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PubMed2006

Esophagectomy for Barrett's esophagus: indications, techniques, and outcome.

Barrett's esophagus describes metaplastic changes from squamous mucosa to specialized columnar epithelium that can progress from low-grade dysplasia to high-grade dysplasia and even invasive carcinoma. The treatment of Barrett's esophagus with low-grade dysplasia or Barrett's adenocarcinoma is relatively standardized; however, controversy remains regarding appropriate therapy for Barrett's esophagus with high-grade dysplasia. Treatment recommendations for high-grade dysplasia vary widely, from periodic endoscopic surveillance to endoscopic ablative therapies and esophagectomy. Selected studies have shown that a relatively high percentage (41% to 47%) of patients with high-grade dysplasia have occult carcinoma. In these patients, surgery is indicated, as esophagectomy can be curative for early stage adenocarcinoma in Barrett's esophagus. A major criticism of esophagectomy is the significant morbidity and mortality. Minimally invasive esophagectomy was developed in an effort to reduce the morbidity associated with open esophagectomy. In minimally invasive esophagectomy, the abdominal laparotomy is replaced with laparoscopy, and the conventional right thoracotomy is replaced with thoracoscopy to reduce the operative trauma. In experienced centers, minimally invasive esophagectomy is now an attractive alternative for the treatment of Barrett's esophagus with high-grade dysplasia.

Journal Article↗

PubMed1997

Is esophagectomy following upfront chemoradiotherapy safe and necessary?

OBJECTIVE: To examine the safety and necessity of esophagectomy following upfront chemoradiotherapy (CRT) in patients with potentially resectable esophageal cancer. DESIGN: Cohort analytic study during a 4-year period. SETTING: Tertiary referral center. PATIENTS: Thirty-seven patients who completed CRT and underwent esophagectomy as compared with 30 patients who underwent esophagectomy alone without pretreatment during the same period. MAIN OUTCOME MEASURES: Resection-related events, perioperative morbidity and mortality, response to CRT, site of residual disease following CRT, and survival of partial responders. RESULTS: Patients receiving CRT followed by esophagectomy were similar to patients who underwent esophagectomy alone for operative characteristics, postoperative course, and perioperative morbidity and mortality. Of the 33 patients who achieved an objective response to CRT, 23 had residual tumor in the resection specimen. Of the 18 patients alive with no evidence of disease at a median follow-up of 30 months, 50% had residual tumor following CRT. CONCLUSIONS: Upfront CRT did not adversely affect resection-related outcome and may facilitate resection by downstaging disease. A considerable number of patients had prolonged survival after esophageal resection despite having residual tumor present following treatment with upfront CRT. Therefore, esophagectomy following upfront CRT can improve locoregional control of disease and should remain a critical component of any multimodality regimen.

Aged↗

PubMed2000

Chylothorax after thoracoscopic esophagectomy.

Among 30 patients who underwent thoracoscopic esophagectomy with lymphadenectomy for thoracic esophageal cancer, from July 1995 to May 1997, chylothorax developed in 2 patients (7%). In Case 1, the ligation of the thoracic duct under conventional right thoracotomy was performed on the 9th day after esophagectomy. After ligation, the pleural effusion was decreased, and the patient was discharged from hospital on the 25th day after the second operation. In Case 2, massive pleural effusion developed on the 10th day after esophagectomy (at 3 days after thoracic drainage tube was removed). The thoracic duct was ligated at the level just cranial to the diaphragm thoracoscopically on the 14th day after esophagectomy. The patient was discharged from hospital on the 30th day after the second operation. Injury to the thoracic duct due to a magnification effect of the view of scopic surgery remains a pitfall in thoracoscopic esophagectomy. But thoracoscopic ligation of thoracic duct was effective and safe for these two cases of chylothorax after esophagectomy.

Chylothorax↗

PubMed2000

Anastomotic diameters and strictures following esophagectomy and total gastrectomy in 256 patients.

