Primary adenocarcinoma arising in an interposed colon

We herein report a rare case of adenocarcinoma arising in an interposed colon. A 71-year-old male underwent total thoracic esophagectomy for thoracic esophageal cancer followed by antesternal reconstruction using the right colon. Seven months later, ¹⁸F-fluorodeoxy-glucose positron emission tomography revealed increased uptake in the interposed colon. Endoscopy detected a mass 25 mm in diameter in the cecum of the interposed colon approximately 10 cm from the distal anastomosis. An endoscopic biopsy showed well-differentiated adenocarcinoma. Partial resection of the interposed colon was performed, and the patient’s postoperative course was uneventful. The patient is currently alive with no signs of recurrence three years after the final surgery. We herein report a case of primary adenocarcinoma arising from an interposed colon after esophagectomy and review the literature.     

Long-term survival after resection of brain metastases from esophagogastric junction adenocarcinoma: report of two cases and review of the literature

The prognosis for brain metastasis from primary esophageal or gastric cancer is often poor because of late detection and a lack of effective treatments. We encountered two cases of long-term survival after resection of brain metastasis that was detected >1 year after primary esophagogastric junction adenocarcinoma resection. Both patients underwent total gastrectomy, middle to lower esophagectomy, and Roux-en-Y reconstruction using the jejunum, and intrathoracic anastomosis was performed via right thoracotomy and laparotomy for primary tumor resection as well as brain metastasis resection followed by CyberKnife irradiation. They remained recurrence free—one remains alive after 6.5 years, while the other died of myocardial infarction 4 years after surgery. The present cases emphasize that long-term survival in patients with brain metastasis from gastric cancer can be expected after resection and stereotactic radiosurgery of brain metastasis detected >1 year after the resection of primary gastric adenocarcinoma.     

Preventing and localizing esophagogastric anastomosis leakage by sleeve-wrapping of the pedicled omentum

AIM:To develop a technique of sleeve-wrapping thepedicled omentum around the esophagogastric anastomosis for preventing and localizing leakage.METHODS:This study includes data from 86 patientswho were diagnosed with esophageal cancer and underwent the technique of sleeve-wrapping the pedicledomentum around esophagogastric anastomosis afteresophagectomy between November 2011 and July 2013.The early complications that occurred during follow-upwere analyzed.RESULTS:Postoperative complications included pulmonary complications(13/86;15.1%)and abdominal orthoracic wound infection(3/86;3.5%).Complicationsthat occurred during follow-up included one case ofanastomosis leakage(limited by omentum;1.2%)andfive case of anastomosis stricture(5.8%).No deathsoccurred.All complications were resolved through traditional treatment.No additional surgery was needed.CONCLUSION:Sleeve-wrapping of the pedicled omentum around esophagogastric anastomosis after esophagectomy is safe and effective for preventing and localizing anastomosis leakage without increasing anastomosis stricture.     

食管贲门癌围手术期二次开胸治疗分析

目的总结食管贲门癌围手术期二次开胸的原因及治疗经验。方法回顾性总结我院2002年1月～2008年6月间12例食管贲门癌围手术期二次开胸手术的原因及治疗情况（在外院手术后需二次开胸手术的患者2例）,其中贲门癌术后食管胃吻合口瘘3例、胃壁瘘1例、术后胸腔内出血3例、术后吻合口及胃残端出血3例、术后胸腔包裹性积液感染1例、术后吻合口完全闭死1例。结果全组二次开胸治疗后,食管胃吻合口瘘患者2例治愈,1例死亡;其余患者均治愈。结论及时的二次开胸手术是治疗某些食管贲门癌手术并发症的有效手段。     

器械吻合在胸中下段食管癌手术中应用231例

目的:总结胸中下段食管癌切除术后胸内食管胃端侧器械吻合的经验和体会.方法:使用国产WH-Y型胃肠吻合器对231例胸中下段食管癌患者进行胸内器械吻合.231例患者术前均经上消化道钡餐造影及纤维胃镜病理检查明确诊断为食管鳞癌.其中胸中段食管癌51例,下段食管癌180例.病变长度0.512cm.本文回顾性分析2005-01/2009-12食管癌患者231例的临床资料.结果:本组231例中,吻合口瘘3例,发生率1.30%(3/231),其中死亡1例,为术后4d出现吻合口瘘.余2例为术后10d出现吻合口瘘,均经通畅引流、营养支持等内科保守治疗治愈.术后4w发生吻合口狭窄2.16%(3/231),均予以胃镜下球囊扩张后治愈.本组手术平均耗时160min,出血平均为500mL,术后平均住院15d.术后随访207例,1、3、5年生存率为53.1%、27.5%、18.4%.结论:应用器械吻合行胸内食管胃端侧吻合术效果可靠,操作方便.     

