Surgical outcome of colon interposition by the posterior mediastinal route for thoracic esophageal cancer.

BACKGROUND: For thoracic esophageal cancer patients with a history of gastrectomy, esophageal reconstruction using segments of colon was often accomplished using the anterior mediastinal route to avoid fatal complications related to colon necrosis. Our aim was to review our experience with reconstruction by the posterior mediastinal route and assess the surgical outcomes. METHODS: Between 1989 and August 2006, 34 esophageal cancer patients at Akita University Hospital underwent esophageal reconstruction accomplished by colon interposition by the posterior mediastinal route. Data from these patients were reviewed. RESULTS: Colon conduits consisted of left colon segments in 4 patients and right colon segments in 30. The grafts were supplied with blood by the left colonic artery in 13 patients, the middle colonic artery in 20, and the right colonic artery in 1. The esophagocolic (pharyngocolic) anastomosis was located in the neck in 33 patients (97%) and in the thorax in 1. No patient died during the initial hospital stay. There were no instances of colon necrosis. An anastomotic fistula occurred in 3 patients (9%). Proximal anastomotic strictures occurred in 2 patients (6%). No late graft redundancies resulting in significant dysphagia occurred. Reductions in body weight did not differ from those seen when the gastric tube was used for reconstruction, and alimentary function was good after surgery. The 1-, 2-, 3-, and 5-year survival rates were 66%, 52%, 48%, and 48%, respectively. CONCLUSIONS: Colon interposition by the posterior mediastinal route provides a good outcome and is considered the route of first choice.

Outcome and treatment strategy for mid- and lower-thoracic esophageal cancer recurring locally in the lymph nodes of the neck.

The aim of the present study was to assess the outcome of treatment for patients with recurrent mid- and lower-thoracic esophageal cancers in whom recurrence was localized to the lymph nodes of the neck, and to determine the best strategy for further treatment. Between 1989 and 2001, 270 patients with mid- and lower-thoracic esophageal cancer underwent curative esophagectomy; 90 of those patients had a cancer recurrence. Our focus was on lymph node recurrence, especially when the recurrent cancers were localized to the lymph nodes in the neck. The outcomes of those patients and the efficacy of the strategies used to treat the recurrent cancers were determined. In 43 patients (48%), recurrent cancer initially appeared in the lymph nodes. Among the 43 patients, 15 (35%) had localized neck recurrence. The time between tumor recurrence and death among the 15 patients with localized neck recurrence was significantly longer than among the 28 patients with other recurrence patterns. In addition, 15 patients underwent lymph node resection, while 28 patients were treated non-surgically. The time between tumor recurrence and death was significantly longer in patients treated surgically. Of the 15 patients in whom recurrence affected the neck lymph nodes only, 10 (67%) were treated surgically; their 2-year survival rate after recurrence was 45%. The outcomes of recurrent esophageal cancers localized to the lymph nodes of the neck were better than those seen with other recurrence patterns, and salvage resection followed by chemoradiation therapy would seem to be indicated for those patients.

Magnetic resonance imaging for chylothorax after esophagectomy.

A 75-year-old man underwent esophagectomy for thoracic esophageal cancer. After the operation, the output fluid from the right chest drain increased, and laboratory analysis confirmed the fluid to be chyle. Magnetic resonance imaging (MRI) was then carried out to identify the leakage point and the size of the injury to the thoracic duct. The MRI clearly showed the leak point to be in the lower thoracic region. It thus appears that this non-invasive new approach using MRI is effective and suitable for diagnosis and establishment of an appropriate treatment plan for chylothorax after thoracic surgery.

[A case of curatively resected AFP producing gastric cancer that responded remarkably to 1 course of TS-1 and showed complete loss of multiple liver metastatic tumors].

A 73-year-old woman was admitted to our hospital for evaluation of hypochondralgia, and a thorough examination revealed an AFP producing gastric cancer with multiple liver metastases. One course of TS-1 100 mg/day for 4 weeks and discontinuation for 2 weeks was started from February, 2003. After 3 months, the level of AFP reduced remarkably from 53,700 ng/ml to the normal limit. The metastatic tumors in the liver showed regression, and after 14 months, CT scanning showed that the tumors had disappeared. Since the size of the original tumor showed no change, distal gastrectomy was performed, and curability A was achieved. We consider this rare case has significant value in terms of treatment of AFP producing gastric cancer with multiple liver metastases. We think the combination of surgery and chemotherapy such as TS-1 will lead to a better prognosis in such cases.

