Subtotal Esophageal Resection Research Articles

268. COMPARISON OF OUTCOME OF GASTRIC TUBE RECONSTRUCTION FOR ESOPHAGEAL CANCER BETWEEN RECONSTRUCTIVE ROUTES

Abstract The route of gastric tube reconstruction after esophageal cancer resection is generally adopted as either posterior sternal or posterior mediastinal. There have been no large-scale comparative studies, and each institution has chosen a route based on its own experience. Therefore, we conducted an observational study at our institution to compare the postoperative outcomes of posterior sternal and posterior mediastinal reconstruction in gastric tube reconstruction for esophageal cancer. The study included 159 patients with thoracic esophageal cancer who underwent subtotal esophagectomy and gastric tube reconstruction (73 patients in the posterior sternal reconstruction (RS) group and 86 patients in the posterior mediastinal reconstruction (PM) group) from 2016 to 2018 and compared perioperative and postoperative complications and postoperative nutritional status. There were no differences in age, location, or pStage between the reconstructive routes, but BMI was significantly higher in RS (22.0 ± 2.9) and PM (20.8 ± 3.1). Anastomotic leakage (RS:PM = 8%:3%) and respiratory complications (RS:PM = 6%:15%) were not significantly different. PM was also significantly more common with ileus (13%). Anastomotic stenosis requiring dilation was significantly less common in PM than RS (31%:17%, p = 0.04). Weight loss was significantly higher in the RS group at 1 year postoperatively (RS/PM:13.9%/10.2%, p = 0.02). We have changed to PM with gastrostomy and the modified Collard anastomosis. These procedures have decreased the occurrence of ileus due to jejunostomy. Anastomotic stenosis was reduced to 5%. In gastric tube reconstruction after subtotal esophageal resection for esophageal cancer, the reconstructive route (posterior sternal or posterior mediastinal route) showed no significant difference in the incidence of postoperative pneumonia or anastomotic leakage. By changing the anastomotic procedure, a decrease in anastomotic stenosis was observed even with posterior sternal reconstruction. We plan to accumulate more cases and investigate the effects on quality of life and nutritional status in the future.

Surgical Treatment of Patients with Adenocarcinoma of the Distal Esophageal Portion and Gastroesophageal Junction Performed After Neoadjuvant Chemotherapy and Combined Chemoradiation

Abstract Esophageal carcinoma is an extremely aggressive cancer with an early distant spread, high rate of local recurrence, and low overall survival. Herewith we present 3 patients with advanced moderately and low differentiated adenocarcinomas, who underwent neoadjuvant chemotherapy (nCT) (two patients) and combined nCT with neoadjuvant radiation therapy (nRT) (one patient), followed by radical surgery. Subtotal esophageal resection, proximal gastric resection, and intrathoracic right gastroesophagoplasty a modo Ivor-Lewis were performed in the first two patients, while total gastrectomy, distal third esophageal resection, splenectomy and left intrathoracic esophagojejunoplasty a modo Roux were performed in the third one. A literature review of the role of neoadjuvant chemoradiotherapy (nCRT) as part of a trimodality therapy for advanced esophageal carcinoma is presented.

“Peptic Esophageal Stricture In A Patient With Parkinson’s Disease”

Benign esophageal strictures are uncommon and their management remains challenging. Herein, we present a rare both functional and organic esophageal stricture in a patient with Parkinson’s disease and reflux esophagitis. The patient was diagnosed with severe complex stricture in the distal part of the esophagus, requiring surgical treatment. We performed subtotal esophageal resection and Ivor-Lewis gastroesophagoplasty. The successful management of antiparkinsonian drug therapy with adequate parenteral substitution in the early postoperative period is of great importance to avoid any further complications.

Esophagogastric junction adenocarcinomas: individualization of resection with special considerations for Siewert type II, and Nishi types EG, E=G and GE cancers.