The prevalence of anastomotic strictures in esophageal anastomoses provides us with limited information about the anastomotic healing process. This prospective study evaluates the exact esophageal anastomotic diameters in 256 patients who underwent esophagectomy and esophagogastrostomy without pyloroplasty (n = 107) or total gastrectomy and Roux reconstruction (n = 149). No perioperative chemoradiotherapy was given. Anastomotic strictures and diameters were assessed during endoscopy by a separately inserted (inflated to the anastomotic width) balloon catheter. The anastomotic diameters increased significantly during the first postoperative year in the esophagectomy (p = 0.001) and gastrectomy (p < 0.001) groups. The anastomoses in the gastrectomy group were significantly wider than those in the esophagectomy group 3 (25.7 versus 19.9 mm), 6 (28.5 versus 22.0 mm), and 12 (30.5 versus 23.3 mm) months after surgery (p < 0.001). Neither the anastomotic site (neck or chest) in the esophagectomy group (p = 0.176) nor that in the gastrectomy group (abdomen or chest) (p = 0.577) influenced the anastomotic diameter. Benign anastomotic strictures were most frequently found after 3 months and after esophagectomy. Esophagojejunostomies performed with 2 linear stapling devices or cartridge size 28 mm showed the widest anastomoses with only 1 stricture. Esophagogastric anastomoses following esophagectomy are narrower and develop more strictures than esophagojejunal anastomoses after total gastrectomy, but both dilate during the first year.

Adult↗

PubMed2001

Kinetics of cytokines and PMN-E in thoracoscopic esophagectomy.

BACKGROUND: Perioperative increases in the levels of cytokines and polymorphonuclear leukocyte elastase (PMN-E) have been shown to be related to degree of surgical trauma. METHODS: We measured the changes in levels of interleukin-6 (IL-6), interleukin-8 (IL-8), and PMN-E in the perioperative period in patients undergoing thoracoscopic esophagectomy (n = 15) and conventional transthoracic esophagectomy (n = 15) for thoracic esophageal cancer. RESULTS: Both IL-6 and IL-8 increased markedly immediately after transthoracic esophagectomy and thereafter, but only a slight increase was observed after the thoracoscopic procedure (IL-6: p = 0.047; IL-8: p = 0.03). A difference was also seen in the pattern of changes in PMN-E. Levels of PMN-E increased immediately after transthoracic esophagectomy and continued to be high up to the 3rd postoperative day, but they remained low after the thoracoscopic procedure and showed no increase (p <lt; 0.01). CONCLUSION: These results suggest that, compared with transthoracic esophagectomy, thoracoscopic esophagectomy results in less production of cytokines and PMN-E and thus causes less surgical trauma.

Cytokines↗

PubMed1995

Can esophagectomy cure cancer of the thoracic esophagus involving the major airways?

To evaluate the effects of aggressive operation for esophageal cancer invading the trachea and main bronchi, we investigated retrospectively 62 patients with proven tracheobronchial involvement who underwent thoracotomy for esophagectomy between 1973 and 1993. We operated unless the tumor was assessed to be definitely unresectable. Esophagectomy was possible in 55 patients, and the resectability rate was 95% after preoperative computed tomography and bronchoscopy became routine. After esophagectomy, no residual cancer lesion was recognizable macroscopically in 53% of patients. The hospital mortality rate in esophagectomy cases was 7% in the past 8 years. The outcome in patients who underwent curative resection was significantly favorable (p < 0.0001), and the 2-year survival was 51%. The patients with nonresectable cancer all died within 6 months compared with a 23% 1-year survival rate for palliative esophagectomy cases (p < 0.006). Among patients with tracheobronchial involvement assessed as resectable on computed tomography and bronchoscopy, a considerable proportion benefited from aggressive therapy with esophagectomy. The possibility of complete cure was high, especially when the cancer responded well to preoperative therapy and no lymph nodes were involved.

Adult↗

PubMed2005

Laparoscopic transhiatal esophagectomy for esophageal cancer.

