Clinical Outcomes of Preserving Bronchial Arteries During Radical Esophagectomy: A Propensity-Score Matched Analysis.

BACKGROUND: Postoperative pneumonia is a common and major cause of mortality after radical esophagectomy. Intraoperative preservation of the bronchial arteries is often aimed at avoiding tracheobronchial ischemia; however, it is unknown whether this contributes to a reduction in postoperative pneumonia. PATIENTS AND METHODS: We enrolled 348 consecutive patients who underwent radical esophagectomy for esophageal cancer at Toranomon Hospital from January 2011 to July 2018. We classified patients into a bronchial artery-resected (BA-R) group (n = 93) and a bronchial artery-preserved (BA-P) group (n = 255) and compared the incidence of postoperative pneumonia between the two groups. A propensity score-matching analysis for bronchial artery preservation versus resection was performed. RESULTS: Overall, 182 patients were matched. Univariate analysis of the propensity score-matched groups showed that Brinkman index ≥ 400, vital capacity (%VC) < 80%, and bronchial artery resection were associated with the development of postoperative pneumonia. Multivariate analysis revealed three significant factors associated with postoperative pneumonia: Brinkman index ≥ 400 [p = 0.006, odds ratio (HR) 3.302, 95% confidence interval (95% CI) 1.399-7.790], %VC < 80% (p = 0.034, HR 6.365, 95% CI 1.151-35.205), and bronchial artery resection (p = 0.034, HR 2.131, 95% CI 1.060-4.282). The incidence of postoperative complications (CD grade III) was higher in the BA-R group (BA-R 42.8% versus BA-P 27.5%, p = 0.030). There was no significant difference in overall survival between the two groups at 5 years (BA-R 63.1% versus BA-P 72.1%, p = 0.130). CONCLUSION: Preserving the bronchial artery is associated with a decreased incidence of postoperative pneumonia.

Re-evaluation of the prognosis of alpha-fetoprotein-producing gastric cancer from a single center: a case series study.

BACKGROUND: Alpha-fetoprotein (AFP)-producing gastric cancer (AFPGC) is reported to have biologically aggressive features and poor prognosis. A relatively large number of patients with AFPGC have achieved a long-term prognosis after surgery in our institution. This study aimed to clarify the clinical features of and re-evaluate the long-term outcomes of AFPGC. METHODS: This analysis involved 465 patients who underwent surgery for gastric cancer (GC) at our institute between 1996 and 2020. The clinical features and long-term outcomes of the 24 patients with AFPGC were assessed. The differences in clinicopathological characteristics between AFPGC and non-AFPGC patients were statistically analyzed. RESULTS: In patients with AFPGC, the median preoperative serum AFP level was 232 ng/mL. Tumor invasion of AFPGC was classified and clinical characteristics of AFPGC patients were as follows: nodal metastasis, simultaneous liver metastasis, with malignant cells in ascites, lymphatic, and venous involvement. Postoperative surveillance revealed adjuvant therapy in fourteen, recurrence in eight, and four patients died of GC. The 3- and 5-year overall survival (OS) rates were 85.2% and 75.7% in AFPGC patients and 79.6% and 77.7% in non-AFPGC patients, respectively. The log-rank test identified no significant difference in OS between AFPGC and non-AFPGC patients. Tumor depth, nodal, and venous involvement showed significant differences between AFPGC and non-AFPGC patients. CONCLUSIONS: AFPGC has aggressive biological features, but long-term prognosis after surgery does not seem to be as poor as claimed in previous studies. Therefore, it may be important to detect and start treatment early when surgery is feasible.

Identification of Preoperative Fat-Free Mass Index for the Prognosis of Curatively Resected Esophageal Cancer.

