Autonomous and intercellular chemokine signaling elicited from mesenchymal stem cells regulates migration of undifferentiated gastric cancer cells.

Accumulating evidence demonstrates that bone marrow (BM)-derived mesenchymal stem cells (MSCs) play critical roles in regulating progression of various types of cancer. We have previously shown that Wnt5a-Ror2 signaling in MSCs induces expression of CXCL16, and that CXCL16 secreted from MSCs then binds to its cognate receptor CXCR6 on the surface of an undifferentiated gastric cancer cell line MKN45 cells, eventually leading to proliferation and migration of MKN45 cells. However, it remains unclear about a possible involvement of another (other) cytokine(s) in regulating progression of gastric cancer. Here, we show that CXCL16-CXCR6 signaling is also activated in MSCs through cell-autonomous machinery, leading to upregulated expression of CCL5. We further show that CCR1 and CCR3, receptors of CCL5, are expressed on the surface of MKN45 cells, and that CCL5 secreted from MSCs promotes migration of MKN45 cells presumably via its binding to CCR1/CCR3. These data indicate that cell-autonomous CXCL16-CXCR6 signaling activated in MSCs upregulates expression of CCL5, and that subsequent activation of CCL5-CCR1/3 signaling in MKN45 cells through intercellular machinery can promote migration of MKN45 cells. Collectively, these findings postulate the presence of orchestrated chemokine signaling emanated from MSCs to regulate progression of undifferentiated gastric cancer cells.

Laparoscopic creation of a retrosternal route for gastric conduit reconstruction.

BACKGROUND: Retrosternal reconstruction is associated with a lower risk of mediastinitis, gastro-tracheal fistula, and hiatal hernia. Historically, traumatic manual creation of the retrosternal tunnel has been performed using one's fist. We report a novel and atraumatic laparoscopic procedure to create the retrosternal route. METHODS: We have laparoscopically created the retrosternal route in 25 thoracoscopic, mediastinoscopic, or robot-assisted minimally invasive esophagectomies since August 2019. Specifically, a peritoneal incision is started at the dorsal side of the xiphoid process. Through a 12-mm port inserted slightly to the right of and superior to the umbilical camera port, we dissect loose connective tissues from the caudal to the cranial side using behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route was calculated. Then, the cumulative sum (CUSUM) method and the simple moving average of five cases were used to evaluate the learning curve of this novel procedure. Operative outcomes were analyzed according to the learning curve results and also compared with 25 cases of postmediastinal reconstruction counterparts. RESULTS: Twenty-five patients were divided into the early group (six patients) and late group (19 patients) based on the peak of the CUSUM chart. The time required for route creation was 28.5 min (median) in the early and 15 min in the late group, indicating a significant difference (P = 0.038). The overall incidence of pleural injury was 20% (5 of 25 patients), with no significant difference between the groups. There was no significant difference in the incidence of perioperative complications. Also, there were no significant differences in perioperative complications or gastric conduit functions 1 year after surgery between the retrosternal and the postmediastinal reconstruction. CONCLUSION: Laparoscopic creation of a retrosternal route for gastric conduit reconstruction is safe and feasible and has a short learning curve.

Comparison of laparoscopic gastrectomy with 3-D/HD and 2-D/4 K camera system for gastric cancer: a prospective randomized control study.