BACKGROUND: Traditional esophagectomy may be associated with mortality, considerable morbidity, and lengthy recovery. It is often performed in cancer patients who are typically older, have associated comorbidities, and are often malnourished, all factors that increase surgical risk. Minimally invasive esophagectomy has the potential advantages of being a less traumatic procedure with an easier postoperative recovery and fewer wound and pulmonary complications. METHODS: A retrospective analysis of patients who underwent laparoscopic transhiatal esophagectomy was performed. Assessed parameters included patient demographics and operative data, pathology results, and long-term follow-up of at least 12 months. RESULTS: Twenty-two patients underwent laparoscopic transhiatal esophagectomy; 19 had esophageal cancer. Two patients were operated on for Barrett esophagus, and 1 patient had achalasia. The majority of patients were men (82%), and the mean age was 59 years (range 15 to 74 years); 1 patient (4.5%) was converted to open surgery. The average operative time was 380 minutes (range 285 to 525 minutes), and the average blood loss was 220 mL; only 3 patients required transfusion. The median hospital stay was 8 days (range 5 to 46 days). Postoperative mortality occurred in 1 patient (4.5%), and postoperative complications developed in 6 patients (27.2%). In the 19 cancer patients, the average number of harvested nodes was 14.3 (range 10 to 19). The average follow-up was 30 months (range 12 to 48 months). The overall survival for cancer patients was 61% (11 of 19), and disease-free survival was 39% (7/19). CONCLUSIONS: Esophagectomy is a major surgery with considerable morbidity and potential mortality. Minimally invasive esophagectomy is a feasible approach that can be safely performed by surgeons with extensive experience in that field. Advantages include less intraoperative blood loss, a smaller incision, and a potentially faster postoperative recovery. In cancer patients, immediate oncologic goals of adequate margins and lymph node dissection can be achieved, and long-term outcome appears to be similar to that found with open approaches.

Adolescent↗

PubMed2005

Intrathoracic manifestations of cervical anastomotic leaks after transthoracic esophagectomy for carcinoma.

BACKGROUND: A purported advantage of the cervical esophagogastrostomy is that drainage is easily accomplished should anastomotic dehiscence occur after esophagectomy. However, support for this statement stems mainly from studies of transhiatal esophagectomy, with little data published when a transthoracic resection is performed. The purpose of this study was to determine the incidence and clinical significance of intrathoracic manifestations of cervical anastomotic leaks after transthoracic esophagectomy. METHODS: A retrospective analysis of a prospectively collected esophageal carcinoma database (1988 to 2004) was performed at a single institution. Operative and pathologic data were collected, as well as details concerning the incidence, clinical features, treatment, and outcome of anastomotic leaks. Patients with leaks were further analyzed on the basis of whether or not intrathoracic manifestations of anastomotic leakage were present. RESULTS: Two hundred, forty-two patients underwent transthoracic esophagectomy with a cervical anastomosis during the study period. There were 27 (11.1%) anastomotic leaks. Of these, 14 patients (52%) had intrathoracic manifestations of their cervical leaks, with empyema being the most common. Patients with intrathoracic spread of sepsis had significantly longer in-hospital (p < 0.001) and anastomotic healing times (p < 0.05) and required more drainage procedures (including reoperation; p < 0.005) than those with leaks confined to the neck. However, no difference in operative mortality or long-term survival was appreciated. CONCLUSIONS: Intrathoracic manifestations of cervical anastomotic leaks are more common after transthoracic esophagectomy than what has historically been reported for transhiatal esophagectomy. This discrepancy may be due to anatomical or technical differences, or both, between the two procedures. Early diagnosis and aggressive drainage are necessary for achieving a favorable outcome.

Abscess↗

PubMedDate not supplied

Multicenter prospective randomized trial comparing standard esophagectomy with chemoradiotherapy for treatment of squamous esophageal cancer: early results from the Chinese University Research Group for Esophageal Cancer (CURE).

We conducted a prospective randomized trial to compare the efficacy and survival outcome by chemoradiation with that by esophagectomy as a curative treatment. From July 2000 to December 2004, 80 patients with potentially resectable squamous cell carcinoma of the mid or lower thoracic esophagus were randomized to esophagectomy or chemoradiotherapy. A two- or three-stage esophagectomy with two-field dissection was performed. Patients treated with chemoradiotherapy received continuous 5-fluorouracil infusion (200 mg/m2/day) from day 1 to 42 and cisplatin (60 mg/m2) on days 1 and 22. The tumor and regional lymphatics were concomitantly irradiated to a total of 50-60 Gy. Tumor response was assessed by endoscopy, endoscopic ultrasonography, and computed tomography scan. Salvage esophagectomy was performed for incomplete response or recurrence. Forty-four patients received standard esophagectomy, whereas 36 were treated with chemoradiotherapy. Median follow-up was 16.9 months. The operative mortality was 6.8%. The incidence of postoperative complications was 38.6%. No difference in the early cumulative survival was found between the two groups (RR = 0.89; 95% confidence interval, 0.37-2.17; log-rank test P = 0.45). There was no difference in the disease-free survival. Patients treated with surgery had a slightly higher proportion of recurrence in the mediastinum, whereas those treated with chemoradiation sustained a higher proportion of recurrence in the cervical or abdominal regions. Standard esophagectomy or chemoradiotherapy offered similar early clinical outcome and survival for patients with squamous cell carcinoma of the esophagus. The challenge lies in the detection of residue disease after chemoradiotherapy.

