The impact on obesity-related quality of life and eating satisfaction in the early period after laparoscopic sleeve gastrectomy.

INTRODUCTION: Obesity impairs patients' quality of life (QoL). Laparoscopic sleeve gastrectomy (LSG) is a common procedure for patients with severe obesity; however, studies reporting changes in obesity-related QoL are limited. The aim of this study was to assess changes in obesity-related QoL and food tolerance in the early postoperative period. METHODS: We included 20 consecutive patients who underwent LSG between May 2021 and July 2023. We evaluated changes in obesity-related QoL 6 months after surgery using an obesity and weight loss QoL questionnaire (OWLQOL) and a weight related symptom measure (WRSM). Additionally, we assessed eating satisfaction and food tolerance after surgery. RESULTS: The percentages of total weight loss and excess weight loss were 28.5% and 79.1%, respectively. OWLQOL scores and WRSM changed from 36.5 to 73.0 points and from 44.0 to 15.0 points (p = .007, .007), respectively. The food tolerance score decreased from 25 to 21.2 points (p < .001), while eating satisfaction showed no significant change (p = .25). CONCLUSION: Obesity-related QoL is enhanced even in the early postoperative period, without sacrificing eating satisfaction. The findings of this study may provide valuable insights for patients when considering LSG.

Increased risk of incisional hernia after stoma closure in patients with colorectal cancer.

PURPOSE: Stoma construction and closure are common surgical strategies in patients with colorectal cancer. The present study evaluated the influence of multiple incisional sites resulting from stoma closure on incisional hernia after colorectal cancer surgery. METHODS: The study included 1681 patients who underwent colorectal cancer surgery. Multiple incisional sites were defined as the coexistence of incisions at the midline and stoma closure sites. We retrospectively investigated the relationship between the presence of multiple incisional sites and incisional hernia development in patients with colorectal cancer. RESULTS: Among the 1681 patients, 420 (25%) underwent stoma construction, with a stoma closure-to-construction ratio of 33% (139/420), and 155 (9.2%) developed incisional hernias after colorectal cancer surgery. In the multivariate analysis, female sex (p < 0.001), body mass index (p < 0.001), multiple incisional sites (p = 0.001), wound infection (p = 0.003), and postoperative chemotherapy (p = 0.030) were independent predictors of incisional hernia. In the multiple incisional sites group, the age (p < 0.001), surgical approach (laparoscopic) (p = 0.013), wound infection rate (p = 0.046), small bowel obstruction rate (p < 0.001), and anastomotic leakage rate (p = 0.008) were higher in those in the single incisional site group. CONCLUSIONS: Multiple incisional sites resulting from stoma closure are associated with the development of incisional hernia following colorectal cancer surgery.

Pathophysiology and surgical outcomes of patients with fungal peritonitis from upper gastrointestinal tract perforation: a retrospective study.

PURPOSE: To compare the pathophysiology and surgical outcomes of emergency surgery for upper gastrointestinal tract perforation with and without fungal peritonitis and identify the risk factors for fungal peritonitis. METHODS: The subjects of this retrospective study were patients with upper gastrointestinal perforation and peritonitis who underwent emergency surgery at a single medical center in Japan. The patients were allocated to two groups according to the presence or absence of fungal peritonitis: group F and group N, respectively. RESULTS: At the time of surgery, ascitic fluid culture or serum ß-D glucan levels were available for 54 patients: 29 from group F and 25 from group N, respectively. The stomach was perforated in 14 patients (25.9%) and the duodenum was perforated in 40 patients (74.1%). Group F had a higher proportion of patients with low preoperative prognostic nutritional index scores (≤ 40) and C-reactive protein levels and a higher postoperative complication rate. The time to initiate food intake and the postoperative hospital stay were also significantly longer in group F. Multivariate analysis identified that the perforation site of the stomach was a risk factor for fungal peritonitis. CONCLUSION: Patients with fungal peritonitis from upper gastrointestinal tract perforation had higher postoperative complication rates, delayed postoperative recovery, and a longer hospital stay. Gastric perforation was a risk factor for fungal peritonitis.

