Ivor Lewis Esophagogastrectomy Research Articles

Intrathoracic Gastrojejunostomy for Gastric Outlet Obstruction After Ivor Lewis Esophagogastrectomy

Gastric outlet obstruction after esophagogastrectomy with a drainage procedure is unusual, but when encountered, its management can be formidable. A Rous-en-Y intrathoracic gastrojejunostomy was created in a 74-year-old woman 2 years after Ivor Lewis esophagogastrectomy for benign disease to treat severe gastric outlet obstruction at the native pylorus.

Is it safe to perform esophagectomy in esophageal cancer patients combined with liver cirrhosis?

Patients with liver cirrhosis undergoing gastrointestinal surgery still suffer from high operative morbid-mortality despite advancements in surgical critical care. The objective of this study is to see if this same relationship applies to patients undergoing esophagectomy for cancer. From 1993 to 2003, sixteen esophageal cancer patients with liver cirrhosis were operated on. They were all male with a mean age of 51.5 years. According to the Child-Pugh classification, 10 patients were Child 'A', 4 patients Child 'B' and Child 'C' in 2 patients. The surgical procedure was through an Ivor-Lewis esophagogastrectomy with intra-thoracic anastomosis. Major morbidity included: 4 respiratory failure, 2 acute renal failure, 3 pneumonia, and one in each of the patients with gastrointestinal bleeding and hepatic failure. The mean follow up among the survivors was 19.1 months. The hospital mortality was 25% (4/16). Using the rate according to Child classification, the mortality rates were: A: 1/10 (10%), B: 2/4 (50%) and C: 2/2 (100%). We conclude that patients with liver cirrhosis in Child-Pugh A could tolerate esophagectomy with an acceptable risk. However, patients with a more advanced state of liver dysfunction are at higher risk for esophagogastrectomy. Careful patient selection and meticulous peri-operative care is warranted in those embarking on surgical resection.

Complete Esophageal Diversion: A Simplified, Easily Reversible Technique

We read with interest the article by Koniaris and colleagues in the December 2004 issue: “Complete esophageal diversion: A simplified, easily reversible technique.” The authors describe how, in addition to primary repair and tube drainage, “complete esophageal diversion can be extremely helpful in controlling ongoing thoracic contamination and sepsis” secondary to thoracic esophageal perforation. We, too, have resorted to diversion, usually when ongoing sepsis prohibits primary repair or resection and reanastomosis. Koniaris and colleagues perform primary repair and tube drainage in addition to proximal esophageal diversion; we more often make no attempt at primary repair in what should be a highly select group of patients “too sick to operate on.” We have found that with complete esophageal diversion and exclusion, neither primary repair nor resection and reconstruction are necessary. Our method of proximal (cervical) diversion is essentially as described by Koniaris and colleagues; we use three number-1 chromic catgut ligatures as our absorbable ligatures. As described by others, distal esophageal diversion of gastric reflux must also be accomplished for complete esophageal exclusion. So, we similarly ligate the esophagogastric junction, placing gastrostomy for suction, jejunostomy for nutrition, and tube thoracostomy for pleural drainage. From March 3, 2000, through December 10, 2004, we have treated 9 patients as described previously out of a total of 27 patients who presented with thoracic esophageal perforation during the same time period. Three patients were treated with primary repair and cervical diversion as described by Koniaris and associates, all surviving, with mean hospitalization of 36 days. One patient required subsequent esophageal dilatation, and two patients required reoperation. In one patient, revision of the primary repair was necessary; another needed resection of the repair, using Ivor Lewis esophagogastrectomy and esophagogastrostomy. Six other extremely sick patients were treated with simple, cervical diversion and exclusion, without any attempt at primary repair, as described previously and elsewhere. All but one patient recovered nicely, and none required delayed primary repair or reconstruction. Mean hospitalization in this group was 30 days. One patient, operated on after incurring esophageal perforation at coronary revascularization with left ventricular aneurysm repair, died from brain death secondary to air embolism related to the aneurysm repair. There were no identifiable problems related to the patient’s diversion and exclusion at the time of death. Otherwise, all patients recovered nicely, with simple outpatient takedown and closure of the cervical esophagocutaneous fistula, usually performed 3 to 4 months later. Only three of the six patients required any esophageal dilatation at the distal cervical or gastroesophageal ligation site, and those patients, only once. All perforations healed naturally, and none of these six patients has any dysphagia at mean followup of 36 months.

