Japanese Classification of Esophageal Cancer, 12th Edition: Part II.

This is the second half of English edition of Japanese Classification of Esophageal Cancer, 12th Edition that was published by the Japan Esophageal Society in 2022.

Japanese Classification of Esophageal Cancer, 12th Edition: Part I.

This is the first half of English edition of Japanese Classification of Esophageal Cancer, 12th Edition that was published by the Japan Esophageal Society in 2022.

Double stapling technique versus hemi-double stapling technique for esophagojejunostomy with OrVil™ after laparoscopic total gastrectomy: a single-blind, randomized clinical trial.

BACKGROUND: The transorally inserted anvil (OrVil™) is frequently selected for esophagojejunostomy after laparoscopic total gastrectomy (LTG) because of its versatility. During anastomosis with OrVil™, the double stapling technique (DST) or hemi-double stapling technique (HDST) can be selected by overlapping the linear stapler and the circular stapler. However, no studies have reported the differences between the methods and their clinical significance. METHODS: A randomized controlled clinical trial with a parallel assignment and single-blind outcomes assessment analysis was conducted. Patients with gastric cancer eligible for LTG who met the selection criteria were randomized. Preoperative characteristics and perioperative and postoperative outcomes were compared between the DST and HDST. The primary endpoint was an anastomosis-related complication, and the secondary endpoints were perioperative outcomes and postoperative complications, excluding anastomosis-related complications. RESULTS: Thirty patients with gastric cancer were eligible and randomized. LTG and esophagojejunostomy were successfully performed in all patients, without conversion to laparotomy. Preoperative characteristics, excluding preoperative chemotherapy, were not significantly different between the two groups. One anastomotic leakage of Clavien-Dindo classification grade ≥ IIIa was observed in the DST, although no significant difference was found between the two groups (6.6% vs. 0%, P = 0.30). In the HDST, one case of anastomotic stricture required endoscopic balloon dilation. No significant differences were found in operative time, whereas the anastomosis time was significantly shorter in the HDST than in the DST (47.5 ± 15.8 vs. 38.2 ± 8.8 min, P = 0.028). Except for anastomosis-related complications, postoperative complications (P = 0.282) and postoperative hospital stay for the DST and HDST were not significantly different. CONCLUSIONS: No superiority was found between the DST and HDST with OrVil™ in esophagojejunostomy of LTG for gastric cancer with respect to postoperative complications, whereas the HDST may be preferable in terms of the simplicity of the surgical technique.

Postoperative complications after a transthoracic esophagectomy or a transhiatal gastrectomy in patients with esophagogastric junctional cancers: a prospective nationwide multicenter study.

BACKGROUND: Esophagogastric junction (EGJ) cancers are resected thorough esophagectomy or gastrectomy, with the incidence of postoperative complications influenced by the chosen procedure. METHODS: In this prospective nationwide multicenter study, patients with cT2-T4 EGJ cancers were enrolled before surgery. Based on the protocol, surgeons performed a transthoracic esophagectomy (TTE) or a transhiatal gastrectomy (THG) and dissected all lymph nodes prespecified as the standardized procedure. Postoperative complications were correlated with the clinical factors in each procedure. RESULTS: A total of 345 patients were eligible for this study. TTE and THG were performed in 120 and 225 patients, respectively. Complications of Clavien-Dindo ≥ Grade II were found in 115/345 (33.3%) patients. Recurrent laryngeal nerve palsy was found only in the TTE group (p < 0.001). The incidence of other complications was not significantly different between the two groups. High body mass index (BMI) in the TTE group, male sex, and longer esophageal invasion in the THG group were significantly correlated with complications ≥ Grade II (p = 0.049, 0.037, and 0.019, respectively). Anastomotic leakage was most frequently observed (12.2%). Tumor size in the THG group (p = 0.02) was significantly associated with leakage. All six patients with ≥ Grade IV leakage underwent THG, whereas, none of the patients in the TTE group had leakage ≥ Grade IV (2.7% vs. 0%, p = 0.096). CONCLUSIONS: Surgical resection should be performed with utmost care, particularly in patients with a high BMI undergoing TTE, and in patients with larger tumors, longer esophageal invasion, or male patients undergoing THG.

