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PubMed1996

Barrett's esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy.

OBJECTIVE: The authors review the results and outcomes of esophagectomy (prophylactic esophagectomy) for patients with Barrett's esophagus and high-grade epithelial dysplasia (HGD). SUMMARY BACKGROUND DATA: The role of prophylactic esophagectomy for Barrett's esophagus with HGD is controversial, with some authors recommending surgery and others favoring endoscopic surveillance until biopsy diagnosis of carcinoma is made. METHODS: Between 1982 and 1994, 30 consecutive patients with HGD underwent esophagectomy and had the pre- and postoperative pathology reviewed at our institution. The medical records were reviewed to determine patient characteristics, preoperative endoscopic data, surgical approach, operative morbidity and mortality, length of hospitalization, and treatment outcome. Patients were divided into two groups based on whether invasive adenocarcinoma was found in the resection specimen (group 1) or not (group 2). RESULTS: The duration of reflux symptoms was 22 +/- 14 years for group 1 and 9 +/- 11 years for group 2 (p = 0.05). There was one operative death (3.3%) and six complications (20%). In 13 patients (43%, group 1), invasive adenocarcinoma was found in the resected esophagus. The American Joint Committee on Cancer stage for these patients was stage I (8 patients), stage II (2 patients), and stage III (3 patients). One stage I patient died of adenocarcinoma (72 months) in an incompletely excised HGD segment. Other stage I and II patients are alive without adenocarcinoma with an 18-and 63-month mean follow-up, respectively. Outcome for stage III patients was one operative death, one noncancer death (6 months), and one patient with metastatic adenocarcinoma (26 months). For group 2 (57%), there were no adenocarcinoma deaths (40 months). CONCLUSIONS: High-grade epithelial dysplasia is an indication for esophagectomy because of the prevalence of occult adenocarcinoma (43%). Esophagectomy can be performed safely, and survival in patients with completely resected Barrett's esophagus and early-stage adenocarcinoma is excellent.

Adenocarcinoma↗

PubMed2001

Skeletonizing en bloc esophagectomy for cancer.

OBJECTIVE: To evaluate the long-term outcome of patients with esophageal cancer after resection of the extraesophageal component of the neoplastic process en bloc with the esophageal tube. SUMMARY BACKGROUND DATA: Opinions are conflicting about the addition of extended resection of locoregional lymph nodes and soft tissue to removal of the esophageal tube. METHODS: Esophagectomy performed en bloc with locoregional lymph nodes and resulting in a real skeletonization of the nonresectable anatomical structures adjacent to the esophagus was attempted in 324 patients. The esophagus was removed using a right thoracic (n = 208), transdiaphragmatic (n = 39), or left thoracic (n = 77) approach. Lymphadenectomy was performed in the upper abdomen and lower mediastinum in all patients. It was extended over the upper mediastinum when a right thoracic approach was used and up to the neck in 17 patients. Esophagectomy was carried out flush with the esophageal wall as soon as it became obvious that a macroscopically complete resection was not feasible. Neoplastic processes were classified according to completeness of the resection, depth of wall penetration, and lymph node involvement. RESULTS: Skeletonizing en bloc esophagectomy was feasible in 235 of the 324 patients (73%). The 5-year survival rate, including in-hospital deaths (5%), was 35% (324 patients); it was 64% in the 117 patients with an intramural neoplastic process versus 19% in the 207 patients having neoplastic tissue outside the esophageal wall or surgical margins (P <.0001). The latter 19% represented 12% of the whole series. The 5-year survival rate after skeletonizing en bloc esophagectomy was 49% (235 patients), 49% for squamous cell versus 47% for glandular carcinomas (P =.4599), 64% for patients with an intramural tumor versus 34% for those with extraesophageal neoplastic tissue (P <.0001), and 43% for patients with fewer than five metastatic nodes versus 11% for those with involvement of five or more lymph nodes (P =.0001). CONCLUSIONS: The strategy of attempting skeletonizing en bloc esophagectomy in all patients offers long-term survival to one third of the patients with resectable extraesophageal neoplastic tissues. These patients represent 12% of the patients with esophageal cancer suitable for esophagectomy and 19% of those having neoplastic tissue outside the esophageal wall or surgical margins.

Adenocarcinoma↗

PubMed2006

Vagal integrity in vagal-sparing esophagectomy: a cadaveric study.

