Prognostic significance of preoperative osteosarcopenia on patient' outcomes after emergency surgery for gastrointestinal perforation.

PURPOSE: Sarcopenia is a prognostic predictor in emergency surgery. However, there are no reports on the relationship between osteopenia and in-hospital mortality. This study clarified the effect of preoperative osteosarcopenia on patients with gastrointestinal perforation after emergency surgery. METHODS: We included 216 patients with gastrointestinal perforations who underwent emergency surgery between January 2013 and December 2022. Osteopenia was evaluated by measuring the pixel density in the mid-vertebral core of the 11th thoracic vertebra. Sarcopenia was evaluated by measuring the area of the psoas muscle at the level of the third lumbar vertebra. Osteosarcopenia is defined as the combination of osteopenia and sarcopenia. RESULTS: Osteosarcomas were identified in 42 patients. Among patients with osteosarcopenia, older and female patients and those with an American Society of Anesthesiologists Physical Status of ≥ 3 were significantly more common, and the body mass index, hemoglobin value, and albumin level were significantly lower in these patients than in patients without osteosarcopenia. Furthermore, the osteosarcopenia group presented with more postoperative complications than patients without osteosarcopenia (P < 0.01). In the multivariate analysis, age ≥ 74 years old (P = 0.04) and osteosarcopenia (P = 0.04) were independent and significant predictors of in-hospital mortality. CONCLUSION: Preoperative osteosarcopenia is a risk factor of in-hospital mortality in patients with gastrointestinal perforation after emergency surgery.

Appropriate concentration setting for the intraoperative administration of indocyanine green for fluorescence imaging to identify the sentinel lymph node in early gastric cancer: a clinical pilot study.

PURPOSE: Some prospective trials have demonstrated the feasibility of sentinel node (SN) biopsy in gastric cancer (GC) surgery. This study aimed to identify the appropriate concentration settings for the intraoperative injection of indocyanine green (ICG) for SN biopsy. METHODS: Before the clinical studies, porcine model experiments explored the optimal concentration of ICG injected intraoperatively. Next, nine GC patients were enrolled in the clinical research. ICG (0.5 ml) was injected intraoperatively into four quadrants of the submucosa around the tumor at various concentrations (0.5, 0.25, and 0.1 mg/ml). The lymphatic basin dissection method was applied to the ICG-positive lymphatic areas. The number and location of the lymphatic basins and positive nodes were recorded intraoperatively. RESULTS: In the porcine model, the visibility gradually became clear at an ICG concentration higher than 0.1 mg/ml. In the clinical study, the average number of detected lymphatic basins was 3.3, 1.7, and 1.7, respectively. The mean number of detected SNs was 14.7, 6.7, and 4.0, respectively. CONCLUSION: To improve the reproducibility of SN biopsy, it is essential to prepare the correct concentration setting of ICG. Under current conditions in which ICG is injected intraoperatively, a 0.1 mg/ml concentration setting of ICG may be necessary and sufficient for SN identification.

Prognostic significance of the preoperative C-reactive protein-albumin-lymphocyte (CALLY) index on outcomes after gastrectomy for gastric cancer.

PURPOSE: Systemic inflammatory response markers are reported to be prognostic for patients with cancer. The C-reactive protein (CRP)-albumin-lymphocyte (CALLY) index has been established as an immuno-nutritional scoring system. The aim of this study was to clarify the impact of the preoperative CALLY index on the outcome of patients undergoing gastrectomy for gastric cancer. METHODS: We analyzed the data of 826 patients who underwent gastrectomy for stage I, II, or III gastric cancer between 2010 and 2017. The CALLY index was defined as (albumin × lymphocyte)/(CRP × 104). RESULTS: The cut-off of the CALLY index was 2. The 147 patients with a preoperative CALLY index < 2 had significantly worse overall survival (OS) and relapse-free survival (RFS) than those with a CALLY index ≥ 2 (P < 0.01, P < 0.01, respectively). Multivariate analysis identified that a CALLY index < 2 (P = 0.02), intraoperative blood loss (P < 0.01), and stage II or III disease (P < 0.01) were independent and significant predictors of worse RFS. A CALLY index < 2 (P = 0.01), intraoperative blood loss (P < 0.01), postoperative complications (P = 0.02), and stage II or III disease (P < 0.01) were independent and significant predictors of worse OS. CONCLUSION: The preoperative CALLY index was independently associated with a poor prognosis for patients after gastrectomy for gastric cancer.