New Proposal Strategy of Sentinel Lymph Node Navigation Surgery for Endoscopic Curability C-2: A Retrospective Study.

BACKGROUND/AIM: The purpose of this study was to evaluate the outcomes of the sentinel node navigation surgery (SNNS) followed by limited gastrectomy for early gastric cancer (EGC) with Endoscopic Curability C-2 (eCuraC-2). PATIENTS AND METHODS: Between 2001 and 2018, 33 patients were included in this study. Following sentinel node (SN) biopsy using indocyanine green combined with an infrared ray laparoscopic system, limited gastrectomy (LG) [wedge resection (WR), or segmental gastrectomy (SG)] was performed without extended lymphadenectomy. RESULTS: SN detection rate was 97% (32/33). The mean number of SNs per case was 7.8. Three patients (9.1%) with lymph node metastasis (LNM) had a positive SN identified by intraoperative pathological examination. When intraoperative pathologic examination showed SN to be LNM negative, 11 patients underwent WR, and seven were subjected to SG. Postoperative pathological examinations showed no false negatives for LNM, and four patients (12%) had residual cancer in their resected stomachs. Overall survival and disease-specific survival five years after SNNS were 87.9% and 100%, respectively. CONCLUSION: SNNS followed by LG with lymphatic basin resection may be one of the ideal procedures for patients with eCuraC-2 due to the accurate diagnosis of LNM and favorable disease-specific prognosis.

Prognostic significance of preoperative osteosarcopenia on patient' outcomes after emergency surgery for gastrointestinal perforation.

PURPOSE: Sarcopenia is a prognostic predictor in emergency surgery. However, there are no reports on the relationship between osteopenia and in-hospital mortality. This study clarified the effect of preoperative osteosarcopenia on patients with gastrointestinal perforation after emergency surgery. METHODS: We included 216 patients with gastrointestinal perforations who underwent emergency surgery between January 2013 and December 2022. Osteopenia was evaluated by measuring the pixel density in the mid-vertebral core of the 11th thoracic vertebra. Sarcopenia was evaluated by measuring the area of the psoas muscle at the level of the third lumbar vertebra. Osteosarcopenia is defined as the combination of osteopenia and sarcopenia. RESULTS: Osteosarcomas were identified in 42 patients. Among patients with osteosarcopenia, older and female patients and those with an American Society of Anesthesiologists Physical Status of ≥ 3 were significantly more common, and the body mass index, hemoglobin value, and albumin level were significantly lower in these patients than in patients without osteosarcopenia. Furthermore, the osteosarcopenia group presented with more postoperative complications than patients without osteosarcopenia (P < 0.01). In the multivariate analysis, age ≥ 74 years old (P = 0.04) and osteosarcopenia (P = 0.04) were independent and significant predictors of in-hospital mortality. CONCLUSION: Preoperative osteosarcopenia is a risk factor of in-hospital mortality in patients with gastrointestinal perforation after emergency surgery.

Fluorescence guidance using near-infrared fluorescent clips in robotic rectal surgery: a case series.

PURPOSE: Tattoo markings are often used as preoperative markers for colorectal cancer. However, scattered ink markings adversely affect tumor site recognition intraoperatively; therefore, interventions for rectal cancer may lead to an inaccurate distal resection margin (DRM) and incomplete total mesorectal excision (TME). This is the first case series of fluorescence-guided robotic rectal surgery in which near-infrared fluorescence clips (NIRFCs) were used to localize rectal cancer lesions. METHODS: We enrolled 20 consecutive patients who underwent robotic surgery for rectal cancer between December 2022 and December 2023 in the current study. The primary endpoints were the rate of intraoperative clip detection and its usefulness for marking the tumor site. Secondary endpoints were oncological assessments, including DRM and the number of lymph nodes. RESULTS: Clip locations were confirmed in 17 of 20 (85%) patients. NIRFCs were not detected in 3 out of 7 patients who underwent preoperative chemoradiation therapy. No adverse events, including bleeding or perforation, were observed at the time of clipping, and no clips were lost. The median DRM was 55 mm (range, 22-86 mm) for rectosigmoid (Rs), 33 mm (range, 16-60 mm) for upper rectum (Ra), and 20 mm (range, 17-30 mm) for low rectum (Rb). The median number of lymph nodes was 13 (range, 10-21). CONCLUSION: The rate of intraoperative clip detection, oncological assessment, including DRM, and the number of lymph nodes indicate that the utility of fluorescence-guided methods with NIRFCs is feasible for rectal cancer.

