Successful Robot-Assisted Surgery for Advanced Metachronous Cancer in a Gastric Conduit after Esophagectomy: A Case Report.

The incidence of gastric tube cancers has increased due to improved survival rates in patients after esophagectomy. However, the optimal surgical approach for gastric tube cancer remains controversial. Here, we report the case of a 70-year-old man with advanced gastric cancer arising from a retrosternally placed gastric conduit, 12 years after thoracic esophagectomy for esophageal cancer. Total resection of the gastric conduit was performed with robotic assistance. Although the working space was limited, secure resection was possible. Continuous en bloc mobilization was achieved with neck dissection, and reconstruction was performed via the same retrosternal route using the ileocolon. The patient was discharged on the 14th postoperative day without any adverse events. Robot-assisted surgery can overcome the technical limitations of laparoscopic mediastinal surgery and has advantages such as improved ergonomics, comfort, and elimination of hand tremors, and therefore may be an option for future minimally invasive surgeries.

Clinical Outcomes of Preserving Bronchial Arteries During Radical Esophagectomy: A Propensity-Score Matched Analysis.

BACKGROUND: Postoperative pneumonia is a common and major cause of mortality after radical esophagectomy. Intraoperative preservation of the bronchial arteries is often aimed at avoiding tracheobronchial ischemia; however, it is unknown whether this contributes to a reduction in postoperative pneumonia. PATIENTS AND METHODS: We enrolled 348 consecutive patients who underwent radical esophagectomy for esophageal cancer at Toranomon Hospital from January 2011 to July 2018. We classified patients into a bronchial artery-resected (BA-R) group (n = 93) and a bronchial artery-preserved (BA-P) group (n = 255) and compared the incidence of postoperative pneumonia between the two groups. A propensity score-matching analysis for bronchial artery preservation versus resection was performed. RESULTS: Overall, 182 patients were matched. Univariate analysis of the propensity score-matched groups showed that Brinkman index ≥ 400, vital capacity (%VC) < 80%, and bronchial artery resection were associated with the development of postoperative pneumonia. Multivariate analysis revealed three significant factors associated with postoperative pneumonia: Brinkman index ≥ 400 [p = 0.006, odds ratio (HR) 3.302, 95% confidence interval (95% CI) 1.399-7.790], %VC < 80% (p = 0.034, HR 6.365, 95% CI 1.151-35.205), and bronchial artery resection (p = 0.034, HR 2.131, 95% CI 1.060-4.282). The incidence of postoperative complications (CD grade III) was higher in the BA-R group (BA-R 42.8% versus BA-P 27.5%, p = 0.030). There was no significant difference in overall survival between the two groups at 5 years (BA-R 63.1% versus BA-P 72.1%, p = 0.130). CONCLUSION: Preserving the bronchial artery is associated with a decreased incidence of postoperative pneumonia.

Phosphoglyceride crystal deposition disease requiring differential diagnosis from malignant tumors and confirmed by Raman spectroscopy: A case report.

BACKGROUND: Phosphoglyceride crystal deposition disease (PCDD) is a rare acquired disease in which phospholipid crystals deposit in bone and soft tissue long after surgery, trauma, or repeated injections. CASE SUMMARY: A 60-year-old-woman was referred to our department because of multiple abdominal masses after open splenectomy for idiopathic thrombocytopenic purpura 29 years earlier. All the masses showed marked fluorodeoxyglucose (FDG) uptake on 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) and were strongly suspected to be malignant tumors. Surgical biopsies were performed, and the abdominal masses were found to be aligned vertically, three in a row, along the tissue layers cut in the patient's previous surgery. Pathological finding of the specimens showed foreign body granuloma consisting of histiocytes and multinucleated giant cells accumulating around needle-like crystals. The crystals were confirmed as phosphoglyceride by Raman spectroscopy, and PCDD was diagnosed. To our knowledge, this is the first report of PCDD diagnosed by Raman spectroscopy. CONCLUSION: We made a definitive diagnosis of PCDD in a patient with multiple tumors showing marked FDG uptake on 18F-FDG-PET by incisional biopsy and compo- sition analysis using Raman spectroscopy, a method that has not previously been reported for the diagnosis of PCDD.

Clinical significance of initial treatment for peritoneal lavage cytology-positive gastric cancer: outcomes according to treatment strategy.

