Re-evaluation of the role of thoracoscopic esophagectomy as a Japanese-style radical surgery

Purpose

To investigate the value of thoracoscopic surgery in radical esophagectomy with three-field lymphadenectomy.

Materials and method

The subjects were 329 consecutive patients who, without preoperative chemoradiotherapy, underwent R0 radical esophagectomy with three-field lymphadenectomy for thoracic squamous cell esophageal cancers during 1998–2013. Open thoracotomy was applied in 212 (O), and thoracoscopic surgery in 117 (V). Survivals according to TNM Stages and Efficacy index (EI) were analyzed.

Results

Hospital death rates of O/V were 1.9/0%. The survivals of V according to TNM Stages had significantly better prognosis in TNM6th cStage III and showed not worse prognosis in general. In the analysis using Cox proportional hazards model, “V or O” was a significant prognostic factor indicating better prognosis of V. More bilateral paratracheal lymph nodes along the recurrent laryngeal nerves tended to be classified as mediastinal instead of cervical in V. Efficacy index of mediastinal paratracheal nodes was higher in V than in O, while cervical lymphadenectomy maintained high EI.

Discussion and conclusion

Though our series have limitations of retrospective study and substantial bias, the feasibility and safety of thoracoscopic esophagectomy with three-field lymphadenectomy was shown. Higher paratracheal lymph nodes along the recurrent laryngeal nerves could be dissected from the mediastinal side in V group. Thoracoscopic esophagectomy, which is regarded as minimally invasive surgery in other countries, is being accepted in Japan mainly in the expectation of more thorough and meticulous lymphadenectomy. At the same time, the dissection range is continuously re-evaluated for safer surgery maintaining radicality.

     

Indications for surgical treatment of intrahepatic cholangiocarcinoma with lymph node metastases

Background/Purpose

The postoperative outcome of patients who have intrahepatic cholangiocarcinoma with lymph node metastases is extremely poor, and the indications for surgery for such patients have yet to be clearly established.

Methods

The demographic and clinical characteristics of 133 patients who underwent lymph node dissection during hepatic resection of intrahepatic cholangiocarcinoma were retrospectively analyzed.

Results

Multivariate analysis identified three independent prognostic factors: intrahepatic metastasis, nodal involvement, and tumor at the margin of resection. Of the patients with tumor-free surgical margins, none of the 24 patients who had both lymph node metastases and intrahepatic metastases survived for 3 years. In contrast, the survival rates for the 23 patients who had lymph node metastases associated with a solitary tumor were 35% at 3 years and 26% at 5 years.

Conclusions

Surgery alone cannot prolong survival when both lymph node metastases and intrahepatic metastases are present, while surgery may provide a chance for long-term survival in some patients who have lymph node metastases associated with a solitary intrahepatic cholangiocarcinoma tumor.

     

Efficacy of lymph node dissection for each station based on esophageal tumor location

Background

The area of nodal dissection should be modified by the location of the primary tumor in an individual patient. The purpose of this study was to evaluate the efficacy of lymph node dissection based on station by the location of the primary tumor based on a multi-institutional nationwide registry of esophageal cancer.

Methods

The study group comprised 1295 patients who underwent R0 resection and three-field esophagectomy. The Efficacy Index (EI) was calculated by multiplying the incidence of metastases to a station and the 5-year survival rate of patients with metastases to that station, by tumor location.

Results

There were 550 patients without nodal metastases and 745 patients with them. In patients with upper tumors, the EIs of recurrent nerve nodes, cervical paraesophageal nodes and supraclavicular nodes were highest. In patients with middle tumors, the EIs of recurrent nerve nodes, cardiac nodes and lesser curvature nodes were highest, and the EIs of supraclavicular nodes and cervical paraesophageal nodes were not negligible. In patients with lower tumors, the EIs of cardiac nodes, lesser curvature nodes and left gastric artery nodes were highest, and the EIs of recurrent nerve nodes were also high.

Conclusion

The EIs of certain node stations were different by location of the primary tumor. Node stations for dissection should be modified by the location of the primary tumor. For upper and middle esophageal tumors, the three-field approach is recommended. Dissection of the upper mediastinum is recommended for patients with lower esophageal tumors.

