Percent vital capacity predicts postoperative sarcopenia after esophagectomy in initially nonsarcopenic esophageal cancer patients: a retrospective cohort study.

PURPOSE: The development of sarcopenia after esophagectomy is reported to affect the outcomes of patients with esophageal cancer (EC); however, the characteristics of patients likely to be predisposed to postoperative sarcopenia have not been defined. This study explores the associations between preoperative respiratory function and surgery-induced sarcopenia in EC patients confirmed as nonsarcopenic preoperatively. METHODS: The subjects of this retrospective review were 128 nonsarcopenic patients who underwent esophagectomy for EC. We took body composition measurements and performed physical function tests 3 and 6 months postoperatively, to establish whether sarcopenia was present, according to the 2019 Asian Working Group for Sarcopenia guideline. We defined patients with surgery-induced sarcopenia as those with evidence of the development of sarcopenia within 6 months postoperatively or those with documented sarcopenia at 3 months but who could not be evaluated at 6 months. RESULTS: Surgery-induced sarcopenia developed in 19 of the 128 patients (14.8%), which correlated significantly with the preoperative %VC value (p < 0.01), but not with the preoperative FEV1.0% value. We set the lower quartile %VC value (91%) as the cut-off for predicting surgery-induced sarcopenia. A low %VC was independently associated with surgery-induced sarcopenia (odds ratio: 5.74; 95% confidence interval: 1.99-16.57; p < 0.01). CONCLUSIONS: Based on the findings of this study, %VC was a simple but valuable factor for predicting sarcopenia induced by esophagectomy.

Association between the antiadhesion membrane and small bowel obstruction after open gastrectomy: A supplemental analysis of the randomized controlled JCOG1001 trial.

Aim: Postoperative small bowel obstruction (SBO) is one of the major complications that is mainly caused by postoperative adhesion. Recently, the antiadhesion membrane has become popular for postoperative SBO prevention. However, its efficacy is yet to be confirmed in the gastric cancer surgery field. Here, we conducted the supplemental analysis of the randomized controlled trial JCOG1001 to investigate the efficacy of the antiadhesion membrane on SBO prevention in patients with open gastrectomy for gastric cancer. Methods: Of the 1204 patients enrolled in JCOG1001, 1200 patients were included. The development of SBO of Grade ≥ IIIa according to the Clavien-Dindo classification was recorded. Univariable and multivariable analyses were performed using the Fine and Gray model to determine the risk factors for SBO. Results: Fifty-one patients developed SBO (median follow-up duration: 5.6 years). Total gastrectomy, combined resection, and blood loss significantly increased the risk for SBO development in the univariable analysis. Large amount of blood loss was independently associated with SBO development in the multivariable analysis (hazard ratio [HR], 3.089; 95% confidence interval [CI], 1.562-6.109, p = 0.0012). Antiadhesion membrane did not reduce the risk for SBO (HR, 1.299; 95% CI 0.683-2.470; p = 0.4246). In the patients belonging to subgroup analyses who received distal and total gastrectomy, the antiadhesion membrane was not associated with the incidence of SBO. Conclusions: Antiadhesion membrane did not decrease SBO occurrence rate after open gastrectomy. Therefore, the use of antiadhesion membrane would not be effective for preventing SBO in gastric cancer surgery.

Low pretherapy skeletal muscle mass index is associated with an increased risk of febrile neutropenia in patients with esophageal cancer receiving docetaxel + cisplatin + 5-fluorouracil (DCF) therapy.

