Should the Supraclavicular Lymph Nodes be Considered Regional Lymph Nodes in Cervical Esophageal Cancer?

BACKGROUND: The importance of supraclavicular lymph node (SCLN) metastases in esophageal cancer (EC) remains unknown. Few studies have reported on the prognostic impact of SCLN metastases on patients with cervical EC (CEC). This study aimed to investigate whether SCLNs should be considered regional lymph nodes and be dissected in patients with CEC. METHODS: This retrospective study enrolled 835 consecutive patients who underwent radical esophagectomy. Of these patients, 67 underwent radical surgery for CEC. These 67 patients were divided into three groups based on the presence of lymph node metastases with or without metastatic SCLNs or the absence of lymph node metastases. RESULTS: Of the 67 patients, 23 (34.3%) did not have metastatic lymph nodes (pN-negative group), 27 (40.3%) had metastatic lymph nodes except for metastatic SCLNs (pN-positive group without metastatic SCLN), and 17 (25.4%) had metastatic lymph nodes including metastatic SCLNs (pN-positive group with metastatic SCLNs). The 5-year overall survival rate was 58.4% for the pN-negative group, 46.2% for the pN-positive group without metastatic SCLNs, and 7.8% for the pN-positive group with metastatic SCLNs. The pN-positive group with metastatic SCLNs tended to show residual tumor cells and complications after surgery. The presence of metastatic SCLNs was a significantly poor prognostic factor (p = 0.004). The efficacy index was lowest for the lymph nodes in the supraclavicular region. CONCLUSIONS: The prognosis of the CEC patients with metastatic SCLNs was dismal. Although the cervical esophagus is located adjacent to the SCLNs, the SCLNs may be considered extra-regional lymph nodes in patients with CEC.

Aggressive and frequent resection of recurrences in retroperitoneal sarcoma contributes to long-term survival.

PURPOSE: Retroperitoneal sarcoma (RPS) is a rare tumor with a poor prognosis and is often undetected until it is significantly enlarged. While surgical resection remains the primary treatment, there is little research on its benefits, especially that concerning the reoperation of recurrent disease. This study investigated the impact of surgical procedures, especially reoperation of recurrent RPS, on prognosis. METHODS: This retrospective study included 51 patients who underwent radical resection surgery (R0 status) for primary or recurrent RPS without distant metastasis. Patient outcomes and prognosis were defined in terms of the clinicopathologic factors and surgical techniques performed. RESULTS: In all cases, the 5-year disease-free survival (DFS) rate was 28.2%, 5-year overall survival rate was 89.9%, and 5-year no residual liposarcoma rate was 54.3% after operation and re-reoperation. There was a statistically significant difference between the 5-year DFS rate and 5-year no residual liposarcoma rate due to frequent re-reoperation (p = 0.011). On univariate analysis of primary and recurrent lesions, the histological type and the number of organs involved were identified as statistically significant prognostic factors. Patients with well-differentiated liposarcomas had a statistically better prognosis than those with other cancer types (primary RPS, p = 0.028; recurrence, p = 0.024). CONCLUSIONS: Aggressive and frequent resection of recurrent RPS with combined resection of adjacent organs contributes to long-term survival. The establishment of a surgical strategy for RPS will require a prospective study.

Prognostic predictions based on pathological findings of peritoneal dissemination in patients with stage IV colorectal cancer without residual disease (R0 status).

PURPOSE: This study aimed to clarify the prognosis of patients after resection of stage IV colorectal cancer and synchronous peritoneal metastasis (no residual disease: R0 status) based on histopathologic findings. METHODS: The subjects of this study were 26 patients who underwent radical resection of synchronous peritoneal metastases of stage IV colorectal cancer. Only patients with one synchronous peritoneal metastasis were included in this study. The peritoneal lesions were initially classified into two categories based on the presence or absence of adenocarcinoma on their surface: RM-negative or RM-positive. The lesions were subsequently classified as being of massive or diffuse type and of small (< 6 mm) or large (≥ 6 mm) type according to the maximum metastatic tumor dimension. RESULTS: Multivariate analysis revealed that massive type metastatic tumors were associated with a better disease-free survival (DFS; p = 0.047) and overall survival (OS; p = 0.033), than diffuse type tumors. CONCLUSION: A detailed stratification of pathological findings could contribute remarkably to prognostic predictions for patients with synchronous peritoneal metastases.

