Effects and risk factors of TAS-102 in real-world patients with metastatic colorectal cancer, EROTAS-R study.

BACKGROUND: Trifluridine/tipiracil (TAS-102) is an anticancer drug for metastatic colorectal cancer (CRC). This study aimed to analyze the effects and risk factors about effects of TAS-102 in real-world patients with metastatic CRC (the EROTAS-R study). METHODS: This study retrospectively analyzed 271 patients aged ≥ 20 years who underwent TAS-102 for metastatic CRC at nine related institutions from 2014 to 2021. Therapeutic results of TAS-102 + bevacizumab (Bev) and TAS-102, effect predictors, adverse events (AE), and AE predictors were examined. RESULTS: The backgrounds of all cases were as follows: average age, 66.7 ± 10.9 years; male ratio, 59.5%; performance status (PS) 0/1/2, 43.5%/50.6%/5.9%; and tumor site right/left, 25.5%/74.5%. The therapeutic results of 109 cases receiving TAS-102 + Bev and 162 cases receiving TAS-102 were as follows: disease control rate, 53.2% vs. 28.0% (p < 0.01); progressive free survival (PFS), 6.2 vs. 4.2 months (p < 0.01); and overall survival (S), 11.8 vs. 9.3 months (p = 0.03). Multivariate analysis for effect-related factors (odds ratio (OR), 95%confidence interval (CI)) showed the following: PS1 + 2 (0.257, 0.134-0.494, p < 0.01) and a combination of Bev (3.052, 1.598-5.827, p < 0.01). The rates of grade 3 AE for TAS-102 + Bev and TAS-102 were 53.2% and 48.8%, respectively (p = 0.47). Various AE predictors were as follows: male sex (p = 0.69), age ≥ 75 years (p = 0.59), PS1 + 2 (p = 0.20), body surface area < 1.53 m2 (p = 0.26), eGFR < 50 ml/min (p = 0.02), and AST ≥ 50 IU/L (p = 0.64). CONCLUSION: A better OS and PFS comparing TAS-102 + Bev to TAS-102 for CRC was achieved in a large number of real-world patients.

The survival after recurrence of colorectal cancer: a retrospective study focused on time to recurrence after curative resection.

PURPOSE: The significance of the duration of the recurrence-free survival after curative resection for colorectal cancer remains unclear. The purpose was to reveal the association between time to recurrence after surgery and the survival after recurrence. METHODS: Patients with stage II and III colorectal cancer who underwent curative resection between 2007 and 2015 were retrospectively reviewed (n = 645). Patients with recurrence after surgery (n = 133) were divided into 2 groups: early recurrence (within 13 months after surgery, n = 63) and late recurrence (more than 13 months after surgery, n = 70). The overall survival after recurrence and clinicopathological features were compared between early recurrence, late recurrence, and without recurrence groups. RESULTS: The overall survival after recurrence was significantly shorter in patients with early recurrence occurring at less than 13 months (hazard ratio: 1.70, p = 0.03). A high preoperative CA19-9 level (odds ratio [OR]: 2.38, p = 0.03), venous invasion (OR: 2.26, p = 0.03), and the absence of adjuvant chemotherapy (OR: 2.08, p = 0.04) were independently correlated with early recurrence. CONCLUSION: Early recurrence was associated with a poor prognosis after recurrence. Venous invasion correlated with early recurrence. Adjuvant chemotherapy may reduce the risk of early recurrence. These results indicate the importance of prudent surveillance and the aggressive application of adjuvant chemotherapy.

[A Case of Gastric Cancer Invading the Pancreas with Pathological Complete Response Treated by Preoperative S-1 plus Oxaliplatin Therapy].

A 66-year-old man with severe anemia was diagnosed with gastric cancer. CT examination revealed primary gastric tumor, which involved the pancreas body, with regional lymph nodes that were enlarged(T4b[panc], cN2, cM0, cStage ⅣA). He received three courses of preoperative S-1 plus oxaliplatin therapy. Primary tumor and metastatic lymph nodes were reduced remarkably. We performed a curative distal gastrectomy(D2)without pancreas resection. Histopathological examination revealed Grade 3 pathological complete response in both primary tumor and metastatic lymph nodes.

Identification of colorectal neoplasia by using serum bile acid profile.

