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Purpose: The relationship between board certification, clinical guideline implementation, and quality of gastric cancer surgery remains unclear. Methods: A web-based questionnaire survey was administered to departments registered in the National Clinical Database (NCD) of Japan between October 2014 and January 2015. Quality indicators (QIs) based on the Donabedian model were evaluated. Structural QIs (e.g., affiliations with academic societies and board certifications) and process QIs (adherence to clinical practice guidelines for gastric cancer) were assessed using risk-adjusted odds ratios (AORs) for surgical mortality. Multivariable logistic regression models with a generalized estimating equation were used. Results: A total of 835 departments performing 40,992 distal gastrectomies and 806 departments performing 19,618 total gastrectomies responded. Some certified institutions and physicians showed significant associations, with lower AORs for surgical mortality. Important process QIs included pre- and postoperative abdominal CT scanning, endoscopic resection based on progression, curative resection with D2 dissection for advanced gastric cancer, laparoscopic surgery, and HER2 testing for patients with unresectable recurrent gastric cancer. Conclusions: Multiple structural and process QIs are associated with surgical mortality after gastrectomy in Japan. Measuring and visualizing QIs may enhance healthcare improvements. [ABSTRACT FROM AUTHOR]

Purpose: Selected patients with initially unresectable colorectal cancer (CRC) and liver metastases undergo conversion surgery after appropriate chemotherapy. The prognosis of these patients is good, with some even cured of the disease. This retrospective, single-institution study analyzes the clinical importance of patient characteristics on the outcomes of conversion hepatectomy. Methods: We evaluated 229 consecutive patients with initially unresectable CRC and liver metastasis, who underwent systemic chemotherapy. The patients were assigned to groups depending on conversion hepatectomy. Results: Conversion hepatectomy was performed in 30 patients (13.1%). The proportion of patients with extrahepatic metastasis was significantly lower in the conversion group than in the unresectable group (30.0 vs. 66.8%; P < 0.01). The rate of left-sided primary colorectal tumors was significantly higher in the conversion group than in the unresectable group (96.7 vs. 65.8%; P < 0.01). Multivariate analyses identified that left-sided tumors, no extrahepatic metastasis, H1 or H2 grade CLM, and treatment with molecular-targeted agents were associated with conversion hepatectomy (odds ratios: 16.314, 4.216, 7.631, and 4.070; P < 0.01). Overall survival was significantly longer in the conversion group than in the unresectable group (MST: 50.0 versus 14.7 months; P < 0.01). Conclusion: Left-sided primary tumors, absence of extrahepatic metastases, H1 or H2 grade, and use of molecular-targeted agents were associated with successful conversion hepatectomy; thus, patients with these characteristics may be candidates for conversion therapy. [ABSTRACT FROM AUTHOR]

Purposes: The aim of this study was to clarify the impact of a board certification system and the implementation of clinical practice guidelines for pancreatic cancer (PC) on the mortality of pancreaticoduodenectomy in Japan. Methods: By a web questionnaire survey via the National Clinical Database (NCD) for departments participating in the NCD, quality indicators (QIs) related to the treatment for PC, namely the board certification systems of various societies and the adherence to clinical practice guidelines for PC, were investigated between October 2014 and January 2015. A multivariable logistic regression analysis was performed to evaluate the relationship between the QIs and mortality of pancreaticoduodenectomy. Results: Of 1415 departments that registered at least 1 pancreaticoduodenectomy between 2013 and 2014 in NCD, 631 departments (44.6%), which performed pancreaticoduodenectomy for a total of 11,684 cases, answered the questionnaire. The mortality of pancreaticoduodenectomy was positively affected by the board certification systems of the Japanese Society of Gastroenterological Surgery, Japanese Society of Hepato-Biliary-Pancreatic Surgery, Japanese Society of Gastroenterology, and Japanese Society of Medical Oncology as well as by institutions that used magnetic resonance imaging of ≥ 3 T for the diagnosis of PC in principle. Conclusions: The measurement of the appropriate QIs is suggested to help improve the mortality in pancreaticoduodenectomy. Masamichi Mizuma and Hiroyuki Yamamoto equally contributed [ABSTRACT FROM AUTHOR]