A case of refractory chylothorax due to an unenclosed esophageal hiatus after subtotal esophagectomy treated with lipiodol lymphangiography.

BACKGROUND: Chylothorax, a rare but serious complication following esophagectomy, can lead to dehydration, malnutrition, and even mortality. Surgical intervention is considered when conservative treatment is ineffective; however, in some refractory cases, the cause of chylothorax remains unclear. We report a case of refractory chylothorax caused by abdominal chyle leakage into the pleural space via an unenclosed esophageal hiatus. CASE PRESENTATION: A 66-year-old man was diagnosed with advanced esophageal squamous cell carcinoma. The patient underwent robot-assisted thoracoscopic subtotal esophagectomy in the prone position with retrosternal gastric tube reconstruction following neoadjuvant chemotherapy. The thoracic duct was ligated and resected because of tumor invasion. Chylothorax and chylous ascites were observed 2 weeks after surgery but did not improve despite conservative management with medications and drainage. Lymphoscintigraphy through the inguinal lymph node showed tracer accumulation in the fluid in both the abdominal and pleural spaces. Lipiodol lymphangiography revealed abdominal lymphoid leakage, but no leakage was detected from the thoracic duct or mediastinum. We considered that the chylothorax was caused by chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus, and we performed surgical intervention. Laparotomy revealed abdominal chyle leakage and a fistula at the esophageal hiatus with the inflow of ascites into the thoracic cavity. Lipiodol lymphangiography was additionally performed for treating abdominal lymphorrhea after surgery, and resulted in the improvement of the chylothorax and ascites. The patient was discharged with no recurrence of chylothorax or chylous ascites. CONCLUSIONS: Refractory chylothorax can occur due to chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus. When the site of chylothorax leakage is unclear, the possibility of inflowing chylous ascites via the unenclosed esophageal hiatus should be explored. Esophageal hiatus closure and lipiodol lymphangiography could be effective in treating refractory chylothorax of unknown cause after esophagectomy.

Thoracoscopic enucleation of an esophageal glomus tumor in the prone position: a case report and literature review.

BACKGROUND: Glomus tumors (GT) generally occur in the skin. However, esophageal GT, an extremely rare condition, has no established standardized treatment guidelines. Herein, we report the case of an esophageal GT successfully removed by thoracoscopic enucleation in the prone position using intra-esophageal balloon compression. CASE PRESENTATION: A 45-year-old man underwent an annual endoscopic examination and was found to have a submucosal tumor in the lower esophagus. Endoscopic ultrasound (EUS) revealed a hyperechoic mass originating from the muscular layer. Contrast-enhanced computed tomography identified a 2 cm mass lesion with high contrast enhancement in the right side of the lower esophagus. Pathologic findings of EUS-guided fine needle aspiration biopsy (EUS-FNA) revealed round to spindle shaped atypical cells without mitotic activity. Immunohistochemically, the tumor was positive for alpha-smooth muscle actin, but negative for CD34, desmin, keratin 18, S-100 protein, melan A, c-kit, and STAT6. He was diagnosed with an esophageal GT and a thoracoscopic approach to tumor resection was planned. Under general anesthesia, a Sengstaken-Blakemore (SB) tube was inserted into the esophagus. The patient was placed in the prone position and a right thoracoscopic approach was achieved. The esophagus around the tumor was mobilized and the SB tube balloon inflated to compress the tumor toward the thoracic cavity. The muscle layer was divided and the tumor was successfully enucleated without mucosal penetration. Oral intake was initiated on postoperative day (POD) 3 and the patient discharged on POD 9. No surgical complications or tumor metastasis were observed during the 1-year postoperative follow-up. CONCLUSIONS: As malignancy criteria for esophageal GT are not yet established, the least invasive procedure for complete resection should be selected on a case-by-case basis. Thoracoscopic enucleation in the prone position using intra-esophageal balloon compression is useful to treat esophageal GT on the right side of the esophagus.

