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A 74-year-old male with post-prostatectomy incontinence underwent artificial urinary sphincter replacement due to device malfunction. Three months after the replacement surgery, he presented for a consultation due to a bulging area in his lower abdomen. Computed tomography revealed a hernia of the pressure-regulating balloon (PRB), while the device was working well. In the reparative surgery, reopening the lower abdominal incision, the PRB was carefully restored to its previous position after creating a sufficient submuscular space. As the rectus abdominis fascia showed an adequate strength, the fascia was tightly sutured without using a prosthetic mesh. Thereafter, the patient has been free from incontinence for two and a half years without hernia recurrence. Given the mechanical nature of the device, replacement surgery is sometimes required over time. Tissue fragility due to repetitive surgeries and increasing ambient pressure due to space reduction derived from the PRB deflation could cause PRB hernia. Such cases can be treated under careful manipulation without damaging the device. Considering the future potential need for repeated surgery, it would be preferable not to use prosthetic mesh, as it can cause dense adhesion.

We determined the anastomotic site during gastric tube reconstruction in esophagectomy according to the "90-to 60-s rule" using indocyanine green (ICG) fluorescence angiography. We evaluated its safety and efficacy in a prospective multicenter setting. We enrolled 129 patients who underwent subtotal esophagectomy for esophageal cancer. ICG fluorescence angiography was performed after making a wide gastric tube, and the time from the initial enhancement of the right gastroepiploic artery to the tip of the gastric tube was used as a parameter. Esophago-gastro anastomosis was made at the area that was enhanced within 90 s (preferably within 60 s). The enhancement time and the incidence of anastomotic leakage were compared. In all cases, anastomosis was made at the site enhanced within 90 s. Anastomotic leakage was found in only 4 (3.1%) of 129 cases; specifically, it was detected in 3 (2.4%) of 126 cases whose anastomotic site was enhanced within 60 s and in 1 (33.3%) of 3 cases where the enhancement time exceeded 60 s (p = 0.09). Determining the anastomotic site using the 90-to 60-s rule with ICG imaging in gastric tube reconstruction helps reduce the rate of anastomotic leakage.

We previously reported on the thin membranous dense connective tissue around the esophagus in the upper mediastinum. This time, we histologically investigated the existence of similar structures in the middle and lower mediastinum, caudal to the bifurcation of the trachea. Semi-sequential transverse sections of the mediastinum were obtained from two cadavers. Hematoxylin and eosin staining and Elastica van Gieson staining were performed. In the middle mediastinum, the “visceral sheath” could not be observed completely around the esophagus. In the lower mediastinum, the thin membranous dense connective tissue was observed beneath the pericardium on the ventral side of the esophagus. On the dorsal side of the esophagus, two thin membranous dense connective tissues were similarly observed in two cadavers. One existed between the dorsal side of the esophagus and the three vessels (i.e., the descending aorta, the azygos vein and the thoracic duct) and was integrated with the thin membranous dense connective tissue of the ventral side of the esophagus at the bilateral side of the esophagus. This integrated dense connective tissue reached the left subpleural region and the adventitia of the aorta on the left side and the peripleural and pulmonary hilum on the right side. The other thin membranous dense connective tissue, which represents the “vascular sheath”, was observed between the descending aorta and the thoracic duct. These two thin membranous dense connective tissues, which are considered to represent the visceral sheath and vascular sheath, are thought to be available as optimal dissecting layers for radical esophagectomy.

Background Locoregional steroid injection prevents post-endoscopic submucosal dissection (ESD) esophageal stricture, but histological changes that occur following steroid injection in the human esophagus are unclear. This study investigated the histopathological characteristics caused by locoregional triamcinolone acetonide (TA) injection using human esophagectomy specimens. Methods From January 2014 to December 2019, among 297 patients (373 lesions) who underwent esophageal ESD, 13 patients who underwent additional esophagectomy after ESD were examined. Seven patients (TA group) with wide excisions were injected with TA after ESD and another six patients (Non-TA group) with smaller tumors were not injected with TA. The clinical background of these patients and histopathological features of ESD ulcer scar obtained from esophagectomy specimens were retrospectively investigated. Results The circumferential rate of ESD excision was more than three-quarters in all cases in the TA group, whereas it was less than three-quarters in the Non-TA group. No other statistical difference in the clinical background was found between the two groups. The subepithelial fibrous tissue of the ESD ulcer scar in the TA group was significantly thinner than that in the Non-TA group (P Conclusions Histological finding of thinning of the subepithelial fibrous tissue of ESD ulcer scar in the human esophagus after TA injection was obtained. This suggests that TA suppresses the proliferation of the fibrous tissue of the subepithelial layer to help prevent esophageal stricture after widespread ESD in the human esophagus.

