Total Thoracic Esophagectomy Research Articles

Primary adenocarcinoma arising in an interposed colon

We herein report a rare case of adenocarcinoma arising in an interposed colon. A 71-year-old male underwent total thoracic esophagectomy for thoracic esophageal cancer followed by antesternal reconstruction using the right colon. Seven months later, 18F-fluorodeoxy-glucose positron emission tomography revealed increased uptake in the interposed colon. Endoscopy detected a mass 25 mm in diameter in the cecum of the interposed colon approximately 10 cm from the distal anastomosis. An endoscopic biopsy showed well-differentiated adenocarcinoma. Partial resection of the interposed colon was performed, and the patient’s postoperative course was uneventful. The patient is currently alive with no signs of recurrence three years after the final surgery. We herein report a case of primary adenocarcinoma arising from an interposed colon after esophagectomy and review the literature.

Aortic Valve Replacement in a Patient with a Retrosternal Gastric Tube

A 65-year-old male with a history of a total thoracic esophagectomy with a retrosternal gastric tube reconstruction required aortic valve replacement for aortic valve stenosis due to a bicuspid aortic valve. Preoperative multidetector computed tomography demonstrated that the gastric tube occupied the retrosternal space and the gastroepiploic artery was located on the left side of the gastric tube. Aortic valve replacement was performed through a median sternotomy approach. Blunt dissection on the anterior and right side of the gastric tube was performed without injury, and we could then perform cardiac surgery with the standard surgical view.

Esophagectomy and substitution of the thoracic esophagus in dogs

To evaluate a technique to remove the thoracic esophagus without thoracotomy and two methods for thoracic esophageal replacement in dogs. 27 ex-vivo dogs were divided into three groups in order to evaluate: G1 - total thoracic esophagectomy by the everting stripping method; G2 - total thoracic esophagectomy and esophageal substitution using the whole stomach; G3 - total thoracic esophagectomy and esophageal substitution using fundus rotation gastroplasty. After esophageal resection in G1, the integrity of the intrathoracic route was evaluated by endoscopy and tested with 1% methylene blue solution. Visceral pleural rupture was observed in all animals. However, this intrathoracic route made it possible to bring both esophagus substitutes (G2 and G3) to be anastomosed to the cut end of the cervical esophagus. Thoracic esophageal substitution using the whole stomach showed less anastomotic tension and was less technically demanding than the fundus rotation gastroplasty method. The ex-vivo results support further studies to validate the techniques in clinical cases.

Esophageal skip metastasis from an adenocarcinoma of the gastric cardia

AbstractAlthough diffuse‐type gastric carcinomas sometimes spread within the esophageal mucosa, a distant skip metastasis from a gastric carcinoma to the esophagus wall has rarely been reported. We herein report the case of a patient found to have a carcinoma of the gastric cardia with a skip metastasis to the esophagus, approximately 10 cm distant from the esophagogastric junction. A 53‐year‐old man was admitted to our department suffering from a sudden hematemesis. An upper gastrointestinal endoscopic study revealed an infiltrative ulcerating tumor of the gastric cardia and a small, reddish, elevated submucosal tumor on the middle third of the esophagus, apart from the tumor on the cardia. A histological study of the biopsy specimens from both tumors showed poorly differentiated adenocarcinomas. The patient underwent total thoracic esophagectomy and proximal gastrectomy combined with a splenectomy through a cervicoabdominal approach. The resected specimen contained a tumor of the cardia, 7.4 × 5.1 cm in area, that had infiltrated the submucosal layers of the lower esophagus up to 2.0 cm from the esophagogastric junction. The skip metastases were located 0.5, 4 and 7.2 cm from the oral side of the main tumor.

Giant Benign Esophageal Schwannoma Requiring Esophagectomy

Benign esophageal schwannomas are rare tumors with only 14 cases reported in the English literature. All previous reports describe excision without major esophageal resection. We report the case of a 33-year-old woman with a giant esophageal schwannoma that required total thoracic esophagectomy.

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months' follow-up).

Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma

Background. Several techniques for esophageal resection have been reported. This study examines the morbidity, mortality, and early survival of patients after transthoracic esophagectomy for esophageal carcinoma using current staging techniques and neoadjuvant therapy. The technique includes right thoracotomy, laparotomy, and cervical esophagogastrostomy (total thoracic esophagectomy) with radical mediastinal and abdominal lymph node dissection. Methods. Three hundred forty-two patients had surgery for esophageal carcinoma between 1989 and 2000 at our institution. Two hundred fifty consecutive patients had esophagectomy using this technique. Kaplan-Meier curves and univariate and multivariate analyses were performed by postsurgical pathologic stage. Results. Median age was 62.7 years (31 to 86 years). Fifty-nine were female. Eighty-one percent (202) had induction chemotherapy (all patients with clinical T3/4 or N1). Early postoperative complications included recurrent laryngeal nerve injury (14% [35]), chylothorax (9%, [22]), and leak (8%, [19]). Median length of stay was 13 days (5 to 330 days). In-hospital or 30-day mortality was 3.6% (9). Overall survival at 3 years was 44%; median survival was 25 months, and 3-year survival by posttreatment pathologic stage was: stage 0 (complete response) (n = 60), 56%; stage I (n = 32), 65%; stage IIA (n = 67), 41%; stage IIB (n = 30), 46%; and stage III (n = 49), 17%. Mean follow-up was 24 months (SEM 1.6, 0 to 138 months). Five patients with tumor in situ, 6 patients with stage IV disease, and 1 patient who could not be staged (12 pts) were excluded from survival and multivariate calculations. In univariate and different models of multivariate analysis, age more than 65 years, posttreatment T3, and nodal involvement were predictive of poor survival. For univariate analysis, p = 0.002, p = 0.004, p = 0.02, respectively; for multivariate analysis, p = 0.001, p = 0.003, p = 0.02, respectively. Conclusions. Total thoracic esophagectomy with node dissection for esophageal cancer appears to have acceptable morbidity and mortality with encouraging survival results in the setting of neoadjuvant therapy. Patients who show complete response after induction chemoradiotherapy appear to have improved long-term survival.

A CASE OF PRIMARY MALIGNANT MELANOMA OF THE ESOPHAGUS WITH GALLBLADDER METASTASIS

A 68-year-old man was seen at the hospital because of epigastric distress. Endoscopic study revealed a tumor in the lower thoracic esophagus. A biopsy showed findings compatible with the diagnosis of poorly differentiated squamous cell carcinoma. A total thoracic esophagectomy were performed, and a cholecystectomy were added to prevent postoperative cholecystitis. The tumor was a type 2 lesion of 4.0×3.5cm in size which was macroscopically blackish in some parts. It was histopathologically diagnosed as malignant melanoma. A polypoid lesion of 3mm in size was also detected in the gallbladder, which was proved to be a metastasis (pT2N2M1, pStage IVb). Since no other primary lesion was seen, the tumor was considered to be primary malignant melanoma. Despite postoperative chemotherapy, he died five months after the operation bucause the tumor had already metastasized to the paraaortic lymph nodes and liver. Primary malignant melanoma arising in the esophagus is rare, and its prognosis is extremely poor. And malignant melanoma rarely metastasize to the gallbladder. Only three cases have been reported in the Japanese literature, but none of them involved primary tumor of the esophagus. We present this case with some bibliographical comments.

A CASE OF BASALOID-SQUAMOUS CARCINOMA OF THE ESOPHAGUS

We experienced a case of basaloid-squamous carcinoma of the esophagus. A 61-year-old man was admitted to the hospital for the purpose of operation for intrathoracic carcinoma which was diagnosed at another hospital. Esophagography revealed a region at ImEi, and endscopy demonstrated an evevated lesion 6.5cm in longer diameter on the anterior wall of the esophagus 35cm from the incisors. A basaloid-squamous carcinoma was diagnosed by a biopsy and a total thoracic esophagectomy was performed. The resected material showed a 6.5×2.0cm type 1 lesion with an uneven surface. The histopathological diagnosis was basaloid-squamous carcinoma of the esophagus, with a stage grouping of a 2 n 1 M 0 Pl 0, stage III. Postoperative recombinant chemotherapy with adriamycin and 5-fluorouracil was conducted. The patient is doing well as of seven months after the surgery. About 54 cases of this carcinoma have been reported in Japan. Basaloid-squamous carcinoma of the esophagus has been reported to have poor prognosis on the whole, but the patients with the disease in early stage (superficial cancer type) have been known to have less lymph node metastasis with consequent long-term survival. We think that improvement in prognosis can be expected by early detection and therapy.

