Search

Background/aim: Postoperative pneumonia is a serious complication of major oesophageal surgery. We aimed to clarify the association between the degree of improvement in oral hygiene by perioperative oral care and postoperative pneumonia in oesophageal cancer patients., Patients and Methods: Oesophageal cancer patients (n=129) who underwent esophagectomy received perioperative oral care. Their oral hygiene was evaluated using the Oral Assessment Guide (OAG). The relationship between perioperative OAG scores and postoperative complications was analysed., Results: The average OAG scores before starting oral care, pre-operation, and post-operation were 11.0±1.7, 9.1±1.5, and 11.2±3.0, respectively (p<0.001). An increase in preoperative OAG scores was independently associated with postoperative pneumonia on multivariate analysis (p=0.027)., Conclusion: Preoperative oral care improves oral hygiene in patients undergoing oesophageal cancer surgery. No improvement in oral hygiene despite preoperative oral care was an independent predictor of postoperative pneumonia., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background : Anastomotic leakage after esophagectomy is significantly associated with more severe complications, such as sepsis and mortality. Early prediction for anastomotic leakage is usually difficult and needs to be treated rapidly. In the current study, we investigated the correlation between hemodynamic and several complications after esophagectomy in patients with esophageal cancer, using the FloTrac system. Materials and Methods : Between April 2013 and December 2014, 39 patients with a mean age of 66.6 ± 8.9 years underwent postoperative supervision using the FloTrac sensor / Vigileo monitoring system after curative surgery for esophageal cancer. We retrospectively evaluated the association between the number of aberrant cardiac index (CI) along with stroke volume variability (SVV) values and clinicopathological parameters of postoperative complications in this report. Results : There were significant positive correlations between the number of aberrant values of CI along with SVV and depth of invasion during pathological stage. Concerning major postoperative complications, there was a significant positive correlation between the number of aberrant values of CI and anastomotic leakage. Discussion: The hemodynamic change by employing the FloTrac system could predicts the complication of anastomotic leakage after esophagectomy. Adequate management of hemodynamic stability by utilizing it will reduce the complications of anastomotic leakage. J. Med. Invest. 67 : 240-245, August, 2020.

Background/aim: Esophagectomy is more invasive compared to other gastrointestinal surgery types. Perioperative circulatory management is important to avoid postoperative heart complications. The FloTrac sensor along with the Vigileo monitor is a minimally invasive haemodynamic monitoring device. Here, we examined different surgical procedures affecting hemodynamics using the FloTrac system in esophageal cancer patients following esophagectomy., Patients and Methods: Thirty-one patients undergoing postoperative monitoring with the FloTrac sensor/Vigileo monitor system following esophagectomy were included. Evaluation of cardiac index (CI) and stroke volume variation (SVV) measurements were performed by analyzing the number of aberrant values. We evaluated the correlation between the number of aberrant values of CI, SVV and surgical methods of esophagectomy and perioperative factors., Results: There was no significant correlation between the number of aberrant values of CI, SVV and operative approach or fields of lymphadenectomy. Regarding the reconstruction route following esophagectomy, there was a significant correlation between the number of aberrant values of CI, SVV and retrosternal route compared with other routes. There was a significant correlation between the number of aberrant values of SVV and preoperative heart complication., Conclusion: Hemodynamic stability management using FloTrac/Vigileo system following esophagectomy is useful for safe performance of postoperative management of esophageal cancer patients., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: To investigate whether malnutrition is associated with poor prognosis of patients who undergo salvage esophagectomy. We examined the association between the preoperative prognostic nutritional index (PNI) and prognosis of patients who undergo salvage esophagectomy., Patients and Methods: We conducted a single-center retrospective study and reviewed hospital patient records for tumor characteristics and patient outcomes. Univariate and multivariate survival analyses were carried out using the Cox proportional hazards regression model., Results: Thirty-two patients with esophageal squamous cell carcinoma (ESCC) who underwent salvage esophagectomy between 1998 and 2015 at our Institute were included in this study. Univariate analysis revealed that clinical response (p=0.045), preoperative PNI (p<0.001), pT (p=0.024), pN (p=0.004), and residual tumors (p<0.001) were significant prognostic factor for overall survival. Multivariate analysis using age and these five variables found no independent prognostic factors. Multivariate analysis using three preoperative variables (age, clinical response, and preoperative PNI) revealed that PNI was an independent prognostic preoperative factor for overall survival (p=0.005)., Conclusion: Preoperative nutritional status is associated with the prognosis of patients undergoing salvage esophagectomy., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aims: Because salvage surgery after definitive chemoradiotherapy for esophageal cancer is associated with high postoperative mortality and morbidity, minimally invasive methods are desirable. We analyzed the validity of minimally invasive salvage operations (MISO)., Methods: Twenty-five patients underwent salvage operation between 2010 and 2016 in our institution, 10 having undergone right transthoracic salvage esophagectomy (TTSE group), 6 transhiatal salvage esophagectomy (THSE), 6 salvage lymphadenectomy (SLA), and 3 salvage endoscopic submucosal dissection (SESD). Patients who had undergone THSE, SLA, or SESD were categorized as the MISO group. Short- and long-term outcomes were assessed., Results: The mean duration of surgery was significantly shorter in the SLA groups than in the TTSE group (p = 0.0248). Blood loss was significantly less in the SLA than the TTSE group (p = 0.0340). Intensive care unit stay was shorter in the THSE than the TTSE group (p = 0.0412). There was no significant difference in postoperative mortality between the MISO and THSE groups. Postoperative hospital stay was significantly shorter in the SLA than the TTSE group (p = 0.0061). Patients' survivals did not differ significantly between the MISO and TTSE groups (p = 0.752). Multivariate analysis revealed that residual disease (R0; HR 4.872, 95% CI 1.387-17.110, p = 0.013) was the only independent factor influencing overall survival., Conclusion: MISO is preferable because short-term outcomes are better and long-term outcomes do not differ from those of TTSE., (© 2018 S. Karger AG, Basel.)