BACKGROUND: Colonoscopy is the gold standard for detecting earlier stages of CRC, although screening of patients is difficult because of invasiveness, low compliance and procedural health risks. Therefore, the need for new screening methods for CRC is rising. Previous studies have demonstrated the diagnostic ability of serum BAs; however, the results have been inconsistent. In this study, we conducted a comprehensive analysis of serum BAs from patients with CRC and verified their diagnostic ability to detect CRC. METHODS: A total of 56 CRC patients (n = 14 each of stages I-IV), 59 patients with colonic adenoma and 60 healthy controls were included. Age and sex were matched for each group. Serum BA compositions were measured by LC-MS/MS and serum concentration of 30 types of BAs were analysed by discriminant analysis with multidimensional scaling method. RESULTS: Free CA, 3epi-DCA&CDCA, 3-dehydro CA, GCA and TCA were extracted as principal component (PC) 1 and free 3-dehydroDCA as PC 2 by canonical discriminant function coefficients. The verification of discriminability using cross-validation method revealed that the correct classification rate was 66.3% for original data and 52.6% for cross-validation data. CONCLUSIONS: A combined analysis using comprehensive serum BA concentration can be an efficient method for screening CRC.

Utility of continuous glucose monitoring following gastrectomy.

BACKGROUND: Glucose fluctuation after gastrectomy represented by dumping syndrome is a well-known post-gastrectomy syndrome that negatively impacts patient quality of life. However, the current methods of post-gastrectomy glucose monitoring do not comprehensively capture the postoperative blood glucose fluctuations that characterize this. METHODS: We used a continuous glucose monitoring (CGM) system to document the glycemic profiles of patients undergoing gastrectomy and compared these between patients undergoing distal gastrectomy (DG) and total gastrectomy (TG). To evaluate post-gastrectomy syndromes, including dumping syndrome, we used the Post-gastrectomy Syndrome Assessment Scale 37-item questionnaire. The glycemic profiles were also compared using this tool. RESULTS: We studied 57 patients who had undergone DG and 13 who had undergone TG between September 2017 and September 2019. Our results revealed larger diurnal glycemic variability and longer periods of nocturnal hypoglycemia after gastrectomy. The dumping score was worse in the TG than in the DG group (TG 2.4 ± 1.4 vs. DG 1.3 ± 1.2, P = 0.0061). Importantly, 30 of 57 DG patients (52.6%) and 5 of 13 TG patients (38.5%) experienced postprandial hypoglycemia following hyperglycemia without hypoglycemic symptoms. There was no correlation between the dumping symptom score and glycemic variability (ρ = 0.0545, P = 0.6662). CONCLUSIONS: CGM demonstrated diurnal glycemic variability and nocturnal hypoglycemia in patients undergoing gastrectomy. Because some hypoglycemic patients did not develop symptoms and glycemic variability was not necessarily associated with dumping symptom, dumping syndrome must only partially explain the postoperative glucose fluctuations.

The impact of postoperative inflammation on recurrence in patients with colorectal cancer.

BACKGROUND: Systemic inflammatory response is strongly linked to among cancer development, progression and poor prognosis. The aim of this study was to clarify the impact of postoperative serum C-reactive protein (CRP) levels on the prognoses of patients with colorectal cancer (CRC). METHODS: A total of 467 patients with stage I-III CRC who underwent curative surgery were retrospectively analyzed. To precisely evaluate the effect of postoperative inflammatory status on prognosis in CRC patients, we excluded patients with postoperative complication or elevated preoperative CRP level (CRP > 1.0 mg/dL). Patients were divided into two groups based on their highest post-resection CRP levels (max CRP): the low CRP group (LCG; < 9.0 mg/dL, n = 385) and high CRP group (HCG; ≥ 9.0 mg/dL, n = 82). Furthermore, the effect of inflammation on malignant potential of CRC cells was evaluated using in vitro peritoneal dissemination model. RESULTS: HCG patients showed significantly worse recurrence-free survival (RFS) than LCG patients (p = 0.012). Multivariate analysis revealed that a higher max CRP was an independent prognostic factor for RFS (HR: 2.07, 95% CI 1.04-3.96, p = 0.038). Concerning the risk factors for high max CRP level, multivariate analysis revealed that older age (p < 0.001), male sex (p < 0.001), higher BMI (p = 0.005), right-sided colorectal cancer (p = 0.008), and longer operative time (p = 0.007) were independent risk factors. A higher max CRP was also significantly associated with peritoneal recurrence (p < 0.001). Additionally, recombinant cytokines enhanced the adhesive ability of CRC cells to mesothelial cell in vitro (p < 0.05). CONCLUSIONS: Postoperative inflammation may be a possible mechanism portending the poor prognosis of CRC patients.