Role of modified Glasgow Prognostic Score in patients with achalasia who underwent laparoscopic Heller-myotomy with Dor-fundoplication.

BACKGROUND: Systemic inflammatory response is significant prognostic indicator in patients with various diseases. The relationship between prognostic scoring systems based on the modified Glasgow Prognostic Score (mGPS) and achalasia in patients treated with laparoscopic Heller­myotomy with Dor­fundoplication (LHD) remains uninvestigated. This study aimed to examine the role of mGPS in patients with achalasia. METHODS: 457 patients with achalasia who underwent LHD as the primary surgery between September 2005 and December 2020 were included. We divided patients into the mGPS 0 and mGPS 1 or 2 groups and compared the patients' background, pathophysiology, symptoms, surgical outcomes, and postoperative course. RESULTS: mGPS was 0 in 379 patients and 1 or 2 in 78 patients. Preoperative vomiting and pneumonia were more common in patients with mGPS of 1 or 2. There were no differences in surgical outcomes. Postoperative upper gastrointestinal endoscopy revealed that severe esophagitis was more frequently observed in patients with mGPS of 1 or 2 (P < 0.01). The clinical success was 91% and 99% in the mGPS 0 and mGPS 1 or 2 groups, respectively (P < 0.01). CONCLUSIONS: Although severe reflux esophagitis was more common in patients with achalasia with a high mGPS, good clinical success was obtained regardless of the preoperative mGPS.

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.

Microscopic venous invasion is a predictor of prognosis in patients with esophageal squamous cell carcinoma undergoing ineffective neoadjuvant chemotherapy and surgery.

BACKGROUND: Neoadjuvant chemotherapy followed by surgery is Japan's most effective treatment modality for advanced thoracic esophageal squamous cell carcinoma. However, the prognosis is not as expected. This study aimed to examine prognostic factors in patients with pathologically ineffective neoadjuvant chemotherapy followed by surgery for esophageal squamous cell carcinoma. METHODS: We retrospectively analyzed patients who underwent neoadjuvant chemotherapy followed by curative esophagectomy for esophageal squamous cell carcinoma between December 2008 and July 2021. The patients were divided into the neoadjuvant chemotherapy effective group and the neoadjuvant chemotherapy ineffective group according to the pathological diagnosis. Clinicopathological data, prognosis, and recurrence were analyzed. RESULTS: A total of 143 patients (121 males, 22 females; median age, 67 years) were included in this study. Of these, 34 patients were classified into the effective group and the remaining 109 patients were assigned to the ineffective group. The ineffective group had significantly worse overall survival and recurrence-free survival than the effective group (p = 0.0192 and p = 0.0070, respectively). In the ineffective group, multivariate analysis demonstrated that microscopic venous invasion was an independent prognostic factor for overall survival (hazard ratio 2.44; 95% confidence interval 1.13-5.30) and recurrence-free survival (hazard ratio 2.43; 95% confidence interval 1.24-4.73). CONCLUSIONS: Microscopic venous invasion was associated with poor survival and cancer recurrence in the neoadjuvant chemotherapy ineffective group of patients who underwent esophagectomy for esophageal squamous cell carcinoma.

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.

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.

Assessment of button-type jejunostomy for nutritional management after esophagectomy in 201 cases.