Currently, there is no consensus for an optimal minimally invasive esophagectomy (MIE) approach. This study aimed to compare hybrid MIE (hMIE) with neck-abdominal first approach to standard open esophagectomy (OE). Data from a cohort of 301 patients were retrospectively analyzed. All participants received either hMIE or OE for the treatment of esophageal squamous cell carcinoma at Tokyo Medical and Dental University between January 2003 and December 2013. Analyses included propensity score matching and the Kaplan–Meier statistical method to determine overall survival (OS) and disease-free survival (DFS) of the cohort. After one-to-one propensity score matching, there were 68 patient pairs. The hMIE group had significantly lower incidence of severe postoperative complications (20.1% vs. 7.4%; p = 0.026) and severe respiratory complications (7.4% vs. 0%; p = 0.058) than the OE group. The 5-year oncological outcomes of the two groups were almost equivalent (OS: OE, 55.0%; hMIE, 69.0%; p = 0.063 and DFS: OE, 54.0%; hMIE, 62.0%; p = 0.28). This study compared hMIE with neck-abdominal first approach to standard OE. The results showed significantly less severe postoperative complications for hMIE with neck-abdominal first approach in comparison with OE, without a compromise in long-term oncological outcomes.

We herein evaluated the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy. Thirty-two cases of subtotal esophagectomy and gastric tube reconstruction for esophageal cancer were studied. The new device measures the regional tissue saturation of oxygen (rSO2: 0–99%) and total hemoglobin index (T-HbI: 0–1.0) with a small sensor. We measured these values at the antrum (point A), final branch of the right gastroepiploic artery (point B) and planned anastomotic point (point C) before and after gastric tube formation. The values at the three points were compared, and the gradients at the three points from before to after gastric tube formation were compared. The mean values of rSO2 at point A, B, and C before gastric tube formation were 57.2%, 57.8% and 56.0%, and those after formation were 54.6%, 58.0% and 55.8%, respectively. There was no significant difference in the comparison of the rSO2 gradient before and after formation (p = 0.167). The mean values of T-HbI at point A, B, and C before formation were 0.126, 0.178 and 0.211, and those after formation were 0.167, 0.247 and 0.292, respectively. There was no significant difference in the gradient of the increase before and after formation (p = 0.461). A new device has shown that the gastric tube used in our facility is one that maintains tissue saturation of oxygen and does not cause excessive congestion at anastomosis.

Purpose Esophagectomy with three-field lymphadenectomy (3FLD) is a potentially curative treatment option for resectable esophageal cancer (EC), which is associated with significant morbidity. Risk scores are useful for patient assessment; this study compares 7 different scores and indexes to find the best model for predicting morbidity in patients undergoing 3FLD. Methods Six years of data from January 2010 to January 2016 were reviewed, patients with EC who underwent 3FLD were retrospectively scored using 4 predictive scores and 3 predictive index models. Postoperative morbidity was assessed according to the extended Clavien-Dindo classification. The outcomes were the presence and severity of morbidity. Validation was performed by calculating the area under the ROC curve and by the assessment of collinearity among the variables independently associated with morbidity in the overall model to determine the best predictive model. Results We included 230 patients were included in the final analysis. Complications after 3FLD occurred in 168 patients (73%; minor complications, n = 96 [41%]; major complications, n=72 [31%]). The AUC values ( Conclusion No score or index could predict the presence or severity of morbidity after 3FLD with good discrimination power. Age (>68 years) was the most critical factor affecting morbidity. The Steyerberg score model, based on the addition and subtraction of risk values was the best model for predicting morbidity after 3FLD.

Background and Aim: The aim of the present study was to evaluate the clinical usefulness of the ¹³C breath test in postoperative patients who underwent gastric tube reconstruction following esophagectomy. Methods: Postoperative patients (POs; n=26) and healthy volunteers (HVs; n=10) were included as subjects. Of the 26 POs, the 7 with late dumping symptoms were regarded as the dumping group (DG), and the remaining were considered the non-dumping group (NDG). Semisolid test meal mixed with 100 mg of ¹³C-sodium acetate was given to each subject. Breath samples for the ¹³C gas analysis and blood samples were collected. Results: The Cmax was 37 ± 13(‰) in the HVs and 49 ± 11(‰) in POs, being significantly higher in POs (p=0.019). The Cmax was 56 ± 14(‰) for DG and 47 ± 8.9(‰) for NDG, indicating that the Cmax in the DG tended to be higher than that in the NDG, although not to a significant degree (p=0.12). The change in the C value and each glucose metabolism-related marker showed a general correlation. Conclusion: The present results suggest that the ¹³C-acetate breath test reflects changes in glucose homeostasis after esophagectomy, making it useful for objectively and simply assessing late dumping symptoms in postoperative esophageal cancer patients.