A CASE OF INTRAMUCOSAL CARCINOMA COEXISTING WITH A LEIOMYOMA OF THE ESOPHAGUS

A case of esophageal intramucosal carcinoma on the top of leiomyoma which is rare is reported. A 56-year-old woman complaining of epigastric discomfort was found to have a white, slightly elevated tumor in the upper intrathoracic esophagus by endoscopic examination. The biopsy specimen taken from the top of the tumor showed squamous cell carcinoma. Total thoracic esophagectomy was performed. The operative diagnosis was early esophageal cancer with the size of 2.2×1.2×0.2cm and in Stage I (Ao No Plo Mo). Histology of the resected material revealed a 20×14mm leiomyoma of the lamina muscularis mucosa coexistent with a 10×18mm intramucosal carcinoma on the top of the leiomyoma. Only 20 cases of esophageal cancer which existed on the top of leiomyoma have been reported in Japan. We briefly reviewed these 20 cases in addition to this new case. The average age was 57.7 years, and the ratio of occurrence in males to females was 2 to 1.19 cases (90%) of them were of early carcinoma. We speculate that the underlying leiomyoma might prevent the cartinoma from infiltrating vertically.

A CASE OF ADENOID CYSTIC CARCINOMA OF THE ESOPHAGUS

A rare case of adenoid cystic carcinoma of the esophagus is reported. A patient was a 48-year-old woman was admitted to the hospital because of dysphagea. Esophagography revealed a lesion at Ei, and an endoscopy demonstrated an uneven elevated lesion on the anterior wall of the esophagus 30-38cm from the incisors. An adenoid cystic carcinoma was diagnosed by a biopsy and a total thoracic esophagectomy was performed. The surgical material showed a 6.5×4.0cm 2type lesion with an ulcer in the center. The histopathological diagnosis of esophageal adenoid cystic carcinoma (mp, n2, stage III) was made. Immunohitological staining for actin was positive in the tumor. Electron micrograph showed microvilli. Esophageal adenoid cystic carcinoma is generally thought to be associated with a poor prognosis, but the patient has not developed recurrence and has been followed as an outpatient as of three years after surgery.

A CASE OF PRIMARY ESOPHAGEEAL MUCOEPIDERMOID CARCINOMA ASSOSIATED WITH AN EARLY GASTRIC CANCER

A 68-year-old man was seen at the hospital because of hematemesis. Castroendoscopic examination revealed no evidence of bleeding, but a flat and slightly elevated lesion in the middle of the intrathoracic esophagus, diagnosed as squamous cell carcinoma by the biopsy specimen and an elevated lesion in the posterior wall of the lesser curvature of the upper part of the gastric body, diagnosed as well differentiated adenocarcinoma. Total thoracic esophagectomy and a total gastrectomy with regional lymph node dissection were performed. Pathologically the esophageal lesion was partially covered with a normal squamous cell epithelium and presented wide submucosal spreading but remained in the submucosal layer. And the carcinoma was composed of squamous cell carcinoma and adenocarcinoma which has a d-PAS and alcian-blue positive mucin. Therefore the diagnosis of mucoepidermoid carcinoma of the esophagus was made. There was n2 lymph node metastasis (stage III). The gastric lesion presented slight submucosal invasion and was diagnosed as well differentiated adenocarcinoma (stage Ia). Immunohistochemically, p53 was positive in almost all cells of the gastric cancer, but negative in both squamous cell carcinma and adenocarcinoma components. Adjuvant chemotherapy and radiation therapy were not performed. The patient is alive 1 year after the operation.

