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Summary Background & aims Malnutrition is common in patients with esophageal cancer, which affects their prognosis. The global leadership initiative on malnutrition (GLIM) criteria was recently proposed as the world's first diagnostic criteria for malnutrition. However, the association between esophageal cancer patients and the GLIM criteria is unclear. The purpose of this study was to evaluate the percentage of patients diagnosed with malnutrition preoperatively using the GLIM criteria, assess the impact of disease-specific symptoms on the severity of malnutrition, and assess the prognostic relevance of GLIM defined malnutrition in patients with esophageal cancer. Methods This was a retrospective single-center cohort study. Preoperative nutritional status of patients with esophageal cancer hospitalized between June 2009 and July 2011 was evaluated according to the GLIM criteria. Factors related to severe malnutrition as per the GLIM criteria were analyzed using multivariable logistic regression analysis. The association between the severity of malnutrition based on the GLIM criteria and 5-year survival was assessed using a multivariable Cox proportional hazard model. Results Overall, 117 esophageal cancer patients were nutritionally assessed. The percentage of moderate malnutrition and severe malnutrition was 21% and 23%, respectively. Subjective dysphagia [odds ratio (OR): 7.39, 95% confidence interval (CI): 1.46–37.52] and subjective esophageal obstruction (OR: 10.49, 95% CI: 3.47–31.70) were independent risk factors for severe malnutrition. The hazard ratio (HR) for 5-year mortality tended to be higher for moderate malnutrition (HR: 2.12, 95% CI: 0.91–4.95); however, it was not significantly associated with either moderate malnutrition or severe malnutrition (HR: 1.30, 95% CI: 0.52–3.27). Cases that were censored during the follow-up period probably affected the survival results. Conclusion Subjective feelings of dysphagia and esophageal obstruction might be related to malnutrition severity in esophageal cancer patients. Malnutrition assessed by the GLIM criteria was not significantly associated with 5-year survival.

Esophageal neuroendocrine carcinoma (ENEC) are rare and aggressive behavior with early dissemination and poor prognosis. According to previous reports, including case reports and reviews, the incidence of ENEC ranges from about 0.8–2.8%. Unfortunately, the rarity of this tumor has not yet permitted the prospective recruitment of patients in clinical trials, in order to establish the optimal therapy. The purpose of this study was to determine the optimal surgical treatment of ENEC. The histological diagnosis of ENEC was determined by examination of surgically resected specimens in patients who underwent surgery. The patients were selected from a prospective study of Department of Surgery, Institute of Gastroenterology Tokyo Women’s Medical University from 1968 to 2021. We study 27 cases of ENEC who performed operation with lymph node dissection. We investigated (1) the patient characteristics, (2) pathological findings including immunohistochemical profiles, (3) recurrence pattern, and survival curves, (4) ki-67 index. This study was approved by the ethics committee of Tokyo Women’s Medical University in Tokyo Japan. (1) gender (mail: female=23: 4), depth (T1: T2; T3: T4)=8: 3: 12: 4 Lymph node (N0: N1)=2: 25 (2) Immunohistochemistry of synaptophysin: chromogranin A: NCAM = 70.4%: 45%: 60% (3) recurrence pattern (liver: lung: Lymph node: bone: dissemination = 8: 6: 4: 2: 4) 50% survival rate (T1: T2-4= 19 months: 6.5 months) p=0.0202, numbers of lymph node (0-2: 3< = 19 months: 4mnths)p Cases in which long-term survival was obtained by surgical treatment was T1 or 0-2 numbers of lymph node. Ki-67 index was more than 80%.

Background & Aims Nitrogen balance (NB) is an important indicator of protein utilization in the body, and a positive NB is essential for maintaining and improving nutritional status. However, information is lacking on the target values of the energy and protein levels required to maintain positive NB in cancer patients. This study aimed to verify the energy and protein requirements for positive NB in preoperative esophageal cancer patients. Methods This study included patients for esophageal cancer surgery who were admitted for radical surgery. Urine urea nitrogen (UUN) levels were measured based on 24-h urine storage. Energy and protein intakes were calculated from the dietary intake during hospitalization and the amount administered from enteral and parenteral nutrition. The characteristics of the positive and negative NB groups were compared, and patients’ characteristics related to UUN excretion were analyzed. Results Seventy-nine patients with esophageal cancer were included, and 46% of patients were negative NB. All patients with energy intake ≥30 kcal/kg/day and protein intake ≥1.3 g/kg/day had positive NB. Whereas, in the group with energy intake ≥30 kcal/kg/day and protein intake Conclusion In preoperative esophageal cancer patients, 30 kcal/kg/day of energy and 1.3 g/kg/day of protein were the guideline values for positive NB. Good short-term nutritional status was a factor associated with increased UUN excretion.

BackgroundIncidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing in Japan as well as Western Country. However, there is no consensus on treatment strategy. The purpose of this study was to determine the optimal range of resection and lymph node dissection for Siewert type II AEG and to develop a strategy for treatment that includes adjuvant therapy to improve the survival rate. MethodsWe retrospectively investigate 88 cases of advanced AEG in patients who underwent surgery with lymph node dissection with 52 cases of superficial AEG, 23 of whom underwent endoscopic treatment (endoscopic mucosal resection [EMR] or endoscopic submucosal dissection [ESD]), and 29 of whom underwent surgery with lymph node dissection. ResultsThe optimal lymph nodes to resect for advanced AEG were in the inferior mediastinum (No. 110), in the lesser curvature (Nos. 1, 3, 7), No. 2, and No 11. According to area of actual lymph node metastasis, lymphadenectomy of lymph nodes 1, 2, 3, 7, and 11 was sufficient to improve survival of patients with superficial AEG. If esophageal involvement was >40 mm, we performed esophagectomy through right thoracotomy. The 5-year overall survival rates were 88% for patients treated with ESD, 78% for those with superficial AEG who under-went surgery, and 24% for those with advanced AEG (p = 0.011). Despite of lymph node dissection, twenty-five patients experienced lymph node metastasis after operation in advanced AEG and there were many disseminations in advanced AEG. There were no differences in survival between patients who received postoperative adjuvant therapy with S-1 for advanced AEG and those who received surgery alone (p = 0.5192).Conclusion Although surgical procedures of superficial and locally advanced AEG are standardized, the role of adjuvant therapy for AEG is still controversial. We recommend nab-paclitaxel plus radiotherapy for advanced AEG as neoadjuvant therapy.