Esophagectomy is associated with a significant number of complications, some of them related to the concomitant vagotomy. The vagal-sparing esophagectomy is an attractive alternative to the conventional procedure; however, few clinical series have attested the integrity of the vagi nerves after esophagectomy. The surgical anatomy of the vagus in the mediastinum has received little interest as well. The anatomy of the vagus was studied in 30 fresh cadavers. Twenty cadavers were submitted to a vagal-sparing esophagectomy, and after the procedure, anatomical vagal integrity was evaluated. Concerning the anatomy of the vagus, one or more vagal trunks were present in all cases. Four patterns were identified: Type I, two distinct trunks without communicating branches, present in eight (26.7%) cases; Type II, two distinct trunks with communicating branches, present in 17 (56.7%) cases; Type III, one or more bifurcated trunks, present in four (13.3%) cases; and Type IV, crossing trunks, present in one (3.3%) case. Regarding the esophagectomy, operative accidents were not noticed; in five cases, there was incomplete removal of the muscular layer of the esophagus. In all cases vagi nerves were preserved. The vagus is preserved in a cadaveric model of the vagal sparing esophagectomy, irrespective of the anatomy of the vagus in the mediastinum.

Adult↗

PubMed2006

Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients.

AIM: To evaluate the risk of esophagectomy for carcinoma of the esophagus in the elderly (70 years or more) compared with younger patients (< 70 years) and to determine whether the short-term outcomes of esophagectomy in the elderly have improved in recent years. METHODS: Preoperative risks, postoperative morbidity and mortality in 60 elderly patients (> or = 70 years) with esophagectomy for carcinoma of the esophagus were compared with the findings in 1782 younger patients (< 70 years) with esophagectomy between January 1990 and December 2004. Changes in perioperative outcome and short-time survival in elderly patients between 1990 to 1997 and 1998 to 2004 were separately analyzed. RESULTS: Preoperatively, there were significantly more patients with hypertension, pulmonary dysfunction, cardiac disease, and diabetes mellitus in the elderly patients as compared with the younger patients. No significant difference was found regarding the operation time, blood loss, organs in reconstruction and anastomotic site between the two groups, but elderly patients were more often to receive blood transfusion than younger patients. Significantly more transhiatal and fewer transthoracic esophagectomies were performed in the elderly patients as compared with the younger patients. Resection was considered curative in 71.66% (43/60) elderly and 64.92% (1157/1782) younger patients, which was not statistically significant (P>0.05). There were no significant differences in the prevalence of surgical complications between the two groups. Postoperative cardiopulmonary medical complications were encountered more frequently in elderly patients. The hospital mortality rate was 3.3% (2/60) for elderly patients and 1.1% (19/1 782) for younger patients without a significant difference. When the study period was divided into a former (1990 to 1997) and a recent (1997 to 2004) period, operation time, blood loss, and percentage of patients receiving blood transfusion of the elderly patients significantly improved from the former period to the recent period. The hospital mortality rate of the elderly patients dropped from the former period (5.9%) to the recent period (2.3%), but it was not statistically significant. CONCLUSION: Preoperative medical risk factors and postoperative cardiopulmonary complications after esophagectomy are more common in the elderly, but operative mortality is comparable to that of younger patients. These encouraging results and improvements in postoperative mortality and morbidity of the elderly patients in recent period are attributed to better surgical techniques and more intensive perioperative care in the elderly.

Aged↗

PubMedDate not supplied

Respiratory function after esophagectomy for patients with esophageal cancer.