BACKGROUND: The progressive, systemic depletion of muscle mass is a poor prognostic factor for various types of cancers. However, the assessment of body composition for patients with esophagectomy remains unclear. Therefore, we evaluated the significance of the fat-free mass index (FFMI) and estimated the appropriate cutoff value. METHODS: We compiled clinicopathological characteristics of patients who underwent curative operation for esophageal cancer between October 2013 and March 2018 at Toranomon Hospital and reviewed them until December 2020. We analyzed the short- and long-term outcomes, compared to conventional nutritional factors, and calculated the area under the receiver operating characteristic (ROC) curve. RESULTS: A total of 200 patients were eligible for inclusion. FFMI was ineffective in predicting postoperative complications, with no correlation with other nutritional biomarkers. Preoperative low FFMI led to poor overall survival (OS), and the lower cutoff values based on the time-dependent ROC analysis were 14.4 and 16.8 kg/m2 in women and men, respectively. Multivariate analysis for OS revealed that low FFMI (p = 0.010, HR 2.437, 95% CI 1.234-4.815) and clinical stage (p = 0.010, HR 4.781, 95% CI 1.447-15.796) were independent prognostic factors. The 3-year survival rates were 68.9% in low FFMI and 88.6% in normal FFMI. CONCLUSIONS: The low FFMI was not predictive of postoperative complications but an independent prognostic factor in esophageal cancer with curative resection, having no correlation with other biomarkers. Our cutoff FFMI values could be useful in selecting the target for muscle improvement programs.

Reducing the risk of postoperative pancreatic fistula in radical gastrectomy: pre-assessment with computed tomography for the diagnosis of pancreatic steatosis.

PURPOSE: To determine whether pancreatic steatosis (PS) is associated with the risk of postoperative pancreatic fistula (POPF) after radical gastrectomy, and if so, to investigate whether pre-assessment by diagnostic imaging can mitigate the risk. METHODS: The clinical records of 276 patients with cStage I gastric cancer who underwent laparoscopic gastrectomy with D1 + lymphadenectomy between 2012 and 2015 were reviewed. In the first phase up to July 2013 (n = 138), PS was classified from computed tomography (CT) findings into type S (superficial fat deposition) or type D (diffuse fatty replacement) and examined for association with POPF. In the second phase (n = 138), the preoperative CT assessment of PS was routinized. Separate samples from pancreatoduodenectomy consistent with each type were histologically examined. RESULTS: In the first phase, the incidence of POPF was significantly higher in group S, but not in group D, compared with normal pancreas (16.3% and 9.1% vs. 3.6%, respectively; P = 0.03). The drain amylase level was lowest in group D, reflecting exocrine insufficiency. Histologically, the loose connective-tissue space between the fat infiltrating the pancreas and the peripancreatic fat containing the lymph nodes was unclear in type D but conserved in type S. In the second phase, surgery was performed with more intention on accurately tracing the dissection plane and significantly lowered incidence of POPF in Group S (16.3% to 2.1%; P = 0.047). CONCLUSION: Peripancreatic lymphadenectomy is more challenging and likely to cause POPF in patients with PS. However, the risk may be reduced using appropriate dissection techniques based on the CT pre-assessment findings.

Importance of long-term surveillance after curative esophagectomy for esophageal squamous cell carcinoma.

BACKGROUND: The long-term outcomes after esophagectomy for esophageal cancer remain uncertain and the optimal surveillance strategy after curative surgery remains controversial. METHODS: In this study, the clinicopathological characteristics of patients who underwent curative thoracic esophagectomy between 1991 and 2015 at Toranomon Hospital were retrospectively analyzed and reviewed until December 2020. We evaluated the accumulated data regarding the pattern and rates of recurrence and second malignancy. RESULTS: A total of 1054 patients were eligible for inclusion in the study. Of these, 97% were followed up for 5 years, and the outcomes after 25 years could be determined in 65.5%. Recurrence was diagnosed in 318 patients (30.2%), and the most common pattern was lymph node metastasis (n = 168, 52.8%). Recurrence was diagnosed within 1 year in 174 patients (54.7%) and within 3 years in 289 (90.9%). Second malignancy possibly occurred through the entire study period after esophagectomy even in early-stage cancer, keeping 2%-5% of the incidental risk. There was no significant difference in the prognosis between 3-year survivors with and without a second malignancy. CONCLUSIONS: Most recurrences after resection of esophageal cancer occurred within 3 years regardless of disease stage. However, these patients have an ongoing risk of developing a second malignancy after esophagectomy. Further consideration is required regarding the efficacy of long-term surveillance.

Clinical significance of initial treatment for peritoneal lavage cytology-positive gastric cancer: outcomes according to treatment strategy.

