Publications by authors named "Kenro Kawada"

55 Publications

Preoperative lymphocyte-to-monocyte ratio is the most predictive inflammatory response marker of survival in gastric cancer.

Langenbecks Arch Surg 2021 Jun 24. Epub 2021 Jun 24.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Purpose: Systemic inflammatory responses play a key role in cancer progression, and detecting the predictive inflammatory response markers is needed. The present study explored inflammatory response markers capable of predicting survival in patients with gastric cancer.

Methods: We enrolled 264 patients, who underwent curative gastrectomy for clinical stage (cStage) I-III gastric cancer between 2012 and 2015. The cut-off point of eight preoperative inflammatory response markers was determined by receiver operating characteristic (ROC) curve analysis. The marker with the highest Harrell's concordance index (C-index) was adopted for subsequent univariate and multivariate analyses using the Cox proportional-hazards model.

Results: Among eight representative inflammatory response markers, lymphocyte-to-monocyte ratio (LMR; cut-off point, 4.60) achieved the highest C-index (0.633). The 5-year survival rate was significantly worse in patients with LMR < 4.60 than in those with LMR ≥ 4.60 (67.5% versus 89.0%, P < 0.001). In multivariate analysis, LMR < 4.60 was identified as an independent prognostic factor (hazard ratio: 2.372; 95% confidence interval: 1.266-4.442; P = 0.007).

Conclusion: In this study, LMR had the strongest ability to predict the survival of patients with gastric cancer among other inflammatory response markers, with lower LMRs being associated with poor survival following curative gastrectomy.
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http://dx.doi.org/10.1007/s00423-021-02230-9DOI Listing
June 2021

Impact of Preoperative Time Interval on Survival in Patients With Gastric Cancer.

World J Surg 2021 Sep 14;45(9):2860-2867. Epub 2021 Jun 14.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Background: A time interval between diagnosis and surgery for gastric cancer is necessary, although its impact on survival remains controversial. We evaluated the impact of preoperative time interval on survival in gastric cancer patients.

Methods: We enrolled 332 patients who underwent curative gastrectomy for clinical stage (cStage) I-III gastric cancer between 2012 and 2015. We separately analyzed early- (cStage I) and advanced-stage (cStages II and III) patients. Early-stage patients were divided according to preoperative time interval: short (≤ 42 days) and long (> 42 days) groups. Advanced-stage patients were also divided into short (≤ 21 days) and long (> 21 days) groups. We compared the survival between the short and long groups in early- and advanced-stage patients.

Results: The median preoperative time interval was 29 days, and no significant differences were found in patient characteristics between the short and long groups in early- and advanced-stage patients. In early-stage patients, the 5-year survival rates of the short and long groups were 86.5% and 88.4%, respectively (P = 0.917). In advanced-stage patients, the 5-year survival rates were 72.1% and 70.0%, respectively (P = 0.552). In multivariate analysis, a longer time interval was not selected as an independent prognostic factor in early- and advanced-stage patients.

Conclusions: In this study, survival difference was not found based upon preoperative time interval. The results do not affirm the delay of treatment without reason, however, imperative extension of preoperative time interval may be justified from the standpoint of long-term survival.
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http://dx.doi.org/10.1007/s00268-021-06187-0DOI Listing
September 2021

Transoral surgery for superficial head and neck cancer: National Multi-Center Survey in Japan.

Cancer Med 2021 Jun 15;10(12):3848-3861. Epub 2021 May 15.

Department of Gastroenterology, Kobe City Medical Center General Hospital, Kobe, Japan.

Head and neck cancers, especially in hypopharynx and oropharynx, are often detected at advanced stage with poor prognosis. Narrow band imaging enables detection of superficial cancers and transoral surgery is performed with curative intent. However, pathological evaluation and real-world safety and clinical outcomes have not been clearly understood. The aim of this nationwide multicenter study was to investigate the safety and efficacy of transoral surgery for superficial head and neck cancer. We collected the patients with superficial head and neck squamous cell carcinoma who were treated by transoral surgery from 27 hospitals in Japan. Central pathology review was undertaken on all of the resected specimens. The primary objective was effectiveness of transoral surgery, and the secondary objective was safety including incidence and severity of adverse events. Among the 568 patients, a total of 662 lesions were primarily treated by 575 sessions of transoral surgery. The median tumor diameter was 12 mm (range 1-75) endoscopically. Among the lesions, 57.4% were diagnosed as squamous cell carcinoma in situ. The median procedure time was 48 minutes (range 2-357). Adverse events occurred in 12.7%. Life-threatening complications occurred in 0.5%, but there were no treatment-related deaths. During a median follow-up period of 46.1 months (range 1-113), the 3-year overall survival rate, relapse-free survival rate, cause-specific survival rate, and larynx-preservation survival rate were 88.1%, 84.4%, 99.6%, and 87.5%, respectively. Transoral surgery for superficial head and neck cancer offers effective minimally invasive treatment. Clinical trials registry number: UMIN000008276.
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http://dx.doi.org/10.1002/cam4.3927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209601PMC
June 2021

The effectiveness of plasma miR-33a-5p as a predictive biomarker for the efficacy of colorectal cancer chemotherapy.

Oncol Lett 2021 Jun 22;21(6):489. Epub 2021 Apr 22.

Department of Gastrointestinal Surgery, Graduate School, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo 113-8519, Japan.