Is Prophylactic Cervical Drainage Effective in Patients Undergoing McKeown Esophagectomy Reconstructed Through the Retrosternal Route with Two-Field Lymphadenectomy?

BACKGROUND: McKeown esophagectomy with two-field lymphadenectomy is the treatment of choice for oncologic esophagectomy. A cervical drain is placed in cases after modern two-field lymph node dissection (M2FD) to provide information on anastomotic leakage. However, the necessity of prophylactic cervical drainage during surgery remains unknown. This study aimed to clarify the clinical significance of cervical drainage in patients who underwent McKeown esophagectomy with M2FD. METHODS: A total of 293 patients underwent McKeown surgery with two-field lymphadenectomy at our institute between January 2013 and December 2019. We compared the day of drain removal, amount of drainage volume, and the appearance of drainage fluid between patients with and without anastomotic leakage. RESULTS: McKeown esophagectomy reconstructed through the retrosternal route is 203 patients (69.3%) of all. Nineteen patients (6.5%) experienced anastomotic leakage. The amount of cervical drain discharge was comparable between patients with and without anastomotic leakage. In addition, no purulent or salivary discharge was observed in patients with anastomotic leakage. There was no difference in the median day of drain removal between the groups. The initial clinical findings for the diagnosis of anastomotic leakage were surgical site infection in 10 (52.6%), fever in 5 (26.3%), prolonged inflammation in a blood test in 3 (15.8%), and bloody discharge from the chest tube in 1 (5.3%). There was no mortality due to any cause. CONCLUSION: A prophylactic cervical drain may not be mandatory in patients with esophageal cancer undergoing McKeown esophagectomy reconstructed through the retrosternal route with two-field lymphadenectomy.

Treatment strategies and outcomes for elderly patients with locally advanced squamous cell carcinoma of the esophagus.

PURPOSE: A multidisciplinary treatment strategy for locally advanced esophageal squamous cell carcinoma (ESCC) is required to achieve prolonged survival. We aimed to clarify the differences in treatment strategies for locally advanced ESCC and the outcomes of elderly (aged ≥ 75 years) vs. younger patients (aged < 75 years). METHODS: We compared the treatment strategy selection and the outcomes of 40 elderly and 160 younger patients with cStage II/III ESCC diagnosed between January, 2014 and December, 2016. RESULTS: Nineteen (47.5%) of the elderly patients and 144 (90.0%) of the younger patients underwent esophagectomy and 9 (22.5%) of the elderly patients and 131 (81.9%) of the younger patients received neoadjuvant chemotherapy. Ivor-Lewis or transhiatal esophagectomy was performed more frequently in the elderly group than in the younger group (P = 0.0096). The survival rate after esophagectomy was higher in the younger group than in the elderly group. The overall survival rate of the elderly patients who underwent esophagectomy was significantly higher than that in those who did not. CONCLUSIONS: Esophagectomy is a practical choice for elderly patients with locally advanced ESCC, although reduced treatment intensity may impact long-term survival.

Clinical features and risk factors for early recurrence after esophagectomy following neoadjuvant chemotherapy for esophageal cancer.

PURPOSE: The purpose of this study was to clarify the clinical features and outcomes of patients with recurrence after esophagectomy following neoadjuvant chemotherapy (NAC) related to the timing of recurrence. METHODS: We reviewed 240 consecutive patients who underwent NAC followed by esophagectomy for clinical stage II/III esophageal squamous cell carcinoma between 2009 and 2014. We compared the clinical features and survival after recurrence among groups of patients stratified by the timing of recurrence diagnosis and identified the risk factors for early recurrence (ER). RESULTS: Recurrence was identified within 1 year in 61 patients and after 1 year in 23 patients. Significant differences were observed between the patients with recurrence within 1 year (early recurrence; ER) and those with recurrence after 1 year (late recurrence; LR). The ER patients had more advanced tumors and higher pretreatment serum squamous cell antigen (SCC-Ag) levels and less experienced downstaging than patients without recurrence (no recurrence; NR). Overall survival was significantly worse for the ER patients than for the LR patients. Multivariate analysis revealed that cN2-3, increased serum SCC-Ag levels, and clinical response to NAC were independent predictors of ER. CONCLUSION: The ER patients had distinctive clinical features from the LR and NR patients. Extensive lymph node metastasis, an elevated SCC-Ag, and inadequate response to NAC were identified as predictors of ER.