Clinical significance of neutrophil-to-lymphocyte ratio as a predictor of lymph node metastasis in gastric cancer.

BACKGROUND: Precise staging is indispensable to select the appropriate treatment strategy for gastric cancer (GC); however, the diagnostic accuracy of conventional modalities needs to be improved. This study investigated the clinical significance of the preoperative neutrophil-to-lymphocyte ratio (NLR) for the prediction of pathological lymph node metastasis (pN+) in GC. METHODS: This was a retrospective study of 429 patients with GC who underwent curative gastrectomy. The predictive ability of NLR for pN+ was examined in comparison with that of computed tomography. RESULTS: The preoperative NLR ranged from 0.6 to 10.8 (median, 2.0), and the optimal cut-off value for predicting pN+ was 1.6 according to the receiver operating characteristic curve with the maximal Youden index. Multivariate analysis identified a NLR ≥ 1.6 (odds ratio (OR) 3.171; 95% confidence interval (CI) 1.448-7.235, p = 0.004) and cN+ (OR 2.426; 95% CI 1.221-4.958, p = 0.011) to be independent factors associated with pN+ in advanced GC (cT2-T4). On the other hand, a NLR ≥ 1.6 was not useful for predicting pN+ in early GC (cT1). In advanced GC, a NLR ≥ 1.6 detected pN+ with a higher sensitivity (84.9%) and negative predictive value (NPV) (63.9%) than conventional modalities (50.0 and 51.7%, respectively). When the subjects were limited to those with advanced GC with cN0, the sensitivity and NPV of a NLR ≥ 1.6 for pN+ increased further (90.7 and 81.0%, respectively). CONCLUSION: The preoperative NLR may be a useful complementary diagnostic tool for predicting pN+ in advanced GC because of its higher sensitivity and NPV than conventional modalities.

Preoperative inflammatory response as prognostic factor of patients with colon cancer.

PURPOSE: This study aimed to investigate the abilities of the modified Glasgow prognostic score (mGPS) and other inflammatory scores to predict recurrence-free survival (RFS) among patients with colon cancer (CC). In addition, we evaluated the abilities of the mGPS to predict recurrence of stage II disease and the efficacy of adjuvant chemotherapy (AC) for stage III disease. METHODS: This retrospective study evaluated 477 patients with stage I-III CC who underwent curative surgery. These patients were categorized as having a low mGPS (mGPS 0) or a high mGPS (mGPS 1-2). RESULTS: Patients in the high mGPS group had significantly poorer RFS than patients in the low mGPS group (p < 0.01). Multivariate analysis revealed that a high mGPS independently predicted poor RFS (p < 0.01). Among patients with stage II CC, multivariate analysis revealed that the independent predictors of poor RFS were pT4 status (p < 0.01) and a high mGPS (p = 0.04). Among patients with stage III CC, AC was not significantly associated with the 5-year RFS for patients with a low mGPS (p = 0.38), although AC significantly improved the 5-year RFS for patients with a high mGPS (p < 0.01). CONCLUSION: The preoperative mGPS significantly predicted recurrence among patients with CC, even among patients with stage II CC. In addition, mGPS may provide valuable information regarding subgroups of patients with stage III CC who might benefit from AC.

Preoperative total cholesterol-lymphocyte score as a novel immunonutritional predictor of survival in gastric cancer.

PURPOSE: Immunonutritional status is a known prognostic correlate in the context of gastric cancer (GC). In the present study, we investigated the prognostic relevance of a lipid profile-based immunonutritional score in patients with GC. METHODS: Data pertaining to 224 patients with stage II and III GC who underwent curative gastrectomy were retrospectively analyzed. The total cholesterol-lymphocyte score (TL score) was defined as follows: patients with both low total cholesterol (TC) and total lymphocyte count were allocated a score of 2; patients with only one or none of these biochemical abnormalities were allocated a score of 1 or 0, respectively. RESULTS: Among the serum lipid indices, low TC was the strongest predictor of cancer-specific survival (CSS; p = 0.001). On multivariate analysis, both low prognostic nutritional index (PNI) (p < 0.001) and high TL score (p = 0.003) were independent prognostic factors. PNI was significantly associated with peritoneal recurrence (p = 0.047), while TL score was significantly associated with locoregional and distant metastasis (p = 0.004 and p = 0.003, respectively). CONCLUSIONS: TL score may facilitate risk stratification of patients based on CSS. TL score plus PNI may help predict the recurrence pattern in patients with stage II and III GC.

