The Present Status and Future of Barrett's Esophageal Adenocarcinoma in Japan.

BACKGROUND: The incidence of esophageal adenocarcinoma in Europe and the United States rapidly increased from the latter half of the 1970s and exceeded that of esophageal squamous cell carcinoma in the latter half of the 1990s, currently accounting for approximately 60% of all esophageal carcinomas. Recently, its incidence has also increased in Japan, raising concerns that it will follow a course similar to that in Europe and the United States. SUMMARY: The incidence of esophageal adenocarcinoma in Japan was about 2% until the 1990s, but in recent years, it has risen to 6.5-7.1%. Causes include the increase in the incidence of obesity due to changes in eating habits with resultant increases in the incidence of hiatal hernia and reflux esophagitis, a decrease in the rate of Helicobacter pylori infection, and the increased interest of physicians in the gastroesophageal junction. The number of gastroesophageal reflux disease patients in Japan rapidly increased from the 1990s, which accordingly increased the number of Barrett's esophageal adenocarcinoma patients from the latter half of the 1990s. Tabulation and analysis of 1,794 reported cases of Barrett's esophageal adenocarcinoma in Japan showed that superficial cancers accounted for 77.6%, and that the concomitant rates of hiatal hernia and reflux esophagitis were high at 87 and 70% respectively. Key Message: The future trend in the incidence of Barrett's esophageal adenocarcinoma in Japan will depend on the increase in the incidence of reflux esophagitis, which is essential for the development of Barrett's esophagus and Barrett's esophageal carcinoma. The obesity rate is lower in Japan than that in Europe and the United States, and the incidence and severity of reflux esophagitis are low. We expect that the incidence of Barrett's esophageal adenocarcinoma in Japan will not rise as high as in Europe and the United States, and will remain below 10%.

[Pericardial Fenestration in a Patient with Myocardial Metastasis and Cardiac Tamponade after Surgery for Esophageal Cancer;Report of a Case].

We report a case of pericardial fenestration in a patient with myocardial metastasis and cardiac tamponade after surgery for esophageal cancer. A 66-year-old man had been suffering from orthopnea, hypotension and general malaise due to cardiac tamponade and heart failure. Esophagectomy was performed with substernal gastric tube reconstruction for advanced esophageal carcinoma. Nine months after the operation, heart failure developed, and myocardial and pericardial metastasis was subsequently detected. Subxiphoidal pericardiocentesis was abandoned due to the substernal gastric tube, and pericardial fenestration was performed through a small left anterior thoracotomy at the 5th intercostal space. His symptoms were ameliorated immediately and the procedure contributed greatly to maintain his quality of life. Preoperative computed tomography was useful for revealing the anatomical positions of the gastric tube and important vessels.

Pancreaticoduodenectomy after postoperative gastric tube reconstruction for esophageal cancer with median arcuate ligament syndrome: a case report.

BACKGROUND: Pancreaticoduodenectomy (PD) is considered a challenging surgery for resecting the gastroduodenal artery (GDA), right gastric artery (RGA), and lymph node tumors. In cases of pancreatic head cancer surgery, vascular anastomosis or right gastroepiploic artery (RGEA)/GDA preservation is necessary after postoperative gastric tube reconstruction for esophageal cancer. Therefore, we report for the first time an extremely rare case of PD in a patient with pancreatic head cancer and median arcuate ligament syndrome (MALS) after gastric tube reconstruction following esophageal cancer surgery, in which the entire pancreatic head arcade was preserved. CASE PRESENTATION: The patient was a 76-year-old man who had undergone esophageal cancer surgery after sternal gastric tube reconstruction 7 years ago. He was referred to our hospital because of the suspicion of intraductal papillary mucinous carcinoma (IPMC) owing to an enlarged cystic lesion and a substantial component in the uncinate process of the pancreas. Preoperative three-dimensional computed (3D-CT) tomography angiography showed celiac axis stenosis and pancreatic head arcade dilation. The diagnosis was IPMC without evidence of invasion; therefore, gastric tube blood flow was maintained by preserving the GDA and RGEA. Due to MALS, the GDA blood flow was supplied through the pancreatic head arcade, necessitating its preservation. The GDA-RGEA, right gastroepiploic vein, and anterior superior pancreaticoduodenal artery were taped over the entire pancreatic head for preservation. The inferior pancreaticoduodenal artery (IPDA) was also taped on the dorsal pancreas and the posterior or anterior IPDA, which further bifurcates were taped to preserve them. Subsequently, PD was performed. CONCLUSION: We report a case of PD after gastric tube reconstruction for esophageal cancer with MALS, in which the pancreatic head arcade vessels were successfully preserved using 3D-CT to confirm the operation of the vessels.