Prognostic usefulness of the C-reactive protein-albumin-lymphocyte (CALLY) index as a novel biomarker in patients undergoing colorectal cancer surgery.

BACKGROUND: The C-reactive protein (CRP)-albumin-lymphocyte (CALLY) index is a novel immuno-nutritional biomarker based on the levels of CRP, serum albumin, and lymphocyte count. This study examined the prognostic value of the CALLY index in patients with colorectal cancer undergoing curative surgery. METHODS: Between 2010 and 2017, 578 patients with stage II-III colorectal cancer who underwent curative resection were enrolled. The CALLY index was defined as (albumin × lymphocyte)/(CRP × 104). We investigated the association of the CALLY index with disease-free survival (DFS) and overall survival (OS). RESULTS: The cutoff value of the CALLY index was determined to be 2. Of the 578 patients, 175 (30%) had a preoperative CALLY index <2. In multivariate analysis, the pre-operative carcinoembryonic antigen (CEA) level (p = 0.003), cell differentiation (p = 0.045), venous invasion (p = 0.036), Tumor-Node-Metastasis stage (p < 0.001), and CALLY index score <2 (p = 0.006) were independent predictors of DFS. Meanwhile, preoperative carbohydrate antigen (CA)19-9 levels (p = 0.019), lymphatic invasion (p = 0.018), preoperative platelet (p = 0.037), and CALLY index score <2 (p = 0.007) were independent predictors of OS. CONCLUSION: The CALLY index may be an independent prognostic biomarker for long-term outcomes in patients with colorectal cancer.

Role of modified Glasgow Prognostic Score in patients with achalasia who underwent laparoscopic Heller-myotomy with Dor-fundoplication.

BACKGROUND: Systemic inflammatory response is significant prognostic indicator in patients with various diseases. The relationship between prognostic scoring systems based on the modified Glasgow Prognostic Score (mGPS) and achalasia in patients treated with laparoscopic Heller­myotomy with Dor­fundoplication (LHD) remains uninvestigated. This study aimed to examine the role of mGPS in patients with achalasia. METHODS: 457 patients with achalasia who underwent LHD as the primary surgery between September 2005 and December 2020 were included. We divided patients into the mGPS 0 and mGPS 1 or 2 groups and compared the patients' background, pathophysiology, symptoms, surgical outcomes, and postoperative course. RESULTS: mGPS was 0 in 379 patients and 1 or 2 in 78 patients. Preoperative vomiting and pneumonia were more common in patients with mGPS of 1 or 2. There were no differences in surgical outcomes. Postoperative upper gastrointestinal endoscopy revealed that severe esophagitis was more frequently observed in patients with mGPS of 1 or 2 (P < 0.01). The clinical success was 91% and 99% in the mGPS 0 and mGPS 1 or 2 groups, respectively (P < 0.01). CONCLUSIONS: Although severe reflux esophagitis was more common in patients with achalasia with a high mGPS, good clinical success was obtained regardless of the preoperative mGPS.

Laparoscopic sleeve gastrectomy combined with Toupet fundoplication (T-sleeve): A short report of a Japanese obesity patient with gastroesophageal reflux disease.

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed procedure in bariatric-metabolic surgery (BMS) worldwide, accounting for approximately 90% of BMS procedures in Japan. While numerous studies have reported on the safety and efficacy of LSG, gastroesophageal reflux disease (GERD) remains a major postoperative complication. Although Roux-en-Y gastric bypass (RYGB) is preferred for severe obesity with GERD, it is less suitable for Japanese patients who have a higher risk of gastric cancer due to the remnant stomach which is difficult to observe with esophago-gastro-duodenoscopy. To address de novo and exacerbation GERD after LSG, we conducted LSG with Toupet fundoplication (T-sleeve) for Japanese patients with severe obesity. In our first T-sleeve case, the patient demonstrated sufficient weight loss and improved GERD following surgery. Hence, we suggest that T-sleeve is a feasible option for Japanese patients with obesity and concurrent GERD.