Use of autologous instead of allogeneic blood transfusion during esophagectomy prolongs disease-free survival among patients with recurrent esophageal cancer.

BACKGROUND AND OBJECTIVES: A substantial body of evidence suggests that allogeneic blood transfusion increases the rate of recurrence of resected malignancies. The present study was conducted with the aim of understanding better the clinical characteristics of recurrent esophageal cancer and determining whether any survival advantage is conferred by transfusing autologous instead of allogeneic blood during the esophagectomy for the original malignancy. METHODS: We retrospectively analyzed 123 patients who received blood transfusion while undergoing esophagectomy for thoracic esophageal cancer between January 1991 and February 1998. We focused on those patients in whom the malignancy recurred. Of them, 23 patients received allogeneic blood and 18 received autologous blood. Compared were the clinico-pathological factors influencing prognosis as well as the disease-free survival periods and the period of survival after recurrence of the cancer. RESULTS: The clinico-pathological factors that influenced prognosis were similar in the two groups. There was also no significant difference in the rate at which the esophageal cancer recurred, or in survival time once it had recurred. On the other hand, disease-free survival prior to recurrence was significantly prolonged in the autologous blood transfusion group. CONCLUSION: Use of autologous instead of allogeneic blood prolongs disease-free survival of esophageal cancer patients.

Soluble Fas and soluble FasL in multiple organ dysfunction syndrome complicating diffuse peritonitis.

The FasL-Fas system has been recognized as one of the apoptosis-inducing systems in the body. We studied the association between the serum levels of sFas, sFasL and TNF-alpha and the severity of the pathophysiological condition in 20 patients with multiple organ dysfunction syndrome (MODS) complicating generalized peritonitis. The serum levels of sFas and TNF-alpha were significantly higher in the patients who died than in those who survived. On the other hand, the sFasL level was significantly higher in the patients who survived than in those who died. A significant correlation was observed between the serum TNF-alpha level and the serum sFas level. These findings suggest that changes in the FasL-Fas system may be involved in the pathogenesis of MODS.

Relationship of the serum procalcitonin level with the severity of acute pancreatitis.

The procalcitonin (PCT) level in the blood was determined in cases of acute pancreatitis. The PCT level was found to show a significant correlation with the severity of acute pancreatitis. Furthermore, the PCT level was significantly higher in the cases which developed MODS than in those which did not. The PCT level was significantly higher in the patients who eventually died than in those who survived. A significant correlation was observed between the serum PCT level and the serum tumor necrosis factor alpha level. Thus, PCT level was found to be a reliable indicator of the severity of acute pancreatitis.

Outcomes of active operation during intensive followup for second primary malignancy after esophagectomy for thoracic squamous cell esophageal carcinoma.

BACKGROUND: Recent advances in the treatment of thoracic esophageal cancer have afforded it a better prognosis. As a consequence, increasing attention is being paid to the outcomes with postoperative monitoring for second primary malignancies after esophagectomy, but no recent study has focused on the longterm followup and outcomes in these patients. STUDY DESIGN: In 1989, we began intensive prospective screening and surveillance designed to detect cancers of the head and neck, lung, stomach, residual esophagus, and colon/rectum after esophagectomy. Between 1989 and 2001, 365 patients underwent esophagectomy for thoracic squamous cell esophageal carcinoma in our department. Of those, 200 were followed up as part of this program. Excluded were patients in whom esophageal cancer recurred, patients with other prior or simultaneous malignancies, and patients who died within a year of operation. Clinicopathologic profiles and treatment outcomes were determined for 33 patients who developed a second primary malignancy after esophagectomy. RESULTS: The interval between the primary esophageal cancer and the secondary carcinoma was 49 +/- 40 months (median, 48 months). The second primary malignancies were located in the stomach (30%), head and neck (24%), lung (24%), colon/rectum (9%), liver (6%), pancreas (3%), and blood (6%). Twenty-one patients (64%) were classified as stage 0, I, or II; 10 (30%) were stage III or IV. Overall, the 2-year, 3-year, and 5-year survival rates following diagnosis of a second primary malignancy were 58.0%, 58.0%, and 48.6%, respectively. Of the 19 patients (58%) in whom second primary malignancies were detected before symptoms developed, the 5-year survival rate was 70.7%, which was significantly greater than that among patients whose secondary malignancies were discovered after symptoms developed (17.1%). CONCLUSIONS: Good outcomes in the treatment of second primary malignancies after esophagectomy for thoracic squamous cell esophageal carcinoma can be obtained with longterm, intensive followup and active surgical intervention for detected malignancies.

