Annual Report 2021
Department of Esophageal Surgery
Takeo Fujita M.D./Ph.D./F.A.C.S, Hisashi Fujiwara M.D./Ph/D., Kazuma Sato M/D.
Introduction
The Department of Esophageal Surgery deals with neoplasms arising from the esophagus. The surgical management of esophageal cancer has been the main clinical and research activity of this department. In particular, our department is striving to establish minimally invasive surgery that consists of neoadjuvant treatment followed by minimally invasive esophagectomy. Our department is conducting a study to define the role of surgery in the multimodal approach to the treatment of esophageal cancer, and is aiming for thoraco-laparoscopic esophagectomy, which consists of thoracoscopic esophagectomy and laparoscopic reconstruction, to become a standard surgical procedure.
The Team and What We Do
Our team performed 158 thoracic esophagectomies in 2021. Additionally, we conducted 24 cervical esophageal cancer procedures (8 total phayngolaryngoesophagectomies, 16 larynx-preserving esophagectomies). We also focused on the postoperative care after surgery. In recent years, we have also actively introduced robot-assisted esophageal surgery to make it even less invasive, and in FY2021, nearly 50 procedures were performed with robot-assisted surgery. Patient support multidisciplinary classroom lessons have been held continuously for some years. On the other hand, regarding academic activities, we attended and made speeches in 11 domestic academic conferences and one international academic conference in 2021.
Table 1. Type of Procedures for Thoracic Esophageal Cancer
Table 2. Type of Procedures for Cervical Esophageal Cancer
Research activities
To achieve the best practice for patients, we are investigating several aspects of tissue perfusion imaging study. First, using the O2 saturation imaging, we are exploring the best gastric conduit and most suitable anastomotic site during surgery. Second, using AI deep learning technology, we are focusing on AI-guided real time surgery particularly for the anatomical recognition of recurrent laryngeal nerves to avoid unexpected injury and subsequent recurrent nerve palsy which greatly impair the patients’ quality of life after surgery. Third, conferring with the preoperative patients and their families, we are doing case control, investigating whether or not an active preoperative rehabilitation program with a nutrition program would improve the postoperative patients’ status, particularly skeletal mass index (which is vital to avoid sarcopenia), and reduce the postoperative fatigue after surgery. Several other research activities are being planned at this point. We are also currently submitting a paper on intraoperative AI analysis of the recurrent nerve.
Clinical trials
Currently, our department is examining the role of thoracolaparoscopic esophagectomy as a minimally invasive esophagectomy that consists of thoracoscopic esophagectomy and laparoscopic reconstruction. For patients without radical chemoradiotherapy, thoracoscopic esophagectomy in the prone position with radical lymph node dissection and laparoscopic reconstruction after esophagectomy for patients without a history of laparotomy are being attempted to make them a standard surgical procedure for esophageal cancer. For treating patients aged over 80 years or at high risk, a two-stage surgical procedure divided into resection and reconstruction is being attempted.
A randomized controlled phase III study comparing cisplatin and 5-fluorouracil versus
cisplatin and 5-fluorouracil plus docetaxel versus cisplatin and 5-fluorouracil with concurrent radiation as a neoadjuvant treatment for locally advanced esophageal cancer is ongoing. A randomized controlled phase III study of minimally invasive versus open esophagectomy for thoracic esophageal cancer (JCOG1409, MONET trial) is ongoing.
Further, a randomized controlled phase III study comparing induction treatment with cisplatin and 5-fluorouracil plus docetaxel and subsequent conversion surgery versus cisplatin and 5-fluorouracil with concurrent radiation as a definitive treatment for locally advanced (cT4b or borderline tumor) esophageal cancer is ongoing. A randomized controlled phase III study of minimally invasive versus open esophagectomy for thoracic esophageal cancer (JCOG1510, TRIANgLE trial) is ongoing. Since 2000, our department has started to perform salvage surgery for patients in whom definitive chemoradiotherapy has failed. The operative procedures and postoperative management have been refined gradually. Our department is also studying the role and efficacy of salvage surgery in the multimodal treatment of esophageal cancer.
Education
In academic training, we teach our residents not only about surgical practice but also several aspects of academic activities for PhD course students. One of our residents achieved a PhD degree in 2021. We are also teaching two PhD course students about research activities. In addition, two of our staff obtained certifications, one as a specialist in the treatment of gastrointestinal cancer surgery and one as a board-certified surgeon in gastroenterology for the treatment of gastrointestinal cancer.
