Safety and efficacy of double-tract reconstruction with remnant stomach conservation in esophagectomy for patients with a history of distal gastrectomy.

BACKGROUND: Total gastrectomy with jejunum or colon reconstruction after esophagectomy is commonly performed in patients with esophageal cancer who have a history of distal gastrectomy. In this study, we examined the safety and effectiveness of double-tract reconstruction (DTR) with preservation of the remnant stomach for said patient population. METHODS: Twenty-seven esophageal cancer patients with a history of distal gastrectomy who underwent transthoracic esophagectomy between 2010 and 2020 in our institution were retrospectively analyzed; 15 of these patients underwent DTR, whereas 12 underwent completion gastrectomy with jejunal Roux-en-Y reconstruction (RYR). Short-term outcomes, postoperative nutritional indexes, and ghrelin levels were evaluated. Moreover, abdominal lymph-node metastasis and recurrence, which were removed by total residual gastrectomy, were examined to determine the oncological validity of residual stomach preservation. RESULTS: There was no metastasis and recurrence in abdominal lymph nodes, such as #4sa or #11d, which were removed by total residual gastrectomy. Total operation time did not differ between the groups (P = 0.4247). The blood loss for the DTR group was 495 ± 446 mL, whereas that for the RYR group was 844 ± 575 mL (P = 0.0168). Clavien-Dindo grade III or higher complications were not significantly different between the groups (P = 0.7063). The rates of serum total protein values at 6 months in the DTR and RYR groups were 112% ± 12.2% and 102.6% ± 10.7% (P = 0.0403), respectively. The prognostic nutritional indexes at 6 months in the DTR and RYR groups were 108.6% ± 14.5% and 83.2% ± 42.6% (P = 0.0376), respectively. CONCLUSIONS: DTR in esophagectomy is safe and effective for patients with a history of distal gastrectomy.

Postoperative pneumonia in the acute phase is an important prognostic factor in patients with esophageal cancer.

BACKGROUND: The impact of pneumonia on prognosis is controversial, and no report has focused on its onset. This study aimed to examine the impact of pneumonia according to its onset on prognosis and its associated risk factors after esophagectomy. METHODS: In total, 484 patients who underwent curative resection for esophageal squamous cell carcinoma were retrospectively reviewed. Patients with pneumonia were divided into two groups by the date of onset: pneumonia in the acute phase within 7 days after surgery (n = 59) and pneumonia in the subacute phase 8 days after surgery (n = 49). RESULTS: The disease-free survival of patients with acute pneumonia was significantly lower than that of those without pneumonia (P = .0002), whereas the disease-free survival of patients with subacute pneumonia was similar to that of patients without pneumonia (P = .5363). In multivariate analysis for disease-free survival, P-stage III to IV (hazard ratio [HR], 3.344; P < .0001), transfusion (HR, 1.4078; P = .0291), and acute pneumonia (HR, 1.8463; P = .0009) were independent prognostic factors. Multivariate analysis revealed that age >75 years (odds ratio [OR], 2.1746; P = .0232), respiratory disease comorbidity (OR, 4.3869; P = .0002), cT3-4 (OR, 2.0143; P = .0477), extended surgery duration (OR, 2.3406; P = .0152), and posterior mediastinal reconstruction (OR, 0.1432; P = .0439) were independent risk factors for acute pneumonia. CONCLUSION: Post-esophagectomy pneumonia in the acute phase was an independent prognostic factor, whereas advanced age, respiratory disease comorbidity, and extended surgery duration were risk factors for acute pneumonia.

Analysis of prognostic factors in patients with lymph node recurrence after radical esophagectomy: importance of locoregional therapy.

PURPOSE: Lymph node (LN) recurrence is frequently encountered in esophageal cancer. The aim of this study was to determine the effects of various factors, including loco-regional treatment of LN-only recurrence, on the survival rate. METHODS: Among 941 patients who underwent curative resection for esophageal squamous cell carcinoma in 2003-2016, we retrospectively reviewed 117 patients (12.4%) who developed LN-only recurrence. RESULTS: One, 2, 3, and 4 or more metastatic LNs were found in 72, 22, 6, and 17 patients, respectively, after a median disease-free interval of 8.4 months (range 1.1-62.0). Among all cases, recurrence was out of the surgical field in 53 cases (45.3%). Recurrent LNs were controlled by loco-regional treatment in 29 (43.9%) and by chemotherapy alone in 3 patients (7.0%). The 3-year survival rates of patients who did and did not achieve local control were 53.2% and 5.2%, respectively. Univariate analysis showed significant relationships between post-recurrence survival rate and pStage I-II at initial surgery, no history of radiotherapy, recurrence in ≤ 2 LN, and loco-regional treatment of LN recurrence. Multivariate analysis identified recurrence in ≤ 2 LN (HR 0.3169, 95% CI 0.1023-0.5314, p = 0.0038) and loco-regional treatment (HR 0.1973, 95% CI 0.0075-0.3871, p = 0.0416) as the only two significant and independent prognostic factors of survival. CONCLUSIONS: Recurrence limited to ≤ 2 LN and loco-regional treatment (chemoradiotheapy or surgery) for LN recurrence were associated with favorable survival of patients with history of radical esophagectomy followed by LN recurrence. Our results emphasize the importance of local control of LN recurrence regardless of location.