BACKGROUND: Although patients with positive lavage cytology (CY1) are classified as having stage IV disease, long-term survival without other unresectable factors (P0CY1) has been reported. Conversion gastrectomy in patients with a change in cytology status after induction chemotherapy might improve survival, but appropriate treatment remains controversial. Here, we reviewed our experience in treating CY1 gastric cancer to evaluate the best treatment strategy. METHODS: Clinical and pathological findings of patients with a diagnosis of P0CY1 gastric cancer at Toranomon Hospital between February 2006 and April 2019 were retrospectively analyzed. Patients were classified into two groups according to initial treatment: a surgery-first group and a chemotherapy-first group. In addition, the patients were categorized into subgroups based on the subsequent treatment pattern. The surgery-first group was divided into two subgroups: adjuvant chemotherapy and palliative gastrectomy only. The chemotherapy-first group was divided into three subgroups with the subsequent treatment pattern depending on the response to chemotherapy: conversion gastrectomy, palliative gastrectomy after induction therapy, and palliative chemotherapy. RESULTS: In total, 38 patients were eligible for inclusion in this study. After initial assessment of cytology status, 21 patients underwent gastrectomy as initial treatment (surgery first) and 17 received induction chemotherapy (chemotherapy first). Ten patients underwent surgery first with adjuvant chemotherapy, 11 underwent palliative gastrectomy alone, 5 underwent conversion surgery, 5 with CY1 disease after induction chemotherapy underwent palliative gastrectomy, and 7 received palliative chemotherapy only. The 3-year survival rate was 23.4% (median survival, 17.7 months) in the surgery-first group and 27.3% (median survival, 19.7 months) in the chemotherapy-first group. The 3-year survival rate was 75% for conversion gastrectomy, 16.7% for palliative chemotherapy, and 0% for palliative gastrectomy after induction chemotherapy. CONCLUSIONS: There was no significant difference in outcome according to whether surgery or chemotherapy was performed first. The prognosis of conversion surgery with curative resection was better than that of the other types of treatment. However, the outlook after induction chemotherapy was poor. Patients with advanced gastric cancer should be treated cautiously until more effective treatment options become available.

Importance of long-term surveillance after curative esophagectomy for esophageal squamous cell carcinoma.

BACKGROUND: The long-term outcomes after esophagectomy for esophageal cancer remain uncertain and the optimal surveillance strategy after curative surgery remains controversial. METHODS: In this study, the clinicopathological characteristics of patients who underwent curative thoracic esophagectomy between 1991 and 2015 at Toranomon Hospital were retrospectively analyzed and reviewed until December 2020. We evaluated the accumulated data regarding the pattern and rates of recurrence and second malignancy. RESULTS: A total of 1054 patients were eligible for inclusion in the study. Of these, 97% were followed up for 5 years, and the outcomes after 25 years could be determined in 65.5%. Recurrence was diagnosed in 318 patients (30.2%), and the most common pattern was lymph node metastasis (n = 168, 52.8%). Recurrence was diagnosed within 1 year in 174 patients (54.7%) and within 3 years in 289 (90.9%). Second malignancy possibly occurred through the entire study period after esophagectomy even in early-stage cancer, keeping 2%-5% of the incidental risk. There was no significant difference in the prognosis between 3-year survivors with and without a second malignancy. CONCLUSIONS: Most recurrences after resection of esophageal cancer occurred within 3 years regardless of disease stage. However, these patients have an ongoing risk of developing a second malignancy after esophagectomy. Further consideration is required regarding the efficacy of long-term surveillance.

Identification of Preoperative Fat-Free Mass Index for the Prognosis of Curatively Resected Esophageal Cancer.