Future Prospects
We are exploring best clinical practice for patients and their families. To achieve this mission, we are exploring best surgical practice and future research activities conducted in cooperation with other domestic and international research institutes.
List of papers published in 2021
Journal
1. Fujita T, Okada N, Sato T, Sato K, Fujiwara H, Kojima T, Daiko H. Propensity-matched analysis of the efficacy of olanexidine gluconate versus chlorhexidine-alcohol as an antiseptic agent in thoracic esophagectomy. BMC surgery, 22:20, 2022
2. Fujita T, Sato K, Ozaki A, Tomohiro A, Sato T, Hirano Y, Fujiwara H, Yoda Y, Kojima T, Yano T, Daiko H. A novel imaging technology to assess oxygen saturation of the gastric conduit in thoracic esophagectomy. Surgical endoscopy, 2022
3. Akutsu T, Fujita T, Kajiyama D, Ozaki A, Sato K, Fujiwara H, Kojima T, Daiko H. Operative outcomes and long-term survival of patients undergoing colon interposition after esophagectomy for cancer. Thoracic cancer, 13:844-852, 2022
4. Kadota T, Sato D, Inaba A, Nishihara K, Takashima K, Nakajo K, Yukami H, Mishima S, Sawada K, Kotani D, Fujiwara H, Nakamura M, Hojo H, Yoda Y, Kojima T, Fujita T, Yano T. Long-term clinical outcomes of patients diagnosed with pT1a-muscularis mucosae with lymphovascular invasion or pT1b after endoscopic resection for cT1N0M0 esophageal squamous cell carcinoma. Esophagus: official journal of the Japan Esophageal Society, 19:153-162, 2022
5. Ikematsu H, Ishihara M, Okawa S, Minamide T, Mitsui T, Kuwata T, Ito M, Kinoshita T, Fujita T, Yano T, Omori T, Ozawa S, Murakoshi D, Irisawa K, Ochiai A. Photoacoustic imaging of fresh human surgically and endoscopically resected gastrointestinal specimens. DEN open, 2:e28, 2022
6. Sato D, Kadota T, Inaba A, Nishihara K, Takashima K, Nakajo K, Sawada K, Kotani D, Fujiwara H, Yoda Y, Kojima T, Fujita T, Fujii S, Yano T. Long-term clinical outcome after endoscopic resection of esophageal squamous cell carcinoma invading the muscularis mucosae without lymphovascular invasion. Gastrointestinal endoscopy, 95:634-641.e3, 2022
7. Okunaka M, Kotani D, Demachi K, Fujiwara H, Sakashita S, Yoshino T, Fujita T, Kojima T. Significance of chemotherapy-free interval and tumor regression grade in patients with recurrent esophageal squamous cell carcinoma receiving chemotherapy with fluorouracil and platinum after esophagectomy following preoperative chemotherapy. Esophagus: official journal of the Japan Esophageal Society, 19:240-249, 2022
8. Daiko H, Fujita T, Oguma J, Sato T, Sato A, Sato K, Hirano Y, Kurita D, Ishiyama K, Fujiwara H. Novel minimally invasive approach to lymph node dissection around the left renal vein in patients with esophagogastric junction cancer. Esophagus: official journal of the Japan Esophageal Society, 18:420-423, 2021
9. Daiko H, Oguma J, Fujiwara H, Ishiyama K, Kurita D, Sato K, Fujita T. Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogastric cancer (RETML-4): a prospective feasibility study. Esophagus: official journal of the Japan Esophageal Society, 18:203-210, 2021
10. Ishiyama K, Fujita T, Fujiwara H, Kurita D, Oguma J, Katai H, Daiko H. Does staged surgical training for minimally invasive esophagectomy have an impact on short-term outcomes? Surgical endoscopy, 35:6251-6258, 2021
11. Sunakawa H, Yoda Y, Takeshita N, Hasegawa H, Takashima K, Kadota T, Fujita T, Akimoto T, Fujii S, Yano T. Endoscopic resection combined with the Cryoballoon focal ablation system in the porcine normal esophagus: a preclinical study. BMC gastroenterology, 21:234, 2021
12. Daiko H, Oguma J, Fujiwara H, Ishiyama K, Kurita D, Sato T, Sato K, Faiz Z, Fujita T. Novel universally applicable technique for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy: a truly minimally invasive procedure. Surgical endoscopy, 35:5186-5192, 2021