Transhiatal Resection Research Articles

Esophageal resection for recurrent achalasia

This study examined esophageal resection as treatment for recurrence or treatment complications of achalasia. From 1976 through 1992, 37 patients (20 men and 17 women) underwent esophageal resection after initial surgical treatment for achalasia. The median age was 56 years (range, 19 to 84 years). Initial surgical treatment consisted of modified Heller myotomy in 28 patients, combined myotomy and antireflux procedure in 6, and antireflux procedure alone in 3. Twenty-six patients required an additional surgical procedure before esophageal resection (70.3%). Indication for esophageal resection was obstructive symptoms in 30 patients, cancer in 3, bleeding in 2, and perforation during dilation in 2. Reconstruction was established with the stomach in 26 patients, colon in 6, and small bowel in 5. Anastomosis was at the cervical level in 20 patients (54.1%) and intrathoracic in 17 (45.9%). There were two operative deaths (5.4%), both caused by intraoperative hemorrhage during transhiatal resection. Twelve patients (32.4%) had complications, which included cardiac dysrhythmia in 3, cervical anastomotic leak in 2, transient vocal cord paralysis in 2, pneumonia in 2, pulmonary embolus in 2, and reexploration for bleeding in 1. Follow-up was complete in all patients and ranged from 1.4 to 16 years (median, 6.3 years). Excellent or good long-term functional results were present in 32 patients (91.4%). Esophageal resection provides reasonable long-term functional results in patients with recurrence or treatment complications of achalasia. In our experience, transhiatal resection is associated with increased morbidity and mortality.

Problem of proximal third gastric carcinoma.

The prevalence of proximal third gastric carcinoma increases rapidly in the Western world. An analysis of prognostic factors indicates that the poor prognosis usually associated with these tumors is due at least in part to late presentation and advanced tumor stages. The current TNM classification usually understages these tumors because it does not take the partly retroperitoneal location of the proximal stomach into account. After correction of the TNM classification a proximal tumor location has no influence on survival. Because these tumors benefit most from radical lymph node dissection, the retroperitoneal lymphatic drainage must be taken into account when performing lymphadenectomy for proximal third gastric cancer. To avoid pancreatic fistulas and the associated morbidity, a pancreas-preserving splenectomy and lymphadenectomy should be adapted if an extended lymph node resection of the retroperitoneum is performed. Because of the high prevalence of "intestinal type" tumors in the proximal third of the stomach the extent of the luminal resection margins can be limited; that is, a total gastrectomy with transhiatal resection of the distal esophagus usually suffices to achieve complete tumor removal at the oral margin.

Esophageal cancer, early disease: diagnosis and current treatment.

Most esophageal cancers are at a fairly advanced stage at the time of diagnosis, and curative therapy is not possible. For those that are detected early, cure may be possible, particularly if there is no lymphatic spread. Radical therapeutic approaches result in increased treatment-related mortality, high treatment-induced morbidity, and reduced quality of life. Therefore it is one of the major targets in the treatment of esophageal cancers to classify the tumor and to perform adequate stage-related therapy. The modern diagnostic procedures, such as endoscopy, endoluminal sonography, computed tomography (CT) scanning, and endoscopic biopsy, have led to major advances in preoperative staging. Endoluminal sonography is able to predict the depth of tumor infiltration in the esophageal wall and the existence of local lymph node metastasis, whereas CT scanning demonstrates distant metastasis. Histologic classification of the tumor together with genetic and cell biologic characteristics can predict the prognosis. Currently, the best prospect for cure of early esophageal cancer is surgical resection through the abdominothoracic approach, although less radical surgical procedures such as transhiatal resection without extensive lymph node dissection seem to achieve the same results. Even less traumatic is the use of minimal invasive techniques, which certainly will be used more often in the future. For early esophageal cancers limited to the epithelium and the lamina propria, local destruction of the tumor leads to long-term survival and cure. Techniques such as endoscopic resection, laser coagulation, photo-dynamic laser activation, and argon beam exposure have been described and seem to achieve similar results.(ABSTRACT TRUNCATED AT 250 WORDS)

Superiority of extended en bloc esophagogastrectomy for carcinoma of the lower esophagus and cardia