The use of an artificial intelligence algorithm for circulating tumor cell detection in patients with esophageal cancer.

Despite recent advances in multidisciplinary treatments of esophageal squamous cell carcinoma (ESCC), patients frequently suffer from distant metastasis after surgery. For numerous types of cancer, circulating tumor cells (CTCs) are considered predictors of distant metastasis, therapeutic response and prognosis. However, as more markers of cytopathological heterogeneity are discovered, the overall detection process for the expression of these markers in CTCs becomes increasingly complex and time consuming. In the present study, the use of a convolutional neural network (CNN)-based artificial intelligence (AI) for CTC detection was assessed using KYSE ESCC cell lines and blood samples from patients with ESCC. The AI algorithm distinguished KYSE cells from peripheral blood-derived mononuclear cells (PBMCs) from healthy volunteers, accompanied with epithelial cell adhesion molecule (EpCAM) and nuclear DAPI staining, with an accuracy of >99.8% when the AI was trained on the same KYSE cell line. In addition, AI trained on KYSE520 distinguished KYSE30 from PBMCs with an accuracy of 99.8%, despite the marked differences in EpCAM expression between the two KYSE cell lines. The average accuracy of distinguishing KYSE cells from PBMCs for the AI and four researchers was 100 and 91.8%, respectively (P=0.011). The average time to complete cell classification for 100 images by the AI and researchers was 0.74 and 630.4 sec, respectively (P=0.012). The average number of EpCAM-positive/DAPI-positive cells detected in blood samples by the AI was 44.5 over 10 patients with ESCC and 2.4 over 5 healthy volunteers (P=0.019). These results indicated that the CNN-based image processing algorithm for CTC detection provides a higher accuracy and shorter analysis time compared to humans, suggesting its applicability for clinical use in patients with ESCC. Moreover, the finding that AI accurately identified even EpCAM-negative KYSEs suggested that the AI algorithm may distinguish CTCs based on as yet unknown features, independent of known marker expression.

Repair using the pectoralis major musculocutaneous flap for refractory anastomotic leakage after total esophagectomy.

BACKGROUND: The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound healing. However, applying PMMF after esophageal surgery is uncommon. We report here, the case of a successfully repaired refractory anastomotic fistula (RF) after total esophagectomy, by PMMF. CASE PRESENTATION: A 73-year-old man had a history of hypopharyngolaryngectomy, cervical esophagectomy, and reconstruction using a free jejunal graft for hypopharyngeal carcinosarcoma at the age of 54. He also received conservative treatment for pharyngo-jejunal anastomotic leakage (AL), then postoperative radiation therapy. This time, he was diagnosed with carcinosarcoma in the upper thoracic esophagus; cT3rN0M0, cStageII, according to the Japanese Classification of Esophageal Cancer 12th Edition. As a salvage surgery, thoracoscopic total resection of the esophageal remnant and reconstruction using gastric tube via posterior mediastinal route was performed. The distal side of the jejunal graft was cut and re-anastomosed with the top of the gastric tube. An AL was observed on the 6th postoperative day (POD), and after 2 months of conservative treatment was then diagnosed as RF. The 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length, and surgical repair using PMMF was performed on POD71. The edge of the defect was exposed and the PMMF (10 × 5 cm) fed by thoracoacromial vessels was prepared. Then, the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen. Although a minor AL was observed on POD19, it healed with conservative treatment. No complications, such as stenosis, reflux, re-leakage, were observed over 3 years of postoperative follow-up. CONCLUSIONS: The PMMF is a useful option for repairing intractable AL after esophagectomy, especially in cases with large defect, as well as difficulties for microvascular anastomosis due to previous operation, radiation, or wound inflammation.