Examination of soluble Fas (sFas) and soluble Fas ligand (sFasL) in patients with burns.

The FasL-Fas system is one of the recognized apoptosis-inducing systems, and has been determined to have important functions in relation to homeostasis and biological defense mechanisms. In this study, we investigated the serum levels of soluble Fas (sFas), soluble FasL (sFasL) and tumor necrosis factor alpha (TNF-alpha) in patients with burns. The sFas levels were found to be significantly higher in the patients who eventually died as compared to those in the patients who survived (3.9+/-1.8ng/ml versus 2.6+/-1.0ng/ml). On the other hand, the sFasL levels were significantly higher in the patients who survived (61.5+/-29.9ng/ml versus 37.2+/-14.4ng/ml) than in those who eventually died. A positive correlation was noted between the TNF-alpha level and the sFas level, and a negative correlation was observed between the TNF-alpha level and the sFasL level. These findings suggest that worsening of the condition of a burns patient may be related to changes in the Fas-FasL system.

Prospective endoscopic follow-up results of reconstructed gastric tube.

BACKGROUND/AIMS: Recent advances in the treatment of esophageal cancer have afforded better prognosis for patients. Despite the increased need to monitor the progress of patients with reconstructed digestive tracts over the long-term, no reliable prospective studies have yet been conducted. This prospective study determined secondary disease of the reconstructed gastric tube after esophagectomy for esophageal cancer. METHODOLOGY: One hundred and fourteen patients who underwent esophagectomy and reconstructed gastric tube via the posterior mediastinal route between April 1992 and March 1999 at Akita University Hospital, were followed up. Follow-up endoscopy was carried out once a year to determine the incidence and characteristics of secondary disease of the reconstructed gastric tube. RESULTS: Fifty-four (47%) patients were found to have secondary gastric abnormalities. Of these, 4 patients (3.5%) had carcinoma of the gastric tube, 12 patients (10.5%) had benign gastric tumor, 7 patients (6.1%) had gastric ulcers, and 40 patients (35.1%) had erosive or hemorrhagic gastritis. Three patients found to have early gastric cancer upon periodic follow-up endoscopy underwent successful complete resections. CONCLUSIONS: Annual follow-up endoscopy is vital to the detection of early, curative secondary gastric cancer and ulceration in patients following esophagectomy for esophageal cancer.

Survival advantage of using autologous blood transfusion during surgery for esophageal cancer.

PURPOSE: There is evidence that blood transfusion is associated with an increased rate of tumor recurrence. This study was conducted to assess the survival advantage of giving autologous blood instead of allogeneic blood during surgery for esophageal cancer. METHODS: We retrospectively analyzed 62 patients who underwent esophagectomy for thoracic esophageal cancer between January 1991 and February 1995 and received allogeneic blood transfusion, and 61 patients operated on between March 1995 and February 1998, who received autologous blood transfusion. The clinicopathological factors and survival rates were compared between the two groups. RESULTS: The clinicopathological factors that influenced prognosis were similar in the two groups; however, a definite survival advantage was evident in the autologous blood transfusion group. According to multivariate analyses, the transfusion of allogeneic blood was an independent prognostic factor ( P = 0.0222), as was the presence of metastatic lymph nodes. Patients who received allogeneic blood transfusions perioperatively had more than a twofold greater risk (Hazard ration 2.406) of death over patients who received autologous blood transfusions. CONCLUSION: Autologous blood transfusion appears to be an independent prognostic factor for the survival of patients with esophageal cancer.

Histological confirmation of healing of gastrobronchial fistula using a muscle flap.

We report a case of gastrobronchial fistula that developed after esophagectomy for esophageal cancer. The fistula was repaired successfully by transposing a pectoralis major muscle flap. Complete healing was confirmed histologically by epithelialization of the fistula site and at autopsy 12 months after surgery. Muscle flap transposition effectively repairs gastrobronchial fistula.