Total Thoracic Esophagectomy Research Articles

Experimental studies on the effect of total thoracic esophagectomy on cardiorespiratory functions and the plasma concentration of chemical mediators

To examine the effects of total thoracic esophagectomy on cardiorespiratory functions and the responses of the body to surgery, changes in the cardiorespiratory parameters and plasma concentrations of chemical mediators were examined before and after surgery in 21 mongrel dogs inflicted with 3 types of surgical damage. Group 1 underwent a simple thoracotomy, Group 2 an ablation around the thoracic esophagus and pulmonary hilus, and Group 3 a total thoracic esophagectomy with extended lymphnode dissection around the tracheobronchial region. In Group 3, lung resistance and extravascular lung water increased by 108 per cent and 83 per cent, respectively, while lung compliance decreased by 71 per cent. Among the cardiovascular parameters, pulmonary arterial pressure and pulmonary wedge pressure increased by 40 per cent and 89 per cent, respectively, these values being significantly higher in this group than in the other two groups. With regard to the plasma chemical mediators, renin-angiotensin-aldosterone, antidiuretic hormone, catecholamine, serotonin, histamine, and thromboxane B2 levels were significantly higher in Group 3 than in Group 1. The increase in thromboxane B2 was particularly notable in Group 3, being about 6,000 pg/ml 60 minutes after surgery. The results of this study showed how total thoracic esophagectomy lead to a marked deterioration in respiratory function caused by division of the pulmonary nerves and changes in plasma chemical medicator concentrations which induced constriction of the pulmonary vessels and/or increased the vascular permeability. The disturbance of pulmonary lymph flow due to surgical disruption of the lymphatic system also contributed to the deteriorated lung function.

Esophageal resection for achalasia: Indications and results

Although esophagomyotomy is highly effective as the initial surgical treatment of most patients with achalasia, those with either recurrent symptoms after a previous esophagomyotomy or a megaesophagus do not respond as well to esophagomyotomy. Total thoracic esophagectomy was performed in 26 patients (average age, 49 years) with achalasia. Eighteen had a history of a previous esophagomyotomy, and 18 had a megaesophagus (esophageal diameter of 8 cm or larger). In 24 patients, a transhiatal esophagectomy without thoracotomy was the operative approach; 2 patients required a transthoracic esophagectomy because of intrathoracic adhesions from prior operations. The stomach was used as the esophageal substitute in all patients; it was positioned in the posterior mediastinum, and a cervical anastomosis was performed. Intraoperative blood loss averaged 765 mL. Major postoperative complications included mediastinal bleeding requiring thoracotomy (2), chylothorax (2), and anastomotic leak (1). There were no postoperative deaths. The average postoperative hospital stay was ten days. Follow-up is complete and ranges from 3 to 91 months (average duration, 30 months). All but 1 patient with severe psychiatric disease eat a regular, unrestricted diet without postprandial regurgitation. Early postoperative anastomotic dilation was required in 10 patients. Dumping syndrome has occurred in 5 patients. It is concluded that esophagectomy provides the most reliable treatment of esophageal obstruction, pulmonary complications, and potential late development of carcinoma in the patient with a megaesophagus of achalasia or a failed prior esophagomyotomy and that it is a far better option in these patients than esophagomyotomy, cardioplasty procedures, or limited esophageal resection.