The belief that transhiatal esophagogastrectomy results in the same survival as a more extensive en bloc resection was tested in 69 patients with carcinoma in the distal esophagus and gastric cardia. Preoperative and intraoperative staging defined three distinct subgroups of patients. Those with apparently limited disease and good general health (group I, n = 30) underwent en bloc resection. Those with apparently limited disease but poor physiologic reserve (group II, n = 16) underwent transhiatal resection, as did those with evidence of more advanced disease (group III, n = 23). Overall, survival was significantly better in the 30 patients who underwent en bloc resection (41%) than in the 39 patients who underwent transhiatal resections (14%; p < 0.001, log-rank). Clinical staging showed apparently limited disease in 46 patients (groups I and II). These groups differed only in the presence of poor physiologic reserve because the percentages of patients with tumors limited to the esophageal wall (group I 13/30, group II 6/16) and four or fewer lymph node metastases (group I 21/30, group II 15/16) at the time of pathologic staging were not significantly different. Survival after en bloc resection was, however, significantly better (41% versus 21%; p < 0.05, log-rank). According to the WNM system of pathologic staging, 19 patients had early lesions defined as intramural lesions associated with four or fewer lymph node metastases, 26 had intermediate lesions defined as either transmural or associated with more than four lymph node metastases, and 24 had late lesions defined as both transmural and associated with fewer than four lymph node metastases. Survival was significantly better in patients with early lesions after en bloc resection compared with transhiatal resection (75% versus 20%, p < 0.01), survival was also significantly better in patients with advanced lesions (27% versus 9%, p < 0.01). For intermediate lesions, the survival was similar (14% versus 20%), although the median survival after en bloc resection was longer (24 months versus 8 months).

Esophagogastrectomy: reoperation for complications.

From 1961 to 1991, a total of 1,452 esophagectomies were performed for esophageal cancer at Memorial Sloan-Kettering Cancer Center. Of these patients, 40 (2.7%) developed complications requiring a second operation during the same hospitalization. The majority of the carcinomas were located in the midesophagus or the gastroesophageal junction. The pathologic diagnosis was squamous cell carcinoma in two-thirds of the patients. Few comorbid factors could be identified. Twenty-nine patients (72%) had a standard Ivor-Lewis resection, 5 (12%) had a transhiatal resection, 5 (12%) had a transabdominal approach, and 1 (3%) had a cervical approach only. Complications requiring reoperation were the following: respiratory failure in 13 patients, anastomotic leak in 6, bowel obstruction in 5, major bleeding in 4, wound dehiscence in 4, tracheo-esophageal fistula in 3, feeding tube malposition in 2, empyema in 1, chyle leak in 1, a positive margin in 1. Twelve of these same patients had a persistent or second complication and required a third operation. Among the 40 patients in this study, the mortality was 40%.

Esophageal resection by cervico-abdominal approach without thoracotomy.

The authors report their experience with transhiatal esophageal resection accumulated during the period between January 1978 and March 1990. Indications for the procedure included cancer of the gastric cardia (26.3%), cancer of the hypopharynx (3.8%), cancer of the esophagus (59.2%), and benign esophageal disease (9.8%). Esophageal substitution was performed using a tubulized stomach (63.6%), ileo-ceco-coloplasty (28.5%), left colon (7.6%), and jejunum (0.3%). The majority of patients with neoplastic disease were found to be in an advanced stage (67.3% of esophageal cancer patients and 69.7% of cancer of the cardia patients with stage III disease). The mean intra-operative volume of blood transfused varied between 533 and 1,220 ml. Sixteen patients required hospitalization in the intensive care unit. The mean length of post-operative hospitalization varied between 16.8 and 20.6 days. Operative complications included hemorrhage (0.3%) and tracheal injury (0.6%). Operative (30 day) mortality was 5.8%. Causes of death included respiratory insufficiency (35.2%), pulmonary sepsis (23.5%), abdominal sepsis (17.8%), and others (undefined, 23.5%). The 5 year survival was 48.5% for cancer of the gastric cardia, 57.1% for cancer of the hypopharynx and 11.8% for esophageal cancer.

