Subtotal Esophagectomy Research Articles

Subtotal Esophagectomy-Akiyama Procedure： In a Case with Esophageal Squamous Cell Carcinoma

Adenocarcinoma, typically in the distal third of the esophagus, and squamous cell carcinoma, typically in the proximal two thirds of the esophagus, each make up 49% of cases of esophageal cancer. The remaining cancers in this area include sarcoma (1%), lymphoma (0.5%), cylindroma (0.25%), and primary melanoma (0.25%). Case report We present patient S.G. 62 years old, male, with the following symptoms started 3 months from hospital admission: difficult swalloing mostly for the hard foods and eventually for the liquids too, chest burning, cough and vomiting, throat pain, weight loss. In the laboratory findings only a mild anemia was found, Hemoglobine 10.8 g/dl, and slightly high values of CRP. Patient was hospitalized in the First Clinic of General Surgery, University Hospital Center “Mother Teresa” Tirana, Albania and underwent an upper gastrointestinal tract endoscopy and 28 cm form the incisive teeth and esophageal narrowing was detected which could not allow the scope to go lower for further examination. Biopsy was taken through endoscopy. Patient was planned for a CT scan and tumor markers, CEA and CA 19-9, both later ones came in normal values. CT scan showed an irregular, asymmetric narrowing of the thoracic esophagus, thickening of the esophagus walls with 4 cm of extension without invasion of local periesophageal fat and regional lymphadenopathy. The biopsy resulted; esophageal squamous cell carcinoma G2. In these circumstances patient underwent a feeding jejunostomy and was sent to follow the protocol of neoadjuvant chemo and radiotherapy. Three months later the patient is returned in our clinic, where he underwent the surgical intervention. Postoperatively the patient was treated in the Intensive Care Unit. The next day after the operation, cervical drains were removed and in the fourth postoperative day the thoracic and abdominal drains were also removed. Patient comes in the surgery ward in the fifth postoperative day where is treated afterwards with an excellent postoperative course. In the tenth postoperative day the anastomosis integrity is verified by x-ray swallowing contrast gastrografin, and the next day he was discharged from the hospital. Keywords: Esophageal, squamous cell carcinoma, subtotal esophagectomy DOI: 10.7176/ALST/79-05 Publication date: March 31 st 2020

Postoperative Complications have Minimal Impact on Long-Term Prognosis in Immunodeficient Patients with Esophageal Cancer.

Postoperative complications have been recognized to have an adverse prognostic impact in various types of cancer. However, in a recent study, it has been reported that postoperative complications of total gastrectomy with splenectomy have little impact on the long-term outcomes of patients with gastric cancer. In addition, the mechanisms underlying the effect of postoperative complications on outcomes remain to be elucidated. We hypothesized that immunosuppression by postoperative complications may affect long-term outcomes in patients with esophageal cancer. In this retrospective study, we assessed in 153 patients with esophageal cancer who underwent curative subtotal esophagectomy at our hospital and examined the correlation between postoperative complications, and multiple clinicopathological factors, and long-term outcomes with the patients stratified by total lymphocyte count (TLC). The median preoperative TLC was 1432. A total of 115 patients (75.2%) had a TLC of ≥ 1000/μL (high TLC group), and the remaining 38 patients (24.8%) had a TLC of < 1000/μL (low TLC group). Postoperative complications occurred in 39 of 153 cases (25.5%). There was no significant correlation between postoperative complications and any of the clinicopathological factors in either group. In the high TLC group, patients with postoperative complications had significantly lower overall and disease-free survival rates compared with those without complications (p < 0.001 and p < 0.01, respectively). In the low TLC group, no survival difference between patients with and without postoperative complications was observed. Postoperative complications may have a minimal impact on long-term outcomes in immunodeficient patients.