Background/aim: Definitive chemoradiotherapy (CRT) without planned surgery has been recently widely used as a therapeutic option for locally advanced esophageal cancer. Salvage esophagectomy can offer the chance of prolonged survival for patients who have locoregional failure after definitive CRT, but many clinicians oppose the use of surgery due to the associated excessive morbidity and mortality. The aim of this study was to identify patients who are good candidates for salvage surgery by investigating factors influencing long-term survival., Patients and Methods: A total of 40 patients underwent concurrent CRT or RT followed by esophagectomy for residual tumor or locoregional recurrence of esophageal squamous cell carcinoma without distant organ metastasis at the Department of General Surgical Science, Gunma University, Gunma, Japan, and were included in this study. As short-term outcomes after salvage esophagectomy, pulmonary and cardiovascular complications, anastomotic leakage, and chylothorax, and the length of postoperative stay were evaluated. Survival rates were calculated using the Kaplan-Meier method, and the Cox proportional hazards model was used for univariate and multivariate analyses of disease-specific survival., Results: Postoperative complications were noted in 20 patients (50%), and pulmonary complications were the most common (25%), followed by anastomotic leakage (20%). There was also one case of in-hospital death, caused by multiple organ failure due to chylothorax. Univariate analysis revealed that sex, clinical residual tumor, CRT response, pathological tumor depth, and pathological residual tumor were significant factors affecting disease-specific survival (p=0.034, p=0.009, p=0.014, p=0.020, and p=0.026, respectively). Moreover, multivariate analysis demonstrated that clinical residual tumor was the only independent factor influencing disease-specific survival (p=0.036). Thirteen patients (32.5%) died from other illnesses after salvage surgery, 53.8% patients from pneumonia., Conclusion: Based on long-term survival, recurrence rather than residual tumor after definitive CRT was a favorable indicator for salvage esophagectomy. Not only management of postoperative morbidity and curative operation but, also long-term rigorous outpatient management, including respiratory rehabilitation to reduce pneumonia, is necessary., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Esophagectomy is a most invasive operation, as compared with other operations of the gastrointestinal tract. Obstructions of the food passageway and the overgrowth of tissue postoperatively may lead to malnutrition. Therefore, significant assessment and management of nutrients is very important for esophageal cancer patients. The body mass index, albumin, the prognostic nutritional index, controlling nutritional status, and the Glasgow Prognostic Score are reported as useful assessment tools for esophageal cancer. The patient's general condition, including his or her nutritional status, influences the performance of esophagectomy. Therefore, improving the nutritional status enables an adaptation of therapy and leads to preventive benefits for decreasing postoperative complications. The previously cited nutritional tools are very useful indices because the measurement of each factor is convenient and fast. Also, early recovery from operative stress is the most important target of postoperative management after esophagectomy. Accurate and adequate perioperative management allows early recovery from operative stress in esophageal cancer patients. Preoperative steroid injection, oral care, respiratory training and rehabilitation, smoking cessation, and so on are very important for esophageal cancer patients. The efforts of a team that includes doctors, nurses, and healthcare providers are necessary for sufficient postoperative management after esophagectomy.

Background: Among patients who undergo gastric tube reconstruction after esophagectomy, it is generally accepted that the incidence of reflux esophagitis (RE) is significantly lower in patients with neck anastomosis than in those with intrathoracic anastomosis. However, the true impact of the level of anastomosis on RE currently remains unclear., Methods: We examined 53 patients with thoracic esophageal cancer underwent radical esophagectomy with gastric tube reconstruction and neck anastomosis. The level of anastomosis was assessed by measuring the distance from the sternal notch to the stapled ring by computed tomography. The relative level of anastomosis was calculated by the distance from the sternal notch to the most caudal side of the stapled ring (mm)/height (cm)., Results: The relative level of anastomosis in 30 (56.6%) patients showed <0, which indicated that anastomosis in these patients was located at a lower level than the sternal notch. The mean relative level of anastomosis was significantly lower in patients with RE (grade A to D) than in those without RE (grade N) (-0.062 vs. -0.012 mm/cm, respectively; p = 0.043). RE was more severe with a lower relative level of anastomosis (p for trends = 0.044)., Conclusions: The level of anastomosis in patients with gastric tube reconstruction following esophagectomy was associated with the incidence of RE. The displacement of anastomosis into the thoracic cavity was detected in approximately half of the patients with neck anastomosis. RE was more severe with a lower level of anastomosis, even in patients with neck anastomosis.

The local control effect of esophagectomy with three-field lymph node dissection (3FLD) is reaching its limit pending technical advancement. Minimally invasive esophagectomy (MIE) by thoracotomy is slowly gaining acceptance due to advantages in short-term outcomes. Although the evidence is slowly increasing, MIE is still controversial. Also, the results of treatment by surgery alone are limiting, and multimodality therapy, which includes surgical and non-surgical treatment options including chemotherapy, radiotherapy, and endoscopic treatment, has become the mainstream therapy. Esophagectomy after neoadjuvant chemotherapy (NAC) is the standard treatment for clinical stages II/III (except for T4) esophageal cancer, whereas chemoradiotherapy (CRT) is regarded as the standard treatment for patients who wish to preserve their esophagus, those who refuse surgery, and those with inoperable disease. CRT is also usually selected for clinical stage IV esophageal cancer. On the other hand, with the spread of CRT, salvage esophagectomy has traditionally been recognized as a feasible option; however, many clinicians oppose the use of surgery due to the associated unfavorable morbidity and mortality profile. In the future, the improvement of each treatment result and the establishment of individual strategies are important although esophageal cancer has many treatment options.

Background/aim: Adequate mediastinal lymphadenectomy during thoracoscopic esophagectomy (TE) requires an extensive operating field. In order to rectify this problem, we developed slender tracheal forceps that can pass through a 12-mm trocar., Patients and Methods: TE in the prone position was performed in 58 patients with esophageal cancer using slender tracheal forceps. Perioperative and postoperative clinical data were compared against those of 61 patients who underwent transthoracic open esophagectomy (OE)., Results: The mean duration of thoracic manipulation was significantly longer in the TE than OE group: 226.2 versus 171.3 minutes (p<0.0001). Mean blood loss was significantly lower in the TE than OE group: 39.9 versus 176.8 g (p<0.0001). A mean of 23.4 mediastinal lymph nodes were dissected in the TE group and 25.1 in the OE group. The timing of extubation tended to be earlier in the TE group. Postoperative morbidity did not differ between groups., Conclusion: Slender tracheal forceps are acceptable for fine mediastinal lymphadenectomy in thoracoscopic surgery for esophageal cancer, and the technique could contribute to development of minimally invasive surgery., (Copyright © 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Background/aims: The purpose of this study is to assess the efficacy of 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) in predicting the pathological response of neoadjuvant chemoradiation (CRT) for clinically diagnosed T4 esophageal squamous cell carcinoma (SCC)., Methodology: We examined 32 patients with T4 thoracic esophageal SCC who received neoadjuvant CRT followed by surgery., Results: Pathological complete response (pCR) was achieved in 7 patients (21.9%). pCR was significant correlated with standardized uptake value (SUV) after neoadjuvant CRT (P = 0.034) and SUV decrease (%) (P = 0.030). The optimal cut-off values to predict pCR were 2.25 for SUV after neoadjuvant CRT and 79.3 for SUV decrease (%). Of note, no patients who did not reach both cut-off values achieved pCR. Conclusions: SUV after CRT and SUV decrease (%) in FDG-PET of the primary tumor are useful tools to predict pathological response of neoadjuvant CRT for T4 esophageal SCC.