BACKGROUND: Many surgeons preferably place a trans-nasal feeding tube or a feeding enterostomy for post-operative nutritional management after esophagectomy. Various types of tubes (such as nasogastric, transgastric, transduodenal, or transjejunal tubes) have been used for enteral feeding; however, the appropriate enteral feeding routes have not yet been proposed. Therefore, this study aimed to evaluate the feasibility and safety of button-type jejunostomy. METHODS: We reviewed 201 patients who underwent esophagectomy with placement of a button-type jejunostomy at the Jikei University Hospital (Tokyo, Japan) between 2008 and 2019. The analyzed variables included clinicopathological characteristics, operative data, jejunostomy-related characteristics, and postoperative complications. Postoperative bodyweight loss was examined 6 months and 1 year after the operation. RESULTS: Refractory enterocutaneous fistula and bowel obstruction occurred in 13 (6.5%) and 14 (7.0%) patients, respectively. The body mass index at button-type jejunostomy removal was significantly lower and the duration of button-type jejunostomy placement was significantly longer in patients with a refractory enterocutaneous fistula (p = 0.023 and p < 0.001, respectively). Bowel obstruction was significantly more likely to develop in patients with a non-squamous cell carcinoma (p = 0.021) and in patients who underwent open abdominal procedures (p < 0.001). After 1 year, the median bodyweight losses were 12.1% and 15.6% in patients with short and long jejunostomy placement durations (p = 0.642), respectively. CONCLUSION: A button-type jejunostomy is durable and allows easy self-management for maintaining the bodyweight without any adverse events. However, it is strongly recommended that the button be removed within a year to prevent refractory enterocutaneous fistula formation.

Feasibility of enhanced recovery protocol in minimally invasive McKeown esophagectomy.

BACKGROUND: Implementation of enhanced recovery after surgery has generally been applied to gastrointestinal surgeries; however, few studies have investigated minimally invasive McKeown esophagectomy. In this study, we aimed to evaluate the safety and feasibility of an enhanced recovery protocol after minimally invasive McKeown esophagectomy. METHODS: Data were collected between January 2015 and April 2020 for patients who underwent esophagectomy. Of these patients, those who underwent minimally invasive McKeown esophagectomy was selected for the investigation. Perioperative outcomes and nutritional index were compared using propensity score matching between the conventional group and the enhanced recovery group. RESULTS: A total of 119 patients were enrolled in this study. Of these, 73 and 46 were treated with conventional and enhanced recovery protocol, respectively. Forty-two pairs were matched in two groups. The enhanced recovery group showed a lower rate of pulmonary complications (9.5% vs. 28.5%, p = 0.0235), abdominal dysfunctions (16.7% vs. 42.9%, p = 0.0078), and shorter hospital stay as compared with the conventional group (17.5 days vs. 23 days, p = 0.0034). The loss of body weight (6.3% vs. 7.7%, p = 0.0065) and body mass index (5.6% vs. 8.1%, p = 0.0017) were significantly lower in the enhanced recovery group than in the conventional group. In contrast, nutritional biochemistry data did not differ significantly between the two groups. CONCLUSIONS: This study shows that the promotion of an enhanced recovery protocol in minimally invasive McKeown esophagectomy maintains nutritional status without increasing postoperative complications.

Quantitative Assessment of Blood Flow in the Gastric Conduit With Thermal Imaging for Esophageal Reconstruction.

OBJECTIVE: The study's primary aim was to evaluate the effectiveness of thermal imaging (TI) and its secondary aim was to compare TI and indocyanine green (ICG) fluorescence angiography, with respect to the evaluation of the viability of the gastric conduit. SUMMARY BACKGROUND DATA: The optimal method for evaluating perfusion in the gastric conduit for esophageal reconstruction has not been established. METHODS: We reviewed the prospectively collected data of 263 patients who had undergone esophagectomy with gastric conduit reconstruction. TI was used in all patients. ICG fluorescence was concomitantly used in 24 patients to aid comparison with TI. A cut-off value of the anastomotic viability index (AVI) was calculated using the receiver operating characteristic curve in TI. RESULTS: Anastomotic leak was significantly less common in patients with AVI > 0.61 compared with those with AVI ≤ 0.61 (2% vs 28%, P< 0.001). Microvascular augmentation was performed in 20 patients with a low AVI score and/or preoperative chemoradiotherapy. Overall ability was comparable between TI and ICG fluorescence regarding the qualitative evaluation of the gastric conduit. However, TI was superior in the quantitative assessment of viability. CONCLUSIONS: TI could delineate the area of good perfusion in the gastric conduit for esophageal reconstruction, which can help identify patients at high risk of anastomotic leak.