Vimentin-positive gastric adenocarcinoma arising in a hyperplastic polyp

We report a case of vimentin-positive early gastric adenocarcinoma arising in a hyperplastic polyp (HP). A 72-year-old Japanese man was admitted for the detailed examination of a gastric polyp. He had a subtotal gastrectomy due to acute abdomen 12 years ago. Upper endoscopy revealed a pedunculated polyp measuring approximately 2 cm on the greater curvature of upper body of the remnant stomach. Magnifying endoscopy revealed that the microsurface pattern was irregular and partially absent accompanied with irregular microvessels at the upper end of the polyp. We speculated that the lesion was an adenocarcinoma arising in the HP. Endoscopic submucosal dissection (ESD) was performed. Histological examination of the ESD specimen revealed that the lesion consisted of well- to poorly differentiated adenocarcinoma at the protruding lesion and foveolar hyperplastic epithelia at the base of the polyp. Immunohistochemically, most of tumor cells that comprised poorly-differentiated adenocarcinoma were positive for both cytokeratin and vimentin. Although carcinomas have occasionally been found in HPs, the histological features of the present case are considered extremely unusual. To the best of our knowledge, this is the first case of vimentin-positive early gastric carcinoma arising in a HP.     

Esophageal endocrine cell carcinoma: a report of eight cases and a review of the literature

Esophageal endocrine cell carcinoma is a rare histopathological type thought to be highly malignant and to have a poor prognosis, but its clinical behavior has not been fully analyzed. We retrospectively reviewed our cases among 386 patients with esophageal cancer in our institution. Eight patients (2.1 %) were pathologically diagnosed with endocrine cell carcinoma. Median patient age was 63 years, and the male-to-female ratio was 7:1. Cancer stage according to the Japanese Classification of Esophageal Cancer (JCEC) 10th edition, was stage II in one case, III in three, IVa in one, and IVb in three. Chromogranin-A staining was positive in six cases, synaptophysin in six, cluster of differentiation (CD)56 in seven, and neuron-specific enolase (NSE) in seven. Treatment included surgery in two cases, chemoradiotherapy in four, best-supportive case in one, and rejection in one. Prognoses were 13 months after surgery for stage II, 6–28 months after chemoradiotherapy for stage III, and 0–10 months for stage IV.     

Thoracoscopic esophagectomy in the prone position for corrosive stricture after esophageal perforation due to balloon dilatation

An 18-year-old man was referred to our hospital because of chest pain after ingestion of a strong hydroxide in an attempted suicide. On post-ingestion day 25, an esophageal endoscopy and esophagram revealed at least three strictures, one each in the cervical, upper, and lower thoracic esophagus. In particular, the upper thoracic esophageal stricture was severe and was 5 cm long. Repeated balloon dilatation was employed, but resulted in perforation of the upper thoracic esophagus on the fourth attempt. On post-ingestion day 95, thoracoscopic esophagectomy in the prone position was performed. The esophagus was reconstructed using a subtotal gastric tube and cervical esophagogastric anastomosis in the supine position. Although the periesophageal adhesions were severe, esophagectomy was successfully performed. Anastomotic leakage developed after surgery, but the patient was discharged on postoperative day 47 on a regular diet.     

Treatment and reconstruction after disconnection of the failed cervical esophagogastric anastomosis

Reconstruction of the esophageal passage after severe complications of the esophagogastric anastomosis (disconnection, long stenosis) remains a surgical challenge. We describe the course of five patients with cervical defects (n = 4) or stenosis (n = 1) after complications of the cervical esophagogastric anastomosis and successful reconstruction by free jejunal transfer. Cause of failure of the anastomosis was ischemia in two, and compression, bleeding and unknown reasons in the other three patients respectively. In four patients, subsequent treatment consisted of disconnection of the anastomosis. In all cases, reconstruction by free jejunal transfer was done between 8 weeks and 12 months after primary surgery. A perforation of the graft was observed in one patient (decubital ulcer from the split sternum). All patients regained normal swallowing function. Free jejunal transfer is a safe method for reconstruction of short defects with a satisfactory functional result and minimal surgical trauma.     