Adult↗

PubMed2006

Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position--experience of 130 patients.

BACKGROUND: To evaluate outcomes after minimally invasive or thoracolaparoscopic esophagectomy (TLE) with thoracoscopic mobilization of the esophagus and mediastinal esophagectomy in prone position. Esophagectomies are being performed increasingly by a minimally invasive route with decreased morbidity and shorter hospital stay compared with conventional esophagectomy. Most series report thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in the left lateral position with respiratory complications up to 8% and prolonged operative time, probably because of inadequate stance of the surgeon during the thoracoscopic part. This study shows the potential of the thoracoscopic part of the procedure in prone position to ease these difficulties. STUDY DESIGN: From January 1997 through April 2005, TLE was performed in 130 patients. All patients had histologically proved squamous cell carcinoma of the middle third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The thoracoscopic part of the procedure was performed in prone position with excellent ergonomics, translating into less operative time and better respiratory results. We performed a minilaparotomy to retrieve the specimen owing to bulky tumors. Feeding jejunostomy and pyloromyotomy were performed in all patients. RESULTS: There were 102 men and 28 women. Median age was 67.5 years (range 38 to 78 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 32 days) and median hospital stay was 8 days (range 4 to 68 days). Perioperative mortality was 1.54% (n = 2). Anastomotic leak rate was 2.31% (n = 3). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean followup of 20 months (range 2 to 70 months), stage-specific survival was similar to open and other minimally invasive series. CONCLUSIONS: TLE with thoracoscopic part in prone position is technically feasible, with a low incidence of respiratory complications and less operative time required. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (1.54%), hospital stay of 8 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.

Adult↗

PubMed1997

Postoperative analgesia reduces mortality and morbidity after esophagectomy.

BACKGROUND: To study the influence of postoperative analgesia on morbidity and mortality after esophagectomy. METHODS: The outcomes of 578 patients who underwent one-stage resection between 1986 and 1995 were analyzed. Patients who received either epidural morphine, patient-controlled analgesia, or continuous intravenous morphine infusion supervised by an anesthesiology-based acute pain service (group APS, n = 299) were compared with those for whom conventional intramuscular meperidine injections were used (group CON, n = 279). RESULTS: For patients who underwent transthoracic esophagectomy, group APS (n = 226) had a lower incidence of pulmonary complications (13% versus 25%, P = 0.002), cardiovascular complications (21% versus 43%, P < 0.001), and hospital mortality (8% versus 14%, P = 0.038) when compared with group CON (n = 189). No similar difference was demonstrated in patients who underwent esophagectomy without thoracotomy. The hospital stay (days) was shorter in group APS than in group CON for both transthoracic esophagectomy (22 +/- 20 versus 30 +/- 37, P = 0.005) and nontransthoracic esophagectomy patients (19 +/- 13 versus 25 +/- 21, P = 0.029). CONCLUSION: Adequate postoperative analgesia is associated with lower cardiopulmonary complications, lower mortality and reduced cost in patients undergoing transthoracic esophagectomy.

Analgesia↗

PubMed1995

Gastrointestinal function following esophagectomy for malignancy.

BACKGROUND: The frequency and causes of gastrointestinal complications following esophagectomy for malignancy are unknown. PATIENTS AND METHODS: We reviewed 295 esophagectomies performed for malignancy between January 1980 and September 1994 in order to determine the frequency and causes of early and late gastrointestinal complications. RESULTS: Compared to transhiatal and left thoracoabdominal esophagectomies, esophagectomies carried out through a right posterolateral thoracotomy with cervical esophagogastric anastomosis had a higher incidence of delayed gastric emptying (11%), pneumonia (26%), and hospital death (9%). The same operation had a higher incidence of gastroesophageal reflux (20%) and dysphagia requiring esophageal dilatation (53%). We found no independent effect of gastric drainage procedures, feeding jejunostomy, preoperative radiotherapy, pathology, or age on these outcomes. Women had no operative mortality, but a higher incidence of gastroesophageal reflux and diarrhea following esophagectomy. CONCLUSIONS: Surgical techniques aimed at improving gastric emptying following esophagectomy for cancer should improve operative morbidity and mortality.