PURPOSE: We conducted a prospective clinical control study to identify the best imaging technology among three-dimensional (3-D) high-definition (HD) stereovision and two-dimensional (2-D) ultra-high-resolution (4 K) technology and confirm their effects on surgical outcomes of laparoscopic gastrectomy for gastric cancer. METHODS: From April 2018 to August 2019, 50 patients were randomly classified into two groups based on the imaging technology (3-D/HD group = 25, 2-D/4 K = 25). After excluding eight patients based on laparoscopic findings, 42 patients were analyzed (3-D/HD group = 21, 2-D/4 K = 21). The primary endpoint was the operative time; the secondary endpoints were blood loss, postoperative infectious complications, and postoperative hospital stay. RESULTS: The patients' backgrounds were similar (sex, age, body mass index [BMI], stage, procedure, and extent of lymph node dissection). There were no significant differences in operative time (252 vs. 238 min, P = 0.70), total blood loss, postoperative infectious complications, and postoperative hospital stay between the two groups. However, video analysis of surgeries revealed a significantly shortened median operative time (18 vs. 25 min, P = 0.04) in the suturing step with 3-D/HD; the median number of camera cleaning procedures during suprapancreatic lymph node dissection was significantly lower with 2-D/4 K than with 3-D/HD (n = 4.4 vs. 2.8, P = 0.02). CONCLUSION: 3-D/HD and 2-D/4 K laparoscopic radical gastrectomies provide similar surgical outcomes. However, the 3-D monitor reduces suturing time during reconstruction, while the 4 K monitor reduces the number of camera cleaning procedures during lymphadenectomy. TRIAL REGISTRATION: Registered in the University Hospital Medical Information Network Clinical Trials Registry (identification number 000029227).

Novel "Modified Bascule Method" for Lymphadenectomy Along the Left Recurrent Laryngeal Nerve During Robot-Assisted Minimally Invasive Esophagectomy.

BACKGROUND: Given the worldwide popularization of conventional minimally invasive esophagectomy (C-MIE), robot-assisted MIE (RAMIE) can be expected to provide a finer procedure. However, controversy remains regarding whether RAMIE is superior to C-MIE in preventing recurrent laryngeal nerve (RLN) palsy. Considering the shallow learning curve for RAMIE, a novel procedure for lymphadenectomy along the RLN during RAMIE is needed. METHODS: Based on a logical and simple understanding of the left upper mediastinum anatomy, the authors developed a novel "modified bascule method" for RAMIE that could simplify lymphadenectomy along the left RLN and prevent it from being touched and stretched. Between 2018 and 2020, 46 patients with esophageal carcinoma underwent RAMIE using this method at Kobe University. RESULTS: The modified bascule method was used to perform RAMIE for 29 men and 17 women with a median age of 67 years (range, 49-82 years). The median thoracoscopic procedure time was 438 min (range, 344-625 min), and the median console time was 351 min (range 273-518 min). The study harvested a median of 24 (range, 8-34) lymph nodes from the thoracic portion and 4 (range, 0-10) lymph nodes from along the left RLN. The mortality rate was 0%. Postoperative left RLN palsy classified as Clavien-Dindo (C-D) grade 1 or higher was observed for 9 patients (19%), whereas grade 2 or higher was not seen (0%). Pneumonia and anastomotic leakage rates higher than C-D grade 2 were respectively 13% and 19%. CONCLUSIONS: The novel modified bascule method for RAMIE can promote feasible lymphadenectomy along the left RLN even when performed during the learning period.

Impact of Lymph Node Ratio on Survival Outcome in Esophageal Squamous Cell Carcinoma After Minimally Invasive Esophagectomy.

BACKGROUND: Esophageal squamous cell cancer (ESCC) is one of the deadliest cancers in the world. Esophagectomy remains the principal treatment, and minimally invasive esophagectomy (MIE) has been performed worldwide. This study aimed to clarify whether the lymph node ratio (LNR), defined as the ratio of metastatic lymph nodes (LNs) to examined, is a prognostic factor for ESCC after MIE. METHODS: This study included 327 MIEs with the patient in the prone position at two institutions from 2010 to 2015. Cox proportional hazards regression analyses using clinicopathologic characteristics and the LNR were performed for the pN1 patients and the whole cohort. RESULTS: In the multivariate analysis for all stages, independent prognostic factors were depth of tumor invasion (P < 0.0001), LNR (P = 0.014), operative time (P = 0.003), and pneumonia (P = 0.012). In the analysis of the pN1 subgroup, the optimum LNR cutoff level for overall survival (OS) was 9 based on receiver operation characteristic analysis. The LNR was significantly associated with depth of tumor invasion (P = 0.004) and number of metastatic LNs (P < 0.0001). The OS curve for the group with an LNR of 9 or higher was significantly worse than for the group with an LNR lower than 9 (P < 0.001). Multivariate analyses demonstrated that the LNR is a unique independent prognostic factor for the pN1 subgroup (hazard ratio, 6.811; 95% confidence interval, 2.009-23.087; P = 0.002). CONCLUSIONS: The LNR is an independent prognostic factor in ESCC after MIE. Especially for patients with pN1 status, the LNR is more useful than the number of metastatic LNs for predicting survival outcome.