BACKGROUND: The progressive, systemic depletion of muscle mass is a poor prognostic factor for various types of cancers. However, the assessment of body composition for patients with esophagectomy remains unclear. Therefore, we evaluated the significance of the fat-free mass index (FFMI) and estimated the appropriate cutoff value. METHODS: We compiled clinicopathological characteristics of patients who underwent curative operation for esophageal cancer between October 2013 and March 2018 at Toranomon Hospital and reviewed them until December 2020. We analyzed the short- and long-term outcomes, compared to conventional nutritional factors, and calculated the area under the receiver operating characteristic (ROC) curve. RESULTS: A total of 200 patients were eligible for inclusion. FFMI was ineffective in predicting postoperative complications, with no correlation with other nutritional biomarkers. Preoperative low FFMI led to poor overall survival (OS), and the lower cutoff values based on the time-dependent ROC analysis were 14.4 and 16.8 kg/m2 in women and men, respectively. Multivariate analysis for OS revealed that low FFMI (p = 0.010, HR 2.437, 95% CI 1.234-4.815) and clinical stage (p = 0.010, HR 4.781, 95% CI 1.447-15.796) were independent prognostic factors. The 3-year survival rates were 68.9% in low FFMI and 88.6% in normal FFMI. CONCLUSIONS: The low FFMI was not predictive of postoperative complications but an independent prognostic factor in esophageal cancer with curative resection, having no correlation with other biomarkers. Our cutoff FFMI values could be useful in selecting the target for muscle improvement programs.

Esophageal Cancer Surgery in Dialyzed Patients: A Single Institution Case Series.

We sought to evaluate the feasibility of esophageal carcinoma (EC) surgery in cases requiring dialysis. Among 250 consecutive patients undergoing surgical resection for EC, three on maintenance dialysis were identified. We retrospectively analyzed their clinical characteristics. The three dialyzed patients were all males, 39-77 years old at EC surgery. The operations were thoracoscopic esophagectomy with nodal clearance (Case 1), cervical esophageal resection without thoracic procedures (Case 2), and thoracoscopic esophagectomy without reconstruction, emergently conducted for tumor bleeding (Case 3). Reoperation had been required for postoperative abdominal hematoma in Case 1. Postoperative tracheostomy had been performed due to severe pneumonia in Case 2. EC surgery for dialyzed patients, despite appearing to be feasible, might be associated with a high risk of life-threatening morbidities. To minimize surgical risk, therapeutic decision-making for such cases should be based on the balance between radicality and safety.

Bilateral Flank Compression Maneuver for Reducing Pain on Coughing after Abdominal Surgery: A Prospective Study.

BACKGROUND: Despite the major advances in analgesic techniques, pain relief in coughing after abdominal surgery remains challenging. Cough-related pain causes postoperative respiratory complications by impairing sputum clearance; nevertheless, an effective technique to abolish it is not yet available. We devised the bilateral flank compression (BFC) maneuver, in which the flanks are compressed medially using both hands. We conducted a prospective, single-center, single arm, nonrandomized, open-label, interventional trial, to investigate whether the BFC maneuver relieves cough-related pain after abdominal surgery and examined the efficacy of this maneuver in relation to patient characteristics and surgical factors. STUDY DESIGN: Participants were patients who underwent gastroenterologic surgery (except for open inguinal hernia repair) at the Department of Surgery, Kyorin University School of Medicine. We evaluated postoperative pain, from postoperative days (PODs) 1 to 7, on coughing, with and without the BFC maneuver, using the Prince Henry pain scale. RESULTS: We finally analyzed 514 patients. On each of the first 7 PODs, the BFC maneuver significantly relieved cough-related pain, especially on POD1; (the mean pain scores [standard deviation] with and without the BFC maneuver were 0.98 [1.030] vs 1.63 [1.112] points, p < 0.0001). On each POD, more patients were free of cough-related pain with than without the BFC maneuver, with the most marked difference on POD7 (52.0% [208/400] vs 16.8% [67/400], p < 0.0001). CONCLUSIONS: The BFC maneuver relieves cough-related pain after abdominal surgery and may help prevent of postoperative pulmonary complications.

Nutritional Outcomes of Thoracic Duct Resection for Radical Esophagectomy by Assessing Body Composition Changes in One Year: A Single-Center Retrospective Study.