     

EBUS-TBNA is Sufficient for Successful Diagnosis of Silicosis with Mediastinal Lymphadenopathy

Background

Silicosis is an occupational lung disease resulting from inhalation of respirable crystalline silica. Recently, an international silicosis epidemic has been noted among artificial stone workers.

Objective

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is currently used for patients with unexplained lymphadenopathy. Since silicosis may present with prominent lymphadenopathy, the diagnostic yield of EBUS-TBNA in diagnosing silicosis was evaluated.

Methods

Twenty-eight patients with suspected silicosis referred for outpatient evaluation in three large tertiary hospitals were evaluated. Patients with mediastinal lymphadenopathy underwent EBUS-TBNA, while others underwent TBB and/or video-assisted thoracoscopic surgery (VATS).

Results

Eleven patients with mediastinal lymphadenopathy (39%) were evaluated using EBUS-TBNA. The diagnosis was accurate in all cases, demonstrating silica particles under polarized light, with no complications. Among the remaining patients, TBB was only 76% diagnostic, therefore requiring VATS.

Conclusions

EBUS-TBNA is a useful and sufficient tool to diagnose silicosis in patients with mediastinal lymphadenopathy along compatible exposure histories.

     

Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence imaging

Purpose

The treatment of splenic flexural colon cancer is not standardized because the lymphatic drainage is variable. The aim of this study is to evaluate the lymph flow at the splenic flexure.

Methods

From July 2013 to January 2016, consecutive patients of the splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. Primary outcome is frequency of the direction of lymph flow from splenic flexure. We injected indocyanine green (2.5 mg) into the submucosal layer around the tumor and observed lymph flow using the laparoscopic near-infrared camera system in 30 min after injection.

Results

Thirty-one patients were enrolled in this study. The lymph flow was visualized in 31 patients (100 %) without any complications. No case exhibited lymph flow in both the left colic artery (LCA) and left branch of the middle colic artery (lt-MCA) areas. There were 19 cases (61.3 %) with lymph flow directed to the area of the root of the inferior mesenteric vein (IMV), regardless of the presence of the left accessory aberrant colic artery. Lymph node metastases were observed in six cases (19.4 %), and all of the involved lymph nodes existed in lymph flow areas determined by real-time indocyanine green fluorescence imaging.

Conclusions

The findings of the lymph flow pattern of splenic flexure suggest that lymph node dissection at the root of the IMV area is important, and it may be not necessary to ligate both the lt-MCA and LCA, at least in cases without widespread lymph node metastases.

     

Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer

Purpose

The purpose of this study was to identify the size criteria of lateral lymph node metastasis in lower rectal cancer both in patients who underwent preoperative CRT and those who did not.

Methods

This study enrolled 150 patients who underwent resection for primary lower rectal adenocarcinoma with lateral lymph node dissection between 2013 and 2015. Patients were divided into two groups: the CRT group, treated with preoperative chemoradiotherapy before surgery, and the non-CRT group, treated with surgery alone. The short-axis diameter of each dissected lateral lymph node was measured. Receiver-operating characteristic curves were generated to reveal the optimal cutoff values for determining lateral lymph node metastasis in both groups.

Results

In the non-CRT group (n = 131), the ROC curve demonstrated that the optimal cutoff value for determining metastasis was 6.0 mm, with a sensitivity of 78.5% and specificity of 82.9%, and the AUC was 0.845. In comparison, in the CRT group (n = 19), the optimal cutoff value was 5.0 mm, with a sensitivity of 71.4% and specificity of 85.3% and an AUC of 0.836.

Conclusion

The cutoff size for determining lateral lymph node metastasis was smaller in the CRT group than in the non-CRT group.

     

Hand-assisted technique beneficial for laparoscopic transhiatal esophagectomy with en-bloc dissection of middle and lower mediastinal lymph nodes: roles of the operator’s left hand

Background

Hand-assisted laparoscopic surgery (HALS) is safe and useful in the management of gastric conduit reconstruction. By applying the HALS technique to mediastinal surgeries, we developed a novel technique for the en-bloc dissection of the middle and lower (M&L) mediastinal lymph nodes (LNs) using a laparoscopic transhiatal approach (LTHA). We describe our technique, with a focus on the roles of the operator’s left hand.