Laparoscopic gastrectomy is commonly performed for gastrointestinal stromal tumors (GISTs). Partial gastrectomy is usually achieved with a wedge resection to preserve gastric function; however, performing a wedge resection to excise a large tumor located close to the esophagogastric junction (EGJ) can result in deformation of the stomach and/or the stenosis of the EGJ if the gastric wall resection is excessive. We describe our procedure, in which the whole layer of the gastric wall was cut, maintaining a sufficient margin and confirming the distance between the tumor and the EGJ, by endoscopy and laparoscopy. The defect in the gastric wall was closed using linear staplers by hanging up the stay sutures. Five patients with GIST close to EGJ underwent this procedure, followed by a good postoperative course. Thus, we consider our procedure to be safe and effective for gastric GISTs close to the EGJ. [ABSTRACT FROM AUTHOR]

Purpose: Both squamous cell carcinomas and adenocarcinomas can develop in the esophagogastric junction. To clarify the appropriate lymph node dissection range, lymph node metastases from cancers in the esophagogastric junction were investigated. Methods: The nodal metastases were analyzed in 64 patients with squamous cell carcinoma and 129 with adenocarcinoma according to Siewert's classification, which is based on topographic anatomical criteria for adenocarcinoma. Results: The squamous cell carcinomas located above the esophagocardial junction had more frequent metastasis to the lower and middle mediastinal lymph nodes in proportion to the depth of the tumor. Nodal metastasis was also often detected in the abdominal lymph nodes. In contrast, adenocarcinomas metastasized less frequently to the mediastinal lymph nodes, and the metastatic rates in the abdominal nodes were higher than those from squamous cell carcinoma. Conclusion: Esophagectomy with mediastinal and abdominal lymph node dissection is considered to be an appropriate approach for surgical resection of squamous cell carcinomas, whereas transhiatally extended gastrectomy with lower mediastinal and abdominal lymph node dissection is recommended for the treatment of adenocarcinomas. [ABSTRACT FROM AUTHOR]

A 46-year-old man was referred to us after he presented to his local physician complaining of difficulty eating. Upper gastrointestinal endoscopy revealed a tumor at the esophagogastric junction (EGJ), and moderately differentiated adenocarcinoma was diagnosed from the biopsy findings. Computed tomography (CT) showed apparent enlargement of the pretracheal lymph nodes, the lymph nodes around the bilateral recurrent laryngeal nerves, and the lower thoracic paraesophageal lymph nodes, confirming metastasis. Since the disease was far advanced esophagogastric cancer with marked lymph node metastases throughout the mediastinum, curative resection would have been unlikely. Thus, he was commenced on systemic chemotherapy with cisplatin (90 mg/body, day 8) + S-1 (120 mg/body/day, given for 3 weeks, followed by a 2-week withdrawal). Even after six cycles of chemotherapy over 8 months, a complete response could not be achieved. Finally, we performed transthoracic subtotal esophagectomy with extensive lymph node dissection reconstructed using a gastric tube through a retrosternal route. The patient remains recurrence-free 7 years later. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effectiveness of using soft coagulation followed by the application of polyglycolic acid (PGA) felt and fibrin glue to prevent pancreatic fistula (PF) after distal pancreatectomy (DP). Methods: A soft coagulation system was applied on the cut surface of the pancreas after ligating the main pancreatic duct, followed by the application of layers of PGA felt and fibrin glue on the layers, to prevent the development of a PF after DP. Results: This technique was applied in nine patients, with mean drain amylase levels of 372 ± 296, 185 ± 209, 54 ± 40, and 47 ± 34 IU/l on days 1, 3, 5, and 7, respectively, after DP. Only one patient (11.1%) showed a Grade A PF on day 3 after surgery; none of the other patients developed a fistula. Conclusions: This technique is an effective prophylactic measure to prevent the development of a PF after DP. [ABSTRACT FROM AUTHOR]

Purpose: Metachronous gastric carcinoma arising in a gastric tube used for esophageal reconstruction has been occasionally encountered in long-term survivors of esophageal cancer. This study investigated 10 cases of gastric tube cancer in order to clarify the characteristics and the outcome of these patients. Methods: Four hundred and seventy-one patients underwent a radical esophagectomy at Kyushu University Hospital between 1989 and 2003. There were 10 cases of gastric tube cancer after an esophagectomy. Results: The interval between the esophagectomy and the development of the gastric tube cancer ranged from 1.1 to 7 years. There was no peak for the incidence of gastric tube cancer. In 6 of 10 cases of gastric tube cancer, endoscopic or surgical resection were performed for the treatment; however, chemotherapy was administered to the other 4 cases for several reasons. The prognosis of patients who underwent resection was better than that of the other patients. Conclusions: Frequent endoscopic examinations are therefore important even several years after performing an esophagectomy, since the risk of gastric tube cancer is higher than the risk of a recurrence of esophageal cancer several years after an esophagectomy. Only an early diagnosis permits a less invasive and appropriate approach for the treatment of gastric tube cancer. [ABSTRACT FROM AUTHOR]

