Correlations between Extranodal Metastasis and Prognosis in Patients with Squamous Cell Carcinoma of the Esophagus

Background Extranodal metastasis (EM) has been reported in carcinomas of many organs. However, the clinicopathological significance of EM in squamous cell carcinoma of the esophagus remains unclear, and this study sought to clarify this issue. MethodsThis study included 220 patients who underwent an esophagectomy with lymphadenectomy for primary esophageal carcinoma from 1996 to 2008. EM was defined as the presence of cancer cells in the soft tissue that were discontinuous with the primary lesion, or in the perinodal soft tissue distinct from the lymph nodes. Results EM was detected in 25 (9.6%) of the 220 patients, and in 56 (0.7%) of the 8,186 nodules retrieved as ‘lymph nodes’. The incidence of EM was significantly higher in patients who had tumors of a larger size (diameter ≥ 4 cm), lymphatic vessel invasion, lymph node metastasis, a high pathological stage, infiltrative growth pattern, or a high pT-stage. The 5-year overall survival rates in N0-1 patients with EM were significantly lower than in the patients without EM (P = 0.005). Conclusion EM is closely associated with the development and aggressiveness of esophageal carcinoma, and the presence of EM can be useful for predicting prognosis after surgery in N0-1esophageal carcinoma patients

Feasibility of Endoscopy-Assisted Laparoscopic Full-Thickness Resection for Superficial Duodenal Neoplasms

Background. Superficial duodenal neoplasms (SDNs) are a challenging target in the digestive tract. Surgical resection is invasive, and it is difficult to determine the site and extent of the lesion from outside the intestine and resect it locally. Endoscopic submucosal dissection (ESD) has scarcely been utilized in the treatment of duodenal tumors because of technical difficulties and possible delayed perforation due to the action of digestive juices. Thus, no standard treatments for SDNs have been established. To challenge this issue, we elaborated endoscopy-assisted laparoscopic full-thickness resection (EALFTR) and analyzed its feasibility and safety. Methods. Twenty-four SDNs in 22 consecutive patients treated by EALFTR between January 2011 and July 2012 were analyzed retrospectively. Results. All lesions were removed en bloc. The lateral and vertical margins of the specimens were negative for tumor cells in all cases. The mean sizes of the resected specimens and lesions were 28.9 mm (SD ± 10.5) and 13.3 mm (SD ± 11.6), respectively. The mean operation time and intraoperative estimated blood loss were 133 min (SD ± 45.2) and 16 ml (SD ± 21.1), respectively. Anastomotic leakage occurred in three patients (13.6%) postoperatively, but all were minor leakage and recovered conservatively. Anastomotic stenosis or bleeding did not occur. Conclusions. EALFTR can be a safe and minimally invasive treatment option for SDNs. However, the number of cases in this study was small, and further accumulations of cases and investigation are necessary

Advantage of Long Ileus-tube Placement by Gastrostomy for Treating Patients with Refractory Intestinal Obstruction

Maintaining a long transnasal ileus tube for a long period can be quite painful for patients such as in those with refractory intestinal obstruction and peritonitis carcinomatosa and it can markedly decrease quality of life (QOL) due to unexpected respiratory complications associated with the tube placement. To mitigate such complications, we undertook a trial insertion of a long ileus tube by gastrostomy in five patients with refractory intestinal obstruction (four cases of peritonitis carcinomatosa and one case of chronic intestinal pseudo-obstruction). We inserted the transgastric ileus tube using a percutaneous gastrostomy catheter kit after puncture with a plastic skin (PS) needle covered with a protective sheath, and then endoscopically placed the tube beyond the ligament of Treitz. Subsequently, we removed the long transnasal ileus tube, and comparable decompression was achieved. In all cases, the entire procedure was easily performed with no complications. Moreover, patients experienced reduced pain and stress and they were able to regain some freedom during activity

Evaluation of Surgical Stress Associated with Video-assisted Thoracic Surgery for Esophageal Cancer According to Interleukin-6 Variation in Pleural Cavity Lavage Fluid