Methods

In our procedure, the operator’s hand has several important roles, such as retraction, maintenance of the route for the laparoscope, and grasping the shaft of the energy device to stabilize operability. After the esophageal hiatus was opened, the pericardium was exposed. The posterior plane of the pericardium was extended, and the anterior side of the subcarinal, main bronchial, thoracic paraaortic, and pulmonary ligament LNs was separated. The posterior side of these LNs was then separated. While lifting these LNs like a membrane, they were resected from the bilateral mediastinal pleura, main bronchi, and tracheal bifurcation. The treatment outcomes of 84 patients with esophageal cancer who underwent M&L mediastinal LN dissection by LTHA were compared with those of 75 patients who underwent their dissection by right thoracotomy.

Results

The total operative time and bleeding were significantly decreased by LTHA. The number of resected M&L mediastinal LNs in the two groups was not significantly different. Postoperative respiratory complications occurred in 14.3 % of patients treated with LTHA and 25.3 % of those treated without it.

Conclusions

In our surgical procedure, a specific technique of the operator’s left hand was essential and resulted in a good surgical view of the mediastinum, and en-bloc dissection of M&L mediastinal LNs was performed safely.

     

Palsy of the recurrent laryngeal nerves in association with an ultrasonic activated device during thoracoscopic esophagectomy with three-field lymphadenectomy

Background

Ultrasonic activated devices (USADs) may produce inadvertent injuries due to heat or shock waves. However, thermal injury and shock waves are considered to be avoidable if these devices are used appropriately.

Methods

Utilizing a porcine model, we examined the relationship between the occurrence of tissue damage around the iliac artery and sciatic nerve and the usage of an USAD. Thereafter, we prospectively determined the clinical outcomes following the usage of the USAD during dissection along the recurrent laryngeal nerves (RLN) in 114 consecutive patients who underwent thoracoscopic esophageal surgery.

Results

The temperatures measured in the pig iliac artery and sciatic nerve more than 2 mm from the activating blade (at a power setting of 70 %, within 2 s) did not increase to 42 °C. In a subsequent clinical series using the short activating technique according to the findings of in vivo experiments, scheduled laryngoscopic studies showed the rate of vocal cord palsy after esophagectomy to be 39 %, which was more sensitive than the substantial presence of hoarseness (28 %).

Conclusions

Adverse effects by using the USAD on the nerves may be avoidable if the activation of the current using an USAD is conducted within 2 s at positions more than 2 mm from the nerves. This short activation technique using the USAD is therefore considered to be safe and feasible for lymph node dissection along the RLNs during thoracoscopic esophagectomy, although the apparent reasons for postoperative dysfunction in the vocal cords remain unclear.

     

Assessment of Mediastinal Lymph Node Size in Pneumococcal Pneumonia with Bacteremia

Introduction

The significance of mediastinal lymphadenopathy in bacterial pneumonia is unclear.

Methods

We performed a retrospective analysis of mediastinal lymph node size determined by chest CT in patients with bacteremic pneumococcal pneumonia. All patients who had positive blood cultures for streptococcus pneumonia over an 11-year period and had a chest CT scan (index CT) within 2 weeks of the positive blood culture were included in the study. Two thoracic radiologists and one pulmonologist independently examined the index CT plus any chest CT scans performed prior (pre-CT) or after (post-CT) the bacteremic episode.

Results

The study cohort of 49 patients was 57% male, 65% White, with mean age of 53 (SD = 20) years. Mediastinal lymphadenopathy was detected in 25/49 (51%) of the cases. The mean size of the largest mediastinal lymph node in short axis was 0.99 (SD = 0.71), ranging from 0.0 to 2.05 cm. There was no correlation noted between the number of lobes involved with pneumonia, and the size of the largest mediastinal lymph node (p = 0.33) or the number of pathologically enlarged mediastinal lymph nodes (p = 0.08). There was a statistically significant increase in the mean size of the largest lymph node between the pre-CT and index-CT group (p = 0.02), and decrease between the index-CT group and the post-CT (p = 0.03).

