Changes in Acidity Levels in the Gastric Tube After Esophagectomy for Esophageal Cancer.

Reflux esophagitis and gastric tube ulcer sometimes cause severe clinical problems in patients undergoing esophagectomy with gastric tube reconstruction. We previously reported that acidity in the gastric tube was decreased for 1 year after esophagectomy, and that lower acidity levels were associated with Helicobacter pylori (H. pylori) infection. However, the long-term changes in gastric acidity remain unknown. We aimed to investigate the long-term changes in gastric acidity after surgery. Eighty-nine patients who underwent esophagectomy with gastric tube reconstruction for esophageal cancer were analyzed. They underwent 24-hour pH monitoring, serum gastrin measurement, and H. pylori infection examination before surgery, at 1 month, 1 year, and 2 years after surgery. The gastric acidity at 1 month and 1 year after surgery was significantly lower than that before surgery (p=0.003, p=0.003). However, there was no difference in gastric acidity before and 2 years after surgery. The gas tric acidity in H. pylori-infected patients was significantly lower in comparison to non-infected patients at each time point (p=0.0003, p<0.0001, p<0.0001, p<0.0001, respectively). In H. pylori-infected patients, gastric acid ity was decreased for 1 year after surgery, and recovered within 2 years after surgery. However, no significant differences were observed in the acidity levels of non-infected patients during the 2-year follow-up period. The serum gastrin level increased after esophagectomy. The acidity levels in the gastric tube recovered within 2 years after surgery. Periodic endoscopy examination is recommended for early detection of acid-related disease, such as reflux esophagitis or gastric tube ulcer, after esophagectomy with gastric tube reconstruction.

Effectiveness of the Gerdq Questionnaire for Diagnosing Gastroesophageal Reflux Disease After Esophagectomy for Esophageal Cancer.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common complication after esophagectomy with gastric tube reconstruction. The GerdQ questionnaire was developed for diagnosing GERD in primary care patients. Its effectiveness in patients after esophagectomy remains unknown. In this study, we evaluated the usefulness of the GerdQ questionnaire for diagnosing GERD after esophagectomy for esophageal cancer. MATERIALS AND METHODS: A total of 124 patients with esophageal cancer underwent right transthoracic esophagectomy with gastric tube reconstruction between January 2010 and December 2016. Esophagogastroduodenoscopy and 24-hour esophageal pH-metry were performed at 1 month, 1 year, and 2 years postoperatively. The GerdQ questionnaire was administered at the same postoperative time points. We assessed any correlation between the GerdQ scores and the endoscopy and pH-metry findings. RESULTS: The incidence rates of GERD at 1 month, 1 year and 2 years post-surgery were 31.6%, 46.9%, and 49.2%, respectively. The GerdQ questionnaire showed 77% sensitivity and 56% specificity for diagnosing GERD at 2 years after esophagectomy when the cutoff point was 7. However, the optimal cutoff points were different at each postoperative time, and the scores showed some imbalance between sensitivity and specificity. Regurgitation may be a useful indicator, as the frequency of regurgitation was significantly higher in patients with GERD than in patients without GERD at 1 year (P = 0.046) and 2 years postoperatively (P = 0.048). CONCLUSION: The GerdQ questionnaire is not a useful diagnostic tool for GERD in patients who have undergone esophagectomy for esophageal cancer.

[A Patient Who Had Postoperative Three-Field Lymph Node Recurrence of Cancer of the Esophagogastric Junction Obtains Complete Response by DCF Treatment].

A 64-year-old woman underwent left-thoracoabdominal esophagectomy and esophagojejunostomy for cancer of the esophagogastric junction. The pathological examination of the resected specimen showed a poorly squamous cell carcinoma (SCC). The pathological stage was pT3, pN1, sM0, and fStage Ⅲ. Three months after surgery, an SCC antigen related to a tumor marker was found to be outside the normal range, and CT showed lymph node recurrence of the three fields(No. 101R, No. 104RL, No. 106recRL, No. 106pre, and No. 16b1). Because the lymph node recurrence was in the three fields, we performed systemic chemotherapy with docetaxel, cisplatin(CDDP), and 5-fluorouracil(5-FU)(collectively, DCF). After the patient received 2 courses of DCF therapy, the lymph nodes where the recurrent occurred decreased in size(partial response), and SCC became within normal range. She received additional chemotherapy with 2 courses of DCF and achieved a complete response. Currently, she has been alive without recurrence for 7 years and 9 months after 4 courses of DCF therapy. We think that we can select DCF therapy as a first-line treatment for lymph node recurrence alone but not for CRT with FP.

Diversity and shared T-cell receptor repertoire analysis in esophageal squamous cell carcinoma.