Incidence of adenocarcinoma of the esophagogastric junction is increasing in Japan. However, in early cases (T1), there is no consensus on treatment strategy. The purpose of this study was to determine the optimal range of resection and lymph node dissection according to lymph node metastasis status and vascular invasion in early adenocarcinoma (T1) of the esophagogastric junction. Methods We investigated patient characteristics, surgical procedures, recurrence pattern, and optimum extent of lymph node dissection in 22 patients who underwent surgery in our hospital from 2000 to 2016 and were diagnosed with early adenocarcinoma of the esophagogastric junction (by Nishi’s classification). Results Four patients with lymph node metastasis, the depth of invasion was sm2 and lymphatic invasion was positive (ly1–ly3, focal lymphatic invasion to prominent lymphatic invasion). In all cases, the site of lymph node metastasis was the lesser gastric curvature. None of the patients developed postoperative lymph node recurrence. An examination of the outcomes revealed that the metastases were hematogenous in all patients with a depth of invasion of sm2 and a positive venous invasion (v1, focal vascular invasion). Conclusion We conclude that transhiatal esophagectomy should be selected as a minimal requirement, and that dissection of the abdominal lymph node (particularly on the lesser curvature side of the superior part of the stomach) is sufficient, for patients with early adenocarcinoma of the esophagogastric junction. In cases where the depth of invasion is sm2 or greater and vascular invasion is present, patients may require adjuvant therapy regardless of lymph node metastasis status.

Generally we use the stomach after esophagectomy as an organ of reconstruction. But we could not use it after we performed gastrectomy. We investigated the usefulness of the reconstruction with pedicled jejunum or pedicled right colon. Methods We performed esophagectomy from 2000 to 2015.15 patients use the reconstruction with pedicled jejunum as a A.10 patients use the reconstruction with pedicled right colon as a B. We study (1) background (2) complication. Results Average Age A:67.1 B:65.5 location (upper:middle:Lower) A:0:14:1 B:1:4:5 depth of tumor invasion (T1:T2:T3:T4) A:9:3:3:0 B:3:5:2 Stage (0:I:II:III:IVa) A:2:6:4:3:0 B:0:1:3:4:2 Reconstruction route (posterior mediastinal:retrosternal:antethoracic) A:4:2:9 B:0:5:5 The reason of the gastrectomy (ulcer: cancer) A 10:5 B 0:10 (distal gastrectomy:total gastrectomy) A:15:0 B:4:6 Reconstruction (BillrothI: BillrothII: Roux-Y) A:12:3:0 B:2:2:6 Complication (leakage)A:B = 3:0 (ileus)A:B = 2:0(weight loss)A:B = 10:0 (diarrhea)A:B = 3:5. Conclusion The best practice of reconstruction method is a reconstruction with pedicled jejunum without stomach. We can use the jejunum without damage of the vessel in the mesenteri of the jejunum.

Generally we use the stomach after esophagectomy as an organ of reconstruction. But we could not use it after we performed gastrectomy. We investigated the usefulness of the reconstruction with pedicled jejunum or pedicled right colon. Methods We performed esophagectomy from 2000 to 2015.15 patients use the reconstruction with pedicled jejunum as a A.10 patients use the reconstruction with pedicled right colon as a B.We study (1) background (2) complication. Results Average Age A:67.1 B:65.5 location(upper:middle:Lower)A:0:14:1 B:1:4:5 depth of tumor invasion (T1:T2:T3:T4)A:9:3:3:0 B:3:5:2 Stage(0:I:II:III:IVa)A:2:6:4:3:0 B:0:1:3:4:2 Reconstruction route(posterior mediastinal:retrosternal:antethoracic)A:4:2:9 B:0:5:5 The reason of the gastrectomy (ulcer: cancer)A 10:5 B 0:10 (distal gastrectomy:total gastrectomy)A:15:0 B:4:6 Reconstruction(BillrothI法:BillrothII法:Roux-Y) A:12:3:0 B:2:2:6 Complication (leakage)A:B = 3:0. (ileus)A:B = 2:0(weight loss)A:B = 10:0 (diarrhea)A:B = 3:5. Conclusion The best practice of reconstruction method is a reconstruction with pedicled jejunum without stomach. We can use the jejunum without damage of the vessel in the mesenteri of the jejunum. I want to show you our video.

Cardiac metastasis is uncommon and rarely diagnosed antemortem. Here, we describe a case of symptomatic cardiac metastasis from esophageal adenocarcinoma. A 64-year-old man developed chest symptoms 26 months after curative esophagogastrectomy for esophageal adenocarcinoma. Initially, ischemic cardiac disease was suspected based on electrocardiography findings, but an infiltrative tumor was seen morphologically in the wall of the interventricular septum and apex. No other lesions were detected. Histological examination of a transcatheter biopsy specimen indicated that the cardiac tumor was metastasis from esophageal adenocarcinoma. Chemoradiotherapy with cisplatin relieved his symptoms, and he had resumed normal activities. However, he opted not to undergo further aggressive treatment due to severe adverse effects from cisplatin. Seventeen months after completion of chemoradiotherapy, metastases to the right ventricle and the left thighbone were detected and he died 27 and 24 months after the diagnosis of cardiac metastasis and completion of chemoradiotherapy, respectively.

