient underwent neoadjuvant chemotherapy, we used the Nuss method to reconstruct the chest and widen the mediastinum. Subsequently, radical thoracoscopic esophagectomy was performed with the patient in the left decubitus position without any difficulty, and the postoperative course was uneventful., Conclusion: Simultaneous funnel chest surgery (Nuss method) and thoracoscopic esophagectomy with the patient in the left decubitus position are recommended for esophageal cancer patients with severe funnel chest.

Background: The problem of recurrent laryngeal nerve (RLN) paralysis (RLNP) after radical esophagectomy remains unresolved. Several studies have confirmed that intraoperative nerve monitoring (IONM) of the RLN during thyroid surgery substantially decreases the incidence of RLN damage. This study tried to determine the feasibility and effectiveness of IONM of the RLN during thoracoscopic esophagectomy in the prone position for esophageal cancer., Methods: All 108 patients who underwent prone esophagectomy at Tohoku University Hospital between July 2012 and March 2015 were included in this study. We divided patients into two groups: a control group (No-Monitoring group, surgery without IONM; n = 54) and a study group (Monitoring group, surgery with IONM; n = 54). In Monitoring group, neural stimulation was performed for both RLNs before and after dissection in the thoracic procedure, then for RLNs and vagus nerves (VNs) in the cervical procedure. The feasibility of IONM in Monitoring group and early surgical outcomes were retrospectively compared with those in No-Monitoring group., Results: IONM could be performed for 47 cases (87.0%) in Monitoring group. Reasons for discontinuation were use of muscle relaxants (3 patients), change in thoracotomy procedure (2 patients), past rib bone fracture (1 patient), and allergic shock by transfusion (1 patient). Right RLNPs were identified postoperatively in 4 patients, and left RLNPs in 23 patients. IONM sensitivities were 92.7 and 88.0% for the right and left VNs, respectively. Incidences of postoperative RLNP, aspiration, and primary pneumonia did not differ significantly between groups., Conclusions: This study confirmed the feasibility and safety of IONM of the RLN for thoracoscopic esophagectomy in the prone position. No significant differences in postoperative outcomes were seen between esophagectomy with and without IONM.

Background: Prone thoracoscopic esophagectomy was introduced at our institution from 2012. This study describes our experiences of the main differences between thoracoscopic esophagectomy in the prone and traditional left lateral decubitus positions together with an analysis of the short-term surgical outcomes., Method: In total, 87 patients undergoing thoracoscopic esophagectomy between January 2012 and October 2013 at Tohoku University Hospital were enrolled; of these, 54 and 33 patients were operated in the prone (Group P) and lateral decubitus (Group L) positions, respectively., Results: The background of the patients was similar, and there was no in-hospital mortality. There were no significant differences between the groups in terms of whole surgical duration, thoracic duration, and number of dissected lymph nodes. Total blood loss and thoracic estimated blood loss were significantly lower in Group P than Group L. Furthermore, postoperative pulmonary complications, intensive care unit stay, and hospital stay were significantly lower in Group P., Conclusion: Thoracoscopic esophagectomy in the prone position is feasible and safe. The prone position technique may be superior to conventional lateral decubitus position esophagectomy.

Background: The prognosis for patients with locally advanced thoracic esophageal cancer is extremely unfavorable. We have been administering neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy to these patients and studying whether REG I expression in untreated endoscopic biopsy specimens is predictive of patient responsiveness to CRT and/or survival after treatment., Methods: Between 1992 and 2003, 47 patients with T4 (direct invasion of adjacent organs) thoracic esophageal cancers were administered neoadjuvant CRT followed by esophagectomy. REG I expression was assessed in untreated endoscopic biopsy specimens and correlated with clinical and histological responses and survival in 37 patients who had also undergone curative surgery., Results: Among the 37 cases that received CRT followed by surgery, the therapeutic response rate for neoadjuvant CRT was 68%, and a complete histological response in resected specimens from the primary lesion was achieved in 8 (22%) patients. These clinical and histological responses to neoadjuvant CRT did not significantly correlate with survival, however. By contrast, 9 patients were judged REG-positive based on analysis of their untreated endoscopic biopsy specimens, and their cumulative survival rate was significantly higher than that of the 28 REG-negative patients (P = 0.0073). Univariate analysis showed REG I expression to be a prognostic factor (P = 0.0386) that increased the risk of death 8.4-fold., Conclusions: Evaluation of REG I expression in untreated endoscopic biopsy specimens may provide a basis for new treatments of locally advanced thoracic squamous cell esophageal cancers.