Total Thoracic Esophagectomy for Esophageal Cancer

Background: Many current methods of esophageal resection have drawbacks that result in inadequate proximal resection, inadequate lymphadenectomy, and difficult gastric and splenic access. We describe a technique that allows reliable and safe access to the chest, abdomen, and neck. Study Design: From 1988 to 1995, 113 patients (82 men; mean age 65.3 ± 4.5 years) with carcinoma of the esophagus or esophagogastric junction (middle third in 34, lower third in 41, and cardia in 38) underwent total thoracic esophagectomy. The histology was adenocarcinoma in 71 (62.8%), squamous cell carcinoma in 32 (28.3%), and undifferentiated carcinoma in 10 (8.9%) of the patients; 57 tumors (50.5%) were stage III. The esophagus and stomach were mobilized through a left thoracoabdominal incision. After completion of the esophageal resection, the fundus of the stomach was sutured to the esophageal stump to allow later delivery of the stomach into the neck. The esophagogastric anastomosis was performed with continuous single-layer absorbable suture through a left oblique cervical incision. Results: The mean duration of the operation was 309.2 ± 47.9 minutes. Hospital stay ranged from 5 to 49 days (median, 12 days). The perioperative mortality rate was 4.4%. Anastomotic leak occurred in six patients (5.3%), one of whom died. The proximal resection margin was microscopically free of tumor in all cases, and with a minimum followup period of 18 months, there has been no anastomotic recurrence in any patient. Actuarial survival at 1 year was 63.4% ± 4.9%, at 3 years 41.4% ± 5.9%, and at 5 years 22.7% ± 6.3%. Conclusions: Total thoracic esophagectomy through the left chest with a separate left cervical incision allows clear access to the esophagus and stomach and good tumor clearance. This procedure may be performed with a low rate of anastomotic leakage, a very low mortality rate, and no anastomotic tumor recurrence.

A CASE OF ESOPHAGO-BRONCHIAL FISTULA SUCCESSFULLY CURED BY TOTAL THORACIC ESOPHAGECTOMY FOLLOWED BY RIGHT LOWER LOBECTOMY OF THE LUNG

We experienced a case of esophago-bronchial fistula caused by large esophageal ulcer of unknown origin successfully cured by total thoracic esophagectomy followed by lower lobectomy of the right lung. A 52-year-old man was admitted to the hospital with a diagnosis of incurable esophageal ulcer. The patient was diagnosed as having an esophago-bronchial fistula by esophagography. Total thoracic esophagectomy with cervical esophago-gastrostomy was performed. After the discharge, hemoptysis occurred. The patient was re-admitted and the right lower lobe of the lung was resected combined with previous remnant fistula. This case was suspected of acquired esophago-brochial fistula from severe inflammation around the fistula. It is thought that such cases of esophago-bronchial fistula caused by large esophageal ulcer as this case may demand both total thoracic esophagectomy and lobectomy of the lung.

A CASE OF ESOPHAGEAL CANCER ASSOCIATED WITH DERMATOMYOSITIS

A case of esophageal cancer associated with dermatomyositis is presented. The patient was a 68-year-old man. In January 1993, edematous erythema appeared on the face, upper arm and fingers. In March, the patient was seen at the hospital and heliotrope erythema, Gottron's sign and elevated CK and aldolase were detected. He was diagnosed with dermatomyositis by skin biopsy. Upon starting steroid therapy, a squamous cell carcinoma was discovered at the middle thoracic esophagus (Im) by examination for the purpose of detecting the malignant tumor. On May 11, a total thoracic esophagectomy under right thoracotomy was performed with gastric tube reconstruction via the posterior sternal route. The resected specimen showed a tumor measuring 3.5×1.5cm in Im. Pathological examination of the specimen revealed poorly differentiated squamous cell carcinoma, moderately invasive, a2, ie (-), ly (+), v (-), n (-), in stage III. After resection of the tumor, the elevated CK, elevated aldolase and dermatomyositis were improved. He did not require steroid. We should carry out examinations for detecting the malignant tumor soon after the diagnosis of dermatomyositis.

