Postoperative hemodynamic changes for predicting anastomotic leakage after esophagectomy in patients with esophageal cancer using the FloTrac system.

Background : Anastomotic leakage after esophagectomy is significantly associated with more severe complications, such as sepsis and mortality. Early prediction for anastomotic leakage is usually difficult and needs to be treated rapidly. In the current study, we investigated the correlation between hemodynamic and several complications after esophagectomy in patients with esophageal cancer, using the FloTrac system. Materials and Methods : Between April 2013 and December 2014, 39 patients with a mean age of 66.6 ±â€…8.9 years underwent postoperative supervision using the FloTrac sensor / Vigileo monitoring system after curative surgery for esophageal cancer. We retrospectively evaluated the association between the number of aberrant cardiac index (CI) along with stroke volume variability (SVV) values and clinicopathological parameters of postoperative complications in this report. Results : There were significant positive correlations between the number of aberrant values of CI along with SVV and depth of invasion during pathological stage. Concerning major postoperative complications, there was a significant positive correlation between the number of aberrant values of CI and anastomotic leakage. Discussion: The hemodynamic change by employing the FloTrac system could predicts the complication of anastomotic leakage after esophagectomy. Adequate management of hemodynamic stability by utilizing it will reduce the complications of anastomotic leakage. J. Med. Invest. 67 : 240-245, August, 2020.

Evaluation of Surgical Procedures that Affect the Hemodynamics Using the FloTrac System in Esophageal Cancer Patients.

BACKGROUND/AIM: Esophagectomy is more invasive compared to other gastrointestinal surgery types. Perioperative circulatory management is important to avoid postoperative heart complications. The FloTrac sensor along with the Vigileo monitor is a minimally invasive haemodynamic monitoring device. Here, we examined different surgical procedures affecting hemodynamics using the FloTrac system in esophageal cancer patients following esophagectomy. PATIENTS AND METHODS: Thirty-one patients undergoing postoperative monitoring with the FloTrac sensor/Vigileo monitor system following esophagectomy were included. Evaluation of cardiac index (CI) and stroke volume variation (SVV) measurements were performed by analyzing the number of aberrant values. We evaluated the correlation between the number of aberrant values of CI, SVV and surgical methods of esophagectomy and perioperative factors. RESULTS: There was no significant correlation between the number of aberrant values of CI, SVV and operative approach or fields of lymphadenectomy. Regarding the reconstruction route following esophagectomy, there was a significant correlation between the number of aberrant values of CI, SVV and retrosternal route compared with other routes. There was a significant correlation between the number of aberrant values of SVV and preoperative heart complication. CONCLUSION: Hemodynamic stability management using FloTrac/Vigileo system following esophagectomy is useful for safe performance of postoperative management of esophageal cancer patients.

Multidisciplinary Therapy for Locally Advanced Oesophageal Cancer With Special Reference to Surgical Conversion and Salvage.

BACKGROUND/AIM: Unresectable oesophageal cancer with surrounding invasion carries a particularly poor prognosis. The chemoradiotherapy treatment for locally-unresectable oesophageal cancer aims to initially control local invasion before proceeding to the next treatment, and is ideally used with curative intent. The aim of this study was to investigate patient treatment course and survival to determine the best treatment and evaluate surgical intervention for these advanced cancers. PATIENTS AND METHODS: A total of 147 patients who were diagnosed with clinical T4b oesophageal cancer were included in this study. RESULTS: Forty-three patients had undergone curative resection of the tumour and surrounding invasion at midterm evaluation, 104 patients continued with definitive chemoradiotherapy, and salvage surgery was performed in 21 patients. Multivariate analysis of disease-specific survival showed that response at the midterm evaluation and surgical intervention (conversion surgery + salvage surgery) were significant prognostic factors. CONCLUSION: Surgical intervention was an independent prognostic factor, and operation should be performed in eligible patients after considering the risks and proper timing.

Post-esophagectomy Adjuvant Chemotherapy Benefits Esophageal Cancer Patients.

BACKGROUND/AIM: Postoperative chemotherapy is an absolutely imperative treatment for advanced esophageal cancer patients, while preoperative chemotherapy is the standard therapy for clinical stage II/III esophageal squamous cell carcinoma (ESCC) in Japan. The aim of this study was to report the effect of postoperative chemotherapy on survival after esophagectomy due to thoracic esophageal squamous cell carcinoma. PATIENTS AND METHODS: One hundred thirteen consecutive patients with esophageal carcinoma who underwent esophagectomy were included. Several regiments were performed at various times. RESULTS: Adjuvant chemotherapy brought a significantly superior overall survival (p=0.002), although there was no significant difference in cancer-specific survival (p=0.054) for clinical stage II or stage III esophageal cancer patients. Depth of invasion (p=0.003), number of lymph node metastases (p=0.048), and venous invasion (p<0.001) were risk factors for recurrence in the adjuvant-chemotherapy group with positive lymph nodes. Additionally, a not well-differentiated type, lymphatic and venous invasions were risk factors for recurrence in the surgery-alone group without positive lymph nodes. CONCLUSION: Postoperative adjuvant chemotherapy contributes to the prognosis of clinical stage II or III esophageal cancer patients.