Several authors have reported on the left trans-cervical and transhiatal approaches under pneumomediastinum and right cervical open surgery for mediastinoscopic esophagectomy. However, with these approaches, sufficient dissection of the right upper mediastinal paraesophageal lymph nodes, right recurrent nerve lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes is thought to be difficult. We herein report the usefulness of the ‘bilateral’ trans-cervical pneumomediastinal approach. Methods Ten patients with thoracic esophageal cancer were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. After this approach, thoracoscopic observation was then performed in the left decubitus position, and if the lymph nodes were not sufficiently dissected, the remnant lymph nodes were retrieved thoracoscopically. Results The average total number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average total number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without the right trans-cervical pneumomediastinal approach, roughly four of the right cervical and upper mediastinal paraesophageal lymph nodes and one or two of the subaortic arch to the left tracheobronchial lymph nodes could not have been retrieved. Conclusion A bilateral trans-cervical pneumomediastinal approach is useful for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

We investigated the merits and demerits of right cervical open surgery with right trans-cervical pneumomediastinal approach in mediastinoscopic esophagectomy. Ten thoracic esophageal cancer patients were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. The average number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without using the right trans-cervical pneumomediastinal approach, it might be impossible to successfully remove some of the right cervical and upper mediastinal paraesophageal lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes lymph nodes. Regarding surgical complications, one case of bilateral recurrent nerve palsy as well as two cases on the right and two cases on the left were noted. Although the rate of recurrent nerve palsy should still be reduced, a bilateral (especially right-sided) trans-cervical pneumomediastinal approach is an available option for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

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

A prospective trial evaluated the feasibility and safety of “mediastinoscopic esophagectomy with lymph node dissection” (MELD). Eligible patients had thoracic esophageal squamous cell carcinoma, excluding T4, a bulky primary lesion or distant metastasis. Ten patients were enrolled and treated between September 2015 and March 2018. Additionally, to verify the integrity of the mediastinal lymph node dissection, thoracoscopic observation and lymph node dissection were followed. The primary end point was the integrity of mediastinal lymph node dissection. The secondary end points were the short-term outcomes, including mortality and morbidity. The median number of dissected lymph nodes in the upper mediastinal to cervical region and middle to lower mediastinal region by mediastinoscopy/thoracoscopy was 27/0.5 and 11.5/0, respectively. The median total operation time was 615 min, the median bleeding amount was 476 ml, and the median postoperative hospital stay was 15.5 days. Regarding complications of more than grade III according to the Clavien–Dindo classification, four had sputum excretion difficulty, one had pneumothorax and one had bilateral recurrent nerve palsy, but none required conversion to thoracotomy, and no operative deaths occurred. Although the rate of recurrent nerve palsy still should be reduced, our mediastinoscopic lymphadenectomy technique is closely similar to radical esophagectomy.

A 72‒year‒old man visited our hospital with a chief complaint of epigastralgia. Upper gastrointestinal endoscopy revealed type 3 advanced gastric cancer at the body of the stomach. Following an investigation, he was diagnosed with human epidermal growth factor receptor 2‒positive gastric cancer with invasion to the pancreas as well as the paraaortic lymph node, and multiple liver metastases were also observed. The cancer was judged to be cT4a, N2M1(H1 LYM: No. 16), cStage Ⅳ and thus was considered suitable for chemotherapy. We performed capecitabine plus cisplatin plus trastuzumab therapy. After 3 courses, the primary lesion and swollen lymph nodes decreased in size. After 20 chemotherapy courses, the primary lesion relapsed, so conversion surgery was performed. The patient underwent total gastrectomy, distal pancreatectomy, and partial resection of the liver. We planned to perform adjuvant chemotherapy, but the patient declined it because of anorexia. At 18 months after the operation, recurrence of the tumor was detected at the celiac artery. Chemotherapy was performed as follows: capecitabine plus trastuzumab 10 courses, ramucirumab plus paclitaxel, irinotecan, and nivolumab. However, the patient eventually died 71 months after the first visit.

Objective To assess the usefulness of modified esophagogastroduodenoscopy (EGD) for the detection of second primary malignancies of the esophagus or hypopharynx in patients with oral squamous cell carcinoma and determine the association between the oral lesion subsite and esophageal or hypopharyngeal lesion occurrence. Study Design Retrospective review. Methods In total, 166 patients with oral squamous cell carcinoma without any established symptoms of esophageal or hypopharyngeal squamous cell carcinoma underwent modified EGD based on the Valsalva maneuver and U-turn method, image-enhanced endoscopy, and chromoendoscopy using Lugol's iodine for diagnosis. All suspected lesions were biopsied to determine the clinical stages and duplication rates. Odds ratios for the occurrence of duplicate lesions according to the oral lesion subsite were determined. Results In total, 37 esophageal and 16 hypopharyngeal lesions were detected. According to the Union for International Cancer Control/American Joint Committee on Cancer classification (2009), 75.7% and 5.4% esophageal lesions were classified as stage IA and IB, respectively, and 50% and 18.8% hypopharyngeal lesions as stage II and stage I, respectively. Approximately 59.1% and 50% esophageal and hypopharyngeal lesions, respectively, were successfully treated by endoscopic resection. Oral lesions involving the floor of the mouth were more frequently accompanied by second primary malignancies of the esophagus or hypopharynx. Conclusions Modified EGD is an effective noninvasive technique for early diagnosis and treatment of second primary malignancies of the esophagus and hypopharynx in patients with oral squamous cell carcinoma. In particular, patients with floor of the mouth lesions need close monitoring for hypopharyngeal and esophageal lesions. Level of Evidence 3b.