BACKGROUND/AIMS: Postoperative respiratory hypofunction sometime ruins quality of life of patients with esophageal cancer. From 1993, we introduced transhiatal esophagectomy without thoracotomy as a less invasive surgery to prevent postoperative respiratory complications for patients who have relatively early stage of esophageal cancer and have preoperative respiratory complication, or who are older in age. In this study, postoperative long-term evaluation of respiratory functions of patients with esophageal cancer who underwent esophagectomy was performed. METHODOLOGY: Among the patients with esophageal cancer who underwent esophagectomy in our hospital between 1993 and 1995, we selected 13 patients who underwent transhiatal esophagectomy (transhiatal group) and 9 patients who underwent transthoracic esophagectomy (transthoracic group). Conventional respiratory function tests (VC, vital capacity; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; FEV1/FVC, ratio of FEV1 to FVC; PEF, peak expiratory flow) were compared between the two groups at 3, 6, and 12 months after operation. RESULTS: In the transhiatal group, postoperative average values of VC, FVC, and FEV1 recovered 92%, 98%, and 93% of preoperative average values at 6 months after operation, while in the transthoracic group, the average values of VC, FVC, and FEV1 were still 78%, 78%, and 72% of preoperative average values at 6 months after operation. Postoperative respiratory complications were detected in 4 patients (transhiatal: 2 and transthoracic: 2). The recovery rates of VC, FVC, FEV1, FEV1/FVC, and PEF at 6 months after operation of these 4 patients were not different from those of 18 patients without postoperative respiratory complications. CONCLUSIONS: In patients treated with transthoracic esophagectomy, postoperative respiratory hypofunctions continued over 6 months after surgery. However, postoperative respiratory complications may not be related with the long-term postoperative respiratory hypofunction in patients with esophageal cancer.

Aged↗

PubMed1992

[Management of patients with impaired glucose tolerance following esophagectomy in carcinoma of the esophagus].

We demonstrated the effectiveness of the "sliding scale" insulin infusion in diabetic patients undergoing esophagectomy. Fifty-eight patients were followed after esophagectomy to clarify differences in energy expenditure and caloric contributions of substrates. Energy expenditure was measured by indirect calorimetry on the 1st, 3rd, 5th, and 7th days after esophagectomy. Out of 58 patients, 7 were divided into diabetic (D), 30 into borderline (B), 21 into normal (N), according to a 75 g oral glucose tolerance test, preoperatively. Forty-four patients underwent esophagectomy by means of right thoracotomy, and blunt esophagectomy was done on 14 patients. The results were as follows: 1) No relation was found between postoperative morbidity and severity of glucose intolerance. 2) There was no significant difference in changes in energy expenditure following operation among groups D, B, and N. No difference was found in ratio of caloric intake to energy expenditure among groups D, B, and N. Caloric contributions of substrates seemed to be comparable among groups D, B, and N. These results suggest that "sliding scale" insulin infusion with total parenteral nutrition enable us to control not only blood glucose level but energy metabolism following esophagectomy in diabetic patients.

Diabetes Complications↗

PubMed2005

[Causes and prevention of anastomotic leakage after esophagectomy and reconstruction through different routes for esophageal cancer].

OBJECTIVE: To compare the anastomotic leakage rates after esophagectomy and reconstruction through different routes for esophageal cancer and analyze the causes for higher anastomotic leakage rate after esophagectomy, systemic lymph node dissection and reconstruction through retrosternal route and its prevention. METHODS: Data of 1105 cases of esophagectomy were reviewed retrospectively. Patients in group A (n=229) underwent esophagectomy through left thoracotomy and intrathoracic anastomosis, patients in group B (n=716), esophagectomy through right anterio-lateral thoracotomy and cervical reconstruction through posterior mediastinal route, patients in group C (n=160) esophagectomy, systemic lymph node dissection and cervical anastomosis through the retrosternal route. RESULTS: The leakage rate was significantly higher (19.4%) in group C than that in group B (11.9%, P< 0.05) and much significantly higher than that in group A (2.2%, P< 0.01). In group C, there was no significant difference in leakage rate between the patients with hand-sewn or mechanical anastomosis (22.2% vs.11.6%, P=0.133), between the patients who had whole stomach or tube-typed gastric reconstruction (25% vs.15.6%, P=0.146). The leakage rate was significantly decreased from 23.3% to 9.1% after prolonged nasal-gastric drainage for seven days (P< 0.05). CONCLUSION: The high anastomotic leakage rate after retrosternal reconstruction is mainly due to compression of the stomach in the anterior mediastinum. Prolonged nasogastric drainage is an effective way to decrease the leakage rate after systemic lymphadenectomy.

Anastomosis, Surgical↗

PubMed1992

[Experimental and clinical study of cardiopulmonary hemodynamics under one-lung ventilation during transthoracic esophagectomy].