18F-FAMT PET Is Useful to Distinguish between Specific Uptake and Nonspecific Uptake Compared to 18F-Flourodeoxyglucose Position Emission Tomography in Esophageal Cancer Patients.

BACKGROUND: L-[3-18F]-α-methyltyrosine (18F-FAMT) solely accumulates in tumor cells via an amino acid transport system. This selective uptake pattern results in a very high tumor-to-background ratio, enabling clear delineation of the tumor. The purpose of the present study was to assess the significance of 18F-FAMT PET, which shows little nonspecific uptake compared to 18F-flourodeoxyglucose position emission tomography (FDG PET) in esophageal cancer patients. METHODOLOGY: PET-CT studies with 18F-FAMT and 18F-FDG were performed as part of pretreatment work-up in 82 patients with histologically confirmed esophageal cancer. We evaluated nonspecific uptakes of 18F-FDG and 18F-FAMT PET. RESULTS: The nonspecific uptake of 18F-FAMT PET was lower than that of 18F-FDG PET (p = 0.282). In the operation group, 26.1% demonstrated nonspecific uptake in 18F-FDG PET, whereas only 2.38% (1 case) demonstrated nonspecific uptake in 18F-FAMT PET (p = 0.433). In the inoperable group, 47.5% showed nonspecific uptake in 18F-FDG PET, whereas 5.0% showed nonspecific uptake in 18F-FAMT PET (p = 0.079). CONCLUSION: A crucial point for the diagnostic value of PET is distinguishing specific and nonspecific uptake. 18F-FAMT-PET is a very superior modality with regard to the lower rate of nonspecific uptake in esophageal cancer.

Postprandial cardiogenic syncope caused by gastric polyp-induced pyloric obstruction in an elderly woman with a giant hiatal hernia: a case report.

BACKGROUND: Hiatal hernias are common. In some reports, hiatal hernias have been implicated in causing dyspnea, syncope, and heart failure. CASE PRESENTATION: An 82-year-old woman with a hiatal hernia was admitted to our hospital because she had experienced postprandial syncope during the last few years. Esophagogastroduodenoscopy revealed a large hiatal hernia and a pedunculated polyp of the stomach antrum that fit into the pylorus. An upper gastrointestinal contrast study showed that the entire stomach had relocated to the thoracic cavity and that the body of the stomach was located above the fundus, resulting in a so-called upside-down stomach. Contrast-enhanced computed tomography revealed that a large portion of the stomach, transverse colon, and part of the pancreas were present in the mediastinum. We then performed transthoracic echocardiography followed by a water pouring test using a nasogastric tube. After instillation of 2000 ml of saline, the left atrium was markedly compressed and the area of the mitral annulus was reduced. We determined that stomach dilation by the hiatal hernia and gastric polyp had caused the syncope. The patient underwent laparoscopic hiatal hernia repair and endoscopic gastric polypectomy, and she experienced no syncopal episodes for 5 months postoperatively. CONCLUSIONS: Clinicians should recognize that a large hiatal hernia may be a risk factor for syncope.

Clinical Significance of Salvage Esophagectomy for Patients with Esophageal Cancer and Factors of Influencing Long-term Survival.

BACKGROUND/AIM: Definitive chemoradiotherapy (CRT) without planned surgery has been recently widely used as a therapeutic option for locally advanced esophageal cancer. Salvage esophagectomy can offer the chance of prolonged survival for patients who have locoregional failure after definitive CRT, but many clinicians oppose the use of surgery due to the associated excessive morbidity and mortality. The aim of this study was to identify patients who are good candidates for salvage surgery by investigating factors influencing long-term survival. PATIENTS AND METHODS: A total of 40 patients underwent concurrent CRT or RT followed by esophagectomy for residual tumor or locoregional recurrence of esophageal squamous cell carcinoma without distant organ metastasis at the Department of General Surgical Science, Gunma University, Gunma, Japan, and were included in this study. As short-term outcomes after salvage esophagectomy, pulmonary and cardiovascular complications, anastomotic leakage, and chylothorax, and the length of postoperative stay were evaluated. Survival rates were calculated using the Kaplan-Meier method, and the Cox proportional hazards model was used for univariate and multivariate analyses of disease-specific survival. RESULTS: Postoperative complications were noted in 20 patients (50%), and pulmonary complications were the most common (25%), followed by anastomotic leakage (20%). There was also one case of in-hospital death, caused by multiple organ failure due to chylothorax. Univariate analysis revealed that sex, clinical residual tumor, CRT response, pathological tumor depth, and pathological residual tumor were significant factors affecting disease-specific survival (p=0.034, p=0.009, p=0.014, p=0.020, and p=0.026, respectively). Moreover, multivariate analysis demonstrated that clinical residual tumor was the only independent factor influencing disease-specific survival (p=0.036). Thirteen patients (32.5%) died from other illnesses after salvage surgery, 53.8% patients from pneumonia. CONCLUSION: Based on long-term survival, recurrence rather than residual tumor after definitive CRT was a favorable indicator for salvage esophagectomy. Not only management of postoperative morbidity and curative operation but, also long-term rigorous outpatient management, including respiratory rehabilitation to reduce pneumonia, is necessary.