Thoracoscopic esophagectomy while in a prone position for esophageal cancer: a preceding anterior approach method.

BACKGROUND: In 2009, the rate of thoracoscopic esophagectomy for esophageal cancer was about 20% in Japan. This low rate may be due to the difficulty in maintaining a good surgical field and the meticulous procedures that are required. The purpose of this study was to establish and evaluate a new procedure for performing a thoracoscopic esophagectomy while the patient is in a prone position using a preceding anterior approach to make the esophagectomy easier to perform. METHODS: We have performed thoracoscopic esophagectomy using our new procedure in 60 patients with esophageal cancer. Each patient was placed in a prone position and five trocars were inserted; only the left lung was ventilated and a pneumothorax was maintained. The esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. The lymph nodes around the esophagus were also dissected anteriorly and posteriorly. The patients were sequentially divided into two groups and their clinical outcomes were evaluated. RESULTS: The mean operative time for the thoracoscopic procedure for the latter 30 cases (203 min) was shorter than that for the former 30 cases (260 min) (P = 0.001). Among the 52 cases without pleural adhesion, the mean blood loss in the latter 26 cases (18 mL) was also less than that in the former 26 cases (40 mL) (P = 0.027). There were no conversions to a thoracotomy and no operative deaths in this series. Postoperative complications related to the thoracoscopic procedure occurred in 8 cases (27%) in the former group and in 4 cases (13%) in the latter group. CONCLUSIONS: Thoracoscopic esophagectomy with the patient in the prone position using a preceding anterior approach is a safe and feasible procedure. As experience performing the procedure increases, the performance of the procedure stabilizes. This method seems to make the esophagectomy easier to perform.

A rare case of esophageal metastasis from signet-ring cell carcinoma of the cecum.

BACKGROUND: Metastatic esophageal cancer is rare. Its common primary lesions include lung cancer and breast cancer. Metastatic esophageal cancer originating from colorectal cancer is rarer. CASE PRESENTATION: A 79-year-old woman visited our hospital because of lower abdominal discomfort. She was endoscopically diagnosed with type 0-IIa + IIc cancer of the cecum, and biopsy of the lesion showed signet-ring cell carcinoma. With a preoperative clinical staging of cStage I (cT2, cN0, cM0), the patient underwent laparoscopic ileocecal resection with D3 lymphadenectomy. Histopathological examination of the resected specimens revealed signet-ring cell carcinoma [type 4, pT4a, pN3 (No. 203), M0, pRM1, stage IIIc, R1]. Despite radial margin positivity, the patient refused resection of the residual tumor and received oral tegafur and uracil. KRAS mutation test showed KRAS wild-type colon cancer, but she refused anti-epidermal growth factor receptor therapy. One year after surgery, her blood carcinoembryonic antigen concentration elevated. Colonoscopy showed anastomotic recurrence and biopsy of the lesion showed signet-ring cell carcinoma. Upper gastrointestinal endoscopy showed multiple longitudinal submucosal tumors with erosions on their surfaces in the esophagus. Tumor biopsy revealed signet-ring cell carcinoma. Immunohistochemistry showed that the histological type of the esophageal tumors was the same as that of the primary colon cancer. Based on these findings, the esophageal tumors were diagnosed with metastasis from signet-ring cell carcinoma of the cecum. The oral chemotherapy was replaced with FOLFOX plus bevacizumab. However, the patient's condition required treatment discontinuation, and she died of cancer progression 1 year and 5 months after surgery. CONCLUSIONS: To our knowledge, this is the first case report on metastatic esophageal cancer from signet-ring cell carcinoma of the cecum. Esophagoscopy showed multiple longitudinal submucosal tumors, which is similar to an endoscopic finding of intramural metastasis from primary esophageal cancer. We consider that the multiple longitudinal submucosal tumors are a notable feature of our case. When metastatic esophageal cancer is suspected, clinicians, endoscopists, and pathologists should consider signet-ring cell carcinoma of the colon as one of potential primary lesions. This consideration could lead the specialists to appropriate examinations and treatments, thereby improving clinical outcomes in patients with the metastasis.