Adenocarcinoma↗

PubMed2000

Minimally invasive esophagectomy.

BACKGROUND: Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published. METHODS: From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy. RESULTS: Indications included esophageal carcinoma (n = 54), Barrett's high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively. CONCLUSIONS: Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.

Adult↗

PubMed2001

Esophagectomy for achalasia: patient selection and clinical experience.

BACKGROUND: In 1989, we predicted an increasing number of esophagectomies for megaesophagus and for recurrent symptoms after prior esophagomyotomy or balloon dilatation for achalasia. Patient selection in this group is challenging, as the potential operative morbidity of an esophagectomy must be weighed against the expected clinical outcome after a redo esophagomyotomy or alternative procedures designed to salvage the native esophagus. METHODS: The hospital records of 93 patients undergoing esophagectomy for achalasia during the past 20 years were reviewed retrospectively and the results of operation assessed using our prospectively established Esophageal Resection Database and follow-up information obtained through personal contact with the patients. RESULTS: Patient age averaged 51 years. Indications for esophagectomy included tortuous megaesophagus (64%), failure of prior myotomy (63%), and associated reflux stricture (7%). Ninety-four percent of the patients underwent a transhiatal esophagectomy. Stomach was used as the esophageal substitute in 91% cases. Intraoperative blood loss averaged 672 mL. Postoperative length of stay averaged 12.5 days. Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis. Follow-up has averaged 38 months. In all, 95% of patients eat well; nearly 50% have required an anastomotic dilatation; troublesome regurgitation has been rare; and 4% have refractory postvagotomy dumping. CONCLUSIONS: Esophagectomy, preferably through a transhiatal approach, is generally safe and effective therapy in selected patients with achalasia. Unique technical considerations include difficulty encircling the dilated cervical esophagus, deviation of the esophagus into the right chest, large aortic esophageal arteries, and adherence of the exposed esophageal submucosa to the adjacent aorta after prior myotomy.

Adolescent↗

PubMed2003

Autopsy findings in patients after curative esophagectomy for esophageal carcinoma.

BACKGROUND: The mode of recurrence after esophagectomy for esophageal cancer has seldom been studied in detail from autopsy findings. STUDY DESIGN: We reviewed the autopsy findings in 43 curatively resected cases of esophageal cancer between 1976 and 1997 at a single institution. RESULTS: Recurrent or residual esophageal cancer was identified in 27 of the 43 patients (62.8%) at autopsy. Local recurrence, lymph node metastases, hematogenous metastases, and serosal carcinomatosis were observed in 11 (25.6%), 18 (41.9%), 17 (39.5%), and 11 patients (25.6%), respectively. Metastases to the thoracic, abdominal, and cervical nodes were observed in 37.2%, 16.3%, and 11.6% of the cases at autopsy, respectively. The pulmonary hilar nodes were most frequently involved (25.6%). The frequency of local recurrence was significantly lower in cases after curative subtotal esophagectomy with two- or three-field dissection (19.4%) than in cases after lower esophagectomy (66.7%) (p = 0.032). The frequency of hematogenous metastases after curative esophagectomy after preoperative radiotherapy was significantly lower in responders (Grades 2 to 3) than in nonresponders (Grades 0 to 1) (p = 0.035). CONCLUSIONS: This study showed the characteristics of recurrence after esophagectomy for esophageal cancer. Despite esophagectomy with lymph node dissection, the frequency of each mode of recurrence was remarkably high. Anatomic difficulty of complete removal of lymph nodes by surgical procedures was suggested. Hematogenous metastases and serosal carcinomatosis were beyond surgical resection. More effective multimodal therapy will be required to improve survival of esophageal cancer patients.

Aged↗

PubMed1998

Outcomes of extended radical esophagectomy for thoracic esophageal cancer.