Long-term outcomes of esophageal squamous cell carcinoma with invasion depth of pathological T1a-muscularis mucosae and T1b-submucosa by endoscopic resection followed by appropriate additional treatment.

OBJECTIVES: Endoscopic resection (ER) is indicated for a wide range of superficial esophageal squamous cell carcinomas (ESCCs). We examined the long-term outcomes in patients with pathological (p) invasion of ESCC into the T1a-muscularis mucosae (MM) and T1b-submucosa (SM) after ER, for which data on prognosis are limited. METHODS: Of the 1217 patients with superficial ESCC who underwent ER, 225 patients with a pathological diagnosis of ESCC invasion into the MM, minute submucosal invasion ≤200 µm (SM1), or massive submucosal invasion (SM2) were included. In patients with lymphovascular invasion, droplet infiltration, or SM2 invasion, additional treatments, including chemoradiation (CRT) or esophagectomy with two- to three-field lymph node dissection, were recommended. The median observation period was 66 months (interquartile range 48-91 months). RESULTS: In total, there were 151, 28, and 46 pT1a-MM, pT1b-SM1, and pT1b-SM2 cases, respectively. Metastatic recurrence was observed in 1.3%, 10.7%, and 6.5% patients with pT1a-MM, pT1b-SM1, and pT1b-SM2 ESCCs, respectively. Of the eight patients with metastatic recurrence, six were successfully treated, and two died of ESCC. The 5-year overall survival rates were 84.1%, 71.4%, and 67.4%, the 5-year relapse-free survival rates were 82.8%, 64.3%, and 65.2%, and the 5-year disease-specific survival rates were 100%, 96.4%, and 99.1% in patients with pT1a-MM, pT1b-SM1, and pT1b-SM2 ESCCs, respectively. Multivariate analysis showed that additional CRT and esophagectomy, and T1b-SM2 were positively and negatively associated with overall survival, respectively. CONCLUSIONS: Endoscopic resection preceding appropriate additional treatments resulted in favorable outcomes. Many cases of metastatic recurrence in this cohort could be successfully treated.

Outcomes of esophagectomy for patients with esophageal squamous cell carcinoma accompanied by recurrent laryngeal nerve palsy at diagnosis.

BACKGROUND: Hoarseness is one of the classical symptoms in patients with locally advanced thoracic esophageal squamous cell carcinoma (ESCC), and it results from recurrent laryngeal nerve palsy, which is caused by nodal metastasis along the recurrent laryngeal nerve or by main tumors. We reviewed the short-term and long-term results of esophagectomy for patients with locally advanced ESCC and hoarseness at diagnosis. PATIENTS: Patients who initially presented with hoarseness from recurrent laryngeal nerve palsy between 2009 and 2018 and underwent esophagectomy for thoracic ESCC were eligible for this study. Pharyngolaryngectomy or cervical ESCC were exclusionary. RESULTS: A total of 15 patients were eligible, and 14 underwent resection of the recurrent laryngeal nerves. The remaining patient had nerve-sparing surgery. Nine patients (60%) had post-operative complications ≥ Clavien-Dindo class II and, pulmonary complications were most common. Two patients (13%) died in the hospital. The 5-year overall survival rate for all patients was 16%. Age (≤ 65 years), cT1/T2 tumor, and remarkably good response to neoadjuvant treatment were likely related to longer survival; however, these relationships were not statistically significant. CONCLUSIONS: Esophagectomy for ESCC patients who are diagnosed with recurrent laryngeal nerve paralysis at initial presentation could be a treatment option if the patient is relatively young, has a cT1/T2 tumor, or shows a remarkably good response to neoadjuvant treatment. However, clinicians should be aware of the possibility of postoperative pulmonary complications, which were frequently observed with the procedure.

Immunogenic characteristics of microsatellite instability-low esophagogastric junction adenocarcinoma based on clinicopathological, molecular, immunological and survival analyses.

