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Cervical anastomotic stricture after esophagectomy is a serious complication that adversely affects postoperative recovery, nutritional status and quality of life. Cervical anastomosis by a circular stapler (CS) has been widely accepted as a simple and convenient method, but anastomotic strictures are likely to occur. The aim of this study was to investigate an association between CS size and the incidence of anastomotic stricture after cervical esophagogastric anastomosis performed by a CS. Between April 2011 and March 2016, 236 consecutive patients underwent cervical esophagogastric anastomosis by a CS via a retrosternal route after esophagectomy for esophageal cancer. These patients were divided into according to CS size for the procedure as follows: small-sized (25 mm) CS group (SG, n = 116) and large-sized (28 or 29 mm) CS group (LG, n = 120). The clinical data of patients were analyzed retrospectively to compare the two groups. Overall, anastomotic strictures were observed in 90 patients (38%). The incidence of anastomotic stricture was significantly lower in the LG than the SG (23% vs. 53%, p

We clarified the effects of perioperative enteral supplementation with glutamine, fiber, and oligosaccharide (GFO) after an esophagectomy on preventing surgical stress. Of 326 patients with esophageal cancer, 189 received GFO administration (GFO group) and 137 did not (control group). The propensity score matching method was used to identify 89 well-balanced pairs of patients to compare postoperative laboratory parameters and clinical and postoperative outcomes. The duration of the systemic inflammatory response syndrome (SIRS) was significantly shorter in the GFO group compared to the control group (p = 0.002). Moreover, the lymphocyte/neutrophil ratio (L/N ratio) had significantly recovered in the GFO group on postoperative day-3, and the CRP value was significantly lower in the GFO group than that in the control group on postoperative day-2. Perioperative use of enteral supplementation with glutamine, fiber, and oligosaccharide likely contributes to a reduction in early surgical stress after an esophagectomy. These beneficial effects can bring about early recovery from postoperative immunosuppressive conditions after radical esophagectomy.

Jejunostomy, which requires the fixation of the jejunum to the abdominal wall, is commonly used as an enteral feeding access after esophagectomy. However, this procedure sometimes causes severe complications, such as mechanical bowel obstruction. In 2009, we developed a modified approach to insert an enteral feeding tube through the reconstructed gastric tube using the round ligament of the liver. The aim of this study is to investigate the usefulness of this approach as compared to the approach through jejunostomy. Between January 2005 and March 2015, 420 patients with thoracic esophageal cancer underwent esophagectomy via thoracotomy and laparotomy. Of these, 214 underwent feeding jejunostomy (FJ group) and 206 patients underwent feeding via gastric tube with round ligament of the liver (FG group). Catheter-related complications, other postoperative complications, and mortality were compared between the two groups. The incidence of catheter site infection during catheterization in the FG group was significantly lower (n = 1/206, 0.5%) compared to the FJ group (n = 11/214, 5.1%) (P < 0.01). The postoperative bowel obstruction did not occur in the FG group, while it occurred in eight patients (3.7%) in the FJ group (P < 0.01). The incidences of other catheter-related and postoperative complications were similar between the two groups. Feeding catheter gastrostomy with the round ligament of the liver can be a useful enteral feeding access after esophagectomy, because the incidence rate of severe catheter-related complications, such as surgical site infection and mechanical obstruction tend to be lower with this technique compare to jejunostomy.

Background: Intrathoracic herniation of gastric tube (IHGT) pull-up via the retrosternal route is a rare complication following esophagectomy, which is caused due to an injury in the parietal pleura during a blunt dissection of the retrosternal space. However, little is known regarding the clinical impact of IHGT pull-up via the retrosternal route. Patients and Methods: Clinical data of 231 patients receiving gastric tube reconstruction via the retrosternal route following esophagectomy were collected from medical charts. Results: Of the 231 patients, 19 (8%) developed IHGT. Vocal cord palsy, particularly with delayed onset, developed at a significantly high frequency in the group of patients with IHGT. There were no significant differences in the frequency of other surgical complications. Conclusion: This is the first report to examine the clinical impact of IHGT pull-up via the retrosternal route. Vocal cord palsy, particularly with delayed onset, developed in the group of patients with IHGT. Therefore, when reconstruction is performed via the retrosternal route, it is very important that blunt and blind dissection of the retrosternal space be performed with extreme care to prevent pleural injury.