For Siewert type II adenocarcinoma of the esophagogastric junction (AEG II), or similar tumors classified as Nishi EG, E=G, GE, the type of surgical resection and reconstruction should be individualized. Criteria for decision making mainly focus on the oral extent of esophageal infiltration, the cT and cN category and the functional status of the patient. For cT1/cT2 adenocarcinomas, which are non-poorly cohesive, intestinal type of Lauren Grading 1 or 2 without clinical signs of lymph node metastasis at the distal stomach, a limited transhiatal proximal gastrectomy with double tract reconstruction is recommended. For advanced adenocarcinomas, subtotal esophageal and proximal gastric resection with gastric pull-up or distal esophageal resection with total gastrectomy and esophagojejunostomy are competing procedures. Criteria for choosing the appropriate type of surgery are discussed.

NEW TREATMENT OPTION FOR ESOPHAGOGASTRIC ANASTOMOTIC LEAK: A CASE REPORT

The formation of esophagogastric anastomosis has a long history due to the search for the most reliable and safe fistula. The use of invagination anastomosis, proposed in the early 90s by Professor M.I. Davydov, fully met all the requirements, allowing significantly improve the quality of life of patients and significantly reducing the frequency of failure of the anastomoses to 0.5%.Case description. We present the case of proximal gastric cancer invading the lower thoracic esophagus. The patient underwent proximal subtotal gastric and lower thoracic esophageal resection using the combination of a laparotomy and right thoracotomy. Contrast radiography performed on day 11 after surgery revealed esophagogastric anastomotic leak. The patient underwent urgent surgery.Conclusion. This article presents a new treatment option for esophagogastric anastomotic leak by using endoscopic transesophageal clipping of the defect in combination with sanitation and drainage of the pleural/mediastinsl cavity. The proposed technique can be considered as a minimally invasive treatment method and can be used in any surgical clinic.

Adenocarcinoma of the oesophagus: neoadjuvant chemoradiation and radical surgery

To retrospectively evaluate long-term treatment results following neoadjuvant chemoradiation (CRT) and radical surgery in patients with advanced adenocarcinoma (AC) of the oesophagus. Between 2005 and 2015, atotal of 102 consecutive patients with amedian age of 64years (range, 44-86years) and AC of the oesophagus were evaluated of whom 84 received afull CRT. Agroup of 51patients was treated with neoadjuvant intent followed by radical surgery. Atotal dose of 50.4 Gy with mostly weekly paclitaxel/fluorouracil chemotherapy was administered. Six to eight weeks following CRT, atransthoracic subtotal oesophageal and proximal gastric resection was performed. Survival curves for overall survival and no evidence of disease (NED) survival (primary endpoints) were calculated according to Kaplan-Meier, and possible prognostic factors were evaluated by the log-rank test as well as by aCox regression analysis. Median follow-up time of the surviving patients was 48months (range, 14-134 months). Overall and NED survival rates for patients of the study group (n = 51) were 40 and 32%, respectively, at 5years. Age (p = 0.04), ypT category (p = 0.1) and the development of distant metastases (p = 0.05) were identified as (marginally) independent prognostic variables with impact on survival. Median survival time for patients of the study group (n = 51) was 45 ± 18months (95%CI 9-81months). Clear resection margins were achieved in 46/51 patients (92%). Regression rates with complete regression rare residual cancer and increased number of residual cells, but predominantly fibrosis were 33, 41, and 10%, respectively. Patterns of failure revealed local with distant recurrence in 2/51 (4%), regional recurrence alone in 2/51 (4%), and distant metastases in 27/51 (53%) patients. Neoadjuvant CRT in patients with AC of the oesophagus followed by thoracoabdominal surgery is alocally very effective concept. Asignificant tumour regression in almost 75% of the patients may stimulate prospective trials on the omission of radical surgery for some elderly patients. Due to ahigh rate of distant metastases further investigations in terms of effective systemic therapy may be warranted.