Background/aims: The optimal treatment for locally advanced esophageal carcinoma has not yet been determined. We report results of neoadjuvant hyperthermo-chemoradiotherapy (HCRT) using weekly low-dose docetaxel followed by surgery in patients with advanced esophageal squamous cell carcinoma., Methodology: Twenty-four patients were enrolled. 7 patients were considered to have inoperable tumors or rejected surgery after HCRT, and the remaining 17 patients had an esophagectomy. Clinical responses, HCRT toxicity and survival after surgery were evaluated., Results: In the 24 patients, the response rate was 41.7%. The pathological complete response (pCR) rate was 17.6% in the 17 patients. HCRT toxicity grade 2 occurred in six patients (25.0%: esophagitis, 4; leukopenia, 6; neutropenia, 4) and grade 3 (pneumonia) in 3 patients (12.5%). The 3- and 5-year survival rates were 56.3% and 50.0%, respectively. When the patients were divided into a pCR group and a pathological partial response (pPR) group, the 3-year survival rates were 66.7% and 42.9% and the 5-year survival rates were 66.7% and 42.9%, respectively (log-rank P = .5842)., Conclusions: Esophagectomy after docetaxel HCRT may have potential for prolonging survival in patients with locally advanced esophageal cancer. A larger randomized, controlled study will be required to confirm the benefit of esophagectomy after HCRT.

In recent years, the number of facilities performing thoracoscopic surgery of the esophagus has increased. Thoracoscopic surgery has many advantages, such as a magnification effect, good lighting, and a wide field of view. Esophagectomy requires fine manipulation within a deep and narrow space. Thus, thoracoscopic surgery is suitable for the performance of esophagectomy. The body position during this procedure may be either prone or left lateral decubitus. Because there are advantages in both cases, the relative merits are controversial. The operation time is longer than that of open thoracotomy, but the amount of bleeding is small in most cases of thoracoscopic esophagectomy. There are also some reports that thoracoscopic esophagectomy is comparable with open esophagectomy in terms of radicality and quality of lymph node dissection, and the intensive care unit and hospital stay durations are shortened. Robot-assisted esophagectomy is a promising technology for the fine manipulations and high quality 3-dimensional visualization required in the performance of esophageal thoracoscopic surgery. Thoracoscopic esophagectomy will become more widespread and undergo further development in the future with the spread of robotic surgery and 3-dimensional endoscopic surgery.

Background/aims: The purpose of this study was to investigate the effectiveness of sternocleidomastoid (SCM) flap repair for anastomotic leakage after esophagectomy., Methods: A refractory cutaneous fistula from the gastric stump developed in 8 patients with esophageal cancer who underwent esophagogastric anastomosis after esophagectomy. All patients underwent SCM flap repair. The cutaneous fistula was removed and resutured. The sternal head of the left SCM was dissected from the manubrium of the sternum and sutured onto the repaired gastric stump., Results: The operative duration was 80-220 min (median, 120 min). The amount of intraoperative bleeding ranged from 5 to 182 g (median, 15 g). The absence of recurrent anastomotic leakage was confirmed after the SCM flap repair in every patient. Oral intake was initiated 7-15 days (median, 10 days) after the repair operation without discomfort., Conclusions: SCM flap repair is an effective and minimally invasive treatment method for cervical anastomotic leakage after esophageal reconstruction. This method may be considered in patients with refractory leakage of the gastric stump after staple anastomosis.

Background: Reflux esophagitis is a significant problem in patients after an esophagectomy with gastric tube reconstruction. The pathogenesis of reflux esophagitis is not fully understood. The aim of the present study was to evaluate whether gastropyloric motility influences the pathogenesis of reflux esophagitis after an esophagectomy., Methods: Thirty esophagectomized patients were assessed by endoscopy and manometry. The patients were classified into 3 groups according to the postoperative period as follows: Group 1 (less than 12 months), group 2 (12 to 24 months), and group 3 (more than 24 months). Gastropyloric motor activity was quantified by calculating the motility index, which is equivalent to the area under the contractile waves., Results: Reflux esophagitis was observed in 80% of group 1, 80% of group 2, and 30% of group 3. The severity of reflux esophagitis decreased with time. Contractions of the gastric body were not observed in any of the patients. The antral motility index in group 3 was significantly greater than that in groups 1 and 2. The pyloric motility index progressively increased. The severity of reflux esophagitis is significantly associated with gastropyloric motor activity., Conclusions: The severity of reflux esophagitis decreases with time, coupled with recovery of antropyloric motor activity. Gastropyloric motor activity plays an important role in the genesis of reflux esophagitis after an esophagectomy., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background/aims: Postoperative complications after thoracic esophagectomy are common and sometimes life-threatening. Optimized perioperative nutrition is essential for patient well-being and recovery. In this paper, we assessed the effects of perioperative parenteral nutrition on the nutritional status of thoracic esophagectomy patients., Methodology: The nutritional status of 25 patients, undergoing either 2- or 3-field lymph node dissection, was evaluated from one day before surgery until 14 days after. Respiratory quotient and energy expenditure were measured by indirect calorimetry. Nitrogen balance was measured as the difference between urophanic and intake nitrogen. We also measured nitrogen loss, total cholesterol, cholinesterase, total protein, rapid turnover protein, and biomarkers that included prealbumin, transferrin, and retinol-binding protein., Results: We observed significant and negative differences between pre- and postoperative calorie intake, caloric balance, respiratory quotient, nitrogen loss, nitrogen balance, total cholesterol, cholinesterase, total protein, and retinol-binding protein. On postoperative days 1-3, calorie intake was insufficient and caloric balance became negative and significantly lower than that before surgery., Conclusions: Parenteral nutrition provides insufficient nutrients to thoracic esophagectomy patients. Preoperative nutrition and early postoperative enteral nutrition in combination with parenteral nutrition may improve nutritional status, particularly in the early stages after surgery.