Treatment of Carcinoma of the Esophagus or Cardia

Esophagogastrectomy is the best available treatment for patients with carcinoma of the esophagus or cardia and is associated with low hospital morbidity and mortality. It provides better longevity than other types of therapy and an acceptable survival rate. After esophagogastrectomy, 80% or more of the patients have satisfactory palliation of dysphagia. During an 18-year experience (1970 to 1988) with surgical treatment of carcinoma of the esophagus or cardia at the Lahey Clinic, 82.3% of patients with this disease were surgical candidates. Of the 310 patients who were treated surgically, 275 (88.7%) underwent resection, and the 30-day mortality rate was 2.2%. In 196 patients, gastrointestinal continuity was reestablished afterward by intrathoracic esophagogastrostomy. Cervical anastomosis was performed in 61 patients, 53 of whom had transhiatal resection. Major complications that prolonged the hospital stay occurred in 40 patients, and minor complications occurred in 28. The adjusted actuarial 5-year survival rate was 20.8% for all patients and 23.3% when only curative resections were considered. Stage of the disease was the most important determinant of long-term survival. Survival statistics were similar for patients with squamous cell epithelioma, adenocarcinoma of the cardia, or adenocarcinoma in Barrett's esophagus.

Surgery and current management for cancer of the esophagus and cardia

The current status of carcinoma of the esophagus is reviewed, with specific discussions on current problems. These are difficulties in staging the disease, confusion in the classification, surgery vs. radiation therapy, palliative vs. curative resection, transthoracic vs. transhiatal resection for palliation, and stomach vs. colon as an esophageal substitute after resection. The importance of dysphagia as the presenting complaint is stressed, and the etiologic factors for squamous and adenocarcinoma are reviewed, with a focus on Barrett's esophagus. In management, an emphasis is placed on intraoperative staging, the selection of patients for curative resection, the theory and use of en bloc resection, and the effect of tumor localization on the choice of surgical procedure. A description of the operative technique for cervical lesions, and transthoracic, transhiatal, and en bloc resection of thoracic lesions is given. The palliative benefit of bougienage, intubation, surgical bypass, radiotherapy, laser therapy, and electrical coagulation is summarized. The benefits of intubation are stressed. The recent advent of combination therapy, particularly with regard to chemotherapy and surgery, is discussed. Although such therapy is exciting in isolated patients, the results are not sufficiently predictable to be considered as standard therapy. More work needs to be done to identify those patients most apt to benefit from the variety of therapeutic modalities available.

Foreword

The current status of carcinoma of the esophagus is reviewed, with specific discussions on current problems. These are difficulties in staging the disease, confusion in the classification, surgery vs. radiation therapy, palliative vs. curative resection, transthoracic vs. transhiatal resection for palliation, and stomach vs. colon as an esophageal substitute after resection. The importance of dysphagia as the presenting complaint is stressed, and the etiologic factors for squamous and adenocarcinoma are reviewed, with a focus on Barrett's esophagus. In management, an emphasis is placed on intraoperative staging, the selection of patients for curative resection, the theory and use of en bloc resection, and the effect of tumor localization on the choice of surgical procedure. A description of the operative technique for cervical lesions, and transthoracic, transhiatal, and en bloc resection of thoracic lesions is given. The palliative benefit of bougienage, intubation, surgical bypass, radiotherapy, laser therapy, and electrical coagulation is summarized. The benefits of intubation are stressed. The recent advent of combination therapy, particularly with regard to chemotherapy and surgery, is discussed. Although such therapy is exciting in isolated patients, the results are not sufficiently predictable to be considered as standard therapy. More work needs to be done to identify those patients most apt to benefit from the variety of therapeutic modalities available.

Surgery and current management for cancer of the esophagus and cardia

The current status of carcinoma of the esophagus is reviewed, with specific discussions on current problems. These are difficulties in staging the disease, confusion in the classification, surgery vs. radiation therapy, palliative vs. curative resection, transthoracic vs. transhiatal resection for palliation, and stomach vs. colon as an esophageal substitute after resection. The importance of dysphagia as the presenting complaint is stressed, and the etiologic factors for squamous and adenocarcinoma are reviewed, with a focus on Barrett's esophagus. In management, an emphasis is placed on intraoperative staging, the selection of patients for curative resection, the theory and use of en bloc resection, and the effect of tumor localization on the choice of surgical procedure. A description of the operative technique for cervical lesions, and transthoracic, transhiatal, and en bloc resection of thoracic lesions is given. The palliative benefit of bougienage, intubation, surgical bypass, radiotherapy, laser therapy, and electrical coagulation is summarized. The benefits of intubation are stressed. The recent advent of combination therapy, particularly with regard to chemotherapy and surgery, is discussed. Although such therapy is exciting in isolated patients, the results are not sufficiently predictable to be considered as standard therapy. More work needs to be done to identify those patients most apt to benefit from the variety of therapeutic modalities available.