Tumor-infiltrating lymphocytes in patients undergoing esophagectomy following neoadjuvant DCF therapy.

BACKGROUND: Accumulating evidence suggests that expression levels of tumor-infiltrating (TI) cells may play a prognostic role in patients with esophageal cancer who have undergone esophagectomy. However, its effect on patients undergoing neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy followed by esophagectomy for esophageal squamous cell carcinoma (ESCC) remains unclear. Therefore, this study aimed to elucidate the prognostic impact of TI cells in patients who underwent esophagectomy following neoadjuvant DCF therapy. METHODS: Overall, 81 patients with ESCC who underwent curative esophagectomy following neoadjuvant DCF therapy were included. The number of TI CD8+ cells was determined using light microscopy at ×400 in tumor invasive margins. Receiver operative characteristic curve was used to determine the cutoff values for mortality for continuous variables; the patients were separated into high and low TI CD8+ cell groups and their backgrounds and clinical outcomes were compared. RESULTS: Overall and relapse-free survival were significantly worse in the TI CD8+-low group than that in the TI CD8+-high group (p < 0.01). Multivariate analysis revealed that positive ypN (hazard ratio [HR], 3.12; 95% confidence interval [CI], 1.08-9.02) and low TI CD8+ cell levels (HR, 2.77; 95% CI, 1.31-5.85) were independent prognostic factors for overall survival. Furthermore, positive venous invasion (HR, 2.63; 95% CI, 1.29-5.35) and low TI CD8+ cell levels (HR, 2.77; 95% CI, 1.70-5.46) were significant prognostic factors for relapse-free survival. CONCLUSIONS: Low TI CD8+ cell level was a prominent prognostic factor for patients with ESCC undergoing neoadjuvant DCF therapy followed by esophagectomy.

Evaluation of the Usefulness of Contrast-Enhanced Computed Tomography for the Early Detection of Anastomotic Leakage After Esophagectomy.

OBJECTIVE: Anastomotic leakage is one of the most severe complications after esophagectomy. However, a diagnostic gold standard for anastomotic leakage has not been established yet. This retrospective cohort study aimed to evaluate the potential use of routine postoperative contrast-enhanced computed tomography findings as an early predictor of anastomotic leakage in patients who underwent esophagectomy for esophageal cancer. METHODS: This study included 75 patients who underwent Mckeown esophagectomy, of whom 22 developed anastomotic leakage after surgery. The computed tomography findings for this patient cohort were categorized into 3 grades based on mural enhancement patterns observed at the anastomotic site. Both semiquantitative and quantitative analyses were performed, and the interobserver agreement between the 2 experienced radiologists was assessed. RESULTS: It was found that poor enhancement in both the early and portal venous phases (grade 2) had a robust association with the occurrence of anastomotic leakage. The computed tomography enhancement ratio that is used to estimate wall degeneration and ischemia was significantly higher in patients with anastomotic leakage. CONCLUSIONS: Routine postoperative contrast-enhanced computed tomography could be beneficial for the early detection of anastomotic leakage, even in asymptomatic patients, after esophagectomy.

Additional Microvascular Anastomosis to Gastric Conduit During Esophagectomy Reduces Anastomotic Leaks: Propensity Score Weighting Study.

BACKGROUND: Impaired gastric conduit perfusion during esophagectomy and reconstruction is considered a key risk factor of anastomotic leaks. The aim of this study is to evaluate the indication and feasibility of additional microvascular anastomosis (AMA) to the gastric conduit in esophageal cancer surgery. PATIENTS AND METHODS: Patients who received an esophagectomy with gastric conduit reconstruction between July 2008 and July 2021 at a single center were reviewed. Patient characteristics, anastomotic viability index (AVI) of the gastric conduit measured with thermal imaging, and operative outcomes were analyzed using Fisher's exact test and Mann-Whitney U test. Two propensity score weighting methods (inverse probability of treatment weighting and overlap weighting) were applied to investigate whether AMA reduces anastomotic leaks. RESULTS: Of the 293 patients who underwent an esophagectomy over the study period, 26 received AMA. AVI in the AMA group was significantly lower than that in the control group (0.64 vs. 0.74, p = 0.026). Overall anastomotic leak rates were 3.8% in the AMA group and 12.4% in the control group. Using two different propensity score weighting methods, the same conclusion was obtained that AMA significantly reduced anastomotic leaks after esophagectomy (both p < 0.001). The logistic regression model for estimating probability of anastomotic leaks provided AVI criteria for AMA application and revealed that AMA significantly reduced the estimated leak rates by a maximum of 49%. CONCLUSIONS: Additional microvascular anastomosis significantly reduced anastomotic leaks after esophagectomy. The proposed AVI criteria for AMA application can help guide surgeons as to when AMA is needed.