The accuracy of endoscopic ultrasonography with fine-needle aspiration, integrated positron emission tomography with computed tomography, and computed tomography in restaging patients with esophageal cancer after neoadjuvant chemoradiotherapy

Patients with esophageal cancer who receive neoadjuvant chemoradiotherapy are restaged with computed tomography (CT), endoscopic ultrasound with fine needle aspiration (EUS-FNA), and integrated positron emission computed tomography (FDG-PET/CT), and the results affect treatment. This is a prospective trial on a consecutive series of patients who had initial chest, abdomen, and pelvis CT scan; EUS-FNA; and fluoro-2-deoxy- d -glucose (FDG)-integrated PET/CT; neoadjuvant chemoradiotherapy; repeat staging tests; pathologic staging; and, if appropriate, resection with lymphadenectomy. The primary objective was to assess the accuracy of these 3 tests in restaging patients after neoadjuvant therapy. There were 48 patients (41 men), and 41 underwent Ivor Lewis esophagogastrectomy with lymphadenectomy. The accuracy of each test for distinguishing pathologic T4 from T1 to T3 disease is 76%, 80%, and 80% for CT scan, EUS-FNA and FDG-PET/CT, respectively. The accuracy for nodal disease was 78%, 78%, and 93% for CT scan, EUS-FNA and FDG-PET/CT, respectively ( P = .04). FDG-PET/CT correctly identified M1b disease in 4 patients, falsely suggested it in 4 patients, and missed it in 2 patients, whereas for CT, it was 3, 3, and 3 patients. Fifteen (31%) patients were complete responders, and FDG-PET/CT accurately predicted complete response in 89% compared with 67% for EUS-FNA ( P = .045) and 71% for CT ( P = .05). FDG-PET/CT is more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy in patients with esophageal cancer. FDG-PET/CT and CT alone provide targets for biopsy, but results are often falsely positive.

Fast Tracking After Ivor Lewis Esophagogastrectomy

We streamlined our care using an algorithm for the postoperative care of patients who undergo Ivor Lewis esophagogastrectomy to try to reduce hospital stay to 7 days and maintain safety and patient satisfaction. A consecutive series of 90 patients who underwent elective esophageal resection by one general thoracic surgeon were studied. An algorithm to guide postoperative care was used, featuring avoidance of the ICU, early ambulation, jejunal tube feeds starting on postoperative day (POD) 1, removal of nasogastric tube and epidural on POD 3, a gastrograffin swallow on PODs 4 or 5, and discharge on POD 7. There were 90 patients (70 men). Fifty-two patients (58%) underwent preoperative radiation and chemotherapy. Esophagectomies were done for cancer or high-grade dysplasia. Forty-two of the last 55 patients (77%) went directly to the floor. Sixteen patients (17.7%) had major complications, which included pneumonia in 5 patients and aspiration pneumonia in 4 patients. There were no anastomotic leaks, and there were four operative deaths (4.4%). There was a greater incidence of failure to fast track, and to have a major complication in patients who underwent neoadjuvant treatment (p = 0.025 and p = 0.048, respectively). Median hospital stay was 7 days (range, 6 to 74 days). Complications or mortality could not be definitively attributed to fast tracking. Ninety-seven percent reported excellent satisfaction with their hospital stay, and four patients were readmitted within 1 month of discharge. Fast tracking patients using an algorithm after esophageal resection is safe and delivers minimal morbidity and mortality, and a high patient satisfaction rate. A median hospital stay of 7 days is possible, and the ICU can be avoided in most patients.

