Residual Esophagus Research Articles

Successful Endoscopic Resection of an Esophageal Metastasis from a Preceding Squamous-Cell Tonsillar Carcinoma

This report describes the case of a 62-year-old man with tonsillar carcinoma who had undergone esophagectomy due to an esophageal metastasis. Subsequently, a second metastasis occurred in the residual esophagus, and he presented for evaluation for local endoscopic therapy. The initial upper endoscopy revealed a type IIa - c lesion at 21 cm from the incisors, within a segment suspicious for Barrett's mucosa. As part of the complex treatment approach in this patient, endoscopic resection of the lesion was carried out using the suck-and-cut technique with ligation. Histology showed that the lesion was a metastasis from a squamous-cell carcinoma, with focal infiltration of the upper submucosal layer and vascular invasion consistent with the hypothesis of hematogenous spread from the preceding tonsillar carcinoma. The resection margins were tumor-free. At the time of writing, the patient had been recurrence-free for more than 9 months. In summary, the present paper describes a unique case of successful endoscopic resection of an esophageal metastasis associated with an antecedent tonsillar carcinoma.

Outcomes of active operation during intensive followup for second primary malignancy after esophagectomy for thoracic squamous cell esophageal carcinoma.

Recent advances in the treatment of thoracic esophageal cancer have afforded it a better prognosis. As a consequence, increasing attention is being paid to the outcomes with postoperative monitoring for second primary malignancies after esophagectomy, but no recent study has focused on the longterm followup and outcomes in these patients. In 1989, we began intensive prospective screening and surveillance designed to detect cancers of the head and neck, lung, stomach, residual esophagus, and colon/rectum after esophagectomy. Between 1989 and 2001, 365 patients underwent esophagectomy for thoracic squamous cell esophageal carcinoma in our department. Of those, 200 were followed up as part of this program. Excluded were patients in whom esophageal cancer recurred, patients with other prior or simultaneous malignancies, and patients who died within a year of operation. Clinicopathologic profiles and treatment outcomes were determined for 33 patients who developed a second primary malignancy after esophagectomy. The interval between the primary esophageal cancer and the secondary carcinoma was 49 +/- 40 months (median, 48 months). The second primary malignancies were located in the stomach (30%), head and neck (24%), lung (24%), colon/rectum (9%), liver (6%), pancreas (3%), and blood (6%). Twenty-one patients (64%) were classified as stage 0, I, or II; 10 (30%) were stage III or IV. Overall, the 2-year, 3-year, and 5-year survival rates following diagnosis of a second primary malignancy were 58.0%, 58.0%, and 48.6%, respectively. Of the 19 patients (58%) in whom second primary malignancies were detected before symptoms developed, the 5-year survival rate was 70.7%, which was significantly greater than that among patients whose secondary malignancies were discovered after symptoms developed (17.1%). Good outcomes in the treatment of second primary malignancies after esophagectomy for thoracic squamous cell esophageal carcinoma can be obtained with longterm, intensive followup and active surgical intervention for detected malignancies.

Decreased expression of stem cell factor in esophageal and gastric mucosa after esophagogastric anastomosis for cancer: potential relevance to motility.

Esophageal replacement with gastric tube is a well-established reconstruction of the alimentary tract after esophagectomy in cancer patients. The resulting molecular events in the transposed gastric tube and residual esophagus have yet to be investigated. Stem cell factor (SCF) was recently shown to be critical for signaling in gastrointestinal motility. SCF expression is here correlated with changes in mucosal morphology, acid and biliary reflux, and motility in the residual esophagus and gastric tube. Thirteen patients surgically resected for squamous esophageal carcinoma with gastric tube replaced by esophagogastric anastomosis underwent upper endoscopy, esophageal manometry, 24-hour pH monitoring, and bile reflux detection. Esophageal and gastric mucosa samples were examined for SCF expression by immunohistochemical and semiquantitative reverse transcriptase-polymerase chain reaction analysis and for SCF serum levels by enzyme-linked immunosorbent assay. All patients showed severe residual esophagus hypoperistalsis and no gastric tube motor activity. The 24-hour pH monitoring was positive in most; 24-hour bile detection was mostly negative. SCF levels in the residual esophageal and gastric tube mucosa were dramatically decreased compared with those of normal subjects. The correlation between SCF and slow-wave activity was positive. Hypomotility of the residual esophagus and gastric tube seems closely associated with disruption of the SCF/c-kit signaling pathway. However, the absence of notable relations between mucosal changes after chronic exposure to acid, biliary gastric content, and SCF expression indicates that this analysis cannot be considered part of endoscopic follow-up.

New options for aerodigestive tract replacement after extended pharyngolaryngectomy.