Postoperative inflammatory markers predict survival in patients after McKeown esophagectomy for esophageal cancer.

BACKGROUND: Preoperative C-reactive protein-to-albumin ratio (CAR) and neutrophil-to-lymphocyte ratio (NLR) are correlated with a poor prognosis of various cancers. The significance of postoperative systemic inflammation markers for prognostic stratification of patients with esophageal cancer (EC) has not been established. Therefore, this study aimed to elucidate the impact of postoperative CAR and NLR on survival in patients with EC for prognostic stratification. METHODS: A total of 235 patients who received curative esophagectomy were analyzed. A Cox proportional hazard model was performed to detect prognostic factors. RESULTS: Multivariate analysis revealed that postoperative CAR ≥ 0.05 (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.01-2.57) and NLR ≥ 3.0 (HR, 2.81; 95% CI, 1.79-4.40) were independent prognostic factors for overall survival. Meanwhile, postoperative CAR ≥ 0.05 (HR, 1.61; 95% CI, 1.07-2.41) and NLR ≥ 3.0 (HR, 1.92; 95% CI, 1.29-2.85) were also significant prognostic factors for relapse-free survival. In addition, the patient group with postoperative CAR ≥ 0.05 and NLR ≥ 3.0 had the worst survival. CONCLUSIONS: Postoperative CAR ≥ 0.05 and NLR ≥ 3.0 can predict the poor survival of patients who received curative esophagectomy for EC.

A Novel Frailty Grade Combined with Cachexia Index and Osteopenia in Esophagectomy.

BACKGROUNDS: The optimal method for evaluating frailty grade in patients with cancer has not been established in patients undergoing esophagectomy for esophageal cancer. This study aimed to clarify the impact of cachexia index (CXI) and osteopenia on survival in esophagectomized patients for esophageal cancer to develop frailty grade for risk stratification of the prognosis. METHODS: A total of 239 patients who underwent esophagectomy were analyzed. CXI was calculated as follows: skeletal muscle index × serum albumin/neutrophil-to-lymphocyte ratio. Meanwhile, osteopenia was defined as below the cutoff value of bone mineral density (BMD) calculated by the receiver operating characteristic curve. We evaluated the average Hounsfield unit within a circle in the lower midvertebral core of the 11th thoracic vertebra on preoperative computed tomography as BMD. RESULTS: Multivariate analysis revealed that low CXI (Hazard ratio [HR], 1.95; 95% confidence interval [CI], 1.25-3.04) and osteopenia (HR, 1.86; 95% CI, 1.19-2.93) were independent prognostic factors for overall survival. Meanwhile, low CXI (HR, 1.58; 95% CI, 1.06-2.34) and osteopenia (HR, 1.57; 95% CI, 1.05-2.36) were also significant prognostic factors for relapse-free survival. A frailty grade combined with CXI and osteopenia stratified into four groups by their prognosis. CONCLUSIONS: Low CXI and osteopenia predict poor survival in patients undergoing esophagectomy for esophageal cancer. Furthermore, a novel frailty grade combined with CXI and osteopenia stratified the patients into four groups according to their prognosis.

Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy.

BACKGROUND: Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available. METHODS: This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM. RESULTS: The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy. CONCLUSION: IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

Effect of the postural transition in minimally invasive esophagectomy: a propensity score matching analysis.