Long-term outcome of metachronous, multiple, early Epstein-Barr virus-associated gastric carcinoma: a case report.

Background: Epstein-Barr virus is associated with various malignancies. Epstein-Barr virus-associated gastric carcinoma (EBVaGC) was reported in 1990. While gastric carcinoma with lymphoid stroma (GCLS) is a rare gastric cancer, 80% to 90% of these tumors are associated with Epstein-Barr virus infection. Case Description: The patient was a 67-year-old male in 2004, when he underwent laparoscopy-assisted distal gastrectomy with Billroth I reconstruction to treat early stage 0-IIc gastric cancer; the pathological diagnosis was moderately differentiated adenocarcinoma, pT1b, pN0, stage IA with a negative margin. In 2009, endoscopic submucosal dissection (ESD) was performed on reoccurring stage 0-IIc gastric cancer; pathology results identified well-differentiated adenocarcinoma, pT1b, Ly0, V0, pHM0, pVM0. Although further gastric resection was recommended, the patient declined the procedure and opted to receive only follow-up evaluation. During the follow-up period, upper gastrointestinal (GI) endoscopy revealed a protruding mass on the remaining gastric fundus; biopsy indicated a poorly differentiated adenocarcinoma. Approximately 15 years after the initial treatment, the patient underwent total resection of the remnant stomach and Roux-en-Y reconstruction. The histopathological diagnosis was gastric cancer, pT1b, N0, no lymphatic and venous invasion, stage IA with lymphoid stroma and lymphocyte infiltration associated with formation of lymphoid follicles. Immunohistochemistry with EBV-encoded RNA in situ hybridization (EBER-ISH) was positive, resulting in diagnosis of EBVaGC. Retrospective EBER-ISH performed on resected specimens from the 2 prior surgeries yielded similar results. Furthermore, immunohistochemistry using anti-programmed death ligand 1 (PD-L1) antibody demonstrated an increase in the combined positive score (CPS) over time. Conclusions: This report describes the rare case of a patient who experienced 3 occurrences of EBVaGC at different times and locations over 15 years and discusses the clinical relevance in the context of a literature review. It aims to increase awareness among clinicians and pathologists of the necessity of considering EBVaGC when deciding on the treatment strategy after reoccurrence of gastric cancer.

Transitional Changes in Job Stress and Psychological Adjustment of Hospital Workers During the COVID-19 Pandemic in Japan.

OBJECTIVES: The aim of the present study was to longitudinally evaluate job stress and burnout before and after the third wave of in Japan and identify transitional changes in the mental health status of a cohort of employees at a coronavirus disease 2019 (COVID-19)-dedicated hospital. METHODS: The same surveys were conducted in October 2020 and March 2021. 151 subjects who responded to both surveys were included. The Maslach Burnout Inventory-General Survey was used to evaluate burnout. Multiple logistic regression analyses were performed to determine odds ratios for factors associated with burnout using a non-burnout group as a reference. RESULTS: In the cohort, 31.1% of employees showed dropout intention and 13.2% of employees were experiencing burnout in March 2021. Hospital workers were more motivated by a sense of contribution and accomplishment, which could balance increased exhaustion in March 2021. The following factors associated with burnout remained to be solved: self-quarantine, unfavorable patient prognosis, poor communication of information, lack of sleep in comparison to the pre-COVID-19 period, and desire for good communication of information. CONCLUSION: It is important to continuously evaluate the mental health status of employees and to provide targeted prevention and intervention in order to mitigate psychological distress and avoid burnout and resignation.