Safety and Feasibility of Temporary Ileostomy in Older Patients: A Retrospective Study.

BACKGROUND: Temporary ileostomy reduces the incidence of severe anastomotic leakage and postoperative mortality. However, little is known about ileostomy-related complications in older adults. PURPOSE: To clarify the safety and feasibility of temporary ileostomy for rectal cancer in older patients. METHODS: Data were collected from a prospectively created database and complemented by secondary chart review for consecutive patients with rectal malignancy who underwent curative proctectomy with diverting loop ileostomy between 2013 and 2018. Ileostomy construction and closure were compared between two groups (defined as elderly and non-elderly patients). Data for 22 patients who were 75 years of age and older (elderly group) and 160 patients who were younger than 75 years (non-elderly group) were analyzed. RESULTS: The median maximum fecal output was significantly higher in the non-elderly group compared with the elderly group. No significant differences were observed between the two groups in postoperative intravenous hydration, creatinine ratio, and ileostomy-related complication rate. Although the elderly group had a higher rate of early stoma closure, the causes were not related to those complications. CONCLUSION: Temporary ileostomy was a safe and feasible procedure in this population of older patients with rectal malignancies.

A novel laparoscopic assisted mediastinal dissection with gastric tube inversion technique for gastric tube cancer reconstructed through a retrosternal route.

A median sternotomy is often performed in patients with gastric tube cancer reconstructed through the retrosternal route; however, this procedure is invasive and has the risk of severe infectious complications. To overcome these problems, we created a novel method to perform the reconstructed gastric tube resection using a gastric tube inversion technique combined with a laparoscopic mediastinal approach. After the duodenum was divided, the oral side of the cut end was sutured with silken threads for traction. The gastric tube was dissected from the caudal side under a laparoscopic mediastinal approach, whereas the cervical esophagus was taped. After the adhesion between the middle side of the posterior sternum and the reconstructed gastric tube was dissected to the cervix, the gastric tube was inverted by guiding and pulling the thread toward the cervical side. Sharp dissection was facilitated between the inverted gastric tube and the surrounding organs under moderate traction and a favorable surgical view. We have performed this procedure and evaluated the short-term outcomes in six cases. The laparoscopic mediastinal approach was completed without a median sternotomy in all six cases. Restorable intraoperative lung injury was observed in one case and no major vessel injuries were observed. The postoperative course was satisfactory with a 29.5-day median length of hospital stay (range, 16-60 days). The gastric tube inversion technique combined with the laparoscopic mediastinal approach for patients with retrosternal-reconstructed gastric tube cancer was shown to be safe and less invasive and should be considered in resection of the reconstructed gastric tube.

Distal partial gastrectomy for gastric tube cancer with intraoperative blood flow evaluation using indocyanine green fluorescence.

With recent advances in the treatment of esophageal cancer and long-term survival after esophagectomy, the number of gastric tube cancer (GTC) has been increasing. Total gastric tube resection with lymph node dissection is considered to be a radical treatment, but it causes high post-operative morbidity and mortality. We report an elderly patient with co-morbidities who developed pyloric obstruction due to GTC after esophagectomy with retrosternal reconstruction. The patient was treated using distal partial gastric tube resection (PGTR) and Roux-en-Y reconstruction with preservation of the right gastroepiploic artery and right gastric artery. Intraoperative blood flow visualization using indocyanine green (ICG) fluorescence demonstrated an irregular demarcation line at the distal side of the preserved gastric tube, indicating a safe surgical margin to completely remove the ischemic area. PGTR with intraoperative ICG evaluation of blood supply in the preserved gastric tube is a safe and less-invasive surgical option in patients with poor physiological condition.