Adenocarcinosarcoma at the esophagogastric junction with long esophageal invasion: a case report

BackgroundCarcinosarcoma of the esophagus or esophagogastric junction (EGJ) is a rare malignancy with both carcinomatous and sarcomatous components. There is no report of carcinosarcoma arising from the EGJ wherein the carcinomatous element was adenocarcinoma. We describe a patient with carcinosarcoma of the EGJ in which the carcinomatous element was adenocarcinoma.Case presentationA 52-year-old man was diagnosed with carcinoma on his EGJ after complaining of appetite loss. All tumor markers (carcinoembryonic antigen, squamous cell carcinoma antigen, alpha-fetoprotein, and carbohydrate antigen 19-9) were within the respective normal ranges. Esophagogastroduodenoscopy showed a 150-mm (100 mm esophageal side and 50 mm gastric side) type 1 tumor on his EGJ. A histopathological examination of a biopsy specimen revealed well-differentiated tubular adenocarcinoma at the gastric side; however, only necrotic tissue was noted on the esophageal side. Contrast-enhanced computed tomography did not reveal any invasion of the adjacent structures; however, it did show five swollen regional lymph nodes. 18F-Fluorodeoxyglucose positron emission tomography with computed tomography did not reveal distant metastases. We performed thoracic subtotal esophagectomy, total gastrectomy, and two-field plus left cervical paraesophageal lymphadenectomy. Macroscopically, the lesion consisted of two components: a 7.5-cm type 2 tumor and a 9-cm type 1 tumor at the proximal end of the type 2 tumor. Microscopically, the type 2 tumor showed predominantly solid or cribriform proliferation of tumor cells with clear cytoplasm, which was moderately differentiated adenocarcinoma with enteroblastic-like differentiation. The tumor cells of the adenocarcinoma component had periodic acid-Schiff (PAS)-positive globules and were positive for sal-like protein 4 (SALL 4) and negative for α-fetoprotein (AFP) or human epidermal growth factor receptor type 2 (HER2). The type 1 tumors consisted of the adenocarcinoma-like type 2 tumor and spindle cells (sarcomatous component). Part of the sarcomatous component showed cartilage differentiation. The type 2 and type 1 lesions were continuous lesions. The epicenter of the tumor was located at the EGJ. The adenocarcinoma component was present in 10 of 27 resected lymph nodes. The tumor was diagnosed as carcinosarcoma of the EGJ.ConclusionsWe report a rare patient with carcinosarcoma of the EGJ wherein the carcinomatous element was adenocarcinoma.

Successful removal of a giant esophageal lipoma by thoracoscopic enucleation: a case report

BackgroundWe report a rare case of giant esophageal lipoma treated with thoracoscopic enucleation successfully.Case presentationA 69-year-old woman was referred to our department with dysphagia. Computed tomography examination revealed a large hypoattenuating submucosal mass with dense fat in the middle and lower esophagus. Upper gastrointestinal endoscopy revealed a submucosal mass with normal mucosa on the middle and lower esophageal wall. On a diagnosis of esophageal lipoma, we performed a video-assisted thoracoscopic operation and the 14.0 × 6.5 × 3.0 cm in size submucosal tumor was completely enucleated. We could successfully avoid a subtotal esophagectomy with high invasiveness. The patient was discharged on the 36th day after operation, and no symptoms had been noted.ConclusionsVideo-assisted thoracoscopic enucleation with minimal invasiveness may be an appropriate treatment option even for such a huge benign esophageal submucosal tumor.

The sterno-tracheal distance is an important factor of anastomotic leakage of retrosternal gastric tube reconstruction after esophagectomy.

Anastomotic leakage (AL) is a serious complication after esophagectomy. The retrosternal (RS) route has been selected majorly to reduce reflux and related pneumonia and considering mediastinal recurrences. AL has been developed more in RS than posterior mediastinal (PM) route reconstruction. Therefore, we suspected the sterno-tracheal distance (STD) might be related to AL and started the selection according to the STD from 2009. A total of 221 patients who underwent a subtotal esophagectomy with gastric tube reconstruction during January 2004-April 2017 were investigated. The patients were classified into the 'after STD selection' (A; n = 144) group and the 'before STD selection' (B, n = 77) group. The incidences of and the risk factors for AL between the two groups were compared. The incidence of AL was high in the B group (18.2%), and 78.6% of the patients who developed AL were treated with RS route reconstruction. The median STDs of the patients with AL and no AL were 10.3mm and 14.5mm, respectively (p = 0.001). These results demonstrated that the STD was a risk factor for AL in the RS route. Based on these results, 13mm was set as the cutoff value. After STD selection, the median STD increased from 14.0 to 17.3mm (p = 0.001), and the incidence of AL decreased significantly from 26.2 to 11.1% in the RS route (p = 0.037). The STD was the independent risk factor for AL in the RS route. RS route reconstruction should be avoided for the patients with STD < 13mm.