[Gastrectomy in Patients Aged<85 Years Who Had Gastric Cancer-A Single-Institutional Experience].

BACKGROUND: This study examined the treatment outcomes of gastrectomy in patients aged<85 years who had gastric cancer(GC). METHODS: The postoperative short- and long-term outcomes of 27 patients aged<85 years who underwent gastrectomy for GC at our institute were retrospectively investigated. RESULTS: The median age was 87 years(range: 85-94 years), and 17 patients(63%)had comorbidities. Total, distal, and proximal gastrectomies were performed for 12, 14, and 1 patient, respectively. Only 13 patients(48%)underwent standard lymph lymphadenectomy(LND), while R0, R1, and R2 were performed for 23, 2, and 2 patients, respectively. The overall, surgical, and non-surgical complication rates were 59%, 26%, and 44%, respectively, even though the incidence of GradeBⅢa complications was only 4%, and there was no mortality. The 1-, 2-, and 3-year overall survival rates(OSR)were 91.7%, 79.4%, and 63.2%, respectively. The 3-year OSRs of the patients who underwent R0, R1, and R2 were 76.2%, 35.4%, and 0%, respectively. The 3-year OSR was significantly higher in the patients who underwent the standard LND(100%)than in those who underwent limited LND(36.6%). CONCLUSION: The standard LND and R0 might also be useful for patients aged<85 years who had GC, although care should be taken for the high incidence of complications.

[Prognostic Significance of Preoperative Neutrophil-Lymphocyte Ratio in Gastric Cancer].

BACKGROUND: This study examined the significance of preoperative neutrophil-lymphocyte ratio(NLR)as a predictor of postoperative outcomes of gastric cancer(GC). METHODS: NLR was calculated in 447 patients with GC undergoing curative gastrectomy, and its associations with postoperative short- and long-term outcomes were retrospectively examined. RESULTS: Patients were divided into high-(n=313)or low-(n=134)NLR groups using an optimal cut-off NLR value of 1.6 according to the ROC curve analysis. A high-NLR was significantly associated with other clinical factors such as undifferentiated histology, advanced cT, and cN+. There was no difference in the incidence of postoperative complications between the 2 groups. Meanwhile, a high NLR was associated with a poor 5-year overall survival. Multivariate analysis identified preoperative NLR to be an independent prognostic factor(hazard ratio: 2.77, 95% confidence interval: 1.39-6.33, p=0.003)along with performance status, tumor location, and cT. CONCLUSION: Preoperative NLR could be one of the useful predictors of postoperative long-term outcomes of GC.

[Prognostic Value of Preoperative Serum C-Reactive Protein Level in Gastric Cancer].

BACKGROUND: This study investigated the prognostic value of preoperative serum C-reactive protein(CRP)level in patients with gastric cancer(GC). METHODS: This retrospective study examined 446GC patients undergoing curative gastrectomy. The associations between preoperative CRP level and postoperative long-term outcomes were examined by univariate and multivariate analyses. RESULTS: The patients were divided into high(n=147)or low(n=299)CRP groups based on an optimal cut- off CRP value of 0.13mg/dL according to the ROC curve analysis. High CRP levels were significantly associated with other clinical factors such as older age(B65 years), high BMI(B25 kg/m2), poor performance status(PS), and advanced cT and cN+. In the survival analyses using only the clinical factors, high CRP levels were significantly associated with worse 5-year overall and cancer-specific survivals. The multivariate analysis for 5-year overall survival identified preoperative CRP to be an independent factor(HR: 1.95, 95%CI: 1.15-3.36, p=0.0129), as well as PS, tumor location, and cT. CONCLUSION: Preoperative CRP level could be a useful prognostic indicator in patients with GC undergoing curative gastrectomy.

Value of Preoperative PET-CT in the Prediction of Pathological Stage of Gastric Cancer.

