Reflux esophagitis (RE) is a known complication disturbing patients' quality of life after esophageal resection. It is generally recognized that bile reflux as well as acid reflux cause RE. However, the clinical influence of acid and bile reflux, and Helicobacter pylori (H. pylori) infection on RE in the cervical esophagus after esophagectomy is not yet clarified. Sixty patients who underwent cervical esophagogastrostomy following esophagectomy were enrolled in this study. They underwent examination for H. pylori infection, endoscopic examination, and continuous 24-hour pH and bilirubin monitoring, at 1 month after surgery. The influence of acid and/or bile reflux, H. pylori infection, and others on the development of RE were investigated. RE was observed in 19 patients (32%) at 1 month after esophagogastrostomy, mild RE in 16 (27%), and severe RE in 3 (5%). The percentage of time duration of both acid and bile reflux into the cervical esophagus was higher in patients with RE than in those without (P = 0.027, P < 0.001). A significant difference in %time pH < 4 acid reflux was found between mild RE and severe RE (P = 0.014), and a statistical difference in %time abs. > 0.14 between non-RE and mild RE (P = 0.017). Acid and/or bile reflux was observed in 31 patients (52%), acid-only reflux in 6 (10%), bile-only reflux in 15 (25%), and acid-and-bile reflux in 10 (17%). Severe RE was observed only in patients having acid-and-bile reflux. On the univariate analysis, no infection of H. pylori, acid reflux, and bile reflux were determined to be the influencing factors to RE among the clinical factors including age, gender, route of esophageal reconstruction, H. pylori infection, and acid-and-bile reflux. In the subanalysis using the logistic model, there were significant correlations between bile reflux and RE irrespective of the presence of H. pylori infection (P = 0.016, P = 0.007). On the other hand, there was a significant correlation between acid reflux and RE only in patients without H. pylori infection (P = 0.039). In the early period after esophagogastrostomy, bile reflux could cause RE irrespective of H. pylori infection, while acid reflex could cause RE only in patients without H. pylori infection. There is a possibility that bile reflux plays an important role in the development of RE after esophagectomy.
The aim of this study was to determine the factors influencing acidity in the gastric conduit after esophagectomy for cancer. Acidity and bile reflux in the stomach and in the gastric conduit were examined by 24-h pH monitoring and bilimetry in 40 patients who underwent transthoracic subtotal esophagectomy followed by esophageal reconstruction using a gastric conduit, which was pulled up to the neck through a posterior mediastinal route in 17 patients, through a retrosternal route in 10 patients, and through a subcutaneous route in 13 patients. They were examined at 1 week before surgery, at 1 month after surgery, and at 1 year after surgery. Helicobacter pylori infection was examined pathologically and using the (13) C-urea breath test. The factors influencing acidity of the gastric conduit were analyzed using the stepwise regression model. Gastric acidity assessed by percentage (%) time of pH < 4 was reduced after surgery and was significantly less in patients with H. pylori infection compared with those without H. pylori infection throughout the period from 1 week before surgery to 1 year after surgery. Duodenogastric reflux (DGR) assessed by % time absorbance > 0.14 into the lower portion of the gastric conduit was significantly increased after surgery throughout the period from 1 month after surgery to 1 year after surgery. Multivariate analysis showed that the acidity in the gastric conduit was influenced by H. pylori infection and DGR at 1 month after surgery, and by H. pylori infection and the route for esophageal reconstruction at 1 year after surgery. Acidity in the gastric conduit was significantly decreased after surgery. Acidity in the gastric conduit for esophageal substitutes is influenced by H. pylori infection and surgery. DGR influences the gastric acidity in the short-term after surgery, but not in the long-term after surgery.
Calculating the residual [Formula: see text]o2 max/m2 preoperatively from the results of lung perfusion scintigraphy and the number of segments scheduled for resection is useful for predicting postoperative exercise capacity.
A new N category for cancer of the cervical esophagus based on lymph node compartments Abstract Background. There remains controversy over what constitutes the optimal rational extent of lymphadenectomy, in other words, the concept of rational lymphadenectomy, for cancer of the cervical esophagus. The purpose of this study was to propose the concept of a rational N category for cancer of the cervical esophagus that indicates more clearly which cluster(s) of lymph nodes should be resected during resection of a cancer of the cervical esophagus. Methods. This study reviews the actual incidence of metastasis in the resected lymph nodes in a consecutive series of 36 patients with a cancer of the cervical esophagus who underwent curative resection. The regional lymph nodes were subsequently classifi ed into three compartments based on the metastatic rates and prognosis after lymphadenectomy. Results. In cases of cancer in the cervical esophagus with invasion into the pharynx (CePh), high rates of positive metastasis were found in the cervical paraesophageal (101) and in the deep cervical nodes (102), and resection of those nodes showed improved prognosis. In cases of cancer in the cervical esophagus without invasion into the pharynx (Ce/ CeUt), high rates of positive metastasis were found in the cervical paraesophageal (101) and in the recurrent nerve nodes (106rec), and resection of those nodes showed improved prognosis. In both cases, however, resection of the mediastinal nodes except for the recurrent nerve nodes (106rec) showed no improvement in prognosis. Only in cases where the cancer involves the pharynx did resection of the peripharyngeal nodes (103) show improved prognosis. Conclusions. The Compartment-I (N1) nodes for cancer of the cervical esophagus with invasion into the pharynx (CePh) were concluded to be the cervical paraesophageal (101) and the deep cervical nodes (102); the Compartment-II (N2) nodes to be the peripharyngeal (103), the supraclavicular (104), and the recurrent nerve nodes (106rec); and the Compartment-III (N3) nodes to be the superfi cial cervical (100) and the upper thoracic paraesophageal nodes (105). The Compartment-I (N1) nodes for cancer of the cervical esophagus without invasion into the pharynx (Ce/ CeUt) were concluded to be the cervical paraesophageal (101) and the recurrent nerve nodes (106rec); the Compartment-II (N2) nodes to be the deep cervical (102) and the supraclavicular nodes (104); and the Compartment-III (N3) nodes were concluded to be the superfi cial cervical (100) and the upper thoracic paraesophageal nodes (105).
A 62-year-old woman was referred to our hospital with presenting pigmentation and/or dermal thickening in the nucha, face, axilla, abdomen, and hands. She also presented a history of weight loss of 4 kg during the previous 3 months. She was pathologically diagnosed as having acanthosis nigricans by skin biopsy. She subsequently underwent 18 F-FDG-PET, CT, and upper gastrointestinal endoscopy, and then was diagnosed as having malignant acanthosis nigricans with squamous cell carcinoma in the esophagus at the clinical stage of T3, N0, M0, stage IIA in the UICC stage classifi cation. She underwent subtotal esophagectomy through a left thoracotomy with thoracoabdominal two-fi eld lymphadenectomy and esophageal reconstruction using a gastric tube through a retrosternal route. The postoperative course was uneventful, and she was discharged at 26 days after the surgery without any adjuvant therapy. At 6 months after the surgery, the dermal thickening and the pigmentation of the acanthosis nigricans were completely relieved. She is well without recurrence at 1 year to date after surgery. Although acanthosis nigricans is frequently associated with malignancy, malignant acanthosis nigricans with squamous cell carcinoma in the esophagus has been rare.
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