Background: Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit. Methods: A total of 326 patients who underwent thoracoscopic/robot‐assisted esophagectomy followed by gastric conduit reconstruction and end‐to‐side anastomosis were enrolled. We divided the gastric conduit into zones I (dominated by the right gastroepiploic vessels), II (dominated by the left gastroepiploic vessels), and III (perfused with short gastric vessels). Before pulling up the gastric conduit to the neck, LDF values were measured at the pylorus, the border between zones I and II (zone I/II), the border between zones II and III (zone II/III), and the gastric conduit tip (tip). The blood flow ratio was calculated as the LDF value divided by the LDF value at the pylorus. Results: Anastomotic leakage developed in 32 of 326 patients. Leakage was significantly associated with the blood flow ratio at the tip (p < 0.001), but not at zone I/II, zone II/III, and the anastomotic site. The receiver‐operating characteristic curve analysis identified an anastomotic leakage cutoff ratio of 0.41 (at the tip). A multivariate Cox analysis showed that a blood flow ratio <0.41 at the tip was an independent risk factor for anastomotic leakage (p < 0.001). Conclusion: Anastomotic leakage after esophagectomy was significantly associated with the blood flow ratio at the tip of the gastric conduit. Preservation of the blood supply to the tip via the gastric wall might contribute to a decreased incidence of anastomotic leakage. [ABSTRACT FROM AUTHOR]

Background: With the improved survival rate of patients with esophageal cancer, secondary cancers, including pharyngolaryngeal cancer, have become a problem. Phanryngolaryngeal cancer surgery often requires esophagogastric anastomosis resection in patients with a previous history of subtotal esophagectomy. Owing to adhesions, especially surrounding the esophagogastric anastomosis, caused by the initial surgery, the second surgery might cause postoperative complications. Case presentation: A 65-year-old man was diagnosed with early stage esophageal squamous cell carcinoma and underwent endoscopic mucosal dissection. However, the histopathological depth of the tumor was pT1b, and additional treatment was required. After administration of the neoadjuvant chemotherapy, he underwent thoracoscopic esophagectomy and retrosternum reconstruction via a gastric tube (pT1N3M0 stage III). Eight months after the first surgery, tumor recurrences were observed at the anastomosis and left cervical lymph node. Definitive chemoradiotherapy was performed for the recurrences, and complete response was achieved. Seven months after chemoradiotherapy, he was diagnosed with hypopharyngeal squamous cell carcinoma in the right piriform fossa (cT2N2bM0 stage IVA), and salvage surgery was chosen as treatment. The surgical findings revealed strong adhesion around the remnant esophagus, which was difficult to dissect from surrounding tissue and was associated with a risk of breaking of the anastomosis. However, indocyanine green fluorescence imaging findings indicated sufficient blood flow to preserve the remnant esophagus, including the anastomosis, even after the interruption of blood flow from the proximal side of the esophagus by total pharyngolaryngectomy. Finally, approximately 4 cm of the remnant esophagus was preserved, and the free jejunum reconstruction with cervical vascular anastomosis was performed. Moreover, the patient was discharged without complications on postoperative day 38. After 10 months of the second surgery, a metastatic lymph node was observed in the right neck. Immune checkpoint inhibitors and chemotherapy were administered, and the patient is alive and under treatment 1.5 years after the second surgery. Conclusions: Blood supply to the remnant cervical esophagus was thought to be from the gastric conduit over the anastomosis and surrounding capillaries. Thus, the preservation of the remnant esophagus can be considered in total pharyngolaryngectomy even after < 2 years of esophagectomy by blood flow evaluation using indocyanine green fluorescence. [ABSTRACT FROM AUTHOR]