BACKGROUND: The advantages of prone position in minimally invasive esophagectomy have not been well studied. This study aimed to investigate the safety and feasibility of a transition from the left lateral decubitus position to the prone position for thoracic procedures in minimally invasive esophagectomy. METHODS: We retrospectively analyzed patients with thoracic esophageal carcinomas who underwent thoracoscopic esophagectomy and laparoscopic gastric mobilization between January 2015 and December 2019. The left decubitus and prone positions were analyzed using propensity score-matched pairs for the baseline characteristics, morbidity, and survival. RESULTS: A total of 114 consecutive patients were included in this study; 90 (78.9%) were male and the median age was 67.2 years old. Of these patients, 39 and 75 underwent left decubitus and prone esophagectomy, respectively. Prone esophagectomy was associated with a lower incidence of pneumonia than that performed in the decubitus position (12.5% vs. 37.5%, p = 0.0187). With respect to the long-term outcomes, there were no significant differences between the 2 groups. The 4-year overall and relapse-free survival rates for prone and decubitus esophagectomy were 73.8% and 73.2%, and 84.4% and 71.8%, respectively (p = 0.9899 and 0.6751, respectively). Prone esophagectomy yielded a shorter operative time (total: 528 [485-579] min vs. 581 [555-610] min, p < 0.0022; thoracic section: 243 [229-271] min vs. 292 [274-309] min, p < 0.0001), less bleeding in the thoracic procedures (0 [0-10] mL vs. 70 [20-138] mL, p < 0.0001), a shorter length of postoperative hospital stay (19 [15-23] vs. 30 [21-46] days, p = 0.0002), and a lower total hospital charge (30,046 [28,175-32,660] US dollars vs. 36,396 [31,533-41,180] US dollars, p < 0.0001). CONCLUSIONS: Transition into the prone position in minimally invasive esophagectomy is feasible with adequate postoperative and oncological safety and economical in esophageal cancer surgery.

Risk stratification of anastomotic stricture using early postoperative endoscopic and computed tomography findings in patients undergoing esophagectomy with cervical esophagogastric anastomosis for esophageal cancer.

Anastomotic stricture (AS) is one of the major complications after esophagectomy for esophageal cancer. We have previously reported that severe mucosal degeneration (MD) of the anastomotic site was associated with the incidence of AS. Meanwhile, there are few reports to correlate anastomotic internal circumference (AIC) with computed tomography (CT) with the incidence of AS. Therefore, this study was conducted to clarify the correlation of early postoperative endoscopic and CT findings with the incidence of AS. We assessed 205 patients who underwent esophagectomy. We then divided them into the non-AS group (n = 164) and the AS group (n = 41) and compared their background data and intraoperative and postoperative outcomes. We also evaluated the risk factors for AS using logistic regression model. Multivariate analysis revealed small AIC (P = 0.003; OR = 4.400; 95% CI = 1.650-11.700) and severe MD (P < 0.001; OR = 7.200; 95% CI = 2.650-19.600) as the independent risk factors for AS development. We also stratified the patients into the following four groups according to the incidence of AS: low-risk (normal AIC and intact or mild MD, 6.2%), intermediate-risk (small AIC and intact or mild MD, 29.4%), high-risk (normal AIC and severe MD, 42.9%), and very high-risk (small AIC and severe MD, 61.1%). Early postoperative endoscopic and CT findings were useful in predicting the development of AS after esophagectomy.

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.

Prognostic Significance of Preoperative Osteopenia in Patients Undergoing Esophagectomy for Esophageal Cancer.

BACKGROUND: Osteopenia, which exhibits low bone mineral density (BMD), has been linked to sarcopenia and recently reported as a prognostic factor in various cancers. However, the prognostic significance of osteopenia in esophageal cancer remains unclear. Hence, this study aimed to clarify the impact of osteopenia on the prognosis of patients undergoing esophagectomy for esophageal cancer. METHODS: We included 229 patients who underwent esophagectomy. BMD was calculated as the average pixel density (Hounsfield unit) within a circle in midvertebral core at the 11th thoracic vertebra on preoperative computed tomography. We then divided the patients into the Osteopenia group (n = 159) and the Non-Osteopenia group (n = 70) according to the optimal cutoff value obtained from the receiver operating characteristic curve. Their clinicopathological data, prognosis, and recurrence were analyzed. RESULTS: The mean age was significantly older in the Osteopenia group (p = 0.047). The Osteopenia group had significantly worse overall survival (OS) and relapse-free survival (RFS) than the Non-Osteopenia group (p = 0.001 and p = 0.012, respectively). Multivariate analysis revealed osteopenia was an independent prognostic factor for OS (p < 0.001; hazard ratio [HR], 2.243; 95% confidence interval [CI], 1.422-3.538) and RFS (p = 0.008; HR, 1.739; 95% CI, 1.154-2.620). In logistic regression model, advanced age and cStage III-IV were independent risk factors for preoperative osteopenia. CONCLUSIONS: Preoperative osteopenia is associated with poor survival and recurrence in patients undergoing esophagectomy for esophageal cancer.