粘膜下浸潤を伴った食道微小癌の1例

A 45-year-old male complaining of anorexia and heartburn was diagnosed by endoscopic findings that 0-IIc lesion with ulcer and the surrounding scattered erosion due to the reflux esophagitis on the lower esophagus (Ei) . The submucosal invasion was suspected and the total thoracic esophagectomy with reconstruction was performed. The operational findings were Ei-Im-Post, 0-IIc, Pl (-) , N (-) , M (-) , Stage I, R3. The resected specimen revealed superficial carcinoma coexisting with a submucosal tumor in the lower part of the esophagus (Ei) . Microscopic findings showed only 2mm sized 0-IIc lesion was moderately differentiated squamous cell carcinoma with submucosal microinvasion (sm) and n0, ly0, vo, ow (-) , aw (-) , ew (-) . It also revealed the submucosal tumor was leiomyoma (5x3mm) which seemed to arise from the muscularis propria. The patient was discharged with no postoperative complications. Only 2mm in size of the 0-IIc esophageal carcinoma had sm1 microinvasion. It was very rare case, but it provided the question about the indication of the endoscopic mucosal resection (EMR) . The post-operative pathological examination of the resected specimen is important, but also it is more important to preoperatively diagnose the acurate depth of invasion.

Achalasia

Achalasia is characterized by failure of relaxation of the lower esophageal sphincter and absence of progressive peristalsis in the esophageal body. Few data are available regarding the morphologic features of achalasia, in particular its histologic progression. The esophagi of 42 patients with achalasia treated with total thoracic esophagectomy were examined histologically in order to systematically identify morphologic features of clinically unresponsive achalasia and to determine what could be learned about the disease's evolution. In all cases, myenteric ganglion cells within the esophageal body were markedly diminished, with 20 specimens having none. Twenty specimens had residual ganglion cells in the proximal esophagus, and 15 specimens had a few randomly distributed ganglion cells in the mid- and distal portions of the esophagus. Inflammation within myenteric nerves, present in all cases, generally consisted of a mixture of lymphocytes and eosinophils, occasionally with plasma and mast cells. Focal replacement of myenteric nerves by collagen occurred in all cases, and there was almost complete replacement in several cases. Actual destruction of the residual ganglion cells was not seen. The resected esophagi also shared extramyenteric morphologic features. Some features probably stemmed from physiologic obstruction, such as muscular hypertrophy, mainly of the muscularis propria (all cases), with secondary degeneration and fibrosis (29 cases), and eosinophilia of the muscularis propria (22 cases). Other changes, probably resulting from chronic stasis of ingested materials in the lumen, included diffuse squamous hyperplasia (all cases), lymphocytic mucosal esophagitis (28 cases), lymphocytic inflammation of the lamina propria and submucosa with prominent germinal centers (all cases), and submucosal periductal or glandular inflammation with complete loss of submucosal glands in half of the cases. One patient had high-grade squamous dysplasia, and another had superficially invasive squamous cell carcinoma. A third group of changes was probably due to previous esophagomyotomy, including abnormal gastroesophageal reflux, as shown by pH reflux testing (13 cases) and Barrett's mucosa (four cases). In one case of Barrett's there was low-grade dysplasia. Clinically unresponsive, surgically resected achalasia has almost total loss of ganglion cells, and widespread destruction of myenteric nerves has already occurred. The only active component is myenteric inflammation. However, it cannot be determined whether this inflammation is a manifestation of ongoing nerve destruction or whether it is a secondary phenomenon.

Comparison of three techniques of esophagectomy within a residency training program

Residency training programs commonly emphasize a single technique of esophagectomy, as the safety and the efficacy of teaching or performing more than one type of esophagectomy are unclear. Between 1986 and 1992, 248 patients were explored for possible esophageal resection. Thoracic surgical residents or fellows performed major components of all resections. Two hundred twenty-one patients (adenocarcinoma, 146; squamous cell carcinoma, 72; and other, 3) underwent transthoracic esophagectomy (n = 134), transhiatal esophagectomy (n = 42), or total thoracic esophagectomy (n = 45), a resectability rate of 89.1% ( 221 / 248 ). Complications occurred in 75% of patients with transthoracic esophagectomy, in 69% with transhiatal esophagectomy, and in 80% with total thoracic esophagectomy. The overall operative mortality rate was 6.8% ( 15 / 221 ). Patients with a cervical anastomosis had a higher leak rate (13%) than those with an intrathoracic anastomosis (6%). Median survival was 22 months (19% 5-year survival) and did not differ by operation type or stage. No patient with unresectable disease (n = 27) survived longer than 10 months. Survival for patients with adenocarcinoma stages 3 and 2a suggested a trend toward improved survival after transthoracic esophagectomy despite similar rates of local and distant recurrence. Transthoracic esophagectomy, transhiatal esophagectomy, and total thoracic esophagectomy performed within a residency training program have similar morbidity, mortality, and recurrence rates as those in other modern series. A specific technique of esophagectomy can be selected for individual patients. Survival and sites of recurrence primarily reflect disease stage, not the technique of esophagectomy used.