To stratify stage IIB (pT4a PN0) colorectal cancer in terms of histopathologic findings. We reviewed the medical records of 80 patients who underwent surgery for stage IIB colorectal cancer. The disease-free survival (DFS) and overall survival (OS) rates were evaluated and correlated with the presence or absence of “Tumor Necrosis”, “Crohn’s-like lymphoid reaction”, and “Perineural Invasion”. Patients with “Tumor Necrosis” had significantly lower DFS rates (p

A germ cell tumor is the most common form of malignancy in early male life, and can be classified as either seminomatous or nonseminomatous. Choriocarcinoma, comprised of nonseminomatous germ cells, is the most aggressive type of germ cell tumor and characteristically metastasizes to the retroperitoneal lymph nodes and less frequently to the lungs, liver, bone or brain [Shibuya et al., 2009;48: 551–554]. A 56-year-old man was admitted to another hospital complaining of abdominal distension. Symptoms included anorexia, vomiting, and diarrhea. The patient was diagnosed with an extragonadal germ cell tumor and referred to our hospital to receive chemotherapy. The day after admission, the patient’s abdominal distension gradually worsened. An emergency operation revealed venous hemorrhage from the surface of a metastatic extragonadal germ cell tumor between the ligament of Treitz and the inferior mesenteric vein in a horizontal position. Hemostatic treatment was performed with 4-0 proline thread attached to a medicated cotton sponge, rather than using a simple proline thread, and the closure area was manually compressed. Chemotherapy was initiated on postoperative day 10. A metastatic extragonadal germ cell tumor that causes massive hemorrhage and gastrointestinal hemorrhage is very rare, and represents a life-threatening emergency. If the patient’s condition carries a substantial risk of bleeding to death, it may be worthwhile to attempt abdominal operations.

A 69-year-old man who had undergone an esophagectomy was diagnosed with chylous leakage on postoperative day 2, and his pleural effusion output gradually increased daily. On postoperative day 6, intranodal lymphangiography using lipiodol demonstrated chylous leakage from branches of an incomplete duplicated left-sided thoracic duct; it also indicated successful ligation of the right-sided thoracic duct at initial operation. After lymphangiography, the chylous leakage did not heal and remained uncontrollable. Based on the preoperative lymphangiographic findings, we ligated the left-sided thoracic duct with left-sided video-assisted thoracoscopic surgery, with the patient in the prone position, on postoperative day 9. The patient experienced no other postoperative complications. The use of the prone position with pneumothorax treatment was helpful in providing a wide operative field in the posterior mediastinum, thus allowing for a better chance for a successful postoperative outcome.

A 77-year-old Japanese female underwent laparoscopic ileocecal resection and lymph node dissection for cecal cancer by a previous doctor. Two years and 9 months after previous operation, contrast-enhanced computed tomography and magnetic resonance imaging with gadolinium ethoxybenzyl-L-diethylenetriamine pentaacetic acid revealed an intraperitoneal tumor at the right subphrenic fossa. 18F-fluorodeoxyglucose position emission tomography showed fluorodeoxyglucose accumulation in the tumor, and we suspected the tumor to be solitary distant peritoneal metastasis of the previous cecal cancer to the right diaphragm. We performed partial diaphragmectomy and direct closure, and pathological examination revealed moderately differentiated tubular adenocarcinoma resembling the previous cecal cancer, which seemed to be disseminated metastasis in the pathological features. Based on the intraoperative findings, we assumed the tumor to be solitary distant peritoneal metastasis caused by procedures during the previous laparoscopic operation. The present report suggests the importance of paying close attention to procedures during laparoscopic colorectal resection to prevent peritoneal seeding. J. Med. Invest. 64: 288-290, August, 2017.