Thoracoscopic subtotal esophageal resection for benign esophageal diseases

To investigate the role of video-assisted subtotal esophageal resection in treatment of patients with benign esophageal diseases. Fifty-one patients with benign esophageal diseases have undergone subtotal esophageal resection in our department for the period 2010-2017. Thoracoscopic technique was applied in 25 cases, open approach - in 26 patients. Total surgery time, thoracoscopic stage duration, length of hospital-stay (LOS), ICU-stay, Clavien-Dindo morbidity rates with separate registration of respiratory complications, mortality have been considered. Groups were similar in terms of age, gender, ASA status. Thoracoscopic stage duration gradually decreased from 175 to 65 min with average time of 102 (75; 123) min. Total surgery time was 390 (270; 495) min in group 1 and 465 (341; 561) min in the control group (р=0.035). Mean ICU-stay decreased up to 2 (1.25; 3.75) days compared with the control group (5 (3.92; 5.85) days, р<0.0001). Conversion rate was 8%. In the main group complications Clavien-Dindo grade 2 were detected in 10 (40%) patients compared with 20 (69%) cases in the control group (р=0.009). Respiratory complications occurred in 5 patients in group 1 and in 13 cases of the control group (р=0.039). Mortality was absent. Thoracoscopic subtotal esophageal resection may be advisable alternative to open surgery for patients with benign esophageal diseases due to lower postoperative morbidity and earlier rehabilitation followed by improved outcomes.

The effects of the herbal medicine Daikenchuto (TJ-100) after esophageal cancer resection, open-label, randomized controlled trial

BackgroundDaikenchuto (TJ-100), a traditional Japanese herbal medicine, is widely used in Japan. Its effects on gastrointestinal motility and microcirculation and its anti-inflammatory effect are known. The purpose of this prospective randomized controlled trial was to investigate the effect of TJ-100 after esophagectomy in esophageal cancer patients.MethodsForty patients for whom subtotal esophageal resection for esophageal cancer was planned at our institute from March 2011 to August 2013 were enrolled and divided into two groups at the point of determination of the operation schedule after informed consent was obtained: a TJ-100 (15 g/day)-treated group (n = 20) and a control group (n = 20). The primary efficacy end-points were maintenance of the nutrition condition and the recovery of gastrointestinal function. The secondary efficacy end-points were the serum C-reactive protein (CRP) level and adrenomedullin level during the postoperative course, the incidence of postoperative complications, and the length of hospital stay after surgery.ResultsWe examined 39 patients because one patient in the TJ-100 group was judged as having unresectable cancer after surgery. The mean age of the TJ-100 group patients was significantly older than that of the control group patients.The rate of body weight decrease at postoperative day 21 was significantly suppressed in the TJ-100 group (3.6% vs. the control group: 7.0%, p = 0.014), but the serum albumin level was not significantly different between the groups. The recovery of gastrointestinal function regarding flatus, defecation, and oral intake showed no significant between-group differences, but postoperative bowel symptoms tended to be rare in the TJ-100 group. There was no significant between-group difference in the length of hospital stay after surgery. The serum CRP level at postoperative day 3 was 4.9 mg/dl in the TJ-100 group and 6.9 mg/dl in the control group, showing a tendency of a suppressed serum CRP level in the TJ-100 group (p = 0.126). The rate of increase in adrenomedullin tended to be high postoperatively, but there was no significant difference between the two groups.ConclusionsTJ-100 treatment after esophageal cancer resection has the effects of prompting the recovery of gastrointestinal motility and minimizing body weight loss, and it might suppress the excess inflammatory reaction related to surgery.