SYMPTOMATIC ESOPHAGEAL DUPLICATION CYST. CASE REPORT AND REVIEW OF LITERATURE

A 34 yo female with a history of gastric ulcers, gerd and asthma presented for follow up egd of her recurrent dyspepsia and recent dysphagia of solids for two months duration. Pt. denied any odynophagia, weight loss, early satiety or fevers. Pt.'s medications included omeprazole and albuterol. Pt. has a family history of colon cancer, a 15 pack year tobacco history, occasional alcohol use and no recent history of travel or risk factors for HIV disease. Physical exam was unremarkable. On EGD, extrinsic compression of the distal esophagus was noted, as well as an irregular Z line and an antral ulcer. CT scan of the chest revealed a 3.5×2.0 cm rounded, smooth walled, soft tissue mass in the anterior border of the distal esophagus. A submucosal mass imaged between 35 and 37 cm was identified on EUS. The mass was localized to the left anterior aspect of the esophageal wall and appeared to involve all layers. There was no adenopathy detected on EUS. Biopsies done at time of EUS were unrevealing for cancer. Pt. underwent Ivor Lewis esophagogastrectomy for definitive diagnosis and treatment. Surgical pathology revealed a large 2 cm, cystic structure that contained mucus and was lined by benign ciliated respiratory epithelium and goblet cells, compatible with a duplication cyst. Multiple smaller cysts were also identified. Benign foci of ectopic salivary gland seromucinous acini and their associated ducts were also present throughout. There was no evidence of malignancy. Esophageal cysts account for 10% of all primary masses of the mediastinum. They can be broadly classified into congenital versus acquired cysts. Esophageal duplication cysts, a subclass of congenital cysts have a prevalence estimated to be 1/8200. Ectopic gastric, pancreatic and salivary gland tissue within these cysts have been descibed. Esophageal cysts usually cause respiratory symptoms in children and are often asymptomatic in adults. Two thirds of esophageal cysts are located in the distal esophagus and about 10% are located in the upper third. The average age of diagnosis for distal lesions is 34 years and the most common presenting symptoms include dysphagia, retrosternal pain and cough. There have been reports of patients presenting with cardiac arrhythmias, intracystic hemorrhage, perforation, infection and transformation into cancer. Regardless of symptoms, surgical resection is the treatment of choice.

PROBLEMATIC ESOPHAGEAL STRICTURES

Purpose: Self-expandable metal stents (SEMS) are routinely used to palliate dysphagia in the patients with unresectable esophageal carcinoma. However, proximally located malignant strictures and benign strictures refractory to endoscopic dilations remain problematic due to the potential for tracheal compression, foreign body sensation and tissue responses leading to inflammation, necrosis, and ulceration, with eventual fibrosis. The hyperplastic tissue reaction may progress to worsening dysphagia and restenosis. The recently developed self-expandable silicone stents (SESS) have demonstrated some advantages over SEMS because of their better biocompatibility and may circumvent these problems. Case reports: We present two cases with refractory benign stricture and proximally located malignant stricture which were treated with SESS. The first case is an 81-year-old man who underwent an Ivor-Lewis esophagogas-trectomy for distal esophageal adenocarcinoma. Four months after, he developed benign circumferential anastomotic stricture requiring frequent endoscopic dilations every 3–4 weeks. Given its benign nature and long life expectancy, SESS was considered over SEMS to avoid potential complications from long-term implantation. He was followed more than 1 year with complete resolution of dysphagia and no complication. The second case is a 53-year-old man who underwent an Ivor-Lewis esophagogastrectomy for proximally located squamous cell carcinoma (SCC). One year later, dysphagia recurred and progressed to an inability to handle oral secretions. Recurrence of SCC was found at 22 cm from the incisors with liver metastasis. Given the location, SESS was chosen to avoid tracheal compression and foreign body sensation from SEMS. The proximal end was located at 20 cm from the incisors, just below upper esophageal sphincter (UES). He was followed for 3 months without recurrence of symptoms. Discussions: We demonstrate our initial experience in using SESS in the treatment of refractory benign stricture and proximally located malignant stricture near UES. These cases represent some of the more difficult-to-treat esophageal strictures. With the inert property resulting in less tissue reaction, SESS seem to be more appropriate device to use in these situations compared to SEMS. No tissue reaction or recurrent symptoms in our patients with more than 1 year follow-up period confirm the feasibility and safety of long-term SESS implantation.