Several chemotherapeutic options are available for patients with metastatic colorectal cancer (mCRC), making it important to individualize treatment regimens. Individualization requires the clinical application of biomarkers for regimen selection, which is presently insufficient. miRNAs serve an important role in the control of biological processes in several types of cancer, acting as plasma biomarkers. The current study aimed to evaluate novel plasma microRNAs for predicting chemo-resistance in chemotherapy for patients with colorectal cancer (CRC) by employing a Toray 3D-Gene microRNA array-based approach, which compared plasma content before and during treatment. Specific miRNAs that acted as biomarkers of the fluoropyrimidine (FP) + oxaliplatin (OX) + bevacizumab (BEV) regime, a common first-line treatment for mCRC, were searched. The plasma samples of 110 patients with mCRC who had received the FP+OX+BEV regimen were subjected to microarray analyses using the 3D-Gene miRNA microarray platform, after which miRNAs levels were quantified via reverse transcription- quantitative PCR. Patients exhibiting complete response, partial response (PR) and reduced stable disease (SD) were defined as responders. Patients with extended SD and progression disease (PD) were defined as non-responders. Following microarray analysis, miR-33a-5p was selected as the candidate miRNA as it was upregulated in non-responder plasma samples. The expression of miR-33a-5p was upregulated in the non-responders (n=15) compared with the responders (n=95) (P=0.032). The high expression group demonstrated significantly poor progression-free survival (P<0.01). To evaluate whether miR-33a-5p can serve as a marker of chemo-resistance, miR-33a-5p expression levels were assessed at the following three time-points: Pre-point (before chemotherapy); PR-point (3-months after chemotherapy began); and PD-point (the time at which recurrence or progression was recorded). The results revealed that expression levels were significantly increased at the PD-point when compared with that at the pre-point (P=0.024). The current study determined that the miR-33a-5p expression level in the plasma may serve as a predictive marker of efficacy and as a biomarker of chemo-resistance.
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http://dx.doi.org/10.3892/ol.2021.12749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8100963PMC
June 2021

The evaluation of the gastric tube blood flow by indocyanine green fluorescence angiography during esophagectomy: a multicenter prospective study.

Gen Thorac Cardiovasc Surg 2021 Jul 30;69(7):1118-1124. Epub 2021 Apr 30.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Objective: We determined the anastomotic site during gastric tube reconstruction in esophagectomy according to the "90-to 60-s rule" using indocyanine green (ICG) fluorescence angiography. We evaluated its safety and efficacy in a prospective multicenter setting.

Methods: We enrolled 129 patients who underwent subtotal esophagectomy for esophageal cancer. ICG fluorescence angiography was performed after making a wide gastric tube, and the time from the initial enhancement of the right gastroepiploic artery to the tip of the gastric tube was used as a parameter. Esophago-gastro anastomosis was made at the area that was enhanced within 90 s (preferably within 60 s). The enhancement time and the incidence of anastomotic leakage were compared.

Results: In all cases, anastomosis was made at the site enhanced within 90 s. Anastomotic leakage was found in only 4 (3.1%) of 129 cases; specifically, it was detected in 3 (2.4%) of 126 cases whose anastomotic site was enhanced within 60 s and in 1 (33.3%) of 3 cases where the enhancement time exceeded 60 s (p = 0.09).

Conclusions: Determining the anastomotic site using the 90-to 60-s rule with ICG imaging in gastric tube reconstruction helps reduce the rate of anastomotic leakage.
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http://dx.doi.org/10.1007/s11748-021-01640-2DOI Listing
July 2021

Evaluation of synchronous multiple primary superficial laryngo-pharyngeal cancers that were treated by endoscopic laryngo-pharyngeal surgery.

Auris Nasus Larynx 2021 Apr 20. Epub 2021 Apr 20.

Department of Head and Neck Surgery, Tokyo Medical and Dental University, Tokyo, Japan.

Objective: ndoscopic laryngopharyngeal surgery (ELPS) is a useful surgery for superficial cancers of the head and neck region, but it has not yet been well evaluated for synchronous multiple primary cancers (multiple primaries). The purpose of this study was to clarify the safety and usefulness of ELPS for patients with multiple superficial primary cancers in the head and neck region.

Methods: rom December 2009 to December 2016, 145patients with superficial head and neck cancers underwent ELPS. The patients were divided into two groups; a group consisting of patients with a single primary cancer (single primary) and another group consisting of patients with synchronous multiple primaries, and the incidences of postoperative complications and lymph node metastasis were retrospectively compared between the two groups.

Results: f the 145 patients, 107 had a single primary cancer and 38 had multiple primaries. There was no significant difference in the age, sex, or rate of intraepithelial cancer between the two groups. Postoperative complications included dysphagia in 6 (5.6%) patients with a single primary and 2 (5.3%) patients with multiple primaries. One patient with multiple primaries required gastrostomy because of aspiration pneumonia. In addition, the following complications were also observed. Laryngeal paralysis occurred in 2 (1.9%) patients with a single primary, and 1 (2.6%) patient with multiple primaries; tracheostomy because of postoperative bleeding in 1 (0.9%) patient with a single primary; infection occurred in 2 (5.3%) patients with multiple primaries. Postoperative lymph node metastasis was found in 7 (6.5%) patients with a single primary and 6 (15.8%) patients with multiple primaries. Lymphatic invasion of the primary cancer was noted in 3 (2.8%) patients with a single primary and 5 (13.2%) patients with multiple primaries, being significantly higher in the latter group.

Conclusion: ELPS is also a safe surgery for patients with multiple primaries. However, the incidence of lymphatic invasion of the primary cancer was significantly higher in patients with multiple primaries.
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http://dx.doi.org/10.1016/j.anl.2021.03.022DOI Listing
April 2021

Histological study of the thin membranous dense connective tissue around the middle and lower thoracic esophagus, caudal to the bifurcation of the trachea.

Gen Thorac Cardiovasc Surg 2021 Jun 13;69(6):983-992. Epub 2021 Mar 13.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Objective: We previously reported on the thin membranous dense connective tissue around the esophagus in the upper mediastinum. This time, we histologically investigated the existence of similar structures in the middle and lower mediastinum, caudal to the bifurcation of the trachea.

Methods: Semi-sequential transverse sections of the mediastinum were obtained from two cadavers. Hematoxylin and eosin staining and Elastica van Gieson staining were performed.