PURPOSE: Docetaxel + cisplatin + 5-fluorouracil (DCF) therapy, a frequently prescribed regimen for esophageal cancer, is associated with a high risk of febrile neutropenia (FN). This study investigated whether a low skeletal muscle mass index (SMI) is an independent risk factor for FN. METHODS: This retrospective, observational study investigated the SMI of patients with esophageal cancer who received DCF therapy between March 2018 and July 2020. Based on the Asian sarcopenia criteria, patients were divided into two groups: high and low SMI (SMI of < 7.0 and 5.7 kg/m2 for males and females, respectively). The incidence of FN was then compared between the two groups. RESULTS: Thirty-nine patients (20 and 19 in the high- and low-SMI groups, respectively) were included in this study. The incidence of FN was significantly higher in the low-SMI group (63.2% vs. 20.0%, P = 0.006). Univariable and multivariable logistic regression analyses revealed that a low SMI was an independent risk factor for FN (odds ratio, 7.178; 95% confidence interval, 1.272-40.507; P = 0.026). In addition, the frequency of dose reduction in DCF therapy was significantly higher in the low-SMI group (68.4% vs. 35.0%, P = 0.037). CONCLUSION: Low SMI is an independent risk factor for FN in patients with esophageal cancer receiving DCF therapy.

Recurrence patterns after curative gastrectomy for pStage II/III gastric cancer: Exploratory analysis of the randomized controlled JCOG1001 trial.

BACKGROUND: Peritoneal, lymph node, and hematogenous recurrence patterns are common after potentially curative surgery for gastric cancer. However, clinicopathological characteristics associated with each recurrence type have rarely been comprehensively reported among patients who received a unified treatment strategy and follow-up protocol. Understanding these recurrence patterns would help with early detection of recurrence and a personalized follow-up plan. We investigated the initial recurrence patterns after curative gastrectomy using data from the randomized clinical JCOG1001 trial. METHODS: Of 1204 patients enrolled in JCOG1001, 932 pStage II/III patients were included. Initial recurrence dates and patterns were recorded by attending physicians according to the protocol. Risk factors for hematogenous, lymph node, and peritoneal recurrence were determined by univariable and multivariable analyses using the Fine-Gray model. RESULTS: Overall, 253 patients developed recurrence. Hematogenous recurrence was the most frequent pattern (n = 115), followed by peritoneal (n = 104) and lymph node recurrence (n = 70). Differentiated type (p = 0.0028), pT4 (p = 0.0466), and pN3 (p < 0.0001) were associated with hematogenous recurrence; however, D2+ lymphadenectomy reduced it (p = 0.0161). Patients with large (≥5 cm) tumors (p = 0.0312), pT4 (p < 0.0001), pN3 (p = 0.0013), and undifferentiated histologic type (p = 0.0001) had significantly higher rates of peritoneal recurrence. Extended lymph node metastasis (pN3) was the only risk factor (p < 0.0001) for lymph node recurrence. CONCLUSIONS: Clinicopathological features differed according to the recurrence patterns. Vigilant follow-up with an understanding of recurrence patterns might be beneficial for some high-risk patients.

Implications of Liver-Directed Therapy for Postoperative Hepatic Metastasis from Esophageal Cancer.

Background: Distant recurrence of esophageal cancer (EC), even after radical resection, is common, and the most frequent site of EC metastasis is the liver. However, a multidisciplinary treatment strategy for postoperative liver metastasis (LM) from EC has yet to be established; in particular, the role of liver-directed therapy (LDT) remains uncertain. We investigated the clinicopathological features and outcomes of patients undergoing post-esophagectomy LM with versus without LDT to explore its therapeutic implications. Methods: Among 624 consecutive patients undergoing R0/R1 esophagectomy for EC, 30 were identified in whom LM had developed as the initial recurrence. Their characteristics were retrospectively reviewed. Results: Six of the 30 subjects underwent LDT for metachronous LM. Five of those 6 also received systemic chemotherapy. A comparison between the 6 LDT and 24 non-LDT cases revealed no significant differences in major clinicopathological and operative factors, except for concurrent metastasis to extrahepatic organs (1/6 vs. 15/24, p=0.044). Twenty-nine of the 30 patients died during the study period, whereas 1 who had received multimodal treatment with LDT remained alive more than 200 months after multiple LM had been detected. Kaplan-Meier analysis for survival after LM demonstrated significantly prolonged survival in LDT cases compared to non-LDT cases treated with systemic chemotherapy alone (p=0.014). Even when the analysis was limited to patients without extrahepatic metastasis, this significant prognostic advantage of LDT was maintained (p=0.047). Conclusion: Multimodal treatment combined with LDT might be beneficial for patients with metachronous LM from EC and should therefore be considered a potential treatment option.