Conclusion

Pneumococcal pneumonia with bacteremia is associated with mild mediastinal lymph node enlargement. The presence of marked mediastinal lymphadenopathy (short axis LN size > 2 cm) should not be assumed from pneumococcal pneumonia.

     

Improvement in short-term outcomes after esophagectomy with a multidisciplinary perioperative care team

Background

Esophagectomy for patients with esophageal cancer remains a high-risk surgery. We introduced a multidisciplinary perioperative management team in the Cancer Institute Hospital (PeriCan) to improve short-term outcomes after esophagectomy.

Methods

To clarify the effect of PeriCan, we compared short-term outcomes between patients who underwent esophagectomy 1 year before the introduction of PeriCan and those who underwent esophagectomy 1 year after the introduction.

Results

One hundred and thirteen patients who underwent esophagectomy between October 2012 and September 2013 were included in the “Before PeriCan” group, while 105 patients who underwent esophagectomy between October 2013 and September 2014 were included in the “PeriCan” group. The incidence of postoperative complications significantly decreased from 73 to 49 % (P = 0.0003) with the introduction of PeriCan. In particular, the incidence of postoperative pneumonia significantly decreased from 43 to 13 % (P < 0.0001). Before the introduction of PeriCan, almost 70 % of patients with recurrent laryngeal nerve palsy experienced postoperative pneumonia, but the incidence significantly decreased to 32 % after the introduction of PeriCan (P = 0.017). Although the operative approach differed between groups, significant reduction in pneumonia was observed both in patients who underwent open esophagectomy and in those who underwent minimally invasive esophagectomy.

Conclusion

The introduction of PeriCan significantly decreased the incidence of postoperative complications, especially pneumonia. Systematic and cooperative interaction among professionals as a perioperative team can minimize the risks associated with esophagectomy.

     

Risk factors of recurrence in T1 colorectal cancers treated by endoscopic resection alone or surgical resection with lymph node dissection

Purpose

The recurrence of T1 colorectal cancers is relatively rare, and the prognostic factors still remain obscure. This study aimed to clarify the risk factors for recurrence in patients with T1 colorectal cancers treated by endoscopic resection (ER) alone or surgical resection (SR) with lymph node dissection, respectively.

Methods

We reviewed 930 patients with resected T1 colorectal cancers (mean follow-up, 52.3 months). Patients were divided into two groups: those who underwent ER alone (298 cases), and those who underwent initial or additional SR with lymph node dissection (632 cases). Group differences in recurrence-free survival were evaluated using the Kaplan–Meier method and log-rank test. Associations between recurrence and clinicopathological features were evaluated in Cox regression analyses; hazard ratios (HRs) were calculated for the total population and each group.

Results

Recurrence occurred in four cases (1.34%) in the ER group and six cases (0.95%) in the SR group (p?=?0.32). Endoscopic resection, rectal location, and poor or mucinous (Por/Muc) differentiation were prognostic factors for recurrence in the total population. Por/Muc differentiation was prognostic factor in both groups. Female sex, depressed-type morphology, and lymphatic invasion were also prognostic factors in the ER group, but not in the SR group.

Conclusions

Endoscopic resection, rectal location, and Por/Muc differentiation are prognostic factors in the total population. For patients who undergo ER alone, female sex, depressed-type morphology, and lymphatic invasion are also risk factors for recurrence. For such patients, regional en-bloc surgery with lymph node dissection could reduce the risk of recurrence.

     

Postoperative delirium after pharyngolaryngectomy with esophagectomy: a role for ramelteon and suvorexant

Background

Postoperative delirium is common after extensive surgery, and is known to be associated with sleeping medications. In this study, we aimed to investigate the relationships between sleeping medications and postoperative delirium after pharyngolaryngectomy with esophagectomy.

Methods

We performed a retrospective analysis of 65 patients who underwent pharyngolaryngectomy with esophagectomy at Shizuoka Cancer Center Hospital between January 2012 and March 2016. All data were assessed by two psychiatrists, and univariate and multivariate analyses were performed.