P139 CHYLE LEAK FOLLOWING RADICAL EN-BLOC OESOPHAGECTOMY WITH 2 FIELD NODAL DISSECTION: PREDISPOSING FACTORS, MANAGEMENT AND OUTCOMES

Abstract Background Chyle leaks may result from damage of the main thoracic duct or its tributaries during radical en-bloc sub-total oesophagectomy (STO). Treatment strategies and outcomes vary and management of this problem remains controversial. This study assessed the incidence, management and outcomes of chyle leaks in a dedicated oesophago-gastric cancer unit. Methods A retrospective study was conducted among patients who underwent elective STO with 2-field nodal dissection for oesophageal cancer between January 1997 and March 2019. The thoracic duct was routinely ligated during surgery. The diagnosis of post-operative chyle leak was performed clinically by a consultant and it was based on high output (&gt; 500 ml/24h) from chest and/or abdominal drains and on visual characteristics of the fluid. Results 1320 patients underwent surgery over the time reviewed. The study group consisted of 347 (26.3%) women and 974 (73.7%) men, with a median age of 65 (IQR 13) years. Oesophageal adenocarcinoma was diagnosed in a total of 937 (70.9%) patients, while squamous cell carcinoma in 274 (20.7%) patients. 93 (7%) patients developed a chylothorax. Univariable analysis showed that lower body weight, lower BMI, female sex and histology of a squamous cell carcinoma were significant independent predictive factors for chyle leak (p&lt;0.005). Chyle leak was associated with a higher risk of return to ITU (45.1% vs 10.1%, p&lt;0.001) and longer hospital stays (median 21.5 vs 15 days, p=0.002). Overall in-hospital mortality was 3.7% and was significantly higher in the chyle leak group (10.75% vs 3.2%, p&lt;0.001), although the causes of death were not directly related to it. Chyle leak was not associated with anastomotic leak, or wound and respiratory infection. Chylothorax was treated surgically in 39 (41.9%) patients and conservatively in 54 (58.1%). Between these two groups, a significant difference in terms of post-operative hospital stay and in 30-day mortality rate was seen (p&lt; 0.002 and p=0.031, respectively). Survival rate was similar in both groups. Conclusions Chyle Leak post oesophagectomy is associated with an increased risk of return to ITU, and longer hospital stay and increased in hospital mortality. However, surgical treatment is safe and early re-operation is recommended in order to diminish hospital stay and to decrease the 30-day mortality rate.

Feasibility of subtotal esophagectomy with systematic lymphadenectomy in selected elderly patients with esophageal cancer; a propensity score matching analysis

BackgroundThe global increase in elderly populations is accompanied by an increasing number of candidates for esophagectomy. Here we aimed to determine the postoperative outcomes after subtotal esophagectomy in elderly patients with esophageal cancer.MethodsPatients (n = 432) with who underwent curative-intent transthoracic subtotal esophagectomy with 2- or 3-field lymphadenectomies for thoracic esophageal cancer were classified as follows: non-elderly (age < 75 years, n = 373) and elderly (age ≥ 75 years, n = 59) and groups. To balance the essential variables including neoadjuvant treatment and stage of progression, we conducted propensity score analysis, and clinical characteristics, perioperative course and prognosis were compared.ResultsAfter two-to-one propensity score matching, 100 and 50 patients were classified in the non-elderly and elderly groups. The elderly group had more comorbidities and lower preoperative cholinesterase activities and prognostic nutrition indexes. Although incidences of postoperative pneumonia, arrhythmia and delirium were slightly increased in the elderly group, no significant differences were observed in overall incidence of postoperative complications, rates of repeat surgery and death caused by surgery, and length of postoperative hospital stay between the two groups. There were no significant differences in disease-free and disease-specific survival as well as overall survival between the two groups.ConclusionOlder age (≥75 years) had limited impact on morbidity, disease recurrence, and survival after subtotal esophagectomy. Therefore, age should not prevent older patients from benefitting from surgery.