BACKGROUND: Great controversy exists concerning the adequate extent of esophagectomy for cure in patients with esophageal cancer. Extended radical esophagectomy combined with three-field lymphadenectomy has been performed to improve the cure rates for patients with the disease in Japan. The purposes of this study were to assess the mortality and morbidity rates after extended radical esophagectomy and to determine the oncologic indications for this procedure. STUDY DESIGN: We reviewed 190 patients who underwent extended radical esophagectomy for invasive esophageal cancer. The procedures were performed prospectively between 1982 and 1996. RESULTS: The 30-day mortality, in-hospital mortality, and morbidity rates were 1.6%, 4.7%, and 58.4%, respectively. The most common postoperative complication was vocal-cord paralysis (45.3%), followed by major pulmonary complications (21.6%). The overall survival rate for the 190 patients was 41.5% at 5 years, with a median followup period of 61 months. Some subgroups of patients had an extremely poor prognosis despite extended radical esophagectomy. Survival was < or = 5 years in all patients with five or more positive nodes; all patients with simultaneous metastases to the cervical, mediastinal, and abdominal lymph nodes; and all patients with cervical metastases from a lower esophageal tumor. CONCLUSIONS: Extended radical esophagectomy is potentially associated with high morbidity rates although the mortality rates are acceptable, suggesting the necessity of careful patient selection. This procedure is indicated oncologically only for patients with four or fewer metastatic nodes or with metastases confined to one or two of the three anatomic compartments (neck, mediastinum, and abdomen) from upper or midesophageal tumors.

Carcinoma, Squamous Cell↗

PubMedDate not supplied

Intratracheal long-term pH monitoring: a new method to evaluate episodes of silent acid aspiration in patients after esophagectomy and gastric pull up.

Aspiration of gastric contents is considered a leading cause of postoperative pulmonary complications after esophagectomy and gastric pull up but has been difficult to diagnose. We used intratracheal long-term pH monitoring to evaluate the prevalence of aspiration of gastric contents in patients undergoing these operations. Continuous intratracheal pH monitoring was carried out during the first 72 postoperative hours in 16 patients with esophageal carcinoma who had undergone esophagectomy and gastric pull up. A drop in the pH to less than 4 was defined as an episode of acid aspiration. All patients except one tolerated the probe without any difficulties. Episodes of acid aspiration could be detected in 12 (80%) of 15 patients (5 of 8 after transhiatal esophagectomy, 7 of 7 after transthoracic esophagectomy, 2 of 5 with reconstruction in the anterior mediastinum, and 9 of 10 with reconstruction in the posterior mediastinum). The number of aspiration episodes was significantly higher during postoperative day 1 (P=0.03) compared to postoperative days 2 and 3. Two patients developed pneumonia later in the postoperative course. Both of them had several episodes of acid aspiration detected by pH monitoring immediately postoperatively. Intratracheal pH monitoring is a safe, feasible, and well-tolerated method for detecting episodes of acid aspiration after esophagectomy and gastric pull up. Aspiration of gastric contents is a common phenomenon particularly during the first 24 postoperative hours after transthoracic esophagectomy and gastric pull up in the posterior mediastinum and appears to correlate with the development of postoperative pneumonia.

Adenocarcinoma↗

PubMed2000

Minimally invasive esophagectomy for Barrett's esophagus with high-grade dysplasia.

BACKGROUND: Barrett's esophagus with high-grade dysplasia (BE/HGD) is associated with invasive carcinoma in 30% to 70% of cases. Esophagectomy is the treatment of choice for patients with BE/HGD but esophagectomy can be associated with high morbidity and mortality. The aim of our study was to report our preliminary experience in applying minimally invasive surgical techniques to esophagectomy for BE/HGD. METHODS: From August 1996 to February 1999, 12 consecutive patients underwent minimally invasive esophagectomy for biopsy-proven BE/HGD. Our consort consisted of 7 men and 5 women; average age was 64 years (range, 40-78 years). All patients underwent a complete laparoscopic or combined laparoscopic and thoracoscopic resection of the esophagus with cervical anastomosis. RESULTS: Mean operative time was 7.8 +/- 2.1 hours, mean intensive care unit stay was 2.6 +/- 2.2 days, and mean length of hospital stay was 8.3 +/- 4.7 days. Five patients (42%) had carcinoma in situ or carcinoma identified on pathologic specimen. Analyses of all resected lymph nodes in the 12 patients were negative for metastatic disease. There were 6 major complications in 5 patients: 1 patient had a small bowel perforation requiring operative repair, 2 patients needed prolonged ventilatory support for respiratory insufficiency, and 3 patients had delayed gastric emptying requiring revision of the pyloromyotomy. The single minor complication in this series was a jejunostomy tube-site infection. There were no conversions to laparotomy or thoracotomy. All patients were alive and free of metastatic disease at a mean follow-up of 12.6 months. CONCLUSIONS: Minimally invasive esophagectomy is a feasible and safe alternative to conventional open esophagectomy for patients with BE/HGD.

Adult↗