Results

Postoperative delirium developed in 9 (13.8%) patients, with most cases (77.8%) occurring between postoperative day (POD) 1 and POD 3. Of the 24 patients taking a minor tranquilizer after surgery, 8 (33.3%) became delirious, but, of the remaining 41 patients taking ramelteon with or without suvorexant, only one (2.4%) became delirious after surgery. Moreover, of the 16 patients taking both ramelteon and suvorexant, no postoperative delirium was observed. Ramelteon with or without suvorexant was significantly associated with a decreased rate of postoperative delirium compared with minor tranquilizer use (p = 0.001). Multivariate analysis confirmed that the use of ramelteon with or without suvorexant was the only significant preventive factor of postoperative delirium (odds ratio 0.060, p = 0.013).

Conclusion

The use of ramelteon with or without suvorexant was the only significant preventive factor of postoperative delirium after pharyngolaryngectomy with esophagectomy. However, using minor tranquilizers was associated with postoperative delirium. We recommend ramelteon with or without suvorexant for preventing postoperative delirium after pharyngolaryngectomy with esophagectomy.

     

Hand grip strength as a predictor of postoperative complications in esophageal cancer patients undergoing esophagectomy

Background

Radical esophagectomy remains the primary treatment option for resectable esophageal cancer. However, it sometimes induces postoperative complications due to its invasive nature. Recently, the impact of loss of muscle mass on postoperative complications and survival among cancer patients has been highlighted. This study aimed to identify the impact of low hand grip strength (HGS) on postoperative complications after esophagectomy.

Methods

A total of 188 patients (male: 166, female: 22) who underwent radical esophagectomy with gastric tube reconstruction between 2008 and 2014 were included. The correlation between HGS and age was analyzed using Pearson’s correlation coefficient. Due to the small patient numbers, only male patients were stratified into two groups according to age (<70 years: non-elderly group, ≥70 years: elderly group). Receiver operating characteristic curve analysis was performed for each group using postoperative complication occurrence as the endpoint to determine an optimal HGS cutoff value.

Results

Postoperative complications occurred in 60.9% of the elderly group and 47.4% of the non-elderly group. When the cutoff values were set at 30.5 and 37 kg for the elderly and non-elderly group, respectively, low HGS was an independent predictive factor of postoperative complications on multivariate analysis only in the elderly group (p = 0.008). In the elderly group, the incidence of postoperative pneumonia was 39.5% among patients with low HGS vs. 3.8% among patients with high HGS.

Conclusion

Preoperative HGS is an independent predictive factor of postoperative complications, especially postoperative pneumonia, for elderly male patients with esophageal cancer treated with radical esophagectomy.

     

Prognosis of video-assisted thoracoscopic pulmonary metastasectomy in patients with colorectal cancer lung metastases: an analysis of 154 cases

Purpose

Video-assisted thoracoscopic surgery (VATS) is widely used in thoracic surgery and increasingly applied to pulmonary metastasectomy. The purpose of this study was to identify prognostic factors of patients undergoing VATS pulmonary metastasectomy from colorectal cancer (CRC).

Methods

Between January 2005 and June 2015, a total of 154 patients underwent VATS pulmonary metastasectomy from CRC. Patient demographic data and characteristics of the primary tumor and pulmonary metastasis were analyzed to identify factors significantly correlated with prognosis.

Results

The median follow-up period after pulmonary resection was 37 months. The cumulative 5-year overall survival rate after VATS pulmonary metastasectomy from CRC was 71.3%. History of metastasis to other sites (p = 0.035), status of mediastinal lymph nodes (p < 0.001), and preoperative carcinoembryonic antigen (CEA) level (p = 0.013) were identified as independent prognostic factors. Subgroup analysis with a combination of these three independent prognostic factors revealed 5-year OS rates of 91.0, 70.0, 30.3, and 0.0% for patients with zero, one, two, and three risk factors, respectively. Other factors, such as sex, disease-free interval, T stage of primary tumor, and status of lymph node near the primary tumor, were not significantly associated with prognosis.

Conclusion

VATS pulmonary metastasectomy is efficacious for patients with CRC pulmonary metastases. History of metastasis to other sites, status of mediastinal lymph nodes, and preoperative CEA level were identified as independent prognostic factors. The number of risk factors significantly influenced patient survival.