Persistent Gastric Stump–Pleural Fistula With Circumscribed Pleural Empyema: A Single Approach for a Twofold Problem

A 62-year-old woman was referred to our department for a gastric stump–pleural fistula after an Ivor-Lewis esophagogastrectomy that had been performed for esophageal cancer. A persistent circumscribed pleural empyema was still present after three consecutive percutaneous chest drainage procedures. Figure 1 is the computed tomography scan showing right-sided circumscribed pleural empyema. A new endoscopy study confirmed the fistula in the gastric stump. The hole was 5 mm in the maximum diameter, as shown on the endoscopic visualization (Fig 2A) by the black arrowhead.Fig 2View Large Image Figure ViewerDownload (PPT) We planned an endoscopic approach to attempt, with a single maneuver, to address both of the problems. A soft silicone 10F catheter was endoscopically inserted, under fluoroscopic control, on a steel wire guide positioned into the fistulous path (Fig. 2B) shows steel wire guide entering the fistula orifice [black arrow]) and into the pleural space up to the circumscribed empyema. Figure 3 is a chest roentgenogram showing the catheter path into the pleural space up to the empyema cavity. A prompt and complete collapse of the empyema cavity with the drainage of 40 mL of corpusculated fluid was obtained, confirmed by a computed tomography scan, as shown in Figure 4. The arrowhead points to the catheter and the arrow points to the stomach.Fig 4View Large Image Figure ViewerDownload (PPT) The catheter was then retracted in a four-step procedure over a 2-day interval, up to the complete extraction from the pleural space and from the gastric stump–fistula orifice. The subsequent outcome was uneventful. The fistula was radiographically and endoscopically confirmed to be completely closed. Pleural empyema did not recur, and the patient was discharged from the hospital 3 days after the catheter was extracted.

High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy

Background. Esophagectomy for high-grade dysplasia in Barrett’s esophagus has been advocated. Although long-term survival data exist, little is known about functional outcome and quality of life in this particular subset of patients. Methods. The records of all patients who underwent esophageal resection for high-grade dysplasia from June 1991 through July 1997 were reviewed. Long-term functional outcome and quality of life were assessed using a two-part written survey. Results. There were 54 patients (48 men, 6 women). Median age was 64 years (range, 36 to 83 years). Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended esophagectomy in 8 (15%), and other in 2 (4%). Invasive carcinoma was found in 19 patients (35%). Five patients (9%) were stage 0, 7 (13%) stage I, 3 (6%) stage IIA, 1 (2%) stage IIB, and 3 patients (6%) stage III. There was one operative death (1.8%). Complications occurred in 31 patients (57%). Median hospitalization was 13 days (range, 11 to 44 days). Follow-up was complete in all patients and ranged from 6 months to 9 years (median, 63 months). Overall 5-year survival was 86% and did not differ significantly from a population matched for age and gender. Five-year survival for patients with only high-grade dysplasia was 96% and 68% for patients with cancer ( p = 0.017). Quality of life was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey. For patients with only high-grade dysplasia, the role-physical and role-emotional scores were better than for the control population ( p < 0.03). For patients with cancer, the health perception score was worse than for the control population ( p < 0.03). Scores measuring physical-function, social function, mental health, bodily pain, and energy/fatigue were similar. Conclusions. Although perioperative morbidity is significant, surgical resection of high-grade dysplasia in Barrett’s esophagus provides excellent long-term survival with acceptable function and quality of life.

