INTRODUCTION:Esophageal cancer is often diagnosed at an advanced stage and with distant metastases. While cardiac metastases from solid tumors have been reported in 0.2%-6.5% of postmortem cases, solitary cardiac metastases remain exceedingly rare. Infective endocarditis, a life-threatening condition typically associated with valvular involvement and bacteremia, has not been widely associated with cardiac metastases. Here, we present an extremely rare case of esophageal squamous cell carcinoma directly invading the left atrium during chemotherapy, which was further complicated by infective endocarditis. CASE PRESENTATION:A 52-year-old female who presented with chest and back pain and progressive dysphagia was diagnosed with esophageal squamous cell carcinoma following an endoscopic biopsy. Chemotherapy and chemoradiotherapy resulted in inadequate tumor control. During the second course of second-line chemoimmunotherapy, the patient developed a high fever, followed by seizures and loss of consciousness, and required emergency intubation. Echocardiography revealed a mobile mass 5 × 30 mm in size attached to the posterior wall of the left atrium. To prevent further embolic complications, emergency surgery was performed, which revealed a tumor invading the left atrial wall. Histopathological findings revealed a necrotic mass containing keratinizing squamous cell carcinoma fragments and a septic thrombus, consistent with infective endocarditis originating from the tumor surface. The patient did not regain consciousness following surgery, possibly because of hypoxic-ischemic brain injury following seizure-induced hypoxemia. Infection control remained poor, and the patient died of sepsis on POD 56. CONCLUSIONS:Direct invasion of the left atrium by esophageal squamous cell carcinoma is rare, and infective endocarditis arising from tumor surfaces within the cardiac chamber is exceptionally uncommon, particularly in immunosuppressed patients. In this case, surgery was performed to prevent further embolic events and remove the infected tumor mass. Although the direct source of the infection was surgically removed, infection control remained difficult, likely due to persistent infection under immunosuppressive conditions and the use of cardiopulmonary bypass. This case highlights the challenges of managing infective endocarditis in patients with cancer and suggests that early surgical intervention may help reduce embolic risk, even when complete infection control cannot be achieved.

Recurrence of hiatal hernia after primary repair is a major concern, particularly early recurrence related to technical factors. Reliable preoperative predictors are essential for optimal surgical strategies. Because the hernial sac area can also affect operative complexity, this study aimed to evaluate early recurrence-associated factors and their relationship with operative time using quantitative computed tomography (CT). We retrospectively analyzed 48 patients who underwent laparoscopic hiatal hernia repair between July 2012 and July 2025. Preoperative CT was used to measure the maximum diameter and area of the hernial sac in the axial and coronal planes. We examined the association between these parameters and surgical outcomes including recurrence. Early recurrence was observed in four patients (8.3

Esophageal perforation is most commonly caused by foreign body ingestion, medical procedures, or spontaneous rupture. In contrast, perforation secondary to bacterial infection is extremely rare, particularly in immunocompetent individuals. A previously healthy 60-year-old man developed pharyngotonsillitis followed by progressive right-sided chest pain. Initial chest radiography showed no abnormalities; however, subsequent computed tomography performed after clinical deterioration revealed right-sided empyema and an intramural abscess of the esophageal wall. Despite chest drainage and broad-spectrum antibiotics, the patient’s respiratory status worsened, necessitating transfer to our hospital. Upper gastrointestinal endoscopy demonstrated extensive circumferential esophageal ulceration with purulent discharge. Streptococcus constellatus, a member of the Streptococcus anginosus group, was isolated from pleural fluid cultures. Because of severe infection, extensive empyema, and marked fragility of the esophageal wall, thoracoscopic total thoracic esophagectomy with a two-stage reconstruction strategy was performed. The postoperative course was favorable, and delayed reconstruction using a gastric conduit was successfully completed. This case suggests that streptococcal pharyngotonsillitis may be associated with life-threatening esophageal perforation and empyema even in immunocompetent patients. Early recognition of disease progression and timely surgical intervention are essential in severe infectious cases.