Risk stratification of anastomotic leakage using eGFR and FIB-4 index in patients undergoing esophageal cancer surgery.

PURPOSE: Renal insufficiency and liver cirrhosis are identified as independent risk factors for anastomotic leakage (AL) after esophagectomy. However, research evaluating the incidence of AL using quantitative data to measure renal function and liver fibrosis remain to be limited. Therefore, this study was conducted to evaluate postoperative AL after esophagectomy using estimated glomerular filtration rate (eGFR) and fibrosis-4 (FIB-4) index. METHODS: In total, 184 patients who underwent esophagectomy were included in this study; then, they were divided into the non-AL group (n = 161) and AL group (n = 23), after which their background data and intraoperative and postoperative outcomes were compared. In addition, risk factors for AL were evaluated using a logistic regression model. RESULTS: Preoperative body mass index of ≥21.5 kg/m2, hemoglobin A1c level of ≥7.3%, FIB-4 index of ≥1.44, and eGFR of <59 ml/min/1.73 m2 were found to be significantly frequent in the AL group compared with the non-AL group. Multivariate analysis revealed FIB-4 index of ≥1.44 (p = 0.013; OR, 3.780; 95% CI, 1.320-10.800) and eGFR of <59 ml/min/1.73 m2 (p = 0.018; OR, 3.110; 95% CI, 1.220-8.020) as the independent risk factors for AL. In addition, we stratified the patients into three groups based on the incidence of AL as follows: low risk (5.5%, low FIB-4 index), intermediate risk (13.0%, high FIB-4 index and eGFR), and high risk (37.5%, high FIB-4 index and low eGFR). CONCLUSION: Preoperative eGFR and FIB-4 index were found to be useful markers to predict AL after 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.

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

PURPOSE: Neoadjuvant chemotherapy (NAC) followed by esophagectomy has become a standard treatment for esophageal squamous cancer (ESCC) in Japan. We used propensity-matching analysis to clarify the safety and efficacy of NAC in daily clinical practice. METHODS: We reviewed the medical records of 335 patients with clinical Stage II/III ESCC diagnosed between 2007 and 2012, including 191 who received preoperative NAC (NAC group) and 144 treated by upfront surgery (US group). After propensity score matching, there were 118 patients in each group. We compared the postoperative complications and long-term outcomes between the groups. RESULTS: Seven patients in the NAC group underwent replacement therapy. Complications occurred in 76 (68.5%) and 76 (64.4%) patients in NAC and US groups, respectively (p = 0.51), and severe complications occurred in 17 (22.4%) and 30 (39.5%) patients, respectively (p = 0.057). One (0.8%) and three patients (2.5%) from the US group died within 30 days and 90 days after surgery, respectively, but none of the patients from the NAC group died within the same period. The 5-year survival rate was 54.9% in the NAC group and 41.2% in the US group (p = 0.024). CONCLUSIONS: NAC is a safe and effective treatment to improve prognosis in the clinical setting.

Prognostic impact of postoperative pulmonary complications following salvage esophagectomy after definitive chemoradiotherapy.

BACKGROUND: Postoperative complications after esophagectomy for esophageal cancer have a negative effect on patients' survival. Although postoperative complications are more frequently observed after salvage esophagectomy than after planned esophagectomy, the effects of postoperative complications on long-term oncologic outcomes after salvage esophagectomy remain unclear. METHODS: This retrospective study of 70 esophageal cancer patients after definitive chemoradiotherapy (dCRT) compared long-term outcomes between those with and without complications. The association between morbidity and overall survival (OS) was evaluated by a Cox regression analysis. To identify the risk factors for pulmonary complications, logistic regression analysis was carried out. RESULTS: Postoperative complications occurred in 42 (60.0%) patients. Pulmonary complications and anastomotic leakage occurred in 23 (32.9%) and 9 (12.9%) patients, respectively. Overall complications and anastomotic leakage did not affect long-term outcomes. Survival was significantly worse for patients with pulmonary complications. Radiation dose (<60 Gy), response to dCRT (complete), ypStage (0-II), residual disease (R0), and pulmonary complications (negative) were independent factors related to a favorable OS. BMI (<20 kg/m2 ), ASA-PS (2-3), and radiation dose (>60 Gy) were significant factors affecting the occurrence of pulmonary complications. CONCLUSIONS: Development of postoperative pulmonary complications was independently associated with poor prognosis in patients who underwent salvage esophagectomy after dCRT.