We reviewed the indications for re-thoracotomy after esophagectomy for esophageal cancer. Hemothorax, chylothorax, tracheobronchial injury (fistula), pneumothorax, and pyothorax were the main causes of re-thoracotomy. Indications for emergency thoracotomy were as follows. 1)Hemothorax:bleeding through the chest drain continuing at >100 ml/hour for ≥5 hour, or in cases when normal blood pressure cannot be maintained without blood transfusion. 2)Chylothorax:in cases with ≥1.5 l/day of chyle drainage for >5 days under conservative treatment. Healing is not seen for 14 days after conservative treatment. Nutritional status of the patient has worsened. 3)Tracheobronchial injury:at 1st respiration state should be understood. After we maintain the patient's airway, fistula is treated by closure and plombage with omentum or muscle flap. Appropriate diagnosis and timing are important for re-thoracotomy for complications after esophagectomy.

Background: Patients frequently experience reflux symptoms of heartburn and regurgitation after a gastric pull-up esophagectomy. The pathogenesis of reflux symptoms is not fully understood. The gastrointestinal tract exhibits a temporally coordinated cyclic motor pattern, termed interdigestive migrating motor contraction, during the interdigestive state. Phase III of interdigestive migrating motor contraction is important in cleaning indigestible solids and basal secretions. Impairment of phase III may result in reflux symptoms of heartburn and regurgitation. The present study evaluated whether gastropyloroduodenal motility after gastric pull-up esophagectomy influences the pathogenesis of reflux symptoms., Methods: Gastropyloroduodenal motility was recorded by manometry in 20 patients after a gastric pull-up esophagectomy. Esophagectomized patients were questioned about the presence of heartburn or regurgitation, or both., Results: Of 20 patients, 8 (40%) were considered the symptomatic group. Phase III, in which contractions originating from the antrum migrate to the pylorus and then move to the duodenum, was observed in only 1 of 8 patients. In the asymptomatic group, phase III was observed in 8 of 12 patients. A significant correlation was found between the presence of reflux symptoms and the paucity of phase III activity (p=0.02)., Conclusions: The presence of reflux symptoms after gastric pull-up esophagectomy is significantly associated with the paucity of gastric phase III. Gastric motor activity is important in the occurrence of reflux symptoms., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ghrelin is a peptide hormone predominantly produced by endocrine cells in the oxyntic mucosa of the stomach and is an endogenous ligand for the growth hormone secretagogue receptor. Ghrelin plays an important role in regulating appetite, food intake, and energy metabolism. We investigated the correlation between clinicopathologic factors and plasma ghrelin concentration before and after esophagectomy with gastric tube reconstruction for esophageal cancer treatment., Methods: The study group comprised 25 patients (22 men, three women, age range 46-78 y) with esophageal cancer who underwent esophagectomy with gastric tube reconstruction between 1999 and 2007. Blood samples were collected before and three times after the operation. Plasma concentrations of ghrelin were determined using a sandwich-type enzyme immunoassay kit., Results: Plasma ghrelin concentrations were significantly decreased to 38.7% of the preoperative concentration at postoperative d 7. Plasma ghrelin concentrations recovered slightly over 6-24 mo postoperatively. After 36 mo or longer, ghrelin concentrations had returned to preoperative levels. There was no relationship between ghrelin concentrations and gender, location of tumor, tumor stage, operative procedure, and reconstruction route at each time point. There was a significant relationship between the decrease in body mass index and decrease in plasma ghrelin in patients at 6-24 mo after esophagectomy (P < 0.01)., Conclusions: Plasma ghrelin concentrations decrease on a temporary basis after esophagectomy with gastric tube reconstruction and are associated with body weight loss after surgery., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Esophagectomy needs experienced surgical techniques and a well-trained perioperative care team. There are now many reports that the mortality rate after esophagectomy is higher in those hospitals with a low volume of esophagectomy and/or low surgeon's volume. The purpose of this study is to decide the respective numbers of esophagectomy operations per year to define low-volume and high-volume hospitals in Japan. If medical policy aims to further reduce mortality and morbidity associated with esophagectomy, then esophagectomy operations should be further centralized, away from low-volume hospitals, into high-volume hospitals. The Japanese Association for Thoracic Surgery has accumulated the surgical outcomes from 31 380 esophagectomy operations, registered from 709 institutes during the period from 2001 to 2006. These institutes are here classified into six groups according to the number of esophagectomy operations per year as 4 or less, 5-9, 10-19, 20-39, 40-79, and 80 or more. Using a statistical model-selection procedure by information criteria, these six groups are then classified into three categories as low-volume, medium-volume, and as high-volume hospitals. Among the 31 380 patients registered, overall, 390 patients (1.2%) died within 30 days, and 1187 patients (3.8%) died during the primary hospital stay. The odds ratio of the greatest volume group to the minimum volume group was 0.307 for the 30-day mortality rate, and 0.288 for the in-hospital mortality rate. For both the 30-day mortality rate and the in-hospital mortality rate, a hospital with less than five esophagectomy operations per year was classified as a low-volume hospital. A hospital with 40 or more esophagectomy operations per year was classified as a high-volume hospital. Concerning the number of esophagectomy operations performed per year in Japan, low-volume hospitals are defined as those where esophagectomy is performed less than five times per year, and high-volume hospitals are defined as those where esophagectomy is performed 40 or more times per year. If medical policy in Japan aims to further decrease the mortality after esophagectomy, then esophagectomy operations should be limited in these identified low-volume hospitals.