Esophageal schwannomas are extremely rare esophageal submucosal tumors. Herein, we report a case of simultaneous resection of left lung cancer and an esophageal schwannoma with video-assisted thoracoscopic surgery. An asymptomatic 74-year-old woman received a diagnosis of an esophageal submucosal tumor during the preoperative assessment of a left lung cancer. The esophageal submucosal tumor arose in the left wall of the lower esophagus, and the patient was diagnosed as having a schwannoma by endoscopic ultrasound-guided fine needle aspiration. She underwent video-assisted thoracoscopic surgery for the simultaneous removal of both tumors. Her postoperative course was uneventful. Thoracoscopic surgery is less invasive than thoracotomy, and this allowed the patient to undergo simultaneous operations for two tumors.

Background Spontaneous esophageal rupture, also known as Boerhaave syndrome, is a very serious life-threatening benign disease of the gastrointestinal tract. It is typically caused by vomiting after heavy eating and drinking. However, in our patient, because of a combination of hypopharyngeal cancer with stenosis and chemoradiotherapy (CRT), which caused chemotherapy-induced vomiting, radiotherapy-induced edema, relaxation failure, and delayed reflexes; resistance to the release of increased pressure due to vomiting was exacerbated, thus leading to Boerhaave syndrome. To the best of our knowledge, this is the first report of a patient with esophageal rupture occurring during CRT for hypopharyngeal cancer with stenosis. Case presentation A 66-year-old man with a sore throat was referred to our hospital. He was found to have stage IVA hypopharyngeal cancer, cT2N2bM0, and underwent radical concurrent CRT consisting of weekly cisplatin (30 mg/m2) and radiation (70 Gy/35fr), for larynx preservation. On day 27 of treatment, he vomited, which was followed by severe left chest pain radiating to the back and the upper abdomen. Enhanced computed tomography (CT) revealed extensive mediastinal emphysema and a small amount of left pleural effusion. Esophagography revealed extravasation into the left thoracic cavity, and the patient was diagnosed with an intrathoracic rupture type of Boerhaave syndrome. He underwent emergency left thoracotomy 21 h after the onset. The ruptured esophageal wall was primarily repaired by closure with two-layer suturing and covered by a pedicled omentum. A jejunostomy tube was placed for postoperative enteral nutrition. On postoperative day (POD) 16, the patient was transferred to head and neck surgery to finish CRT and was discharged on POD 56. He has survived without relapse for 11 months after surgery. Conclusion Patients with head and neck cancer are at risk for developing Boerhaave syndrome during CRT. In addition, since such patients often are in poor overall condition because of immunosuppression and protracted wound healing, Boerhaave syndrome can rapidly lead to severe life-threatening infections such as empyema and mediastinitis. Therefore, awareness of this condition is important so that appropriate treatment can rapidly be implemented to increase the likelihood of a good outcome.

Conservative treatments are usually attempted for the management of post-esophagectomy chylous leakage. However, surgical intervention may be needed when the chylous leakage cannot be stopped using conservative treatments. For the therapeutic management of refractory chylous leakage, it is important to identify the leakage sites when deciding if surgical intervention is required. Nine patients underwent lymphangiography for the treatment of refractory post-esophagectomy chylous leakage. Radiological findings, the daily outputs of pleural effusion after lymphangiography, and the clinical outcomes after lymphangiography were analyzed in our cases and in a retrospective collection of 24 cases from 1983 to 2015 recorded with precise detail. In the 9 cases directly studied in our center, the median postoperative day of lymphangiography was 15 days. The detection rate of leakage sites after lymphangiography was 89 %. After lymphangiography, daily outputs of pleural effusion less than 500 ml were observed in 5 patients (56 %), all of whom healed conservatively. Daily outputs of more than 500 ml were seen in 4 patients (44 %). Of these patients, 1 patient had leakage from the main trunk and underwent clipping of the thoracic duct. In the remaining 3 patients, the leakages were instead observed in branches or were not observed; the 2 patients who had no anatomical variants were healed by chemical pleurodesis, and the 1 patient who had anatomical variants required surgical intervention. In the analysis of 33 previously reported cases (which included our 9 cases), the therapeutic policy was determined after lymphangiography, and all patients were successfully healed. Early lymphangiography is recommended for patients with refractory post-esophagectomy chylous leakage. Lymphangiography may contribute valuable information in deciding whether surgical intervention is required.