Assess the results of a new type of reconstruction of the aerodigestive tract after extended pharyngolaryngectomy. Follow-up of a total of eight patients who had surgery using ileocolic free graft. The surgical technique is described. Five patients underwent pharyngolaryngectomy/cervical esophagectomy, and three patients had total laryngectomy with subtotal pharyngectomy. Patients were monitored to assess complications and recovery of satisfactory swallowing and speech. The technique, thanks to the use of material from the colon, proved to be extremely useful for the reconstruction of the digestive tract. At the same time, ileal anastomosis with the tracheal stump enabled aerodigestive crossing restoration, protected by the ileocecal valve. All patients recovered good swallowing capacity and phoniatric expression, which were obtained by digital occlusion of the tracheostomy, forcing the expiratory air through the ileum and ileocecal valve. Manometric tests also showed that after a while there was a gradual synchronization of swallowing between the transplanted colic segment and the residual esophagus. The technique described in the present study may be regarded, also in the light of possible further applications, as a new and interesting option for the reconstruction of the aerodigestive tract.

Radioisotope evaluation of the esophageal remnant and the gastric conduit after gastric pull-up esophagectomy

Background: The act of swallowing after gastric pull-up esophagectomy has not been thoroughly investigated. The aim of this study was to evaluate deglutition in the esophageal remnant and in the gastric conduit in patients who have undergone this operation. Methods: The residual radionuclide activity was measured 15 seconds after a swallow in the esophageal remnant and at intervals up to a maximum of 120 minutes after a swallow in the gastric conduit. The scintigraphic rate of transit of a bolus in both areas was compared in patients who had anastomosis in the neck (n = 15) versus patients who had anastomosis in the chest (n = 19). Comparisons were also made between patients with and without symptoms of dysphagia. The scintigraphic measurements were also correlated with anastomotic diameters, measured with use of a volumetric balloon insufflation method, at 3, 6, and 12 months after operation. Results: There were no significant differences in esophageal residual radionuclide activity at 15 seconds after a swallow in the groups with anastomosis in the neck versus anastomosis in the chest, with 30% residual activity up to 12 months after operation in both groups ( P = .24). In the patients as a whole the 50% gastric conduit emptying time of 44 to 61 minutes did not change during the first postoperative year ( P = .12). There was no association between anastomotic diameter and residual activity in the remaining esophagus ( P > .126). Moderate and severe dysphagia was reported in only a few patients, and there was no correlation between dysphagic symptoms and retention in the residual esophagus or slower emptying in the gastric conduit. Conclusions: The amount of peristaltic activity in the remaining esophagus after esophagectomy with gastric replacement is unaffected by the level of the anastomosis. The gastric conduit empties slowly in all patients, and there is no correlation between the rate of emptying and either anastomotic diameter or symptoms of dysphagia. (Surgery 1999;125:297-303.)

Second primary carcinoma in the residual cervical esophagus after thoracic esophagectomy: Report of five cases

Second primary carcinoma in the residual cervical esophagus after thoracic esophagectomy: Report of five cases

気管食道領域の多科共同手術 喉摘を伴う下咽頭頚部食道癌手術における多科共同手術

Among 254 patients undergoing resection of hypopharyngeal and cervical esophageal carcinoma since 1972, muscle, fasciocutaneous or musculocutaneous flaps were used in 26 cases. Free intestinal grafting was performed in 28 patients. The surgical treatment of these patients which required plastic surgery techniques was reviewed.The combination of extended lymph node dissection of the superior mediastinum via right thoracotomy and median sternotomy, laryngopharyngectomy, and permanent tracheostomy can lead to friction between the brachiocephalic artery and the trachea, with a risk of lethal fistula formation between the two structures. Pectoralis muscle interposition between these two structures is an important, but not infallible, technique for preventing this lethal complication. Ischemic necrosis of the trachea and preoperative radiation are risk factors. Grillo's operation was successfully done in 8 patients. Pectoralis musculocutaneous flaps were used in 7 patients for reconstruction, and a latisimus dorsi muscle flap was used in 1 patient. Free intestinal grafting is a useful technique, but great care should be taken to avoid leaving another malignant lesion in the residual esophagus in the thorax.When surgeons of various specialities work together on a patient with hypopharyngeal or cervical esophageal cancer, detailed preoperative discussion and flexible intraoperative judgments can help achieve success.