Cardiopulmonary hemodynamics in pre- and postoperative period after transthoracic esophagectomy under one-lung ventilation (OLV) was investigated in experimental and clinical studies. In experimental study, 30 mongrel dogs were assigned to one of the groups: Group 1 (n = 10): 2 hour right thoracotomy alone under one (n = 5)- or two-lung ventilation (TLV) (n = 5), Group 2 (n = 10): thoracotomy + esophagectomy, Group 3 (n = 10): esophagectomy + right thoracic vagotomy. For further evaluation of the effect of vagotomy on increase of extravascular lung water (EVLW) on 3rd POD, the following 2 groups were designed as Group 4-1) (n = 5): thoracotomy + right thoracic vagotomy and Group 4-3) (n = 5): esophagectomy + left thoracic vagotomy. In clinical study, 30 patients underwent transthoracic esophagectomy were randomly divided into either OLV or TLV group. Cardiopulmonary hemodynamics and postoperative complications were investigated in pre- and up to 3 POD. 1. Cardiopulmonary parameters and EVLW except PaO2 and shunt ratio were not different between OLV and TLW groups in experimental study. PaO2 of OLV group dropped from the pre-thoracotomy value of 577 +/- 75 mmHg to 98 +/- 47 mmHg. This decrease was significant in comparison with TLV (582 +/- 85 mmHg to 215 +/- 132 mmHg) (p less than 0.05). Shunt ratio increased in the OLV group from 10 +/- 11% to 37 +/- 13%. This increase was also significant in comparison with TLV (24 +/- 10% from 9 +/- 9%) (p less than 0.05). However, both PaO2 and shunt ratio returned to the pre-thoracotomy value after stopping of OLV and showed no difference compared with TLV. 2. EVLW per kg was not different between 5 groups. Values of right to left lung ratio of EVLW in Group 3 and Group 4-3), 1.77 +/- 0.26 and 1.82 +/- 0.26, were greater than that in Group 1, 1.39 +/- 0.17 (p less than 0.05). This difference seems to be caused by increase of permeability of pulmonary capillaries. 3. Cardiopulmonary parameters and postoperative complications were not different between OLV and TLV groups in clinical study. In conclusion, OLV is a desirable procedure, not only for good exposure of the operative filed, but also for its safety regarding the cardiopulmonary hemodynamics. Transthoracic esophagectomy plus vagal branch denervation, which is necessary for aggressive lymphadenectomy around the trachea, increases EVLW and subsequent pulmonary edema compared with thoracotomy alone.

Aged↗

PubMed2006

Simplifying minimally invasive transhiatal esophagectomy with the inversion approach: Lessons learned from the first 20 cases.

HYPOTHESIS: The laparoscopic transhiatal esophagectomy can be simplified and performed safely and effectively by using a novel esophageal inversion technique. DESIGN: Case series describing technique, initial experience, and learning curve with laparoscopic inversion esophagectomy. SETTING: Tertiary care university hospital and veteran's hospital. PATIENTS: Twenty consecutive patients with high-grade dysplasia (n = 16) and esophageal adenocarcinoma (n = 4). INTERVENTION: Laparoscopic inversion esophagectomy, a totally laparoscopic approach to transhiatal esophagectomy that incorporates distal to proximal inversion to improve mediastinal exposure and ease of dissection. MAIN OUTCOME MEASURES: Perioperative end points and complications, compared between the first and second groups of 10 patients. RESULTS: There were 19 men and 1 woman. Median operative time was 448 minutes. Median blood loss was 175 cm3. Median intensive care unit stay was 4 days, and median total hospital stay was 9 days. Overall anastomotic leak rate was 20%. Five patients developed an anastomotic stricture, all successfully managed with endoscopic dilation. There were 2 recurrent laryngeal nerve injuries, which resolved. There was no intraoperative or 30-day mortality. Between the first 10 consecutive cases and last 10 procedures, the incidence of anastomotic leak and stricture formation decreased from 30% to 10% and 40% to 10%, respectively. During this period, the number of lymph nodes harvested increased 9-fold, and duration of intensive care unit stay decreased from 8.00 to 2.50 days. CONCLUSIONS: Laparoscopic inversion esophagectomy is a safe procedure. The learning curve for the inversion approach is approximately 10 operations in the hands of esophageal surgeons with advanced laparoscopic expertise.

Adenocarcinoma↗

PubMed1999

Prognostic factors after extended esophagectomy for squamous cell carcinoma of the thoracic esophagus.