To investigate the influence of addition of docetaxel to neoadjuvant chemotherapy (NAC) with cisplatin plus 5-fluorouracil (CF) in patients with clinical stage III or T3 esophageal squamous cell carcinoma. Information about 209 esophageal cancer patients with stage III or T3 disease, who underwent NAC consisting of CF with or without docetaxel, was reviewed. The survival outcomes were analyzed using the Kaplan–Meier method and propensity score-adjusted Cox proportional hazards models. The relevant variables were included in the propensity score model. NAC was administered to 149 patients in the CF group and 60 patients in the docetaxel plus CF (DCF) group. Overall, 129 patients treated with CF and 58 patients treated with DCF underwent surgery after NAC. The overall response rate was significantly higher in the DCF group compared with the CF group (61.0 vs. 43.2 %, p = 0.021). After matching, recurrence-free survival did not differ statistically between the CF and DCF groups [hazard ratio (HR) 0.83, 95 % confidence interval (CI) 0.50–1.37, p = 0.46]. After matching, the improvement in overall survival in the DCF group reached statistical significance (HR 0.49, 95 % CI 0.24–0.999, p = 0.050). No significant differences in rate of locoregional or distant recurrences were observed between the CF and DCF groups (53.0 vs. 48.3 %, p = 0.54). NAC with DCF is superior to CF in patients with clinical stage III or T3 esophageal squamous cell carcinoma.

We retrospectively compared the effects of immediate extubation (IE) in the operating room with those of overnight mechanical ventilation (MV) after radical transthoracic esophagectomy with 3-field lymphadenectomy in patients with thoracic esophageal cancer. A total of 96 patients were evaluated. 48 patients were extubated in the operating room after surgery (IE group). The other 48 patients were extubated on the following morning (MV group). The propensity score-matching method was used to assemble a well-balanced cohort. Clinical and postoperative outcomes were investigated in each group. We also compared postoperative laboratory parameters between groups. The rate of ambulation on postoperative day (POD) 1 was significantly higher in the IE group compared with that in the MV group (50 vs 19%, respectively, p = 0.003). Moreover, the rate of catecholamine use in the ICU was significantly lower in the IE group compared with that in the MV group (15 vs 65%, respectively, p

Tracheal diverticulum, a benign entity characterized by single or multiple invaginations of the tracheal wall, is commonly asymptomatic and detected incidentally. We report the case of a 76-year-old man with a tracheal diverticulum who underwent thoracoscopic esophagectomy with a three-field lymphadenectomy for middle thoracic esophageal cancer. The tracheal diverticulum was located at the right posterolateral region of the trachea, which overlapped the region of dissection of the right recurrent laryngeal nerve lymph nodes. Paratracheal lymph node dissection is an important surgical procedure for thoracic esophageal cancer. In such cases, there is a risk of misidentifying a tracheal diverticulum as an enlarged lymph node and injuring it. Injury of a tracheal diverticulum causes serious complications such as mediastinal emphysema, mediastinitis, and pulmonary fistula. It is important to recognize its existence preoperatively and perform accurate lymph node dissection by taking full advantage of the magnified visual effect provided by thoracoscopic surgery.