Purpose: Thoracic esophagectomy for esophageal cancer is among the most invasive operations, requiring thoracotomy and laparotomy. With regard to postoperative status, the increment of vascular permeability caused by various inflammatory cytokines might influence the postoperative respiratory condition. The PiCCO (pulse contour cardiac output) system (Pulsion Medical Systems AG, Munich, Germany), a new technique based on an arterial thermodilution technique, allows the measurement of extravascular lung water (EVLW). In this study, we hypothesized that EVLW might be a useful parameter to assess the respiratory condition and evaluated respiratory status using values for EVLW after thoracic esophagectomy., Patients and Methods: The PiCCO system was established in the intensive care unit (ICU) in 25 patients immediately after thoracic esophagectomy for esophageal cancer. EVLWI (EVLW/body weight, normal range: 3-7 ml/kg) was measured on ICU days (ICUD) 1, 2, and 3. The PaO(2)/FiO(2) (P/F ratio), pulmonary compliance, and lung injury score (LIS) were also calculated, and relationships between EVLWI and those parameters were evaluated., Results: Mean operating time, blood volume, and fluid balance during surgery were 515+/- 16 (395-690) min, 721+/- 91 (167-1,770) ml, and 3,462+/- 292 (1,892-7,300) ml, respectively. The mean ICU stay was 3.4 +/- 0.3 (2-10) days, and all patients were discharged from the ICU without complications. EVLWI gradually increased after surgery with values of 8.6+/- 1.9 ml/kg on ICUD 1, 9.7+/- 2.7 ml/kg on ICUD 2, and 10.0+/- 3.0 ml/kg on ICUD 3. EVLWI was well correlated with P/F ratio (r = -0.358, p = 0.0135), pulmonary compliance (r = -0.625, p = 0.0001), and LIS (r = 0.614, p = 0.0001)., Conclusion: EVLWI may be a useful parameter for evaluation of the respiratory condition after thoracic esophagectomy.

Background/aims: Thoracic esophagectomy is one of the most invasive operations, and it is necessary to have a precise understanding of postoperative hemodynamics in order to maintain normal circulation. PiCCO (pulse contour cardiac output, Pulsion Medical Systems; Munich, Germany), a new technique based on an arterial thermodilution technique, allows the measurement of intra-thoracic blood volume index (ITBVI), which has been reported to be a useful parameter for cardiac preload. In this study, changes of ITBVI were analyzed after thoracic esophagectomy using the PiCCO system. Simultaneously, the patient's circulating blood volume (cBV) and cardiac index (CI) were measured using dye densitometry and the relation between the CI and ITBVI was evaluated., Methodology: The PiCCO system was introduced in 20 patients immediately after thoracic esophagectomy, and circulatory parameters such as central venous pressure (CVP), and ITBVI were measured on ICU Days (ICUD) 1, 2 and 3. cBV and CI were simultaneously measured using the Dye Densitogram (DDG) Analyzer System (Nihon Koden, Tokyo, Japan)., Results: The mean fluid balance during the operation was 3462 +/- 1341mL. CI was 3.8 +/- 0.7L/min/m2 on ICUD 1, 4.4 +/- 0.8L/min/m2 on ICUD 2, and 4.3 +/- 1.OL/ min/m2 on ICUD 3, and postoperative hemodynamics were well maintained. The ITBVI (normal range: 850-1000mL/m2) was also well controlled with 977 +/- 216mL/m2 on ICUD 1, 1061 +/- 221mL/m2 on ICUD 2, and 1043 +/- 151mL/m2 on ICUD 3, respectively, although BV ratio (measured cBV / Japanese standard cBV based on height and weight) was less than 1.0 during the same period. Additionally, ITBVI had better correlation with CI (r = 0.559, p = 0.003) compared with CVP (r = 0.036, p = 0.861)., Conclusions: Following thoracic esophagectomy, ITBVI was maintained within the normal range, in spite of a decrease in cBV. There was a correlation between ITBVI and CI, indicating that ITBVI might be a useful parameter for cardiac preload.

Background: After esophagectomy a swallowing abnormality is the predominant symptom for esophageal cancer. The aims of this study were to examine (i) oropharyngeal swallowing by comparing pre- and postoperative period, and (ii) the relationship between oropharyngeal swallowing and the alimentary reconstruction route after esophagectomy., Patients and Methods: We studied 27 patients in the upright position using videofluoroscopy in the lateral projection. Each patient was studied during 10 mL barium swallows in the pre- and post-operative period., Results: Of the 27 patients studied, alimentary reconstruction with the retrosternal route (RS group) was performed in 8 patients, that with posterior mediastinal route (PM group) in 8 patients, and the intrathoracic (IT group) esophagogastrostomy inside the posterior mediastinum in 11 patients. With regard to the maximal extent of structural movement, the superior and anterior excursion of the hyoid bone was significantly reduced postoperatively among all groups. The maximal extent of the cricopharyngeal opening was significantly reduced postoperatively in the RS group, but not in the IT group. The changes in the peri-operative structural movement were the lowest in the RS group., Conclusion: A new-onset oropharyngeal swallowing abnormality following retrosternal reconstruction after esophagectomy may have appeared because the change in the peri-operative movement was the lowest. The results of the swallowing evaluation using videofluoroscopy suggest that to avoid oropharyngeal swallowing abnormalities the intrathoracic or cervical anastomosis with posterior mediastinal route should be chosen as reconstruction after esophagectomy if possible.

Background/aims: Postoperative pulmonary complications are often fatal in patients with esophageal cancer. The aim of this study was to clarify the association between cytokines and temporary ventilation during one-lung ventilation., Methodology: Serum and BALF IL-6, 8 were measured in 39 patients with esophageal cancer, and the relationship between cytokine response and temporary ventilation during one-lung ventilation in esophagectomy was examined., Results: Pulmonary complications did not occur in our patients. Serum IL-6 levels were significantly increased in the high one-lung ventilation ratio and long-term one-lung ventilation groups. Serum IL-6 levels in the one or more times ventilation group during one-lung ventilation were significantly low compared to the no-ventilation group. There were no significant differences in serum IL-8 and BALF IL-6, 8 levels., Conclusions: Our results indicate that it is important to ventilate one or more times during one-lung ventilation in order to reduce postoperative pulmonary complications.

