Small Bowel Obstruction Caused by Small Intestinal Metastasis Secondary to Esophageal Carcinoma

Despite the frequent rapid spread of esophageal cancers to other organs, metastases to the small intestine are uncommon. As such, this paper describes a case of a 60-year-old male who developed a small intestinal obstruction due to metastasis from esophageal carcinoma. This patient had received radical esophagectomy for esophageal carcinoma 14 months prior to the diagnosis. Furthermore, the important role of computed tomography scans played in composing the differential diagnosis will be explored. In order to relieve the obstruction, resection of the small intestine was performed, and the patient survived six months postoperatively.

The Impact of Anastomosis Location in Patients with Lower Thoracic Esophageal Squamous Cell Carcinoma: A Retrospective Observational Study

BackgroundSeveral kinds of anastomoses with varying locations that can be performed after the surgical resection of lower thoracic esophageal squamous cell carcinoma. In this study, we evaluated the prognostic impact of anastomosis locations in these patients who underwent radical esophagectomy.MethodsLower thoracic esophageal squamous cell carcinoma patients which underwent radical esophagectomy and confirmed as microscopically complete resection were retrospectively enrolled. Anastomoses below the aortic arch or below the azygos arch were defined as low anastomosis. Other anastomoses were defined as high anastomosis. Overall survival of these two kinds of anastomoses were analyzed using the log-rank test and Cox regression model.ResultsOf the 781 patients enrolled, 196 and 585 were classified as the low anastomosis and high anastomosis groups, respectively. Overall, the survival time in low anastomosis group (median OS, 36.1 versus 65.4; P=0.01) was shorter than high anastomosis group but no statistical difference was observed in multivariate analysis (P=0.195). Again, no significant difference in survival between low anastomosis and high anastomosis group (median OS, 140.9 versus 124.8; P=0.345) were observed in pT1-T2 subgroup. In pT3-T4 subgroups, patients with low anastomosis group had significantly poorer survival that those with high anastomosis (median OS, 27.1 versus 42.9, P=0.003), even after controlling for other confounders (P=0.026). Notably, the impact of anastomosis location on long-term survival in pT3-4 patients was not significantly modified by nodal status. The internal validation of patients undergoing Sweet approach shown that pT3-T4 patients with high anastomosis had survival advantages (adjusted HR=0.711, 95%CI, 0.601 0.990, P=0.041)ConclusionsFor lower thoracic esophageal squamous cell carcinoma with declared T3-4 status, low anastomosis is associated with worse prognosis and should be avoided.

Effect of single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy on respiration and circulation

Background and purpose We previously developed a new surgical method, namely, single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy. The purpose of this study was to evaluate the effect of carbon dioxide inflation on respiration and circulation using this approach. Methods From April 2018 to October 2020, 105 patients underwent this novel surgical approach. The changes in respiratory and circulatory functions were reported when the mediastinal pressure and pneumoperitoneum pressure were 10 and 12 mmHg, respectively. Data on blood loss, operative time, and postoperative complications were also collected. Results 104 patients completed the operation successfully, except for 1 patient who was converted to thoracotomy because of intraoperative injury. During the operation, respectively, the heart rate, mean arterial pressure, central venous pressure, peak airway pressure, end-expiratory partial pressure of carbon dioxide and partial pressure of carbon dioxide increased in an admissibility range. The pH and oxygenation index decreased 1 h after inflation, but these values were all within a safe and acceptable range and restored to the baseline level after CO2 elimination. Postoperative complications included anastomotic fistula (8.6%), pleural effusion that needed to be treated (8.6%), chylothorax (0.9%), pneumonia (7.6%), arrhythmia (3.8%) and postoperative hoarseness (18.2%). There were no cases of perioperative death. Conclusions When the inflation pressure in the mediastinum and abdomen was 10 mmHg and 12 mmHg, respectively, the inflation of carbon dioxide from single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy did not cause serious changes in respiratory and circulatory function or increase perioperative complications.

111 CLINICAL IMPORTANCE OF MEAN CORPUSCULAR VOLUME AS A PROGNOSTIC MARKER AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

High MCV is suggested to be relevant to the incidence and prognosis of several malignancies. However, few studies investigating the correlation between MCV and survival outcome of esophageal cancer have been conducted. Methods This study included 570 patients with esophageal cancer who underwent radical esophagectomy between April 2005 and December 2017. Patients were divided into two groups according to the standard value of pretreatment MCV: normal (83–99 fL) and high (>99 fL) groups. Clinical backgrounds, short-term outcomes, and prognostic outcomes post-esophagectomy were retrospectively compared between the groups. Results Of all patients, 410 (71.9%) had normal MCV, and 160 (28.1%) had high MCV. High MCV was significantly associated with lower body mass index, higher frequency of habitual alcohol and tobacco use, and higher incidence of multiple primary malignancies other than esophageal cancer. High MCV also correlated with higher incidence of postoperative morbidity of the Clavien–Dindo classification ≥II and pulmonary morbidity. Overall survival was significantly worse in patients with high MCV. Multivariate analysis suggested that high MCV was an independent risk factor for worse survival outcome (hazard ratio, 1.54; 95% confidence interval, 1.098–2.151; p = 0.012). Conclusion Patients with high MCV have various disadvantages in clinical background that can adversely affect both short-term and long-term outcomes after esophagectomy. MCV can become a predictive marker to estimate survival outcome after esophagectomy for esophageal cancer.