Microsatellite instability (MSI) is categorized by mutation frequency: high MSI (MSI-H), low MSI (MSI-L) and microsatellite stable (MSS). MSI-H tumors have a distinct immunogenic phenotype, with immunotherapies using checkpoint inhibitors already approved for the treatment of MSI-H gastroesophageal adenocarcinoma (GEA); this is not observed for MSI-L or MSS. Here, we tested the hypothesis that MSI-L tumors are also a distinct phenotype and potentially immunogenic. MSI-PCR assays (BAT25, BAT26, BAT40, D2S123, D5S346 and D17S250) were performed on 363 Epstein-Barr virus-negative, surgically resected esophagogastric junction (EGJ) adenocarcinoma samples. Tumors were characterized as MSI-H (≥2 markers), MSI-L (1 marker) or MSS (0 markers). CD8+ cell counts, PD-L1 and HER2 expression levels, TP53 mutations, epigenetic alterations and prognostic significance were also examined. All pathological and molecular experiments were conducted using serial, whole-tumor sections of chemo-naïve surgical specimens. MSI-H and MSI-L were assigned to 28 (7.7%) and 24 (6.6%) cases, respectively. Compared to MSS cases, MSI-L cases had significantly higher intratumoral CD8+ cell infiltration (P = .048) and favorable EGJ cancer-specific survival (multivariate hazard ratio = 0.35, 95% CI, 0.12-0.82; P = .012). MSI-L tumors were also significantly associated with TP53-truncating mutations as compared to MSI-H (P = .009) and MSS (P = .012) cases, and this trend was also observed in GEA data from The Cancer Genome Atlas (TCGA). Indel mutational burden among TCGA MSI-L tumors was significantly higher than that of MSS tumors (P = .016). These results suggest that MSI-L tumors may have a distinct tumor phenotype and be potentially immunogenic in EGJ adenocarcinoma.

Mapping of Lymph Node Metastasis From Esophagogastric Junction Tumors: A Prospective Nationwide Multicenter Study.

OBJECTIVE: The aim of the study was to determine the optimal extent of lymph node dissection for the 2 histological types of esophagogastric junction (EGJ) tumors based on the incidence of metastasis in a prospective nationwide multicenter study. BACKGROUND: Because most previous studies were retrospective, the optimal surgical procedure for EGJ tumors has not been standardized. METHODS: Patients with cT2-T4 adenocarcinoma or squamous cell carcinoma located within 2.0 cm of the EGJ were enrolled before surgery. Surgeons dissected all lymph nodes prespecified in the protocol, using either the abdominal transhiatal or right transthoracic approach. The primary endpoint was the metastasis rate of each lymph node. Lymph nodes were classified according to metastasis rate, as follows: category-1 (strongly recommended for dissection), rate more than 10%; category-2 (weakly recommended for dissection), rate from 5% to 10%; and category-3 (not recommended for dissection), rate less than 5%. RESULTS: Between 2014 and 2017, 1065 patients with EGJ tumor were screened, and 371 were enrolled. Among 358 patients who underwent surgical resection, category-1 nodes included abdominal stations 1, 2, 3, 7, 9, and 11p, whereas category-2 nodes included abdominal stations 8a, 19, and lower mediastinal station 110. If esophageal involvement exceeded 2.0 cm, station 110 was assigned to category-1. Among 98 patients who had either adenocarcinoma with esophageal involvement over 3.0 cm or squamous cell carcinoma, there were no category-1 nodes in the upper/middle mediastinal field, whereas category-2 nodes included upper mediastinal station 106recR and middle mediastinal station 108. When esophageal involvement exceeded 4.0 cm, station 106recR was assigned to category-1. CONCLUSION: The study accurately identified the distribution of lymph node metastases from EGJ tumors and the optimal extent of subsequent lymph node dissection.

Clinical Significance of Pretherapeutic Serum Squamous Cell Carcinoma Antigen Level in Patients with Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma.