Esophagogastric anastomotic wound healing in rats

Esophagectomy with esophagogastric anastomosis is commonly complicated by anastomotic dehiscence. Although this is a major problem in clinical esophageal surgery, laboratory investigation of esophagogastric anastomotic wound healing has been hampered by the lack of a practical rodent model. Problems with aspiration pneumonia and anastomotic strictures hindered our previous studies in the rat. Other researchers have turned to large animal experiments, or used various upper gastrointestinal pseudoanastomotic techniques in rodents. None of these approaches has proved satisfactory. We developed a technique of side-to-side esophagogastric anastomosis in the rat, and then studied normal esophagogastric anastomotic healing in this model. Anastomoses were performed in 24 rats. Anastomotic breaking strength and hydroxyproline concentration were measured 1 and 2 weeks after surgery. Anastomotic breaking strength was 3.78 +/- 1.18 N at 1 week and 4.83 +/- 0.91 N after 2 weeks (p < 0.03). Anastomotic tissue hydroxyproline concentration was 370.6 +/- 31.2 nmol/mg at 1 week and 462.1 +/- 69.7 nmol/mg after 2 weeks (p < 0.001). Many of the problems encountered in esophagogastric anastomotic studies in the rat have been overcome using this new model.     

Resection of skeletal muscle metastases from squamous cell carcinoma of the esophagus: case report and literature review

Skeletal muscle metastasis from esophageal squamous cell carcinoma is an unusual entity. A 72-year-old man underwent a subtotal esophagectomy for advanced esophageal squamous cell carcinoma. Mediastinal lymph node metastases developed 36 months after operation, and the patient received chemoradiotherapy. He complained about two painful, subcutaneous masses in the upper part of the left arm at 3 months after the end of chemoradiotherapy. Histopathological examination of tissue specimens obtained by explorative surgery showed skeletal muscle metastases from poorly differentiated squamous cell carcinoma. The patient died of multiple metastases 7 months after chemoradiotherapy. This is considered a very rare case of metastasis from squamous cell carcinoma of the esophagus to the triceps muscle of the left arm.     

Use of efficient purse-string stapling technique for esophagogastric anastomosis in minimally invasive Ivor Lewis esophagectomy

Minimally invasive esophagectomy (MIE) is increasingly accepted in the treatment of locoregional or advanced esophageal cancer. Laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has been proved to be effective in treating middle and distal esophageal cancer, however, intrathoracic esophagogastric anastomosis is technically complex. When using circular stapler for making intrathoracic anastomosis in MIE, both transoral and transthoracic methods are frequently used for delivering the anvil into the esophageal stump. Herein, we report a new method to construct a thoracoscopic esophagogastric anastomosis by using a circular stapler: efficient purse-string stapling technique (EST). This technique is easy to handle and especially good to be used in patients with distal esophageal cancer or expanded esophageal cavity.KEYWORDS : Minimally invasive esophagectomy (MIE), Ivor Lewis esophagectomy, esophageal cancer, esophagogastric anastomosis, efficient purse-string stapling technique (EST)     

Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomsis

We retrospectively analyzed the clinical data of 112 patients who underwent esophagectomy for esophageal carcinoma and gastro-esophageal anastomosis in right thoracic cavity from October 2011 to June 2013. First, the gastric tube was created with the aid of linear stapling device by removing the stomach and dissecting lymph nodes under laparoscopy and making a 3-4 cm incision through the subxiphoid area in the upper abdomen. Second, the thoracic esophagus and lymph nodes were dissected during thoracoscopic procedure. Gastric tube was inserted into the chest cavity and placed in the posterior mediastinum. The thoracic gastro-esophageal anastomosis was stapled with a circular stapler. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is technically feasible and safe, with minimized trauma, less operative blood loss and quick recovery.KEYWORDS : Laparoscopic, thoracoscopic, esophagectomy, esophagogastric anastomosis, esophageal carcinoma     