788P - A phase I study of docetaxel/oxaliplatin/S-1 (DOS) combination neoadjuvant chemotherapy for patients with locally advanced adenocarcinoma of the esophagogastric junction

BackgroundA triple chemotherapeutic regimen including docetaxel, oxaliplatin, and S-1 (DOS) for a neoadjuvant setting has a promising efficacy for locally advanced adenocarcinoma of the esophagogastric junction (AEG). However, the optimal dose of each drug in Japanese population remained to be clarified. The aim of this phase I study is to determine a recommended dose for a triweekly combination neoadjuvant DOS chemotherapy for patients with locally advanced AEG. MethodsPatients with cT3 or more advanced AEG without distant metastasis were eligible for this study. The planned dosages of docetaxel (mg/m2, day 1), oxaliplatin (mg/m2, day 1), and S-1 (mg/day, days 1–14) were 50/100/80–120 at level 1, and 60/100/80–120 at level 2. The treatment cycle was repeated every 3 weeks, and patients were assessed for response to the treatment after 2 and 3 cycles. This study was registered with UMIN Clinical Trial Registry (UMIN 000022210). ResultsTwelve patients with locally advanced AEG were enrolled in this study. At dose level 1, one of six patients experienced dose-limiting toxicity (DLT) of grade 3 febrile neutropenia. At dose level 2, two of the next six patients experienced the same DLT of need for withdrawal of chemotherapy due to serious adverse events. Based on these results, level 2 was considered the recommended dose for this regimen. Total or proximal gastrectomy plus lower esophagectomy, or subtotal esophagectomy was performed in all the 12 patients with the R0 resection rate of 92% (11/12). Histological response evaluation based on the classification defined by Japanese Gastric Cancer Association revealed four patients with grade 1a, two with grade 1b, three with grade 2, and three with Grade 3. ConclusionsRecommended doses for a neoadjuvant DOS chemotherapy regimen for locally advanced AEG were determined as Docetaxel: 60mg/m2, Oxaliplatin: 100mg/m2 on day 1, S-1: <1.25m2, 80mg; 1.25–1.5m2, 100mg; >1.5m2, 120mg twice a day on days 1–14. DOS chemotherapy showed good preliminary efficacy with acceptable toxicity in this study warranting a further phase II trial to investigate the efficacy of the DOS regimen. Clinical trial identificationUMIN 000022210. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Thyroid metastasis from esophageal adenocarcinoma: a case report and literature review

BackgroundThe incidence of metastatic spread of gastrointestinal malignancies to the thyroid gland is relatively low and most of these malignancies originate from the colorectum. Thyroid metastasis originating from the esophagus is poorly documented.Case presentationA 79-year-old man presented with hoarseness of voice and swallowing difficulty. Eighteen months earlier, he had undergone preoperative chemotherapy (S-1 and oxaliplatin [SOX] therapy) and subtotal esophagectomy with regional lymph nodes dissection and retrosternal narrow gastric tube reconstruction for advanced Barrett’s esophageal adenocarcinoma. In the ultrasonographic examination, there was a hypoechoic, indistinct border and heterogeneous nodule in the left lobe of the thyroid gland. Pathological examination of an ultrasound-guided fine-needle aspiration showed adenocarcinoma, supporting a diagnosis of esophageal adenocarcinoma metastases in the thyroid.ConclusionThis is a first case of a patient with thyroid metastasis from Barrett’s esophageal adenocarcinoma after subtotal esophagectomy.

Risk factors associated with increased drainage volumes of chest tubes after transthoracic esophagectomy for esophageal cancer.