BACKGROUND: Thoracic duct (TD) resection is performed when the tumor or a metastatic lymph node directly invades the TD, and is sometimes indicated for radical lymphadenectomy during esophagectomy in esophageal cancer patients. However, the effect of TD resection on nutritional status has not been established. PATIENTS AND METHODS: In total, 174 consecutive patients from October 2015 to March 2019 who underwent radical esophagectomy for esophageal cancer in Toranomon Hospital were classified into thoracic duct preserved group (n = 51) and TD-resected (TD-R) group (n = 123). We compared laboratory data, body composition data from bioelectrical impedance analysis measured preoperatively and at 1 and 12 months after surgery, and postoperative complications between the two groups. RESULTS: Clinical stage was significantly more advanced in the TD-R group. Total body weight, body mass index, and fat mass continuously decreased in the two groups over 12 months after surgery, and the decreases were statistically greater in the TD-R group at 12 months after surgery. Skeletal muscle mass and fat-free mass decreased over 1 month after surgery and stayed in a reduced state until 12 months after surgery without statistically significant differences between the two groups. TD resection did not increase incidence of postoperative complications (Clavien-Dindo classification ≥ grade III), but TD resection increased incidence of chylothorax. CONCLUSIONS: Our results suggest that loss of body fat mass, which was a main contributor to body weight loss, was accelerated in the TD-R group, but TD resection does not deteriorate loss of muscle mass at 12 months after surgery.

Successful treatment of adult cecorectal intussusception caused by cecum cancer with mobile cecum: a case report.

BACKGROUND: Intussusception occurs when a segment of the bowel (the intussusceptum) telescopes into an adjacent segment (the intussuscipiens). Adult intussusception occurs rarely and often requires surgical resection for its treatment. We describe the case of an adult patient with extremely rare cecorectal intussusception treated using a novel combined transabdominal and trans-anal approach, which has not yet been reported in the literature. CASE PRESENTATION: A 71-year-old woman was transferred to our hospital for the treatment of upper abdominal pain. Physical examination, laboratory tests, and imaging inspections showed strangulated bowel obstruction induced by intussusception associated with the intra-rectal mass. We performed an emergency operation and treated the intussusception using a combined transabdominal and trans-anal approach. The intraoperative findings revealed bloody ascites and a potentially malignant tumor that had moved toward the anal side from peritoneal reflection. The tumor served as the lead point in the cecum with mobile cecum. After reducing the intussusception using the combined procedure, we removed the ileocecal portion. The intraoperative and histopathological findings suggested that cecum cancer with mobile cecum had caused the cecorectal intussusception. The patient had an uneventful postoperative course, except for postoperative pulmonary pneumonia. CONCLUSION: To the best of our knowledge, this is the first reported case of adult cecorectal intussusception due to cecum cancer with mobile cecum successfully treated using the combined transabdominal and trans-anal approach. This combined procedure may be useful in treating the intussusception where the lead point is distal from the peritoneal reflection.

Comparative analysis of the prognostic utility of preoperative nutritional parameters in patients with resectable esophageal carcinoma.

OBJECTIVE: Although surgical resection is a mainstay in the management of esophageal carcinoma (EC), its postoperative outcomes remain unsatisfactory. To optimize surgical strategies for EC, a simple method of stratifying patients according to risk factors is desired. Controlling nutritional status (CONUT), the prognostic nutritional index (PNI), transthyretin and transferrin are nutritional parameters used to predict the long-term outcomes of EC patients. We aimed to comparatively evaluate the prognostic significance of these four markers, measured preoperatively, in patients with operable EC. METHODS: In total, 224 patients undergoing surgical resection for EC were retrospectively reviewed. Overall/cancer-specific survivals (OS/CSS) were estimated applying the Cox proportional hazard model to univariate and multivariate analyses. PNI, transthyretin and transferrin levels were treated as continuous variables in these analyses. RESULTS: Preoperative CONUT had significant associations with tumor location, depth and preoperative irradiation. The other three markers all showed significant relationships with age and tumor depth. On univariate Cox regression analysis, preoperative CONUT, PNI, transthyretin and transferrin all correlated significantly with OS and CSS. On multivariate Cox regression analysis, the preoperative transthyretin level was identified as an independent predictor of OS (HR 0.51 per 10 mg/dL increase, 95% CI 0.29-0.88, p = 0.017) and CSS (HR 0.50, 95% CI 0.27-0.91, p = 0.027) as well as tumor depth, nodal metastasis and preoperative irradiation, while the other three parameters were not. CONCLUSIONS: Preoperative transthyretin, as a continuous variable, independently predicted both OS and CSS in resectable EC patients, appearing to be the best prognosticator among conventional nutrition-related parameters.

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy.

A 54-year-old man had a 65-mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ-preserving laparoscopic surgery, we conducted laparoscopy-assisted pancreas-sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port-site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.