Acute upper gastrointestinal bleeding from multiple Barrett's ulcers associated with metachronous multiple colorectal carcinomas

Although gastroesophageal reflux disease is sometimes associated with esophageal ulcer and/or mucosal erosion, acute upper gastrointestinal bleeding from an esophageal ulcer is uncommon. We report a case of acute gastrointestinal bleeding from one of multiple esophageal ulcers in extensive Barrett's esophagus in the postoperative period after low anterior resection performed for descending colon carcinoma. A 74-year-old Japanese woman had undergone sigmoid colon resection 6 years earlier. The patient had a history of repeated reflux esophagitis. She was referred to a local hospital for a simple health screening 5 years after surgery. The patient had noticed bloody stool and felt mild difficulty at defecation 2 weeks before admission. Lower gastrointestinal endoscopy performed at a local hospital revealed a type 2 tumor located approximately 15 cm from the anal verge, which was obviously the cause of the bloody stool and constipation. The patient was admitted to our hospital for surgical treatment. Ten days after the low anterior resection, upper gastrointestinal bleeding occurred. Upper gastrointestinal endoscopy revealed multiple ulcers in the lower esophagus, which had caused the bleeding. Endoscopic biopsy revealed that esophageal ulcer occurred in the Barrett's esophagus, extending 15 cm from the functional esophagogastric junction. This case highlights acute upper gastrointestinal bleeding from multiple Barrett's ulcers in extensive Barrett's epithelium occurring in the postoperative period of colorectal carcinoma, and indicates an association of Barrett's esophagus with metachronous multiple colon carcinoma.     

胃食管吻合术联合Nissen胃底折叠术对食管中段癌患者术后胃食管反流的影响

目的探讨胃食管吻合术联合Nissen胃底折叠术对食管中段癌术后患者胃食管反流的影响。 方法选取2015年9月至2017年3月,新疆维吾尔自治区人民医院住院并行食管癌切除术31例食管中段癌患者的临床资料。根据手术方式分为2组,即接受胃食管吻合术联合Nissen胃底折叠术15例（观察组）,接受胃食管吻合术16例（对照组）,术后2周待患者恢复正常的胃肠道功能后采用pH动态监测仪对其进行24 h pH监测,术后1、3、6、12个月依据胃食管反流病调查问卷（GerdQ）对患者的胃食管反流相关症状进行评分,比较2组患者术后胃食管反流发生情况。 结果2组患者均未出现死亡病例,且术后均未发生有吻合口瘘及胸胃排空障碍等并发症;观察组患者术后2周24 h酸反流次数显著少于对照组、最长酸反流时间和pH值<4的总时间短于对照组,DeMeester评分显著低于对照组,组间比较均有统计学意义（P<0.05）;观察组术后3、6、12个月胃食管反流病调查问卷（GerdQ）评分显著低于对照组,组间比较均有统计学意义（P<0.05）。 结论胃食管吻合术联合Nissen胃底折叠术对食管癌切术后的胃食管反流病情起到更为理想的控制效果,为食管中段癌患者术中吻合术式的选择提供一定参考价值。     

Five-year postsurgical monitoring of serum p53 antibody for locally advanced esophageal squamous cell carcinoma

Serum p53 antibody (s-p53-Ab) titers were postoperatively monitored for over 5 years in a 67-year-old man with locally advanced esophageal squamous cell carcinoma. The tumor stage was classified as clinical stage II (cT3N0M0). Serum SCC antigen (s-SCC-Ag; 6.2 ng/mL) and s-p53-Ab (3.83 U/mL) were noted to be positive before surgery. Radical esophagectomy with three-field lymph node dissection was performed without neoadjuvant therapy. Pathological findings of the surgically resected specimens revealed a stage II tumor (pT3N0M0). Postoperatively, the patients did not receive any adjuvant therapy. Although the s-SCC-Ag was found to be negative at 2 months postoperatively, s-SCC-Ag was found to be six times positive despite no signs of recurrence. The s-p53-Ab titers constantly decreased to less than the cutoff value at 6 months postoperatively and continuously decreased over 5 years postoperatively. Finally, s-p53-Ab titers became less than the detection limit value at 60 months postoperatively. No recurrence was observed throughout the postoperative course. This case report is the first to describe the five-year monitoring of postoperative changes in s-p53-Ab titers in a patient with locally advanced esophageal squamous cell carcinoma without recurrence. s-p53-Ab titers seemed to be more useful than s-SCC-Ag for disease monitoring in this case.     