Treatment of carcinoma of the esophagus with 5-fluorouracil and recombinant alfa-2a-interferon

Combinations of 5-fluorouracil (5FU) and recombinant alfa-2a-interferon (IFN) are synergistic in vitro and have demonstrated activity in colorectal carcinoma, renal cell carcinoma, and urothelial tumors. A Phase II trial of the combination of 5FU, 750 mg/m2 daily x 5 followed by weekly bolus therapy, and IFN, 9 MU subcutaneously three times per week, was initiated in patients with esophageal carcinomas. Patients were required to have biopsy-proven squamous cell or adenocarcinoma of the esophagus, locally advanced or metastatic disease beyond the scope of surgical resection, and adequate performance status, renal, hepatic, and bone marrow function. Twenty-one patients were enrolled; one patient was inevaluable for response because he had received prior chemotherapy, but was evaluated for toxicity. Eleven patients had metastatic disease, and 10 had locally advanced disease. Thirteen patients had squamous cell carcinoma and 8 adenocarcinoma. Toxicities were acceptable with no serious diarrhea and only two cases of serious stomatitis, although a greater than expected incidence of neurologic toxicity was observed. There were five responders (25%) including two patients with advanced or locally advanced disease rendered pathologically free of disease. One patient, initially considered surgically unresectable, was able to undergo a total thoracic esophagectomy after responding to treatment with 5FU/IFN, at which time only a single microscopic focus of carcinoma in situ was found. She remains alive and free of disease at 18+ months. A second patient who presented with metastatic disease and nearly complete obstruction of the esophagus regained normal swallowing function after treatment with 5FU/IFN; rebiopsy of all lesions revealed the patient to be pathologically free of disease. He survived over 2 years. This regimen employing a single cytotoxic agent has activity in esophageal carcinoma. Strategies employing biochemical modulation deserve additional investigation in the treatment of esophageal carcinoma.

Perioperative alterations in polymorphonuclear leukocyte function of gastrointestinal surgery.

To characterize the alteration of perioperative polymorphonuclear leukocytes (PMNs) function in surgical stress, we studied twenty six patients undergoing gastrointestinal surgery. Seventeen patients with thoracic esophageal cancer underwent total thoracic esophagectomy through a right thoracotomy (severe surgical stress group). Nine patients underwent cholecystectomy (slight surgical stress group). Phagocytic oxygen-dependent microbicidal activity in the esophagectomy patients significantly increased postoperatively, by measuring O2- production (35.3 +/- 7.0 nmol/10(6) cells/ml/20 min on postoperative day 1 vs. 28.6 +/- 6.2 preoperatively, p < 0.01) and luminol-dependent chemiluminescence (99.5 +/- 29.9 x 10(5) cpm/10(5) cells on postoperative day 3 vs. 67.5 +/- 12.8 preoperatively, p < 0.01). On the other hand, only a slight change was seen in the cholecystectomy patients. We conclude that the postoperative PMN function in terms of oxygen-dependent microbicidal activity significantly increases when the degree of surgical stress is sufficient. In order to gain insight into the mechanism of PMN activation, we specifically analyzed the expression of complement receptors. Up-regulation of complement receptors were seen in the esophagectomy patients, which parallels the activation of PMN microbicidal activities. It was suggested that phagocytic PMN function in severe surgical stress significantly increases postoperatively, in part, based on the upregulation of cell surface complement receptors.