Mucosa-associated lymphoid tissue (MALT) lymphoma is a type of lymphoma that commonly originates in the gastrointestinal (GI) tract, and in rare instances may also occur in the head and neck region. In this report, we present a case of early stage, primary asymptomatic MALT lymphoma of the hypopharynx as detected by esophagogastroduodenoscopy (EGD). A 73-year-old man underwent EGD for an examination of the upper GI tract. At the left pyriform sinus, a swollen irregular mucosa was detected. Biopsy specimens confirmed histologically prominent proliferation of lymphocytes in the epithelium. Immunohistochemical analysis showed that the neoplastic lymphocytes were positive for CD20 and negative for CD3. Based on the other imaging studies, we diagnosed the lesion as a localized MALT lymphoma of the hypopharynx at Stage IA. In total, 46 Gy of radiotherapy was administered to the lesion. In the subsequent 5 years after the treatment, there have been no signs of recurrence.

A 65-year-old man was admitted to our hospital following 6 months of dysphagia. At first, conventional endoscopy showed a reddish and depressed lesion in the stomach and an elevated lesion in the posterior wall of the hypopharynx. An endoscopic biopsy showed adenocarcinoma in the stomach, and squamous cell carcinoma in the hypopharynx. On the further examination, trans-nasal endoscopy with narrow band imaging (NBI) was performed. During the trumpet maneuver, a huge protruded lesion was observed and it reached to the orifice of the esophagus. Other superficial lesion located at left pyriform sinus was detected by NBI system as brownish area with brown dots. Furthermore, superficial esophageal cancer in the cervical esophagus was detected. Finally, 4 carcinomas in upper gastrointestinal tract were detected. Among them, the hypopharyngeal cancer was the most advanced (T3N0). The patient hoped to preserve his voice and swallowing function, endoscopic laryngo-pharyngeal surgery (ELPS) was performed for the hypopharyngeal cancer. Endoscopic mucosal resection (EMR) was performed for the esophageal cancer, and Endoscopic submucosal dissection (ESD) was performed for the gastric cancer. Under collaboration between a head and neck surgeon and an endoscopist, the tumor was resected en-bloc. The histopathological findings of hypopharyngeal cancer were squamous cell carcinoma, subeipthelial invasion, 29 × 28 × 4.2 mm. The others were diagnosed as mucosal cancers. The patient is currently alive with no recurrence at 28 months after the surgery; there is no stricture at the cervical esophagus. Endoscopic laryngopharyngeal surgery for the tumor of pharyngo-esophageal junction can provide a less invasive treatment.

In cadavers, even Thiel-embalmed cadavers, the arteries (especially the thoracic aorta) are extremely collapsed. This is in marked contrast to the state of the arteries in a living body. Aortic inflation is necessary to improve this unfavorable situation for anatomical observation or dissection. To inflate the aorta, we injected 500 ml of hot liquid agar into the aorta using a 18-Fr catheter inserted into the common femoral artery and subclavian artery. The injected agar then rapidly cools to room temperature and solidifies. As a result, the thoracic aorta remains sufficiently and constantly inflated in the mediastinum. This method is not only easy and inexpensive, but also useful and effective for achieving a life-like anatomy in cadavers used in surgical training for operations involving mediastinal organs, with the exception of the heart and great vessels.

We previously reported the performance of “mediastinoscopic esophagectomy with lymph node dissection” (MELD) under pneumomediastinum using a transcervical and transhiatal approach, as a method of radical esophagectomy. The procedure included the dissection of the left tracheobronchial lymph nodes (106tbL). We described our technique for dissecting the upper mediastinal lymph nodes. We revealed that the 106tbL lymph nodes were almost completely retrieved but that the upper thoracic paraesophageal lymph nodes (105) and the right recurrent nerve lymph nodes (106recR) were not completely retrieved. We are therefore of the opinion that a right cervical pneumomediastinal approach is necessary to achieve total dissection. We herein describe a case that was surgically treated using a bilateral cervicopneumomediastinal approach. A 68-year-old male patient was referred to our institution to undergo treatment for lower thoracic esophageal squamous cell carcinoma. The right recurrent nerve was first identified using an open approach. Pneumomediastinum was then initiated to allow for the 105 and 106recR lymph nodes to be completely dissected along the right mediastinal pleura, the right vagus nerve, the proximal portion of the azygos vein, and the right bronchial artery. The left recurrent nerve lymph nodes (106recL) and 106tbL lymph nodes were dissected as described previously. In order to perform bilateral upper mediastinal lymph node dissection and esophagectomy, a bilateral cervicopneumomediastinal approach is needed.