Background/aims: Esophagectomy is a very invasive operation, therefore, it is important to improve the postoperative quality of life (QOL) of the patients. The aim of this study was to evaluate the QOL of patients who had undergone esophagectomy for thoracic esophageal cancer., Methodology: We investigated 37 patients who had undergone esophagectomy. The anastomosis was made at the cervical location by the retrosternal route in 12 patients (RS group), at the high thoracic location by the posterior mediastinal route in 18 patients (HT group), and at the cervical location by the posterior mediastinal route in seven patients (PM group). QOL was evaluated by patient questionnaires concerning reflux esophagitis using QUEST and dumping syndrome, body weight, ambulatory pH monitoring, and immunostaining for iNOS and COX-2 as markers of inflammation., Results: The QUEST score revealed that the findings suggesting reflux were few in the HT group. Patients suffered from dumping syndrome were significantly few in the HT group (p = 0.0399). The percentage time of pH < or =4.0 was shortest in the HT group at the position of the esophagogastric anastomosis (p < 0.0281). Body weight recovery was best in HT group (p < 0.0001). There was a tendency that iNOS and COX-2 immunoreactivity were weaker in HT group than other two groups., Conclusions: Our results suggest that QOL after esophageal reconstruction using a gastric tube is good in patients with the anastomosis at the high thoracic location by the posterior mediastinal route.

Background: The purpose of this study is to examine the effects of neutrophil elastase inhibitor on postoperative cytokine levels in patients after esophagectomy., Methods: Fifteen patients were divided into two groups; group 1: 9 patients receiving neutrophil elastase inhibitor (0.2 mg x kg(-1) x hr(-1) from the admission to ICU to extubation), group 2: 6 patients as a control. We measured neutrophil elastase activity, interleukin 1-beta, interleukin 6 and interleukin 8 preoperatively, just after the admission to ICU, and 24, 48 and 72 hours after the surgery., Results: There were significant differences in neutrophil elastase activity and interleukin 8 in group 1 24 hours after the surgery, compared with those in group 2. The time necessary for mechanical ventilation in group 1 was shorter than that in group 2 (group 1: 44.7 +/- 24.7 hrs, group 2: 112.8 +/- 90.3 hrs, P = 0.048)., Conclusions: The administration of neutrophil elastase inhibitor may be useful for patients after esophagectomy to reduce overexpression of plasma cytokine levels after surgery.

Background: We investigated whether secretory leukocyte protease inhibitor (SLPI) is associated with pulmonary complications after esophagectomy., Methods: We measured serial changes in the SLPI concentration in the bronchoalveolar lavage fluid (BALF) of 34 patients who underwent and examined the relationship between SLPI and postoperative morbidity., Results: Fifteen (44%) of 34 patients (high group) had a BALF SLPI concentration >90,000 pg/mL at the end of the surgery (postoperative day [POD] 0). There was no significant difference between the high group and other 19 patients (low group) with respect to age, sex, preoperative comorbid conditions, tumor stage, surgical technique, operating time, or blood loss volume. Days of intubation and pulmonary complication rate were significantly increased in the high group compared with the low group. Logistic regression analysis revealed that the BALF SLPI level on POD 0 was significant for pulmonary complications., Conclusions: Our results indicate that assaying SLPI levels in BALF can be useful for the prediction of pulmonary complications after esophagectomy.

Background/aims: Controversy remains regarding which treatment should be employed for superficial esophageal cancer. The treatment modalities for such superficial cancers vary from a local excision, including an endoscopic mucosal resection (EMR) to an extended radical esophagectomy (three-field lymphadenectomy). In the current report, we proposed the use of either a transthoracal partial resection or local excision of the esophagus with a radical mediastinal lymphadenectomy for the patients with small superficial esophageal squamous cell carcinoma, in order to perform effective radical cancer surgery and maintain the quality of life (QOL) of the patients., Methodology: Surgical procedures: After thoracotomy and detaching of the esophagus from the surrounding tissues, the proximal and distal resection lines were determined by careful palpation of the clips within the esophagus which had been placed during the preoperative endoscopic examination. Thereafter, a mediastinal lymph node dissection, including the bilateral recurrent nerve nodes and paratracheal nodes, was performed. After this procedure, intrathoracic esophageal end-to-end anastomosis was performed in the ordinary manner. We performed this procedure on three patients with small localized esophageal cancer., Results: Operations were safely performed on these three patients and postoperative quality of life was almost satisfactory., Conclusions: Transthoracal partial resection or local excision with a radical mediastinal lymphadenectomy was useful for the patients with small localized esophageal carcinoma.

Background: Activated polymorphonuclear leucocytes play a pivotal role in pulmonary complications after oesophagectomy. A lot of inflammatory mediators including interferon-gamma and granulocyte colony-stimulating factor are reported to modify the life span of polymorphonuclear leucocytes., Aims: In this study we investigated whether interferon-gamma and granulocyte colony-stimulating factor are associated with pulmonary complications after oesophagectomy., Patients and Methods: We measured interferon-gamma and granulocyte colony-stimulating factor concentrations in bronchoalveolar lavage fluid of 37 patients who had undergone oesophagectomy and examined the relationship between these mediators and pulmonary complications., Results: Pulmonary complications occurred in nine patients (24%, Pneum(+)). There was no significant difference in age, gender, preoperative comorbid conditions, tumour stage, operation method, operating time or blood loss between the Pneum(+) group and another 28 patients(Pneum(-)). Days until extubation were significantly increased in the Pneum(+) group than in the Pneum(-) group. Interferon-gamma (on postoperative day 2) and granulocyte colony-stimulating factor (on postoperative days 1-3) in bronchoalveolar lavage fluid were significantly increased in the Pneum(+) group than in the Pneum(-) group and granulocyte colony-stimulating factor was significantly correlated with days until extubation., Conclusions: Our results indicate that bronchoalveolar lavage fluid granulocyte colony-stimulating factor is associated with respiratory conditions after oesophagectomy and assaying it can be useful for predicting pulmonary complications.