Prolonged chest drain placement can extend the postoperative hospital stay after esophagectomy in esophageal cancer (EC) patients. This study aimed to identify whether or not the risk factors associated with this prolonged chest tube placement are clinically important. A total of 138 patients who underwent subtotal esophagectomy for thoracic EC were retrospectively analyzed. Using the 75th percentile of the total drainage volume of chest tubes as a cutoff value, the high-output (HO; n = 35) and low-output (LO; n = 103) groups were compared in terms of the clinicopathological parameters. The median durations of right and left chest tube placement were 6 and 9days, respectively, with a median total drainage volume of 2692ml. When compared with the LO group, the HO group was significantly associated with male gender, a subcutaneous route for reconstruction, blood transfusion, higher morbidity, and prolonged chest drainage and postoperative hospital stays. A multivariable analysis further identified blood loss (p = 0.03) and the subcutaneous route for reconstruction (p = 0.04) as independent risk factors for increased chest tube drainage after esophagectomy. Blood loss and the subcutaneous route of reconstruction are risk factors for increased drainage of chest tube after esophagectomy for EC.

Risk Prediction of Postoperative Pneumonia After Subtotal Esophagectomy Based on Preoperative Serum Cholinesterase Concentrations

Patients undergoing subtotal esophagectomy for esophageal cancer frequently experience postoperative pneumonia. Development of preoperatively determined predictors for postoperative pneumonia will facilitate identifying high-risk patients and will assist with informing patients about their risk of postoperative pneumonia, enabling physicians to estimate with greater accuracy, will result in tailoring perioperative management. Postoperative pneumonia was defined according to the revised Uniform Pneumonia Score. We analyzed the data for 355 patients to compare 32 potential predictive variables associated with postoperative pneumonia after subtotal esophagectomy. Forty-one patients (11.5%) had postoperative pneumonia. Preoperative cholinesterase (ChE) concentrations demonstrated the greatest area under the curve value (0.662) to predict postoperative pneumonia (optimal cutoff value = 217IU/l). Univariate analysis identified a continuous value of preoperative ChE concentration as a significant risk factor for postoperative pneumonia (P = 0.0014). Multivariable analysis using factors potentially relevant to pneumonia revealed that preoperative ChE concentration was one of independent risk factors for pneumonia after esophagectomy (P = 0.008). Patients with low ChE concentrations were at increased risk of postoperative pneumonia in most patient subgroups. Moreover, the odds ratios of low ChE concentrations were highest in patients undergoing neoadjuvant treatment. A combination of preoperative serum ChE concentrations and Brinkman index stratified patients into low, intermediate, and high risk of postoperative pneumonia. Our findings indicate that preoperative ChE concentrations, particularly in combination with Brinkman index, may serve simply as a determined predictor of pneumonia after subtotal esophagectomy and may facilitate physicians' efforts to reduce the incidence of postoperative pneumonia.

Postoperative Inflammation Is an Independent Prognostic Factor in Patients With Thoracic Esophageal Squamous Cell Carcinoma.

The aim of this study was to elucidate the impact of postoperative inflammatory response on prognosis in patients with stage I thoracic esophageal squamous cell carcinoma (ESCC). Seventy-five consecutive patients who underwent subtotal esophagectomy for clinical stage I thoracic ESCC were reviewed retrospectively. Maximum serum CRP level (CRPmax) and white blood celI count (WBCmax) were evaluated as postoperative inflammatory parameters. Prognostic factors were analyzed using Cox proportional hazards modeling. Optimal cut-off values were 10.7 mg/dl for CRPmax and 19,700/mm3 for WBCmax On univariate analyses, older age, worse performance status, higher WBCmax, and infectious complications were significantly associated with poorer overall survival. Multivariate analysis revealed WBCmax >19,700/mm3 to be an independent prognostic factor for poorer overall survival (hazard ratio=3.356; 95% confidence interval=1.221-9.220; p=0.019). A high WBCmax in the early postoperative phase, but not infectious complications, was an independent prognostic factor for poor overall survival in patients with clinical stage I thoracic ESCC.