BACKGROUNDS AND OBJECTIVES: In Japan, extended esophagectomy with extensive lymphadenectomy has become the standard surgical procedure for carcinoma of the thoracic esophagus. Although mortality and morbidity rates after such extensive esophagectomy have been acceptable, the long-term outcomes are not necessarily satisfactory. METHODS: Among 235 patients with primary squamous cell carcinoma of the thoracic esophagus between June 1981 and March 1998, 143 patients (60.9%) underwent extended esophagectomy with extensive lymphadenectomy. To exclude the effects of surgery-related postoperative complications, 14 patients who died within 90 days after operation were excluded. Thus, clinicopathological characteristics and prognostic factors of 129 patients were retrospectively investigated. RESULTS: Sixty-three patients were alive and free of cancer. Sixty-six patients died: 37 of recurrence of the esophageal cancer and 29 of other causes. The 1-, 3-, 5-, and 10-year overall survival rates in the 129 patients were 78.8%, 53.5%, 45.8%, and 30.9%, respectively, and the disease-specific survival rates were 85.7%, 69.1%, 67.9%, and 56.2%, respectively. The factors influencing the disease-specific survival rate were tumor location (upper third vs. non-upper third), Borrmann classification (0, 1 vs. 2, 3), size of tumor (</=3.0 vs. >3.0 cm), depth of invasion (T1, 2 vs. T3, 4), number of lymph node metastases (0 or 1 vs. >/=2), time of operation (</=420 vs. >420 min), amount of blood transfused (</=2 vs. >/=3 U), lymph vessel invasion (marked vs. not marked), and blood vessel invasion (marked vs. not marked). Among those significant variables, independent prognostic factors for survival determined by multivariate analysis were number of lymph node metastases (P < 0.001), amount of blood transfusions (P = 0.0016), and tumor location (P = 0.0382). CONCLUSIONS: Patients with a single metastatic node after extended esophagectomy should be considered to have excellent prognosis, like patients with pN0 tumors. Patients with multiple involved nodes should receive aggressive postoperative adjuvant treatments. Reduced blood loss during extended esophagectomy and minimal blood transfusions might improve the outcome of curative esophageal resections.

Aged↗

PubMed1998

High dose chemoradiotherapy followed by esophagectomy for adenocarcinoma of the esophagus and gastroesophageal junction: results of a phase II study of the Eastern Cooperative Oncology Group.

BACKGROUND: To assess the toxicity, local response, and survival associated with multimodality therapy in a cooperative group setting, patients with biopsy-proven clinical Stage I or II adenocarcinoma of the esophagus (staged according to 1983 American Joint Committee on Cancer criteria) or gastroesophageal junction were treated with concomitant radiation and chemotherapy followed by esophagectomy. METHODS: Radiotherapy was administered in daily 2-gray (Gy) fractions 5 days a week until a total of 60 Gy was reached. 5-fluorouracil (5-FU) was infused continuously at a dose of 1000 mg/m2/day for 96 hours on Days 2-5 and 28-31. On Day 2, a 10 mg/m2 bolus of mitomycin was injected intravenously. Esophagectomy was performed 4-8 weeks following completion of the radiotherapy. RESULTS: During the 18-month study period (August 1991 through January 1993), 46 eligible patients were accrued from 21 institutions. Eight patients were Stage I and 38 Stage II. Eighty-seven percent of patients (40 of 46) received 6000 centigray (cGy), and all received >5000 cGy. Seventy-eight percent of patients (36 of 46) received >90% of the planned 5-FU dose. Follow-up ranged from 11 to 36 months (median, 22 months). There were eight treatment-related deaths; two were preoperative (from adult respiratory distress syndrome) and six were postoperative. Complete or partial response prior to esophagectomy was observed in 63% of cases, stable disease in 15%, and progression in 20%. Thirty-three patients underwent esophagectomy (transhiatal, n=14; Ivor Lewis, n=16; other, n=3). No tumor was found in the specimens resected from 8 of these 33 patients; this represented a pathologic complete response rate of 17% overall and 24% for those who underwent esophagectomy. Overall median survival was 16.6 months, 1-year survival 57%, and 2-year survival 27%. Survival was significantly worse for patients with circumferential cancers (median, 18.1 months vs. 8.3 months; P <0.05). CONCLUSION: High dose radiation therapy with concurrent 5-FU and mitomycin may be administered to patients with esophageal adenocarcinoma with acceptable morbidity. However, in a cooperative group setting, esophagogastrectomy following intensive chemoradiotherapy is associated with excessive morbidity and mortality. Circumferential tumor growth is a significant adverse prognostic factor.