BACKGROUND: Preoperative precise staging is essential for the treatment of gastric cancer (GC); however, the diagnostic accuracy of conventional modalities needs to be increased. The present study investigated the clinical value of positron emission tomography-computed tomography (PET-CT) for the staging of GC. METHODS: This was a retrospective study of 117 patients with a clinical diagnosis of advanced GC who underwent PET-CT followed by gastrectomy. The incidence of FDG uptake in the primary tumor or lymph nodes and its relationship with clinicopathological factors, particularly pathological stage (pStage) III/IV, were examined. RESULTS: FDG uptake in the primary tumor was noted in 83 patients (70.9%). FDG uptake in the lymph nodes was detected in 21 patients (17.9%), and its sensitivity and specificity for lymph node metastasis were 22.7 and 90.5%, respectively. Multiple logistic regression analyses showed that FDG uptake in the primary tumor (odds ratio (OR) 2.764; 95% confidence interval (CI) 1.104-7.459, p = 0.029) and that in the lymph nodes (OR 4.660; 95% CI 1.675-13.84, p = 0.003) were factors independently associated with pStage III/IV. FDG uptake in the primary tumor detected pStage III/IV with higher sensitivity (80.4%) and that in lymph nodes found pStage III/IV with higher specificity (88.7%) than those of upper endoscopy plus CT (60.9 and 67.6%, respectively). CONCLUSIONS: PET-CT appears to be a useful complementary modality in the assessment of pStage III/IV because of the high sensitivity of FDG uptake in the primary tumor and the high specificity of FDG uptake in the lymph nodes.

[A Useful Case of Photodynamic Diagnosis of Inferior Vena Cava Invasion by Pancreatic Head Cancer Using 5-Aminolevulinic Acid(5-ALA)].

Curative resection is necessary to survival in pancreatic cancer, however after surgery, pathologic examination sometimes diagnoses the remains of cancer at the resected stump. Therefore, it is necessary to evaluate the stump by intraoperative rapid pathological examination. 5-aminolevulinic acid(5-ALA)is an endogenous natural amino acid and precursor of the heme pathway. 5-ALA is metabolized and accumulated as protoporphyrin IX(Pp IX)that is photosensitive substance. 5-ALA mediated photodynamic diagnosis(PDD)(ALA-PDD)has high diagnostic ability. Andwe previously reportedusefulness of ALA-PDD for lymph node metastasis and peritoneal dissemination in gastric cancer and colorectal cancer patients. A case was 73-year-oldman who hadpancreatic headcancer. Since pancreatic cancer invasion to the inferior vena cava(IVC)was suspected during the operation, fluorescence observation was undergone. Pp IX fluorescence signal observedin the tissue around IVC by fluorescence observation. And, the tissue diagnosed adenocarcinoma by pathological findings. Therefore, it was judged that curative resection was difficult and the operation was completed. In conclusion, it was suggested that ALAPDD may be one of the methods of intraoperatively diagnosing the residual lesion of pancreatic cancer.

[Inflammatory Pseudotumor in the Cecum-A Case Report and Review of Literature].

A 42-year-old woman with complaints of fever and abdominal pain, was diagnosed to have perforative appendicitis, for which emergency surgery was performed. Marked thickening and edema around the cecum, ileum, and the mesentery was observed. Ileocecal resection was performed, as malignant disease could not be excluded. Histopathological examination revealed abscess formation in the lining membrane of the intestine, inflammatory granulation and proliferation of the spindleshaped cells in the serosal membrane extensively, and an inflammatory pseudotumor(IPT)was diagnosed. It is generally difficult to clearly distinguish IPT from a malignant tumor before surgery. We thus report this case, along with a review of literature.

[Two Cases of Anal Canal Adenocarcinoma with Pagetoid Spread Treated with Laparoscopic Abdominoperineal Resection].

Anal canal adenocarcinoma with pagetoid spread has different a treatment strategy and prognosis from extramammary perianal Paget disease. We report two cases of anal canal adenocarcinoma with pagetoid spread along with a literature review. Case 1: A 69-year-old woman complained of perianal pain, redness, and erosion. Biopsy revealed adenocarcinoma with pagetoid spread. Laparoscopic abdominoperineal resection was performed, which resulted in 12 months' survival without postoperative recurrence. Case 2: A 62-year-old man complained of fecal occult blood and hemorrhoid. Under the diagnosis of anal canal cancer, transanal tumor resection was performed. Five years after surgery, he underwent endoscopic submucosal dissection for anal canal cancer. Ten years after surgery, he complained of anal tumor and perianal redness. Biopsy revealed adenocarcinoma with pagetoid spread. Laparoscopic abdominoperineal resection was performed, which resulted in 10 months' survival without postoperative recurrence.