BACKGROUND: Although squamous cell carcinoma antigen (SCC-Ag) is a tumor marker widely used to estimate the progression of esophageal SCC (ESCC), only a few studies have focused on the relationship between serum SCC-Ag levels and the therapeutic effect of neoadjuvant chemotherapy (NAC). OBJECTIVE: This study aimed to elucidate the clinical significance of pretherapeutic serum SCC-Ag levels in patients who underwent NAC followed by esophagectomy. METHODS: Data of 453 patients who underwent NAC followed by esophagectomy were collected from the esophageal cancer database of two high-volume Japanese centers. Serum SCC-Ag levels were measured prior to NAC, and the pathological therapeutic effect of NAC and patient survival were evaluated. Patients were classified according to the tertiles of the serum SCC-Ag value (low, middle, and high groups), and the outcomes among the groups were compared. RESULTS: The levels of serum SCC-Ag were significantly associated with tumor stage (p < 0.01). With regard to the pathological therapeutic effect, the levels of serum SCC-Ag were negatively correlated with the therapeutic effect (p = 0.02). Moreover, increased levels of serum SCC-Ag negatively influenced relapse-free survival (p < 0.01). Multivariate analyses revealed the 'high' group as the independent factor for both the unfavorable therapeutic effect (p = 0.01) and the increased risk of disease recurrence (p < 0.01) when compared with the 'low' group. CONCLUSION: Elevated levels of pretherapeutic serum SCC-Ag are significantly associated with advanced tumor stage, poor response to NAC, and increased risk of disease recurrence.

Successful transition from open to minimally invasive approach in Ivor Lewis esophagectomy: a single-center experience in Japan.

PURPOSE: This study evaluates surgical outcomes of Ivor Lewis esophagectomy (ILE) in our institution, with the transition from open ILE to hybrid or totally minimally invasive ILE (MI-ILE). METHODS: Selected patients who underwent ILE for esophageal cancer between 2013 and 2020 were included. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes. RESULTS: In this period, among a total of 858 esophagectomies, selected seventy-one patients (8.3%) underwent ILE, consisted of 17 cases with completely open procedures, 27 with hybrid MI-ILE, and 27 with total MI-ILE. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction (33.8%) and patients with prior treatment of head and neck cancer (31.0%). Among these approaches, there were no significant differences in the characteristics including age, body mass index (BMI), tumor location, preoperative therapy, and clinical TNM stage, except for histology. Compared to the completely open and hybrid groups, incidences of both total and severe complications in the total MI-ILE group were significantly lower (total 70.6 vs. 66.6 vs. 37.0%, p=0.036; severe 35.3 vs. 44.4 vs. 11.1%, p=0.023), and also, those of pneumonia (41.2 vs. 29.6 vs. 7.4%, p=0.026) and postoperative stricture (11.8 vs. 18.5 vs. 0%, p=0.001) were significantly fewer in the total MI-ILE group. CONCLUSIONS: We have been able to achieve the transition from completely open to total MI-ILE with better short-term outcomes. Total MI-ILE with linear-stapled anastomosis can be a good alternative to open procedures for the selected patients with reducing the incidence of postoperative pneumonia and anastomotic stricture.

Comparison of the outcomes between total eversion and conventional triangulating stapling technique in cervical esophagogastric anastomosis after esophagectomy: a propensity score-matched analysis.

BACKGROUND: Anastomotic leakage and stenosis remain major problems after esophageal reconstruction. This study evaluated the clinical outcomes between the total eversion (TE) triangulating stapling technique (TST) and conventional (C) TST. METHODS: The study included 404 consecutive patients with esophageal cancer who underwent cervical esophagogastrostomy by TST between January 2013 and December 2018. The postoperative outcomes were compared between TE-TST and C-TST using propensity score-matched analysis. RESULTS: Before matching, the cT stage and the cTNM stage were different between the groups. After matching, each group consisted of 128 patients. The patients' background characteristics were similar between the groups. Although the incidence of anastomotic leakage was similar between the groups (p = 0.216), anastomotic stricture occurred in 19 (14.8%) and 7 (5.5%) patients in the C-TST and the TE-TST groups, respectively (p = 0.021). CONCLUSIONS: The incidence of anastomotic stenosis was significantly lower in the TE-TST group than in the C-TST group. TE-TST decreases the incidence of anastomotic stricture and can improve the quality of life in patients undergoing esophagectomy.

Efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma patients with positive circumferential resection margin.