BACKGROUND: Although patients with positive lavage cytology (CY1) are classified as having stage IV disease, long-term survival without other unresectable factors (P0CY1) has been reported. Conversion gastrectomy in patients with a change in cytology status after induction chemotherapy might improve survival, but appropriate treatment remains controversial. Here, we reviewed our experience in treating CY1 gastric cancer to evaluate the best treatment strategy. METHODS: Clinical and pathological findings of patients with a diagnosis of P0CY1 gastric cancer at Toranomon Hospital between February 2006 and April 2019 were retrospectively analyzed. Patients were classified into two groups according to initial treatment: a surgery-first group and a chemotherapy-first group. In addition, the patients were categorized into subgroups based on the subsequent treatment pattern. The surgery-first group was divided into two subgroups: adjuvant chemotherapy and palliative gastrectomy only. The chemotherapy-first group was divided into three subgroups with the subsequent treatment pattern depending on the response to chemotherapy: conversion gastrectomy, palliative gastrectomy after induction therapy, and palliative chemotherapy. RESULTS: In total, 38 patients were eligible for inclusion in this study. After initial assessment of cytology status, 21 patients underwent gastrectomy as initial treatment (surgery first) and 17 received induction chemotherapy (chemotherapy first). Ten patients underwent surgery first with adjuvant chemotherapy, 11 underwent palliative gastrectomy alone, 5 underwent conversion surgery, 5 with CY1 disease after induction chemotherapy underwent palliative gastrectomy, and 7 received palliative chemotherapy only. The 3-year survival rate was 23.4% (median survival, 17.7 months) in the surgery-first group and 27.3% (median survival, 19.7 months) in the chemotherapy-first group. The 3-year survival rate was 75% for conversion gastrectomy, 16.7% for palliative chemotherapy, and 0% for palliative gastrectomy after induction chemotherapy. CONCLUSIONS: There was no significant difference in outcome according to whether surgery or chemotherapy was performed first. The prognosis of conversion surgery with curative resection was better than that of the other types of treatment. However, the outlook after induction chemotherapy was poor. Patients with advanced gastric cancer should be treated cautiously until more effective treatment options become available.

Effectiveness of lymphadenectomy along the thoracic duct for radical esophagectomy.

BACKGROUND: There has been much debate on whether to perform TD resection in radical esophagectomy for esophageal cancer from the perspectives of metastatic rate, effect on postoperative hemodynamics, and other factors. The objective of this study was to determine whether TDLN dissection contributes to improved prognosis. METHODS: This study involved 1211 patients who underwent D2/D3 dissection with TD resection for thoracic esophageal cancer between 1984 and 2020. The lymph nodes along the TD were defined as TDLNs and the remaining No. 112 nodes as non-TDLNs. The metastatic rate in TDLNs and non-TDLNs and their outcomes were compared with those of other thoracic lymph nodes. Correlation with the invasion depth of the main lesion was also analyzed (T0-2 545 patients, T3-4 666 patients). RESULTS: The metastatic rates in TDLNs/non-TDLNs in all patients were 7.3%/7.5%, respectively, while those in T0-2 were 2.2%/3.9%, and those in T3-4 were 11.5%/10.6%, with both having higher rates in advanced cases. The efficacy index (EI) for lymphadenectomy in T3-4 was 2.94 for TDLNs and 3.44 for non-TDLNs, with no significant difference. The metastatic rate in TDLNs by tumor site was as follows: Ut/Mt/Lt = 1.1/2.4/2.4% (T0-2) and 7.7/14.5/8.4% (T3-4), being especially high (~ 15%) in patients with advanced cases in Mt region. The EI was comparable or higher for TDLNs compared with other group-2 (Mt/Lt) and group-3 (Ut) regional lymph nodes, regardless of site. CONCLUSIONS: The significance of TD resection was low in T0-2 due to the low metastatic rate but became evident in cases with invasion depth of T3-4. TDLN resection was at least as effective as dissection of other group-2 or -3 lymph nodes, including No. 112 nodes.

Nutritional Outcomes of Thoracic Duct Resection for Radical Esophagectomy by Assessing Body Composition Changes in One Year: A Single-Center Retrospective Study.