Older patients with unresectable advanced or recurrent gastric cancer remain underrepresented in clinical trials of immune checkpoint inhibitors. This study assessed the clinical feasibility of first-line nivolumab plus chemotherapy in patients aged ≥ 75 years treated at our institutions. This retrospective study included 82 patients with HER2-negative unresectable advanced or recurrent gastric cancer who received first-line nivolumab-containing chemotherapy between January 2022 and February 2025. Patients were divided into two groups: those aged < 75 years (n = 52) and those aged ≥ 75 years (n = 30). The primary endpoint was progression-free survival (PFS); secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate (DCR), and adverse events (AEs). Patients aged ≥ 75 years more frequently had comorbidities, hypertension, and initial dose reductions. Median follow-up was 27.7 months in the < 75 years group and 24.3 months in the ≥ 75 years group. Median PFS was 7.2 months in the < 75 years group and 5.6 months in the ≥ 75 years group (P = 0.779). Median OS was 12.5 and 13.3 months, respectively (P = 0.852). No significant differences were observed in ORR, DCR, or AEs between the two groups. These findings suggest that first-line nivolumab plus chemotherapy may represent a clinically feasible treatment option for selected patients aged ≥ 75 years with HER2-negative, unresectable, advanced or recurrent gastric cancer. Nevertheless, given the limited sample size, these results should be interpreted with caution and should not be construed as evidence of equivalent efficacy or safety between age groups.

PURPOSE:Trisomy 21 is associated with neonatal surgical disorders, such as duodenal atresia, Hirschsprung's disease, and anorectal malformation (ARM). Therefore, the purpose of this study was to compare postoperative complications in patients with vs. without trisomy 21 who underwent neonatal gastrointestinal surgery and to identify risk factors for postoperative complications after these surgeries in the Japanese population. METHODS:From the National Clinical Database-Pediatric, we selected patients with duodenal atresia/stenosis, Hirschsprung's disease, and ARM operated in the neonatal period from 2016 to 2020 and analyzed the risk factors for postoperative complications. RESULTS:Duodenal atresia/stenosis, Hirschsprung's disease, and ARM were diagnosed in 4052 patients, of which 2486 patients were operated on in the neonatal period. These patients comprised 801 with duodenal atresia/stenosis, 289 with Hirschsprung's disease, and 1446 with ARM. The numbers of patients with complicated trisomy 21 were 212 (26.5%), 16 (5.5%), and 102 (7.1%) for duodenal atresia/stenosis, Hirschsprung's disease, and ARM, respectively. Regarding duodenal atresia/stenosis, multivariable logistic regression analysis showed that trisomy 21 were risk factors for postoperative complications. CONCLUSION:In this analysis of Japanese data, trisomy 21 was an independent risk factor for postoperative complications in patients with duodenal atresia/stenosis.

Background Bioelectrical impedance analysis (BIA) is increasingly used to assess body composition after bariatric surgery. However, longitudinal changes in the extracellular water-to-total body water ratio (ECW/TBW) after laparoscopic sleeve gastrectomy (LSG) and their clinical implications remain poorly understood. This study aimed to characterize perioperative changes in ECW/TBW following LSG and to explore its associations with body composition and clinical parameters. Methods This retrospective single-center study included patients with severe obesity who underwent LSG between 2019 and 2025. Of the 23 patients who underwent surgery during the study period, 16 with complete body composition and laboratory data at all scheduled time points were analyzed. Body composition was assessed preoperatively and at 3, 6, and 12 months postoperatively using multifrequency BIA. Longitudinal changes were evaluated using the Friedman test, and correlations were assessed using Spearman’s rank correlation coefficient. Results The median preoperative body mass index was 46.1 kg/m². Body weight, body mass index, and body fat mass decreased significantly during follow-up (p < 0.001). ECW/TBW increased at 3 months after surgery (median 0.401 vs. 0.390 at baseline) and then decreased slightly at 6 and 12 months (both 0.399), remaining marginally higher than baseline (p < 0.001). Preoperative ECW/TBW correlated positively with body mass index (ρ = 0.566, p = 0.022). At 12 months, ECW/TBW showed a modest inverse correlation with serum albumin (ρ = −0.514, p = 0.042) but was not associated with weight-loss metrics or body composition parameters. A strong positive correlation was observed between preoperative and 12-month ECW/TBW values (ρ = 0.695, p = 0.003). Conclusions ECW/TBW showed a characteristic temporal pattern after LSG, with a transient early postoperative increase followed by partial normalization. Baseline ECW/TBW strongly correlated with postoperative values, suggesting persistence of individual fluid distribution characteristics despite substantial weight loss.