BACKGROUND: The significance of postoperative radiotherapy for residual disease after esophageal cancer surgery remains controversial. The purpose of this study was to elucidate the efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma (ESCC) patients with positive circumferential resection margin (CRM). METHODS: We retrospectively analyzed data from 1190 patients who underwent esophagectomy for ESCC at our hospital from 2005 to 2018, of whom 61 (5.1%) patients were diagnosed with positive CRM of ESCC. Overall survival (OS), progression-specific survival (PSS), local progression-specific survival (LPSS), and clinicopathological factors were compared between patients with and without postoperative radiotherapy. The efficacy of additional radiotherapy on patient outcomes was evaluated. RESULTS: Among the 61 patients analyzed, 29 (47.5%) underwent radiotherapy (RT group) and 32 (52.5%) did not (NRT group). In the RT group, 22 patients (75.9%) received radiotherapy and 7 patients (24.1%) received chemoradiotherapy. The RT group included younger patients, a greater number of upper-esophageal tumors, and a greater rate of R2 resections than the NRT group. The LPSS and PSS of the RT group were significantly better than those of the NRT group (P = 0.007, P < 0.001, respectively). In multivariate analysis, postoperative radiotherapy was an independent factor for LPSS [P < 0.001; hazard ratio (HR) 0.17; 95% confidence interval (CI) 0.06-0.46] and PSS (P < 0.001; HR 0.31; 95% CI 0.16-0.60). CONCLUSIONS: Postoperative radiotherapy contributed to the control of residual tumor and was significantly associated with better LPSS and PSS among patients with positive CRM after esophagectomy for ESCC.

Influence of Preoperative Oropharyngeal Microflora on the Occurrence of Postoperative Pneumonia and Survival in Patients Undergoing Esophagectomy for Esophageal Cancer.

OBJECTIVE: The aim of this study was to clarify the correlation between oropharyngeal microflora and postoperative complications as well as long-term survival after esophagectomy. BACKGROUND: Although the oral cavity is known to be a potential reservoir for pathogens, the influence of abnormal oropharyngeal microflora on the outcomes of patients undergoing esophagectomy remains unknown. METHODS: This study included 675 patients who underwent esophagectomy between 2007 and 2014. Saliva samples from the oropharynx were collected 2 days before the operation. There were 442 patients with indigenous flora (Ind group) and 233 with allopatric flora. Among the patients with allopatric flora, 140 had antibiotic-sensitive microbes only (Allo-S group) while 93 had different types of antibiotic-resistant microbes (Allo-R group). We investigated the correlation between the types of oropharyngeal microflora and the incidence of postoperative complications as well as long-term outcomes. RESULTS: Sixteen microbes could be cultivated from the saliva samples. The incidence of postoperative pneumonia in the Allo-S and Allo-R groups was significantly higher than in the Ind group (P < 0.001). In addition, acute respiratory distress syndrome was more often observed in the Allo-R group than in the other groups (P = 0.002). A significantly higher rate of antibiotic use and longer hospital stays were observed in the Allo-R group compared with the Ind group. Multivariate logistic regression analysis revealed that the presence of allopatric antibiotic-resistant microbes in the oropharynx was an independent risk factor for postoperative pneumonia (odds ratio, 3.93; 95% confidence interval, 2.41-6.42). The overall survival was significantly poorer in the Allo-R group than in the other groups. CONCLUSIONS: Preoperative oropharyngeal culture is a simple and low-cost method that can predict both the occurrence of postoperative pneumonia and poor prognosis after esophagectomy.

Neoadjuvant Chemoradiotherapy with Cisplatin Plus Fluorouracil for Borderline Resectable Esophageal Squamous Cell Carcinoma.