Results: In the middle mediastinum, the "visceral sheath" could not be observed completely around the esophagus. In the lower mediastinum, the thin membranous dense connective tissue was observed beneath the pericardium on the ventral side of the esophagus. On the dorsal side of the esophagus, two thin membranous dense connective tissues were similarly observed in two cadavers. One existed between the dorsal side of the esophagus and the three vessels (i.e., the descending aorta, the azygos vein and the thoracic duct) and was integrated with the thin membranous dense connective tissue of the ventral side of the esophagus at the bilateral side of the esophagus. This integrated dense connective tissue reached the left subpleural region and the adventitia of the aorta on the left side and the peripleural and pulmonary hilum on the right side. The other thin membranous dense connective tissue, which represents the "vascular sheath", was observed between the descending aorta and the thoracic duct.

Conclusion: These two thin membranous dense connective tissues, which are considered to represent the visceral sheath and vascular sheath, are thought to be available as optimal dissecting layers for radical esophagectomy.
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http://dx.doi.org/10.1007/s11748-021-01615-3DOI Listing
June 2021

Histological changes in the human esophagus following triamcinolone injection to prevent esophageal stricture after endoscopic submucosal dissection.

Esophagus 2021 Jul 2;18(3):594-603. Epub 2021 Mar 2.

Department of Gastrointestinal Surgery, Graduate School of Medical and Dental Sciences (Medicine), Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Background: Locoregional steroid injection prevents post-endoscopic submucosal dissection (ESD) esophageal stricture, but histological changes that occur following steroid injection in the human esophagus are unclear. This study investigated the histopathological characteristics caused by locoregional triamcinolone acetonide (TA) injection using human esophagectomy specimens.

Methods: From January 2014 to December 2019, among 297 patients (373 lesions) who underwent esophageal ESD, 13 patients who underwent additional esophagectomy after ESD were examined. Seven patients (TA group) with wide excisions were injected with TA after ESD and another six patients (Non-TA group) with smaller tumors were not injected with TA. The clinical background of these patients and histopathological features of ESD ulcer scar obtained from esophagectomy specimens were retrospectively investigated.

Results: The circumferential rate of ESD excision was more than three-quarters in all cases in the TA group, whereas it was less than three-quarters in the Non-TA group. No other statistical difference in the clinical background was found between the two groups. The subepithelial fibrous tissue of the ESD ulcer scar in the TA group was significantly thinner than that in the Non-TA group (P < 0.05). There was no significant difference in the thickness of the regenerated epithelium and muscularis propria layer of the ESD ulcer scar.

Conclusions: Histological finding of thinning of the subepithelial fibrous tissue of ESD ulcer scar in the human esophagus after TA injection was obtained. This suggests that TA suppresses the proliferation of the fibrous tissue of the subepithelial layer to help prevent esophageal stricture after widespread ESD in the human esophagus.
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http://dx.doi.org/10.1007/s10388-021-00818-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172396PMC
July 2021

Linked Color Imaging Focused on Neoplasm Detection in the Upper Gastrointestinal Tract : A Randomized Trial.

Ann Intern Med 2021 01 20;174(1):18-24. Epub 2020 Oct 20.

National Hospital Organization Hakodate National Hospital, Hakodate, Japan (M.K.).

Background: Linked color imaging (LCI) is a new image-enhanced endoscopy technique that allows users to recognize slight differences in mucosal color.

Objective: To compare the performance of LCI with white light imaging (WLI) in detecting neoplastic lesions in the upper gastrointestinal tract.

Design: A controlled, multicenter trial with randomization using minimization. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000023863).

Setting: 16 university hospitals and 3 tertiary care hospitals in Japan.

Patients: 1502 patients with known previous or current cancer of the gastrointestinal tract and undergoing surveillance for gastrointestinal cancer.

Intervention: WLI followed by LCI examination (WLI group) or LCI followed by WLI examination (LCI group).

Measurements: Diagnosis of 1 or more neoplastic lesions in the pharynx, esophagus, or stomach in the first examination (primary outcome) and 1 or more neoplastic lesions overlooked in the first examination (secondary outcome).

Results: 752 patients were assigned to the WLI group and 750 to the LCI group. The percentage of patients with 1 or more neoplastic lesions diagnosed in the first examination was higher with LCI than with WLI (60 of 750 patients or 8.0% [95% CI, 6.2% to 10.2%] vs. 36 of 752 patients or 4.8% [CI, 3.4% to 6.6%]; risk ratio, 1.67 [CI, 1.12 to 2.50;  = 0.011]). The proportion with overlooked neoplasms was lower in the LCI group than in the WLI group (5 of 750 patients or 0.67% [CI, 0.2% to 1.6%] vs. 26 of 752 patients or 3.5% [CI, 2.3% to 5.0%]; risk ratio, 0.19 [CI, 0.07 to 0.50]).

Limitation: Endoscopists were not blinded.

Conclusion: LCI is more effective than WLI for detecting neoplastic lesions in the pharynx, esophagus, and stomach.

Primary Funding Source: Fujifilm Corporation.
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http://dx.doi.org/10.7326/M19-2561DOI Listing
January 2021

The Impact of Hybrid Minimally Invasive Esophagectomy with Neck-Abdominal First Approach on the Short- and Long-Term Outcomes for Esophageal Squamous Cell Carcinoma.

World J Surg 2020 Nov;44(11):3829-3836

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima Bunkyo-ku, Tokyo, 113-8519, Japan.

Background: Currently, there is no consensus for an optimal minimally invasive esophagectomy (MIE) approach. This study aimed to compare hybrid MIE (hMIE) with neck-abdominal first approach to standard open esophagectomy (OE).

Methods: Data from a cohort of 301 patients were retrospectively analyzed. All participants received either hMIE or OE for the treatment of esophageal squamous cell carcinoma at Tokyo Medical and Dental University between January 2003 and December 2013. Analyses included propensity score matching and the Kaplan-Meier statistical method to determine overall survival (OS) and disease-free survival (DFS) of the cohort.