Herein, we report coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. The patient was an 83-year-old man who had undergone the aforementioned procedure (Stage IIA) in the referral hospital. At the 10-month follow-up, computed tomography showed two tumours around 3 cm in diameter: one on the right-flank abdominal wall - the surgical port-site - and the other at the functional end-to-end anastomosis. Likewise, a positron emission tomography scan was positive for two tumours. Endoscopic examination showed an ulcerated tumour with a clear margin, and a biopsy confirmed moderately differentiated tubular adenocarcinoma. The patient was diagnosed with coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. We re-operated in March 2016. The tumours at the functional end-to-end anastomosisand functional end-to-end anastomosiswere resected. After 7 months, no recurrence was detected. J. Med. Invest. 64: 177-180, February, 2017.

症例は57歳の男性で，17歳時に特発性血小板減少性紫斑病で脾臓摘出の既往がある．自覚症状はなく，健診で膵尾部腫瘤を指摘された．血液検査上，血小板数・腫瘍マーカー・ホルモン値の異常は認めなかった．腹部造影CTにて，膵尾部に早期から造影効果を伴う直径約2.5cmの球状の腫瘤を認めた．MRIでは，T1強調画像・T2強調画像・拡散強調画像のいずれにおいても腫瘤は低信号を示した．腫瘍内部に変性を伴う非機能性膵内分泌腫瘍と術前診断し膵尾部切除を施行した．切除標本の病理組織学的検査にて，腫瘤は膵尾部に接する脾症と診断した．組織内にヘモジデリンが豊富に沈着しており，これによりMRIのT2強調画像で著明な低信号，拡散強調画像にて低信号を呈したと考えられた．

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

Our intent was to compare survival following neoadjuvant chemotherapy followed by surgery versus chemoradiotherapy (CRT) among patients with potentially resectable esophageal squamous cell carcinoma. Information about 406 consecutive esophageal cancer patients with resectable disease who underwent surgery with neoadjuvant chemotherapy consisting of cisplatin plus 5-fluorouracil or who underwent definitive CRT was reviewed. The survival outcomes were analyzed using the Kaplan–Meier method and propensity score-adjusted Cox proportional hazards models. Relevant variables were included in the propensity score model. Overall, 206 patients planned to undergo surgery (S group) and 200 patients planned to undergo CRT (CRT group). In the unadjusted situation, progression-free survival and overall survival did not differ statistically between the groups. After matching, both survival outcomes were better in the S group compared to the CRT group. Subanalysis showed both survival outcomes were better in the S group for patients with only stage III disease. However, survival outcomes for stages I, II, and IV were not significantly different between treatment groups. Among patients with resectable disease, survival outcomes in the S group were favored over those of the CRT group. These results indicate that different therapeutic strategies should be used for stage III esophageal cancer than for other stages.

Rectourethral fistula is one of the complications that can occur after prostatectomy in the urologic discipline. However, a delayed-onset rectourethral fistula after intersphincteric resection (ISR) for low rectal cancer is extremely rare. Here, we report one such case in a 57-year-old man. After ISR for low rectal cancer with a diverting stoma (DS), the DS was closed. After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas and abdominal computed tomography examinations revealed a rectourethral fistula from an anastomosis to the urethra. The colonoscopic appearance revealed a pinhole fistula on the anastomotic line, with thick pus. We performed a transverse colostomy, and the pneumaturia and right orchitis were no longer observed. Two months later, colonoscopy, contrast enemas, and cystoscopy revealed no rectourethral fistula. To the best of our knowledge, our case is the first report of a delayed-onset rectourethral fistula after ISR.

Neoadjuvant therapy has been proven to be extremely valuable and is widely used for advanced esophageal cancer. However, a significant proportion of treated patients (60%-70%) does not respond well to neoadjuvant treatments and develop severe adverse effects. Therefore, predictive markers for individualization of multimodality treatments are urgently needed in esophageal cancer. Recently, molecular biomarkers that predict the response to neoadjuvant therapy have been explored in multimodal approaches in esophageal cancer and successful examples of biomarker identification have been reported. In this review, promising candidates for predictive molecular biomarkers developed by using multiple molecular approaches are reviewed. Moreover, treatment strategies based on the status of predicted biomarkers are discussed, while considering the international differences in the clinical background. However, in the absence of adequate treatment options related to the results of the biomarker test, the usefulness of these diagnostic tools is limited and new effective therapies for biomarker-identified nonresponders to cancer treatment should be concurrent with the progress of predictive technologies. Further improvement in the prognosis of esophageal cancer patients can be achieved through the introduction of novel therapeutic approaches in clinical practice.