Background: Intensive care unit (ICU) psychosis is still a relatively frequent complication after esophageal surgery. We investigated the correlation between ICU psychosis and serum melatonin concentration during the period after esophagectomy., Methods: The study group comprised 41 patients who underwent esophagectomy for treatment of esophageal cancer between 1999 and 2001. The cohort included 36 men and 5 women, aged 36 to 78 years. After surgery, blood samples were collected 4 times a day for 4 days. Serum levels of melatonin were determined with a melatonin radioimmunoassay kit. The regularity of the melatonin circadian rhythm pattern, as defined by the frequency of occurrence of the peak level of melatonin secretion, was determined (the pattern was described as irregular at less than 3 times in the measurement period)., Results: Of the 41 patients who met the inclusion criteria, 11 (26.8%) had ICU psychosis develop. These patients were older than those patients in whom ICU psychosis did not develop (P =.01). No significant differences were seen in the duration of surgery, volume of blood loss, term in the ICU, term of intubation, tumor location, disturbances of organ function, and postoperative complications between patients in whom ICU psychosis developed, and those patients in whom it did not. Patients with ICU psychosis tended to have abnormally low serum levels of melatonin. Of the 41 patients studied, 9 (22%) had an irregular pattern of melatonin circadian rhythm. A significant correlation was seen between ICU psychosis and an irregular melatonin circadian rhythm (P =.0001)., Conclusion: Irregular patterns of melatonin circadian rhythm may be associated with ICU psychosis. Supplementation with melatonin, or acceleration of melatonin secretion, may protect patients from development of ICU psychosis and may promote recovery to a normal mental state.

Anastomotic insufficiency is considered to be one of the most serious complications associated with esophageal reconstruction. The purposes of this study were to identify (1) the relationship between anastomotic insufficiency and tissue blood flow (TBF) in the gastric tube in the perioperative period, and (2) the effects of intravenous prostaglandin E1 (PGE1) on TBF in the gastric tube. The study group consisted of 44 patients who were to undergo esophagectomy for esophageal cancer. Intraoperative and postoperative TBF on the serosal side of the gastric tube were measured by laser-Doppler tissue blood flowmetry. The TBF of the Leakage(+) group (n = 5) was poorer than that of the Leakage(?) group (n = 39) during the intraoperative and postoperative periods. There was a significant difference in TBF between the two groups at postoperative day (POD) 3. There was a tendency in the PGE1(+) group (n = 18) to exhibit richer blood flow through the anastomosis than the PGE1(?) group (n = 26), intraoperatively, but the difference was not significant. Two of five Leakage(+) cases were also in the PGE1(+) group. There was no relationship between intraoperative medication with PGE1 and incidence of leakage. The TBF of three-field lymph node dissection and reconstruction of the retrosternal route group (n = 21) was poorer than that of the two-field lymph-node dissection and reconstruction of the posterior mediastinal route group (n = 23). The TBF in the gastric tube after esophagectomy may be a predictor of anastomotic insufficiency. However, PGE1 treatment in the intraoperative period alone is not effective in preventing anastomotic insufficiency.

Background: The motor activity of the gastric tube as an esophageal replacement after esophagectomy is poorly understood. The aims of the present study were to examine the gastropyloric motility of the gastric tube and the effects of erythromycin given orally., Methods: Interdigestive gastropyloric motility was recorded by manometry with a sleeve sensor in 23 esophagectomized patients. The 23 patients were classified into 3-, 12-, and 24-month groups according to postoperative follow-up time. Radiopaque markers were used in 8 patients to assess gastric emptying. The effects of erythromycin were studied after the patients received 600 mg during fasting and 1 g postprandially., Results: Compared with the 3-month group, the 12-month group and the 24-month group showed significantly increased pyloric and antral motility, respectively. During a fast, erythromycin induced phase III in 44.4% of the patients with more than 12 months of follow-up. In contrast to the normal subjects, esophagectomized patients showed delayed gastric emptying at 3 and 4 hours. However, erythromycin significantly accelerated gastric emptying at 1, 2, 3, and 4 hours., Conclusions: The motor activity of the gastric tube returns towards normal in a progression over time from the pylorus cephalad. Erythromycin given orally might be used as a prokinetic agent in patients after esophagectomy.

Background: An evaluation of the safe resection margin in esophagectomy or esophageal endoscopic mucosal resection for carcinoma, based on serial histologic investigations by measuring the length of subepithelial extension of the lesion beneath the noncancerous epithelium, has not been reported., Methods: Forty-eight patients with esophageal carcinoma restricted to within the esophageal wall including 67 lesions (27 mucosal, 27 submucosal cancer, and 13 lesions of cancer invading to proper muscular layer) were histopathologically examined. The length of subepithelial extension (SEE) beneath the noncancerous epithelium of each lesion was measured and the clinicopathologic significance of SEE was discussed., Results: Among these 67 lesions in 48 cases, there were 17 (25.4%) lesions with SEE. The rates of coexistence of SEE were 3.7, 37.0, and 46.2% in mucosal and submucosal cancer, and cancer invading the proper muscular layer, respectively. When the positive rate was more than 50% for the factors of SEE--lymphatic permeation, blood vessel permeation, and intramural metastasis--the prognosis was significantly poorer in the patients with esophageal cancer., Conclusions: When the lesion was restricted to within the mucosal layer, SEE was almost negligible at resection. The coexistence of SEE was thus found to be one of the prognostic factors predicting a poor prognosis.

Background: We investigated whether or not interleukin-8 (IL-8) and granulocyte elastase (GE) can be associated with pulmonary complication after esophagectomy (the most common cause of postoperative death)., Methods: We measured serial changes in the IL-8 concentration and GE activity in the plasma and bronchoalveolar lavage fluid (BALF) of 17 patients who had undergone esophagectomy, and examined the relationship between these mediators and postoperative pulmonary complication., Results: Pulmonary complication occurred in 6 patients (35%, Pneum+ group). Plasma IL-8 increased at the end of the surgery then decreased, but there was no significant difference between the Pneum+ group and the group without pulmonary complication (11[65%], Pneum- group). IL-8 and GE in BALF were significantly higher in the Pneum+ group than in the Pneum- group on days 1 and 3 after the operation. There was a significant and positive correlation between IL-8 and GE in BALF., Conclusions: Our results indicate that IL-8 and GE in BALF may be useful for the prediction of postoperative pulmonary complication.

Recent studies have focused on biochemical modulation with the combined use of CDDP and 5-FU for esophageal cancer. The combination of chemo- and radiotherapy is one of the most effective regimens for esophageal carcinoma. This combination therapy led to complete clinical remission in up to 30% of the cases in a prospective randomized study. We introduce many trials about postoperative adjuvant therapy after surgical treatment for esophageal carcinoma. The development and investigation of more effective chemotherapy regimens, as well as precise assessments of the response to preoperative treatment, is the challenge for randomized trials in the future.