Double lumen esophagus: A rare complication of gastroesophageal reflux disease

Double lumen esophagus or esophagogastric fistula is a very rare endoscopic finding. Approximately 11 cases have been reported in the past. Formation of an esophagogastric fistula is predisposed by previous esophagogastric surgery, persistent gastroesophageal reflux, esophageal ulcer or esophageal carcinoma. Dysphagia and odynophagia are common symptoms. Endoscopy is the procedure of choice for diagnosis. Symptomatic management is the mainstay of treatment. Early diagnosis andmanagement of gastroesophageal reflux is essential to prevent reflux‐related fistulas. We report the case of a 48‐year‐old man with a history of dysphagia who was found to have esophagogastric fistula on endoscopy. He was treated conservatively with proton pump inhibitors leading to symptomatic improvement.     

Laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis for middle or lower esophageal carcinoma

Thoracoscopic mobilization of esophagus and laparoscopic mobilization of stomach with cervical anastomosis is employed widely in minimally invasive esophagectomy (MIE) for esophageal carcinoma. However, it is associated with high incidence of complications, including recurrent laryngeal nerve injury and anastomotic leak. This paper summarizes the key techniques in total laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis for MIE in 62 patients of middle or lower esophageal cancer between March 2012 and August 2013. Total laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis was performed to treat the middle or lower esophageal cancer. Laparoscopic and thoracoscopic Ivor-Lewis esophagectomy was performed using a circular stapler (Johnson and Johnson) intrathoracically to staple esophagogastric anastomosis and reconstruct the digestive tract. In addition, we performed tension-relieving anastomotic suture and embedded with pedicled omental flap. Compared with the trans-orally inserted anvil (OrVil) approach, the technique reported here is safe, feasible and user-friendly. Total thoracoscopic intrathoracic anastomosis can be performed with a circular stapler (Johnson and Johnson).     

Thoracoscopic and laparoscopic esophagectomy with cervical manual anastomosis for esophageal cancer

Evidence on the benefits of minimally invasive approach over traditional open procedure in gastrointestinal surgery is continuing to accumulate. This is also the case for esophageal surgery.Although laparoscopic esophageal surgery was initially reserved for benign pathology, the technical development, increasing experience with laparoscopic and thoracoscopic techniques and the theoretical advantages of minimally invasive surgery have widened the scope of minimally invasive approach to esophageal cancer. The surgical treatment of esophageal cancer often requires extensive procedures and is therefore, considered one of the most challenging and invasive procedure of gastrointestinal surgery. While transhiatal and transthoracic esophagectomy are common approaches for esophageal resection, data regarding the combined thoracoscopic and laparoscopic approach to esophagectomy are limited. The minimally invasive technique of esophagectomy to be described consists of three phases: thoracoscopic esophageal mobilization and mediastinal lymphadenectomy followed by laparoscopic gastric mobilization, abdominal lymphadenectomy and gastric conduit formation and finally retrieval of the resection specimen followed by an esophagogastric anastomosis via a left cervical incision.     

Primary malignant melanoma of esophagus following chemoradiotherapy for esophageal squamous cell carcinoma: report of a case

Primary malignant melanoma of the esophagus (PMME) is a rare neoplasm. We observed a case of PMME that had occurred at an irradiated site in the thoracic esophagus. The patient was a 74-year-old man who had received definitive chemoradiotherapy for esophageal squamous cell carcinoma at the age of 68, and had completely recovered. Six years later, via periodic upper gastrointestinal endoscopy, he had been diagnosed with esophageal tumors. After the patient underwent esophagectomy, the removed esophageal tumors were immunohistologically diagnosed as PMME, and most of the tumor was observed to be located within the irradiated area corresponding to the previous radiotherapy. The patient has been free of recurrence and metastasis and alive for 20 months after the second surgery without any additional treatment. The clinical course of this patient suggests that therapeutic radiation may be a factor in the occurrence of PMME.