Adenocarcinoma↗

PubMed2001

Hospital volume and hospital mortality for esophagectomy.

BACKGROUND: Hospital mortality after esophagectomy has decreased from 29% to 7.5% over the last decades because of improved surgical techniques and better perioperative care. Suggestions have been made that a further decrease in hospital mortality may be achieved by centralization of esophagectomies in high volume centers. METHODS: The effect of hospital volume on hospital mortality after esophagectomy in the Netherlands was analyzed based on data from the Dutch National Medical Registry and the Dutch Network and National Database for Pathology over the period 1993-1998. RESULTS: Annually, approximately 310 (range, 264-321) esophagectomies are performed in the Netherlands. Fifty-two percent are performed in 43-55 low volume centers (1-10 resections a year). Six percent are performed in 1-3 medium volume centers (11-20 resections a year). The remainder (42%) is performed in two high volume centers (> 50 resections a year). Hospital mortality is 12.1%, 7.5% and 4.9% respectively (P < 0.001). The high volume centers seem to see slightly more advanced tumors than the low and medium volume centers. CONCLUSIONS: There is a significant (inverse) relation between hospital mortality and hospital volume for esophageal resection in the Netherlands. Although hospital mortality is not the only measure for quality of care, these data suggest a potential beneficial effect to centralization of esophagectomy in the Netherlands.

Aged↗

PubMed2004

Postoperative pulmonary complications are associated with worse short- and long-term outcomes after extended esophagectomy.

BACKGROUND: Risk analysis of pulmonary complications after extended esophagectomy with three-field lymph node dissection (3FLND) has been little reported in the literature. METHODS: Risk factors of developing postoperative pneumonia after extended esophagectomy and its effects on in-hospital death and overall long-term survival were compared between 38 patients who developed pneumonia and 80 patients who did not. RESULTS: Eight patients died of postoperative complications during the hospital stay after esophagectomy. Seven of those 8 patients developed pneumonia, whereas 31 patients of 110 patients who were discharged from the hospital developed pneumonia (P < 0.01). Pneumonia occurred more frequently in elderly patients (P < 0.01), in heavy smokers (P < 0.05), in patients with preoperative pulmonary obstructive dysfunction (P < 0.05), and in patients who received 3 U or more perioperative blood transfusion (P < 0.05). Five-year overall survival rate (26.7%) of 38 patients who developed pneumonia was significantly worse than 53.4% who did not develop pneumonia (P < 0.01). Multivariate analysis of prognostic factors for overall survival showed that pathological tumor stage (hazard ratio 5.380, P < 0.01) and pneumonia (hazard ratio 2.369, P < 0.01) were independent risk factors. Postoperative pneumonia is correlated with in-hospital death and poorer long-term survival after extended esophagectomy with 3FLND. CONCLUSIONS: Elderly patients with a history of heavy smoking and poor pulmonary function should be regarded as a high-risk group of patients for developing pneumonia and very careful selection is required before subjecting such patients to extended esophagectomy.

Aged↗

PubMed1997

Radical transhiatal esophagectomy with two-field lymphadenectomy and endodissection for distal esophageal adenocarcinoma.