Cervical esophagogastric anastomosis for benign disease: Functional results

Ninety-one adult patients (average age 49 years) with various benign esophageal disorders treated by total thoracic esophagectomy and a cervical esophagogastric anastomosis have been followed up with personal interviews and examinations from 6 to 104 months (average 34 months). Outpatient esophageal dilation has been used liberally for any degree of postoperative cervical dysphagia. At their latest follow-up, 39 patients (43%) eat without dysphagia; four patients (4%) have mild dysphagia necessitating no treatment; 34 patients (37%) have undergone one to three dilations during the first 6 to 12 postoperative months for intermittent dysphagia; and 14 patients (16%) have more severe dysphagia necessitating regular anastomotic dilations (two thirds of these perform home self-dilations). Mild regurgitation of gastric contents has been experienced by 27 (30%), particularly when recumbent after eating, but only four patients sleep with the head of the bed elevated to prevent nocturnal regurgitation. No patient has had pulmonary complications resulting from aspiration. Twenty patients (22%) have had varying degrees of "dumping syndrome," generally transient and well controlled with medication. Two patients have required an additional gastric drainage operation 16 months and 82 months, respectively, after the esophagectomy. At their latest evaluation, 33% of the patients weigh 3 to 83 (average 19) pounds more than they weighed preoperatively, 38% weigh 5 to 40 (average 12) pounds less, and 29% have had no change in their weight. The stomach functions well as a visceral esophageal substitute and, like the esophagus, is more thick-walled and resilient than colon. Significant gastroesophageal reflux is uncommon after a properly performed cervical esophagogastric anastomosis. Postoperative dysphagia can be minimized by attention to technique in constructing the anastomosis. These data support our belief that the stomach is the preferred organ for esophageal replacement, not only for carcinoma, but also for benign diseases as well.

Esophagectomy for complex benign esophageal disease

We evaluated the use of total thoracic esophagectomy and replacement with stomach in a group of 21 patients between 1976 and 1986 who had undergone multiple unsuccessful esophageal operations. All patients had between one and four unsuccessful operations for benign esophageal disorders. Sixteen patients had primary motor disorders: achalasia in nine and esophageal spasm in seven. Of these patients, 11 also had recurrent gastroesophageal reflux and peptic esophagitis. Complicated reflux disease characterized by severe esophagitis, stricture, and impaired peristalsis without primary motor disorder occurred in five patients. In one patient a functionally impaired long-segment colon interposition was removed and replaced with stomach. Total thoracic esophagectomy and cervical esophagogastric reconstruction was done in all patients. The transhiatal approach was chosen for resection in 16 patients and thoracotomy was used in the other five. There was one perioperative death (5%), from massive aspiration 4 days after transhiatal esophagectomy. Other complications included transient anastomotic leak (three patients), tracheoesophageal fistula (one), recurrent nerve palsy (one), and transient hoarseness (two). Follow-up is complete between 1 and 10 years and reveals the following functional results: 12 patients good to excellent, seven fair, one poor. In this patient group in which multiple prior procedures have failed to improve severe incapacitating symptoms, we believe further attempts at hiatal reconstruction are unlikely to succeed. For this circumstance, we recommend total thoracic esophagectomy with the use of stomach as the replacement organ of choice.

異時性多発舌癌に合併した同時性多発食道表圧癌の一例

Incidence of esophageal cancer among patients with head and neck cancer was estimated as about 1%. Recently, we had a rare case with double cancer of metachronous multiple tongue cancer and synchronous multiple superficial esophageal cancer.A 48 year old man admitted the hospital for his tongue ulcer. He had underwent partial resection and irradiation of tongue cancer 4 years before. Further examination revealed epidermoid carcinoma at tongue ulcer and multiple superficial esophageal cancer. The tongue cancer was estimated as metachronous multiple cancer, because the lesion occupied opposite side of the tongue to the former tumor and there suspected no continuity between them. Partial resection of the tongue and total thoracic esophagectomy were carried out. Histological studies on resected specimens disclosed the tongue cancer as T1NO (stage I) and five esophageal cancers as superficial cancer (3 mucosal cancers, and 2 submucosal cancers) . There found only one lymphnode metastasis at para-tracheal node (n=1/98) .Postoperative chemotherapy was carried out using CDDP 50 mg, MTX 30 mg and BLM 15 mg, and it repeated four times. Post operative course was uneventful.

Cisplatin and 5-fluorouracil in the primary management of squamous esophageal cancer.

A combined treatment program consisting of chemotherapy with cisplatin and infusion 5-fluorouracil (5-FU) for three cycles followed by esophagectomy or radiation, or both, has been conducted in 26 patients with squamous cancer of the esophagus localized to the primary site. Eleven patients had objective evidence of partial or complete response to the chemotherapy. Fourteen patients were operated on and ten underwent total esophagectomy. Drug toxicity was considerable with severe mucositis and myelosuppression occurring in 11 and seven patients, respectively. There were no drug-related deaths. Median survival is 17.8 months. Ten patients have lived more than 2 years. Six of these patients have undergone total thoracic esophagectomy after the induction chemotherapy. Determination of the ultimate benefits of combined modality therapy may require prospective randomized trials isolating the major treatment components but our data suggest that chemotherapy contributes to improved results in this disease and that drug therapy is emerging as an integral component of combined therapy.