Background: The incidence of esophagogastric junction cancer (EGJC) is increasing in both Western and Eastern countries. Despite this trend, a globally accepted treatment strategy remains elusive due to the tumor’s anatomical complexity and variability in clinical practice. Aim: This review aims to provide a comprehensive overview of current evidence regarding EGJC treatment, focusing on the surgical approach, extent of lymph node dissection, and perioperative therapy. Special attention is given to regional differences and the implications of recent clinical trials. Findings: Transhiatal and minimally invasive surgical approaches have demonstrated favorable safety profiles, particularly for Siewert type II tumors. Lymph node dissection strategies are increasingly tailored based on the extent of esophageal invasion. Pre- and postoperative chemotherapy and chemoradiotherapy are standard in the West, while East Asian countries are gradually adopting these approaches through trials such as RESOLVE (China) and PRODIGY (Korea). Immunotherapy has also emerged as a promising option following the CheckMate 577 trial. Conclusions: EGJC requires individualized treatment planning based on tumor characteristics and regional practices. While ongoing trials continue to inform optimal management, international collaboration and a stepwise, biomarker-informed approach will be essential to harmonize treatment strategies for this anatomically and therapeutically complex disease.

Background: Immune checkpoint inhibitors (ICIs) such as pembrolizumab (Pem) have demonstrated clinical benefits in esophageal cancer. Cisplatin, 5-fluorouracil, and Pem combination (CF plus Pem) has emerged as a promising first-line regimen. However, dose reduction of cytotoxic agents is necessary in real-world practice in patients with advanced age and/or renal dysfunction. This study aimed to evaluate the real-world effectiveness and safety of CF plus Pem therapy and assess survival outcomes based on the initial dose intensity. Methods: We retrospectively analyzed patients with unresectable or recurrent esophageal cancer who received CF plus Pem between February 2022 and February 2025. Clinical data, including patient characteristics, treatment details, tumor response, adverse events, and survival outcomes, were collected and analyzed. Results: We included 54 patients (median age, 72.5 years; 74.1% male). The initial CF dose was reduced in 55.6% of the patients. The overall response and disease control rates were 55.6% and 81.5%, respectively. The median overall survival (OS) and progression-free survival (PFS) were 18.6 and 6.5 months, respectively, with no significant differences observed among groups based on dose reduction, age, or change in treatment interval. Grade ≥ 3 adverse events occurred in 16.7% of patients, with fewer events and higher treatment continuity in the dose-reduction group. Conclusions: Thus, CF plus Pem therapy is effective and tolerable in real-world settings. Initial dose reduction does not compromise survival and supports individualized dosing strategies for esophageal cancer treatment.

BACKGROUND:We occasionally experience incomplete resection of esophageal cancer due to the surrounding organ invasion. The efficacy of additional treatment in these cases is unknown. METHODS:We studied 445 patients with esophageal squamous cell carcinoma who were unable to undergo curative esophagectomy due to cancer invasion to the surrounding organs at 45 esophageal centers in Japan. Survival outcomes were compared based on the additional treatment modalities. RESULTS:Postoperatively, 175 (40.0%) received no additional treatment, while 59 (13.5%), 153 (35.0%), and 50 (11.4%) received additional chemotherapy, chemoradiotherapy, or radiotherapy, respectively. The three-year disease progression and overall survival rates were 90.6% (95% confidence interval 87.2-93.1%) and 15.4% (95% confidence interval 12.2-19.3%), respectively. Multivariable analysis revealed that chemotherapy, chemoradiotherapy, and radiotherapy were all independently associated with reduced disease progression (hazard ratios [95% confidence intervals]: 0.57 [0.40-0.81], 0.52 [0.39-0.69], and 0.48 [0.33-0.72], respectively). Meanwhile, additional treatment with chemotherapeutic agents (chemotherapy and chemoradiotherapy) was independently associated with better overall survival (hazard ratios [95% confidence intervals]: 0.51 [0.35-0.73] and 0.59 [0.44-0.79], respectively); however, radiotherapy alone had a limited impact (hazard ratio [95% confidence interval]: 0.74 [0.50-1.10]). CONCLUSIONS:Any additional treatment could suppress disease progression after incomplete resection, but radiotherapy alone has a limited effect. Additional systemic chemotherapeutics may increase patient survival.