Results: After one-to-one propensity score matching, there were 68 patient pairs. The hMIE group had significantly lower incidence of severe postoperative complications (20.1% vs. 7.4%; p = 0.026) and severe respiratory complications (7.4% vs. 0%; p = 0.058) than the OE group. The 5-year oncological outcomes of the two groups were almost equivalent (OS: OE, 55.0%; hMIE, 69.0%; p = 0.063 and DFS: OE, 54.0%; hMIE, 62.0%; p = 0.28).

Conclusions: This study compared hMIE with neck-abdominal first approach to standard OE. The results showed significantly less severe postoperative complications for hMIE with neck-abdominal first approach in comparison with OE, without a compromise in long-term oncological outcomes.
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http://dx.doi.org/10.1007/s00268-020-05655-3DOI Listing
November 2020

The evaluation of the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy.

Gen Thorac Cardiovasc Surg 2020 Aug 13;68(8):841-847. Epub 2020 Apr 13.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Objective: We herein evaluated the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy.

Methods: Thirty-two cases of subtotal esophagectomy and gastric tube reconstruction for esophageal cancer were studied. The new device measures the regional tissue saturation of oxygen (rSO: 0-99%) and total hemoglobin index (T-HbI: 0-1.0) with a small sensor. We measured these values at the antrum (point A), final branch of the right gastroepiploic artery (point B) and planned anastomotic point (point C) before and after gastric tube formation. The values at the three points were compared, and the gradients at the three points from before to after gastric tube formation were compared.

Results: The mean values of rSO at point A, B, and C before gastric tube formation were 57.2%, 57.8% and 56.0%, and those after formation were 54.6%, 58.0% and 55.8%, respectively. There was no significant difference in the comparison of the rSO gradient before and after formation (p = 0.167). The mean values of T-HbI at point A, B, and C before formation were 0.126, 0.178 and 0.211, and those after formation were 0.167, 0.247 and 0.292, respectively. There was no significant difference in the gradient of the increase before and after formation (p = 0.461).

Conclusion: A new device has shown that the gastric tube used in our facility is one that maintains tissue saturation of oxygen and does not cause excessive congestion at anastomosis.
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http://dx.doi.org/10.1007/s11748-020-01350-1DOI Listing
August 2020

Flexible Gastric Tube: A Novel Gastric Tube Formation Method to Prevent Anastomotic Leakage.

Ann Thorac Surg 2020 06 20;109(6):e445-e447. Epub 2020 Feb 20.

Department of Esophageal Surgery, Tokyo Medical and Dental University, Tokyo, Japan.

Gastric tube reconstruction is now the method most frequently used for digestive tract reconstruction after the resection of esophageal carcinoma. In our institute, a flexible gastric tube designed to supply a sufficient amount of blood to the tip of the gastric tube (the same as a subtotal gastric tube) and simultaneously provide sufficient length for tension-free anastomosis in the cervical surgical field (the same as a narrow gastric tube) was introduced. This gastric tube formation method has contributed to reducing the rate of anastomotic leakage.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.084DOI Listing
June 2020

The usefulness of a bilateral trans-cervical pneumomediastinal approach for mediastinoscopic radical esophagectomy: a right transcervical approach is an available option.

Gen Thorac Cardiovasc Surg 2019 Oct 25;67(10):884-890. Epub 2019 Jul 25.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Objective: We investigated the merits and demerits of right cervical open surgery with right trans-cervical pneumomediastinal approach in mediastinoscopic esophagectomy.

Methods: Ten thoracic esophageal cancer patients were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach.

Results: The average number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without using the right trans-cervical pneumomediastinal approach, it might be impossible to successfully remove some of the right cervical and upper mediastinal paraesophageal lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes lymph nodes. Regarding surgical complications, one case of bilateral recurrent nerve palsy as well as two cases on the right and two cases on the left were noted.

Conclusions: Although the rate of recurrent nerve palsy should still be reduced, a bilateral (especially right-sided) trans-cervical pneumomediastinal approach is an available option for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.
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http://dx.doi.org/10.1007/s11748-019-01179-3DOI Listing
October 2019

Mid- and long-term outcomes of endoscopic resection for submucosal esophageal cancer types pT1b-SM1 and pT1b-SM2.

Endosc Int Open 2019 Jun 17;7(6):E733-E742. Epub 2019 May 17.

Department of Esophageal Surgery, Tokyo Medical and Dental University, Tokyo, Japan.

 Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) are promising therapeutic options for early esophageal cancer (EC). The factors that can affect mid- and long-term survival in patients with submucosal EC (SM1 and SM2) have not been described in the literature. We aim to describe clinicopathological outcomes and factors that can affect the mid- and long-term survival in patients with resected submucosal tumors.  We performed a retrospective analysis of patients who underwent endoscopic resection (ER) for submucosal tumors over a 20-year period. The final study population included 119 cases with 137 lesions. Information was collected according to the Japanese Classification of Esophageal Cancer 11-edition and factors affecting survival for 2 and 5 years after ER were analyzed.  EMR was performed in 99 cases (72.3 %), ESD in 38 cases (27.7 %). There were no significant complications. Two- and 5-year survival rates were 91 % and 82 %, respectively. Mean age was 67.22 years (± 9.49 years), mortality caused by EC occurred in 13 cases (11 %). Factors that had a significant impact on long-term survival were age > 65 years (  = 0.0026), number of resected specimens (  = 0.0031), presence of another progressive disease (not EC) (  ≤ 0.001), recurrence (  = 0.0002), and relation between histopathological positive vertical margin and recurrence (  = 0.0112).  ER is viable treatment for esophageal submucosal cancer, selection between ESD/EMR can depend on tumor size and patient condition, and en bloc ER is the recommended technique for submucosal tumors. Long-term survival factors were identified.
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http://dx.doi.org/10.1055/a-0838-5180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524998PMC
June 2019

A feasibility study of mediastinoscopic radical esophagectomy for thoracic esophageal cancer from the viewpoint of the dissected mediastinal lymph nodes validated with thoracoscopic procedure: a prospective clinical trial.