Collisions between the laparoscope and the forceps remain a specific problem for single-incision laparoscopic surgery (SILS). We considered that the use of a long forceps would resolve this problem and use the long forceps in SILS for totally extraperitoneal repair (TEP). SILS for TEP (S-TEP) was performed to treat 34 inguinal hernias in 27 patients from November 2013 to February 2015. Among them, unilateral inguinal hernia repair was performed in 5 patients (median age: 71 years; range: 40–88 years) using a laparosonic coagulating shears (LCS) device and a straight long (43 cm) forceps. A 1-cm umbilical incision was made, a 5-mm flexible laparoscope was moved into the peritoneal cavity, and the type of inguinal hernia was diagnosed. Next, preperitoneal space was made using a finger or gauze. The single-port device was applied at preperitoneal space and insufflation was initiated with CO2 gas. The preperitoneal space was more easily created using a long straight forceps rather than standard ones. The hernia sac was then freed from the spermatic cord and a mesh was rolled, inserted, and deployed. Absorbable spiral tackers were used for fixation over the Cooper's ligament, lateral to the inferior epigastric vessels. The use of a long forceps was considered to be associated with reduction of the difficulty for dissection in S-TEP. We considered the use of a long forceps to be useful to the S-TEP operation.

Background Cation transport regulator 1 (CHAC1), a newly discovered enzyme that degrades glutathione, is induced in Helicobacter pylori (H. pylori)‐infected gastric epithelial cells in culture. The CHAC1‐induced decrease in glutathione leads to an accumulation of reactive oxygen species and somatic mutations in TP53. We evaluated the possible correlation between H. pylori infection and CHAC1 expression in human gastric mucosa. Materials and Methods Both fresh‐frozen and formalin‐fixed paraffin‐embedded tissue samples of gastric mucosa with or without H. pylori infection were obtained from 41 esophageal cancer patients that underwent esophago‐gastrectomy. Fresh samples were used for real‐time polymerase chain reaction for H. pylori DNA and CHAC1 mRNA, and formalin‐fixed samples were used for immunohistochemistry with anti‐CHAC1 and anti‐H. pylori monoclonal antibodies. Double‐enzyme or fluorescence immunohistochemistry and immuno‐electron microscopy were used for further analysis. Results Significant CHAC1 overexpression was detected in H. pylori‐infected parietal cells that expressed the human proton pump/H,K‐ATPase α subunit, whereas a constitutively low level of CHAC1 mRNA expression was observed in the other samples regardless of the H. pylori infection status, reflecting the weak CHAC1 expression detected by immunohistochemistry in the fundic‐gland areas. Immuno‐electron microscopy revealed intact H. pylori cells in the secretory canaliculi of infected parietal cells. Some parietal cells exhibited positive nuclear signals for Ki67 in the neck zone of the gastric fundic‐gland mucosa with H. pylori infection. Conclusion Cation transport regulator 1 overexpression in H. pylori‐infected parietal cells may cause the H. pylori‐induced somatic mutations that contribute to the development of gastric cancer.

We evaluated and compared the diagnostic potential of computed tomography (CT) and herniography in the identification of inguinal hernias. Herniography is typically utilized in the diagnosis of inguinal hernias in our institute. We utilized transabdominal preperitoneal repair in the treatment of inguinal hernias since October 2010 and performed a laparoscopic diagnosis followed by single-incision laparoscopic surgery for totally extraperitoneal repair since November 2013. We herein evaluated and compared the diagnostic potential of CT and herniography. From February 2012 to March 2016, 46 patients (male/female: 43/3; median age: 70 years) with 63 inguinal hernias were investigated using CT and herniography. We classified each inguinal hernia according to the Japan Hernia Society classification using CT (prone position) and herniography, and evaluated the accuracy of each of the diagnostic methods. A total of 29 patients had unilateral hernias and 17 had bilateral hernias; 62% (39/63) and 84% (53/63) of the inguinal hernias were correctly diagnosed and classified by CT and herniography, respectively. A total of 87% (55/63) and 98% (62/63) of the inguinal hernias were detected by CT and herniography, respectively. Thus, herniography was found to be more sensitive than CT and the difference in the detectability of inguinal hernias by the 2 methods was statistically significant. Herniography appears to be superior to CT, for both the classification and detection of inguinal hernias.

Lobar torsion is a rare but fatal complication, with such cases being mostly treated with pulmonary resection. Only a few cases of pulmonary torsion following esophagectomy have thus far been reported, and all cases occurred subsequent to transthoracic esophagectomy. We herein present the case of a patient with the right middle lobe torsion after thoracoscopic esophagectomy in a 64-year-old male. As the patient exhibited a hemodynamically unstable condition immediately after surgery and bronchoscopy and computed tomography revealed right middle lobe torsion, urgent surgery was performed. As torsion of right middle lobe was confirmed during a second operation, repositioning for torsion was performed. Fortunately, right middle lobe was aerated and exhibited a good complexion immediately after repositioning; therefore, pneumonectomy was not performed. Because it is difficult to observe the process of reinflation of a collapsed lung under direct vision in order to prevent lobar torsion when performing thoracoscopic esophagectomy, it is imperative to confirm the patency of the proximal bronchi during the operation using bronchoscopy.