Postoperative recurrent laryngeal nerve palsy is associated with pneumonia in minimally invasive esophagectomy for esophageal cancer.

BACKGROUND: During the past decade, minimally invasive esophagectomy (MIE) for esophageal cancer has been adopted worldwide with expectations of lower invasiveness. However, the rate of postoperative pneumonia, which is an independent risk factor for oncological prognosis in esophageal cancer, remains high. The aim of this retrospective follow-up study is to clarify whether there is a strong correlation between recurrent laryngeal nerve (RLN) palsy and postoperative pneumonia in MIE. METHODS: This retrospective follow-up study included 209 patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position (TEP) at Kobe University between 2011 and 2018. Inclusion criteria included age 18-85 years; cT1-3, cN0-3 disease; upper mediastinal lymphadenectomy; and ability to undergo simultaneous esophagectomy and reconstruction of the gastric conduit or pedicled jejunum. Univariate and multivariate logistic regression were conducted to identify independent risk factors for pneumonia. RESULTS: Among 209 TEPs, pneumonia of Clavien-Dindo classification grade > II occurred in 44 patients (21%). In the pneumonia positive and negative groups, there were significant differences in age (67.9 ± 7.5 vs. 64.9 ± 8.6 years), 3-field lymph node dissection [27 (61%) vs. 67 (41%)], transfusion [20 (45%) vs. 41 (25%)], left RLN palsy [19 (43%) vs. 18 (11%)], and any RLN palsy [20 (45%) vs. 18 (11%)]. In multivariate analysis, any RLN palsy was associated with a higher incidence of pneumonia [odds ratio (OR), 6.210; 95% confidence interval (CI), 2.728-14.480; P < 0.0001]. In addition, age was associated with a higher incidence of pneumonia (OR, 1.049; 95% CI, 1.001-1.103; P = 0.046). Changes in the rate of any RLN palsy over time were quite similar to changes in the incidence of pneumonia. CONCLUSION: There is a strong correlation between RLN palsy and pneumonia in MIE for esophageal cancer. Prevention of RLN palsy may reduce the incidence of pneumonia, leading to better oncological prognosis.

Transperineal minimally invasive abdominoperineal resection for low rectal cancer: standardized technique and clinical outcomes.

BACKGROUND: Despite the increasing utilization of transanal total mesorectal excision as a promising approach for low rectal cancer, the feasibility and safety of transperineal minimally invasive abdominoperineal resection (tp-APR) remain unclear. METHODS: In total, 25 patients who underwent tp-APR between April 2017 and May 2020 (tp-APR group) and 27 patients who underwent conventional laparoscopic APR between May 2009 and September 2016 (lap-APR group) for low rectal cancer were enrolled in this retrospective study. Clinical outcomes were compared between the groups before and after propensity score matching. The primary outcome was the incidence of the overall postoperative complications with Clavien-Dindo grade II or above. Standardized technique of tp-APR was also demonstrated. RESULTS: On comparison, operative time, intraoperative blood loss, and overall postoperative complications with Clavien-Dindo grade II or above were significantly less in the tp-APR group both before and after propensity score matching. The rates of urinary disturbance and perineal wound infection were significantly less in the tp-APR group after matching. Further, postoperative hospital stay was significantly shorter in the tp-APR group both before and after matching. However, pathological outcomes did not differ between the groups before and after matching. There has been no local recurrence in the tp-APR group with a median follow-up period of 18 months. CONCLUSION: Standardized tp-APR for low rectal cancer is feasible and seems superior to conventional laparoscopic APR in terms of short-term outcomes. Further larger-scale studies with a longer follow-up period are required to evaluate oncological outcomes.