Barrett’s mucosa in the remnant esophagus (BMRE) is often identified after gastric pull-up reconstruction after esophagectomy. This study aimed to determine the clinical characteristics of BMRE and the factors that affect the development of BMRE. The characteristics of BMRE and factors affecting its occurrence were studied in patients with subtotal esophagectomy and gastric pull-up reconstruction who survived at least 3 years after esophageal cancer surgery and who were evaluated by endoscopy. A total of 187 eligible patients were identified, BMRE was found in 105 (56.1

Esophageal hiatal hernia is a condition in which the esophageal hiatus opens and the stomach escapes from the abdominal cavity into the mediastinum. The basic surgical procedures are 1) return of the prolapsed stomach into the abdominal cavity, 2) suture of the dilated esophageal hiatus, and 3) fundoplication and fixation of the stomach to prevent gastroesophageal reflux disease (GERD). The Japanese guidelines for the treatment of GERD recommend laparoscopic Toupet fundoplication as the standard procedure, which we also follow. It is important to determine the position of ports by considering the angle at which the esophageal hiatus can be easily approached. The dissection of the hernia sac from the left side enables effective surgical procedure. In Toupet fundoplication, loosening the wrapping for the elderly is important to prevent dysphagia. Postoperative complications include aspiration pneumonia, delayed gastric emptying, and esophageal stricture. It is important to accurately understand the normal anatomy and the situation causing the hernia, and to perform a careful repair operation.

Second primary esophageal cancer often develops in patients with head and neck cancer, and esophagectomy in patients with a history of total pharyngolaryngectomy (TPL) is challenging. However, the clinical outcomes of these patients have yet to be examined in a multicenter setting. We evaluated the surgical outcomes of a nationwide cohort of 62 patients who underwent esophagectomy for esophageal cancer with a history of TPL. Ivor-Lewis and McKeown esophagectomies were performed in 32 (51.6

Although free-flap jejunal reconstruction is frequently performed after cervical esophagectomy for cervical esophageal cancer, the procedure after gastric surgery has not been reported. We encountered two patients with esophageal cancer and previous gastric surgeries who eventually underwent segmental esophagectomy with free-flap jejunal reconstruction. Case one involved a 75-year-old man who underwent abdominal abscess and duodenal ulcer perforation surgeries (abdominal drainage and subsequent gastrojejunal bypass). A type 0–IIa tumor was located posterior to the cervical esophagus’s right wall, 21 cm from the incisor, without lymph node swelling or distant metastasis. The left lobe of the thyroid gland was mobilized to ensure an oral resection margin. Severe abdominal adhesions required careful adhesiolysis to harvest the jejunum (20 cm long) 40 cm from the jejunojejunostomy. An end-to-side and side-to-end esophagojejunostomy were performed for the proximal and distal ends, respectively. Case two involved a 75-year-old male with a history of distal gastrectomy with Billroth I reconstruction for early gastric cancer. A submucosal tumor-like lesion was located on the cervical esophageal wall on the left side, 21 cm from the incisor. The distal esophagus required additional segmental resection because the anal resection line was close to the tumor. Jejunum (10 cm long) 30 cm from Ligament of Treitz was harvested. An end-to-side and end-to-end esophagojejunostomy for the proximal and distal ends, respectively, was performed. This surgery requires a thorough preoperative examination to ensure an adequate surgical margin and a careful free-flap harvest based on post-gastric surgery anatomy.

Laparoscopic Heller myotomy with Dor fundoplication is the standard surgical treatment for esophageal achalasia. However, there are few reports on the use of this method after gastric surgery. We report a case of a 78-year-old man who underwent laparoscopic Heller myotomy with Dor fundoplication for achalasia after distal gastrectomy and Billroth-II reconstruction. After the intraabdominal adhesion was sharply dissected using an ultrasonic coagulation incision device (UCID), Heller myotomy was performed 5 cm above and 2 cm below the esophagogastric junction using the UCID. To prevent postoperative gastroesophageal reflux (GER), Dor fundoplication was performed without cutting the short gastric artery and vein. The postoperative course was uneventful, and the patient is in good health without symptoms of dysphagia or GER. Although per-oral endoscopic myotomy is becoming the mainstay of treatment for achalasia after gastric surgery, laparoscopic Heller myotomy with Dor fundoplication is also an effective strategy.