     

Preoperative patient-related factors associated with prognosis after esophagectomy for esophageal cancer

Background

To investigate the impact of the preoperative patient-related factors on survival after esophagectomy in patients with esophageal cancer.

Methods

We retrospectively reviewed 140 patients with esophageal cancer who underwent esophagectomy. Preoperative comorbidities, nutritional and inflammation status including the neutrophil to lymphocyte ratio and Glasgow prognostic score (GPS), and their pathological findings were analyzed to assess their relationships with prognosis.

Results

Univariate analysis demonstrated that a history of cardiovascular disease (CVD), a GPS of 1 or 2, lack of neo-adjuvant chemotherapy (NAC), no thoracoscopic esophagectomy, blood loss volume ≥255 ml, the number of lymph node metastasis (LNM) ≥2, lymphatic invasion, venous invasion, and residual cancer were associated with poor survival. Multivariate analysis revealed that a history of CVD [hazard ratio (HR) 2.129; 95% confidence interval (CI) 1.327–4.226; P = 0.041], a GPS of 1 or 2 (HR 3.232; 95% CI 1.516–6.437; P = 0.003), LNM ≥2 (HR 3.133; 95% CI 1.355–7.760; P = 0.007), and pathological residual cancer (HR 2.429; 95% CI 1.050–5.105; P = 0.039) were independently associated with poor survival, and NAC was associate with better survival (HR 0.289; 95% CI 0.118–0.667; P = 0.003).

Conclusions

Preoperative patient-related factors including a history of CVD and a GPS of 1 or 2 were predictors of poor prognosis after esophagectomy in patients with esophageal cancer.

     

Postoperative recurrence and risk factors of colorectal cancer perforation

Purpose

The common causes of colorectal perforation are benign. However, perforated colorectal cancer confers a risk of recurrence in the long term because of the malignant nature of the disease. In addition, the recurrence rate can also increase because of dissemination of cancer cells, reduced extent of lymph node dissection to prioritize saving life, and other reasons.

Methods

We evaluated the clinical features and postoperative recurrence in patients with perforated colorectal cancer who developed general peritonitis and underwent emergency surgery during a 7-year period between April 2007 and March 2014.

Results

During the study period, 44 patients had colorectal cancer perforation. The cancer sites were the ascending colon in 6 patients, transverse colon in 1, descending colon in 4, sigmoid colon in 15, and rectum in 18. The disease stage was stage II in 18 patients, stage III in 15, and stage IV in 7. Among 22 patients who could be followed up, 8 had postoperative recurrence. The recurrence rates were 18.2% for stage II cancer and 54.5% for stage III. Postoperative recurrence was more likely to occur in the patients positive for lymph node metastasis, those with poorly differentiated adenocarcinoma, those with T4 cancer, and those who did not receive postoperative adjuvant chemotherapy.

Conclusion

The recurrence rate was higher in the patients with perforated colorectal cancer than in those who underwent surgery for common colorectal cancer. The prognosis can be expected to improve by performing standard surgical procedures, to the maximum extent possible, followed by postoperative adjuvant chemotherapy.

     

Diagnostik des Lungenkarzinoms

Background

The prognosis of specific subgroups of patients has been significantly improved by a personalized medicine due to histological differentiation, discovery of new oncogene driver mutations in adenocarcinomas and the introduction of targeted therapies.

Objective

Minimally invasive endoscopic methods as well as surgical procedures are available for obtaining histological and cytological material for molecular diagnostics. The various diagnostic options with their advantages and disadvantages are described.

Material and methods

A literature search was carried out in PubMed.

Results

In every patient it should be possible for clinically practical reasons to perform molecular diagnostic investigations on biopsies, which are as small as possible. Endoscopic transbronchial needle aspiration (TBNA) has a high sensitivity and represents the diagnostic method of choice. If radiologically suspicious mediastinal lymph nodes are present and the cytological result is negative, surgical evaluation is still necessary.

Discussion

In the future the aim will be to find further molecular alterations that make a targeted therapy possible and which can be used as prognostic biomarkers or to predict therapy response. Research into entirely noninvasive methods, such as analysis of circulating tumor cells is ongoing.