Significance and Function of MicroRNA-7 in Oesophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: We detected microRNA-7 (miR-7) as being specific for oesophageal squamous cell carcinoma (ESCC) by using database analysis. However, the significance of miR-7 in clinical ESCC remains unexplored. This study aimed to clarify the clinicopathological significance of miR-7 in ESCC, and investigate miR-7 function. MATERIALS AND METHODS: Quantitative TaqMan reverse transcription polymerase chain reaction was used to evaluate miR-7 expression in 85 ESCC samples to determine the clinicopathological significance of miR-7 expression. The regulation of proliferation by miR-7 was examined with miR-7 precursor-transfected cells. RESULTS: The expression of miR-7 in ESCC was higher than that in normal tissues. Low expression levels of miR-7 were associated with poor prognosis. Multivariate analysis indicated that low miR-7 expression was an independent prognostic factor for poor survival. In vitro assays showed miR-7 precursor treatment suppressed the proliferation of ESCC cells. CONCLUSION: miR-7 might be a promising prognostic marker and therapeutic target in ESCC.

Surgical management for achalasia after coronary artery bypass graft using the right gastroepiploic artery: a case report.

BACKGROUND: The right gastroepiploic artery is commonly used in coronary artery bypass grafting. Appropriate strategies are required when performing upper abdominal surgeries after the right gastroepiploic artery has been used in coronary artery bypass grafting because compressing or injuring the graft may cause myocardial ischemia and fatal arrhythmias. To our knowledge, this is the first reported case of surgery for achalasia performed after coronary artery bypass grafting using the right gastroepiploic artery. We have discussed the surgical procedure and particular intraoperative considerations. CASE PRESENTATION: A 62-year-old man who had undergone coronary artery bypass grafting using the right gastroepiploic artery presented with achalasia. Because medication and balloon dilation had been ineffective and he was having difficulty ingesting food, we performed a Heller-Dor procedure via laparotomy. The right gastroepiploic artery was not damaged during this surgery, and there were no perioperative cardiovascular complications. Adequate control of symptoms was achieved. CONCLUSIONS: When performing upper abdominal surgeries after coronary artery bypass grafting with the right gastroepiploic artery, it is necessary to investigate the patient carefully preoperatively and adapt the intraoperative procedure to minimize risk of injury to the graft and consequent cardiovascular complications.

Utility of double endoscopic intraluminal operation for esophageal cancer.

OBJECTIVES: Endoscopic submucosal dissection (ESD) is a more difficult technique for esophageal cancer than for gastric cancer because the working space for esophageal ESD is small. Further, the difficulty level gradually increases depending on the size of the carcinoma. To overcome these difficulties, double endoscopic intraluminal operation (DEILO), which enables the resection of mucosal lesions using two fine endoscopes and monopolar shears, was reported previously. Here, we report the utility of DEILO for esophageal cancer. METHODS: A total of 26 esophageal cancer patients (19 men and seven women) with 26 lesions treated using DEILO between 2011 and 2014 at Gunma University Hospital were included. We evaluated the utility and safety of DEILO for early esophageal cancer. RESULTS: For all patients (100%), the DEILO procedure was performed successfully, and en bloc resection was achieved. The median operation time, postoperative hospital stay, and the longitudinal dimension of resected specimens were 123 min (range 45-236 min), 5 days, and 32 mm, respectively. Perioperative perforation, pneumothorax, and mediastinal emphysema were not recognized. Only one patient was diagnosed with a postoperative hemorrhage, but the bleeding was successfully treated by bleeding vessel coagulation. CONCLUSION: DEILO has good utility as a technique of ESD for early esophageal cancers. Additional improvement and advancement of the procedure will increase the indication of DEILO.

Resection of an esophageal schwannoma with thoracoscopic surgery: a case report.