A CASE OF MINUTE INTRAEPITHELIAL ESOPHAGEAL CANCER

On gastroesophagoscopy during a routine medical examination, a 57-year-old woman was found to have a minute depressed lesion with reddening of the surrounding mucosa on the wall of the thoracic esophagus. The lesion was subsequently identified by biopsy as squamous cell carcinoma and was referred to us. X-ray examination on admission failed to delineate the lesion, but endoscopy disclosed a minute erosion-like depressed lesion of the esophageal mucosa situated at a distance of 25cm from the incisors. Under the diagnosis of early esophageal cancer she underwent total thoracic esophagectomy and an operation of retrosternal quasi-total gastric reconstruction. In the excised portion of the esophagus there was a shallow depressed lesion, 4×2mm in size, surrounded by a slightly reddened area of mucosa. This was shown histologically to consist of a squamous cell carcinoma 1mm in diameter confined within the mucosal epithelium and haloed by an area of dysplasia 3mm in diameter. Leukoplakia and chronic inflammatory cell infiltration were also present as concomitant changes. Of all cases of intraepithelial cancer of the esophagus so far reported in Japan, data compiled from 28 well documented cases were analyzed for pathological and other conditions.

Management of Adenocarcinoma in a Columnar-Lined Esophagus

Of 89 patients diagnosed between 1973 and 1983 as having at least 3 cm of columnar-lined esophagus, 22 were found to have adenocarcinoma. There was no difference in sex ratio, smoking, or the use of alcohol between the benign and adenocarcinoma groups. The patients with adenocarcinoma were older (63 years versus 57 years) and had a higher frequency of dysphagia (64% versus 46%), gastrointestinal bleeding (36% versus 24%), extended columnar-lined esophagus (94% versus 28%), and epithelial dysplasia (68% versus 10%). Heartburn was less frequent in the adenocarcinoma group (59% versus 79%), but when it occurred, it was of longer duration (mean, 18.8 years versus 10.9 years). In 2 patients, progression from benign columnar-lined esophagus to early adenocarcinoma was observed. Of the patients with adenocarcinoma, 2 received palliative treatment without resection and died four and nine months later. Six underwent partial esophagogastrectomy with 1 postoperative death. Four had residual columnar-lined esophagus at the resection margins. In one of them, stricture developed and in one, anastomotic recurrence of adenocarcinoma; 1-year survival was 50%. Fourteen patients underwent total thoracic esophagectomy with no operative deaths, strictures, or anastomotic recurrences; 1-year survival was 5 of 6. Surgical staging revealed that 63% had transmural spread and 55%, lymph node involvement. Patients with columnar-lined esophagus, particularly with epithelial dysplasia, extended columnar-lined esophagus, and a long duration of heartburn, are at risk of developing adenocarcinoma. Adenocarcinoma may be diagnosed at an early stage if patients with epithelial dysplasia are followed with regular endoscopy. Total versus partial removal of the esophagus for adenocarcinoma in columnar-lined esophagus decreases the risk of complications from residual columnar-lined esophagus.

Carcinoma of the Esophagus: A Disaster

Because of the extremely high morbidity and mortality associated with esophageal carcinoma and our impression that squamous cell carcinoma of the esophagus was being seen with great frequency in young blacks, a retrospective study was undertaken at Charity Hospital of Louisiana and Touro Infirmary, both in New Orleans, from 1950 to 1965. Of the total of 548 patients studied, 9 survived five years, a rate of 1.6%. This extremely dismal picture was improved in patients who underwent palliative resection, among whom the five-year survival was 6%. Those in whom curative resection was attempted had a five-year survival of 15%. Attention should be paid to nutritional factors in the preoperative period. Preoperative radiation therapy should be considered, and it is suggested that many of these patients would do best with staged procedures involving total thoracic esophagectomy followed by retrosternal colon transplantation.