Acute esophageal necrosis with esophagus perforation treated by thoracoscopic subtotal esophagectomy and reconstructive surgery on a secondary esophageal stricture: a case report

BackgroundAcute esophageal necrosis is defined as necrosis of the esophageal mucosa causing diffuse black pigmentation of the esophagus, the so-called black esophagus from its endoscopic findings. The prevalence is only 0.001~0.2%, while its mortality rate is up to 32%. However, most of the cases are fatal by comorbidities.Case presentationA 67-year-old female with diabetes mellitus was transported to the emergency room with hematemesis and disordered consciousness. She had suffered from nausea and epigastralgia for 2 days. The patient’s general status was shock evidenced by vital signs, and she did not respond to rehydration. After intubation, emergency endoscopic examination revealed black pigmentation of the esophageal mucosa, and the condition was diagnosed as acute esophageal necrosis. Antibiotics and plasmapheresis had been started, and the patient gradually stabilized. One week after the admission, esophagus perforation was suspected from the significant increase of the right pleural effusion and free air at the esophagus wall and the mediastinum on CT scan. Emergency thoracoscopy revealed an edematous esophagus which was colored black. Esophagectomy with esophagostomy and enterostomy was performed.On resected specimen, mucosal necrosis was found only on the squamous epithelium, with three perforating areas in the middle to lower thoracic esophagus. No signs of inflammation or ischemia were found on the gastric mucosa of the esophagogastric junction. After the operation, the patient recovered generally well, except for the severe stenosis of the cervical esophagus. Cervical esophagectomy, tracheotomy, and anterior thoracic route reconstruction with free jejunum interposition and gastric tube were performed 9 months after the first surgery. No postoperative complications occurred; on the 37th day after the operation, the patient was eating well and was transferred to continue swallowing rehabilitation.ConclusionIt is important to detect the esophagus perforation and mediastinitis early and thereby not to miss the chance of surgical intervention to save the patient’s life. Surgery should be minimized, and reconstruction should be considered next.If the cervical esophagus is also affected, reconstruction surgery should be performed by removing cervical esophagus and anastomosing it to the hypopharynx using a gastric tube and free jejunum interposition as needed.

Efficacy of Novel Multispectral Imaging Device to Determine Anastomosis for Esophagogastrostomy

BackgroundBiomedical imaging devices that utilize the optical characteristics of hemoglobin (Hb) have become widespread. In the field of gastroenterology, there is a strong demand for devices that can apply this technique to surgical navigation. We aimed to introduce our novel multispectral device capable of intraoperatively performing quantitative imaging of the oxygen (O2) saturation and Hb amount of tissues noninvasively and in real time, and to examine its application for deciding the appropriate anastomosis point after subtotal or total esophagectomy. Materials and methodsA total of 39 patients with esophageal cancer were studied. Tissue O2 saturation and Hb amount of the gastric tube just before esophagogastric anastomosis were evaluated using a multispectral tissue quantitative imaging device. The anastomosis point was decided depending on the quantitative values and patterns of both the tissue O2 saturation and Hb amount. ResultsThe device can instantaneously and noninvasively quantify and visualize the tissue O2 saturation and Hb amount using reflected light. The tissue Hb status could be classified into the following four types: good circulation type, congestion type, ischemia type, and mixed type of congestion and ischemia. Postoperative anastomotic failure occurred in 2 cases, and both were mixed cases. ConclusionsThe method of quantitatively imaging the tissue O2 saturation and Hb level in real time and noninvasively using a multispectral device allows instantaneous determination of the anastomosis and related organ conditions, thereby contributing to determining the appropriate treatment direction.