Purpose: With the broadening indications for hepatectomy to treat colorectal liver metastases (CRLM), early recurrence is a major problem. The aim of this study is to identify risk factors of early recurrence, defined as recurrence within 1 year after surgery. Methods: A retrospective analysis was performed on 121 consecutive patients who underwent hepatectomy for CRLM. Results: Among 121 patients, 52 (43.0%) developed early recurrence. The independent risk factor for early recurrence was 'number of liver metastases ≥3' (odds ratio 2.65). There were significantly more patients with liver recurrence (51.9%) and recurrence beyond curative surgical resection (63.5%) in those with early recurrence. In addition, patients with three or more liver metastases had significantly more liver recurrence (66.7%; P = 0.02) and recurrence beyond curative surgical resection (70.8%; P = 0.04). The overall survival rates of both patients with early recurrence (5-year survival rate 20%) and those with three or more liver metastases (5-year survival rate 24%) were significantly worse. Conclusions: The independent risk factor for early recurrence is the 'number of liver metastases ≥3.' Patients with three or more liver metastases have a significantly higher risk of liver recurrence and a higher rate of recurrence beyond curative surgical resection, and these are correlated with a poor prognosis. [ABSTRACT FROM AUTHOR]

The fear of serious complications, such as a necrotic conduit caused by an impaired blood circulation can arise when replacing the esophagus with an intestinal conduit. The aim of this paper is to present effective superdrainage of an intestinal conduit using an inferior mesenteric vein (IMV) interposition graft. In 2008, we performed superdrainage of the ileocolic vein to the internal jugular vein interposed by an IMV graft in replacing the esophagus with the right hemicolon for advanced thoracic esophageal cancer in three patients with a synchronous gastric cancer or a previous gastrectomy. No leakage at the enteric anastomoses occurred. Neither ischemic lesions in these intestinal conduits nor complications caused by harvesting an IMV graft were observed. Superdrainage of the ileocolic vein to the internal jugular vein interposed by an IMV graft effectively improves the blood circulation in intestinal conduits brought up to the neck as an esophageal replacement. [ABSTRACT FROM AUTHOR]

An ongoing analysis of 762 patients with esophageal cancer revealed 4 (0.52%) male patients with synchronous hepatocellular carcinoma (HCC). A long history of habitual alcohol intake and heavy cigarette smoking was recognized in all four patients and, therefore, the possibility of these two factors being independent risk factors for this double cancer was suggested. Palliative treatment was undertaken since either one or both cancers were too far advanced, or because liver function was poor even in those patients with resectable cancers. The prognosis correlated more closely to the TNM stage of esophageal cancer rather than the HCC and the causes of death were related to the esophageal cancer in all four patients. These findings suggest that, in patients with this combination of double cancer, the state of the esophageal cancer may be a more reliable prognostic factor than that of the HCC and thus, the curability of esophageal cancer is of primary importance. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the safety and feasibility of the triangulating stapling technique (TST) for cervical esophagogastric anastomosis after esophagectomy (CEGA)., Methods: The subjects were 123 patients who underwent transthoracic esophagectomy with three-field lymph node dissection and reconstruction with a 3.5-cm wide gastric tube, for thoracic esophageal cancer. We performed the TST for CEGA in 33 patients operated on after December, 2006 (TST group) and hand-sewn anastomosis in 90 patients operated on between 2002 and 2006 (HSA group)., Results: In the TST group, CEGA was performed in an end-to-end fashion using three linear staplers. The first anastomosis was applied to the posterior walls of the remnant esophagus and gastric tube in an inverted fashion. The second and the third anastomoses were done in an everted fashion to make the anterior wall. The end-to-end HSA was performed with interrupted sutures using 4-0 absorbable material. Anastomotic leakage occurred in only 1 (3.0%) of the 33 TST patients, but in 13 (14.4%) of the 90 HSA patients (P = 0.07). The frequency of anastomotic stenosis was 9.1% and 25.6% in the TST and HSA groups, respectively (P < 0.05)., Conclusions: Cervical esophagogastric anastomosis using TST may reduce the frequency of anastomotic leakage and stenosis. This technique is a safe and reliable alternative for CEGA after esophagectomy.