We have sometimes experienced technical difficulty performing thoracoscopic esophagectomy because of the position of the descending aorta or width of the mediastinal space. In this study, we retrospectively investigated predictive preoperative factors that influence the procedure of thoracoscopic esophagectomy with a focus on the position of the descending aorta and width of the mediastinal space. Ninety-five patients who underwent thoracoscopic esophagectomy for esophageal cancer by two specialists were included in this study. Thirty patients in whom both the operation time and blood loss in the thoracic region exceeded the median were categorized to the difficult group. The remaining 65 patients were categorized into the common group. During the evaluation of the position of the descending aorta, we measured the aorta–vertebra angle at the level of the left inferior pulmonary vein. During the evaluation of the width of the mediastinal space, we measured the sternum–vertebra distance at the level of the tracheal bifurcation. A forward stepwise logistic regression analysis revealed the following independent predictive factors of the technical difficulty of thoracoscopic esophagectomy: aorta–vertebra angle (≥ 30°), sternum–vertebra distance (

Background: We investigated the relationship between the preoperative psychological state and the perioperative nutritional conditions of patients with esophageal cancer. Methods: Seventy-three participants underwent operations for esophageal cancer in our hospital. Depressive state was evaluated using the Self-Rating Depression Scale (SDS). General quality of life (QOL) was assessed using the SF-8™, and the nutritional assessments were evaluated through anthropometric analysis, bioelectrical impedance analysis (BIA) and some biochemical assessments. Results: In the preoperative stage, patients with higher SDS scores, representing a more depressive state, had low arm circumference, grip strength, serum albumin levels and prognostic nutritional index. Patients with higher SDS scores also had a tendency for a lower physical component summary, representing physical QOL by the Eight-Item Short Form Health Survey (SF-8™). At 3 months after surgery, patients with higher preoperative SDS scores had significantly lower body mass indexes (BMIs) and had a lower tendency of body fat masses. In the univariate and multivariate analyses on the recovery of BMI at 3 months after surgery, preoperative SDS score was the only independent risk factor (odd ratio (OR): 4.07, 95% confidence interval (CI): 1.15 - 14.35) in this study. Conclusion: Preoperative depressive mood, as evaluated by the SDS, was the sole relevant factor for postoperative body weight recovery of patients with esophageal cancer. Preoperative depressive mood of patients with esophageal cancer might delay recovery from operation-related malnutrition. Some measures against preoperative depressive mood might be necessary for early recovery from postoperative malnutrition in patients with esophageal cancer. J Clin Med Res. 2019;11(3):188-195 doi: https://doi.org/10.14740/jocmr3704

Neoadjuvant chemotherapy (NAC) involving two cycles of cisplatin plus fluorouracil is recommended in Japan as a standard treatment for resectable, locally advanced esophageal squamous cell carcinoma (ESCC). We have encountered patients who were administered incomplete chemotherapy because of adverse events or the patient’s refusal of treatment. Here, we retrospectively investigated the influence on perioperative outcomes and long-term prognosis of patients with ESCC who underwent complete (two cycles) or incomplete (one cycle) NAC. We retrospectively investigated 133 patients with locally advanced ESCC of the thoracic esophagus who underwent NAC. We compared the perioperative results and prognoses of patients who underwent complete or incomplete NAC because of adverse events or the patient’s refusal of treatment. Of 133 patients, 37 patients did not receive the second cycle of NAC; the remaining 96 patients received the second cycle of NAC as scheduled. There were no significant differences in the clinical backgrounds, surgical results, or operative morbidity rates between the groups. Patients in both groups were similarly administered postoperative chemotherapy regimens. There was no significant difference in disease-free survival or overall survival. We suggest that perioperative outcomes and long-term prognosis of patients with locally advanced ESCC were not significantly influenced, even if the patients did not receive a complete cycle of NAC. When certain adverse events occur after the first cycle of NAC, we believe that it is nevertheless possible to discontinue chemotherapy.

Neoadjuvant chemotherapy (NAC) with cisplatin and fluorouracil is the recommended standard treatment for resectable locally advanced esophageal cancer (EC) in Japan. We investigated the effects of NAC on the safety and feasibility of thoracoscopic esophagectomy with total mediastinal lymphadenectomy for EC. This retrospective study analyzed data from 225 consecutive patients who underwent thoracoscopic esophagectomy with lymph node dissection between April 2007 and December 2015. Patients with clinical stage IB, IIA, IIB, IIIA, or IIIB EC, and no active concomitant malignancy were included. We compared intraoperative outcomes, and postoperative morbidity and mortality between patients who received NAC (n = 139; NAC group) and patients who did not (n = 86; non-NAC group). Preoperative laboratory data revealed that anemia, thrombopenia, and renal dysfunction were more common in the NAC group than in the non-NAC group. There were no differences between the groups in operating times, blood loss, number of dissected lymph nodes, overall complication rates, or length of postoperative hospital stay. Based on our findings, thoracoscopic esophagectomy is safe and effective for locally advanced EC, even after NAC.

This study investigated the long-term risk factors for pneumonia after esophageal reconstruction using a gastric tube via the posterior mediastinal route following esophagectomy for esophageal cancer. The influence of columnar metaplasia in the remnant esophagus was specifically assessed. Among 225 patients who underwent esophagectomy between January 2004 and December 2010, the subjects were 54 patients who could be followed up for more than 5 years. Routine oncologic follow-up consisted of CT scanning of the abdomen and chest every 4–6 months and annual endoscopy. Data on the occurrence of pneumonia were collected by retrospective review of chest CT scans. Risk factors for pneumonia investigated by univariate and multivariate analyses included the age, gender, diameter of the stapler, length of the intrathoracic remnant esophagus, anastomotic stricture, and presence of columnar metaplasia in the remnant esophagus. The median age was 62.4 years (interquartile range: 55.8–68.0 years). Forty-three patients were men. Pneumonia was detected in 39 patients (72.2%). The incidence of columnar metaplasia in the remnant esophagus increases with time. Anastomotic stricture was significantly related to the absence of columnar metaplasia on endoscopy in the first year after esophagectomy (p = 0.013). Univariate analysis showed that the frequency of pneumonia was significantly related to the intrathoracic remnant esophagus length ≥4.4 cm (p = 0.014), age over 65 years (p = 0.014), and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy (p = 0.005). Among them, age over 65 years and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy were found to be independent indicators of the postoperative pneumonia by multivariate analysis. Pneumonia occurred in 72.2% (39/54) of patients after esophagectomy for esophageal cancer. The presence of columnar metaplasia after esophagectomy is an indicator for pneumonia over the long term.

