Toshikatsu Tsuji

Background/Objectives: First-line therapy for advanced gastric cancer (AGC) has evolved from cytotoxic chemotherapy to HER2-targeted and immune checkpoint inhibitor (ICI)-based regimens, yet conversion surgery (CS) outcomes across these strategies remain poorly characterized. We describe CS outcomes and prognostic factors by first-line strategy at a single center. Methods: We retrospectively reviewed 187 patients with AGC who began first-line therapy from 2011, grouped as cytotoxic (CTX, n = 127), HER2-targeted (trastuzumab, n = 21), or ICI (n = 39). CS was defined as resection after response, including an extended oligometastatic definition (n = 74). Overall survival (OS) was measured from chemotherapy initiation, and prognostic factors were assessed by Cox regression. Results: Median OS was 14.8, 18.9, and 20.9 months for CTX, trastuzumab, and ICI, respectively (p = 0.048). CS rates were comparable (41%, 33%, and 38%; p = 0.794). Pathological response was more pronounced after trastuzumab/ICI (grade 3 and ypStage 0/1; both p < 0.001). Among CS cases, R0 resection (hazard ratio [HR] 0.31) and trastuzumab/ICI therapy (HR 0.37) were independent favorable factors, whereas high inflammatory–nutritional indices (NLR, CAR) were independent poor prognostic factors. OS was comparable between oligometastatic and conventional CS (p = 0.324). Conclusions: In this hypothesis-generating study, response depth tracked tumor biology, whereas survival was determined by R0 resection, targeted/ICI therapy, and host inflammatory–nutritional status—two largely dissociable axes informing biology- and host-based selection of CS candidates for prospective testing.

Background: Malnutrition is common among patients with cancer and has been associated with unfavorable postoperative outcomes, including higher rates of complications. This study aimed to synthesize current evidence on the relationship between malnutrition, as defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria, and postoperative outcomes after curative surgery for upper gastrointestinal (GI) cancers. Methods: We systematically searched the literature from database inception to 28 March 2026. Studies were eligible if they included adult patients with upper GI cancer who underwent surgical resection and had their nutritional status evaluated according to the GLIM criteria. We conducted a systematic review and random-effects meta-analysis. The primary outcomes were overall survival and overall postoperative complications, defined as events with a Clavien–Dindo grade ≥ II occurring within 30 days after surgery. Hazard ratios with 95% confidence intervals for overall survival and risk ratios with 95% CIs for postoperative complications were pooled. Results: Fourteen studies (17 reports) including a total of 7876 patients were eligible for both qualitative and quantitative synthesis. Compared with patients without malnutrition, those with GLIM-defined malnutrition showed poorer overall survival (hazard ratio: 1.96, 95% confidence interval: 1.57–2.45) and a higher risk of postoperative complications (risk ratio: 1.43, 95% confidence interval: 1.14–1.79). Conclusions: GLIM-defined malnutrition was associated with shorter overall survival and a higher incidence of postoperative complications in patients with upper GI cancer after surgery. However, because most included studies were observational and at low-to-moderate certainty of evidence, these associations should be interpreted with appropriate caution.

Background/Objective: Evaluating the response to neoadjuvant chemotherapy in esophageal squamous cell carcinoma (ESCC) is challenging because primary tumors are often classified as non-measurable under the RECIST criteria. This study investigated whether two-dimensional computed tomography (CT) measurements predict pathological response and prognosis after neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy in ESCC. Methods: We retrospectively analyzed 123 patients who underwent radical esophagectomy following DCF therapy at two institutions (April 2011–March 2024). Changes in the short-axis, long-axis, and short-axis × long-axis diameters of the primary tumor after preoperative chemotherapy were measured on contrast-enhanced CT, and the reduction rate for each parameter was assessed. Based on the optimal cutoff values, univariate and multivariate analyses were conducted to identify significant predictors of pathological response. Results: The short-axis × long-axis diameter reduction rate (SLRR) demonstrated the highest area under the curve (0.901), with a cutoff value of 0.55 for predicting pathological response, and it was the only independent predictor in the multivariate analysis (odds ratio, 6.27; p = 0.048). In group comparisons using the SLRR cutoff value, patients with a high SLRR had significantly better 3-year recurrence-free survival (67.8% vs. 29.4%, p < 0.001) and overall survival (79.5% vs. 46.6%, p < 0.001) than those with a low SLRR. Conclusions: The CT-based SLRR independently predicts both pathological response and prognosis after neoadjuvant DCF therapy in ESCC.