Background: The clinical features of postoperative primary tracheobronchial necrosis (P‐TBN; the necrosis without anastomotic leakage or other cervical and mediastinal abscess) remains unclear. This nationwide multicenter retrospective study first investigated the clinical features of P‐TBN after esophagectomy for upper aerodigestive tract cancer with a large cohort. Methods: As a study of the Japan Broncho‐Esophagological Society, a nationwide questionnaire survey was conducted in 67 institutions. The clinical data of 6370 patients who underwent esophagectomy for laryngeal, pharyngeal, and esophageal cancer between 2010 and 2019 were collected. Grades of P‐TBN were defined as follows: Grade 1, mucosal necrosis; Grade 2, transmural bronchial wall necrosis without fistula or perforation; Grade 3, transmural bronchial wall necrosis with fistula or perforation. Results: P‐TBN was observed in 48 (0.75%) of 6370 patients. The incidences of P‐TBN for pharyngo‐laryngo‐cervical esophagectomy (PLCE; n = 1650), total pharyngo‐laryngo‐esophagectomy (TPLE; n = 205), and subtotal esophagectomy (SE; n = 4515) were 2.0%, 5.4%, and 0.1%, respectively. The upper mediastinal LN dissection (P = 0.016) and the higher level of the tracheal resection (P = 0.039) were significantly associated with a higher grade of necrosis in PLCE and TPLE. Overall survival rates were significantly lower in patients with Grade 2 (P = 0.009) and Grade 3 (P = 0.004) than in those with Grade 1. Conclusion: The incidence of TBN restricted to P‐TBN was lower than previously reported. Maintaining the tracheal blood flow is essential to prevent worsening P‐TBN, especially in PLCE and TPLE. Our new P‐TBN severity grade may predict the outcome of patients with P‐TBN. [ABSTRACT FROM AUTHOR]

Background: Esophageal achalasia causes dysphagia following impaired relaxation of the lower esophageal sphincter due to the degeneration of Auerbach's plexus in the esophageal smooth muscle. Recently, peroral endoscopic myotomy (POEM) has become one of the preferred treatment options for esophageal achalasia. However, pathomorphological changes after POEM have not been well examined. Case presentation: A 65-year-old man with a history of POEM for esophageal achalasia was diagnosed with clinical stage II (cT2-N0-M0) thoracic esophageal squamous cell carcinoma and was consequently treated with neoadjuvant chemotherapy followed by thoracoscopic esophagectomy. Intraoperatively, the esophagus appeared dilated, reflecting esophageal achalasia; however, fairly slight fibrous adhesions were observed between the esophagus and the pericardial surface despite previously performed POEM via an anterior incision. Histopathological examination revealed esophageal wall thickening, edema, and fibrosis extending from the lamina propria to the submucosa. Besides, the majority of the inner layer and some proportion of the outer layer of the muscularis propria were found to be missing or atrophic at the esophagogastric junction (EGJ). No ganglion cells could be detected at the Auerbach's plexus. Conclusions: The previous history of POEM did not affect circumferential mediastinal periesophageal dissection during thoracoscopic esophagectomy. Nevertheless, a large proportion of the inner layer of the muscularis propria at the EGJ level seemed to have become lost or atrophic because of the POEM procedure. [ABSTRACT FROM AUTHOR]

Background Although the outcome of patients with recurrent esophageal cancer following radical esophagectomy is extremely poor, long-term survival can be achieved with multimodal therapy, including surgical resection of the recurrent lesion. Developing a treatment strategy is a critical issue; therefore, we examined the indications and optimal timing for surgical treatment in patients with recurrence. Methods A total of 184 patients with recurrent esophageal cancer after radical esophagectomy were studied between 2001 and 2015, with a focus on surgical resection. Results The first recurrence site was the lymph nodes (124 cases; 67%) [neck (35; 19%), mediastinum (82; 45%), abdomen (35; 19%)], lung (36; 20%), liver (32; 17%), pleura (18; 10%), bone (13; 7%), etc. Second-line treatment following recurrence was surgery (8 cases), chemoradiotherapy (89 cases), chemotherapy (64 cases), and best supportive care (23 cases). Patients with single organ or solitary recurrence and recurrence more than 8 months after surgery had better prognoses. All the surgical cases had single-site recurrence (lung-3, cervical lymph nodes-3, colon-1, and brain-1). Good prognosis was expected for the patients with lung or cervical lymph node recurrence. Conclusion Surgical treatment for recurrent esophageal cancer following radical esophagectomy was considered beneficial for the recurrence of cervical lymph node or lung metastasis of solitary lesions at least 8 months after esophagectomy. Immune checkpoint inhibitors have recently been indicated for esophageal cancer and expected for improving prognosis, and the role of surgery in multidisciplinary treatment for metastatic recurrence needs repeated investigation. [ABSTRACT FROM AUTHOR]

