Purpose: With the enhancement of recovery after surgery protocols, additional medical fees for perioperative management have been introduced. However, few large-scale reports have investigated the relationship between medical fee items and their impact on complication control in conjunction with clinical data. In this study, we conducted a questionnaire survey on medical fee items related to perioperative management in upper gastrointestinal surgery and analyzed the impact on perioperative complications by linking to the National Clinical Database (NCD). Materials and Methods: A questionnaire survey was administered to departments performing upper gastrointestinal tract surgery at facilities certified by the Japanese Society of Gastroenterological Surgery to assess eight medical fee items related to perioperative management. The results were analyzed by linking to NCD postoperative outcomes: the incidence of postoperative complications, mortality within 30 days after surgery, and length of hospital stay after surgery. Result: Of 884 certified facilities, 633 (71.6%) responded. Adoption of nutrition support and collaboration with dentists resulted in a significantly shorter postoperative hospital stay after distal gastrectomy and total gastrectomy, and significantly lower mortality within 30 days after esophagectomy. Adoption of perioperative oral function management resulted in a significantly shorter hospital stay after any type of surgery and significantly lower mortality within 30 days after esophagectomy. Conclusion: This study revealed a correlation between medical fee items and postoperative complications after surgery for gastric cancer and esophageal cancer.

The patient was a 67-year-old man who had been admitted to our hospital for an investigation of dysphagia 17 years earlier. Three strictures were found in the upper, middle, and lower esophagus of the chest, and we diagnosed esophageal achalasia and cicatricial stricture associated with esophagitis. Endoscopic dilatation was performed repeatedly, but the stenotic symptoms repeatedly improved and recurred．We judged that the condition would not improve, and thoracoscopic subtotal esophagectomy was performed. The pathological findings included infiltration of inflammatory cells into the Auerbach plexus and a decrease or disappearance of ganglion cells throughout the esophageal wall. A loss of nerve cells and hyperplasia of collagen fibers were observed in the three stenotic sites, but no malignant findings were observed. Numerous scarring ulcers were also present. It is thought that esophageal achalasia occurred first, and thereafter cicatricial stenosis occurred on the oral side due to repeated inflammation. The occurrence of multiple strictures associated with esophageal achalasia has not been previously reported, and therefore, this is considered to be an extremely rare condition.

A 65-year-old man was diagnosed with multiple esophageal cancers, one of which was located within the esophageal diverticulum. The diverticulum was recognized as a cystic mass-like nodule on the dorsal left lobe of the thyroid gland and the lateral side of the cervical esophagus on a CT scan, leading to diagnosis of Killian-Jamieson (K-J) diverticulum. The patient underwent thoracoscopic subtotal esophagectomy (two-field lymphadenectomy) with reconstruction via a posterior sternal route for multiple esophageal cancers. Zenker’s diverticulum is common as a pharyngo-esophageal diverticulum, but there is need to recognize K-J diverticulum and differentiate from Zenker’s diverticulum from an anatomical perspective. Cancer arising within an esophageal diverticulum is rare, and there have been no reports of esophageal cancer within a K-J diverticulum. The indication of endoscopic treatment depends on the characteristics of the diverticulum, such as the presence or absence of muscularis propria. Consequently, the choice of treatment including esophagectomy should be based on careful consideration of the status of the pharyngo-esophageal diverticulum.

The patient was an 81-year-old man who was brought to the emergency room with fever and dyspnea due to aspiration pneumonia. The pneumonia improved with antibiotic therapy; however, the patient underwent gastrostomy placement due to development of swallowing dysfunction. On day 26 after gastrostomy, the patient had fever, elevated inflammatory response, and bloody drainage from the gastrostomy. Abdominal contrast-enhanced CT showed gastric wall thickening, poor contrast enhancement of gastric mucosa, gastric emphysema, and hepatic portal venous gas. Upper gastrointestinal endoscopy showed diffuse dark red, edematous changes of the mucosa, leading to diagnosis of phlegmonous gastritis. Total gastrectomy following staging laparoscopy was considered, but conservative treatment was chosen due to the high surgical risk. We report this case as an example of phlegmonous gastritis with portal venous gas after gastrostomy, which resolved with conservative treatment.

A 58-year-old woman underwent laparoscopic distal gastrectomy for gastric cancer and laparoscopic-assisted partial resection of the small intestine for an arteriovenous malformation. Follow-up contrast-enhanced abdominal CT showed a peripherally enhanced mass lesion of 19 mm in diameter in the tail of the pancreas. Contrast-enhanced MRI also showed a mass lesion at the same site. There was no evidence of recurrence. The patient was diagnosed with a pancreatic neuroendocrine tumor, and laparoscopic spleen-preserving distal pancreatectomy was performed. She was subsequently discharged without postoperative complications. A histopathological examination revealed an epithelial cyst arising in the intrapancreatic accessory spleen, which is relatively rare and difficult to diagnose preoperatively. However, there is a need to pay attention to blood flow in the residual stomach while performing distal pancreatectomy in patients with a medical history of gastrectomy. Herein, we report a case of laparoscopic spleen-preserving distal pancreatectomy for an epithelial cyst arising in an intrapancreatic accessory spleen after distal gastrectomy.

A 71-year-old female visited our hospital due to a tumor in front of the pancreas detected on abdominal US. The hypoechoic tumor was 30 mm in size and infiltrated the accessory right colic vein. The primary mesenteric tumor was suspected to be gastrointestinal stromal tumor or neuroendocrine tumor (NET). Laparoscopic tumor resection was performed. In laparoscopic findings, the tumor had no anatomical continuity with the mesentery of the transverse colon, and the tumor artery was a branch from the right gastroepiploic artery. Thus, the postoperative pathological diagnosis was NET derived from the gastrocolonic mesentery. In immunostaining, tumor cells were positive for chromogranin A, synaptophysin and CD56, and Ki-67 was 1%. These findings show that the tumor was NET G1. Gastrocolonic mesentery NET is extremely rare. Laparoscopic resection was feasible and the visibility was sufficient to see the anatomical continuity with the surrounding organs. We report this extremely rare case of gastrocolonic mesentery NET with a literature review.