BACKGROUND: Thoracic duct (TD) resection is performed when the tumor or a metastatic lymph node directly invades the TD, and is sometimes indicated for radical lymphadenectomy during esophagectomy in esophageal cancer patients. However, the effect of TD resection on nutritional status has not been established. PATIENTS AND METHODS: In total, 174 consecutive patients from October 2015 to March 2019 who underwent radical esophagectomy for esophageal cancer in Toranomon Hospital were classified into thoracic duct preserved group (n = 51) and TD-resected (TD-R) group (n = 123). We compared laboratory data, body composition data from bioelectrical impedance analysis measured preoperatively and at 1 and 12 months after surgery, and postoperative complications between the two groups. RESULTS: Clinical stage was significantly more advanced in the TD-R group. Total body weight, body mass index, and fat mass continuously decreased in the two groups over 12 months after surgery, and the decreases were statistically greater in the TD-R group at 12 months after surgery. Skeletal muscle mass and fat-free mass decreased over 1 month after surgery and stayed in a reduced state until 12 months after surgery without statistically significant differences between the two groups. TD resection did not increase incidence of postoperative complications (Clavien-Dindo classification ≥ grade III), but TD resection increased incidence of chylothorax. CONCLUSIONS: Our results suggest that loss of body fat mass, which was a main contributor to body weight loss, was accelerated in the TD-R group, but TD resection does not deteriorate loss of muscle mass at 12 months after surgery.

Adequate period of surveillance in each stage for curatively resected gastric cancer: analyzing the time and rates of recurrence.

BACKGROUND: Surveillance after curative surgery for gastric cancer is conventionally performed for 5 years. However, the appropriate follow-up period remains controversial. METHODS: This study retrospectively compiled a clinicopathological database of patients who underwent curative gastrectomy between 1975 and 2010 at Toranomon Hospital and were reviewed until March 2020. Analyzing the follow-up rate and recurrence rate for each stage in each postoperative year, we set each follow-up endpoint when the subsequent recurrence rate fell below 1%. RESULTS: A total of 5235 patients were eligible for inclusion in the study. The rate of patients followed up for 5 years was 90.3%. The rates of follow-up were 52.7% at 10 years, 38.3% at 15 years, and 10.3% at 20 years. Recurrence was confirmed in 850 patients in total (16.2%) and in 50 patients beyond 5 years. The adequate follow-up endpoints according to stage (with < 1% recurrence risk) were 2 years for stage IA, 4 years for IB, 6 years for IIA, 9 years for IIB, 7 years for IIIA, and 8 years for IV (curative). For stage IIIB and IIIC, the recurrence risk remained. CONCLUSIONS: The adequate surveillance duration of resected gastric cancer might be different in each stage. Although the follow-up duration for stage I disease could be reduced to less than 5 years, advanced gastric cancer such as stage III or IV disease has risk of recurrence beyond 5 years and therefore additional follow-up is required. These results could help decide the strategy for surveillance.

Efficacy of Vonoprazan for Refractory Reflux Esophagitis after Esophagectomy.

BACKGROUND: Refractory reflux esophagitis (RRE), unresponsive to conventional proton-pump inhibitors (PPIs), is a complication in esophagectomy with gastric pull-up. Vonoprazan (VPZ), a novel potassium-competitive acid blocker, has been available in Japan since 2015. Here, we investigated the efficacy of VPZ on PPI-resistant RRE after esophagectomy with gastric pull-up. METHODS: This was a single-center retrospective study. We used the revised Los Angeles (r-LA) classification based on the Los Angeles classification and the modified Los Angeles classification to evaluate abnormal forms of mucosal breaks such as lateral spreading consistently. Patients who underwent esophagectomy with gastric pull-up and had RRE grade B-D as per the r-LA classification, despite using standard-dose PPIs or double dose of rabeprazole, were included. Sixteen patients who switched to VPZ (20 mg/day) and 14 patients who continued PPIs were assigned to the VPZ and PPI groups, respectively. Endoscopic observations were reviewed by 3 endoscopists using the r-LA classification to ensure consistent diagnosis, while the treatment arm and patient information were blinded to evaluators. We defined mucosal breaks that improved by at least one grade after treatment as improved mucosa and recovery to grade M or N as mucosal healing. RESULTS: The percentage of patients with improved mucosa in the VPZ and PPI groups was 81.3 and 14.3%, respectively (p < 0.001). The rate of mucosal healing was 68.8 and 7.1%, respectively (p = 0.001). CONCLUSION: VPZ significantly improved PPI-resistant RRE after esophagectomy with gastric pull-up.