The relation between an esophageal cancer and associated cancers in adjacent organs

The relation between esophageal cancers and head and neck tumors was studied in order to improve the treatment results in patients with multiple cancers. We reviewed the records of 3,375 patients with an indexed squamous cell carcinoma of the head and neck treated at our institution between 1960 and 1994; and 81 patients were found to have an associated esophageal carcinoma. Similarly, the records of 434 patients with an indexed esophageal cancer were reviewed; and 54 patients had cancers in other organs or in the residual esophagus. A total of 135 esophageal cancers with 154 synchronous or metachronous cancers were entered into the analysis. The risk of developing esophageal cancer was ten times higher in male patients with head and neck cancer than in female patients. Synchronous or metachronous esophageal cancer associated with head and neck cancer was most frequently seen with pharyngeal cancer (28/360 = 7.8%), followed by in the oral cavity (47/2148 = 2.2%). Better knowledge of the relation between an esophageal cancer and a head and neck cancer may lead to the early detection of subsequent small, potentially curable neoplasms sited in either the esophagus or the head and neck region.

胸部食道癌術後に発見された頸部食道表在癌の検討

胸部食道癌術後に発見された頸部食道表在癌の検討

Functional evaluation of gastric transplants used in esophageal reconstruction.

Gastric transplants using the Akiyama method were used to treat esophageal carcinoma in 12 patients. Endoscopic examination, prolonged manometry (greater than 30 min), and 24 h pH monitoring were performed postoperatively to evaluate functional results. All patients could swallow without difficulty at the time of examination and had no dysphagia, regurgitation, heartburn, or sensation of abdominal fullness. Histologic examinations of residual esophagus showed microscopic esophagitis in 5 patients. Percentage of time that pH less than 4 was 42.6 +/- 10.9% (mean +/- SEM) and median pH was 4.3 +/- 1.0. The manometric examination showed no 'esophageal-like' peristaltic waves, but synchronous contractions were demonstrated in 9 patients, gastric type activity in two patients, and no activity was detected in one patient. We conclude that retained gastric peristaltic function is not a prerequisite for a good clinical outcome for swallowing and that despite vagotomy, the stomach continues to produce enough acid to maintain an acidic pH.

遊離空腸移植による下咽頭頚部食道再建術における内圧測定からみた再建食道の運動機能

Nine cases with free jejunal reconstruction after hypopharyngolaryngoesophagectomy were evaluated reconstructed esophageal functions by manometric studies.The pharyngoesophageal high pressure zone disappeared, and the intra luminal pressure of freely transplanted jejunum was almost equal to atomospheric pressure, although the remaining intact esophagus including the lower esophageal high pressure zone had no significant changes on the resting pressure.Spontaneous movement of transplanted jejunum was observed for 26% of the examination time of four to five hours after meals. Movement similar to phase III intestinal contractions of Code's classification was seen intermittently for 43% of the spontaneous movement. Over night continuous recording showed that these rhythmic high pressure contractions were less predominant in the three hours after meals than in the four to twelve hours after meals.No propagating pressure waves were observed in the transplanted jejunum on deglutition with or without jejunal spontaneous movement, though synchronous spike waves were also seen in the pharynx and jejunum. However normal peristaltic waves in the residual esophagus and normal reluxation of lower esophageal sphincter also appeared.We speculate from this study that patients' symptoms of disswallowing or nasal regurgitation in the early postoperative period are mainly owing to phase III contractions occasionally encountered, because the pressure sometimes rise up to more than 100cmH2O and it may be higher than the degultition pressure or the obstructive pressure of nasopharyngeal cavity.

Radiology of colonic interposition and its associated complications.

A retrospective review of the medical records, pathology reports, and radiographic studies of 81 patients who had undergone colonic interposition was undertaken, with special attention to postoperative complications. Both early (within 30 days postoperatively, 81 patients) and late (later than 30 days postoperatively, 57 patients) complications were reviewed. Early findings included anastomotic narrowing (18 patients), anastomotic leak (13), aspiration (11), and ischemic necrosis of the colon (3). Late findings included aspiration (9 patients), anastomotic strictures (8), gastric stasis (6), redundancy and tortuosity of the colon (5), anastomotic ulcers (4), gastrocolic reflux (3), and gastroesophageal reflux into the residual esophagus (2).

The Treatment of Esophageal Perforation with Delayed Recognition and Continuing Sepsis

Five patients, recently treated for esophageal ruptures, provided a spectrum of “late” perforations. Treatment was individualized for each patient and ranged from suture closure of the perforation to esophagectomy. Four of the 5 patients survived and now have no dietary restrictions. The goals of treatment should be: (1) elimination of sources of chemical and bacterial soilage; (2) drainage of infected areas; (3) augmentation of host defenses by antibiotics; and (4) provision of adequate nutrition. Several treatment adjuncts, alone or in combination, may be used to accomplish these goals. The selection of treatment methods should be influenced by the site of perforation, the extent of local inflammation, the status of the residual esophagus, the overall status of the patient, and the chronicity of the perforation. As the risk of uncontrolled sepsis increases, the surgeon should take more aggressive and definitive steps, up to and including esophagectomy in certain cases, to prevent further soilage.