Esophagus 2019 04 8;16(2):214-219. Epub 2019 Feb 8.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Purpose: A prospective trial evaluated the feasibility and safety of "mediastinoscopic esophagectomy with lymph node dissection" (MELD).

Methods: Eligible patients had thoracic esophageal squamous cell carcinoma, excluding T4, a bulky primary lesion or distant metastasis. Ten patients were enrolled and treated between September 2015 and March 2018. Additionally, to verify the integrity of the mediastinal lymph node dissection, thoracoscopic observation and lymph node dissection were followed. The primary end point was the integrity of mediastinal lymph node dissection. The secondary end points were the short-term outcomes, including mortality and morbidity.

Results: The median number of dissected lymph nodes in the upper mediastinal to cervical region and middle to lower mediastinal region by mediastinoscopy/thoracoscopy was 27/0.5 and 11.5/0, respectively. The median total operation time was 615 min, the median bleeding amount was 476 ml, and the median postoperative hospital stay was 15.5 days. Regarding complications of more than grade III according to the Clavien-Dindo classification, four had sputum excretion difficulty, one had pneumothorax and one had bilateral recurrent nerve palsy, but none required conversion to thoracotomy, and no operative deaths occurred.

Conclusion: Although the rate of recurrent nerve palsy still should be reduced, our mediastinoscopic lymphadenectomy technique is closely similar to radical esophagectomy.
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http://dx.doi.org/10.1007/s10388-018-00656-7DOI Listing
April 2019

Long-term outcomes of endoscopic resection and metachronous cancer after endoscopic resection for adenocarcinoma of the esophagogastric junction in Japan.

Gastrointest Endosc 2019 06 18;89(6):1120-1128. Epub 2018 Dec 18.

Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan.

Background And Aims: Endoscopic resection (ER) of superficial adenocarcinoma of the esophagogastric junction (AEGJ) has been shown to be safe and effective. However, long-term data in patients undergoing ER for superficial AEGJ in Japan are still limited. The aim of this study was to determine the effect of ER on survival and occurrence of metachronous cancer of patients with superficial AEGJ.

Methods: A retrospective analysis of patients who underwent or endoscopic submucosal dissection (ESD) for superficial AEJG in 13 centers in Japan was performed. The patients were classified as either low risk or high risk for lymph node metastasis based on histologic features. The incidence of metachronous AEGJ as well as overall survival and disease-specific survival rates were calculated.

Results: A total of 372 patients who underwent ER were included, in which 277 patients were low risk and 95 high risk for lymph node metastasis. Five-year cumulative incidences of local recurrence were 13% and .5% in the EMR and ESD groups, respectively (P < .01). Six AEGJ deaths were observed in the high-risk group and none in the low-risk group. The 5-year overall survival rates in the low-risk group without additional treatment, the high-risk group with additional treatment, and the high-risk group without additional treatment were 93.9%, 77.7%, and 81.6%, respectively. The 5-year disease-specific survival rates in the 3 groups were 100%, 94.4%, and 92.8%, respectively. The 5-year cumulative incidence of metachronous AEGJ in 316 patients without additional treatment was 1.1%.

Conclusions: Favorable long-term outcomes with ER were observed in patients with AEGJ who met the low-risk criteria for lymph node metastasis. ESD was a reasonable and effective treatment in Japanese patients.
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http://dx.doi.org/10.1016/j.gie.2018.12.010DOI Listing
June 2019

Diagnosis using deep-learning artificial intelligence based on the endocytoscopic observation of the esophagus.

Esophagus 2019 04 13;16(2):180-187. Epub 2018 Dec 13.

AI Medical Service Inc., Tokyo, Japan.

Background And Aims: The endocytoscopic system (ECS) helps in virtual realization of histology and can aid in confirming histological diagnosis in vivo. We propose replacing biopsy-based histology for esophageal squamous cell carcinoma (ESCC) by using the ECS. We applied deep-learning artificial intelligence (AI) to analyse ECS images of the esophagus to determine whether AI can support endoscopists for the replacement of biopsy-based histology.

Methods: A convolutional neural network-based AI was constructed based on GoogLeNet and trained using 4715 ECS images of the esophagus (1141 malignant and 3574 non-malignant images). To evaluate the diagnostic accuracy of the AI, an independent test set of 1520 ECS images, collected from 55 consecutive patients (27 ESCCs and 28 benign esophageal lesions) were examined.

Results: On the basis of the receiver-operating characteristic curve analysis, the areas under the curve of the total images, higher magnification pictures, and lower magnification pictures were 0.85, 0.90, and 0.72, respectively. The AI correctly diagnosed 25 of the 27 ESCC cases, with an overall sensitivity of 92.6%. Twenty-five of the 28 non-cancerous lesions were diagnosed as non-malignant, with a specificity of 89.3% and an overall accuracy of 90.9%. Two cases of malignant lesions, misdiagnosed as non-malignant by the AI, were correctly diagnosed as malignant by the endoscopist. Among the 3 cases of non-cancerous lesions diagnosed as malignant by the AI, 2 were of radiation-related esophagitis and one was of gastroesophageal reflux disease.

Conclusion: AI is expected to support endoscopists in diagnosing ESCC based on ECS images without biopsy-based histological reference.
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http://dx.doi.org/10.1007/s10388-018-0651-7DOI Listing
April 2019

Detection of Second Primary Malignancies of the Esophagus and Hypophraynx in Oral Squamous Cell Carcinoma Patients.

Laryngoscope Investig Otolaryngol 2018 Aug 9;3(4):263-267. Epub 2018 Aug 9.

Department of Surgery Soka Municipal Hospital Saitama Japan.

Objective: To assess the usefulness of modified esophagogastroduodenoscopy (EGD) for the detection of second primary malignancies of the esophagus or hypopharynx in patients with oral squamous cell carcinoma and determine the association between the oral lesion subsite and esophageal or hypopharyngeal lesion occurrence.

Study Design: Retrospective review.