Three-dimensional visualization system is one of the factors that improve short-term outcomes after minimally invasive esophagectomy.

PURPOSE: Minimally invasive esophagectomy (MIE) has been increasingly used, but many reports have stated that recurrent laryngeal nerve (RLN) palsy after MIE is a major complication associated with postoperative pneumonia. Prevention of RLN palsy clearly has been a challenging task. The study aim was to determine if a three-dimensional (3-D) stereoscopic vision system can reduce the RLN palsy rate after MIE. METHODS: This was a retrospective study of MIE (McKeown esophagectomy) using a 3-D or 2-D stereoscopic vision system to treat 358 patients in the prone position between April 2010 and March 2019. The patients who underwent 3-D MIE (3-D group) or 2-D MIE (2-D group) were matched by using propensity score matching. After matching, the perioperative outcomes were compared between the groups. RESULTS: After propensity score matching, 154 patients were analyzed (77 patients, 3-D group; 77 patients, 2-D group). There were no significant differences in the patients' baseline characteristics in the matched cohort. There were no significant differences in the rates of pneumonia (Clavien-Dindo (C-D) grade ≥ II, 3-D vs. 2-D, 11 (14%) vs. 12 (16%)), anastomotic leakage (C-D grade ≥ II, 10 (13%) vs. 18 (23%)) and mortality. The rates of left RLN palsy (C-D grade ≥ IIIa, 1 (1.3%) vs. 7 (9.1%), P = 0.029), right RLN palsy (C-D grade ≥ I, 2 (3%) vs. 8 (10%), P = 0.049), comprehensive complication index (CCI®) (8.5 vs. 14.3, P = 0.011), and postoperative hospital stay period (median: 25 vs. 30 days, P = 0.034) were significantly lower in the 3-D group than in the 2-D group, respectively. CONCLUSIONS: In MIE, the 3-D viewing system was one of the factors that reduced postoperative morbidities such as the rates of each RLN palsy and CCI®, leading to shorter postoperative hospital stay.

Preoperative endoscopic tattooing using India ink to determine the resection margins during totally laparoscopic distal gastrectomy for gastric cancer.

PURPOSE: This study was conducted to determine whether establishing the proximal resection line using India ink tattooing can ensure safe resection margins during totally laparoscopic distal gastrectomy. METHODS: This retrospective study included 81 patients who underwent totally laparoscopic distal gastrectomy for gastric cancer on the lower two-thirds of the stomach. The proximal resection margins were analyzed with respect to the macroscopic type and clinical T stage, and the intraoperative appearance of the stain on the serosa was classified by reviewing surgical videos. RESULTS: R0 resection was performed in all patients. The rates of the intended margins were 89.2% in patients without a frozen section diagnosis and 84.2% in patients with differentiated type lesions who underwent a frozen section diagnosis; however, most patients with undifferentiated advanced lesions failed to achieve the intended resection margins. Intraoperative appearance revealed that 85.2% of patients had localized type stains, whereas 11.1% had widespread-type stains. CONCLUSIONS: Our procedure to determine the proximal resection line in totally laparoscopic distal gastrectomy is oncologically safe. However, careful observation of the resected specimen and a frozen section analysis should be performed for undifferentiated advanced lesions.

Multimodality approaches to control esophageal cancer: development of chemoradiotherapy, chemotherapy, and immunotherapy.