[Diagnosis and treatment of spontaneous esophageal rupture].

Spontaneous esophageal rupture is a comparatively rare disease, and thought to be a severe emergency disease clinically. Most patients of spontaneous esophageal rupture complained of chest pain after vomiting, which required an appropriate diagnosis. Emergency operation for the extra-mediastinal rupture type and intra-mediastinal rupture type, also conservative treatment for the intra-mediastinal rupture type achieved satisfactory results. The procedure consisted of closure of the perforation site with left thoracotomy and gastric fundic patch via the transhiatal approach. To prevent post-operative empyema and mediastinal abscess formation, insertion of a conventional thoracic drainage tube and another fixed drainage tube from the posterior diaphragm to the lateral border of the vertebral column along the thoracic descending aorta seemed effective. The patients with spontaneous esophageal rupture underwent continuous irrigation and suction via these drainage tubes after the operation.

[Recent advances in endoscopic resection for esophageal cancer].

The indications for endoscopic resection (ER) in esophageal cancer are limited to cases without lymph node metastasis because it is a local therapy. The relationship between cancer depth and lymph node metastasis has been clarified according to the pathologic analysis of lymph nodes removed during esophagectomy for early esophageal cancer. Cancer invasion remaining in the lamina propria mucosa rarely metastasizes to the lymph nodes, and ER is thus indicated. ER allows the esophagus to be preserved and is less invasive, enabling the specimen to be examined pathologically. Lesions extending to a large area can be resected by repeated endoscopic mucosal resection (EMR), but have recently been resected en bloc in the endoscopic submucosal dissection (ESD) procedure, which is also indicated for the treatment of gastric cancer. The selection of EMR or ESD depends on the size of the lesion, the technique of the surgeon, the time the patient can safely spend under anesthesia, and economic management. ER is now employed in T1a-MM, SM1 cases without lymph node metastasis, although some require additional treatment including surgery after pathologic examination of the resected lesions.

[Treatment of esophageal cancer in elderly patients].

During the last 30 years, the median survival time and 5-year survival rate of esophageal cancer have improved significantly. In recent years, two major factors have greatly contributed to improve the outcomes of treatment for esophageal cancer in Japan. One is the establishment of endoscopic diagnosis and treatment of superficial esophageal cancer, and another is the establishment of a standard surgical procedure, subtotal esophagectomy with dissection of three field lymph nodes. In an aging society like Japan, with the increased incidence, the diagnosis and treatment of esophageal cancer will become increasingly important in the future. The effectiveness and risk of surgical treatment, chemotherapy, radiotherapy and combination therapy for elderly patients with esophageal cancer will also become important. However, the average life expectancy has reached 79 years for Japanese men, and various evidence from clinical research on patients less than 75 years old is not longer sufficient. Care of elderly patients with esophageal cancer has relied on past experience. Now, clinical studies on elderly esophageal cancer must be improved.

Successful combination of endoscopic and laparoscopic removal of multiple ingested needles: A case report.