Lymphatic invasion is a prognostic factor of pathological N0 esophageal squamous cell carcinoma.

Adjuvant treatment after upfront esophagectomy for esophageal squamous cell carcinoma (ESCC) is indicated only for patients with lymph node metastasis in Japan. However, the recurrence rate after curative resection is high even for node-negative patients; thus, understanding the prognostic factors for patients with node-negative ESCC, which still remains unidentified, is important. Here, we aimed to reveal the prognostic factors for the long-term outcomes of patients with node-negative ESCC. Moreover, we compared the long-term outcomes among high-risk node-negative and node-positive patients. This single-institution retrospective study included 103 patients with pT1b-3N0 ESCC who underwent upfront surgery to identify the population at a high risk of recurrence. To compare overall survival (OS) and recurrence-free survival (RFS) between high-risk node-negative and node-positive patients, 51 node-positive ESCC patients with pStage IIIA or less who had undergone upfront surgery were also included. Univariable and multivariable analyses were performed using the Cox proportional hazard regression model. OS and RFS were compared using the log-rank test. Only lymphatic invasion (Ly+) was associated with worse 3-year OS (hazard ratio, 8.63; 95% confidence interval, 2.09-35.69; P = 0.0029) and RFS (hazard ratio, 4.87; 95% confidence interval, 1.69-14.02; P = 0.0034). The node-negative and Ly+ patients showed significantly worse OS (P = 0.0242) and RFS (P = 0.0114) than the node-positive patients who underwent chemotherapy. Ly+ is the only independent prognostic factor in patients with node-negative ESCC. Patients with node-negative and Ly+ ESCC may benefit from adjuvant treatment.

Salvage treatment after definitive chemoradiotherapy for esophageal squamous cell carcinoma.

Definitive chemoradiotherapy (dCRT) for the esophageal squamous cell carcinoma (ESCC) is performed for patients with cT4 disease without distant metastasis and also for those with cStage I-III who are unable to tolerate or who refuse surgery. The rates of clinical complete response (cCR) after dCRT differ depending on the cStage, and patients who once achieved cCR frequently experience tumor recurrence. For those with residual tumor or with recurrence, salvage treatment is performed to achieve a cure. Several procedures have been reported as salvage treatments. Salvage esophagectomy is associated with high rates of morbidity and mortality, but can offer long-term survival. With R0 resection, with cCR to dCRT, pulmonary complications appear to be important prognostic factors affecting overall survival (OS). Lymphadenectomy is performed for the patients with lymph node metastasis without recurrence of primary lesions or distant metastasis, but the contribution to long-term OS is unclear. Metastasectomy is performed when distant metastasis is limited to the lung and there are few lesions, possibly contributing to long-term OS. Endoscopic resection and photodynamic therapy are indicated for cT1a and cT1-2 residual or recurrent tumors, respectively, and can yield favorable outcomes. Re-CRT and re-radiotherapy are performed for the patients with contraindications for surgery, but neither appears to contribute to long-term OS despite high incidences of esophageal fistula and perforation.

Trunk fat volume can be a predictor of postoperative complications after gastrectomy: a retrospective cohort study.