Esophageal cancer has a poor prognosis despite the fact that surgical techniques have been advanced and optimized, and systemic multimodality approaches have progressed recently. Adding chemotherapy, radiotherapy, and immunotherapy to the basic surgical approach have been shown to have therapeutic benefit for esophageal cancer. This review describes the latest development of chemoradiotherapy, chemotherapy, and immunotherapy, which have contributed to the reduction in esophageal cancer growth and improved the survival of patients. Chemoradiation is a treatment option for resectable esophageal cancer to preserve the esophagus for patients who cannot tolerate surgery. Moreover, a combination of chemoradiotherapy and salvage surgery could extend the survival of patients. The effects of a triplet chemotherapy regimen are currently being verified in some Phase III studies for unresectable advanced/recurrent esophageal cancer. In addition, with the great promise of immune checkpoint inhibitors, strategies that incorporate the use of immunotherapy may shift from the metastatic setting to the neoadjuvant/adjuvant setting as a result of clinical trials. More precise comprehension of the molecular biology of esophageal cancer is expected to further control disease progression using multimodality treatments in the future.

Correction to: Thoracic Duct Resection During Esophagectomy Does Not Contribute to Improved Prognosis in Esophageal Squamous Cell Carcinoma: A Propensity Score Matched-Cohort Study.

In the original article, there are errors in Fig. 1. Following is the corrected figure.

Tooth Loss Predicts Long-Term Prognosis of Esophageal Cancer After Esophagectomy.

BACKGROUND: Oral health is associated with various diseases, including cancer. Tooth loss is a simple and objective index of oral health. OBJECTIVE: The purpose of this study was to investigate the association between preoperative tooth loss and esophageal cancer prognosis after esophagectomy. METHODS: This study included 191 patients who underwent esophagectomy for esophageal cancer after perioperative dental evaluation and oral care at Kobe University Hospital from April 2011 to March 2016. Patients were divided into two groups: Group A (tooth loss < 7) and Group B (tooth loss ≥ 7). Three-year overall survival (OS) and multivariate analysis were performed, along with subgroup analysis for elderly patients (age ≥ 65 years). RESULTS: The 3-year OS rate was 68.1% in Group A (104 patients) and 49.2% in Group B (87 patients). Group A had significantly higher OS than Group B (p = 0.002), and there were no significant differences in sex and clinical T or N stage between the two groups. However, the mean age of Group A was younger than that of Group B (64.2 vs. 68.5 years; p = 0.0002). Among elderly patients, the 3-year OS rate was 68.2% in Group A (55 patients) and 45.1% in Group B (65 patients) [p = 0.003]. Multivariate analysis that included age demonstrated that tooth loss is an independent prognostic factor (hazard ratio 1.87, 95% confidence interval 1.22-2.87), in addition to clinical T stage and preoperative serum albumin. CONCLUSION: Tooth loss is an independent prognostic factor for esophageal cancer after esophagectomy.

Severe weight loss after minimally invasive oesophagectomy is associated with poor survival in patients with oesophageal cancer at 5 years.

BACKGROUND: Patients often experience severe weight loss after oesophagectomy. Enteral nutrition via a feeding jejunostomy tube (FT) is commonly practised. This study aimed to assess the effect of severe weight loss postoperatively and enteral nutrition via an FT on long-term prognosis after oesophagectomy. METHODS: This study analysed 317 patients who underwent minimally invasive oesophagectomy at Kobe University Hospital and Hyogo Cancer Center from 2010 to 2015. The patients' body weight was evaluated at 3 months postoperatively. They were organised into the severe weight loss (n = 65) and moderate weight loss (n = 252) groups. Furthermore, they were categorised into the FT group (184 patients who had an FT placed during oesophagectomy) and no-FT group (133 patients without FT). Patients (119 per group) matched for the FT and no-FT groups were identified via propensity score matching. RESULTS: The 5-year overall survival (OS) rate in the severe weight loss group was significantly lower (p = 0.024). In the multivariate analysis, tumour invasion depth (pT3-4), preoperative therapy and severe weight loss had a worse OS (hazard ratio = 1.89; 95% confidence interval = 1.12-3.17, hazard ratio = 2.11; 95% confidence interval = 1.25-3.54, hazard ratio = 1.82; 95% confidence interval = 1.02-3.524, respectively). No significant differences in the number of severe weight loss patients and OS were found between the FT and no-FT groups. CONCLUSION: Severe weight loss is significantly associated with poor OS. In addition, enteral nutrition via an FT did not improve the severe weight loss and OS.