Since 1995, video-assisted thoracoscopic oesophagectomy (VATS), according the same surgical principles as the Japanese open surgery, has been completed in 700 patients with oesophageal cancer. Our indication for VATS is (I) no extensive pleural adhesion; (II) no contiguous tumor spread; (III) pulmonary function capable of sustaining single-lung ventilation, and (IV) non radiated patients. We use 4 ports around a 5 cm mini-thoracotomy on 5th intercostal space. We laid emphasis on utilizing magnifying effect of video (5 to 20 magnifications), obtained by positioning the camera at close vicinity to the dissection. Magnified view facilitates recognizing the fine layer structure of the mediastinum. The dissection should be performed following this layer structure just like open the page of a book. Tearing the layer makes the dissection irrational and cause unnecessary bleeding and invasiveness. The microanatomies we recognize during upper mediastinal dissection are (I) the most outer layer below the mediastinal pleura are branches from the vagus nerve and thoracic sympathetic trunk; (II) there is no vessel flow in the nerves or out, in the field of dissection; (III) the ideal layer of dissection along the nerve is exposing the epineurium; (IV) the strongest fixing structures in the mediastinum are the vagal nerves and nerves form thoracic sympathetic trunk; (V) the stump of thoracic duct shows particular appearance because of the intramural smooth muscle; (VI) the lymphonodes in the mediastinum are fixed strongly with nerves and gently with vessels; (VII) the aorta is covered with fine fibrous membrane consisting of branches form thoracic sympathetic trunk, etc. Magnified view shows the microstructure of the lymph node such as the afferent lymphatics penetrating the capsule and the hilum structure consisting the efferent lymphatics, artery, vein and nerve. The direction of the hilum of nodes is defined in each region. Therefore, understanding the hilum direction facilitates rational dissection. The hospital mortality was four patients (0.6%). The rate of regional control was 95%. The 5-year survival rates of the patients with pStage 0, 1, 2, 3, 4 were 92%, 88%, 69%, 52% and 24%, respectively, which were favorably compared with open surgery.

In patients treated surgically for esophageal cancer, time-dependent data on nutritional status from the perioperative to postoperative period are questionable. We investigated time-dependent data on weight, body composition, and nutritional indices of patients with esophageal cancer from the preoperative period through the 12-month postoperative period. Eighty patients with esophageal cancer were enrolled and subsequently underwent esophagectomy. Forty out of eighty patients were completed the 12-month follow-up survey period and analyzed. We assessed clinical, anthropometric measurement, laboratory data, and nutritional status data preoperatively and at 1, 3, 6, and 12 months postoperatively. Patients with esophageal cancer had 7.2% weight loss in the preoperative period compared with the usual body weight (UBW) before morbidity and 9.3% weight loss from preoperative to 12-month postoperative period. Weight gain in the postoperative survey period was not significant. Conversely, there was a time lag in the time-dependent changes in the postoperative nutritional status; this was considered to coincide with internal organ protein, body protein, and body fat levels, in that order. Multivariate analysis identified a ≥ 10% preoperative weight loss compared with UBW as the only independent factor negatively contributing to ≥ 85% weight recovery at 12 months postoperatively (OR 6.54, 95% CI 1.14–37.60, p = 0.036). For sufficient nutritional status recovery in patients treated with esophagectomy, minimizing weight loss preoperatively is important. Regardless of neoadjuvant therapy or age, preoperative nutritional treatment should be promptly administered for all patients.

Although the anti-inflammatory effects of immunomodulating diets (IMDs) have recently attracted attention, the efficacy of enteral feeding of such diets after radical surgery remains controversial. Thus, we conducted a new prospective, randomized controlled study to elucidate any beneficial effect of an IMD containing eicosapentaenoic acid (EPA) and γ-linolenic acid (GLA) in patients undergoing radical esophagectomy for thoracic esophageal cancer. From November 2009 to July 2011, 87 consecutive patients were randomized to receive either an IMD enriched with EPA, GLA, and antioxidants (n = 42) or a standard isocaloric, isonitrogenous diet (control group, n = 45) after esophagectomy with radical lymphadenectomy. The primary outcome measure was changes in the oxygenation status (PaO2/FIO2 ratio), and the secondary outcome measures were body composition, inflammation-related factors, coagulation markers, cholesterol concentrations, and major clinical outcomes. Oxygenation was significantly better on postoperative days (PODs) 4, 6, and 8 in the IMD than control group (366.5 ± 63.3 vs. 317.3 ± 58.8, P = 0.001; 361.5 ± 52.6 vs. 314.0 ± 53.2, P

Background: During esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy. In order to improve the quality of the dissection and standardization of the procedure, we describe the surgical anatomy and steps involved in this procedure. Methods: We retrospectively evaluated twenty consecutive and unedited videos of thoracoscopic esophageal resections. We recorded the vascular anatomy of the supracarinal esophagus, lymph node stations and the steps taken in this procedure. The resulting concept was validated in a prospective study including five patients. Results: Seventy percent of patients in the retrospective study had one right bronchial artery (RBA) and two left bronchial arteries (LBA). The RBA was divided at both sides of the esophagus in 18 patients, with preservation of one LBA or at least one esophageal branch in all cases. Both recurrent laryngeal nerves were identified in 18 patients. All patients in the prospective study had one RBA and two LBA, and in four patients the RBA was divided at both sides of the esophagus and preserved one of the LBA. Lymphadenectomy was performed of stations 4R, 4L, 2R and 2L, with a median of 11 resected lymph nodes. Both recurrent laryngeal nerves were identified in four patients. In three patients, only the left recurrent nerve could be identified. Two patients showed palsy of the left recurrent laryngeal nerve, and one showed neuropraxia of the left vocal cord. Conclusions: Knowledge of the surgical anatomy of the upper mediastinum and its anatomical variations is important for standardization of an adequate esophageal resection and paratracheal lymphadenectomy with preservation of any vascularization of the trachea, bronchi and the recurrent laryngeal nerves.

Background: Patients undergoing surgery for esophageal cancer are at risk of prolonged hospital stay for postoperative malnutrition. Postoperative early oral feeing is a part of the &ldquo, enhanced recovery after surgery protocol&rdquo, for coping with this risk. However, the usefulness of early oral intake during perioperatively is questionable. Methods: In total, 117 patients treated surgically for esophageal cancer were analyzed in the study. We assessed the oral energy sufficiency rate per nutritional requirement (oral-E/NR) at the fourth week postoperatively and classified the patients into two groups: Poor oral intake group (POI group, &lt, 25% oral-E/NR) and the control group (&ge, 25% oral-E/NR). We analyzed the relationship among postoperative oral intake and prognoses. Results: The POI group had worse postoperative nutritional status and a lower survival rate than the control group. In a multivariate analysis, &lt, 25% oral-E/NR was one of the independent factors contributing to negative outcomes postoperatively (adjusted hazard ratio: 2.70, 95% confidence interval: 1.30&ndash, 5.61). Conclusions: In patients undergoing surgery for esophageal cancer, poor postoperative oral intake negatively affected not only on their postoperative nutritional status but also their overall prognosis. It is necessary to improve the adequacy of oral intake postoperatively for patients with esophageal cancer.