Ivor Lewis esophagogastrectomy for esophageal cancer

Background. To examine the efficacy of the Ivor Lewis esophagogastrectomy for esophageal carcinoma prior to the widespread use of preoperative chemotherapy and irradiation, we reviewed our experience.Methods. We reexamined the cases of 220 consecutive patients who underwent an Ivor Lewis esophagogastrectomy for esophageal cancer from January 1992 through December 1995.Results. There were 196 men (89.1%) and 24 women. Median age was 65 years (range, 29 to 85 years). The results of pathological study showed adenocarcinoma in 188 patients (85.5%), squamous cell carcinoma in 31 (14.1%), and leiomyosarcoma in 1 patient (0.5%). Postsurgical staging was as follows: stage 0 in 10 patients, stage I in 19, stage IIa in 38, stage IIb in 28, stage III in 111, and stage IV in 14. The operative mortality rate was 1.4% (3 patients), and complications occurred in 83 patients (37.7%). Follow-up was 98.6% complete. Median survival for operative survivors was 1.9 years (range, 32 days to 8.7 years). The overall 5-year survival rate was 25.2%; it was 80% for patients in stage 0, 94.4% for those in stage I, 36.0% for those in stage IIa, 14.3% for patients in stage IIb, 10% for those in stage III and 0% for patients in stage IV.Conclusions. Ivor Lewis esophagogastrectomy for esophageal cancer is a safe operation. Long-term survival is stage dependent. The low survival associated with advanced cancers should stimulate the search for effective neoadjuvant therapy.

Factors Affecting Morbidity, Mortality, and Survival in Patients Undergoing Ivor Lewis Esophagogastrectomy

To examine the safety of transthoracic esophagogastrectomy (TTE) in a multidisciplinary cancer center and to determine which clinical parameters influenced survival and the rates of death and complications. Although the incidence of cancer at the gastroesophageal junction has been rising rapidly in the United States, controversy still exists about the safety of surgical procedures designed to remove the distal esophagus and proximal stomach. Alternatives to TTE have been proposed because of the reportedly high rates of death and complications associated with the procedure. Data from 143 patients treated by TTE by one author (1989-1999) were entered into a computerized database. Preoperative clinical parameters were tested for effect on death, complications, and survival. The patient population consisted of 127 men and 16 women. One hundred twenty-one patients had a history of tobacco abuse, and 118 reported the regular ingestion of alcohol. One hundred fifteen patients had adenocarcinoma, 16 had squamous cell cancer, 6 had another form of esophageal tumor, and 6 had high-grade dysplasia associated with Barrett epithelia. Fifty-six patients had adenocarcinomas arising in Barrett epithelium. Twenty-eight patients were treated with neoadjuvant chemoradiation before surgery. Three patients died within 30 days of surgery (mortality rate 2.1%). Five patients (3.5%) had a documented anastomotic leak; three died). Overall, 42 patients had complications (29%). Twenty-six had pulmonary complications (19%). The mean length of stay in the intensive care unit was 3.35 days; the mean hospital length of stay was 13.54 days. The overall 3-year survival rate was 29.6%. A high ASA score and the development of complications predicted an increased length of stay. The presence of diabetes predicted the development of complication and an increased length of stay. None of the other parameters tested predicted perioperative death or complications. Only disease stage, diabetes, and blood transfusion affected overall survival. From these results with a large series of patients with gastroesophageal junction cancers, TTE can be performed with a low death rate (2.1%), a low leak rate (3. 5%), and an acceptable complication rate (29%).

Muscle-splitting posterolateral thoracotomy: a novel technique

Purpose In an effort to decrease the morbidity of a standard posterolateral thoracotomy, numerous muscle-sparing approaches have been developed. However, these incisions have been limited by the need for excessive muscle retraction with resultant neuropraxia, difficulty with exposure, and postoperative wound seroma. We report our results of a novel muscle-splitting thoracotomy incision, which affords excellent exposure without significant morbidity. Methods We conducted a retrospective chart review of 37 consecutive patients who underwent “muscle-splitting” thoracotomy from June 1997 to June 1998. The technique, which involves a bidirectional spread of the latissimus dorsi and serratus anterior muscles, was performed by the same attending surgeon in all patients. Results There were 22 male and 15 female patients, aged 26 to 81 (mean, 58), with a body mass index ranging from 18 to 40 kg/m 2 (mean, 25 kg/m 2). Procedures included lobectomy/segmentectomy (19), wedge resection (5), pneumonectomy (2), Belsey IV fundoplication (5), Ivor–Lewis esophagogastrectomy (1), T8/T9 thoracic exposure (1), and miscellaneous thoracic cases (4). Operative time ranged from 90 minutes to 420 minutes (mean, 176), which was comparable with similar procedures through a standard incision. No patients required conversion to a muscle-cutting thoracotomy. Conclusions Our technique of muscle-splitting posterolateral thoracotomy appears to provide excellent operative exposure and to avoid problems seen with current muscle-sparing incisions. A prospective, randomized trial to compare this technique with a standard thoracotomy incision would be useful in determining its viability as an alternative thoracic approach.