Surgical Strategy for Rectovaginal Fistula After Colorectal Anastomosis at a High-volume Cancer Center According to Image Type and Colonoscopy Findings.

BACKGROUND/AIM: The reported incidence of rectovaginal fistula is very low. Although some case reports have described surgical procedures, no systematic approach to the treatment of rectovaginal fistula according to diagnostic image and colonoscopy findings has been proposed. We present a comprehensive surgical strategy for rectovaginal fistula after colorectal anastomosis according to diagnostic image and colonoscopy findings. PATIENTS AND METHODS: This retrospective study included 11 patients who developed rectovaginal fistula after colorectal anastomosis. Rectovaginal fistula was classified into 4 types according to contrast enema images and colonoscopy findings, i.e., "Alone type", "Dead space type", "Anastomotic stricture type", and "Dead space and Anastomotic stricture type". The surgical strategies were "Diversion (Stoma)", "Percutaneous drainage", "Anastomotic stricture type", "Endoscopic balloon dilation", "Curettage of foreign bodies", "Simple full-thickness closure", "Split-thickness closure", "Pedicled flaps packing", and "Reanastomosis". The surgical strategy appropriate for each rectovaginal fistula type was investigated. RESULTS: Among "Alone type" cases, 5 (71.4%) healed with "only Diversion (Stoma)". "Alone type" cases (n=11) and all other cases (n=4) healed with "only Diversion (Stoma)" (n=5) or any other method (n=6) (p=0.022). CONCLUSION: For treatment of rectovaginal fistula after colorectal anastomosis, less invasive treatment approaches should be attempted first.

Ileal conduit necrosis after total pelvic exenteration for recurrence of gastrointestinal stromal tumor.

We report a case of ileal conduit necrosis after total pelvic exenteration for recurrence of gastrointestinal stromal tumor. A 47-year-old man was diagnosed with recurrence of gastrointestinal stromal tumor adjacent to the prostate after abdominoperineal resection 10 years prior. With imatinib administration for 18 months, the local recurrence decreased in size but did not separate from the prostate. We performed urinary diversion with conventional total pelvic exenteration. Ileal conduit necrosis was suspected the following day and emergency surgery was performed. The serosa of the ileal conduit showed segmental necrosis extending about 10 cm from the orifice. The ureterointestinal anastomotic site was opposite the orifice and was not necrotic. We resected the necrotic ileum and reconstructed an ileal conduit. The patient was discharged without any symptoms 46 days after surgery for further adjustment to use of a urostomy.

Perforation of abdominal esophagus following nasogastric feeding tube intubation: A case report.

INTRODUCTION: Perforation of the abdominal esophagus caused by nasogastric tube (NGT) intubation has been rarely reported in adults. PRESENTATION OF CASE: A 73-year-old man was admitted to our hospital with pneumonia. He had been bedridden long-term and had previously undergone a gastrectomy for gastric ulcer. Since admission was prolonged, and he required enteral feeding because of his inability to swallow, a NGT was inserted blindly. The next day, he had a high fever and abdominal pain. Abdominal computed tomography scan revealed that the tube was inserted through the wall of the abdominal esophagus into the abdominal cavity. In the emergency surgery, we sutured the perforated site of abdominal esophagus and patched it with lesser omentum. The postoperative course was good. DISCUSSION: Abdominal esophageal perforation due to NGT insertion is very rare. The cause of perforation was suggested to be an abnormal deformity created by adhesion due to previous distal gastrectomy and long-term bedridden status. A chest X-ray usually is performed to confirm the position of the NGT tube. In this case, a frontal radiographic view apparently showed the NGT placed in the stomach. CONCLUSION: When NGT is inserted to such patients, frontal and lateral radiographic views or fluoroscopic guidance should be obtained.