Aortoesophageal Fistula

Introduction: A 83-year-old man with past medical history significant for non-small cell lung cancer in remission status post-surgical resection 9 years ago presented with hematemesis. Aortoenteric fistula is an uncommon etiology of gastrointestinal bleeding. Considering the most common site for aortoenteric fistulas is the third or fourth portion of the duodenum, aortoesophageal fistulas are rarer, representing less than 10% of aortoenteric fistula cases. In the U.S., the most frequent clinical setting where primary aortoesophageal fistulas are observed is the expansion of thoracic aortic aneurysms. Secondary causes include aortic graft complications (51% cases), ingested foreign bodies (19% cases), infiltrating esophageal neoplasms, esophageal ulcerations, trauma, and mediastinal radiation therapy. First described by Chiari in 1914, characteristic symptoms include mid thoracic pain, sentinel upper arterial hemorrhage, and rapid exsanguination. CT scanning is often an adequate diagnostic modality revealing aortic fistulas, phlegmons and active extravasation (Figure 2). Endoscopy may reveal a graft, an ulcer with adherent clot, or an extrinsic pulsatile mass (Figure 1). A recent case review recommended urgent management of the aortic tear with endovascular aortic repair (EVAR) and subtotal esophageal resection followed by gastroesophageal reconstruction. Previous literature has suggested a mortality rate of approximately 40% with surgical intervention and a mortality rate approaching 100% without intervention. Though rarely seen, it is important to consider aortoesophageal fistulas in cases of gastrointestinal bleeding, particularly in the presence of aortic aneurysms.Figure 2Figure 1

Cancer of the oesophagus and gastroesophageal junction - a difficult clinical problem.

IntroductionCancer located in the oesophagus and gastroesophageal junction is a complex clinical problem and the results of its treatment still remain unsatisfactory. The objective of the study was the clinical analysis of a group of patients with cancer of the oesophagus or gastroesophageal junction, who received combined medical and surgical treatment.Material and methodsThe analysis was performed on a group of 128 patients with the diagnosis of oesophageal cancer or cancer of the gastroesophageal junction. Analysis of medical records and follow-up examinations were used in the research procedure.ResultsFrom among 128 patients with a diagnosis of oesophageal or gastroesophageal junction cancer, 50 (38.5%) received surgical resections. The surgery most frequently performed (n = 15) was sub-total oesophageal resection according to Akiyama procedure by right-sided thoracotomy (oesophageal anastomosis in the neck). The largest group were patients (n = 26) with stage T3N1M0 of advancement of the disease. In all cases of cancer located in the lower third of the oesophagus, an adenocarcinoma pattern was diagnosed in the histopathological examination, whereas in the case of cancers located in the middle third and upper third of the thoracic oesophagus a carcinoma planoepitheliale pattern was seen. Anastomotic leaks occurred in seven patients (14%). Six patients died during the post-operative period (12%). The mean survival time in the group of analysed patients was two years.ConclusionsCancer of the oesophagus or gastroesophageal junction is associated with low resectability, high risk of complications after surgery, and poor oncologic outcome. It is necessary to seek new methods of treatment.

Management options for aorto-oesophageal fistula: case histories and review of the literature

An aorto-oesophageal fistula is a rare clinical entity, leading to life-threatening gastrointestinal bleeding. Thoracic aortic aneurysms are the most common cause of aorto-oesophageal fistulae; further causes involve foreign body ingestion, trauma (in most cases iatrogenic), carcinoma or, very rarely, aortitis tuberculotica. Due to its rarity, there are no large multicentre studies present to evaluate the efficacy of different therapeutic management options. Since it is associated with significant morbidity and mortality, we give a short summary of various treatment approaches performed in our clinical practice in the past three years. The most straightforward therapeutic option may be an endovascular aortic repair and subtotal oesophageal resection followed by gastro-oesophageal reconstruction, but other alternative treatment possibilities are also present, although with probable higher morbidity. Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.

Intrathoracic versus Cervical Anastomosis after Resection of Esophageal Cancer: A matched pair analysis of 72 patients in a single center study