Prognostic significance of the preoperative C-reactive protein-albumin-lymphocyte (CALLY) index on outcomes after gastrectomy for gastric cancer.

PURPOSE: Systemic inflammatory response markers are reported to be prognostic for patients with cancer. The C-reactive protein (CRP)-albumin-lymphocyte (CALLY) index has been established as an immuno-nutritional scoring system. The aim of this study was to clarify the impact of the preoperative CALLY index on the outcome of patients undergoing gastrectomy for gastric cancer. METHODS: We analyzed the data of 826 patients who underwent gastrectomy for stage I, II, or III gastric cancer between 2010 and 2017. The CALLY index was defined as (albumin × lymphocyte)/(CRP × 104). RESULTS: The cut-off of the CALLY index was 2. The 147 patients with a preoperative CALLY index < 2 had significantly worse overall survival (OS) and relapse-free survival (RFS) than those with a CALLY index ≥ 2 (P < 0.01, P < 0.01, respectively). Multivariate analysis identified that a CALLY index < 2 (P = 0.02), intraoperative blood loss (P < 0.01), and stage II or III disease (P < 0.01) were independent and significant predictors of worse RFS. A CALLY index < 2 (P = 0.01), intraoperative blood loss (P < 0.01), postoperative complications (P = 0.02), and stage II or III disease (P < 0.01) were independent and significant predictors of worse OS. CONCLUSION: The preoperative CALLY index was independently associated with a poor prognosis for patients after gastrectomy for gastric cancer.

Implementable assay for monitoring minimum residual disease after radical treatment for colorectal cancer.

Considering the cost and invasiveness of monitoring postoperative minimal residual disease (MRD) of colorectal cancer (CRC) after adjuvant chemoradiotherapy (ACT), we developed a favorable approach based on methylated circulating tumor DNA to detect MRD after radical resection. Analyzing the public database, we identified the methylated promoter regions of the genes FGD5, GPC6, and MSC. Using digital polymerase chain reaction (dPCR), we termed the "amplicon of methylated sites using a specific enzyme" assay as "AMUSE." We examined 180 and 114 pre- and postoperative serial plasma samples from 28 recurrent and 19 recurrence-free pathological stage III CRC patients, respectively. The results showed 22 AMUSE-positive of 28 recurrent patients (sensitivity, 78.6%) and 17 AMUSE-negative of 19 recurrence-free patients (specificity, 89.5%). AMUSE predicted recurrence 208 days before conventional diagnosis using radiological imaging. Regarding ACT evaluation by the reactive response, 19 AMUSE-positive patients during their second or third blood samples showed a significantly poorer prognosis than the other patients (p = 9E-04). The AMUSE assay stratified four groups by the altered patterns of tumor burden postoperatively. Interestingly, only 34.8% of cases tested AMUSE-negative during ACT treatment, indicating eligibility for ACT. The AMUSE assay addresses the clinical need for accurate MRD monitoring with universal applicability, minimal invasiveness, and cost-effectiveness, thereby enabling the timely detection of recurrences. This assay can effectively evaluate the efficacy of ACT in patients with stage III CRC following curative resection. Our study strongly recommends reevaluating the clinical application of ACT using the AMUSE assay.

Proctoring System Enables Safe Induction of Robotic Gastrectomy: Short-term Outcomes of the First 10 Cases.

BACKGROUND/AIM: The Japan Society of Endoscopic Surgery (JSES) proctoring system was established to prevent serious pancreatic pressure injuries in Japan in 2019. To safely perform robotic gastrectomy (RG) in our hospital, which has no experience in robotic surgery, we conducted a clinical trial with the support of this proctoring system. PATIENTS AND METHODS: The present study was a single-center clinical prospective study. The primary endpoint was morbidity determined using Clavien-Dindo classification (C-D) Grade IIIa or higher. RESULTS: Ten patients, seven males and three females, were recruited in this study. RG was performed under the proctoring system of the JSES in the initial six cases and was completed independently for the remaining four patients. We successfully performed the initial ten cases without C-D classification grade IIIa or higher morbidities. CONCLUSION: This study underscores the significance of a proctoring system for introducing RG to facilities with limited experience in robotic surgery. Despite some limitations, this study demonstrated successful outcomes in the initial ten cases, emphasizing the benefits for both surgeons and patients. This study provides valuable insights into the safety of RG in small institutions and calls for further research in this area.