At our institution, larynx-preserving surgery has been aggressively performed for cervical esophageal carcinoma, even when the oral side of the tumor margin extends beyond the esophageal orifice. Our aim was to clarify the clinical outcomes of surgery, with a focus on larynx-preserving surgery. Eleven patients who were diagnosed with resectable cervical esophageal carcinoma and received larynx-preserving surgery as the initial treatment were enrolled. For larynx-preserving surgery, the following two surgical techniques were introduced: the “larynx rotation method,” where the larynx and hypopharynx are manually rotated counterclockwise more than 90° by holding down the thyroid cartilage, and the “tracheal traction method,” where the trachea is moved forward with the larynx and hypopharynx. By selecting these methods, the transection of the cervical esophagus on the oral side of the tumor and anastomosis with a substituted organ can thus be achieved, even around the narrow area surrounded by the larynx, trachea and vertebral body. Nine patients who received definitive chemoradiotherapy as the initial treatment were also enrolled to compare the long-term clinical outcomes. Larynx-preserving surgery was successfully performed and the larynx could thus be preserved in all the cases. Although all patients developed recurrent nerve paralysis, including two patients who showed bilateral recurrent nerve paralysis, such paralysis was temporary. Although postoperative pneumonia, surgical site infection, and anastomotic stenosis were experienced, these problems were not severe and the postoperative morbidities were tolerable. The recurrence rate was 36.4 %, and the 5-year progression-free survival rate and overall survival rate were 62.3 and 90.9 %, respectively. There was no significant difference in the long-term clinical outcomes between the patients who underwent larynx-preserving surgery and chemoradiotherapy Larynx-preserving surgery is considered to be acceptable because both organ preservation and functional preservation can be achieved with tolerable long-term clinical outcomes.

Esophagorespiratory fistula (ERF) caused by esophageal carcinoma is a fatal complication. In our institution, esophageal bypass surgery has been indicated when possible. We herein retrospectively describe the clinical results of esophageal bypass surgery for ERF. Between April 2001 and March 2015, 20 patients with ERF underwent esophageal bypass surgery. For these patients, the clinical safety, validity, and effectiveness of esophageal bypass surgery were examined and compared with the results of bypass surgery without ERF. Eight patients developed ERF at the initial diagnosis, while 10 patients developed ERF during and after chemoradiotherapy. Postoperative complications such as pneumonia, surgical site infection, and anastomotic leakage developed in 12, 5, and 1 patient, respectively. All the patients could eat solid foods at a median of 9 postoperative days. Two patients died within 30 days after the operation and 1 patient developed in-hospital death. Fourteen patients received chemo(radio)therapy after the operation. The median overall survival was 244 days and the one-year and three-year overall survival rates were 45.7 and 15.3 %, respectively. There was no significant difference in terms of the intraoperative findings, postoperative morbidities, and short-term and long-term clinical results between the two groups. Esophageal bypass surgery for ERF is not considered to be highly invasive or risky compared with bypass surgery without ERF. After the operation, respiratory symptoms caused by ERF may improve and oral intake can be achieved. Esophageal bypass surgery should therefore be aggressively performed for patients with a tolerable performance status.

Background/Aims: We investigated factors affecting the post-recurrence prognosis in order to develop adequate therapeutic guidelines for determining the indication for treatment of recurrent esophageal squamous cell carcinoma (ESCC). Methods: Ninety-three thoracic ESCC patients who developed postoperative recurrence after undergoing curative esophagectomy with 3-field lymphadenectomy at our institute and who received treatment for recurrence were enrolled in this study. Results: A univariate analysis showed that distant organ recurrence, the number of recurrent tumors, the longest diameter of the largest recurrent tumor, the sum of all of the longest diameters of the recurrent tumors, invasion into adjacent structures and the speed of growth of the representative recurrent tumors were significantly associated with the post-recurrence prognosis. A multivariate analysis showed that distant organ recurrence, the longest diameter of the largest recurrent tumor, invasion into adjacent structures and the speed of growth of the representative recurrent tumors were significantly associated with the prognosis. The patients whose recurrent tumor(s) did not meet all 4 of these factors showed a better prognosis. In contrast, the prognosis of the patients whose recurrent tumor(s) demonstrated all 4 factors was almost the same as that observed in the patients who did not receive any treatment for recurrence. Conclusions: The evaluation of these 4 factors may potentially be used to determine the indication for treatment for recurrence.

Background/Aims: Our prospective randomized study examined the possibility of perioperative management of esophagectomy without a central venous catheter (CVC). Methods: Forty patients who underwent esophagectomy for esophageal cancer were divided into the total parenteral nutrition (TPN; receiving conventional perioperative management via a CVC) and peripheral parenteral nutrition (PPN; receiving perioperative management without a CVC) groups. Albumin and retinol-binding protein (RBP) levels were used as measurements of the nutritional status. Early postoperative complications and catheter-related complications were also evaluated. Results: The actual calories administered per kg of body weight and the albumin and RBP levels did not significantly differ between the groups. Additionally, there was no significant difference in the morbidity of early postoperative complications between the groups. Catheter-related complications were observed in 4 patients in the TPN group (2 catheter infections, 1 case of thrombosis, and 1 case of iatrogenic pneumothorax), and 4 cases of peripheral phlebitis occurred in the PPN group. The incidence of catheter-related complications did not significantly differ between the groups. Conclusions: Perioperative management without a CVC can be safely performed in esophagectomy patients, and the decision to insert a CVC should be made based on the patient's perioperative condition.

