Annual Report 2023
Department of Esophageal Surgery
Takeo Fujita M.D./Ph.D., Naoto Fujiwara M.D./Ph.D., Kazuma Sato M.D./Ph.D.
Introduction
The Department of Esophageal Surgery deals with neoplasms arising from the esophagus. The surgical management of esophageal cancer has been the primary 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 make it a standard surgical procedure.
The Team and What We Do
In our department, we performed 160 cases of thoracoscopic surgery for esophageal cancer in 2023, with a particular focus on robotic surgery. In addition, robotic surgery has become the standard procedure for abdominal operations, replacing laparoscopic surgery. Alongside these, in recent years we have been actively introducing mediastinoscopy for very elderly patients over the age of 85 and for cases with poor tolerance of thoracotomy.
In addition, we perform multidisciplinary treatment, including preoperative treatment, for cervical esophageal cancer in collaboration with plastic surgery, and in 2023, we performed radical surgery for 9 cases of cervical esophageal cancer, and of these, we performed larynx-sparing cervical esophageal surgery for 6 cases, including cases in which a response was obtained through preoperative chemotherapy, etc. In the future, it is expected that Japan as a whole will move beyond being a super-aged society and enter a period of being a society with a very high proportion of elderly people. As the number of esophageal cancer surgery cases increases with the aging of the population, it is important to provide individualized minimally invasive surgery for the elderly, depending on their physical functions and the degree of tumor progression, therefore we are working to provide safe surgical treatment that maintains quality of life. In recent years, we have also actively introduced robot-assisted esophageal surgery to further reduce invasiveness, and in 2023 we performed over 100 cases under robot-assisted surgery. In 2023, we also introduced robot-assisted trans-cervical mediastinoscopic esophagectomy (RACE), which is still rarely used worldwide, and by March 2024 we had performed 33 cases, with good results.
In addition to JCOG activities, we are also conducting research on gastric blood flow evaluation using oxygen saturation imaging technology to evaluate the optimal anastomotic site, and research on evaluating blood flow in reconstructed organs using tissue oxygen saturation and hemoglobin index. We are also conducting research on intraoperative AI analysis of the recurrent nerve using deep learning methods, which have been developed significantly in recent years.
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, we use the O2 saturation imaging to explore the best gastric conduit and the most suitable anastomotic site during surgery. Second, we use AI deep learning technology to focus 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 conducting a 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. Several other research activities are 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 performed to determine their role as standard surgical procedures 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 conducted.
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.
Furthermore, 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 performing salvage surgery for patients with unsuccessful definitive chemoradiotherapy. 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. As the National Cancer Center attracts excellent young physicians from all over the country, it is important that they make full use of the center's resident program to gain a thorough understanding of the role of esophageal surgery in cancer treatment and diagnosis. In addition to the usual surgical training, we also provide education through patient education classes with a range of different professionals. In terms of research, in 2023, one resident specializing in cancer treatment obtained a degree from the Cancer Center and the affiliated graduate school, and a graduate student from the affiliated graduate school is conducting research for a degree. One graduate of our department has obtained a specialist qualification in esophageal surgery. In addition, one resident specializing in cancer treatment and one resident have obtained specialist qualifications in surgical treatment for gastrointestinal cancer and certification in surgical treatment for gastrointestinal cancer.
Future Prospects
We are exploring the best clinical practice for patients and their families. To achieve this mission, we will continue to explore the best surgical practice and future research activities conducted in cooperation with other domestic and international research institutes.