RATIONALE: Foreign body (FB) ingestion is a relatively common clinical situation in the emergency department. However, multiple sharply pointed foreign bodies located in different organs are rare conditions and no definite treatment guidelines has been established. PATIENT CONCERNS: A 31-year-old amateur magician visited the outpatient clinic with a chief complaint of epigastric discomfort. He might have accidentally swallowed some needles while practicing a magic trick 2 days before. DIAGNOSIS: Imaging tests revealed 1 needle was stuck in the left liver lobe through the stomach wall, 1 was in the third portion of the duodenum, 3 were in the ascending colon, and 2 were in the transverse colon. INTERVENTIONS: A needle in the duodenum and 5 in the colon were removed by endoscopy. The needle stuck in the liver from the stomach was not visible inside the stomach and was successfully removed by laparoscopy a few days later. OUTCOMES: The patient was able to tolerate an oral diet and was discharged on postoperative day 4 without any complications. LESSONS: Developing a treatment plan in cases of multiple sharp FB may be difficult. A multidisciplinary team of endoscopists and surgeons is needed to determine the best possible treatment plan. This experience illustrates the importance of the planning of the sequence and method of removal of multiple foreign bodies from the gastrointestinal tract.

[Recent advances of endoscopic treatment for esophageal cancer].

The indications for endoscopic treatment are limited to cases without lymph node metastasis, because it is only a local therapy. The relationship between cancer depth and lymph node metastasis has been clarified based on the pathologic analysis of lymph nodes removed during esophagectomy for early esophageal cancer. Cancer confined to the lamina propria mucosa rarely undergoes lymph node metastasis and complete endoscopic resection (ER) is indicated. ER allows the esophagus to be preserved and is less invasive, enabling specimens to be pathologically examined. Lesions extending over large area can be resected by repeating endoscopic mucosal resection (EMR), but have recently been resected using endoscopic submucosal dissection (ESD), as indicated for gastric cancer. Which of the two procedures, EMR or ESD, to be chosen depends on the difficulty, skill of the surgeon, time to be spared, and economic management. ER is now performed in SM1 without lymph node metastasis, although some patients require additional treatment after pathologic examination of resected lesions.

Clinical analysis of reflux esophagitis following esophagectomy with gastric tube reconstruction.

BACKGROUND: Recently, the rate of postoperative long-term survival has increased in cases of esophageal cancer. We report on our analysis of postoperative reflux esophagitis (RE) at Tokai University. METHODS: We enrolled 48 patients who underwent gastric tube reconstruction after esophagectomy. The diagnosis of RE was confirmed by endoscopy. RESULTS: Of the 48 patients, 28 (58.3%) were found to have RE. Among the 28 patients with RE, only four (14.3%) reported symptoms. The distribution of the severity of RE according to the Los Angeles classification in the patients was as follows: grade M, 1 (3.6%); grade A, 2 (7.1%); grade B, 6 (21.4%); grade C, 17 (60.7%); and grade D, 2 cases (7.1%). Barrett's epithelium was detected in 9 of the 28 patients (31%) with RE and in 3 of the 20 (15%) patients with no evidence of RE. CONCLUSIONS: To detect the presence of RE as well as monitor for recurrence and development of metachronous cancer, we consider it important to perform endoscopy regularly over the long term. As Barrett's epithelium is frequently encountered, care should be exercised to detect the specialized columnar epithelium showing dysplastic changes.

A Surgical Case of Primary Splenic Malignant Lymphoma Complicating Chronic Hepatitis C.

The patient was a 70-year-old man. Hepatic dysfunction was found in 1988 and chronic hepatitis C was diagnosed in 1993. He received interferon-alpha therapy, but did not respond to it. Thereafter, he was treated with ursodeoxycholic acid. In September 2010, abdominal ultrasound showed a hypoechoic tumor (29 × 25 mm) in the lower pole of the spleen, and this lesion became larger one year later (74 × 66 × 71 mm). Abdominal CT revealed a hypovascular heterogeneous tumor with smooth margins on both dynamic and delayed phase scans. MRI displayed a tumor with a low signal intensity on T2WI. Abdominal angiography confirmed that the lesion was hypovascular. 67Ga scintigraphy showed abnormal accumulation confined to the spleen. Bone marrow biopsy did not reveal any abnormalities. Based on these findings, primary splenic malignant lymphoma (PSML) complicating chronic hepatitis C was diagnosed and splenectomy was performed. A tumor (78 × 60 mm) was found in the lower pole of the resected spleen and pathologic examination revealed diffuse large B cell lymphoma (DLBCL). Four courses of postoperative R-CHOP therapy were performed. At present, he continues to use ursodeoxycholic acid with no recurrence after four years. In conclusion, we report our experience of a patient who had PSML complicating chronic hepatitis C with discussion of the literature.