BackgroundThe aim of this study was to analyze the early postoperative outcome of esophageal cancer treated by subtotal esophageal resection, gastric interposition and either intrathoracic or cervical anastomosis in a single center study.Methods72 patients who received either a cervical or intrathoracic anastomosis after esophageal resection for esophageal cancer were matched by age and tumor stage. Collected data from these patients were analyzed retrospectively regarding morbidity and mortality rates.ResultsAnastomotic leakage rate was significantly lower in the intrathoracic anastomosis group than in the cervical anastomosis group (4 of 36 patients (11%) vs. 11 of 36 patients (31%); p = 0.040). The hospital stay was significantly shorter in the intrathoracic anastomosis group compared to the cervical anastomosis group (14 (range 10–110) vs. 26 days (range 12 – 105); p = 0.012). Wound infection and temporary paresis of the recurrent laryngeal nerve occurred significantly more often in the cervical anastomosis group compared to the intrathoracic anastomosis group (28% vs. 0%; p = 0.002 and 11% vs. 0%; p = 0.046). The overall In-hospital mortality rate was 6% (4 of 72 patients) without any differences between the study groups.ConclusionsThe present data support the assumption that the transthoracic approach with an intrathoracic anastomosis compared to a cervical esophagogastrostomy is the safer and more beneficial procedure in patients with carcinoma of the lower and middle third of the esophagus due to a significant reduction of anastomotic leakage, wound infection, paresis of the recurrent laryngeal nerve and shorter hospital stay.

Verrucous Squamous Carcinoma of the Esophagus Successfully Diagnosed by Endoscopic Mucosal Resecion: A Case Report

A 62-year-old male with a history of type 2 diabetes mellitus and alcoholic liver disease presented with dysphagia, heartburn, and appetite loss. He had lost 10 kg weight within 1 month. The patient gave a history of excessive alcohol intake and a smoking habit of 60 cigarettes per day for 40 years. Upper gastroenteroscopy revealed a wartlike, whitish, protruding mass with circumferential stricture at a point 35 cm from the incisor down to the cardia. Although esophageal cancer was suspected, repeated biopsies of the mass revealed no malignant findings. Concurrent esophageal candidiasis was treated with an antifungal drug. Increased esophageal stricture made food intake impossible; therefore, total parenteral nutrition was initiated. Endoscopic mucosal resection revealed highly keratinized, well-differentiated squamous cell carcinoma with invasion into the submucosa. A diagnosis of verrucous squamous carcinoma was confirmed. Subtotal esophageal resection and esophagostomy was performed with video assistance. Postoperative pathological findings were compatible with the diagnosis of verrucous squamous carcinoma, which is known to be a slow-growing tumor that rarely metastasizes to lymph nodes or distant organs. However, verrucous squamous carcinoma is rarely diagnosed by endoscopic biopsy. Moreover, endoscopic mucosal resection or surgery should be considered in cases when endoscopic examination fails to confirm the diagnosis of carcinoma and if the lesion presents some characteristics of verrucous squamous carcinoma.

Adenocarcinoma of the esophagogastric junction: Neoadjuvant radiochemotherapy and radical surgery

To retrospectively evaluate treatment results and toxicity following a combined approach consisting of neoadjuvant radiochemotherapy and radical surgery in advanced adenocarcinoma of the esophagus and gastroesophageal junction. Between 2005 and 2009, a total of 41 consecutive patients with newly diagnosed nonmetastatic adeno-carcinoma of the esophagus and the esophagogastric junction were evaluated, of whom 23 received neoadjuvant radiochemo-therapy (RCT). A total dose of 50.4 Gy with 2 cycles of simultaneous cisplatin/5-fluorouracil (FU) or Taxol/FU-chemotherapy were applied. A radical transthoracic subtotal esophageal and proximal gastric resection through a right thoracoabdominal laparotomy with intrathoracic anastomosis was performed 6-8 weeks following RCT. This was combined with a two-field lymphadenectomy of mediastinal and abdominal lymph nodes. Standard histopathological evaluation included the application of regression grading according to Werner and Höfler. Toxicity was recorded on the basis of CTC criteria; survival curves were calculated according to Kaplan-Meier. V10, V15, and V20 data were correlated with pulmonary toxicity. Overall survival for all 23 patients was 61% at 3 years. Of the original 23 patients, 18 (78%) patients proceeded to radical surgery. Reasons for no surgery included advanced age of 79, 82, and 86 years (n = 3), severe comorbidity (n = 1), and progression during radiochemotherapy (n = 1). Surgical morbidity (grade 3-4) and mortality rates were 35% and 6%, respectively. Resurgery was necessary in 3 cases (18%). Clear resection margins were achieved in 17 of 18 patients (94%). Twelve of 18 (67%) patients initially diagnosed with T3 tumors and 3 of 3 patients with T4 tumors experienced downstaging. The ypN0 rate was 12 of 18 patients (67%). Out of a total of 18 patients, regression grading revealed < 10% viable cells in 8 (44%) including 3 cases (17%) with complete regression, 10-50% viable cells in 9 (50%) and > 50% viable cells in 1 patient. During the postoperative course or thereafter, 8 of 23 (35%) patients experienced pulmonary complications including pneumonia and/or pneumonitis. V10 > 20% (p = 0.019), V15 > 13% (p = 0.008), and V20 > 10% (p = 0.008) were associated with a significant increase in the rate of pulmonary toxic effects. Neoadjuvant radiochemotherapy in patients with advanced adenocarcinoma of the esophagogastric junction followed by thoracoabdominal surgery is a feasible concept. Significant tumor regression in 44% of the patients and an ypN0 rate in 67% of the patients may favor this approach due to its high efficacy. However, to avoid toxic pulmonary effects constraints for low-dose radiation volume parameters need specific attention.