Esophagectomy for esophageal cancer is one of the most invasive gastrointestinal surgeries. In 1996, we introduced video-assisted thoracic surgery for esophageal cancer (VATS-E) to reduce surgical stress. In 2010, we started employing artificial pneumothorax (AP) using carbon dioxide gas in VATS-E to further reduce surgical stress. In this study, we evaluated interleukin-6 (IL-6) levels in pleural cavity lavage fluid (PLF) of patients undergoing VATS-E with or without AP, and examined the effect of AP on VATS-E-induced stress. This non-randomized study included patients who underwent VATS-E with or without AP at Showa University Hospital between 2009 and 2013 and from whom PLF could be collected. IL-6 concentrations in PLF were examined before and after the thoracic part of the operation. We compared IL-6 variation, defined as the difference between IL-6 concentrations in PLF before and after the thoracic part of the operation, between patients for whom AP was used and those for whom it was not used. A total of 52 patients were included in the study; 26 underwent VATS-E with AP (group AP), and 26 underwent VATS-E without AP (group NP). IL-6 concentrations in PLF were significantly elevated immediately after the thoracic part of the operation in both groups. IL-6 variation in PLF correlated with both thoracic operative time and blood loss, which were considered practical parameters of surgical stress, and was significantly lower in group AP than in group NP. In conclusion, IL-6 variation in PLF is a useful and sensitive maker of surgical stress during VATS-E. VATS-E with AP is less invasive than VATS-E without AP because AP lowers the perioperative systemic inflammatory response to thoracic surgery

ICG for RGC

This video is a digest of 2 cases of laparoscopic total gastrectomy for remnant gastric cancer using intraoperative real-time ICG fluorescence imaging.</p

LTG for RGC with ICG-F

This video is a digest of 2 cases of laparoscopic total gastrectomy for remnant gastric cancer using Intraoperative real-time ICG fluorescence imaging.</p

Controlling Nutritional Status is Useful for Predicting Postoperative Complications in very Elderly Patients with Colorectal Cancer: A Retrospective Study

Controlling Nutritional Status (CONUT) is an efficient tool for early detection of malnutrition, measured using two biochemical parameters (serum albumin and total cholesterol) and one immune indicator (total lymphocyte count). The aim of this study was to define the efficacy of CONUT for predicting postoperative complications in very elderly patients with colorectal cancer. This study enrolled 52 patients aged 85 years or older with colorectal cancer for whom we were able to measure CONUT before surgery, conducted at the Department of Gastroenterological and General Surgery of Showa University Hospital in Japan between January 2010 and December 2014. The patients were subdivided into those with complications (Group C, n=9) and those with no complications (Group NC, n=43), and then were retrospectively compared for clinical characteristics, CONUT, and surgical outcomes. Multivariate analysis was finally performed to identify the risk factors of complications. The percentage of patients with a CONUT score of 5 or more in Group C was significantly greater than that in Group NC (7 vs. 12 patients, 77.8% vs. 27.9%, P=0.0079). No other significant difference was observed in the clinical characteristics between Group C and Group NC. Multivariate analysis identified CONUT score as the only significant predictor of complications in this patient cohort (odds ratio=1.374; 95% confidence interval, 1.019-1.949; P=0.0366). Our study suggests that CONUT score is predictive of postoperative complications in very elderly patients with colorectal cancer

Intrathoracic Hernia after Total Gastrectomy

Intrathoracic hernias after total gastrectomy are rare. We report the case of a 78-year-old man who underwent total gastrectomy with antecolic Roux-Y reconstruction for residual gastric cancer. He had alcoholic liver cirrhosis and received radical laparoscopic proximal gastrectomy for gastric cancer 3 years ago. Early gastric cancer in the remnant stomach was found by routine upper gastrointestinal endoscopy. We initially performed endoscopic submucosal dissection, but the vertical margin was positive in a pathological result. We performed total gastrectomy with antecolic Roux-Y reconstruction by laparotomy. For adhesion of the esophageal hiatus, the left chest was connected with the abdominal cavity. A pleural defect was not repaired. Two days after the operation, the patient was suspected of having intrathoracic hernia by chest X-rays. Computed tomography showed that the transverse colon and Roux limb were incarcerated in the left thoracic cavity. He was diagnosed with intrathoracic hernia, and emergency reduction and repair were performed. Operative findings showed that the Roux limb and transverse colon were incarcerated in the thoracic cavity. After reduction, the orifice of the hernia was closed by suturing the crus of the diaphragm with the ligament of the jejunum and omentum. After the second operation, he experienced anastomotic leakage and left pyothorax. Anastomotic leakage was improved with conservative therapy and he was discharged 76 days after the second operation