Case series Patients: Male, 48 • Male, 60 • Male, 63 • Male, 69 • Male, 68 • Female, 63 Final Diagnosis: Esophageal cancer Symptoms: None Medication: — Clinical Procedure: — Specialty: Oncology Objective: Rare disease Background: Patients with esophageal achalasia are considered to be a high-risk group for esophageal carcinoma, and it has been reported that this cancer often arises at a long interval after surgery for achalasia. However, it is unclear whether esophageal carcinoma is frequent when achalasia has been treated successfully and the patient is without dysphagia. In this study, we reviewed patients with esophageal carcinoma who were detected by regular follow-up after surgical treatment of achalasia. Case Report: Esophageal cancer was detected by periodic upper GI endoscopy in 6 patients. Most of them had early cancers that were treated by endoscopic resection. All 6 patients had undergone surgery for achalasia and the outcome had been rated as excellent or good. Annual follow-up endoscopy was done and the average duration of follow-up until cancer was seen after surgery was 14.3 years (range: 5 to 40 years). Five patients had early cancer. Four cases had multiple lesions. Conclusions: In conclusion, surgery for achalasia usually improves passage symptoms, but esophageal cancer still arises in some cases and the number of tumors occurring many years later is not negligible. Accordingly, long-term endoscopic follow-up is needed for detection of malignancy at an early stage.

A 73-year-old man was diagnosed with essential thrombocythemia and treated with acetylsalicylic acid and hydroxyurea for 15 years. He was referred to our hospital for treatment of esophageal cancer detected by endoscopy. The cancer stage was T1N1M0, cStage IIB according to the classification of the Union for International Cancer Control, 7th edition. After administering two courses of preoperative chemotherapy (5-fluorouracil + cisplatin), the patient underwent video-assisted thoracoscopic radical esophagectomy. Hydroxyurea administration was discontinued during anticancer therapy and restarted to control the platelet count. Heparin was continuously infused during the perioperative period, and hydroxyurea was restarted through a jejunostomy tube on the postoperative day 2. No thrombosis or hemorrhage developed, and the patient was discharged from the hospital on the postoperative day 33. This is the first case report of video-assisted thoracoscopic radical esophagectomy for esophageal cancer in a patient with essential thrombocythemia.

We evaluated the effectiveness of neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy for cT4 esophageal cancer or lymph node metastases (LNM) invading adjacent structures. We retrospectively evaluated 42 consecutive patients with thoracic esophageal cancer who underwent CRT followed by esophagectomy between 2008 and 2013. All were initially considered to be unresectable because of cT4 (n = 32) disease or LN invasion (n = 10). Radiotherapy was administered at 41.4 Gy/23 fr with concurrent chemotherapy. At completion of CRT, restaging was performed using computed tomography (CT). All cT4 tumors were downstaged, LNM invading to adjacent structures were considered to be released, and subtotal esophagectomy was performed. The median follow-up period was 42 months. The curative resection (R0) rate was 94% in cT4 group and 70% in LN invasion group. The 3-year overall survival (OS) and 3-year locoregional control (LRC) rates were 65–80% in the cT4 group and 50–67% in LN invasion group, respectively. The cT4 group showed good rates of R0, OS, and LRC. Surgical resection should be an effective option when downstaging is achieved by CRT for patients with initially inoperable thoracic esophageal cancer.

Since the first report by Dallemagne in the left lateral position in 1991 and by Cuschieri in the prone position in 1992, the minimally invasive oesphagectomy for cancer has been becoming popular gradually and been performed widely. For oesophageal cancer, the same quality of mediastinal dissection as open surgery should be entailed even through thoracoscopy. However, after learning in the technique, the previously undescribed fine anatomy, namely microanatomy, became obvious under magnified view obtained by positioning the camera at close vicinity to the dissection and thoracoscopic surgeon’s knowledge of the layer structure in the mediastinum became profounder. The proper dissection along the anatomical layer minimizes the tissue damage, bleeding and duration of the procedure, without oncological compromise. Reducing surgical insulation in the mediastinum by the rational dissection along the anatomical layers is the important factor in minimally invasive surgery together with reducing the thoracic wound.

Background Neuroendocrine tumors of the esophagus are very rare. The prognosis is known to be poor, and there is no consensus on treatment strategy. Methods We investigated 27 patients who underwent surgery for neuroendocrine tumor of the esophagus at our institute between 1968 and 2017. We researched (1) Background, (2) Treatment, (3) Types of the recurrences, and (4) Prognosis. Results (1) Male: female = 22: 5, Median age; 64.2 (24–77), Location; Ut: Mt: Lt: Ae = 1: 15: 9: 2, Depth of the tumors: T1: T2: T3: T4 = 9: 3: 11: 4, Median length of the tumors; 57.7 mm (14–130), Pathological types; pure type: mixed type = 10:17, Lymph node metastasis; N0: N(+ ) = 3: 24. (2) Surgical approach; right thoracotomy:left thoracoabdominal incision:transhiatal approach = 24: 2: 1, Organ used for reconstruction; stomach: colon = 25: 2, Route of reconstruction; antethoracic: retrosternal: posterior mediastinal = 10: 5: 12, Neoadjuvant therapy; (+ ): (-) = 15: 12. (3) Types of recurrences; liver: lung: lymph nodes: bone: dissemination = 7: 6: 4: 2: 4. (4) Median survival time was 10 months (1–98). Compared by (a) tumor depth, (b) number of metastatic LNs, (c)with or without adjuvant therapy were as follows; (a) T1: T2–4 = 19: 5 months (P = 0.0202), (b) 0–2: > 2 = 19: 4 months (P Conclusion Approximately 2/3 cases were accompanied with poorly differentiated SCC, and most of those cases were diagnosed as NET after surgery. Prognosis is poor, but pT1 cases and cases with small number of LN metastases showed better prognosis. Although without significant difference, cases with adjuvant therapy showed longer prognosis. Our opinion is, if with selection of cases and strong adjuvant therapy, surgery can be a feasible choice. Disclosure All authors have declared no conflicts of interest.