OBJECTIVE:Treatment for borderline resectable (cT3br) esophageal squamous cell carcinoma (SCC) is currently undefined. This study aimed to analyze the outcome of treatment strategies including induction chemotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF) against T3br esophageal SCC.METHODS:A total of 32 patients with cT3br esophageal SCC enrolled in this study were treated with two cycles of DCF induction therapy.RESULTS:The overall response rate to DCF induction therapy was 62.5%, while the disease control rate was 93.8% (complete response (CR), three; partial response (PR), 17; stable disease (SD), 10; progressive disease (PD), 2). After DCF induction chemotherapy, 27 patients underwent conversion surgery (CS) and five patients underwent definitive chemoradiotherapy (CRT). Out of 27 patients who underwent CS, 17 underwent transthoracic esophagectomy and 10 underwent thoracoscopic esophagectomy. Anastomotic leakage occurred in five patients (18.5%) and pneumonia in four (14.8%). Recurrent laryngeal nerve paralysis and arrhythmia were observed in two patients (7.4%). The R0 resection rate was 81.5%. Among the five patients who underwent definitive CRT, only one patient (20.0%) achieved CR. Two patients (40.0%) had PR and two (40.0%) had PD. Salvage esophagectomy was performed in one patient after definitive CRT. The 1-, 3-, and 5-year overall survival rates were 75.0, 50.6, and 46.4%, respectively, whereas the 1-, 3-, and 5-year disease-free survival rates were 54.9, 38.8, and 38.8%, respectively.CONCLUSION:DCF induction therapy and subsequent CS or definitive CRT are promising treatment strategies for cT3br esophageal SCC.

Abstract Background Levodopa–carbidopa intestinal gel (LCIG) treatment is an effective Parkinson’s disease (PD) treatment that requires percutaneous endoscopic gastrostomy with a jejunal extension tube (PEG-J). Buried bumper syndrome (BBS) is an uncommon but significant complication of PEG-J for LCIG. Case presentation A 71-year-old man had been undergoing LCIG therapy for PD since a PEG-J was implemented at our department two years previously. He presented with appetite loss. Computed tomography showed that the gastrostomy bumper was buried in the gastric wall. The patient was surgically treated with the simultaneous removal and replacement of PEG-J. Postoperative gastrocutaneous fistula occurred, which was conservatively treated. Conclusions Notably, patients and medical staff should be aware that patients with PD on LCIG treatment have a high risk of BBS in PEG-J and that there might be some patients with latent BBS. When simultaneous removal and replacement surgery is performed, establishing a new route at the stomach and abdominal wall is recommended.

Proton beam therapy (PBT) with space-making surgery has been used recently; however, its effectiveness for recurrent esophageal cancer (EC) is unclear. We herein report an unusual case of successful PBT with space-making surgery (omental plombage) for recurrent liver metastasis after EC surgery. A 58-year-old Japanese man underwent proximal gastrectomy for esophagogastric (EG) junction cancer seven months before presentation to our hospital. Microscopic findings after the surgery showed that the tumor was adenocarcinoma of the EG junction (pT1N0M0, stage I). Seven months after the proximal gastrectomy, liver metastases in S6 and S8 were revealed by positron emission tomography-computed tomography. Initial PBT was performed for those two liver metastases, and complete response (CR) was obtained for both liver metastases. Recurrence of liver metastasis in S2 was found eight months after the first PBT, and CR was achieved by chemotherapy. However, new liver metastasis recurred in S2. Considering the effects of radiation exposure on the surrounding gastrointestinal organs, we performed space-making surgery to place the omentum around the liver metastasis. We were able to complete the second PBT for the liver metastasis with 72.6 Gy relative biological effectiveness in 22 fractions. After the second PBT, the patient survived for seven years without recurrence. PBT with space-making surgery (omental plombage) for recurrent liver metastasis after EC surgery is considered to be a therapeutic option.