Novel tumor marker index using carcinoembryonic antigen and carbohydrate antigen 19-9 is a significant prognostic factor for resectable colorectal cancer.

We evaluated the usefulness of a newly devised tumor marker index (TMI), namely, the geometric mean of normalized carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), in determining colorectal cancer (CRC) prognosis. This retrospective cohort study included 306 patients with stages I-III CRC who underwent elective laparoscopic resection between April 2010 and March 2020. Survival rates and risk factors of relapse-free survival (RFS) and cancer-specific survival (CSS) were analyzed using Kaplan-Meier curves and Cox proportional hazards model. High-TMI group (122 patients) had significantly lower rates (95% confidence interval [95% CI]) for 5-year RFS (89.7%, 83.9-93.5 vs. 65.8%, 56.3-73.8, p < 0.001) and CSS (94.9%, 89.4-97.6 vs. 77.3%, 67.7-84.4, p < 0.001) than low-TMI group. Multivariate analysis (hazard ratio [95% CI]) indicated ≥ T3 disease (RFS: 2.69, 1.12-6.45, p = 0.026; CSS: 7.64, 1.02-57.3, p = 0.048), stage III CRC (RFS: 3.30, 1.74-6.28, p < 0.001; CSS: 6.23, 2.04-19.0, p = 0.001), and high TMI (RFS: 2.50, 1.43-4.38, p = 0.001; CSS: 3.80, 1.63-8.87, p = 0.002) as significant RFS and CSS predictors. Area under the curve (AUC) of 5-year cancer deaths (0.739, p < 0.001) was significantly higher for TMI than for CEA or CA19-9 alone. Preoperative TMI is a useful prognostic indicator for patients with resectable CRC.

Association of Cholinesterase With Postoperative Pneumonia After Gastrectomy for Gastric Cancer.

INTRODUCTION: Cholinesterase is a classical marker that reflects nutritional and inflammatory status. The aim of the present study was to evaluate the association between serum cholinesterase levels and postoperative infectious complications in patients undergoing gastrectomy for gastric cancer. MATERIALS AND METHODS: This retrospective study comprised 108 patients who underwent gastrectomy for gastric cancer. We comprehensively investigated the association between clinicopathological variables and postoperative infectious complications after gastrectomy. Then patients were divided into the cholinesterase-high and -low groups to analyze their clinicopathological variables. Finally, we analyzed the types of infectious complications that were most associated with preoperative serum cholinesterase levels. RESULTS: Twenty-six patients (24%) developed postoperative infectious complications. Multivariate analysis revealed that serum cholinesterase levels (P = 0.026) and N stage (P = 0.009) were independent risk factors for postoperative infectious complications. In particular, the incidence of pneumonia (P = 0.001) was significantly higher in the cholinesterase-low group. Age (P = 0.023), cerebrovascular comorbidities (P = 0.006), serum cholinesterase levels (P = 0.013), and total gastrectomy (P = 0.017) were identified as independent risk factors for postoperative pneumonia. CONCLUSIONS: Preoperative serum cholinesterase levels were associated with postoperative pneumonia after gastrectomy for gastric cancer, suggesting the importance of preoperative nutritional assessment in gastric cancer surgery.

High-output stoma is a risk factor for stoma outlet obstruction in defunctioning loop ileostomies after rectal cancer surgery.