This study aimed to compare short-term outcomes of minimally invasive esophagectomy (MIE) with those of open esophagectomy (OE) for thoracic esophageal cancer using a nationwide Japanese database. Overall, 9584 patients with thoracic esophageal cancer who underwent esophagectomy at 864 hospitals in 2011–2012 were evaluated. We performed one-to-one matching between the MIE and OE groups on the basis of estimated propensity scores for each patient. After propensity score matching, operative time was significantly longer in the MIE group (n = 3515) than in the OE group (n = 3515) [526 ± 149 vs. 461 ± 156 min, p

Aberrant hypermethylation of specific genes is present in esophageal squamous cell carcinomas (ESCCs). Such hypermethylation is also present in normal-appearing esophageal mucosae of ESCC patients and is considered to contribute to the formation of a field for cancerization. On the other hand, the presence of global hypomethylation in ESCCs or in their background esophageal mucosae is unknown. We collected 184 samples of esophageal mucosae (95 normal mucosae from healthy subjects, and 89 non-cancerous background mucosae from ESCC patients) and 93 samples of ESCCs. Methylation levels of repetitive elements (Alu, LINE1) and cancer/testis antigen genes (NY-ESO-1, MAGE-C1) were measured by bisulfite pyrosequencing and quantitative methylation-specific PCR, respectively. Methylation levels of Alu, LINE1, NY-ESO-1, and MAGE-C1 were significantly lower in ESCCs than in their background and normal mucosae. Also, in the background mucosae, a significant decrease of the Alu methylation level compared with the normal mucosae was present. In ESCCs, methylation levels of the two repetitive elements and the two cancer/testis antigen genes were correlated with each other. This is the first study to show the presence of global hypomethylation in ESCCs, and even in their non-cancerous background mucosae. Alu hypomethylation might reflect the severity of an epigenetic field for cancerization.

Massive bleeding from large vessels is a serious and life-threatening complication after radical esophagectomy. Here, we present the rare case of patient survival following two episodes of massive bleeding from a tracheo-brachiocephalic artery fistula after salvage surgery for cervical esophageal cancer following definitive chemoradiation. During the first episode of bleeding, the damaged part of the brachiocephalic artery was transected with an extra-anatomical arterial bypass (right femoro-axillo artery bypass graft) to maintain the arterial blood flow to the brain and the free jejunal graft. During the second bleeding, the distal stump of the brachiocephalic artery was reclosed. During both episodes of bleeding, the musculocutaneous flap was effectively employed to seal the stumps of the brachiocephalic artery and fill the dead space. Finally, the patient was discharged 351 days after the first surgery. (132/150).

Here, we report on an anomaly of the right pulmonary vein in the subcarinal area and emphasis the importance of its focus in subcarinal lymph node dissection. A 51-year-old Japanese man underwent thoracoscopic radical esophagectomy with regional lymph node dissection for esophageal carcinoma T1bN1M0, stage IIB. While dissecting the subcarinal lymph node, we encountered a thick vein crossing posterior to the intermediate right bronchus. We recognized the anomalous right pulmonary vein (anomalous V2) that drained into the left atrium from the right posterior segment (S2). We cautiously dissected the subcarinal lymph node and were able to preserve the anomalous vein. This anomalous pulmonary vein can cause serious complications. If the anomalous V2 had been injured or ligated, congestion of the right S2 or cardiac tamponade might have develop. Since anomalous pulmonary veins are easily identified by enhanced computed tomography, careful observation is essential for avoiding their unnecessary injury.

SUMMARY Attainment of proficiency in video-assisted thoracoscopic radical esophagectomy (VATS) for thoracic esophageal cancer requires much experience. We have mastered this procedure safely under the direction of an experienced surgeon. After adoption of the procedure, the educated surgeon directed induction of this surgical procedure at another institution. We evaluated the efficacy of instruction during the induction period by comparing the results at the two institutions in which VATS had been newly induced. We defined the induction period as the time from the beginning of VATS to the time when the last instruction was carried out. From January 2003 to December 2007, 53 patients were candidates for VATS at Kanazawa University (institution 1). Of these, 46 patients underwent curative VATS by a single operator. We divided this period into three parts: the induction period of VATS, post-induction period, and proficient period when the educated surgeon of institution 1 directed the procedure at Maebashi Red Cross Hospital (institution 2). At institution 1, 12 VATS were scheduled, and nine procedures (75%) (group A) including eight instructions were completed during the induction period (from January 2003 to August 2004). Thereafter, VATS was performed without instruction. In the post-induction period, nine VATS were scheduled, and eight procedures (88.8%) (group B) were completed from September 2004 to August 2005. Subsequently, 32 VATS were scheduled, and 29 procedures (90.6%) (group C) were completed during the proficient period (from September 2005 to December 2007). The surgeon at Maebashi Red Cross Hospital (institution 2) started to perform VATS under the direction of the surgeon who had been educated at institution 1 from September 2005. VATS was completed in 13 (76.4%) (group D) of 17 cases by a single surgeon including seven instructions during the induction period at institution 2 from September 2005 to December 2007. No lethal complication occurred during the induction period at both institutions. We compared the results of VATS among four groups from the two institutions. There were no differences in the background and clinicopathological features among the four groups. The number of dissected lymph nodes and amount of thoracic blood loss were similar in the four groups (35 [22–52] vs 41 [26–53] vs 32 [17–69] vs 29 [17–42] nodes, P = 0.139, and 170 [90–380] vs 275 [130–550] vs 220 [10–660] vs 210 [75–543] g, P = 0.373, respectively). There was no difference in the duration of the thoracic procedure during the induction period at the two institutions. However, the duration of the procedure was significantly shorter in the proficient period of institution 1 (group C: 266 [195–555] minutes) than in the induction period of both institutions (group A: 350 [280–448] minutes [P = 0.005] and group D: 345 [270–420] mL [P = 0.002]). There were no surgery-related deaths in any of the groups. The incidence of postoperative complications did not differ among the four groups. Thoracoscopic radical esophagectomy can be mastered quickly and safely with a flat learning curve under the direction of an experienced surgeon. The educated surgeon can instruct surgeons at another institution on how to perform thoracoscopic esophagectomy. The operation time of thoracoscopic surgery is shortened by experience.