INTRODUCTION: Primary parahiatal hernias are rare in adults. We report the case of a young woman with a parahiatal hernia without obvious predisposing factors that resulted in gastric fundus necrosis.CASE PRESENTATION: A 34-year-old woman had experienced intermittent chest pain for 2 months but had not sought medical attention. She developed sudden-onset left chest pain without a history of trauma, with the pain worsening on inspiration. Her previous physician suspected a left lung abscess and referred her to our facility. Contrast-enhanced CT revealed a cavity with internal air above the diaphragm in the left thoracic cavity, which was continuous with the stomach in the abdominal cavity. We diagnosed an incarcerated diaphragmatic hernia with gastric ischemia and proceeded with emergency laparoscopic surgery. Intraoperatively, the gastric fundus was found to be incarcerated in the left diaphragm, and the hernial orifice was located just to the left of the esophageal hiatus. A diagnosis of parahiatal hernia was confirmed. The incarcerated gastric fundus was repositioned into the abdominal cavity. The hernial orifice was closed using nonabsorbable barbed sutures, and the necrotic gastric fundus was resected. The postoperative course was uneventful, and the patient was discharged on POD 13. CT at the 1-month follow-up revealed no recurrence of the parahiatal hernia.CONCLUSIONS: Parahiatal hernia is extremely rare but may be life-threatening if diagnosed late. In this case, laparoscopic repair and resection of the necrotic gastric fundus were successfully performed.

Background: Double-tract reconstruction is commonly performed after proximal gastrectomy to prevent gastroesophageal reflux and ensure adequate nutrition. We developed a modified double-tract reconstruction intervention, denominated the NI method, in which the anastomosis between the remnant stomach and jejunum was strategically configured to optimize food passage and suppress gastroesophageal reflux. Methods: This retrospective study included patients with upper-third gastric cancer and adenocarcinoma of the esophagogastric junction who underwent proximal gastrectomy with either conventional or NI-modified double-tract reconstruction at two institutions. Postoperative outcomes, including body weight loss and incidence of reflux esophagitis, were compared. Results: In total, 115 patients underwent proximal gastrectomy with double-tract reconstruction, including 35 with the NI method and 110 using the conventional method. No significant differences were observed in the baseline characteristics between the two groups. The incidence of reflux esophagitis was significantly lower in the NI group (0% vs. 14.3%, P = 0.032). Although not statistically significant, the NI group showed consistently lower weight loss rates, with approximately 2% less reduction at both 6 and 12 months after surgery. Conclusions: The NI-modified double-tract reconstruction is a safe and function-preserving technique for proximal gastrectomy. The unique gastrojejunostomy design may contribute to reduce reflux and achieve better nutritional outcomes by restoring more physiological food passage.

Background Rikkunshito is a traditional Japanese herbal medicine known to alleviate chemotherapy-induced gastrointestinal symptoms. However, the clinical impact of rikkunshito on patients undergoing neoadjuvant or conversion chemotherapy followed by curative surgery for esophageal cancer remains unclear. Methods We analyzed 57 patients with esophageal cancer who underwent curative surgery with preoperative chemotherapy between April 2021 and December 2024. Patients who did and did not receive rikkunshito during chemotherapy were assigned to the rikkunshito and control groups, respectively. Nutritional status was evaluated using albumin levels, lymphocyte counts, prognostic nutritional index, geriatric nutritional risk index, body weight, and body mass index (BMI), and skeletal muscle area (SMA) at L3 before and after chemotherapy. Propensity score matching (PSM) based on baseline characteristics, including age, sex, initial BMI, clinical stage, chemotherapy regimen, and initial PNI and SMA was performed. Results Overall, the rikkunshito group showed significantly lower rates of body weight (p = 0.016) and BMI loss (p = 0.011) than controls. Although SMA reduction did not reach statistical significance, a trend toward preservation was observed (p = 0.093). After PSM (n = 16 per group), the rikkunshito group showed a significantly lower reduction in body weight (p = 0.031), BMI (p = 0.016), and SMA (p < 0.001). Conclusions Rikkunshito administration during preoperative chemotherapy for esophageal cancer was associated with better preservation of body composition, including skeletal muscle mass. This suggests the potential role of rikkunshito as a supportive therapy to mitigate sarcopenia and nutritional decline during intensive treatment of esophageal cancer.