Management and outcomes of resectable gastric conduit cancer: a retrospective comparative study of 51 cases.

PURPOSE: Although gastric conduit cancer (GCC) arising after esophagectomy is increasingly being reported, therapeutic strategies for resectable GCC have yet to be optimized. We investigated clinicopathological features of patients undergoing endoscopic versus more invasive surgical treatments for GCC and compared their outcomes. METHODS: Fifty-one patients, who had a history of esophagectomy with gastric conduit reconstruction for esophageal cancer and underwent resection for metachronous GCC, were identified. Their characteristics and outcomes were retrospectively reviewed. RESULTS: There were 48 males and three females, ranging in age from 46-86 years. Twelve patients underwent surgery for GCC (group S) and 39 underwent only endoscopic resection (group E). The most common cause of death was pneumonia (10/51, 19.6%). Neither overall survival nor cumulative incidence of pneumonia-caused death differed significantly between the two groups (P = 0.60, 0.84, respectively). In group S, partial gastrectomy was performed in four cases and total gastrectomy in seven. Partial resections, including three antrectomy without sternotomy or intrathoracic procedures, were completed with significantly shorter operative durations than total resections (median 208 vs 513 min, P = 0.012). GCC recurrence was experienced in two cases: one undergoing open approach partial resection of the corpus and the other thoracoscopic total gastrectomy. CONCLUSION: Even compared with endoscopic treatment, outcomes following surgery for GCC appeared to be acceptable. Open approach total gastric gastrectomy could be the most radical modality, while other less invasive alternatives, e.g., antrectomy, are also an option. Clinicians may select a treatment strategy balancing radicality and patient status, reflecting tolerance to invasive procedures.

Clinicopathologic Characteristics of Oligometastases from Esophageal Cancer and Long-Term Outcomes of Resection.

BACKGROUND: Recurrent esophageal cancer after radical therapy usually is thought to be incurable and treated with palliative-intent systemic therapy. However, it is empirically known that surgical resection may be effective for selected patients, although no consensus exists on the efficacy of surgery for recurrent esophageal cancer. This study sought to identify a group of patients for whom surgical resection is considered effective. METHODS: The study enrolled 206 patients at a single center who had recurrence after radical therapy for esophageal cancer. Prognostic factors after recurrence were identified, and efficacy of surgery was analyzed according to whether the recurrent lesions were oligometastases (i.e., ≤ 5 lesions in a single domain) or not. RESULTS: In the multivariate analysis, oligometastatic presentation was the only factor associated with survival after recurrence (hazard ratio 6.29; 95% confidence interval, 4.10-9.71). The actuarial survival rates for the patients with oligometastases were 59.5% at 3 years and 51.7% at 5 years. The survival rates at 3 and 5 years were significantly higher for the patients who underwent resection (64.3% and 55.6%, respectively) than for those who did not (both 100%) and for the patients with multiple metastases (9.8% and 0%, respectively). The survival rates for the patients who had oligometastases without resection were comparably lower than for the patients with multiple metastases. CONCLUSION: Oligometastatic presentation at recurrence was associated with better survival outcomes for the patients who experienced recurrence after radical treatment for esophageal cancer, and surgical resection could be a choice of treatment for this group of patients.

Development of a model predicting the risk of eight major postoperative complications after esophagectomy based on 10 826 cases in the Japan National Clinical Database.