Background The development of minimally invasive surgery has yielded many benefits, therefore the number of patients undergoing thoracoscopic radical esophagectomy (TRE) for esophageal cancer has been increasing worldwide. However, in the Japanese nationwide web-based database report, the incidence of recurrent laryngeal nerve (RLN) paralysis and overall morbidity were significantly higher in the TRE group than in the open esophagectomy group. In recent years, intraoperative nerve monitoring (IONM) is commonly being used in thyroid and parathyroid surgery in many centers. We tried to determine the feasibility and effectiveness of IONM of RLN during upper mediastinal lymph node dissection in TRE. Methods All 628 patients who underwent TRE in the left lateral decubitus position at Osaka City University Hospital between May 1995 and February 2018 were enrolled in the present study. We introduced IONM using NIM® (Medtronic) during TRE from October 2016 at our hospital. We divided retrospectively the patients into two groups: IONM group (TRE with IONM of RLN; n = 49) and No-IONM group (TRE without IONM of RLN; n = 579). Diagnosis of RLN paralysis was performed using laryngoscopy. The feasibility of IONM during TRE and the incidence of postoperative RLN paralysis were compared with those in No-IONM group. Results IONM could be performed for 46 patients (93.9%) in IONM group. Three patients (6.1%) could not keep single-lung ventilation using a single lumen tracheal tube with a bronchial blocker and needed to replace a tracheal tube by a double lumen tube during TRE. The incidence of postoperative RLN paralysis (CD≧ 1; CD; Clavien-Dindo classification of surgical complications) was 17.4% in IONM group and 30.2% in No- IONM group. There was a significant difference in the incidence of postoperative RLN paralysis (P Conclusion IONM of RLN during TRE is technically feasible. The introduction of standardized IONM of RLN during TRE is able to reduce the incidence of postoperative RLN paralysis. Disclosure All authors have declared no conflicts of interest.

Background Definitive chemoradiotherapy for esophageal cancer which was unresectable tumor has become common therapy. In recently, we have perform chemoradiotherapy for resectable tumor because esophagectomy for esophageal cancer is an invasive surgical procedure. But some cases were recurrent. We examined the treatment strategy and clinical outcomes of salvage esophagectomy after definitive chemoradiotherapy for esophageal cancer. Methods We reviewed 46 cases of subjects with esophageal cancer who underwent salvage esophagectomy after definitive chemoradiotherapy with more than 50Gy of radiation from 2000 to 2017. We exam (1) Back ground (2) Term after Chemoradiotherapy (3)Surgical approach (4) Route of reconstruction (5)Rang of lymphanodectomy (6)Complication (7)Prognosis. Results Age 63.0(43–79), Male: Female = 44:2, Location: Upper/Middle/Lower = 15/25/8, T1/T2/T3/T4 = 11:2:25:8 R0: R1: R2 = 35:9:2 (2) Within1 year/More than 1 year = 31/15 (3) Neck digection/Right thoracotomy: Left thoracotomy: laparotomy = 8:31:5:2 (4) Mediastinal rute/Ante/Retro = 34:9:3 (5) 1 Field:2 Field:3 Field = 11:27:8 (6) Anastleakage/Pneumonia/Abcess/Meningitis/Fluid in the thoracic cavity = 11: 9: 4: 1: 8 (7) 5-years survival rate was 36%. Hospital death was4.3% Conclusion There were high rate complications for salvage esophagectomy after definitive chemoradiotherapy for esophageal cancer. Patients should be carefully selected for salvage esophagectomy.Surgeons should consider the indications and techniques for esophageal surgery to increase cure rates and decrease morbidity. Disclosure All authors have declared no conflicts of interest.

Background Incidence of adenocarcinoma of the esophagogastric junction is increasing in Japan as Europe or America. However, there is no consensus on treatment strategy. The purpose of this study was to determine the optimal range of resection and lymph node dissection according to lymph node metastasis status in adenocarcinoma of the esophagogastric junction Methods We investigated 75 patients who were diagnosed with advanced adenocarcinoma(A) of the esophagogastric junction and 22 patients were diagnosed with early adenocarcinoma(B). Results (1) Location(EG: E = G: GE: G) A = 37:20:17:1 B = 5:4:13(2)The depth of tumor (m2: m3: sm1: sm2: sm3: T2: T3: T4) = 1:6:2:10:3:13:59:3)(3) Degree of lymph node metastasis(n + : n-) A = 49:26 B = 4:18 (4) Surgical approach (Right thoracotomy:Left thoracoabdominal incision:Laparotomy (Transhiatal approach) A = 13:47:15 B = 1:5:16 (5) Neoadjuvant therapy (Chemotherapy before operation:Chemo-radiotherapy before operation:Chemotherapy after operation:Chemo-radiotherapy after operation) A = 1:12:33:1 B were without neoadjuvant therapy (6) Lymph node metastasis (Number of metastasis of lymphnode/Area of the dissection of lymphnode) Cervical: Upper thoracic: Middle: Lower: abdominal A = (1/7, 2/13, 4/31, 15/62, 46/75) B = (0/1, 0/3, 0/8, 4/22) (7) Type of the recurrence (Cervical Lymph node: mediastainal lymphnode: abdominal lymphnode: dissemination: Liver: Lung: Born: Remunant esophagus: Skin: Brain: Other disease) A = (3:8:6:13:9:4:2:1:1:1) B = (0:0:0:0:1:0:1:0:0:0:3) (8) Index (metastatic rate x3-yearOS/100)A = No1: No2: No3: No.7: No11: No20: No110: No112 = 12.1:10.6:12.9:13.5:18.1:50:12.9:9.09 B were not showed because incidence of metastasis of the lymph node were low.(9) 5-years survival rate for advanced cancer was 38% and early cancer was 88% Conclusion Proximal gastrectomy may be a minimally invasive surgical technique in for early and advanced adenocarcinoma of the esophagogastric junction according to the lymph node metastasis status. Surgical resection has been mainstream treatment but It was necessary to perform definitive or neoadjuvant chemoradiotherapy. Disclosure All authors have declared no conflicts of interest.