Skeletal muscle loss after laparoscopic gastrectomy assessed by measuring the total psoas area.

PURPOSE: Skeletal muscle loss after gastrectomy can worsen patients' quality of life and prognosis. Laparoscopic gastrectomy is less invasive than open gastrectomy and has become commonly performed. However, the degree of skeletal muscle loss after laparoscopic procedures remains unclear. We herein report the degree and risk factors of psoas muscle loss after laparoscopic gastrectomy for gastric cancer. METHODS: The total psoas area (TPA) on computed tomography of 50 consecutive patients who underwent laparoscopic total gastrectomy (LTG) and 167 consecutive patients who underwent laparoscopic distal gastrectomy (LDG) for gastric cancer was retrospectively evaluated at one postoperative year. The TPA loss was compared between LDG and LTG and univariate and multivariate analyses were performed to identify the risk factors for TPA loss > 10%. RESULTS: The median TPA decrease rate was 5.9% in the LDG group and 15.6% in the LTG group. LTG and postoperative respiratory complications were independent factors associated with a severe TPA loss of > 10%. In the LTG group, no independent factors were identified in a multivariate analysis. In the LDG group, postoperative complications were identified as an independent risk factor for TPA loss > 10%. CONCLUSIONS: Laparoscopic gastrectomy leads to postoperative TPA loss, especially in patients who underwent LTG and had postoperative respiratory complications. Postoperative complications after LDG were also a risk factor for TPA loss.

Prophylactic Cervical Lymph Node Dissection in Thoracoscopic Esophagectomy for Esophageal Cancer Increases Postoperative Complications and Does Not Improve Survival.

BACKGROUND: Esophagectomy with three-field lymph node dissection is common, but the effects of cervical lymph node dissection on overall survival in patients with thoracic esophageal cancer remain controversial. Recently, we performed thoracoscopic esophagectomy and superior mediastinum and paracervical esophageal lymph nodes could have been effectively dissected from the thoracic cavity. This study assessed the risks and benefits of prophylactic supraclavicular lymph node dissection in patients who underwent thoracoscopic esophagectomy. METHODS: This retrospective study included 294 patients who underwent thoracoscopic esophagectomy at Kobe University Hospital and Hyogo Cancer Center between April 2010 and December 2015. Patients in the two-field (paracervical esophageal lymph nodes were dissected from the thoracic cavity) and three-field lymph node dissection groups were matched using propensity score matching. We compared overall survival and the incidence of postoperative complications in the matched cohort and assessed the estimated efficacy of additional lymphadenectomy for supraclavicular lymph node recurrence in the entire cohort. RESULTS: In the matched cohort, overall survival was not significantly different between the two groups, but the incidence of recurrent laryngeal nerve palsy was significantly higher in the 3FL group than in the 2FL group. In the entire cohort, 162 patients underwent a two-field lymph node dissection; 11 experienced supraclavicular nodal recurrence. We performed additional supraclavicular lymph node dissection in three patients without systemic metastasis, all of whom are alive without any other recurrence. CONCLUSIONS: Prophylactic cervical lymph nodes dissection in thoracoscopic esophagectomy does not improve long-term survival but does increase the risk of postoperative complications.