Patterns and Outcomes of Recurrent Esophageal Cancer After Curative Esophagectomy.

BACKGROUND: The recurrence patterns and therapeutic outcomes of patients with recurrent esophageal cancer after curative esophagectomy are not fully understood. METHODS: Data on recurrence patterns and sites of recurrence in patients with recurrent esophageal cancer after curative esophagectomy from 2005 to 2015 were retrospectively analyzed. Time to recurrence after curative esophagectomy and survival after recurrence were compared among groups stratified by recurrence pattern and site. Multivariate analysis was performed to identify clinicopathological parameters influencing survival after recurrence. RESULTS: Of the 290 patients identified, a single pattern of recurrence occurred in 224 patients (77.2%) and a multiple pattern of recurrence occurred in 66 patients (22.8%). The most frequent recurrence pattern was lymph node in 173 patients (59.7%), followed by distant organ in 133 patients (45.9%). Median time to recurrence and median survival after recurrence of all patients were 228 and 327 days, respectively. Among patients with lymph node or lung recurrence, there were 5-year survivors after recurrence who underwent multimodal therapy. Multivariate analysis revealed that longer disease-free interval [hazard ratio (HR) 0.70, 95% confidence interval (95% CI) 0.52-0.93], single pattern of recurrence (HR 0.54, 95% CI 0.39-0.74), and curative treatment for recurrence (HR 0.17, 95% CI 0.10-0.28) were significantly associated with favorable prognosis. CONCLUSIONS: Although the prognosis of recurrent esophageal cancer remains unfavorable, if multimodal treatment that includes local therapy was curative, prognosis could improve, especially in patients with lymph node or lung recurrence.

Glycemic Status and Prognosis of Patients with Squamous Cell Carcinoma of the Esophagus.

BACKGROUND: The impact of glycemic status on esophageal squamous cell carcinoma (ESCC) prognosis is unclear. METHODS: A total of 623 patients who underwent curative subtotal esophagectomy for ESCC were evaluated. Diabetes was defined as a prior diagnosis of diabetes under treatment or newly diagnosed diabetes based on preoperative glycosylated hemoglobin (HbA1c) levels. Poor glycemic control was defined as HbA1c ≥ 7.0%, whereas good glycemic control was defined as HbA1c < 7.0%. The impact of glycemic status on long-term survival after esophagectomy was evaluated. RESULTS: Among the 623 patients, 64 (10.3%) had diabetes including 30 (4.8%) with poor glycemic control. Although diabetes did not influence patient survival, patients with poor glycemic control had worse overall and disease-specific survival compared with those with good glycemic control (P = 0.011 and 0.039, respectively). Comparing poor glycemic control with good glycemic control, the hazard ratios (HRs) for overall and disease-specific mortality were 1.91 (1.15-3.18) and 1.89 (1.02-3.49) in univariate analysis. After multivariate adjustment, poor glycemic control also had increased risk of overall and disease-specific mortality [HR 1.72 (95% CI 1.02-2.88) and 1.65 (95% CI 0.89-3.08), respectively]. Poor glycemic control did not increase the risk of overall or disease-specific mortality in patients with stages 0-II disease but significantly increased this risk in those with stages III-IV disease [HR 2.05 (1.14-3.69) and 1.95 (1.01-3.80), respectively]. CONCLUSIONS: Poor glycemic control is an independent risk factor for overall and disease-specific mortality after esophagectomy for advanced-stage ESCC.

Preoperative Glycosylated Hemoglobin Levels Predict Anastomotic Leak After Esophagectomy with Cervical Esophagogastric Anastomosis.