Proposed Revision Of The Staging Classification For Esophageal Cancer

Objectives: This study analyzed survival with respect to lymph node involvement to develop a new staging system for patients with esophageal cancer that accurately reflects prognosis. Methods: The records of patients undergoing resection of primary esophageal cancer from 1989 to 1993 were reviewed. The data collected included patient age and sex, tumor histologic characteristics and location, the use of preoperative or postoperative radiation and chemotherapy, the type of resection, the depth of tumor invasion, the number and location of benign and malignant lymph nodes in the resected specimen, the disease status at last follow-up, and the first site of relapse. With an anatomically specific lymph node map, tumors designated in the current American Joint Committee on Cancer system as M1 because of extensive lymph node metastases were reclassified as N2, reserving the M1 category for visceral metastases. Survival was analyzed by the Kaplan-Meier method, and prognostic factors were assessed by log-rank and Cox regression analyses. Results: There were 216 patients (159 men, 57 women) with a median age of 63.5 years. Adenocarcinoma of the distal esophagus or gastroesophageal junction was the most common tumor (127 patients, 59%) and Ivor Lewis esophagogastrectomy was the most frequently performed operation. Both lymph node location (N1 versus N2) and number (0 vs 1 to 3 vs 4 or more) significantly influenced survival. Conclusions: A new staging system that adds an N2 M0 descriptor and reclassifies stage groupings reflects prognosis more accurately than does the current American Joint Committee on Cancer staging system. The number of positive lymph nodes is also an important stratification factor. (J Thorac Cardiovasc Surg 1998;115:660-70)

Results on Ivor-Lewis esophagogastrectomy for 338 cases of carcinoma of esophagus

Three hundred thirty-eight patients with carcinoma in the middle and lower thirds of the esophagus received Ivor-Lewis esophagogastrectomy (separate laparotomy and right thoracotomy incisions) from February 1986 to June 1992. The total resectability was 95.2%. Lymph node metastases were found in 136 cases (40.2%). Postoperative complications developed in 103% of the patients. No anastomotic leakage, nor postoperative (within 30 days) death and hospital death occurred. Major pulmonary complications occurred in 28.6% of the patients. The overall 1-, 3- and 5-year survival rate was 88.5% (231/261), 63.1% (125/198) and 48.4% (60/124), respectively. The 5-year survival rate was 64.1% (41/64) in patients with negative lymph nodes as compared to 31.7% (19/60) with positive nodes. The superiority of this technique was a significant improvement of the 5-year survival rate. This was due to better exposure of the operation field which made thorough dissection of lymph nodes possible, especially those along the right recurrent laryngeal nerve. Better operative exposure also provided chances for radical resection with less interference from the aortic arch. It made anastomosis easier to perform so that stenosis and leakage were less likely to occur. Ivor-Lewis esophagogastrectomy was a superior surgical procedure of choice for the treatment of cancer at the lower and middle thirds of the esophagus.

