Between January 2017 and December 2021, 178 patients with esophageal and esophagogastric junction cancer (EGJC) were retrospectively reviewed. All patients underwent esophagogastroduodenoscopy (EGD) and computed tomography (CT) from the neck to the pelvis to determine the clinical stage. The clinical and pathological stages were determined based on the Union for International Cancer Control TNM classification of malignant tumors, 8th edition [13].

Patients who met the following criteria were enrolled in this study: (1) age > 20 years, (2) Eastern Cooperative Oncology Group performance status ≤ 1, (3) radical esophagectomy, (4) reconstruction via a gastric conduit, (5) no double cancer, (6) no prior irradiation, (7) one-stage surgery, and (8) follow-up for more than 1 year. Patients were excluded from the study based on the following criteria: salvage surgery (n = 8), colon conduit reconstruction (n = 10), invasion to surrounding organs (n = 2), residual disease (n = 1), postoperative in-hospital death (n = 1), and interruption of follow-up within 1 year (n = 4). Finally, 152 patients were included in this study (Fig. 1).

In accordance with the esophageal cancer practice guidelines 2017 in Japan, neoadjuvant chemotherapy (NAC) was administered to patients with non-Stage I squamous cell carcinoma (SCC) [3, 4]. At our institution, patients with adenocarcinoma with bulky lymph node (LN) metastases underwent NAC. For SCC, the treatment regimens were a combination of cisplatin and 5-fluorouracil or a combination of docetaxel, cisplatin, and 5-fluorouracil for SCC and a combination of S-1 and oxaliplatin for adenocarcinoma. A right transthoracic subtotal esophagectomy with 2- or 3-field LNs dissection was performed as a standard surgical procedure at our institution [14, 15]. Upper, middle, and lower mediastinal LNs and abdominal LNs were routinely dissected. The upper mediastinal region included the upper thoracic paraesophageal nodes, and left and right paratracheal nodes; the middle mediastinal region included the middle thoracic paraesophageal nodes, subcarinal nodes, and main bronchus nodes; and the lower mediastinal region included the lower thoracic paraesophageal nodes, posterior mediastinal nodes, and supradiaphragmatic nodes. In the abdominal region, bilateral paracardial nodes, lesser curvature nodes, and LNs along the left gastric artery, common hepatic artery, celiac artery, and proximal splenic artery were dissected. Except for patients with low surgical tolerance or high surgical risk, bilateral cervical LNs dissection was generally performed for advanced cancer or superficial cancer in the middle or upper thoracic esophagus. Gastric conduit reconstruction via the posterior mediastinal route was performed with hand-sewn anastomosis in the neck. The retrosternal route was selected when the risk of anastomotic leakage (AL) was considered high, such as in those who took steroids or suspected insufficient blood flow in the gastric conduit. In posterior mediastinal route reconstruction, a 12-Fr jejunostomy catheter was inserted into the proximal jejunum. Further, we inserted this into the gastric antrum in retrosternal route reconstruction. Following esophagectomy, cefazolin 1 g was administered twice daily via a peripheral intravenous line for 3 days as a prophylactic antibiotic.

The Clavien–Dindo classification was used to assess postoperative complications such as pneumonia, AL, and surgical site infection (SSI). Further, postoperative complications of grade ≥ II were identified [16]. Postoperative body weight (BW), body mass index (BMI), serum total protein, serum albumin, serum cholinesterase, prognostic nutritional index (PNI) were used to assess nutritional status [17]. Additionally, the serum C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) were used as inflammatory markers. BW and BMI were measured before and at 1 and 3 months after surgery. Other parameters were measured in blood samples taken before and 1 month after surgery. These parameters were measured after NAC but before surgery in patients who received NAC. Patients were divided into high and low groups using median values for PNI and NLR and the institutional reference level for CRP (0.3 mg/dl).

In April 2017, a multidisciplinary support team was established to prevent complications and improve nutritional status [18]. Before treatment, dietitians assessed the oral intake and recommended oral nutritional supplements for those whose calorie intake was insufficient. Patients with severe dysphagia caused by massive tumors were admitted early, and EF via a nasogastric tube was performed during NAC. Other patients were admitted 5 days prior to surgery and received oral nutritional support the following day. An elemental diet was started at 10 ml/h (240 kcal/day) on the day of surgery via a jejunostomy tube. EF speed was gradually increased to 50 ml/h (1200 kcal/day) based on the patient’s abdominal condition (Online Resource 1). EF was reduced or stopped temporarily because of diarrhea, abdominal fullness, chylothorax, or anorexia. On postoperative day 7, the EF agent was gradually changed from an elemental diet to a fat-containing agent. CT and upper gastrointestinal contrast imaging were performed on postoperative day 7 to ensure that there are no complications such as AL. Video-fluoroscopic and video-endoscopic examinations of the swallowing function were performed before starting oral intake (Online Resource 1). However, patients with AL were deferred from starting the oral diet. When diarrhea occurred, the EF speed was reduced first. We changed the EF agent or started probiotics if no improvement was observed. A multidisciplinary team conference was held to discuss the required calories, nutritional status, dietary intake, EF agents, and stool condition of the patients [6, 18]. EF was continued in patients after hospital discharge until oral intake was satisfactory. The degree of preoperative food passage obstruction was assessed using the dysphagia score (Table 1).

The King’s Stool Chart (KSC), which incorporates the frequency, consistency, and weight of fecal output during EF, was used to assess diarrhea (Table 2) [19]. The daily fecal score was calculated by scoring fecal conditions into 12 categories and summing the daily scores. Patients with KSC scored ≥ 16 should have their EF speed, or agents changed [19, 20]. In this study, diarrhea was defined as KSC ≥ 16 for 3 days.

For 5 years after surgery, CT was performed every 6 months, and EGD was performed yearly. Recurrence-free survival (RFS) was calculated from the day of surgery to the day of esophageal cancer or EGJC recurrence. Overall survival (OS) was calculated from the day of surgery to the day of death. Patients were followed up until death, five years after esophagectomy, or the study termination (December 31, 2022). Patients who were alive at the study termination, interrupted follow-up, and died due to an illness unrelated to their primary disease were recognized as censored.

All statistical analyses were performed using IBM SPSS Statistics version 26 for Windows (IBM Corp., Armonk, NY, USA). Medians and ranges were calculated, and differences were identified using the Mann–Whitney U test. Differences between categorical variables were identified using the Chi-squared or Fisher’s exact test. Repeated measures analysis of variance was used to analyze the association between preoperative and postoperative nutritional status. Survival curves were generated using the Kaplan–Meier survival method and the log-rank test. Odds ratios (OR) and hazard ratios (HR) were calculated. Univariate and multivariate analyses were performed using logistic regression analysis for nominal variables and Cox proportional hazards regression models for survival analysis. Univariate and multivariate analyses of clinicopathologic factors that may be risk factors for diarrhea were performed using logistic regression analysis. The clinicopathological factors previously reported to be associated with prognosis, such as age, NAC, transthoracic approach, postoperative complications (pneumonia and AL), pathological stage, PNI, CRP, NLR, and diarrhea during EF, were evaluated by univariate and multivariate analysis using the Cox proportional hazards model. The threshold for significance was set at p < 0.05.