BACKGROUND: Patients with diabetes are considered at increased risk of delayed wound healing and infectious complications, yet the relationship between diabetes and anastomotic leak (AL) remains unclear. Given that glycosylated hemoglobin (HbA1c) is a validated indicator of the long-term glycemic state, we evaluated the relationship between preoperative HbA1c levels and AL after esophagectomy. METHODS: We assessed 300 consecutive patients who underwent esophagectomy reconstructed with cervical esophagogastric anastomosis between 2011 and 2015. HbA1c levels were measured within 90 days before esophagectomy. We performed comparison between the patients with and without diabetes. In addition, the predictive factors for AL, as well as the relationship between HbA1c levels and AL, were investigated. RESULTS: Among the 300 patients, 35 had diabetes. The overall prevalence of AL was 11.7%, and patients with diabetes had a higher prevalence of AL than those without (p = 0.045). In univariate analysis, we identified diabetes, HbA1c level, and hand-sewn anastomosis as risk factors for AL significantly (p = 0.033, 0.009, and 0.011, respectively), but we also found previous smoking history, chronic hepatic disease, and supracarinal tumor location also showed tendencies to be risk factors (p = 0.057, 0.055, and 0.064, respectively). Multivariate logistic regression analysis indicated that chronic hepatic disease (p = 0.048), increased HbA1c level (p = 0.011), and hand-sewn anastomosis (p = 0.021) were independent risk factors for AL. CONCLUSIONS: Preoperative HbA1c level was significantly associated with the development of AL after cervical esophagogastric anastomosis. We recommend preoperative HbA1c screening for all patients scheduled to undergo esophagectomy.

Clinical Significance of the Pre-therapeutic Nodal Size in Patients Undergoing Neo-Adjuvant Treatment Followed by Esophagectomy for Esophageal Squamous Cell Carcinoma.

BACKGROUND: The clinical significance of pre-therapeutic nodal size in patients with esophageal squamous cell carcinoma (ESCC) is not clear. We investigated whether nodal size was correlated with survival in patients undergoing neo-adjuvant treatment followed by esophagectomy for ESCC. METHODS: In 2009-2013, 222 patients who underwent neo-adjuvant treatment followed by esophagectomy for ESCC were enrolled in this retrospective study. Nodal size was measured along the short axis of the largest node using pre-therapeutic CT images. Patients were then stratified based on this short axis, and nodal size was correlated with clinicopathological factors and survival. RESULTS: Patients with larger nodes were likely to have deeper cT, higher cN status, and poorer survival. Among the clinical factors cT, cN, cM, and nodal size, only cT and nodal size were independent prognostic factors in multivariate analysis [hazard ratio (HR) 2.0, 95 % confidence interval (CI) 1.1-3.5, p = 0.025 and HR 1.5, 95 % CI 1-2.3, p = 0.036, respectively]. In addition, nodal size was significantly associated with hematological recurrence (p = 0.007), but not lymphatic relapse (p = 0.272). CONCLUSIONS: The short axis of the largest node before neo-adjuvant treatment in patients with ESCC is a prognostic factor.

Clinical Impact of Abdominal Fat Distribution on Prognosis After Esophagectomy for Esophageal Squamous Cell Carcinoma.

BACKGROUND: Excessive visceral fat may promote cancer development and progression because of metabolic derangements. The purpose of this study was to clarify the impact of abdominal fat distribution on patient prognosis after esophagectomy for esophageal squamous cell carcinoma (ESCC). METHODS: Computed tomography volumetry was performed in 150 patients who underwent curative esophagectomy for ESCC between 2012 and 2013. Visceral fat area (VFA) and subcutaneous fat area (SFA) at umbilicus level were measured, and the VFA/SFA ratio was calculated in each patient. Prognoses of the patients were compared between groups classified according to VFA/SFA ratio. RESULTS: Both relapse-free survival and overall survival of the low VFA/SFA group were significantly better than those of the high VFA/SFA group (log-rank test p = 0.005, p = 0.01). Univariate analysis also found that low VFA/SFA ratio significantly predicted an increase in relapse-free and overall survival. In multivariate analysis, low VFA/SFA ratio was an independent factor for relapse-free survival [p = 0.042, hazard ratio (HR) 0.12, 95 % confidence interval (CI) 0.01-0.93]. In addition, low VFA/SFA ratio tended to be a significant variable that predicted better overall survival (p = 0.057, HR 0.14, 95 % CI 0.01-1.05). CONCLUSIONS: Low VFA/SFA ratio was significantly associated with better prognosis in patients who undergo curative esophagectomy for ESCC. Abdominal fat distribution may influence the biological features of ESCC.