Methods: In total, 166 patients with oral squamous cell carcinoma without any established symptoms of esophageal or hypopharyngeal squamous cell carcinoma underwent modified EGD based on the Valsalva maneuver and U-turn method, image-enhanced endoscopy, and chromoendoscopy using Lugol's iodine for diagnosis. All suspected lesions were biopsied to determine the clinical stages and duplication rates. Odds ratios for the occurrence of duplicate lesions according to the oral lesion subsite were determined.

Results: In total, 37 esophageal and 16 hypopharyngeal lesions were detected. According to the Union for International Cancer Control/American Joint Committee on Cancer classification (2009), 75.7% and 5.4% esophageal lesions were classified as stage IA and IB, respectively, and 50% and 18.8% hypopharyngeal lesions as stage II and stage I, respectively. Approximately 59.1% and 50% esophageal and hypopharyngeal lesions, respectively, were successfully treated by endoscopic resection. Oral lesions involving the floor of the mouth were more frequently accompanied by second primary malignancies of the esophagus or hypopharynx.

Conclusions: Modified EGD is an effective noninvasive technique for early diagnosis and treatment of second primary malignancies of the esophagus and hypopharynx in patients with oral squamous cell carcinoma. In particular, patients with floor of the mouth lesions need close monitoring for hypopharyngeal and esophageal lesions.

Level Of Evidence: 3b.
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http://dx.doi.org/10.1002/lio2.179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119782PMC
August 2018

Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum.

Esophagus 2018 10 13;15(4):272-280. Epub 2018 Jun 13.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Background: The structure of the fascia in upper mediastinum has already been reported from gross anatomical viewpoints by Sarrazin. But it is necessary to understand meticulous anatomy for thoracoscopic or mediastinoscopic surgery. So herein, we investigate histologically the thin membranous structure made of dense connective tissues.

Methods: Semi-sequential transverse sections of the mediastinum were obtained from three cadavers. Hematoxylin and eosin staining, Elastica van Gieson staining, and Masson trichrome staining were performed to identify the presence and location of the thin membranous structure made of dense connective tissues.

Results: The "visceral sheath" and "vascular sheath," as previously described by Sarrazin, were observed histologically. These two thin membranous structures do not surround the esophagus and trachea cylindrically. In addition, the "visceral sheath" on the right side of the upper mediastinum was unclear in comparison to the left side. The "visceral sheath" (on the left side) gradually became unclear, and seemed to almost disappear; the esophagus was found to be very close to the thoracic duct on the caudal side of the bifurcation of the trachea. Although the left recurrent nerve was located inside the "visceral sheath" in all cadavers, the left recurrent nerve lymph nodes were located inside the "visceral sheath" in cadaver 1 and between the "visceral sheath" and "vascular sheath" in cadaver 3.

Conclusion: The "visceral sheath" around the esophagus in the upper mediastinum was histologically demonstrated; however, the findings were not constant.
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http://dx.doi.org/10.1007/s10388-018-0625-9DOI Listing
October 2018

Comparative Study of Predictive Mortality Scores in Esophagectomy with Three-Field Lymph Node Dissection in Patients with Esophageal Cancer.

Dig Surg 2019 30;36(1):67-75. Epub 2018 Jan 30.

Background/aim: Esophagectomy is still the best therapeutic option for curing resectable esophageal cancer (EC). Radical surgical resection with three-field lymphadenectomy (3FLD) is a potentially curative treatment option. We compared the predictive accuracy of 5 different scores in patients with EC who underwent 3FLD.

Methods: Five years' worth of medical records in a single institution were analyzed (January 2010 to January 2015) from 311 patients who underwent esophagectomy for EC. We selected 191 in whom 3FLD was performed. Mortality was calculated based on 5 predictive scores. Outcomes measures were intraoperative mortality, 30-day mortality, and 1- and 2-year mortality after surgery.

Results: Intraoperative mortality and 30-day mortality after surgery was 0%; 1 and 2-year mortality were 19.8 and 31.4%, respectively. The area under the curve showed poor discriminatory power for all 5 scores (<0.7). In one-way analysis of variance, for 1 year mortality, Portsmouth-Physiological and Operative Severity Score for mortality (P-Possum) was significant (p = 0.0424); in a multivariable analysis for 2-year mortality, P-Possum (p < 0.0001) remained significant.

Conclusion: There is no accurate prognosis score for esophagectomy in patients who undergo high-risk procedures like 3FLD. New scores are needed to predict the mortality after 3FLD with good discriminatory power. Independent factors affect survival and may function as the baseline for obtaining a new accurate mortality score.
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http://dx.doi.org/10.1159/000486551DOI Listing
April 2019

Comparative analysis of avascular areas in superficial esophageal squamous cell carcinomas using in vivo and ex vivo magnifying endoscopy.

Endosc Int Open 2017 Oct 9;5(10):E999-E1004. Epub 2017 Oct 9.

Tokyo Medical and Dental University Hospital - Gastrointestinal Surgery, Tokyo, Japan.

Background And Study Aims:  An avascular area (AVA), one of the microvasculature changes in superficial esophageal cancers, appears when a tumor demonstrates a bulky growth pattern. We aimed to compare endoscopic and histopathological findings by observing formalin-fixed AVA specimens using magnifying endoscopy.

Patients And Methods:  A prospective analysis was conducted on 16 patients with superficial esophageal cancer, including AVA, who underwent endoscopic submucosal dissection (ESD). Magnifying endoscopy and blue laser imaging were used to identify AVAs. After the ESD, the AVA width was measured on formalin-fixed specimens using magnifying endoscopy, and AVA thickness and depth were determined after hematoxylin and eosin staining using microscopy.

Results:  Mean AVA widths of M1, M2, and M3/SM-lesions were 0.434, 0.578, and 0.835 mm, respectively (M1 vs. M2, P = 0.16; M2 vs. M3/SM-,  = 0.07). Mean AVA thicknesses of M1, M2, and M3/SM-lesions were significantly different (0.176, 0.518, and 0.800 mm; M1 vs. M2, P < 0.01; M2 vs. M3/SM-,  < 0.05). There was a significant correlation between AVA width and thickness.