BACKGROUND: Obesity can affect postoperative outcomes of gastrectomy. Visceral fat area is superior to body mass index in predicting postoperative complications. However, visceral fat area measurement is time-consuming and is not optimum for clinical use. Meanwhile, trunk fat volume (TFV) can be easily measured via bioelectrical impedance analysis. Hence, the current study aimed to determine the ability of TFV to predict the occurrence of complications after gastrectomy. METHODS: We retrospectively reviewed patients who underwent curative gastrectomy for gastric cancer between November 2016 and November 2019. The trunk fat volume-to-the ideal amount (%TFV) ratio was obtained using InBody 770 before surgery. The patients were classified into the obese and nonobese groups according to %TFV (TFV-H group, ≥ 150%; TFV-L group, < 150%) and body mass index (BMI-H group, ≥ 25 kg/m2; BMI-L group, < 25 kg/m2). We compared the short-term postoperative outcomes (e.g., operative time, blood loss volume, number of resected lymph nodes, and duration of hospital stay) between the obese and nonobese patients. Risk factors for complications were assessed using logistic regression analysis. RESULTS: In total, 232 patients were included in this study. The TFV-H and BMI-H groups had a significantly longer operative time than the TFV-L (p = 0.022) and BMI-L groups (p = 0.006). Moreover, the TFV-H group had a significantly higher complication rate (p = 0.004) and a lower number of resected lymph nodes (p < 0.001) than the TFV-L group. In the univariate analysis, %TFV ≥ 150, total or proximal gastrectomy, and open gastrectomy were found to be potentially associated with higher complication rates (p < 0.1 for all). Moreover, the multivariate analysis revealed that %TFV ≥ 150 (OR: 2.73; 95% CI: 1.37-5.46; p = 0.005) and total or proximal gastrectomy (OR: 3.57; 95% CI: 1.79-7.12; p < 0.001) were independently correlated with postoperative morbidity. CONCLUSIONS: %TFV independently affected postoperative complications. Hence, it may be a useful parameter for the evaluation of obesity and a predictor of complications after gastrectomy.

Disadvantages of Complete No. 10 Lymph Node Dissection in Gastric Cancer and the Possibility of Spleen-Preserving Dissection: Review.

Splenic hilar lymph node dissection has been the standard treatment for advanced proximal gastric cancer. Splenectomy is typically performed as part of this procedure. However, splenectomy has some disadvantages, such as increased risk of postoperative complications, especially pancreatic fistula. Moreover, patients who underwent splenectomy are vulnerable to potentially fatal infection caused by encapsulated bacteria. Furthermore, several studies have shown an association of splenectomy with cancer development and increased risk of thromboembolic events. Therefore, splenectomy should be avoided if it does not confer a distinct oncological advantage. Most studies that compared patients who underwent splenectomy and those who did not failed to demonstrate the efficacy of splenectomy. Based on the results of a randomized controlled trial conducted in Japan, prophylactic dissection with splenectomy is no longer recommended in patients with gastric cancer with no invasion of the greater curvature. However, patients with greater curvature invasion or those with remnant gastric cancer still need to undergo splenectomy to facilitate splenic hilar node dissection. Spleen-preserving splenic hilar node dissection is a new procedure that may help delink splenic hilar node dissection and splenectomy. In this review, we examine the evidence pertaining to the efficacy and disadvantages of splenectomy. We discuss the possibility of spleen-preserving surgery for prophylactic splenic hilar node dissection to overcome the disadvantages of splenectomy.

Preoperative Exercise Habits are Associated with Post-gastrectomy Complications.

BACKGROUND: Sarcopenia is reportedly associated with postoperative complications of gastrectomy, which would presumably be affected by exercise habits aimed at maintaining muscle quantity and quality. However, the potential benefits of exercise habits have yet to be clarified. METHODS: We included 178 patients undergoing gastrectomy in this study. Postoperative complications above grade 2 according to the Clavien-Dindo classification were regarded as clinically significant. Patients were classified according to exercise quantity employing the International Physical Activity Questionnaire Short Form and relationships between exercise habits and complications were investigated. RESULTS: On univariate analysis, low exercise habits (p = 0.008) and total gastrectomy (p = 0.004) were significantly associated with morbidity after gastrectomy. Although severe comorbidity (p = 0.095) and combined resection (p = 0.064) tended to be associated with complications, multivariate analysis demonstrated only low levels of exercise (Odds ratio = 2.42, p = 0.014) and total gastrectomy (Odds ratio = 3.67, p = 0.028) to be independently associated with postoperative complications. Anastomotic leakage (p = 0.028) and systemic complications (p = 0.006), especially pneumonia, were significantly more frequent in the low exercise group. CONCLUSIONS: Preoperative exercise habits independently affected short-term postoperative outcomes. Our results raise the possibility that exercise intervention would reduce the morbidity experienced by gastrectomy patients.