Objective: The safe resection margin in esophagectomy for esophageal squamous cell carcinoma (SCC) was determined based on the extent of epithelial and subepithelial accessory lesions from the main lesions of esophageal SCC., Background: There have been many reports on the high incidence of a positive resection margin for esophageal cancer. Although there were some studies on the relationships of the proximal clearance to postoperative local recurrence, no pathologic study on the resection margin has been reported., Methods: Four hundred twenty specimens of a whole resected esophagus were examined histopathologically and the longitudinal length from the main lesion to the five types of accessory lesions was measured on microscopic slides., Results: Contiguous intraepithelial carcinoma existed in 69 (46%) of 150 sites of main lesions restricted to the mucosa or submucosa and subepithelial lesions existed in 131 (54%) of 245 sites and 82 (55%) of 150 sites of main lesions invading an adventitia and into neighboring structures, respectively. The risk of a positive resection margin due to subepithelial lesions was below 5% at 10 mm in the main lesion, restricted to the submucosa or the muscularis propria, and at 30 mm in the main lesion, invading the adventitia in the potentially curative operation cases., Conclusion: These clearances of the resection margin, in which the risk of a positive resection margin is below 5%, are acceptable, although these clearances should only be accepted after the extent of epithelial accessory lesions is accurately determined by the Lugol's stain method.

Esophageal dissection under laparoscopic monitoring is performed during total esophagectomy to treat patients with cervical esophageal carcinoma. Using this technique, a safe esophageal dissection can be made from the surrounding mediastinal tissues. Some of the disadvantageous consequences of a blunt dissection, including the blind maneuver, may thus be prevented and various intraoperative and postoperative complications may be avoided.

Background: A large number of patients with esophageal cancer experience recurrence, even when a curative operation is performed. The purpose of this study was to clarify the characteristics of recurrence after a curative esophagectomy., Methods: The patterns and the time of recurrence after curative esophagectomy were examined in 187 cases of thoracic esophageal cancer. Ninety-five of these patients died of evident recurrence. The recurrence patterns were classified into lymphatic, hematogenic, mixed type (lymphatic and concomitant hematogenic), and intramural recurrences., Results: The number of cases in each recurrence group were 46, 23, 22, and 4, respectively. The disease free intervals were fairly closely correlated with pTNM stage in the lymphatic and mixed type groups whereas they were within 2 years in all cases of the hematogenic group. Among the 22 cases of the mixed type, hematogenic recurrence preceded lymphatic recurrence in only one case. Furthermore, 17 of 20 cases with either cervical or mediastinal lymph node recurrence of the mixed type were accompanied with lung recurrence, whereas the remaining two cases with abdominal lymph node recurrence had liver recurrence., Conclusions: These findings suggest that most mixed type recurrences and most lymphatic ones are primarily caused by lymph node metastases; thus the importance of a radical lymphadenectomy was supported. On the other hand, a careful examination for hematogenic recurrence is essential soon after operation.

In this paper we report on the long-term results achieved in 75 patients with superficial carcinoma of the thoracic esophagus who have been treated since 1965 with esophagectomy at our institute. In three of these patients, the carcinoma was limited to the epithelium (intra-epithelial carcinoma), while in 13 cases it was confined to the mucosa, and in 59 cases to the submucosa. There was no lymph node metastasis in patients with intra-epithelial or mucosal carcinoma, but lymph node involvement was found in 13 (22.0%) of the 59 cases of submucosal carcinoma. The five-year survival rate of patients with intra-epithelial carcinoma and mucosal carcinoma was 100%, which was significantly better than that for carcinoma invading the submucosa (49%). The five-year survival rate for patients with lymph node involvement was only 46%, which was significantly worse than that for patients without lymph node involvement (60%). No recurrence occurred in patients with intra-epithelial carcinoma or mucosal carcinoma, while recurrent disease occurred in 19 (32.2%) of the 59 patients with submucosal carcinoma. Lymph node recurrence and hematogenic recurrence such as lung and bone metastasis were the most frequent developments in patients with submucosal carcinoma of the esophagus.

We performed a curative local excision for mucosal esophageal carcinoma through a thoracotomy with the help of intraoperative endoscopy and Lugol's staining. The mucosa and submucosa containing the lesion is completely resected, with neither narrowing nor shortening of the esophagus left remaining.

A 70-year-old man was found to have a moderately differentiated squamous cell carcinoma in the mid-esophagus on X-ray and endoscopy. These examinations revealed no lesion in the stomach at that time. Ten days after termination of preoperative hyperthermo-chemo-radiotherapy (HCR), a subtotal esophagectomy and gastric tube reconstruction via the retrosternal route were performed (pTNM stage I). Seven months later, another early cancer was detected in the reconstructed gastric tube. Via a median sternotomy, a wedge resection of the gastric tube was performed, and histopathological studies revealed a well-differentiated adenocarcinoma, which was limited to the submucosa (pTNM stage I). The patient has since done well with no signs of recurrence for the twenty-two months that have elapsed since the second operation was performed. Since the incidence of double cancer in the esophagus and stomach is high, and cases such as that described here will be detected more and more frequently in the future, not only a thorough investigation of a stomach intended for use in the reconstruction of the esophagus, but also strict postoperative checkups of the gastric tube when the esophagus has been reconstructed using the stomach must be considered of great importance.

To determine the contributing factors for eight postoperative complications after esophagectomy through a right thoracoabdominal approach, a multivariate analysis was carried out on preoperative and intraoperative variables in 141 patients with thoracic esophageal cancer. Although postoperative complications occurred in 125 patients, only 7 died of such complications. The multivariate analysis indicated that the retrosternal route was a significant factor predisposing to postoperative atelectasis. Age, preoperative arterial oxygen tension, and volume transfused were significant factors predisposing to postoperative hypoxemia, whereas age, routes other than the intrathoracic route, and volume transfused were significant factors predisposing to prolonged respiratory support. In addition, preoperative total serum bilirubin level and volume transfused were significant factors predisposing to postoperative hyperbilirubinemia; preoperative serum creatinine level was a significant contributing factor for postoperative renal insufficiency; and sex, antesternal route, and substituted colon were significant contributing factors for anastomotic leakage. There were no significant factors predisposing to postoperative pneumonia and liver dysfunction. These significant factors should be taken into consideration not only during perioperative management but also when choosing the operative procedures and extending the surgical indication for esophagectomy through a right thoracoabdominal approach.