     

Malignant mediastinal lymphadenopathy detected by endoscopic ultrasound and guided fine needle aspiration in patients with resectable pancreaticobiliary cancer

Background

Resection surgery for pancreaticobiliary malignancies carries significant morbidity and mortality. Hence, preoperative assessment to exclude unresectable disease is mandatory. CT abdomen is the primary modality for staging of pancreaticobiliary cancers. However, some patients have malignant mediastinal lymphadenopathy (MML), which may be detected on endoscopic ultrasound (EUS) but not on CT scan.

Methods

We prospectively evaluated 75 consecutive patients (median age 54 years: 44 men) with a diagnosis of resectable pancreaticobiliary cancer (carcinoma gallbladder, carcinoma pancreas, cholangiocarcinoma, or periampullary carcinoma) for the presence of MML using EUS by an experienced endosonographer. If a lymph node had one or more features suggestive of malignancy, i.e. size exceeding 1 cm, hypoechoic appearance, a round shape, and regular margins, it was subjected to EUS-FNA.

Results

In seven (9.3%; 95% confidence intervals: 3.8% to 18.2%) of the 75 patients, EUS revealed enlarged mediastinal lymph nodes. The location of these lymph nodes was subcarinal in three, paraesophageal in two, and paratracheal in one patient; another patient had lymph nodes at two sites, i.e. the subcarinal and aortopulmonary window. In four of these seven patients, FNA documented the presence of MML. The overall rate of pathologically proven MML was 4/75 (5.3%; 95% CI [1.4% to 13%]).

Conclusion

EUS-FNA diagnosed MML in 5.3% of patients with pancreaticobiliary cancer. It may be useful to consider EUS assessment in patients with otherwise resectable pancreaticobiliary malignancy.

     

In vivo and ex vivo sentinel node mapping does not identify the same lymph nodes in colon cancer

Introduction

Identification of lymph nodes and pathological analysis is crucial for the correct staging of colon cancer. Lymph nodes that drain directly from the tumor area are called “sentinel nodes” and are believed to be the first place for metastasis. The purpose of this study was to perform sentinel node mapping in vivo with indocyanine green and ex vivo with methylene blue in order to evaluate if the sentinel lymph nodes can be identified by both techniques.

Methods

Patients with colon cancer UICC stage I–III were included from two institutions in Denmark from February 2015 to January 2016. In vivo sentinel node mapping with indocyanine green during laparoscopy and ex vivo sentinel node mapping with methylene blue were performed in all patients.

Results

Twenty-nine patients were included. The in vivo sentinel node mapping was successful in 19 cases, and ex vivo sentinel node mapping was successful in 13 cases. In seven cases, no sentinel nodes were identified. A total of 51 sentinel nodes were identified, only one of these where identified by both techniques (2.0%). In vivo sentinel node mapping identified 32 sentinel nodes, while 20 sentinel nodes were identified by ex vivo sentinel node mapping. Lymph node metastases were found in 10 patients, and only two had metastases in a sentinel node.

Conclusion

Placing a deposit in relation to the tumor by indocyanine green in vivo or of methylene blue ex vivo could only identify sentinel lymph nodes in a small group of patients.

     

Usefulness of two-point fixed endoscopic submucosal dissection for superficial esophageal neoplasms

Background

Endoscopic submucosal dissection (ESD) is becoming widely regarded as a highly complicated but useful treatment for superficial esophageal neoplasms. However, the technique tends to be associated with adverse events. To evaluate the safety and utility of two-point fixed ESD for superficial esophageal neoplasms, and to discuss future directions.

Methods

Between December 2006 and December 2013, we performed two types of ESD procedures, the two-point fixed ESD that uses continuous countertraction to ensure a sufficient operative field was performed in 107 patients and conventional ESD was performed in 80 patients. Short-term outcomes and adverse events were evaluated. This study was retrospective study from a single institution.

Results

Significant differences were observed between conventional ESD and the two-point fixed ESD with regard to the operation time, tumor positive and unknown vertical margins of the resected specimen, perforation as an adverse event, mediastinal emphysema, and postoperative stenosis.

Conclusion

The two-point fixed ESD is a very useful method compared with the conventional procedure.