The evaluation of the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy.

OBJECTIVE: We herein evaluated the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy. METHODS: Thirty-two cases of subtotal esophagectomy and gastric tube reconstruction for esophageal cancer were studied. The new device measures the regional tissue saturation of oxygen (rSO2: 0-99%) and total hemoglobin index (T-HbI: 0-1.0) with a small sensor. We measured these values at the antrum (point A), final branch of the right gastroepiploic artery (point B) and planned anastomotic point (point C) before and after gastric tube formation. The values at the three points were compared, and the gradients at the three points from before to after gastric tube formation were compared. RESULTS: The mean values of rSO2 at point A, B, and C before gastric tube formation were 57.2%, 57.8% and 56.0%, and those after formation were 54.6%, 58.0% and 55.8%, respectively. There was no significant difference in the comparison of the rSO2 gradient before and after formation (p = 0.167). The mean values of T-HbI at point A, B, and C before formation were 0.126, 0.178 and 0.211, and those after formation were 0.167, 0.247 and 0.292, respectively. There was no significant difference in the gradient of the increase before and after formation (p = 0.461). CONCLUSION: A new device has shown that the gastric tube used in our facility is one that maintains tissue saturation of oxygen and does not cause excessive congestion at anastomosis.

A feasibility study of mediastinoscopic radical esophagectomy for thoracic esophageal cancer from the viewpoint of the dissected mediastinal lymph nodes validated with thoracoscopic procedure: a prospective clinical trial.

PURPOSE: A prospective trial evaluated the feasibility and safety of "mediastinoscopic esophagectomy with lymph node dissection" (MELD). METHODS: Eligible patients had thoracic esophageal squamous cell carcinoma, excluding T4, a bulky primary lesion or distant metastasis. Ten patients were enrolled and treated between September 2015 and March 2018. Additionally, to verify the integrity of the mediastinal lymph node dissection, thoracoscopic observation and lymph node dissection were followed. The primary end point was the integrity of mediastinal lymph node dissection. The secondary end points were the short-term outcomes, including mortality and morbidity. RESULTS: The median number of dissected lymph nodes in the upper mediastinal to cervical region and middle to lower mediastinal region by mediastinoscopy/thoracoscopy was 27/0.5 and 11.5/0, respectively. The median total operation time was 615 min, the median bleeding amount was 476 ml, and the median postoperative hospital stay was 15.5 days. Regarding complications of more than grade III according to the Clavien-Dindo classification, four had sputum excretion difficulty, one had pneumothorax and one had bilateral recurrent nerve palsy, but none required conversion to thoracotomy, and no operative deaths occurred. CONCLUSION: Although the rate of recurrent nerve palsy still should be reduced, our mediastinoscopic lymphadenectomy technique is closely similar to radical esophagectomy.

Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum.

BACKGROUND: The structure of the fascia in upper mediastinum has already been reported from gross anatomical viewpoints by Sarrazin. But it is necessary to understand meticulous anatomy for thoracoscopic or mediastinoscopic surgery. So herein, we investigate histologically the thin membranous structure made of dense connective tissues. METHODS: Semi-sequential transverse sections of the mediastinum were obtained from three cadavers. Hematoxylin and eosin staining, Elastica van Gieson staining, and Masson trichrome staining were performed to identify the presence and location of the thin membranous structure made of dense connective tissues. RESULTS: The "visceral sheath" and "vascular sheath," as previously described by Sarrazin, were observed histologically. These two thin membranous structures do not surround the esophagus and trachea cylindrically. In addition, the "visceral sheath" on the right side of the upper mediastinum was unclear in comparison to the left side. The "visceral sheath" (on the left side) gradually became unclear, and seemed to almost disappear; the esophagus was found to be very close to the thoracic duct on the caudal side of the bifurcation of the trachea. Although the left recurrent nerve was located inside the "visceral sheath" in all cadavers, the left recurrent nerve lymph nodes were located inside the "visceral sheath" in cadaver 1 and between the "visceral sheath" and "vascular sheath" in cadaver 3. CONCLUSION: The "visceral sheath" around the esophagus in the upper mediastinum was histologically demonstrated; however, the findings were not constant.

Subcloning and characterization of highly metastatic cells derived from human esophageal squamous cell carcinoma KYSE150 cells by in vivo selection.

Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer-related deaths worldwide. Despite the research progress in understanding the disease, the mechanism underlying the metastasis is still unclear. Here, we successfully generated a highly metastatic cell subline, designated as KYSE150-LuM, derived from an esophageal squamous cell carcinoma cell line (KYSE150) by in vivo selection. To elucidate the mechanisms driving metastasis, we characterized the gene expression differences between LuM cells and parent KYSE150 cells. IL-6, IL-1ß, and LCN2, previously associated with tumor growth and metastasis, were up-regulated in LuM cells. Recent studies on cancer have increasingly focused on the tumor microenvironment, from which these cytokines are released. The fact that these three cytokines (IL-6, IL-1ß, LCN2) were up-regulated in LuM cells indicates that these highly metastatic cells obtained through in vivo selection will be a useful resource for further studies on elucidating the mechanisms underlying the tumor microenvironment which is associated with cytokine-related tumor growth and metastasis. Moreover, LuM cells could disseminate to the lung in shorter period of time in vivo, indicating their utility for in vivo experiments of metastasis and new therapeutic targets in a shorter period of time than currently possible.

Case of Superficial Cancer Located at the Pharyngoesophageal Junction Which Was Dissected by Endoscopic Laryngopharyngeal Surgery Combined with Endoscopic Submucosal Dissection.

Aims. In order to determine the indications of transoral surgery for a tumor located at the pharyngoesophageal junction, the trumpet maneuver with transnasal endoscopy was used. Its efficacy is reported here. Material and Methods. An 88-year-old woman complaining of dysphagia, diagnosed with cervical esophageal cancer, and hoping to preserve her voice and swallowing function was admitted to our hospital. Conventional endoscopy showed that the tumor had invaded the hypopharynx. When inspecting the hypopharynx and the orifice of the esophagus, we asked the patient to blow hard and puff her cheeks with her mouth closed (trumpet maneuver). After the trumpet maneuver, the pharyngeal mucosa was stretched out. The pedicle of the tumor arose from the left-anterior wall of the pharyngoesophageal junction, so we decided to perform endoscopic resection. Result. Under general anesthesia, the curved laryngoscope made it possible to view the whole hypopharynx, including the apex of the piriform sinus and the orifice of the esophagus. The cervical esophageal cancer was pulled up to the hypopharynx. Under collaboration between a head and neck surgeon and an endoscopist, the tumor was resected en bloc by endoscopic laryngopharyngeal surgery combined with endoscopic submucosal dissection. Conclusion. Transnasal endoscopy using the trumpet maneuver is useful for a precise diagnosis of the pharyngoesophageal junction. Close collaboration between head and neck surgeons and endoscopists can provide good results in treating tumors of the pharyngoesophageal junction.

Mediastinoscopic subaortic and tracheobronchial lymph node dissection with a new cervico-hiatal crossover approach in thiel-embalmed cadavers.

The use of mediastinal surgery for minimally invasive esophagectomy (MIE) has been proposed; however, this method is not performed as radical surgery because it has been thought to be impossible to perform complete upper mediastinal dissection, including the left tracheobronchial lymph nodes (106tbL). We herein describe a new method for performing complete dissection of the upper mediastinum. We developed a method for performing complete mediastinoscopic esophagectomy as radical surgery via the bilateral transcervical and transhiatal approach in 6 Thiel-embalmed human cadavers. The lower and middle mediastinal lymph nodes are dissected via the transhiatal approach. The dorsal side of the left recurrent nerve is dissected up to the aortic arch and left recurrent nerve lymph nodes (106recL) are dissected under pneumomediastinum. Next, the right recurrent nerve lymph nodes (106recR) are dissected. The cartilage of the left main bronchus is dissected and pushed downward, thereby obtaining a good view between the aortic arch and left main bronchus via the transhiatal approach. The 106tbL lymph nodes are dissected until the aortic arch is reached. Simultaneously, the lymph nodes are dissected via a right cervical incision. This method is termed the "cross-over technique." We herein demonstrated that the upper mediastinal lymph nodes, including the 106tbL nodes, can be dissected using the bilateral transcervical and transhiatal approach under pneumomediastinum and named this method "mediastinoscopic esophagectomy with lymph node dissection" (MELD). MELD is therefore considered to be a useful modality based on our experience with Thiel-embalmed human cadavers.