An Investigation of Factors Related to Food Intake Ability and Swallowing Difficulty After Surgery for Thoracic Esophageal Cancer

Swallowing difficulty is among the major complications that can occur after surgery for thoracic esophageal cancer. Recurrent laryngeal nerve paralysis (RLNP) has been considered the most significant cause of a postoperative swallowing difficulty, but association between the two has not been adequately explained. We investigated the relation between postoperative RLNP and swallowing difficulty by means of video fluoroscopy. Our study included 32 patients who underwent subtotal esophagectomy for thoracic esophageal cancer at St. Marianna University School of Medicine between April 2014 and March 2017. We evaluated patients’ age and sex, disease stage, preoperative presence of a swallowing difficulty, nutritional status, extent and duration of surgery, blood loss volume, and postoperative presence of RLNP and/or hoarseness. Patients were divided into two groups according to whether oral food intake was possible when video fluoroscopy was performed on postoperative day (POD) 7, and we analyzed the associated factors. Postoperative RLNP occurred in 21 patients (65.6%); hoarseness occurred in 19 (59.4%). Eleven patients (34.4%) suffered swallowing difficulty that prevented food intake. No significant association was found between postoperative swallowing difficulty and postoperative RLNP or hoarseness, but a significant relation was found between the prognostic nutritional index and intraoperative lymph node dissection. Multivariable analysis revealed a significant relation between postoperative swallowing difficulty and only one factor: cervical lymph node dissection (P = 0.0075). There appears to be no relation between RLNP pursuant to esophageal cancer surgery and swallowing difficulty that prevents oral food intake.

Updated German S3 guidelines on esophageal cancer and supplements from a surgical perspective

The updated German S3 guidelines recommend transthoracic subtotal esophagectomy with 2‑field lymphadenectomy for surgical treatment of esophageal cancer in patients with squamous cell carcinoma and adenocarcinoma of the esophagogastric (AEG typeI) junction of the middle and lower third. For AEG typeIII transhiatal extended total gastrectomy with distal esophageal resection is favored. Patients with AEG typeII can be treated by both procedures under the prerequisite that an R0 resection can be achieved. Alimited resection of the distal esophagus and the proximal stomach can only be considered in cT1 N0 M0 possibly cT2 AEG junction without an oncological risk constellation, i.e. gradeG1/G2, intestinal type and no poorly cohesive carcinoma, because the rate of lymph node metastasis at the distal stomach is less than 2%. Minimally invasive procedures provide advantages compared to open esophagectomy due to the lower rate of postoperative total and especially pulmonary complications. This is true for hybrid esophagectomy (laparoscopy and thoracotomy) versus open access in cases of intrathoracic anastomoses and for total minimally invasive esophagectomy including robotic techniques versus open access in cervical esophagogastrostomy.

Is complete right cervical paraesophageal lymph node dissection possible in the prone position during thoracoscopic esophagectomy?

Effective treatment of esophageal cancer requires dissection of the regional lymph nodes (LNs) from the cervical to the abdominal area. In this study, we hypothesized that adequate no. 101R dissection is achieved through a thoracoscopic approach in the prone position. The study cohort was limited to 42 patients who underwent thoracoscopic subtotal esophagectomy with bilateral cervical lymphadenectomy for thoracic esophageal cancer between January 2015 and March 2017. The number of LNs and the incidence of metastasis were analyzed. During the proposed thoracoscopic procedure, cervical paraesophageal LNs were dissected continuously, with the LNs surrounding the recurrent laryngeal nerve (RLN; no. 106rec) as an en bloc resection. In this study, LNs that required further picking up via a cervical incision were defined as no. 101. The recurrent sites among the consecutive patients during the 3-year follow-up, for whom bilateral cervical lymphadenectomy was omitted for lower and middle thoracic tumors between 2012 and 2014, were analyzed further. The data of 42 patients were analyzed. The lymphatic tissues dorsal to the right cervical RLN were almost completely dissected via thoracoscopy. A median of 0 (0-6) LNs were ventral to the right RLN (no. 101R) and no LN metastasis was observed. There were no lymph nodes in 27 patients (64%). By contrast, there was a median of 1(0-10) no. 101L nodes, and LN metastasis was observed in two patients (4.7%). The numbers of LNs at no. 106recR and no. 106recL were 3 (0-9) and 2(0-13), respectively, and the corresponding numbers of patients with metastases at these sites were 11(26%) and 5(12%), respectively. Among the 33 patients who completed the 3-year follow-up, 9 patients developed recurrence, but none involved 101R LNs. There were no residual LNs in the area ventral to the right cervical RLN in 64% of the patients who underwent additional cervical lymphadenectomy after the right thoracoscopic approach in the prone position. Further studies with larger patient cohort or randomization are required to confirm our results.