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.

Early prediction of complex benign anastomotic stricture after esophagectomy using early postoperative endoscopic findings.

BACKGROUND: Benign anastomotic stricture after esophagectomy and reconstruction adversely affects oral intake and can increase the risk of aspiration pneumonia. Some patients experience relapse that requires frequent endoscopic dilatations. This study aimed to investigate whether the endoscopic appearance of anastomosis during the early postoperative period is associated with the complexity of subsequent anastomotic strictures. METHODS: Data of 213 patients who underwent esophagectomy with gastric tube reconstruction and early postoperative endoscopy between July 2008 and September 2018 were prospectively collected. Relationships among various risk factors, including the severity of mucosal degeneration of the anastomosis and complexity of anastomotic stricture, were studied using multivariate logistic regression analysis. RESULTS: Fifty-three patients (25%) developed anastomotic strictures at a median of 55 days after surgery, requiring a median of 5 endoscopic dilations. In multivariate analysis, severe mucosal degeneration was the only significant risk factor for any type of anastomotic stricture (P < 0.001). Twenty-seven patients (51%) developed refractory anastomotic strictures. In multivariate analysis, younger age (< 65 years) (P = 0.01), lack of neoadjuvant therapy (P = 0.02), severe mucosal degeneration (P = 0.03), and stricture development within 55 days (P = 0.01) were the risk factors for refractory stricture. The analysis of the risk factors for severe mucosal degeneration revealed that comorbidities and anastomotic techniques were independently correlated (P < 0.01). CONCLUSIONS: Early postoperative severe mucosal degeneration of esophagogastrostomy was the only predictor of strictures, regardless of their type. Mucosal degeneration, early postoperative stricture, younger age, and front surgery were associated with refractory anastomotic strictures.

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.

Lateral thermal spread induced by energy devices: a porcine model to evaluate the influence on the recurrent laryngeal nerve.

BACKGROUND: Recurrent laryngeal nerve (RLN) paralysis is a frequently observed complication after esophagectomy, and thermal injury is considered to be one of the causes. The difference in the lateral thermal spread associated with the grasping range of various energy devices remains unknown. METHODS: Ultrasonic devices (Harmonic® HD1000i and Sonicision™) and a vessel-sealing device (Ligasure™) were studied. We evaluated the temperature of these devices, the activation time required, and the thermal spread on porcine muscle when the devices were used with different grasping ranges (thermal spread study). In addition, we evaluated the influence of thermal spread by short grasping use of the energy devices on the viability of RLN in a live porcine model (NIM study). RESULTS: In the thermal spread study, the temperature of the ultrasonic devices lowered as grasping range increased, whereas the highest temperature of Ligasure was observed when used with two-thirds grasping. The activation time of ultrasonic devices became longer as grasping range increased, whereas the grasping range did not influence the activation time of Ligasure. Thermal spreads 1 mm from the energy devices were unaffected by the grasping ranges. Although the temperature of the Ligasure was lower than that of the ultrasonic devices, thermal spread by Ligasure was significantly greater than that induced by the ultrasonic devices. In the NIM study, the activation of the Sonicision with one-third grasping range did not cause EMG changes at distances of up to 1 mm from the RLN, whereas applying Ligasure with a one-third grasping range 1 mm away from the RLN led to a critical result. CONCLUSIONS: The grasping range did not influence the thermal spread induced by the energy devices. Ultrasonic devices may be safer in terms of lateral thermal spread to the RLN than Ligasure.