BACKGROUND: Esophagectomy is a highly invasive procedure with a high incidence of complications. The objectives of this study were to create risk prediction models for postoperative morbidity associated with esophagectomy and to test their performance using a population-based large database. METHODS: A total of 10 862 patients who underwent esophagectomy between January 2011 and December 2012 derived from the Japanese national clinical database (NCD) were included. Based on the 148 preoperative clinical variables collected, risk prediction models for eight major postoperative morbidities were created using 80% (8715 patients) of the study population and validated using the remaining 20% (2147 patients) of the patients. RESULTS: The mortality rate was 3.1% and postoperative morbidity was observed in 42.6% of the patients. The c-statistics of the eight risk models established by the training set were surgical site infection (0.564), anastomotic leakage (0.531), need for transfusion (0.636), blood loss >1000 mL (0.644), pneumonia (0.632), unplanned intubation (0.607), prolonged mechanical ventilation over 48 hours (0.614), and sepsis (0.618) in the validation analysis. CONCLUSIONS: Risk prediction models for postoperative morbidity after esophagectomy using the population-based large database showed relatively fair performance. The current models may offer baseline information for risk stratification in clinical decision makings and help select more suitable surgical and nonsurgical treatment options and future clinical studies.

Perioperative risk factors of psychological distress in patients undergoing treatment for esophageal cancer.

BACKGROUND: Esophageal cancer patients often feel depressed and are fearful of metastasis and death. The objective of this study was to clarify the characteristics of patients with psychological distress at all 5 time points compared with patients with no psychological distress especially from standpoints of personal coping styles and QOL. METHODS: In total, 102 of 152 consecutive patients who attended the outpatient clinic at Toranomon Hospital between April 2017 and April 2019 met eligibility criteria for inclusion in this study. Questionnaires designed to identify psychological distress (HADS-scores) and assess QOL (EORTC QLQ C-30/OES18) were administered at 5 time points from the time of the first outpatient consultation to 3 months after esophagectomy. The questionnaire of coping strategies (MAC-scales) was administered at only time 1 point. RESULTS: Based on the trends of HADS-scores, we defined two groups: "persistent high-HAD scores" and "persistent low-HADS scores." There are strong relationships between psychological distress and coping strategy, and psychological distress and QOL. The possibility that there are relationships between stress coping strategies and some QOL status depending on some point of treatment. CONCLUSIONS: The psychological distress during the treatment course of esophageal cancer is significantly associated with the coping strategies and QOL influenced by esophagectomy. This study can provide baseline information for identifying patients in need of psychological management and paves the way for larger clinical studies in the future.

Relationship between psychological distress and health-related quality of life at each point of the treatment of esophageal cancer.

BACKGROUND: Patients with esophageal cancer often feel depression or fear of death influenced by multiple clinical factors. This study sought to investigate the clinical factors associated with psychological distress, focusing on the influence of health-related quality of life (HRQOL) for better psychological management of patients with esophageal cancer. METHODS: In total, 102 of 152 consecutive patients surgically treated at Toranomon Hospital met the eligibility criteria for analysis. Questionnaires designed to identify psychological distress and QOL (EORTC QLQ C-30/OES18) were administered at five time points during the treatment course. Degree of psychological distress was assessed by Hospital Anxiety and Depression Scale (HADS). RESULTS: Patients with HADS score ≥ 11 at each visit showed significantly higher level of symptoms or problems measured by the score of EORTC QLQ C-30/OES18 compared with those with HADS score ≤ 10. Emotional status was a significant factor associated with psychological distress at all times. Although functional scales including global health status or QOL status and symptom scales associated with esophageal cancer were strongly associated with psychological distress before treatment, scales associated with changes in habitus after esophagectomy showed significant correlation with psychological distress after surgery. No significant correlation was observed between psychological distress and individual baseline characteristics, apart from history of surgery and pathological staging. CONCLUSIONS: Psychological distress during treatment course of esophageal cancer is significantly associated with HRQOL influenced by esophagectomy. The current results may warrant prospective intervention through enhanced recovery after surgery to better manage patients undergoing highly invasive procedures for esophageal cancer.

Prognostic Factors and Appropriate Lymph Node Dissection in Salvage Esophagectomy for Locally Advanced T4 Esophageal Cancer.