Prognosis and prognostic factors of esophageal spindle cell carcinoma treated by esophagectomy: a retrospective single-institution analysis.

Esophageal spindle cell carcinoma (ESpCC) is a malignant tumor composed of sarcomatous components. ESpCC is treated as a squamous cell carcinoma. However, because ESpCC is a rare tumor, little is known regarding its prognosis. This study aimed to analyze patients with ESpCC who were surgically treated at our hospital, determine the validity of surgery, and identify factors that indicate a prognosis. Treatment characteristics, overall survival (OS), and recurrence-free survival (RFS) of 28 patients with ESpCC who underwent surgery at our hospital between 1990 and 2016 were assessed. Furthermore, factors associated with OS and RFS were analyzed. Subtotal esophagectomy with 3-field lymph node dissection and lower esophagectomy with 2-field lymph node dissection were performed in 25 and 3 patients, respectively. Chemotherapy was administered as preoperative therapy to two patients. Postoperative therapy, comprising radiotherapy and chemotherapy, was administered to three and nine patients, respectively. The 3- and 5-year RFS were 66.4% and 61.6% and the 3- and 5-year OS were 73% and 61.9%, respectively. Macroscopic type was identified as a prognostic factor. In terms of OS, prognosis was significantly worse in ulcerative-type ESpCC than in the polypoid type. The 5-year OS of ESpCC mainly treated with surgical therapy was 61.9%. However, prognosis was poor in some patients with ulcerative-type ESpCC according to macroscopic type. In the future, it will be necessary to accumulate more cases and investigate therapeutic strategies added to surgery to improve prognosis.

Anastomotic leakage following retrosternal pull-up.

Narrow thoracic inlet might be associated with increased incidence of cervical anastomotic leakage (AL) after esophagectomy with retrosternal reconstruction. We retrospectively evaluated the relationship of the length from the suprasternal notch to the trachea (LST) and AL using computed tomography. In this retrospective study including 121 patients with esophageal cancer who underwent subtotal esophagectomy with retrosternal reconstruction between 2008 and 2016, clinicopathological characteristics, including the LST, surgical procedures, and perioperative outcomes, were compared between the AL and non-AL groups. AL occurred in 19 of the 121 patients (15.7%). There were no associations between AL development and age, sex, body mass index, tumor location, TNM stage, histological type, surgical approach, or type of the anastomotic procedure. Surgery duration was longer in the AL group than in the non-AL group (p = 0.004). Other surgical factors such as intra-operative blood loss and anastomotic technique were not associated with AL. LST was significantly shorter in the AL group than in the non-AL group (p < 0.001). Multivariate analysis revealed that LST was a significant predictor of AL (p < 0.001). LST is a simple and useful predictor of AL after esophagectomy with retrosternal reconstruction.

Primary amelanotic malignant melanoma of the esophagus: a case report

BackgroundPrimary amelanotic malignant melanoma of esophagus, which is a subtype of primary malignant melanoma of the esophagus (PMME), is a very rare disease with a poor prognosis. We herein report a case of the amelanotic type of PMME.Case presentationAn 86-year-old woman was admitted to our hospital with symptoms of dysphagia. An endoscopic examination and constructed radiography revealed an elevated and semipedunculated lesion with an ulcer in the lower thoracic esophagus accompanied by another submucosal lesion of the esophagus. She was diagnosed with esophageal squamous cell carcinoma by a preoperative endoscopic biopsy. We performed thoracoscopy- and laparoscopy-assisted subtotal esophagectomy with lymphadenectomy. Based on the surgical specimens, although there were no melanocytes, we made a diagnosis of a malignant melanoma immunohistochemically; the tumor cells were positive for S-100 protein and HMB45 focally and partially for Melan-A.ConclusionWe experienced a case of primary amelanotic malignant melanoma, and the patient has remained disease-free for 1 year since the surgery. Since the diagnosis of amelanotic type of PMME is difficult, it should be made by the combination of a morphological examination, pathological examination, and immunohistochemistry.