Choreo-ballistic movement after thalamotomy in a patient with Lewy body dementia.

Thalamotomy is an established treatment for medically refractory tremor. Major complications of thalamotomy include cognitive disturbance, paralysis, dysphagia, sensory loss, and speech disturbance. Hemiballism is a rare complication after thalamotomy. We herein present a 74-year-old female patient who developed choreo-ballistic movement after thalamotomy. She was diagnosed with Lewy body dementia at the age of 70 years and exhibited worsening bilateral hand tremor. Her tremor was severe and pharmacoresistant. Left thalamotomy was planned with the trajectory passing through the ventralis intermedius (VIM) nucleus to the posterior subthalamic area (PSA). The right VIM nucleus and PSA were both coagulated with one trajectory, resulting in the immediate amelioration of right hand tremor. However, four days after surgery, choreo-ballistic movement appeared in the right leg and persisted for six months. Furthermore, tremor recurred after one month. Postoperative MRI showed a small coagulated lesion in the subthalamic nucleus. Although choreo-ballistic movement is a rare complication, it needs to be considered, particularly in patients in which the inferior border of the VIM nucleus is targeted.

Peri-electrode edema after deep brain stimulation.

Peri-electrode edema can occur after deep brain stimulation (DBS). The diagnosis and management of peri-electrode edema may be challenging. We herein report non-infectious peri-electrode edema after the placement of DBS electrodes in patients with Parkinson's disease (PD). Fifteen patients who underwent DBS surgery between 2010 and 2018 at Sapporo Medical University were included to identify post-operative peri-electrode edema. Pre- and post-operative CT and MRI were retrospectively analyzed. Six patients showed hyperintensity around the electrodes on FLAIR/T2 MRI without neurological deficits. Two patients showed limited FLAIR and DWI hyperintensities in deep white matter, and microvessels may have been occluded in these patients. In five patients, MRI revealed extensive FLAIR or T2 hyperintensity in surface white matter around the electrodes without vessel injury, whereas DWI showed no abnormal signals. The eosinophil count was increased in one of these five patients. Peri-electrode edema after DBS surgery is not an uncommon phenomenon, and includes two types: (1) limited edema in deep white matter and (2) extensive edema in surface white matter. Different mechanisms may be associated with these types of edemas.

Prophylactic hepatic arterial infusion chemotherapy for the prevention of liver metastasis in patients with colon carcinoma: a randomized control trial.

BACKGROUND: The liver is the most frequent site of recurrence after curative resection in patients with colon carcinoma. For liver metastasis, a high response rate can be achieved with hepatic arterial infusion (HAI) chemotherapy. In the current study, the authors administered 5-fluorouracil (5-FU) as adjuvant chemotherapy by HAI to patients with colon carcinoma without liver metastases and studied its effects on recurrence in the liver and survival. METHODS: A total of 316 patients with preoperative Stage II or Stage III colon carcinoma (according to the 1997 revision of the International Union Against Cancer TNM staging system) were randomly assigned to receive surgery plus 3-week continuous HAI of 5-FU or surgery alone. There were 305 eligible patients, of whom the 119 patients assigned to the HAI arm actually received 5-FU. The primary endpoint was disease-free survival, whereas the secondary endpoints were overall survival and liver metastasis-free survival. Analysis was by intent to treat. RESULTS: There were no significant differences noted in morbidity between the two treatment arms. During the follow-up period (median, 59.0 months), the incidence of liver metastasis was significantly decreased in the HAI arm whereas there were no significant differences reported between the 2 arms with regard to the frequency of metastasis at other sites. In the HAI arm, the risk ratio for recurrence was 0.40 (95% confidence interval [95% CI], 0.24-0.64; P=0.0002), the risk ratio for death was 0.37 (95% CI, 0.21-0.67; P=0.0009), and the risk ratio for liver metastasis was 0.38 (95% CI, 0.22-0.66; P=0.0005). These differences were found to be significant only for patients with Stage III disease. Toxicities were mild. CONCLUSIONS: A schedule of 3-week HAI of 5-FU given as adjuvant chemotherapy to patients with Stage III colon carcinoma appeared to contribute to a significant decrease in the frequency of liver metastases and was associated with an improved survival rate.