Mucin expression and proliferating cell index of esophageal Barrett's adenocarcinoma.

Barrett's esophagus is a premalignant condition associated with gastroesophageal reflux disease, and consists of mucosa with a metaplastic columnar epithelium (specialized columnar epithelium). In this study, we examined the expression of mucin and the Ki-67 labeling index (LI) in 15 cases of esophageal Barrett's adenocarcinoma, and clarified the significance of incomplete intestinal metaplasia of Barrett's mucosa as a premalignant lesion. Gastric mucin (MUC5AC, HGM, and/or MUC6) was detected in 93.3% of the adenocarcinomas, while MUC2 and CD10 (markers of intestinal phenotypes) were detected in 73.3% and 46.2%, respectively. The Ki-67 LI was 34.1% in Barrett's adenocarcinoma. In all cases, gastric mucin was found in the non-neoplastic Barrett's mucosa around the adenocarcinoma. MUC2 was detected in 86.7% of proximal non-neoplastic mucosa and 100% of distal non-neoplastic mucosa, while CD10 was found in 20.0% of proximal non-neoplastic mucosa and 40.0% of distal non-neoplastic mucosa of Barrett's adenocarcinoma. In conclusion, Barrett's esophageal mucosa with intestinal metaplasia and a high Ki-67 LI is suggested to be more important as a premalignant lesion, and predominantly found in the proximal rather than distal region of Barrett's esophagus.

Multiple gastric carcinoids associated with hypergastrinemia. A review of five cases with clinicopathological analysis and surgical strategies.

Previously, total gastrectomy was regarded as the treatment for multiple gastric carcinoids because of the unknown biological characteristics of this disease. Recent studies, however, have revealed that type 1 gastric carcinoids have a low potential for malignancy. In this study, five patients with hypergastrinemia and multiple gastric carcinoids, who underwent gastrectomy with regional node dissection, were analyzed. On serum chemistry examinations, the serum gastrin level was found to be high (515.5-over 3000 pg/ml) in all patients pre-operatively, but returned to a normal range (40-50 pg/ml) in all three cases examined post-operatively. Histopathological examination of our five cases revealed multiple gastric tumors, i.e. three to five tumors in Cases 1-4 and numerous tumors in Case 5. The multiple tumors were histologically carcinoid tumors up to 15 mm in size, limited to the submucosa, and no lymph node metastasis was identified in any of the cases. The patients were followed-up at outpatient clinics with no additional adjuvant therapy, and there was no evidence of recurrence during follow-up. Recently, minor invasive surgery such as endoscopic mucosal resection or laparoscopic antrectomy has been performed to treat type 1 gastric carcinoids. Our data provide important insights into understanding the biological behavior of multiple gastric carcinoids.

[Sentinel lymph node concept in patients with esophageal cancer].

It is not uncommon that first lymph node involvement appears at a distant lymph node not at a nearest node from the primary lesion in patients with esophageal cancer. Identification of the sentinel node, which permits the detection of the first draining node from a primary lesion, is expected to individualize the treatment of esophageal cancer. From our study in 23 patients with esophageal cancer using Tc-99 m tin colloids, the sentinel node concept seemed to be applicable to patients with esophageal cancer (-pT2). However, injection techniques and intraoperative probe searching for hot nodes are more difficult and uncertain in esophageal cancer compared to superficial cancers such as breast cancer and malignant melanoma. Further studies are necessary to reliably apply the sentinel node biopsy technique to patients with esophageal cancer.