Background Robot-assisted minimally invasive esophagectomy (RAMIE) has become widely performed in Japan, and the technique and short-term results have been accumulated. In our institute, we started with daVinci S in 2013, switched to Xi in 2018, and have experienced 110 cases so far. Method; Technique and Devices: Semi-prone position with the left upper extremity placed under the body, 4 ports +1 assist port (Air Seal), double bipolar system—is the basic approach. The right upper extremity is placed so that it is attached to the head to provide axillary working space, and orthoglass to avoid direct compression of the right upper arm and robotic 4th arm. The range of motion of the 4th arm in the lower mediastinum is limited by the patient's physique, so assistant forceps are used to assist as needed. Be willing to invert the camera to view the back of the operative field. Intraoperative recurrent nerve monitoring (NIM) was used in all cases. Results Five surgeons have performed RAMIE procedures. There have been no cases of conversion to thoracoscopic or open thoracotomy. The thoracic procedure time was significantly longer in RAMIE (299 min:274 min) than in thoracoscopic MIE. Blood loss tended to be less (17.1 mL: 44.0 mL). The incidence of recurrent nerve palsy (CD grade I or higher) was 44%:37%, that of pneumonia (CD grade II or higher) was 19%:18% and perioperative complications were similar between the two groups. Comparing the first half of the period when RAMIE was initiated with the second half, there was a significant decrease in the amount of bleeding, surgery time, and incidence of pneumonia, indicating an improvement in technique due to the number of experienced cases. Conclusion RAMIE can be performed safely, although no clear advantages can be demonstrated compared to thoracoscopic MIE at this time. RAMIE has clear advantages in terms of visual magnification of the dissected layer and stability of the surgical field, therefore, it is expected to reduce complications due to improved technique. [ABSTRACT FROM AUTHOR]

Background Neoadjuvant chemotherapy (NAC) by 5-fluorouracil (5-FU) and cisplatin followed by esophagectomy has been established as a standard approach for the patients with clinical stage II/III esophageal squamous cell carcinoma (ESCC) in Japan. However, NAC is not always effective in all these patients, and it is important to identify biomarkers for predicting the response. Therefore, the present study aimed to identify markers for predicting the response to chemotherapy and the clinical outcomes. Methods This study included 62 ESCC patients who underwent esophagectomy following NAC. We performed immunohistochemical analyses for murine double minute 2 (MDM2), thymidine phosphorylase (TP), dihydropyrimidine dehydrogenase (DPD), and excision repair cross-complementing rodent repair deficiency-1 (ERCC1) in surgical specimens following NAC and assessed the associations of the findings with clinicopathological features in individual patients. Results The MDM2 status and ERCC1 status demonstrated significant inverse associations with the response to NAC (MDM2: P  = 0.025, ERCC1: P  = 0.021). In addition, a high TP status in the tumor was significantly associated with tumor differentiation (P  = 0.008), depth of invasion (P  < 0.001), lymphatic invasion (P  = 0.003), venous invasion (P  < 0.001) and tumor stage (P  = 0.006). Moreover, a high DPD status was associated with tumor differentiation (P  = 0.008), depth of invasion (P  < 0.001), venous invasion (P  = 0.003) and tumor stage (P  = 0.007). The TP status also significantly predicted the eventual clinical outcome of patients following surgery. Conclusion Recently, overexpression of MDM2 has been reported for poor prognosis in patients with ESCC treated by chemoradiotherapy. 5-FU metabolic enzymes, such as TP andDPD, have been investigated for sensitivity to 5-FU. ERCC1, a key component of homologous recombination-based repair of interstrand DNA cross-links, has been reported to predict sensitivity to cisplatin. In our study, MDM2 and ERCC1 immunoreactivity predict chemosensitivity of NAC based on 5-FU and cisplatin. High intratumoral TP status and DPD status are associated with tumor progression and prognosis in ESCC patients receiving NAC. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Background Chylothorax is relatively rare complication in esophagus cancer surgery. But once it happens, appropriate treatment is absolutely essential to avoid another severe complication. We report our treatment results of chylothorax after thoracoscopic esophagectomy and represent the appropriate treatment strategy for this complication. Methods We examined 468 patients who underwent thoracoscopic esophagectomy for esophageal cancer from January 2009 to November 2017. Thoracic duct was mostly preserved except the case which had cancer invasion. Also, MRI scan was performed in all cases to detect the location of thoracic duct preoperatively. When the surgical approach was planned for chylothorax after esophagectomy, 250ml of 20% soybean oil was administrated through jejunostomy tube 30 minutes prior to the surgery. Thoracic duct is usually detected at the inferior mediastinum by thoracoscopy and applies ligation or clipping. Treatment effect can be checked during the surgery by interruption of soybean oil leakage which was easily recognized before ligation. Results Postoperative chylothorax was detected in seven out of 468 cases (1.50%). Thoracic duct had been preserved in all of those seven cases. Among them, two cases improved just by drainage and five needed to undergo thoracoscopic thoracic duct ligature. The mean amount of daily thoracic drainage was 1106 ml in the ligation group whereas 565 ml in the conservative treatment group. The median hospitalization days after surgery among ligation and conservative group was 33.5 and 25days, the median day until oral intake was 21 and 13 days, the median days until thoracic drain removal was 10.5 and 9 days, respectively. Conclusion In the case of chylothorax after esophagectomy, early oral intake and short hospitalization was possible by performing thoracoscopic thoracic duct ligature, especially in the case which had large amount of pleural effusion drainage. MRI was useful equipment to detect the variant of thoracic duct and to perform thoracoscopic thoracic duct ligature safely. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Background Recently, operation cases of elderly patients are increasing in esophageal carcinoma. Because elderly patients often have pre-existing disease and may easily cause postoperative complications, it is necessary to consider whether surgical treatment is appropriate for those elderly patients. The aim of this study is to investigate the safety of esophagectomy for elderly patients with esophageal carcinoma. Methods All 483 patients who underwent esophagectomy for esophageal carcinoma between April 2007 and March 2015 were included in this study. Patients were divided into two groups: elderly group (over 75 years old: n = 72) and control group (under 75 years old: n = 411). The short and long-term outcomes were retrospectively examined to those groups. Results In the elderly group, their median age was 77 [75–85] and all of their performance status was 0 or 1, except 4 patients. 66 cases of the elderly group had some comorbidity, which was significantly higher than that of the control group (93.0 vs. 80.2%, P = 0.007). Pre-surgical treatment was performed to 38.9% of the elderly group, whereas 58.9% in the control group (P = 0.002). No significant differences were demonstrated in clinical stage, occupation site, histological type and pathological stage between these groups. The operation time was relatively shorter in the elderly group compare to the control group (549 vs. 585min, P = 0.018). The number of dissected lymph node was also smaller in elderly group (31 vs. 35, P = 0.048). The postoperative complications such as pneumonia, recurrent laryngeal nerve paralysis did not show any difference between these groups. The 5-year overall survival rate (OS) and the 5-year disease specific survival rate (DSS) also did not show statistical differences between the elderly and control group (OS: 53.0 vs. 57.0%, P = 0.765; DSS: 64.6 vs. 62.7%, P = 0.605). Conclusion Between elderly and control group, there was no difference in postoperative complication and long-term survival. This study confirmed the safety of esophagectomy for elderly patients with esophageal carcinoma by reducing treatment stress such as neoadjuvant therapy, extended operation time and extensive lymphadenectomy. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Background: Acute esophageal necrosis is defined as necrosis of the esophageal mucosa causing diffuse black pigmentation of the esophagus, the so-called black esophagus from its endoscopic findings. The prevalence is only 0.001~0.2%, while its mortality rate is up to 32%. However, most of the cases are fatal by comorbidities. Case presentation: A 67-year-old female with diabetes mellitus was transported to the emergency room with hematemesis and disordered consciousness. She had suffered from nausea and epigastralgia for 2 days. The patient's general status was shock evidenced by vital signs, and she did not respond to rehydration. After intubation, emergency endoscopic examination revealed black pigmentation of the esophageal mucosa, and the condition was diagnosed as acute esophageal necrosis. Antibiotics and plasmapheresis had been started, and the patient gradually stabilized. One week after the admission, esophagus perforation was suspected from the significant increase of the right pleural effusion and free air at the esophagus wall and the mediastinum on CT scan. Emergency thoracoscopy revealed an edematous esophagus which was colored black. Esophagectomy with esophagostomy and enterostomy was performed. On resected specimen, mucosal necrosis was found only on the squamous epithelium, with three perforating areas in the middle to lower thoracic esophagus. No signs of inflammation or ischemia were found on the gastric mucosa of the esophagogastric junction. After the operation, the patient recovered generally well, except for the severe stenosis of the cervical esophagus. Cervical esophagectomy, tracheotomy, and anterior thoracic route reconstruction with free jejunum interposition and gastric tube were performed 9 months after the first surgery. No postoperative complications occurred; on the 37th day after the operation, the patient was eating well and was transferred to continue swallowing rehabilitation. Conclusion: It is important to detect the esophagus perforation and mediastinitis early and thereby not to miss the chance of surgical intervention to save the patient's life. Surgery should be minimized, and reconstruction should be considered next. If the cervical esophagus is also affected, reconstruction surgery should be performed by removing cervical esophagus and anastomosing it to the hypopharynx using a gastric tube and free jejunum interposition as needed. [ABSTRACT FROM AUTHOR]

Background In 1996 Akaishi et al. reported the first thoracoscopic esophagectomy (TE) in Japan. Total 650 TEs for esophageal cancer have been performed in our institute by October 2016. There are many reports about the short-term outcomes of TE compared with open esophagectomy (OE), but the long-term outcomes of TE have been under debate. The aim of this study is to investigate the survival benefits of TE and to compare with OE and long-term outcomes which other previous reports showed. Methods A total 750 cases who underwent TE (N = 650) or OE (N = 100) between 1994 and 2015 in our hospital were included in this study. They were divided into four groups; surgery without any preoperative treatments (group S, N = 414), surgery after neoadjuvant chemotherapy (Group NAC, clinical stage II or III, N = 116), surgery after neoadjuvant chemoradiotherapy (Group NACRT, clinical stage II or III, N = 68) and salvage surgery after definitive chemoradiotherapy (Group SALV, N = 76). In group S, 100 patients received OE and 314 received TE. The other 3 groups (Group NAC, NACRT and SALV) received only TE. 3-year, 5-year overall survival (OS) and progression-free survival (PFS) rates for each group were analyzed and compared. Results In group S, the 5-year OS rate of TE was 63.4% and that of OE was 68.3%, there was no significant difference (Log-Rank test P  = 0.41). Stage-specific OS rates of TE and OE were also compared and there was no significant difference. PFS rates of OE and TE showed the same tendency of OS. 5-year OS rate of group NAC was 63.5%. 3-year OS of group NACRT was 61.4%. 3-year and 5-year OS of group SALV were 41.4% and 34.0%. These results were the same or better than what the previous reports showed. View large Download slide View large Download slide Conclusion The long-term outcomes of TE were almost same as those of OE. The TE procedure resulted in similar or potentially better long-term outcomes in case of NAC, NACRT and SALV. It's acceptable to say thoracoscopic approach is the standard of esophagectomy. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Background Acute necrotizing esophagus is defined as the diffuse black pigmentation of the esophagus due to the necrosis of the esophageal mucosa, and so called 'black esophagus' from its endoscopic findings. The prevalence is only 0.001∼0.2%, although the mortality rate is up to 32%. Methods 67 years old female with medical history of diabetes mellitus, transported to the emergency room with hematemesis and conscious disorder. She had suffered from nausea and epigastralgia for two days. Her general status was in shock vitals and didn't respond to rehydration. After intubation, emergency endoscopic examination revealed black pigmentation of the esophageal mucosa and diagnosed as acute necrotizing esophagitis. Antibiotics and blood absorption therapy had been started and the patient gradually stabilized. 1 week after the admission, esophagus perforation was suspected from the significant increase of the right pleural effusion and free air at the esophagus wall and the mediastinum on CT scan. Emergency thoracoscopy was performed and found that the esophagus was edematous and adventitia was colored into black. The esophagectomy with esophagostomy and enterostomy was performed. Results On resected specimen, mucosal necrosis was found only on squamous epithelium with three perforating areas in the middle to lower thoracic esophagus. No signs of inflammation nor ischemia was found on the gastric mucosa of the esophagogastric junction. After the operation, patient recovered generally well, except the severe stenosis of the cervical esophagus had developed. Although endoscopic dilation had been constantly performed, the reconstruction remains unsolved issue. Conclusion In acute necrotizing esophagitis, stabilization of the patient's condition by treating comorbid diseases is extremely important. Improving the nutritional status in addition to the administration of antacids and antibiotics is also required. Surgical intervention should be performed when perforating mediastinitis or abscess formation occurs. Primary closure shouldn't be attempted, and esophageal resection with delayed reconstruction should be considered in addition to drainage. In this case, we could successfully rescued the patient with necrotic esophagitis by performing surgical intervention promptly. It is important to detect the esophagus perforation and mediastinitis early, not to miss the chance of surgical intervention for curative treatment. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

Background Aorto-esophageal fistula (AEF) is relatively rare, but life-threatening condition. AEF is usually caused in the patients with thoracic aortic diseases, such as aneurysms, or after thoracic aortic surgery. We present our surgical strategy for AEF. Methods From May 2004 to November 2017, 12 patients with AEF were treated at our hospital. The age ranges from 44 to 83 years, and the number of male/female was 9/3. Five patients had previous thoracic endovascular aortic repair (TEVER) in the descending aorta, four patients had descending or total arch replacement. Two patients caused by rupture of thoracic aortic aneurysm, and one patient had penetration of esophagus caused by aspiration of Press Through Package. As the first procedures for surgical treatment, we perform TEVAR in order to prevent the fatal hemorrhage from aortic pseudoaneurysm. At the same day, removal of esophagus with debridement of adjacent infected tissues is performed by open thoracic procedure. After a few days, excision of the infected graft or the aorta followed by new graft replacement with omental flap installation is performed. Four patients used homograft and four patients used rifampicin-soaked graft. After the patient's general condition improve, we plan to perform open surgery for reconstruction of esophagus. Results A 3-year survival rate was 50%, and perioperative mortality was 25%. Hospital mortality was noted in 3 patients due to sepsis, brainstem infarction and pulmonary hemorrhage (6–117 days after the first surgery). Late death occurred in 4 patients (n = 2: ileus, n = 1: carcinoma, n = 1: pneumonia). Eight patients could undergo esophagus reconstruction, by colon graft in 4 patients, a pedicled jejunum and a gastric tube in 2 patients, respectively. The duration from esophageal resection to reconstruction was 1–11 months. Conclusion Because AEF usually accompanied with hemodynamic instability, immediate surgical intervention is regarded as the only effective treatment. Corporation between gastrointestinal surgeons and cardiovascular surgeons is necessary to achieve this treatment. We share our experiences of AEF treatment and discuss surgical strategy. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]