BACKGROUND: A suitable treatment strategy for esophageal cancer after definitive chemoradiotherapy for T4 cases has not been established and remains unclear. This study aimed to clarify the independent prognostic factors, surgical indications, and optimal extent of lymphadenectomy for T4 esophageal cancer. METHODS: Of 803 patients who underwent esophagectomy for esophageal cancer at the authors' institution from 2006 to March 2018, the study included 33 patients who underwent salvage esophagectomy with locally advanced T4 cancer. The study examined the baseline attributes and treatment results of these cases and evaluated the prognostic factors and treatment strategies. RESULTS: The independent favorable prognostic factors in T4 cancer (T4a/T4b = 11/22) included non-T4b status [hazard ratio (HR), 15.311; 95% confidence-interval (CI), 1.277-183.5] and R0 resection (HR, 14.706; 95% CI, 1.193-166.67). For the cases in which R0 resection was possible (n = 14), both the 1- and 5-year survival rates were 90.9%, whereas for the cases without R0 dissection (n = 19), the 1- and 5-year survival rates were respectively 44.9% and 0%. In the univariate analysis, the patients who underwent two- or three-field lymph node dissection tended to have a better prognosis (p = 0.062), and those with 60 or more lymph nodes dissected had a significantly better prognosis (p = 0.038). For the patients who underwent salvage esophagectomy with typical lymph node dissection, the rate of complications classified as Clavien-Dindo grade 3 or higher (33.3%) was not increased, indicating that the procedure was relatively safe. CONCLUSIONS: The results showed that in salvage esophagectomy for T4 esophageal cancer, R0 resection led to improved prognosis. Because typical two- or three-field lymph node dissection including prophylactic dissection could be performed safely and led to a better prognosis in salvage esophagectomy, typical esophagectomy including prophylactic lymph node dissection should be performed if possible.

Combined hepatocellular-cholangiocarcinoma with angiosarcomatoid change: A case report with immunohistochemical study.

Sarcomatoid combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare condition, with only 16 cases reported to date; however, there have been no reports of hepatic sarcomatoid carcinoma with angiosarcomatous features. Here, we report a rare case of cHCC-CCA with angiosarcomatoid changes in a 77-year-old man. The tumor was biphasic with malignant epithelial and mesenchymal components. Histologically, the epithelial component was concordant with classical type cHCC-CCA. The mesenchymal component included angiosarcomatoid cells growing in a vasoformative structure and undifferentiated spindle cells. Immunohistochemical analyses showed that angiosarcomatoid cells were positive for CD31, factor VIII-related antigen, and other angiosarcoma markers. Characteristically diffuse and strong expression of p53 protein was observed in the nuclei of angiosarcomatoid cells but not in carcinoma cells, suggesting that TP53 gene mutations commonly occur in these cells. Transitional zones were observed between HCC and spindle cells and between HCC and angiosarcomatoid cells. A small portion of undifferentiated spindle cells expressed pan-cytokeratin. These findings suggested that this extremely rare tumor developed from dedifferentiation or metaplastic changes of cHCC-CCA.

Diaphragmatic herniation following total gastrectomy: review of the long-term experience of a tertiary institution.

PURPOSE: Diaphragmatic herniation (DH) is a rare but potentially fatal event after total gastrectomy (TG). Despite being life-threatening, risk factors for postoperative DH have yet to be elucidated. We conducted a retrospective analysis to identify clinical characteristics of patients developing DH after TG, along with a comprehensive review of the published literature. METHODS: Among 1361 consecutive patients undergoing TG for esophagogastric cancer between 1985 and 2013 in Toranomon Hospital, those requiring surgical intervention for postoperative DH were included. We also conducted a PubMed literature search on DH following TG. RESULTS: Five patients (four males, one female), with a median age of 68 at DH surgery, were identified. Intervals between TG and DH repair ranged from 2.9 to 189.0 (median, 78.1) months. Four patients had needed emergency surgery. Three patients had undergone open TG and two others laparoscopic TG, suggesting a significantly higher incidence of DH after laparoscopic TG (3/1302 vs. 2/59, p = 0.017). The diaphragmatic crus incision, creating the space for esophagojejunostomy, had been performed in all cases. The literature yielded seven relevant publications (16 patients). Intervals between TG and DH reduction ranged from 2 days to 36 months. All operations for DH had been carried out emergently. CONCLUSION: The risk of DH persisted after TG. DH is potentially a very late complication of TG, presenting as a surgical emergency. Laparoscopic TG was suggested to be a risk factor for postgastrectomy DH. Incising the crus might also be a predictor of DH. Measures to prevent DH, e.g., appropriate closure of the crus, would be recommended in minimally invasive TG.