BACKGROUND: The optimal treatment strategy for patients with borderline resectable (BR) esophageal squamous cell carcinoma (ESCC), in which tumors grow very close to the adjacent vital organs, remains unclear. This study evaluated the efficacy of neoadjuvant chemoradiotherapy (NACRT) with cisplatin plus fluorouracil (CF) and irradiation (40 Gy) for these patients. METHODS: The study cohort included 50 patients with BR-ESCC who received NACRT as the initial treatment and were allocated to one of two groups: patients who achieved curative resection (R0 group) or those who did not (Non-R0 group). The overall survival (OS), relapse-free survival (RFS), and pre-therapeutic predictive factors for Non-R0 were evaluated. RESULTS: Among the 50 patients, 22 (44%) achieved curative resection clinically. The median OS was significantly better in the R0 group than in the Non-R0 group (2.4 vs 0.8 years; hazard ratio [HR], 0.29; 95% confidence interval [CI], 0.12-0.67; p < 0.01). The independent predictive factors before NACRT for Non-R0 were higher serum SCC antigen level (p < 0.01) and clinical nodal involvement (p = 0.02). In addition, OS was significantly worse for the patients with higher levels of serum SCC antigen than for those with lower levels (p < 0.01). CONCLUSIONS: Curative resection was achieved for about 40% of the patients who received NACRT for BR-ESCC. Therefore, NACRT could be a useful neoadjuvant treatment option for BR-ESCC. However, a higher serum SCC antigen level before NACRT is predictive of treatment failure and poor survival.

Steam induced by the activation of energy devices under a wet condition may cause thermal injury.

BACKGROUND: During esophagectomy for esophageal cancer, meticulous attention is needed to prevent thermal injury to the vital organs, such as the recurrent laryngeal nerve (RLN) and tracheobronchus. In order to clarify the novel mechanism behind thermal injury induced by energy devices, we investigated the temperature of steam with the use of two different devices under wet and dry conditions. METHODS: An ultrasonic device (Sonicision™) and a vessel sealing device (Ligasure™) were studied. We evaluated the temperature at the tip of the devices and the steam when the devices were activated under different grasping ranges, under four different combinations of device and muscle, and under four different wet/dry conditions (dry-dry, dry-wet, wet-dry, and wet-wet). RESULTS: Although the maximum temperature of the devices was significantly higher with Sonicision™ than with Ligasure™, the maximum temperature of the steam was significantly higher with Ligasure™ than with Sonicision™ in almost all situations. At 1 mm away from Sonicision™, the critical temperature more than 60 °C was observed only when used with one-third grasping range under the wet-dry or the wet-wet conditions. In case of Ligasure™, high-temperature steam was observed when used with one-third grasping under the wet-dry or the wet-wet condition and two-third grasping under the dry-wet, the wet-dry, or the wet-wet condition. Under the wet condition, the emission of steam from the non-grasping part of Ligasure™ caused a spike in temperature that exceeded the critical temperature. CONCLUSION: We demonstrated that the use of energy devices under a wet condition generates steam from the non-grasping part of the devices. The temperatures of steam from Ligasure™ were significantly higher than that from Sonicision™. To prevent thermal injury to the vital organs, a very attentive and meticulous surgical technique is imperative considering the characteristics of each device.

The Optimal Feeding Enterostomy Creation During Esophagectomy to Reduce the Long-Term Risk of Small Bowel Obstruction.

BACKGROUND: Although feeding jejunostomy (FJ) is commonly created during esophagectomy for postoperative enteral nutrition, it can be a cause of postoperative small bowel obstruction (SBO). We introduced a technique of feeding enterostomy using the round ligament of the liver (FERL) to reduce SBO. In this study, we aimed to clarify the efficacy of FERL in reducing the postoperative SBO compared with FJ. METHODS: We assessed 400 consecutive patients who underwent esophagectomy with gastric tube reconstruction between 2011 and 2016, before and after the introduction of FERL (FJ, n = 200; FERL, n = 200). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy were compared between the FJ and the FERL groups. RESULTS: Thoracoscopic and laparoscopic surgery was more frequent in the FERL group than in the FJ group (p < 0.001). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in the FERL group were significantly less frequent than those in the FJ group (p < 0.001 and p = 0.006, respectively). When stratifying by the abdominal surgical approach, the cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in a laparoscopic approach were less frequent in the FERL group than those in the FJ group (both p < 0.001). CONCLUSIONS: The FERL technique can reduce the incidences of postoperative SBO and SBO associated with feeding enterostomy in patients undergoing esophagectomy.

Correction to: Safety and efficacy of preoperative chemotherapy followed by esophagectomy versus upfront surgery for resectable esophageal squamous cell carcinoma.

In the original publication, in Abstract, the second sentence of Results has been incorrectly published as.