PURPOSE: Defunctioning loop ileostomy has been reported to reduce symptomatic anastomotic leakage after rectal cancer surgery; however, stoma outlet obstruction (SOO) is a serious postileostomy complication. We, therefore, explored novel risk factors for SOO in defunctioning loop ileostomy after rectal cancer surgery. METHODS: This is a retrospective study that included 92 patients who underwent defunctioning loop ileostomy with rectal cancer surgery at our institution. Among them, 77 and 15 ileostomies were created at the right lower abdominal and umbilical sites, respectively. We defined the output volumeMAX as the maximum output volume the day before the onset of SOO or-for those without SOO-that was observed during hospitalization. Univariate and multivariate analyses were performed to evaluate risk factors for SOO. RESULTS: SOO was observed in 24 cases, and the median onset was 6 days postoperatively. The stoma output volume in the SOO group was consistently higher than that in the non-SOO group. In the multivariate analysis, the rectus abdominis thickness (p < 0.01) and output volumeMAX (p < 0.01) were independent risk factors for SOO. CONCLUSION: A high-output stoma may predict SOO in patients with defunctioning loop ileostomy for rectal cancer. Considering that SOO occurs even at umbilical sites with no rectus abdominis, a high-output stoma may trigger SOO primarily.

Effect of low visceral fat area on long-term survival of stage I-III colorectal cancer.

OBJECTIVE: The prognostic significance of a low visceral fat area (VFA) in colorectal cancer (CRC) remains unclear. The aim of this study was to evaluate the prognostic effects of a low VFA on the long-term outcomes of patients with CRC after laparoscopic surgery. METHODS: This retrospective study included 306 patients with stages I-III CRC who underwent R0 resection. VFA was preoperatively measured via computed tomography using image processing software. Relapse-free survival (RFS) and overall survival (OS) rates were analyzed using the Cox proportional hazards model and Kaplan-Meier curves. RESULTS: Low VFA was identified in 153 patients. The low VFA group had significantly lower RFS and OS rates than did the high VFA group (5-y RFS rates: 72 versus 89%, P = 0.0002; 5-y OS rates: 72 versus 92%, P = 0.0001). The independent significant predictors of RFS were T3 or T4 disease (hazard ratio [HR], 2.75; 95% confidence interval [CI], 1.12-6.76; P = 0.027), stage III CRC (HR, 3.49; 95% CI, 1.82-6.69; P < 0.001), low psoas muscle index (PMI; HR, 2.12; 95% CI, 1.19-3.79; P = 0.011), and low VFA (HR, 2.12; 95% CI, 1.16-3.86; P = 0.014). The independent significant predictors of OS were age ≥65 y (HR, 2.59; 95% CI, 1.13-5.92, P = 0.024), carbohydrate antigen 19-9 levels ≥37 ng/mL (HR, 2.32; 95% CI, 1.18-4.58; P = 0.015), stage III CRC (HR, 2.66; 95% CI, 1.37-5.17; P = 0.004), low PMI (HR, 2.00; 95% CI, 1.06-3.77; P = 0.031), and low VFA (HR, 2.42; 95% CI, 1.24-4.70; P = 0.009). CONCLUSION: A low preoperative VFA was significantly associated with worse RFS and OS rates in patients who underwent CRC resection.

Is it meaningful to add mesh reinforcement to laparoscopic fundoplication for esophageal hiatal hernias in the patients with high risk of hiatal hernia recurrence?

BACKGROUND: While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof. The aim of this study is to investigate whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias. METHODS: The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias. RESULTS: The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p = 0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p = 0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p < 0.0001) and a higher frequency of intraoperative complications (p = 0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p = 0.049), with the rate of postoperative reflux esophagitis also tending to be low (p = 0.083). CONCLUSIONS: Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.

Tumor-infiltrating lymphocytes in patients undergoing esophagectomy following neoadjuvant DCF therapy.