Thoracic esophageal cancer with a double aortic arch is extremely rare. We herein report the case of a 63-year-old man with a double aortic arch who underwent an esophagectomy with a three-field lymphadenectomy for cancer in the lower thoracic esophagus. In such cases, it is important to recognize the relationship between the right and left aortic arches and the bilateral recurrent laryngeal nerves (RLNs). We were able to accurately understand the anatomical position of the RLNs using a precedent cervical procedure with partial resection of the manubrium to remove the nodes along the bilateral RLNs.

Background: Surgical resection has been advocated as an effective treatment for hepatic neuroendocrine tumors (HNETs) in Western countries, but few data are available to define its indications. We evaluated the results of Japanese patients to determine the prognostic factors and the feasibility of our aggressive surgical approach. Methods: The records of all consecutive patients who underwent surgical resection for HNETs at our institution were retrospectively reviewed. Patients were selected for surgery if all tumors were deemed resectable, regardless of their extent. Results: A total of 21 patients were identified. Bilobar disease was present in 13 patients (62%). Eleven patients (52%) underwent major hepatectomy, which included right trisectionectomy, extended right or left hepatectomy and right hepatectomy. No in-hospital death occurred. The overall 1-, 3- and 5-year survival rates were 95, 68 and 41%, respectively, with a median follow-up of 34 months. Metastatic HNETs from bronchopulmonary primaries exhibited significantly poor outcome compared with other primary sites (P ¼ 0.04). Patients who underwent curative resection had an improved overall 5-year survival rate of 73% compared with palliative resection (0%, P ¼ 0.01). The longest survival in the latter group was 57 months. Complete symptom resolution rate was 92%. Conclusions: This is the first study from Asia demonstrating the safety of aggressive hepatic resection for HNETs. Significant symptom relief and long-term survival were achieved irrespective of the extent of disease or the magnitude of operation. Metastatic HNETs from bronchopulmonary primaries may represent a more lethal subset of tumors.

Objective Chemoradiotherapy is a popular definitive therapy for esophageal carcinoma among many patients and oncologists. Although the complete response rates are high and short-term survival is favorable after chemoradiotherapy, persistent or recurrent locoregional disease is frequent. Salvage surgery is the sole curative intent treatment option for this course of the disease. The present study evaluates the safety and value of salvage esophagectomy for locoregional failure after high-dose definitive chemoradiotherapy for esophageal squamous cell carcinoma. Methods We reviewed 59 consecutive patients with thoracic esophageal squamous cell carcinoma who underwent salvage esophagectomy after definitive chemoradiotherapy. All patients received more than 60 Gy of radiation plus concurrent chemotherapy for curative intent. The data were compared with those of patients who received esophagectomy without preoperative therapy. Results Postoperative morbidity and mortality rates were increased among patients who underwent salvage esophagectomy compared with those who underwent esophagectomy without preoperative therapy (mean hospital stay, 38 vs 33 days; anastomotic leak rates, 31% vs 25%; respiratory complication rates, 31% vs 20%; reintubation within 1 week, 2% vs 2%; hospital mortality rates, 8% vs 2%). Tracheobronchial necrosis and gastric conduit necrosis were highly lethal complications after salvage esophagectomy; 3-year postoperative survivals were 38% and 58%, respectively. Conclusion Patients who underwent salvage esophagectomy after definitive high-dose chemoradiotherapy had increased morbidity and mortality. Nevertheless, this is acceptable in view of the potential long-term survival after salvage esophagectomy. Such treatment should be considered for carefully selected patients at specialized centers.