The tumor immune response is dependent on the interaction between tumor cells and the T-cell subset expressing the T-cell receptor (TCR) repertoire that infiltrates into the tumor microenvironment. The present study explored the diversity and shared TCR repertoires expressed on the surface of locoregional T cells and identified the T lymphocyte subsets infiltrating into esophageal squamous cell carcinoma (ESCC), in order to provide insight into the efficiency of immunotherapy and the development of a novel immune-oriented therapeutic strategy. A total of 53 patients with ESCC were enrolled in the present study, and immunohistochemical analysis of CD3, CD8, CD45RO, FOXP3, CD274, HLA class I and AE1/AE3 was performed. Digital pathological assessment was performed to evaluate the expression level of each marker. The clinicopathological significance of the immuno relation high (IR-Hi) group was assessed. Adaptor ligation PCR and next-generation sequencing were performed to explore the diversity of the TCR repertoire and to investigate the shared TCR repertoire in the IR-Hi group. Repertoire dissimilarity index (RDI) analysis was performed to assess the diversity of TCR, and the existence of shared TCRα and TCRß was also investigated. Further stratification was performed according to the expression of markers of different T-cell subsets. Patients were stratified into IR-Hi and immuno relation low (IR-Lo) groups. Cancer-specific survival and recurrence-free survival rates were significantly improved in the IR-Hi group compared with in the IT-Lo group. The diversity of the TCR repertoire was significantly higher in the IR-Hi group. TCR repertoire analysis revealed 27 combinations of TCRα and 23 combinations of TCRß VJ regions that were shared among the IR-Hi group. The IR-Hi group was divided into three clusters. Overall, the current findings revealed that the IR-Hi group maintained the diversity of TCR, and a portion of the IR-Hi cases held the T cells with shared TCR repertoires, implying recognition of shared antigens. The prognosis of patients with ESCC was affected by the existence of immune response cells and may possibly be stratified by the T-cell subsets.

Argon plasma coagulation for superficial squamous cell carcinoma in the residual esophagus after esophagectomy.

BACKGROUND: Patients after esophagectomy for esophageal squamous cell carcinoma (SCC) occasionally develop metachronous SCC in the residual esophagus. Although most of these second primary lesions are detected as superficial cancer at follow-up endoscopy, it is often difficult to perform endoscopic resection for these lesions near the site of anastomosis. METHODS: The objective of this study was to evaluate the effectiveness of argon plasma coagulation (APC) for superficial SCC in the residual esophagus after esophagectomy. Twelve patients (involving 15 s primary lesions) received APC for superficial SCC in the residual esophagus after esophagectomy. These lesions were difficult to perform endoscopic resection and they were treated using APC. RESULTS: There was no treatment-related complication. Complete remission (CR) was achieved in 13 (86.6%) of the 15 lesions: CR was achieved in 11 lesions (73.3%) after the first APC course, and in another 2 lesions (13.3%) after two or more APC courses. Of the 2 patients with persisting residual tumor, 1 patient received 12 times repeated-APC courses over 6 years, and eventually achieved local control without metastasis, the other patient received radiotherapy and cervical esophagectomy after treatment failure with APC. All patients survived except for one patient who died of old age and another patient who died of tongue cancer. CONCLUSIONS: APC was a safe treatment that was easy to perform. APC was concluded to be an effective treatment for superficial SCC in the residual esophagus after esophagectomy when endoscopic resection was difficult.

Surgery for Killian-Jamieson diverticulum: a report of two cases.

BACKGROUND: Killian-Jamieson diverticulum (KJD) is a rare diverticulum arising from a muscular gap in the anterolateral wall of the proximal cervical esophagus. The first choice of treatment for KJD remains controversial due to its rare incidence. Here, we report two cases of KJD for which we performed different surgery: diverticulectomy in one case and diverticulopexy in the other. CASE PRESENTATION: Case 1 involved a 58-year-old woman presenting progressive pharyngeal discomfort for the past year. She was diagnosed as KJD using endoscopic and radiographic findings. She underwent diverticulectomy with cricopharyngeal and proximal esophageal myotomy. Staple line leakage developed at 1 month after surgery and was successfully treated conservatively. At 5 months after surgery, she was asymptomatic. Case 2 involved a 77-year-old woman presenting dysphagia for the past 2 years. She had a history of bilateral breast cancer and had hypertension, asthma, and osteoporosis. Taking her age and medical history into account, we selected diverticulopexy with cricopharyngeal and proximal esophageal myotomy. The postoperative course was uneventful. At 2 years after surgery, she remained free of dysphagia. CONCLUSION: The first choice of surgery for KJD is diverticulectomy. In a high-risk patient, diverticulopexy is a reasonable treatment. We recommend the addition of myotomy as a part of any surgical treatment.

Hand-assisted laparoscopic surgery for Bochdalek hernia in an adult patient with a history of laparotomy: A case report.

INTRODUCTION: Bochdalek hernia (BH) is a congenital diaphragmatic hernia that generally occurs in infants and is rarely seen in adults. Surgical repair of BH is recommended, but the approach for repairing BH should be selected carefully in individual cases. It is well known that hand-assisted laparoscopic surgery (HALS) has the advantage of preserving tactile sensation compared with standard laparoscopic surgery. We describe an adult patient with a history of abdominal incisional hernia who developed BH that was treated safely by HALS. PRESENTATION OF CASE: An 87-year-old woman was admitted to our hospital with nausea. She had a history of right hemicolectomy and repair of an abdominal incisional hernia using mesh at 5 years after hemicolectomy. Chest and abdominal computed tomography revealed herniation of the gastric corpus through the left posterior diaphragm. BH was diagnosed and hernia repair by HALS was selected as the approach because dense adhesions were expected in the abdominal cavity. The operation was performed safely and her postoperative course was uneventful. CONCLUSION: HALS was useful, especially when removing adhesions around the hernial orifice. HALS is a feasible approach for BH and should be considered as one of the options in patients with a history of previous abdominal surgery.