Conclusions:  AVA size can be measured accurately on formalin-fixed specimens with magnifying endoscopy. AVA thickness can be useful for determining tumor depth.
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http://dx.doi.org/10.1055/s-0043-117956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633492PMC
October 2017

Anatomical study of the left superior mediastinal lymphatics for tracheal branches of left recurrent laryngeal nerve-preserving mediastinoscope-assisted surgery in esophageal cancer.

Surg Today 2018 Mar 20;48(3):333-337. Epub 2017 Oct 20.

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.

Purpose: Curative treatment of esophageal cancer requires meticulous superior mediastinal lymphadenectomy, in addition to esophagectomy, because superior mediastinal lymph node metastases are common in esophageal cancer. When preserving the tracheal branches of the left recurrent laryngeal nerve (RLN), good anatomical understanding is required for confirmation of the positional relationships between the courses of lymphatic vessels, lymph node distribution, and the left RLN and its tracheal branches. We performed a detailed anatomical examination of these relationships.

Methods: Macroscopic anatomical observation and histological examination was performed on cadavers. In addition to hematoxylin and eosin staining, immunostaining using antipodoplanin antibody D2-40 (podoplanin) was performed to identify the lymphatic vessels.

Results: The tracheal branches of the left RLN were clearly observed, but no lymphatic vessels crossing the ventral or dorsal side of the branches were identified either macro-anatomically or histologically.

Conclusion: No complex lymphatic network structure straddling the plane composed of tracheal branches of the left RLN was found in the left superior mediastinum. This suggests that dissection of the lymph nodes around the left RLN via the pneumomediastinum method using the left cervical approach may allow preservation of the tracheal branches of the left RLN by maintaining dissection accuracy.
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http://dx.doi.org/10.1007/s00595-017-1600-0DOI Listing
March 2018

A Pilot Trial of S-1 and Paclitaxel in Unresectable or Postoperative Recurrent Esophageal Squamous Cell Carcinoma Pretreated by Fluorouracil, Cisplatin, and Docetaxel Chemotherapy.

Dig Surg 2018 30;35(2):131-137. Epub 2017 May 30.

Department of Esophageal Surgery, Tokyo Medical and Dental University, Tokyo, Japan.

Background/aims: This study documents the clinical efficacy and toxicity of S-1 and paclitaxel (S1/PTX) in patients with unresectable or postoperative recurrent esophageal squamous cell carcinoma (ESCC) who had been previously treated with fluorouracil (5FU), cisplatin, and docetaxel.

Methods: Twenty-eight ESCC patients treated using S1/PTX at our institute since 2010 were enrolled in this study. S1 was administered orally at a dose of 80 mg/m2/day from days 1 to 14, and PTX was administered intravenously on days 1 and 8 at a dose of 80-100 mg/m2.

Results: A total of 106 cycles (median 2.5 cycles, range 1-12 cycles) were administered. The response rate was 14.8%, including 3 complete responses. The median progression-free survival time was 137 days, and the median overall survival time was 306 days. Severe neutropenia occurred in 13 patients, and 3 showed febrile neutropenia. All non-hematological toxicities were mild, and peripheral nerve paralysis was observed in 2 patients.

Conclusion: S1/PTX was found to have tolerable clinical efficacy in terms of the response rate, survival and toxicity in patients with unresectable or postoperative recurrent ESCC who had previously been treated with 5FU, cisplatin, and docetaxel.
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http://dx.doi.org/10.1159/000477265DOI Listing
September 2018

Case of Superficial Cancer Located at the Pharyngoesophageal Junction Which Was Dissected by Endoscopic Laryngopharyngeal Surgery Combined with Endoscopic Submucosal Dissection.

Case Rep Otolaryngol 2017 5;2017:1341059. Epub 2017 Jan 5.

Department of Human Pathology, Tokyo Medical and Dental University, Tokyo, Japan.

. In order to determine the indications of transoral surgery for a tumor located at the pharyngoesophageal junction, the trumpet maneuver with transnasal endoscopy was used. Its efficacy is reported here. . An 88-year-old woman complaining of dysphagia, diagnosed with cervical esophageal cancer, and hoping to preserve her voice and swallowing function was admitted to our hospital. Conventional endoscopy showed that the tumor had invaded the hypopharynx. When inspecting the hypopharynx and the orifice of the esophagus, we asked the patient to blow hard and puff her cheeks with her mouth closed (trumpet maneuver). After the trumpet maneuver, the pharyngeal mucosa was stretched out. The pedicle of the tumor arose from the left-anterior wall of the pharyngoesophageal junction, so we decided to perform endoscopic resection. . Under general anesthesia, the curved laryngoscope made it possible to view the whole hypopharynx, including the apex of the piriform sinus and the orifice of the esophagus. The cervical esophageal cancer was pulled up to the hypopharynx. Under collaboration between a head and neck surgeon and an endoscopist, the tumor was resected en bloc by endoscopic laryngopharyngeal surgery combined with endoscopic submucosal dissection. . Transnasal endoscopy using the trumpet maneuver is useful for a precise diagnosis of the pharyngoesophageal junction. Close collaboration between head and neck surgeons and endoscopists can provide good results in treating tumors of the pharyngoesophageal junction.
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http://dx.doi.org/10.1155/2017/1341059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244026PMC
January 2017

A prospective study of nutritional supplementation for preventing oral mucositis in cancer patients receiving chemotherapy.

Asia Pac J Clin Nutr 2017 Jan;26(1):42-48

Department of Esophageal Surgery, Tokyo Medical and Dental University, Japan.

Background And Objectives: Patients undergoing chemotherapy often develop distressing adverse effects such as oral mucositis and diarrhea. Nutritional support with elemental diet is effective against various gastrointestinal complications and may exert protective effects against adverse effects induced by chemotherapy. To evaluate the influence of elemental diet on chemotherapy-induced oral mucositis and diarrhea, we conducted a randomized control trial in patients with esophageal cancer undergoing chemotherapy.