Distal adenocarcinoma of the esophagus is defined as a tumor originating from an endobrachyesophagus or a tumor with its main tumor mass (more than two-thirds) located in the distal tubular esophagus. Controversy exists about the optimal mode of surgical resection. Some favor transthoracic esophagectomy, whereas others prefer transhiatal (blunt) esophagectomy. A radical transhiatal esophagectomy (RTE) combined with two-field lymphadenectomy and mediastinoscopic dissection of the upper thoracic esophagus (endodissection) is described herein. We assessed the short- and long-term results of this technique and compared them to a historical group of patients undergoing conventional transhiatal esophagectomy (THE) for adenocarcinoma of the distal esophagus. Altogether 124 patients underwent transmediastinal esophagectomy because of adenocarcinoma of the distal esophagus in our department between January 1986 and May 1995. Thirteen of these patients were excluded from this analysis because of preoperative chemotherapy. The remaining 109 patients were divided into two groups: 62 patients who underwent THE between January 1986 and March 1991 (51 men, 11 women; mean age 65.3 years, range 31-83 years) and 47 patients who had RTE between April 1991 and May 1995 (44 men, 3 women; mean age 63.4 years, range 41-84 years). To compare the long-term results of RTE and THE, we used a matched-pairs analysis considering tumor stage and age. The hospital (30-day) mortality was marginally lower in the RTE group (4.3% versus 6.4%), resulting in an overall mortality of 5.5%. The rate of pulmonary complications was insignificantly lower in the RTE group [19.1% RTE versus 25.8% THE; not significant (NS), and the rate of postoperative cardiac abnormalities significantly decreased after RTE (2.6% RTE versus 19.3% THE; p < 0.05). The overall rate of R0 resections was 87.2% (82.2% RTE, 87.1% THE). Overall survival was similar within the two study groups. Complete tumor removal, T and N stages, and the lymph node ratio were identified as prognostic factors for long-term survival. Overall survival was better after RTE than after conventional THE in patients with involved lymph nodes. The mean number of resected lymph nodes per patient in the RTE group was 26.7. Positive lymph nodes were most common in the paracardial region and at the lesser curvature (72%/10.8% of all invaded abdominal nodes). In the mediastinum positive nodes were most common in the paraesophageal and paraaortal region (48%/27% of all mediastinal nodes). Patients with positive abdominal and mediastinal lymph nodes had a poor long-term prognosis. Distal adenocarcinoma of the esophagus can be safely resected by RTE with two-field lymphadenectomy and endodissection. This technique allows radical "enbloc" resection of the tumor-bearing distal third of the esophagus, which includes the primary area of lymph node metastasis of adenocarcinoma of the distal esophagus: the lower mediastinum and paracardial region. The analysis showed that RTE incurred fewer cardiac complications and a better overall survival in N1-positive patients when compared retrospectively to THE. Intraoperative mediastinoscopy allows controlled dissection of the upper mediastinum and biopsy of several mediastinal lymph nodes, with the advantage of providing additional staging information.

Adenocarcinoma↗

PubMed2003

High incidence of reflux esophagitis observed by routine endoscopic examination after gastric pull-up esophagectomy.

A gastric tube has been widely used for reconstruction of the esophagus after esophagectomy for esophageal cancer. Reflux esophagitis after esophagectomy is frequently observed. Therefore we retrospectively investigated the risk factors for reflux esophagitis after gastric pull-up esophagectomy in 74 outpatients with thoracic esophageal cancer. Reflux esophagitis was diagnosed endoscopically. Esophagitis was classified according to the Los Angeles classification. Reflux symptoms, medications, and the surgical procedure were reviewed. The relation between reflux symptoms and reflux esophagitis and the influence of the anastomotic site were evaluated. Reflux esophagitis was observed in 53 patients. Severe esophagitis (grade C or D) was found in 75.6% of these patients. Although all patients with esophagitis took antacid agents, histamine receptor-2 blocker was effective in only 35% of them. The correlation between reflux symptoms and reflux esophagitis was not significant. Reflux esophagitis was present in 56.4% of patients with neck anastomosis and in 88.6% of patients with intrathoracic anastomosis ( p = 0.0039). We concluded that routine endoscopic examination is necessary after gastric pull-up esophagectomy because reflux esophagitis is not diagnosed based on reflux symptoms. When a gastric tube is used for reconstruction after esophagectomy, neck anastomosis is recommended to lower the risk of reflux esophagitis.

Aged↗

PubMed2006

Minimally invasive esophagectomy for cancer: prospective evaluation of laparoscopic gastric mobilization.