Obesity is a risk factor for internal hernia after laparoscopic or robot-assisted gastrectomy with mesenteric defect closure for gastric cancer.

BACKGROUND: Internal hernia (IH) is a life-threatening complication after gastrectomy. The increase in the frequency of minimally invasive surgery is considered to be related to the increase in the frequency of IH, and mesenteric defect closure has been recommended to reduce this complication. However, IH can occur even when mesenteric defects are closed, so the risk of IH in the patients with mesenteric closure remains uncertain. We attempted to clarify the risk factors for IH in these patients. METHODS: From 2013 to 2017, we retrospectively reviewed 310 patients with gastric cancer who underwent laparoscopic or robot-assisted gastrectomy with Roux-en-Y (RY) or double-tract (DT) reconstruction with mesenteric defect closure. Univariate and multivariate analyses were performed to identify the risk factors. RESULTS: The incidence of IH was 1.3% (n = 4). A preoperative body mass index (BMI) ≥ 25 kg/m2 (p = 0.044), postoperative chemotherapy (p = 0.034), and body weight loss rate at 6 months ≥ 15% (p = 0.045) were risk factors for IH on a univariate analysis. A multivariate analysis showed that a BMI at the time of surgery of ≥ 25 kg/m2 was an independent risk factor for IH (odds ratio = 11.9, p = 0.049). CONCLUSIONS: Preoperative obesity is an independent risk factor for IH after minimally invasive gastrectomy followed by RY or DT reconstruction with mesenteric defect closure. We need to conduct vigilant follow-up for IH, especially in these patients.

Hemodynamic benefits of celiac artery release for ruptured right gastric artery aneurysm associated with median arcuate ligament syndrome: a case report.

BACKGROUND: It has been reported that median arcuate ligament syndrome is closely associated with gastric or pancreaticoduodenal artery aneurysms. Hemodynamic state plays an important role in the formation of the aneurysms. These aneurysms are treated with open resection or endovascular exclusion. However, whether revascularization of the celiac artery can prevent the aneurysm formation is unknown. This report indicated a possibility that prophylactic revascularization for celiac artery stenosis resulted in decreased shear stress on the collaterals, which may otherwise be susceptible to new aneurysms. CASE PRESENTATION: This report describes a 51-year-old man who presented with epigastric pain at our hospital. According to contrast enhanced computed tomography (CT), he was diagnosed with a ruptured right gastric artery aneurysm and celiac artery stenosis caused by the median arcuate ligament (MAL). He had a vascular anomaly of the common hepatic artery arising from the superior mesenteric artery (SMA). His vital signs were stable. We informed him of the situation and he chose open surgery rather than endovascular treatment. Following, we resected the aneurysm and transected the MAL. Intraoperative angiography after transection of the MAL showed the antegrade blood flow to the splenic artery instead of the retrograde flow via the prominent collaterals. Follow-up CT confirmed narrowed collateral vessels between the SMA and the celiac artery without de-novo aneurysms. CONCLUSION: While the necessity of celiac artery release could be questioned, the present case supports the hemodynamic benefits of MAL transection in terms of de-novo aneurysm prevention.

[A Case of Axillary Nodal Metastasis of Adenocarcinoma of an Unknown Primary Site Effectively Treated with Anti-HER2plus AC plus Paclitaxel Therapy].

A 68-year-old woman who presented with a left axillary mass was admitted. A computed tomography scan showed swelling ofthe left axillary and supraclavicular lymph nodes, but magnetic resonance imaging(MRI)and fluorodeoxyglucose positron emission tomography(FDG-PET)did not reveal these primary sites. Histological findings of the axillary mass revealed a HER2-positive adenocarcinoma. We diagnosed the patient with axillary nodal metastasis ofadenocarcinoma ofan unknown primary site and treated her with neoadjuvant chemotherapy including paclitaxel and trastuzumab followed by doxorubicin and cyclophosphamide. The lesions almost disappeared after 3 courses of chemotherapy and she showed a pathologically complete response(CR)after surgery. The patient has been recurrence-free since the operation owing to treatment with adjuvant trastuzumab.