BACKGROUND: Esophageal schwannomas are rare primary submucosal esophageal tumors. We herein report a case of an esophageal schwannoma that was difficult to diagnose. CASE PRESENTATION: A 39-year-old woman presented with chief complaints of difficulty swallowing and epigastric pain. Enhanced computed tomography of her chest revealed a tumor mass at the upper thoracic esophagus with internal heterogeneity. 18-Fluorodeoxyglucose positron emission tomography/computed tomography showed a hypermetabolic appearance matching the tumor mass; the accumulation had a maximum standardized uptake value of 5.5. We performed endoscopic ultrasound-guided fine-needle aspiration biopsy under general anesthesia, but the small specimens obtained prevented a definitive diagnosis. Thoracoscopic esophagectomy was performed due to the large size of the tumor, suspicion of its malignant potential, and the patient's symptoms. Histopathological examination revealed spindle-shaped cells in a fasciculated and disarrayed architecture in the proper muscle layer. Immunohistochemical studies showed S100 protein positivity and the absence of CD34 and c-kit. We diagnosed the tumor as a benign schwannoma. CONCLUSIONS: We herein report a relatively rare case of schwannoma of the esophagus that was diagnosed with difficulty.

L-[3-¹8F]-α-methyltyrosine uptake by lymph node metastasis is a predictor of complete response to CRT in esophageal cancer.

BACKGROUND/AIM: The amino acid positron emission tomography (PET) tracer [(18)F]-3-fluoro-alpha-methyltyrosine ((18)F-FAMT) is known to be highly specific for malignancies. We evaluated the accumulation of (18)F-FDG or (18)F-FAMT in lymph nodes (LN) prior to definitive chemoradiotherapy (CRT) for esophageal cancer. PATIENTS AND METHODS: We retrospectively reviewed 30 patients with esophageal squamous cell carcinoma. All patients received definitive CRT. The relationship between the accumulation of (18)F-FDG PET or (18)F-FAMT PET in LNs prior to CRT and clinical outcomes was assessed. RESULTS: A correlation was observed between LNs in which most of (18)F-FAMT was accumulated and complete response (CR) rate, but was not for (18)F-FDG. Additionally, for (18)F-FAMT, the CR rate was significantly higher in the LN accumulated lesion ≤ 1 group than in the LN accumulated lesion >2 group. DISCUSSION: To predict the outcome of definitive CRT in patients with esophageal cancer, it is important to evaluate the LN status.

Use of pre-treatment 18F-FAMT PET to predict patient survival in squamous cell carcinoma of the esophagus treated by curative surgery.

BACKGROUND: [18F]-3-fluoro-alpha-methyl tyrosine (18F-FAMT) as an amino acid tracer in positron emission tomography (PET) has been widely investigated in several tumor types. Herein we investigated the clinical significance of 18F-FAMT PET uptake as a prognostic marker together in our updated data of patients with esophageal cancer. PATIENTS AND METHODS: We retrospectively assessed the treatment outcomes of 42 patients with histologically-confirmed esophageal cancer. The survival rate was analyzed using the median peak standardized uptake value (SUV) with 2.2 as the cut-off value. RESULTS: FAMT uptakes were significantly correlated with factors reflecting tumor progression. Moreover, a significant correlation was observed between FAMT uptake and disease-free survival (p=0.023). Moreover, on evaluation of individual lymph node groups, the specificity and positive predictive value were significantly higher for 18F-FAMT-PET than for 18F-FDG-PET and computed tomography (CT). CONCLUSION: 18F-FAMT is an important pre-treatment diagnostic modality and its accumulation is a good predictor of disease-free survival (DFS) in patients with operable esophageal cancer.

L-[3-18F]-α-methyltyrosine accumulation as a definitive chemoradiotherapy response predictor in patients with esophageal cancer.

AIMS: L-[3-(18)F]-α-Methyltyrosine ((18)F-FAMT) has high specificity for malignant tumors on positron emission tomography (PET), and its role and potential usefulness has been previously investigated in operable esophageal carcinoma. We aimed to assess the ability of (18)F-FAMT PET to predict the response of esophageal cancer to definitive chemoradiotherapy. PATIENTS AND METHODS: We retrospectively reviewed 40 patients with esophageal cancer imaged with (18)F-FAMT PET. The relationship between (18)F-FAMT PET uptake before chemoradiotherapy and clinical outcomes was assessed. RESULTS: The primary tumor was visualized in 95% patients. (18)F-FAMT uptake was significantly positively correlated with lymph node metastasis. The low-(18)F-FAMT accumulation group had significantly higher complete response (CR) rates than did the high-accumulation group. The addition of a lymph node metastasis category with low (18)F-FAMT uptake provides a more precise predictor of CR. CONCLUSION: (18)F-FAMT uptake prior to treatment is a good predictor of CR rate after CRT for esophageal cancer.