Long-Term Outcomes of Thoracoscopic Esophagectomy in the Prone versus Lateral Position: A Propensity Score-Matched Analysis.

BACKGROUND: Several studies have suggested that thoracoscopic esophagectomy (TE) in the prone position (TEP) may be more feasible than TE in the lateral position (TEL); however, few studies have compared long-term survival between the two procedures. We evaluated whether TEP is oncologically equivalent to TEL. METHODS: Surgical outcomes of TEs performed from January 2006 to December 2013 at our hospital were retrospectively analyzed. Propensity score matching was used to control for confounding factors. RESULTS: TE was performed in 200 patients diagnosed with esophageal squamous cell carcinoma; 78 patients were matched in two procedures. The mean thoracic operative time in TEL was shorter than in TEP (228.9 min vs. 299.1 min; p < 0.001); however, the mean thoracic blood loss in TEL was higher than in TEP (186.9 ml vs. 76.5 ml; p < 0.001). The mean number of thoracic lymph nodes harvested in TEL was lower than in TEP (23.5 vs. 26.9; p < 0.05), and the pulmonary complication rate in TEL was higher than in TEP (30.8% vs. 15.4%; p < 0.05). The 5-year overall survival rates in pathological stage I (81.2% vs. 81.6%; p = 0.82), stage II (65.3% vs. 80.9%; p = 0.21), stage III (26.7% vs. 24.2%; p = 0.86) and all stages (63.6% vs. 62.3%; p = 0.88), and the 5-year progression-free survival rates in pathological stage I (78.0% vs. 81.8%; p = 0.54), stage II (53.5% vs. 77.6%; p = 0.13), stage III (10.5% vs. 12.8%; p = 0.81) and all stages (53.6% vs. 57.9%; p = 0.50) were not significantly different between the two procedures. CONCLUSION: TEP and TEL provide equal oncological efficiency.

Thoracic Duct Resection During Esophagectomy Does Not Contribute to Improved Prognosis in Esophageal Squamous Cell Carcinoma: A Propensity Score Matched-Cohort Study.

PURPOSE: Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal squamous cell carcinoma (ESCC). Thoracic duct (TD) resection has been recommended as part of extended lymphadenectomy, although its merits are unclear. The aim of this two-institutional, matched-cohort study is to clarify whether TD resection improves prognosis in esophagectomy for ESCC. PATIENTS AND METHODS: In this two-institutional, matched-cohort study of 399 patients with ESCC who underwent McKeown esophagectomy between 2010 and 2014, the primary outcomes were overall survival (OS), disease-free survival (DFS), and cause-specific survival (CSS). Secondary outcomes were perioperative results and recurrence patterns. RESULTS: Based on a propensity score, 122 TD-resected or 122 TD-preserved patients in all stages were selected (median follow-up 4.5 years). The 5-year OS, DFS, and CSS rates in the TD-resected versus TD-preserved groups were 49% versus 60%, 53% versus 57%, and 58% versus 70%, respectively, without any significant differences. Operative time for the thoracic procedure was significantly longer and the number of retrieved mediastinal nodes was significantly higher in the TD-resected group (P = 0.009 and 0.005, respectively). The rates of chylothorax and left recurrent laryngeal nerve (RLN) palsy were significantly higher in the TD-resected group (P = 0.041 and 0.018, respectively). There were no significant differences in rates of local or distant metastases between the two groups. CONCLUSIONS: TD resection does not contribute to improve OS, DFS, or CSS in ESCC but increases incidence of chylothorax and left RLN palsy. Prophylactic TD resection should be avoided in esophagectomy for ESCC.

Medial approach for subcarinal lymphadenectomy during thoracoscopic esophagectomy in the prone position.