BACKGROUND: Accumulating evidence suggests that expression levels of tumor-infiltrating (TI) cells may play a prognostic role in patients with esophageal cancer who have undergone esophagectomy. However, its effect on patients undergoing neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy followed by esophagectomy for esophageal squamous cell carcinoma (ESCC) remains unclear. Therefore, this study aimed to elucidate the prognostic impact of TI cells in patients who underwent esophagectomy following neoadjuvant DCF therapy. METHODS: Overall, 81 patients with ESCC who underwent curative esophagectomy following neoadjuvant DCF therapy were included. The number of TI CD8+ cells was determined using light microscopy at ×400 in tumor invasive margins. Receiver operative characteristic curve was used to determine the cutoff values for mortality for continuous variables; the patients were separated into high and low TI CD8+ cell groups and their backgrounds and clinical outcomes were compared. RESULTS: Overall and relapse-free survival were significantly worse in the TI CD8+-low group than that in the TI CD8+-high group (p < 0.01). Multivariate analysis revealed that positive ypN (hazard ratio [HR], 3.12; 95% confidence interval [CI], 1.08-9.02) and low TI CD8+ cell levels (HR, 2.77; 95% CI, 1.31-5.85) were independent prognostic factors for overall survival. Furthermore, positive venous invasion (HR, 2.63; 95% CI, 1.29-5.35) and low TI CD8+ cell levels (HR, 2.77; 95% CI, 1.70-5.46) were significant prognostic factors for relapse-free survival. CONCLUSIONS: Low TI CD8+ cell level was a prominent prognostic factor for patients with ESCC undergoing neoadjuvant DCF therapy followed by esophagectomy.

Appropriate concentration setting for the intraoperative administration of indocyanine green for fluorescence imaging to identify the sentinel lymph node in early gastric cancer: a clinical pilot study.

PURPOSE: Some prospective trials have demonstrated the feasibility of sentinel node (SN) biopsy in gastric cancer (GC) surgery. This study aimed to identify the appropriate concentration settings for the intraoperative injection of indocyanine green (ICG) for SN biopsy. METHODS: Before the clinical studies, porcine model experiments explored the optimal concentration of ICG injected intraoperatively. Next, nine GC patients were enrolled in the clinical research. ICG (0.5 ml) was injected intraoperatively into four quadrants of the submucosa around the tumor at various concentrations (0.5, 0.25, and 0.1 mg/ml). The lymphatic basin dissection method was applied to the ICG-positive lymphatic areas. The number and location of the lymphatic basins and positive nodes were recorded intraoperatively. RESULTS: In the porcine model, the visibility gradually became clear at an ICG concentration higher than 0.1 mg/ml. In the clinical study, the average number of detected lymphatic basins was 3.3, 1.7, and 1.7, respectively. The mean number of detected SNs was 14.7, 6.7, and 4.0, respectively. CONCLUSION: To improve the reproducibility of SN biopsy, it is essential to prepare the correct concentration setting of ICG. Under current conditions in which ICG is injected intraoperatively, a 0.1 mg/ml concentration setting of ICG may be necessary and sufficient for SN identification.

Anatomical and anastomotic viability indexes for stratifying the risk of anastomotic leakage in esophagectomy with retrosternal reconstruction.

Background: Risk prediction of anastomotic leakage using anatomical and vascular factors has not been well established. This study aimed to assess the anatomical and vascular factors affecting the hemodynamics of the gastric conduit and develop a novel risk stratification system in patients undergoing esophagectomy with retrosternal reconstruction. Methods: This retrospective cohort study analyzed 202 patients with esophageal cancer who underwent subtotal esophagectomy with gastric tube retrosternal reconstruction between January 2008 and December 2020. Risk factors for anastomotic leakage (AL), including the anatomical index (AI) and anastomotic viability index (AVI), were evaluated using a logistic regression model. Results: According to the logistic regression model, the independent risk factors for AL were preoperative body mass index ≥23.6 kg/m2 (odds ratio [OR], 7.97; 95% confidence interval [CI], 2.44-26.00; P < 0.01), AI <1.4 (OR, 23.90; 95% CI, 5.02-114.00; P < 0.01), and AVI <0.62 (OR, 8.02; 95% CI, 2.57-25.00; P < 0.01). The patients were stratified into four AL risk groups using AI and AVI as follows: low-risk group (AI ≥1.4, AVI ≥0.62 [2/99, 2.0%]), intermediate low-risk group (AI ≥1.4, AVI <0.62 [2/29, 6.9%]), intermediate high-risk group (AI <1.4, AVI ≥0.62 [8/53, 15.1%]), and high-risk group (AI <1.4, AVI <0.62 [11/21, 52.4%]). Conclusion: The combination of AI and AVI strongly predicted AL. Additionally, the use of AI and AVI enabled the stratification of the risk of AL in patients who underwent esophagectomy with retrosternal reconstruction.