BACKGROUND: Esophagectomy carries high morbidity, mainly respiratory. Minimally invasive surgery has been demonstrated to improve postoperative outcome in digestive surgery, without impairment of oncological results. A prospective study was conducted to evaluate feasibility, postoperative outcome, and mid-term oncological results of minimally invasive esophagectomy (MIE) in cancer. METHODS: From July 2001 to August 2005, 25 patients underwent esophagectomy with laparoscopic gastric mobilization (LGM) for epidermoid carcinoma (n=15) or adenocarcinoma (n=10). Tumors were located on the cardia (n=6), on the lower third (n=14), or on the median third (n=5) of the esophagus. Following LGM, transthoracic esophagectomy was performed. RESULTS: Complete LGM was achieved in all patients but 1. Mean operative time for LGM was 191+/-49 minutes. Fifteen patients (60%) developed complications, mainly respiratory. Anastomotic leakage occurred in 2 patients, with a favorable outcome. Pylorospasm (n=1) was the only intra-abdominal complication. Median hospital stay was 18 days. Two patients died (8%). Twenty-three patients underwent R0 resection. A mean of 12+/-4 lymph nodes (range 4-19 nodes) were analyzed. With a mean follow-up of 14 months (1-46 months), actuarial survival at 1 and 2 years was, respectively, 73% and 56%. CONCLUSION: Esophagectomy with LGM is feasible with few specific complications. However, no decrease in morbidity and hospital stay could be observed. Mid-term oncological results seem comparable to those of conventional surgery. Further studies are required to evaluate the extent of lymphadenectomy and the oncologic safety of MIE.

Adenocarcinoma↗

PubMed2003

Management of inflammatory tracheoesophageal adhesions during transhiatal esophagectomy.

PURPOSE: Mediastinal adhesions, caused by the transerosal spread of disease, inflammatory diseases, or preoperative chemoradiotherapy, can result in diffi-culties and major complications during transhiatal esophagectomy (THE). However, few studies have specifically addressed the incidence and management of inflammatory adhesions encountered during THE. METHODS: We retrospectively analyzed the operative details and postoperative outcome of 70 patients who underwent THE between 1998 and 2000. Patients with inflammatory tracheoesophageal adhesions were identified and their operative records were reviewed for operative findings, intraoperative management, morbidity, and mortality. Patients with upper thoracic esophageal tumors and direct tumor spread to the airways were excluded from the analysis. RESULTS: Eight (11.4%) of the 70 patients had inflammatory adhesions and esophagectomy was possible in 7 of these 8 patients. Due to poor pulmonary status, one patient required conversion to the trnsthoracic approach, but the other six were managed transhiatally. Three patients underwent subtotal esophagectomy, the esophagectomy was completed by the inversion extraction technique in two, one required extended transhiatal dissection, and esophagectomy could not be completed in one due to dense inseparable adhesions between the trachea and esophagus. There was no major airway injury or bleeding. CONCLUSIONS: Inflammatory tracheoesophageal adhesions may be encountered in patients undergoing THE in developing countries. Thus, an awareness of the possibility of these adhesions and suitable modifications of the operating procedures are necessary to prevent major complications.

Adult↗

PubMed2006

Initial experience with minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: We have previously reported our experience with minimally invasive esophagectomy. Our standard approach involves laparoscopic and thoracoscopic mobilization of the esophagus with a cervical esophagogastric anastomosis. In the present study we report our early experience with a modification of this technique, in which a high intrathoracic anastomosis is performed. METHODS: From 2002 to 2005, a minimally invasive Ivor Lewis esophagectomy was performed in 50 patients. The planned approach included a totally laparoscopic abdominal procedure and either a minithoracotomy or thoracoscopy. Indications for esophagectomy included short segment Barrett's esophagus with high-grade dysplasia or resectable adenocarcinoma of the gastroesophageal junction (GEJ) with minimal proximal esophageal extension. . RESULTS: The median age was 62.3 years (range, 38 to 79). Twenty-five patients (50%) received either preoperative chemotherapy or chemoradiation. There was one nonemergent conversion to an open procedure during laparoscopy. Planned minithoracotomy was successful in 35 patients; an additional 15 patients had the entire thoracic component performed thoracoscopically. A circular stapled anastomosis was performed in all patients. The operative mortality was 6%. Three patients (6%) developed an anastomotic leak; all were successfully managed nonoperatively. Four patients (8%) developed postoperative pneumonia. There were no recurrent laryngeal nerve injuries. CONCLUSIONS: Minimally invasive Ivor Lewis esophagectomy was technically feasible and resulted in good initial results in our center, which is experienced in minimally invasive and open esophagectomy. This approach minimizes the degree of gastric mobilization, almost eliminates recurrent laryngeal nerve injury and pharyngeal dysfunction, and allows additional gastric resection margin in the case of cardia extension of GEJ tumors.

Adult↗