Methods And Study Design: Twenty esophageal cancer patients receiving chemotherapy with 5-fluorouracil plus cisplatin were assigned randomly to one of the following two groups: (1) receiving elemental diet with Elental (one pack per day) for 14 days and (2) not receiving Elental during chemotherapy. The severity of oral mucositis and diarrhea was graded using clinical examination by doctors and a standard questionnaireon days 1-14.

Results: Based on the analysis of the standard questionnaire, the distribution of the maximum severity of oral mucositis showed a statistically significant reduction in the Elental group (p=0.020), while clinical examination showed insignificant reduction but shift toward lower grade. In the Elental group, the incidence of oral mucositis (grade >=2) reduced consistently and the median grade was lower at all-time points. Regarding diarrhea, no difference was observed between the two groups based on the analysis of the standard questionnaire and clinical examination results.

Conclusions: This study illustrates the effectiveness of oral elemental diet in preventing oral mucositis during chemotherapy. This is a preliminary report and further study with larger patients groups should be devoted to optimization of efficacy.
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http://dx.doi.org/10.6133/apjcn.112015.03DOI Listing
January 2017

A newly developed continuous zoom-focus endocytoscope.

Endoscopy 2017 Feb 14;49(2):176-180. Epub 2016 Nov 14.

Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.

 We report the features of a newly developed endocytoscopy system (ECS), the GIF-Y0074.  The GIF-Y0074 offers high-definition resolution with a consecutive increase of magnification to × 500. Using ECS, we observed 32 cases of esophageal squamous cell carcinoma (ESCC), 11 cases of gastric cancer, and five cases of duodenal adenoma.  The images of cells obtained using the GIF-Y0074 at maximum magnification were brighter and clearer than those obtained with previous ECS systems. For diagnosis of ESCC, clearer visualization of the nucleus made nuclear abnormality easier to recognize. Cancer cells were visualized in 10/11 cases of gastric cancer, but removal of mucus still remained a problem. Duodenal adenomas were found to have atypical cells with villi and tubules at the mucosal surface, thus assisting their histological diagnosis in vivo.  The GIF-Y0074 is an excellent ECS in terms of ease of use, satisfactory resolution, and magnification power, and therefore achieves a level of utility that makes its commercial release justifiable. This ECS heralds a new era of endoscopic and histological diagnosis.
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http://dx.doi.org/10.1055/s-0042-119267DOI Listing
February 2017

Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population.

J Gastroenterol 2017 Jul 18;52(7):800-808. Epub 2016 Oct 18.

Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan.

Background: Little is known about the specific risks of metastasis in esophageal adenocarcinoma in relation to invasion depth or other pathologic factors.

Methods: We conducted a multicenter retrospective study in 13 high-volume centers in Japan from January 2000 to October 2014 to elucidate the risk of metastasis of esophageal adenocarcinoma. A total of 458 patients (217 surgically resected and 241 endoscopically resected) with esophageal adenocarcinoma or esophagogastric adenocarcinoma involving the esophagus were included. Metastasis was considered positive if there was histologically confirmed metastasis in the surgical specimen or clinically confirmed metastasis during follow-up. Metastasis was considered negative if no metastasis was identified in resected specimens and during follow-up in patients treated surgically or no metastasis during follow-up for >5 years in patients treated by endoscopic resection.

Results: Metastasis was identified in 72 patients. Multivariate analysis confirmed lymphovascular involvement [odds ratio (OR) 6.20; 95 % confidence interval (CI) 3.12-12.32; p < 0.001], a poorly differentiated component (OR 3.69; 95 % CI 1.92-7.10; p < 0.001), and lesion size >30 mm (OR 3.12; 95 % CI 1.63-5.97; p = 0.001) as independent risk factors for metastasis. No metastasis was detected in patients with mucosal cancer without lymphovascular involvement and a poorly differentiated component (0/186 lesions) or in patients with cancer invading the submucosa (1-500 µm) without lymphovascular involvement, a poorly differentiated component, and ≤30 mm (0/32 lesions).

Conclusions: Mucosal and submucosal cancers (1-500 µm invasion) without risk factors have a low incidence of metastasis and may thus be good candidates for endoscopic resection.
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http://dx.doi.org/10.1007/s00535-016-1275-0DOI Listing
July 2017

Is a Central Venous Catheter Necessary for the Perioperative Management of Esophagectomy? A Prospective Randomized Pilot Study Comparing Two Different Perioperative Regimens.

Dig Surg 2016 3;33(6):478-87. Epub 2016 Jun 3.

Department of Esophageal Surgery, Tokyo Medical and Dental University, Tokyo, Japan.

Background/aims: Our prospective randomized study examined the possibility of perioperative management of esophagectomy without a central venous catheter (CVC).

Methods: Forty patients who underwent esophagectomy for esophageal cancer were divided into the total parenteral nutrition (TPN; receiving conventional perioperative management via a CVC) and peripheral parenteral nutrition (PPN; receiving perioperative management without a CVC) groups. Albumin and retinol-binding protein (RBP) levels were used as measurements of the nutritional status. Early postoperative complications and catheter-related complications were also evaluated.

Results: The actual calories administered per kg of body weight and the albumin and RBP levels did not significantly differ between the groups. Additionally, there was no significant difference in the morbidity of early postoperative complications between the groups. Catheter-related complications were observed in 4 patients in the TPN group (2 catheter infections, 1 case of thrombosis, and 1 case of iatrogenic pneumothorax), and 4 cases of peripheral phlebitis occurred in the PPN group. The incidence of catheter-related complications did not significantly differ between the groups.

Conclusions: Perioperative management without a CVC can be safely performed in esophagectomy patients, and the decision to insert a CVC should be made based on the patient's perioperative condition.
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http://dx.doi.org/10.1159/000446572DOI Listing
June 2017
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