A new technique for performing laparoscopic anterior resection is described. Main differences from the standard technique are (1) pneumoperitoneum to improve exposure of the rectum, even in a narrow pelvis; (2) rectal division performed using a conventional linear stapler inserted via a 4.5 cm suprapubic incision; and (3) eversion of the rectum for tumors close to the anal verge, with transection performed under direct vision. Results in 78 patients who underwent transabdominal transection and in 7 patients requiring rectal eversion were compared retrospectively with those in 61 consecutive patients who had undergone standard laparoscopic resection. The duration of the operation and estimated blood loss were greater with rectal eversion, and more staple cartridges were used for the conventional technique; however, the incidence of complications was similar for all three groups. Five patients in the conventional group required conversion to an open procedure. The new technique should improve the safety of resection.

金沢大学医学部附属病院胃腸外科, Objective. The attainment of proficiency in thoracoscopic radical esophagectomy for thoracic esophageal cancer requires much experience. We aimed to master this procedure safely with our regular surgical team members under the direction of an experienced surgeon. We evaluated the efficacy of instruction during the induction period and the significance of our results. Methods. We compared the results of 12 thoracic esophageal cancer patients who underwent thoracoscopic radical esophagectomy in our institution (group A) to those of the initial 17 patients who underwent the same operation at the director's institution (group B). Results. We were able to perform complete thoracoscopic radical esophagectomies without any direction after experiencing 10 cases that were performed under adequate direction. The number of dissected lymph nodes and the duration of the procedure were similar in the two groups: 34 (22-53) vs. 26 (9-55) nodes, P = 0.23; and 327.5 (230-455) vs. 315 (190-515) min, P = 0.947, respectively. The amount of thoracic blood loss was significantly less in group A than in group B: 185 (110-380) g vs. 440 (110-2360) g, P = 0.0035. Postoperative pneumonia and atelectasis were observed in 25.0% of group A patients and in 17.6% of group B patients. The incidence of recurrent nerve palsy was 30.7% in group A and 11.7% in group B, but there was no statistically significant difference (P = 0.19). The morbidity rates in group A and group B were 41.6% and 29.4%, respectively (P = 0.694). Conclusion. Thoracoscopic radical esophagectomy can be mastered relatively quickly and safely under the direction of an experienced surgeon and a regular surgical team. © 2008 The Japanese Association for Thoracic Surgery.

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patient's figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The "triangulating stapling technique" (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patient's figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.

症例は82歳，男性．2005年7月頃より右腰背部の膨隆を自覚していた．腹部CT施行されたところ広背筋の腹側にて腰方形筋と内腹斜筋の間より脱出する後腹膜脂肪織を認め上腰ヘルニアと診断され手術目的にて当科紹介受診となった．右第12肋骨下縁三横指尾側，脊柱の右側に鶏卵大の柔らかな腹圧により膨隆する腫瘤を触知した．2006年3月に硬膜外麻酔下に左側臥位にて手術を施行した．ヘルニア門周囲を構成している筋群が比較的健常であったため直接縫合・閉鎖が可能であった．術後合併症なく13病日に退院した．以後の再発は認めていない．腰ヘルニアは稀な疾患であり，直接縫合閉鎖により修復可能であった上腰ヘルニア1例を経験したので報告する．

of the survey We sent out survey questionnaire forms to the departments of each category in all 1896 institutions nationwide in early June 2005. The response rates by the end of December 2005 were 94.7%, 91.6%, and 86.0% for the cardiovascular, general thoracic, and esophageal categories respectively. This is the annual report by The Japanese Association for Thoracic Surgery from the Committee for Scientifi c Affairs Y. Ueda, MD Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan H. Osada, MD Department of Surgery, Division of Chest Surgery, St. Marianna University School of Medicine, Kawasaki, Japan H. Osugi, MD Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan 378 Gen Thorac Cardiovasc Surg (2007) 55:377–399

食道癌術後には凝固異常が発症することが知られている。この凝固異常に対しては，現在までステロイドなどさまざまな薬剤投与が試みられてきた。今回われわれは，好中球エラスターゼの特異的阻害剤（シベレスタットナトリウム，以下SN）投与の食道癌術後の凝固能におよぼす影響について検討した。対象は食道癌切除再建を一期的に行った41例で，これら症例を術後SNを投与した21例（SN+群）と，SNを投与しなかった20例（SN-群）に分けた。SN+群でSNを，術直後より0.2mg/kg/hrで術5病日まで持続的に投与した。全例で術直前にメチルプレドニゾロン（500mg）を投与し，術7病日まで血小板数・FBG·FDP·D-Dimer·AT3·TAT·APTT·Protein C・α2PIを経時的に測定した。血小板数・FBG·FDP·D-Dimer·TATの変動には両群に差がなかった。AT3とProtein Cは術2·3病日でSN+群が有意に高値で，α2PIは術3病日でSN+群が有意に高値であった。APTTは，術3病日にSN-群で有意に高かった。食道癌術後管理におけるエラスターゼ阻害剤投与は食道癌術後の凝固異常状態を制御し，早期に回復させることが可能である。

We report a case of pneumocystis pneumonia (PCP) during adjuvant chemotherapy for advanced sigmoid colon cancer. A 70-year-old Japanese man was referred to our hospital after complaining of bloody stools. He was diagnosed with advanced sigmoid colon cancer, T2N2aM1b, Stage IV B. After 3 cycles of mFOLFOX6 plus panitumumab as first-line chemotherapy, he received FOLFIRI plus bevacizumab as second-line chemotherapy because of progressive disease. Aprepitant and steroids were administered as antiemetic agents for a short period during each chemotherapy session. During the 2 cycle of FOLFIRI plus bevacizumab, he developed a high fever without respiratory symptoms. Chest CT revealed ground-glass opacities in both the lungs. We first treated him with antibiotics (PIPC/TAZ plus GRNX), suspecting bacterial pneumonia. However, based on the elevation of serum b -D-glucan (148 pg/mL), we diagnosed PCP and initiated SMX/TMP in addition to PIPC/TAZ. The inflammation promptly decreased, and follow-up chest CT revealed the disappearance of the ground-glass opacities. If a patient develops a fever or respiratory symptoms during a course of chemotherapy, we should consider the possibility of PCP and perform careful examinations.