INTRODUCTION: Ischemic colitis is a common gastrointestinal disorder. However, severe cases requiring surgical intervention are rare. Severe ischemic colitis is particularly uncommon following surgery for colorectal cancer, with a reported incidence of only 0.7%. To our knowledge, there have been no previous reports of ischemic colitis leading to perforation in the late postoperative period following colorectal cancer surgery. Herein, we report a rare case of ischemic colitis that developed following surgery for transverse colon cancer and progressed to colonic perforation despite conservative treatment, ultimately necessitating emergency surgery.CASE PRESENTATION: A 60-year-old man with a history of dilated cardiomyopathy, chronic kidney disease, and stage III colorectal cancer underwent laparoscopic anterior resection 15 months prior. The patient presented with lower abdominal pain, hematochezia, and fever. CT and colonoscopy revealed extensive ischemic changes from the descending to the sigmoid colon, leading to a diagnosis of ischemic colitis. The patient’s condition failed to improve despite conservative treatment, and he subsequently developed cerebral infarction and worsening heart failure during hospitalization. In the 6th week of admission, he experienced perforative peritonitis, necessitating high-risk emergency surgery consisting of left hemicolectomy, rectal resection, and transverse colostomy. Pathological examination revealed no malignancy, consistent with the ischemic changes. The patient gradually recovered under intensive care and was discharged on POD 44, after 86 days of hospitalization.CONCLUSIONS: This case highlights the challenges in managing ischemic colitis in patients with severe heart failure after colorectal surgery. Vigilant monitoring and early surgical intervention are crucial for high-risk individuals.

The malignancy risk has increased following improvements in the long-term survival rates after liver transplantation. Reports show a 23.4-fold increase in the risk of de novo esophageal cancer after liver transplantation compared to the general population. We report the case of a 47-year-old female diagnosed with early esophageal cancer after liver transplantation. Endoscopic submucosal dissection was performed; however, due to it being a noncurative resection, additional treatment was required. Total robot-assisted minimally invasive esophagectomy (RAMIE) was performed using a robot for thoracic and abdominal procedures. Although extensive adhesions were observed after liver transplantation, precise surgery using the robot did not damage any vital organs, such as the graft blood vessels. The patient was discharged without postoperative complications. Total RAMIE for esophageal cancer after liver transplantation is a feasible and safe option following careful evaluation of the patient’s condition, and expands the possibilities of successful complex posttransplant surgeries through robotic precision.

Background: Peritoneal metastasis (PM) remains a major challenge in patients with gastric cancer (GC) and occurs preferentially in adipose-rich organs, such as the omentum. Adipose-derived stem cells (ASCs) may influence cancer behavior. This study aimed to investigate whether ASCs isolated from the omentum can act as progenitors of cancer-associated fibroblasts (CAFs) and analyze their effects on the cancer stem cell (CSC) niche and the treatment resistance of GC cells. Methods: ASCs were isolated from the human omentum and their cellular characteristics were analyzed during co-culturing with GC cells. Results: ASCs express CAF markers and promote desmoplasia in cancer stroma in a mouse xenograft model. When co-cultured with GC cells, ASCs enhanced the sphere-forming efficiency of MKN45 and MKN74 cells. ASCs increased IL-6 secretion and enhanced the expression of Nanog and CD44v6 in GC cells; however, these changes were suppressed by the inhibition of IL-6. Xenograft mouse models co-inoculated with MKN45 cells and ASCs showed enhanced CD44v6 and Nanog expression and markedly reduced apoptosis induced by 5-FU treatment. Conclusion: This study improves our understanding of ASCs’ role in PM treatment resistance and has demonstrated the potential for new treatment strategies targeting ASCs.

To our knowledge, this is the first report of percutaneous endoscopic intragastric surgery (PEIGS) for gastric metastases from other organs. A 70‐year‐old male with a history of renal cell carcinoma (RCC) was referred to our department for the treatment of gastric metastasis of RCC. Partial gastrectomy was performed using single‐incision PEIGS. Two years after the surgery, a follow‐up esophagogastroduodenoscopy revealed a tumor located on the middle greater curvature of the stomach. The diagnosis was metastatic renal cell carcinoma, prompting a similar surgery. No recurrence was observed after the second surgery. PEIGS is a minimally invasive option for the treatment of metastatic gastric tumors.