List of papers published in 2023
Journal
1. Fujita T, Sato K, Fujiwara N, Kajiyama D, Shigeno T, Otomo M, Daiko H. Robot-assisted transcervical esophagectomy with a bilateral cervical approach for thoracic esophagectomy. Surgical endoscopy, 38:1617-1625, 2024
2. Fujita T, Sato K, Fujiwara N, Kajiyama D, Shigeno T, Daiko H. A novel imaging technology to assess tissue oxygen saturation and its correlation with indocyanine green in the gastric conduit during thoracic esophagectomy. Surgery, 175:360-367, 2024
3. Fujita T, Shigeno T, Kajiyama D, Sato K, Fujiwara N, Daiko H. A novel device to assess the oxygen saturation and congestion status of the gastric conduit in thoracic esophagectomy. BMC surgery, 24:17, 2024
4. Okunaka M, Kotani D, Fujiwara H, Sato K, Fujiwara N, Mishima S, Sakashita S, Yoshino T, Fujita T, Kojima T. Prognosis of patients with residual pathological disease after neoadjuvant docetaxel, cisplatin, and 5-fluorouracil therapy and surgery for esophageal squamous cell carcinoma: a retrospective cohort study. Therapeutic advances in medical oncology, 16:17588359241229432, 2024
5. Okui J, Nagashima K, Matsuda S, Sato Y, Okamura A, Kawakubo H, Muto M, Kakeji Y, Kono K, Takeuchi H, Watanabe M, Doki Y, Bamba T, Fukuda T, Fujiwara H, Sato S, Noma K, Miyata H, Fujita T, Kitagawa Y. Recurrence-free survival as a surrogate endpoint for overall survival after neoadjuvant chemotherapy and surgery for oesophageal squamous cell carcinoma . The British journal of surgery, 111:znae038 , 2024
6. Hirano Y, Fujita T, Konishi T, Takemura R, Sato K, Kurita D, Ishiyama K, Fujiwara H, Oguma J, Itano O, Daiko H. Impact of pre-diabetes, well-controlled diabetes, and poorly controlled diabetes on anastomotic leakage after esophagectomy for esophageal cancer: a two-center retrospective cohort study of 1901 patients. Esophagus, 20:246-255, 2023
7. Habu T, Kumanishi R, Ogata T, Fujisawa T, Mishima S, Kotani D, Kadowaki S, Nakamura M, Hojo H, Fujiwara H, Kumagai S, Koyama S, Fujita T, Kinoshita T, Nishikawa H, Yano T, Tajika M, Muro K, Mitsunaga S, Kojima T, Bando H. Complete response to definitive chemoradiotherapy in unresectable locally advanced esophageal squamous cell carcinoma. Esophagus, 20:533-540, 2023
8. Harada T, Tsuji T, Yanagisawa T, Ueno J, Hijikata N, Ishikawa A, Hiroshige K, Kotani D, Kojima T, Fujita T. Skeletal muscle mass recovery after oesophagectomy and neoadjuvant chemotherapy in oesophageal cancer: retrospective cohort study. BMJ supportive & palliative care, spcare-2023-004245, 2023
9. Shigeno T, Kajiyama D, Sato K, Fujiwara N, Kinugasa Y, Yano T, Daiko H, Fujita T. The feasibility of post-photodynamic therapy salvage esophagectomy in patients with esophageal squamous cell carcinoma treated with definitive chemoradiotherapy. Esophagus, 20:643-650, 2023
10. Harada T, Tsuji T, Ueno J, Hijikata N, Ishikawa A, Kotani D, Kojima T, Fujita T. Association of sarcopenia with relative dose intensity of neoadjuvant chemotherapy in older patients with locally advanced esophageal cancer: A retrospective cohort study. Journal of geriatric oncology, 14:101580, 2023
11. Fujita T, Fujiwara N, Sato K, Kajiyama D, Shigeno T, Daiko H. [Management of Postoperative Infectious Complications After Thoracic Esophagectomy]. Kyobu geka. The Japanese journal of thoracic surgery, 76:898-903, 2023
12. Matsuda A, Maruyama H, Akagi S, Inoue T, Uemura K, Kobayashi M, Shiomi H, Watanabe M, Fujita T, Takahata R, Takeda S, Fukui Y, Toiyama Y, Hagiwara N, Kaito A, Matsutani T, Yasuda T, Yoshida H, Tsujimoto H, Kitagawa Y. Survival impact of surgical site infection in esophageal cancer surgery: A multicenter retrospective cohort study . Annals of gastroenterological surgery, 7:603-614 , 2023