The management of high grade dysplasia and early cancer in Barrett's esophagus

The incidence of Barrett's-associated esophageal adenocarcinoma is rising, but experience in the treatment of high-grade dysplasia (HGD) or early cancer is limited. Based on an endoscopic surveillance program, the authors developed a systematic multidisciplinary approach to this problem. Surgical resection was considered if biopsies of the Barrett's segment, performed according to a published protocol, showed invasive cancer, intramucosal carcinoma, or repeated evidence of HGD. The type of resection was based on the length of the Barrett's segment and included an en bloc lymph node dissection for staging purposes. Careful intraoperative pathologic evaluation ensured that all of the Barrett's mucosa was resected. From 1984 to 1993, 27 consecutive patients (23 men, 4 women), with median age of 61 years (range, 45-75 years) underwent surgical exploration. Indications for operation were invasive cancer in 17 patients, intramucosal carcinoma in 5 patients, and HGD in 5 patients. Median length of the Barrett's segment was 9 cm (range, 1-17 cm). Only 15 patients (55%) had abnormalities visible with endoscopic examination that were potentially suspicious for malignancy. Twenty-six patients underwent resection with complete removal of the Barrett's mucosa, 20 by Ivor Lewis esophagogastrectomy, and 6 by transhiatal esophagectomy. Pathologic tumor stages were: TisN0M0 in 10 patients; T1N0M0 in 11 patients; T2N0M0 in 2 patients; T3N0M0 in 3 patients; and T1NXM1 in 1 patient. There were no postoperative deaths or anastomotic leaks. Major complications occurred in 4 patients. With a median follow-up of 3.7 years, 22 patients were alive, and only 2 patients had recurrences. This increasingly important group of patients with HGD or early carcinoma in the Barrett's esophagus has a high chance of cure but requires careful multidisciplinary treatment by the surgeon, gastroenterologist, and pathologist.

Operable esophageal cancer: current results from the West.

Results are presented from a consecutive series of 396 patients referred to hospital in one of the areas of highest incidence in the United Kingdom in a unit that saw all referred cases for assessment and subsequent decision on the most appropriate therapeutic modality. Standard criteria were applied when selecting those patients in whom an attempt at curative resection was justified. Of the 396 patients, only 164 (41%) were considered fit enough to undergo thoracoabdominal resection and to have a tumor that had not invaded contiguous structures or metastasized. The remainder were treated by palliative intubation and more recently by laser photocoagulation. Of the patients who underwent resection, most had an Ivor Lewis esophagogastrectomy and lymphadenectomy, those with proximal lesions undergoing three-stage total esophagectomy. The overall 30-day mortality was 8.3%, falling to 6.7% during the period 1985-1990 when thoracic epidural analgesia was used routinely and fatal respiratory complications were avoided. Overall 5-year survival rate was 23%. However, stratification for tumor staging showed that the 5-year survival for node-negative patients was 47% and for tumors confined within the adventitia 71%. Results of surgical treatment of squamous esophageal carcinoma in the West are considerably more depressing than those in many Eastern series. This difference is largely related to the late presentation in the West, as the relatively low incidence does not justify screening programs. However, results equivalent to those in Eastern series are obtained for the small subset of patients who do present with early disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Ivor Lewis Esophagogastrectomy for Carcinoma of the Esophagus: Early and Late Functional Results

One hundred adult patients underwent Ivor Lewis esophagogastrectomy for documented carcinoma of the esophagus from 1980 through 1982. After operation, 7 patients were classified in Stage I, 11 in Stage II, and 82 in Stage III. Major postoperative complications occurred in 27 patients and included pulmonary problems in 11, suture line leak in 9, wound infection in 5, empyema in 4, renal failure in 4, abdominal abscess in 4, bleeding in 2, myocardial infarction in 2, and chylothorax in 1. There were 3 deaths within 30 days of operation. Five-year survival was 85.7% for patients with Stage I disease, 34.1% for patients with Stage II disease ( p = .052), and 15.2% for patients with Stage III disease ( p = .001). Late morbidity included weight loss in 60 patients, dysphagia in 40, gastroesophageal reflux in 14, and gastroduodenal dumping in 5. Thirty-one patients required postoperative esophageal dilations (mean, 3.4). Most patients, however, were eating without dysphagia at the time of last follow-up or death. We conclude that the Ivor Lewis esophagogastrectomy can be performed with low mortality, can provide adequate palliation, and does result in satisfactory long-term survival for those patients with more favorable postsurgical stages of cancer. These results support the continued use of the Ivor Lewis esophagogastrectomy for treatment of carcinoma of the esophagus.