En bloc esophageal mucosectomy for concentric circumferential mucosal resection (with video)

With conventional EMR, specimens are fragmented, metaplasia may be left behind, and invasive lesions could be missed because of incomplete sampling. Concentric subtotal esophageal mucosectomy would address these limitations. To examine en bloc esophageal mucosectomy (EEM). A prospective case series. An academic hospital. Nine swine. Conventional EMR was performed in the proximal esophagus. The submucosal space was entered, and the distal two thirds of the esophageal mucosa was freed with blunt dissection. A snare was threaded over the column of mucosa to the gastroesophageal junction. The column was resected, and the mucosa was retrieved. Clinical examination, follow-up endoscopy, necropsy, and gross and histopathologic examination. EEM permitted subtotal esophageal mucosectomy in 9 of 9 swine (tissue specimens removed ranged 9-15 cm in length). The mean procedure duration was 110 minutes. In the survival series, 4 of 4 swine thrived after surgery, for 9 to 13 days. At 9 days, there was no evidence of a perforation, stricture, or leak. At 13 days, 2 swine had a mild proximal stricture, which was easily traversed with a 9.8-mm gastroscope. On necropsy, the mediastinal and thoracic cavities were unremarkable in 3 of 4 swine. One swine was found to have a contained abscess containing cellulose, presumably secondary to ingestion of wood-chip bedding material postoperatively. Reepithelialization was present on histologic examination. An animal study. EEM is feasible and enabled concentric subtotal esophageal mucosal resection. The technique could completely and circumferentially excise intramucosal lesions. Longer follow-up and larger studies are needed to evaluate infection, stricture, and safety.

Primary malignant melanoma of the oesophagus: a case report

Primary malignant melanoma of the oesophagus is a rare neoplasm comprising less than 0.2% of all primary oesophageal neoplasms. There are fewer than 250 reported cases in worldwide literature. Several reports suggest that it has a mean survival rate of 2.2% at 5 years and a median survival rate of 10 months. A 48 year old male presented to our surgical service complaining of a three month history of progressively worsening dysphagia with associated regurgitation and unintentional weight loss of 14 kg. There was no prior history of cutaneous or ocular melanoma. He was treated with a combination of subtotal oesophageal resection and immunomodulatory therapy. We present herein a case of primary malignant melanoma of the oesophagus including the associated clinical, pathological and radiological findings.

Drainage of Cervical Esophagogastrostomy: Essential or Dangerous?