190 THE USEFULNESS OF A BILATERAL TRANS-CERVICAL PNEUMOMEDIASTINAL APPROACH FOR MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY

Several authors have reported on the left trans-cervical and transhiatal approaches under pneumomediastinum and right cervical open surgery for mediastinoscopic esophagectomy. However, with these approaches, sufficient dissection of the right upper mediastinal paraesophageal lymph nodes, right recurrent nerve lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes is thought to be difficult. We herein report the usefulness of the ‘bilateral’ trans-cervical pneumomediastinal approach. Methods Ten patients with thoracic esophageal cancer 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. After this approach, thoracoscopic observation was then performed in the left decubitus position, and if the lymph nodes were not sufficiently dissected, the remnant lymph nodes were retrieved thoracoscopically. Results The average total 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 total 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 the right trans-cervical pneumomediastinal approach, roughly four of the right cervical and upper mediastinal paraesophageal lymph nodes and one or two of the subaortic arch to the left tracheobronchial lymph nodes could not have been retrieved. Conclusion A bilateral trans-cervical pneumomediastinal approach is useful for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

303 LONG-TERM SURVIVAL AND PULMONARY COMPLICATIONS IN MEDIASTINOSCOPIC ESOPHAGECTOMY

The radical esophagectomy for esophageal cancer is an invasive therapy due to a long one-lung ventilation. The mediastinoscopic esophagectomy in consideration of pulmonary complications became eligible for Japanese health insurance. Methods Radical esophagectomies (R0/1, gastric tube reconstruction) by thoracotomy/thoracoscopy (groupT) or mediastinoscopy (groupM) were performed for 118/58 or 225 patients with esophageal cancer. The long-term therapeutic results of mediastinoscopic radical esophagectomy are investigated. Results In clinicopathological features, younger and lower PS patients, neoadjuvant chemotherapy, advanced cases, or R1 resection were more frequent in groupT (p < 0.01). Pulmonary complication was not significantly different in both groups (15.5 vs 11.0%, p = 0.19), whereas the any complications, including the recurrent nerve paralysis, were significantly frequent in groupM. The 5-years overall survival was better in group M (53.0% vs 68.2%, p = 0.04), but it may be because of the difference of cancer progression. In the subgroup analysis, the overall survival rate was similar in each clinical stage. The survival of patients with pulmonary complication was significantly worse in groupT. Conclusion The survival of patients underwent trans-mediastinoscopic radical esophagectomy was not different from that with conventional esophagectomy. The influence of pulmonary complications on survival may be lower in mediastinoscopic esophagectomy.

152 SURGICAL PROCEDURE AND OUTCOME OF MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY FOR ESOPHAGOGASTRIC JUNCTION CANCER

We started performing mediastinal lymph node dissection by a laparoscopic transhiatal approach (LTHA) in 2009. To date, 371 patients had undergone our method during various esophageal surgical procedures, including esophagogastric junction cancer (EGJC). Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a simple technique for transmediastinal radical esophagectomy (TMr) without thoracic approach (258 cases). Forty patients with EGJC were also treated by TMr. Methods Left single-port mediastinoscopic cervical approach was performed with pneumomediastinum. Mainly for advanced SCC, upper mediastinal lymph node dissection including recurrent laryngeal nerve LNs was performed with intraoperative monitoring using NIM system. Next, LTHA was performed for en bloc mediastinal lymph node dissection. The esophageal hiatus was opened, and working space was secured by Long Retractors. The posterior plane of the pericardium was extended. The posterior side of LNs was then separated. Finally, while lifting LNs like a membrane, they were resected from bilateral mediastinal pleura. Reconstruction with narrow gastric conduit was performed through substernal tract. Results Patients with EGJC performed TMr were analyzed (n = 40, SCC/Adeno/Others = 21/17/2). Upper mediastinal lymph node metastasis was found in 6 cases (SCC/Adeno = 3/3), middle mediastinal lymph node metastasis was found in 2 cases (SCC/Adeno = 1/1), and all of them had advanced tumors. Their perioperative outcome were compared with those performed the right thoracotomy (n = 41). The operative time and bleeding were decreased by TMr. The number of resected mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in the two groups were not different. In 95.0% of patients treated by TMr, extubation was performed at 0 POD. Postoperative respiratory complications was decreased by TMr (TMr:7.5%, thoracotomy:17.1%). Conclusion This procedure, TMr, resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications in patients with EGJC.

Retrospective analysis of predictive factors for lymph node metastasis in superficial esophageal squamous cell carcinoma

This study aimed to identify the risk factors of lymph node metastasis (LNM) in superficial esophageal squamous cell carcinoma and use these factors to establish a prediction model. We retrospectively analyzed the data from training set (n = 280) and validation set (n = 240) underwent radical esophagectomy between March 2005 and April 2018. Our results of univariate and multivariate analyses showed that tumor size, tumor invasion depth, tumor differentiation and lymphovascular invasion were significantly correlated with LNM. Incorporating these 4 variables above, model A achieved AUC of 0.765 and 0.770 in predicting LNM in the training and validation sets, respectively. Adding macroscopic type to the model A did not appreciably change the AUC but led to statistically significant improvements in both the integrated discrimination improvement and net reclassification improvement. Finally, a nomogram was constructed by using these five variables and showed good concordance indexes of 0.765 and 0.770 in the training and validation sets, and the calibration curves had good fitting degree. Decision curve analysis demonstrated that the nomogram was clinically useful in both sets. It is possible to predict the status of LNM using this nomogram score system, which can aid the selection of an appropriate treatment plan.