PURPOSE: In esophageal squamous cell carcinoma (ESCC), lymph nodes (LNs) around the subcarina and main bronchi are thought to be highly involved. Therefore, complete dissection of these LNs with preservation of the pulmonary branches of the vagus nerves, which control important pulmonary functions, is recommended. The aim of this retrospective study was to investigate the feasibility of reliable method for lymphadenectomy around the subcarina and main bronchi, named the medial approach, during thoracoscopic esophagectomy in the prone position (TEP). METHODS: This was a case-matched control study of patients who underwent TEP for ESCC. The fundamental concept in this method is to first exfoliate the LNs around the subcarina and main bronchi from the pericardium. Developing the operative field contributes to visualizing and preserving the pulmonary branches of the right vagus nerve. Twenty-three patients who underwent the medial approach and 23 patients who underwent the conventional approach were selected by the use of propensity score matching to compare the operative outcomes. RESULTS: The medial approach significantly reduced operative time for procedure (16 ± 3 vs 30 ± 6 min, p < 0.0001) and operative blood loss (123 ± 108 vs 207 ± 162 ml, p = 0.046) comparing with conventional approach. The incidence of postoperative pneumonia was lower in the medial approach group (4%) than in the conventional approach group (15%) (p = 0.069). CONCLUSIONS: The medial approach for lymphadenectomy around the subcarina and both main bronchi during TEP is technically safe and feasible in shorting the operative time with possibility to reduce postoperative pneumonia.

Meaning of C-reactive protein around esophagectomy for cStage III esophageal cancer.

PURPOSE: The prognosis of esophageal cancer is dismal, and the 3-year overall survival of cStage III does not reach 50.0%. C-reactive protein (CRP) is a well-known protein that reflects the short- and long-term operative outcomes of esophageal cancer. However, since elevated CRP levels are often observed in cStage III esophageal cancer, whether or not CRP still reflects the prognosis is unclear. METHODS: Eighty-four patients who were diagnosed with cStage III esophageal cancer and underwent R0/1 operation from January 2007 to December 2014 were retrospectively evaluated. RESULTS: The mean age was 66.8 years, and the majority of patients were male. The median preoperative and postoperative CRP levels were 0.15 and 1.47 mg/dl, respectively. A majority of the patients underwent thoracoscopic surgery, and the median blood loss and operation duration were 456 ml and 11.6 h, respectively. Forty-six patients (54.8%) died during the observation period, and the 3-year overall survival was 52.4%. A multivariate analysis showed that the preoperative CRP level, postoperative albumin level, blood loss, and complications were independent prognostic factors. A multiple linear regression analysis showed that an elevated postoperative CRP level was affected by the operation duration and preoperative CRP levels. CONCLUSIONS: These findings suggest that the preoperative CRP level is a prognostic factor for cStage III esophageal cancer and that postoperative elevation in the CRP level is affected by the operation duration.

[A Case of Colon Neuroendocrine Carcinoma Believed to Be a Recurrence of Appendiceal Adenocarcinoma].

Neuroendocrine carcinomas in the right-side colon are rare. We report a case of neuroendocrine carcinoma occurring in the anastomotic site after ileocecal resection. The patient was a 55-year-old man who underwent ileocecal resection for adenocarcinoma in his appendix. Following surgery, he was administered adjuvant chemotherapy. Two and a half years after the surgery, he was diagnosedwith left ilium bone metastasis andreceivedrad iotherapy. After the radiotherapy, an anastomotic tumor andperitoneal metastasis were found. He was administeredFOLFIRI but couldnot tolerate the therapy. After changing to FOLFOX therapy, he reportedabd ominal pain from perforation of the anastomotic tumor, which was not improvedby antibiotics. Therefore, he was referredto our hospital for surgery. The surgery includedresection of part of the anastomosis. Histopathological examination showed that the tumor at the anastomosis was not adenocarcinoma but rather neuroendocrine carcinoma. After discharge, the patient started a new chemotherapy regimen(CDDP plus VP-16). This case indicates that resection of the recurrence site may leadto new treatment, improve patient' QOL, andextendthe life prognosis.