The structure of the fascia in upper mediastinum has already been reported from gross anatomical viewpoints by Sarrazin. But it is necessary to understand meticulous anatomy for thoracoscopic or mediastinoscopic surgery. So herein, we investigate histologically the thin membranous structure made of dense connective tissues. Semi-sequential transverse sections of the mediastinum were obtained from three cadavers. Hematoxylin and eosin staining, Elastica van Gieson staining, and Masson trichrome staining were performed to identify the presence and location of the thin membranous structure made of dense connective tissues. The “visceral sheath” and “vascular sheath,” as previously described by Sarrazin, were observed histologically. These two thin membranous structures do not surround the esophagus and trachea cylindrically. In addition, the “visceral sheath” on the right side of the upper mediastinum was unclear in comparison to the left side. The “visceral sheath” (on the left side) gradually became unclear, and seemed to almost disappear; the esophagus was found to be very close to the thoracic duct on the caudal side of the bifurcation of the trachea. Although the left recurrent nerve was located inside the “visceral sheath” in all cadavers, the left recurrent nerve lymph nodes were located inside the “visceral sheath” in cadaver 1 and between the “visceral sheath” and “vascular sheath” in cadaver 3. The “visceral sheath” around the esophagus in the upper mediastinum was histologically demonstrated; however, the findings were not constant.

To determine the usefulness of ultra-high-resolution magnetic resonance (MR) imaging at an ultra-high field strength (7.0T), using a voxel volume of 9.5-14nL, as means of evaluating the depth of mural invasion by esophageal carcinomas.Twenty esophageal specimens containing 20 carcinomas were studied using a 7.0-T MR imaging system with a four-channel surface coil. Ultra-high-resolution MR images were obtained with a field of view of 50-60mm×25-30mm, a matrix of 512×256, and a section thickness of 1.0mm, resulting in a voxel volume of 0.0095-0.014mm(3) (9.5-14nL). Differences between tumor tissue and the esophageal wall layers and between tumor tissue and fibrosis were evaluated using visual signal intensity scoring measurements. MR images were then compared with histopathologic findings as the reference standard.Ultra-high-resolution T2-weighted MR images at 7.0T clearly depicted the normal esophageal wall in all 20 specimens (100%) as consisting of eight layers, which clearly corresponded to the tissue layers of the esophageal wall. Ultra-high-resolution T2-weighted MR images made it possible to differentiate between the tumor tissue and fibrosis clearly (P0.01). In all 20 esophageal carcinomas (100%), ultra-high-resolution T2-weighted MR images made it possible to determine the depth of tumor invasion in the esophageal wall as observed in the histopathologic sections. Regional lymph node involvement was also clearly depicted in four specimens.Ultra-high-resolution 7.0-T MR imaging, using a voxel volume of 9.5-14nL, provides clear delineation of the esophageal wall layers, clear differentiation of tumor tissue from fibrosis, and excellent diagnostic accuracy for evaluating mural invasion by esophageal carcinomas.

The use of mediastinal surgery for minimally invasive esophagectomy (MIE) has been proposed; however, this method is not performed as radical surgery because it has been thought to be impossible to perform complete upper mediastinal dissection, including the left tracheobronchial lymph nodes (106tbL). We herein describe a new method for performing complete dissection of the upper mediastinum. We developed a method for performing complete mediastinoscopic esophagectomy as radical surgery via the bilateral transcervical and transhiatal approach in 6 Thiel-embalmed human cadavers. The lower and middle mediastinal lymph nodes are dissected via the transhiatal approach. The dorsal side of the left recurrent nerve is dissected up to the aortic arch and left recurrent nerve lymph nodes (106recL) are dissected under pneumomediastinum. Next, the right recurrent nerve lymph nodes (106recR) are dissected. The cartilage of the left main bronchus is dissected and pushed downward, thereby obtaining a good view between the aortic arch and left main bronchus via the transhiatal approach. The 106tbL lymph nodes are dissected until the aortic arch is reached. Simultaneously, the lymph nodes are dissected via a right cervical incision. This method is termed the “cross-over technique.” We herein demonstrated that the upper mediastinal lymph nodes, including the 106tbL nodes, can be dissected using the bilateral transcervical and transhiatal approach under pneumomediastinum and named this method “mediastinoscopic esophagectomy with lymph node dissection” (MELD). MELD is therefore considered to be a useful modality based on our experience with Thiel-embalmed human cadavers.