[A Case of Advanced Gastric Cancer with Extensive Lymph Node Metastasis That Showed pCR to Preoperative Chemotherapy ContainingXP].

A 67-year-old man was admitted to our hospital because of a type 2 tumor on the posterior wall of the cardia, and a biopsy resulted in a diagnosis of moderately differentiated tubular adenocarcinoma. Abdominal CT revealed swelling of the No. 1, 3, 11p(bulky N), and No.16a2lat lymph nodes. He was diagnosed with gastric cancer, T4aN2M1(LYM), cStage ⅣB, and was administered chemotherapy. After 2 courses of chemotherapy containing capecitabine plus cisplatin(XP), both the primary tumor and lymph nodes markedly decreased in size; then, total gastrectomy with D2+No.16a2lat was performed. Pathological examinations showed no residual cancer cells both in the primary lesion and lymph nodes; thus, the treatment effect of chemotherapy was Grade 3. Some gastric cancer patients may undergo curative resection even with extensive lymph node metastases when effective chemotherapy has been administered. Further discussions are needed about optimal chemotherapeutic regimens and surgical procedures.

[A Case of cStage â ¢ Esophagogastric Junction Adenocarcinoma That Showed pCR to Preoperative Chemotherapy Containing SOX].

A 68-year-old man was diagnosed with esophagogastric junction adenocarcinoma, cT4a(SE)N3aM0, cStage Ⅲ. Because "bulky N" was present, he was administered 2 courses of preoperative chemotherapy containing S-1 plus oxaliplatin(SOX). Both the primary tumor and enlarged lymph nodes had greatly decreased in size following chemotherapy, and total gastrectomy and lower esophagectomy with D2 lymphadenectomy were then performed. Histopathological examinations showed no residual cancer cell both in the primary lesion and dissected lymph nodes; thus, the efficacy of the chemotherapy was Grade 3. Preoperative chemotherapy containing SOX could be one of the useful treatment options for gastric cancer patients with extensive lymph node metastases including "bulky N".

[Two Cases of Local Recurrence in the Descending Aorta after Radical Esophagectomy, Resected after Placement of a Thoracic Endovascular Stent].

Case 1 was that of a 65-year-old woman. Radical esophagectomy was performed after neoadjuvant chemotherapy(NAC) for lower thoracic esophageal cancer. Nineteen months after surgery, local recurrence was indicated on the dorsal side of the descending aorta. After chemoradiotherapy(CRT)and chemotherapy, residual cancer with aortic invasion was diagnosed. Case 2 was that of a 64-year-old man. Radical esophagectomy was performed after NAC for middle thoracic esophageal cancer. Five months after surgery, local recurrence was indicated between the descending aorta and left inferior pulmonary vein. After CRT and chemotherapy, residual cancer with invasion of the aorta and left lung was diagnosed. In both cases, we inserted an aortic stent and safely performed residual cancer resection including the aortic adventitia. In summary, aortic stent insertion enables safe resection of local recurrent tumors in the aorta after radical esophagectomy.

[Two-Stage Reconstruction Surgery with Free Jejunum Graft for Necrosis of the Gastric Tube Following Subtotal Esophagectomy-A Case Report].

The case is a 73-year-old man who underwent esophagectomy and retrosternal gastric conduit reconstruction for esophageal cancer. Reoperation was performed because the oral side of the gastric tube developed necrosis on the 31st postoperative day. The necrotic parts of the gastric tube were resected, and a cervical esophageal stoma was created. The remaining gastric tube was pulled up at the anterosternal subcutaneous location in preparation for the two-stage reconstructive operation. The reconstructive operation with a free jejunum graft through the anterosternal subcutaneous route was performed 35 days after the reoperation. Vascular anastomosis was performed with the right internal thoracic artery and vein by microsurgery. The postoperative course was satisfactory. Necrosis of the gastric tube is a rare and severe complication of esophagectomy. Reconstructive surgery for gastric tube necrosis is generally necessary but difficult to perform because of the severe surgical stress it confers on the patient. In this paper, we showed a new approach for two-stage reconstruction with a free jejunum graft through the anterosternal subcutaneous route. This operative procedure causes relatively less surgical stress than other procedures; hence, it is considered to be a beneficial reconstructive approach for patients with gastric tube necrosis.