Influence of age on postoperative complications especially pneumonia after gastrectomy for gastric cancer.

BACKGROUND: The aim of this study was to investigate the influence of patients' age on postoperative morbidities including pneumonia. METHODS: We reviewed the clinical records of 211 patients with stages I - III gastric cancer undergoing curative distal gastrectomy (DG) or total gastrectomy (TG). Patients were classified into an elderly (≧80 y.o.) or a control (< 80 y.o.) group. We compared patient characteristics (sex ratio, disease stage, degree of lymph node dissection, number of retrieved lymph nodes, and type of reconstruction) and early postoperative outcomes (operation time, intra-operative blood loss, and postoperative morbidity including pneumonia, and mortality) between the two groups separately in DG and TG. RESULTS: There were 134 and 77 patients who underwent DG and TG, respectively. The numbers of patients in the elderly and control groups were 25 and 109 in DG and 12 and 65 in TG. The percentage of female patients in the elderly group was greater than that in the control group in both DG and TG. The extent of lymph node dissection did not differ between two groups in TG; in contrast in DG, the rate of a D1 dissection was greater in the elderly group than in the control group. There were no differences between the two groups in distribution of disease stage, number of retrieved lymph nodes, operation time, and blood loss in DG and in TG. Overall postoperative morbidity did not differ between two groups after DG and after TG. The rate of infectious complications in the elderly group was not different from that in the control group after DG and after TG. The incidence of pneumonia was more frequent in the elderly group compared to the control group after DG (8% vs. 1%, P < 0.05) but not after TG (17% vs. 5%). When patients were compared between the elderly and the control groups regardless of type of gastrectomy, the incidence of pneumonia in the elderly group (4/37 (11%)) was greater than that in the control group (4/174 (2%), P < 0.05). CONCLUSIONS: These results suggest that pneumonia is increased in patients older than 80 years after DG.

Hiatal hernia involving prolapse of the entire stomach into the mediastinum after distal gastrectomy: a case report.

BACKGROUND: Prolapse of a small part of the proximal stomach through the hiatus into the mediastinum is relatively common. Hiatal hernia involving the postoperative stomach has been reported previously, but the degree of hernia was not so severe, and hiatal hernia involving the prolapse of the entire stomach following gastrectomy into the mediastinum has never been reported. We describe a very rare case of large hiatal hernia involving the entire postoperative stomach. CASE PRESENTATION: A 79-year-old man with a history of distal gastrectomy for submucosal benign tumor 40 years ago was referred to our hospital because of dysphagia and weight loss. Computed tomography revealed prolapse of the entire postoperative stomach into the mediastinum, and a radical operation was performed. There was a strong adhesion in the hernial sac of the mediastinum, but only little adhesion due to a previous open surgery in the abdominal cavity was present. After the stomach was pulled into the abdominal cavity, suture cruroplasty and Toupet fundoplication without dissection of the short gastric artery were performed. The patient experienced postoperative paralytic ileus, but the rest of the postoperative course was uneventful and the symptom of dysphagia improved. CONCLUSIONS: We presented a very rare large hiatal hernia involving the entire postoperative stomach. Toupet fundoplication preserving the short gastric artery could be one of the optimal surgeries to prevent postoperative regurgitation of the remnant stomach.

Combined thoracoscopic and endoscopic surgery for a large esophageal schwannoma.

A 47-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy identified a submucosal tumor in the left wall of the esophagus that was diagnosed as a benign schwannoma on biopsy. Computed tomography revealed a tumor of length 60 mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. On endoscopy, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its oral end was dissected from the mucosal and muscular layers. This was followed by the resection of the entire tumor by left-sided thoracoscopy. The esophageal defect was closed in layer by continuous suture from the thoracic side. Endoscopic closure was achieved by using clips. No postoperative complications were observed. Oral diet was resumed from postoperative day 7 and the patient was discharged on postoperative day 9. This combined approach has not been described for similar tumors. Our experience demonstrated that large esophageal tumors can be safely excised with minimally invasive surgery by using a combination of thoracoscopy and endoscopy.

Estrogen receptor α and ß in esophageal squamous cell carcinoma.

A gender difference has been reported in the morbidity of esophageal squamous cell carcinoma (ESCC). Estrogens have been proposed to play a role in this difference but the details have not yet been clarified. Therefore, in the present study, we examined the status of estrogen receptor (ER)α and ERß in 90 Japanese ESCC patients. ERα and ERß immunoreactivity was detected in the nuclei of ESCC cells (41.1 and 97.8%, respectively). There was a significant positive association between the ERß H score and histological differentiation (P = 0.0403), TNM-pM (LYM) (P = 0.00164) and Ki67/MIB1 LI of carcinoma cells (P = 0.0497, r = 0.207). In addition, the ERß status of carcinoma cells was significantly correlated with unfavorable clinical outcome of the patients. Multivariate analysis further revealed the ERß status in carcinoma cells as an independent unfavorable prognostic factor of these patients. We further examined the effects of estrogen treatment on ESCC cell line (ECGI-10) transfected with ERα or ERß in vitro. The number of ECGI-10 transfected with ERß was increased by estradiol or ERß specific agonist but estradiol did not exert any effect upon the cell number of ECGI-10 transfected with ERα. In summary, the results of the present study clearly demonstrate that the status of ERß in ESCC was closely associated with the unfavorable prognosis, possibly through altering cell proliferation of carcinoma cells.

Steroid and xenobiotic receptor in human esophageal squamous cell carcinoma: a potent prognostic factor.

Steroid and xenobiotic receptor (SXR) is a nuclear receptor activated by diverse exogenous and endogenous compounds and has been demonstrated to play a pivotal role in detoxification through its regulation of various metabolizing enzymes and transporters. Recent studies also demonstrated the potential roles of SXR in the regulation of apoptosis and inflammation in various carcinoma cells, but the status of SXR in human esophageal squamous cell carcinoma (ESCC) has not been examined. Therefore, in this study, we performed immunohistochemical and quantitative RT-PCR evaluations in human ESCC in order to clarify its biological and clinical significance. We first immunolocalized SXR in 73 human ESCC cases. SXR immunoreactivity was detected in the nuclei, or in both nuclei and cytoplasm of carcinoma cells (98%, 20% of cases, respectively). The status of nuclear SXR immunoreactivity was inversely correlated with histological grade, lymph node status, ki67/MIB1 labeling index, and positively correlated with retinoid X receptor alpha status. In addition, high nuclear SXR expression was significantly correlated with favorable clinical outcome of the patients. Multivariate analysis further demonstrated SXR status in carcinoma cells as an independent favorable prognostic factor of the patients. Results of quantitative RT-PCR study demonstrated that SXR mRNA expression was detected in three of five cases, and was marked higher in the cancerous tissue than non-neoplastic tissue of these patients. This is the first study to demonstrate the status of SXR in human ESCC and the results suggest that SXR is a potent favorable prognostic factor of human ESCC.