Aims: In order to observe the pharyngoesophageal junction, the trumpet maneuver with trans-nasal endoscopy was used. Its efficacy is reported here. Material and Methods: A 71-year-old man who underwent esophagectomy in esophageal cancer 2 years ago was admitted to our hospital with primary pharyngeal cancer. The type of upper endoscope used was EG-580NW (FUJI Film, Tokyo, Japan). The endoscope is a trans-nasal endoscope that can provide high quality endoscopic images. The pharyngeal cancer located at right lateral wall which was previously detected could be observed easily. We asked the patient to blow hard and puff his cheeks with his mouth closed. When inspecting the hypopharynx and the orifice of the esophagus, we told the patient that we would start the trumpet maneuver. Results: After the trumpet maneuver, the pharyngeal mucosa was stretched out. Another primary lesion was observed at the posterior wall of the hypopharynx near the pharyngoesophageal junction. This technique provided a much better view of the lesion than had been possible with trans-oral endoscopy，allowing us to remove the biopsy specimen without sedation. Conclusion: In conclusion, the trumpet maneuver using trans-nasal endoscopy is a useful technique for precise inspection before treatments for patients who have already detected the lesions.

Background Recently an increase in the incidence of oropharyngeal squamous cell carcinoma has been noted in the United States Squamous cell carcinoma of the base of the tongue is often diagnosed at an advanced stage with a dismal prognosis With advances in endoscopy more cases of superficial cancer are now being found However observing the base of the tongue using trans oral endoscopy is difficult Aim Starting in April we introduced a new technique for observing the base of the tongue using trans nasal esophagogastroduodenoscopy known as the intra oropharyngeal U turn method Its efficacy is reported here Results Eleven cases of superficial squamous cell carcinoma of the base of the tongue were detected using trans nasal endoscopy between April and March Five lesions were flat type four were elevated and two were depressed Regarding the tumor size eight were T and three were T No lymph node metastasis was detected in any case Seven were resected and three were treated with chemo radiotherapy while one was followed because of esophageal cancer For the seven resected specimens the median tumor thickness was mu m range mu m and the median tumor diameter was mm range mm Histologically of these lesions were squamous cell carcinoma in situ and five showed microinvasion of the subepithelial tissue During a median follow up period of months range months patient developed lymph node metastasis which was treated by neck lymphadenectomy and chemo radiotherapy Three of the patients died of another disease and were alive as of drafting this manuscript Conclusion The intra oropharyngeal U turn method with trans nasal endoscopy is useful for detecting superficial squamous cell carcinoma of the base of the tongue

Curative treatment of esophageal cancer requires meticulous superior mediastinal lymphadenectomy, in addition to esophagectomy, because superior mediastinal lymph node metastases are common in esophageal cancer. When preserving the tracheal branches of the left recurrent laryngeal nerve (RLN), good anatomical understanding is required for confirmation of the positional relationships between the courses of lymphatic vessels, lymph node distribution, and the left RLN and its tracheal branches. We performed a detailed anatomical examination of these relationships. Macroscopic anatomical observation and histological examination was performed on cadavers. In addition to hematoxylin and eosin staining, immunostaining using antipodoplanin antibody D2-40 (podoplanin) was performed to identify the lymphatic vessels. The tracheal branches of the left RLN were clearly observed, but no lymphatic vessels crossing the ventral or dorsal side of the branches were identified either macro-anatomically or histologically. No complex lymphatic network structure straddling the plane composed of tracheal branches of the left RLN was found in the left superior mediastinum. This suggests that dissection of the lymph nodes around the left RLN via the pneumomediastinum method using the left cervical approach may allow preservation of the tracheal branches of the left RLN by maintaining dissection accuracy.

Patients undergoing chemotherapy often develop distressing adverse effects such as oral mucositis and diarrhea. Nutritional support with elemental diet is effective against various gastrointestinal complications and may exert protective effects against adverse effects induced by chemotherapy. To evaluate the influence of elemental diet on chemotherapy-induced oral mucositis and diarrhea, we conducted a randomized control trial in patients with esophageal cancer undergoing chemotherapy.Twenty esophageal cancer patients receiving chemotherapy with 5-fluorouracil plus cisplatin were assigned randomly to one of the following two groups: (1) receiving elemental diet with Elental (one pack per day) for 14 days and (2) not receiving Elental during chemotherapy. The severity of oral mucositis and diarrhea was graded using clinical examination by doctors and a standard questionnaireon days 1-14.Based on the analysis of the standard questionnaire, the distribution of the maximum severity of oral mucositis showed a statistically significant reduction in the Elental group (p=0.020), while clinical examination showed insignificant reduction but shift toward lower grade. In the Elental group, the incidence of oral mucositis (grade=2) reduced consistently and the median grade was lower at all-time points. Regarding diarrhea, no difference was observed between the two groups based on the analysis of the standard questionnaire and clinical examination results.This study illustrates the effectiveness of oral elemental diet in preventing oral mucositis during chemotherapy. This is a preliminary report and further study with larger patients groups should be devoted to optimization of efficacy.

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