Leakage from a cervical esophagogastric anastomosis still accounts for major morbidity and mortality after subtotal esophageal resection. Its prevalence might adversely be affected by drainage of the anastomosis. Therefore we conducted a prospective randomized trial on 60 consecutive patients after subtotal esophagectomy and cervical esophagogastrostomy. The patients were assigned to either a drainage (n = 29) or a non-drainage group (n = 31). Suture-line disruption was more common in the non-drainage (n = 6) than in the drainage group (n = 3), and other complications were also more frequent in the non-drainage than in the drainage group. We did not note any adverse effects of drainage itself. Taking this small collective into account, we nevertheless recommend drainage for cervical esophagogastrostomy because it is simple, free of complications and seems to have no major impact on the incidence of anastomotic disruption.

A CASE OF ADENOID CYSTIC CARCINOMA OF THE ESOPHAGUS

This paper reports a case adenoid cystic carcinoma of the esophagus. A 74-year-old man was admitted to the hospital because of discomfort in swallowing. Polypoid lesion was found in the middle third of the esophagus and an adenoid cystic carcinoma was suspected by biopsy. Subtotal esophageal resection was performed. The resected specimen was 25×22mm in size. Histological studies revealed that the specimen had cribriforme and tubular pattern, and mucinous substance in the interstitum and cystic space was positive in alcian-blue stain. We diagnosed as pure adenoid cystic carcinoma. His-tologically it was sm, n (-), ly (+), v (+), in stage I. In a review of the Japanese literature, 43 cases including this case were clinically analyzed. When compared with squamous cell carcinoma, this adenoid cystic carcinoma was common in women and had a poorer prognosis. The 43 cases of patients with adenoid cystic carcinoma in the Japaneses literature were reviewed. The rate of woman was less and prognosis was worth than squamous cell carcinoma. Histologically pure cases of adenoid cystic car-cinoma represented 59% of all cases and the tumor must have origniated from the esophageal gland.

Multimodality Therapy for Esophageal Carcinoma-Update

Transhiatal esophagectomy with mobilization of the stomach to replace the esophagus has been used to provide palliation of dysphagia at the University of Michigan for more than 15 years. The subtotal esophageal resection is believed to be preferable to the transthoracic approach that has been considered the standard for this surgery. As experience with the technique has increased, complications have decreased. Most patients are discharged, able to swallow, by the 10th or 11th postoperative day. Survival in these patients is no worse than that reported after more traditional transthoracic esophagectomy, and the transhiatal route has reduced postoperative pulmonary complications and the incidence of mediastinitis from anastomotic leak, which is fatal in 50% of patients. In a phase II trial of preoperative combined radiation therapy and chemotherapy with cisplatin, vinblastine, and continuous-infusion 5-fluorouracil in 45 patients, survival after esophagectomy seemed considerably better than in our historical control subjects treated with transhiatal esophagectomy alone. The 3-year survival of the 43 patients was 46% compared with 23% of those who received only surgery. Considering only the 27% of those patients who had no cancer in their resected specimens, ie, the complete responders, the 5-year survival is 70%. A phase III trial is now accruing patients in an attempt to confirm these results.

Serum Granulocytic Elastase and Superoxide Dismutase Activity after Administration of Protease-Inhibitor to Postoperative Patients

Summary Postroperative changes in the plasma levels of granulocytic elastase and superoxide dismutase were examined clinically. Seven patients who had undergone cholecystectomy and eight patients who had undergone subtotal esophageal resection were considered. The protease inhibitor ulinastatin was administered to four of the latter patients. The levels of granulocytic elastase were elevated, and those of superoxide dismutase, decreased, in the non-medicated patients who had undergone esophageal resection (p<0.05). Furthermore, in the patients given the daily medication of 3 X 105 units of urinastatin for more than 3 days postoperatively, the elevation of granulocytic elastase levels and the decline of the superoxide dismutase levels were markedly suppressed (p<0.05). On the other hand, granulocytic elastase levels of the plasma to which ulinastatin had been added in vitro did not decrease. It is considered that the medicament of ulinastatin may be useful in the prevention of tissue injury caused by granulocytic elastase in cases where a disproportion of proteases and endogenous protease inhibitors exists.