Transhiatal esophagectomy

Controversy still remains regarding the appropriateness of THE asa cancer operation. Critics argue that without an en bloc mediastinal lymphadenectomy, THE does not provide accurate staging or the potential for a curative procedure; however, operative margins are similar after transthoracic and transhiatal esophagectomy, and van Sandick and co-workers reported that 73% of margins were microscopically negative. In many cases, esophageal carcinoma appears to be a systemic disease at the time of diagnosis. According to Orringer and colleagues, 46% of patients have Stage III or IV disease at the time of operation, and Altorki and co-authors found that 35% of patients thought to be potentially curable were found to have occult cervical lymph node disease after three-field lymph node dissection. In addition, survival after THE is similar to that reported after transthoracic esophagectomy as well as radical esophagectomy with mediastinal lymphadenectomy. The most important determinants of survival appear to be the biologic behavior of the tumor and the stage at the time of resection rather than the operative approach, and esophageal carcinoma will likely require systemic therapy for a cure.Transhiatal esophagectomy has been used increasingly in the resection of benign and malignant disease, and has several potential advantages over transthoracic esophagectomy, including significantly decreased respiratory complications and mediastinitis due to the avoidance of thoracotomy and intrathoracic anastomosis. In a meta-analysis of fifty studies comparing transthoracic and transhiatal resection, Hulscher et al found significantly higher early morbidity and mortality rates after transthoracic resections, which was confirmed in a later randomized study of 220 patients(Table 2). Survival after THE is also equivalent to or better than that seen after transthoracic esophagectomy, and transhiatal esophagectomy should be considered in all patients requiring esophagectomy for benign or malignant disease.     

Transhiatal esophagectomy for treatment of benign and malignant esophageal diseases

In 1978 the technique of transhiatal esophagectomy without thoracotomy was rediscovered and now it is widely used in certain, selected, cases. Between 1987 and 2003 we have performed transhiatal esophagectomy in 35 patients with intrathoracic esophageal disease: 13 (37.14%) for benign lesions of the esophagus and 22 (62.85%) for malignant lesions (22.72% upper, 9% middle and 68.18% lower third of the thoracic esophagus). The reconstruction was performed at the same operation in all but two patients. The esophageal substitute was stomach in all but one patient when left colon was used. Hospital mortality was 14.28% with one death due to uncontrollable intraoperative hemorrhage. Major complications included anastomotic leak, recurrent laryngeal nerve paralysis, atelectasis/pneumonia. The advantages of this approach over standard transthoracic esophagectomy are avoidance of a combined thoracoabdominal operation in a debilitated patient and fewer postoperative pulmonary complications and also avoidance of an intrathoracic esophagogastric anastomotic leak with high mortality due to mediastinitis.     

Transhiatal esophagectomy

Between 1991-2001, 40 patients underwent esophagectomy without thoracotomy for: caustic esophageal stenosis (26 cases), cervical esophageal cancer (1), lower esophageal cancer (7), and acute post-caustic oesophagitis (2). Thirty-four patients underwent transhiatal esophagectomy, 3 patients had an esophagectomy by "stripping" and in 3 other patients a combination of stripping and transhiatal esophagectomy. Postoperative complications included: injuries of the laryngeal recurrent nerve (2), pulmonary complications (13), anastomotic leakage (5). Two patients died in the postoperative period one from a myocardial infarction and the other from an acute myocardial dilatation. Trans-hiatal esophagectomy can be considered as a viable alternative to transthoracic esophagectomy in the management of the benign and malignant diseases of the esophagus. Transhiatal esophagectomy is a safe method of resection because of its reported lower morbidity and mortality and similar survival rates compared to transthoracic esophagectomy.     

Three elderly patients with lower esophageal cancer successfully treated by transhiatal esophagectomy assisted by mediastinoscopy

Mediastinoscopy-assisted transhiatal esophagectomy recently has been applied in patients with intrathoracic esophageal cancer. Elderly patients with esophageal cancer experience several types of complications and often cannot undergo standard transthoracic esophagectomy. In this study, three elderly patients with preoperative complications underwent mediastinoscopy-assisted transhiatal esophagectomy for esophageal cancer located in the lower part of the esophagus. Patient 1 was an 80-year-old man with alcoholic liver cirrhosis. Patient 2 was a 78-year-old man with bronchial asthma. Patient 3 was an 81-year-old-man with diabetes mellitus and an atherosclerotic obstruction of the lower extremities. In these patients, mediastinoscopy-assisted transhiatal esophagectomy concomitant with reconstruction by means of a gastric tube was performed. Lymph node dissections of the middle and lower mediastinum and of the abdomen, including the regions surrounding the left gastric and celiac arteries, were performed. Postoperative complications developed only in patient 1; minor leakage of the esophagogastrostomy and high bilirubinemia were observed. Metastasis was detected in the lymph nodes surrounding the celiac artery in patient 1 and surrounding the left gastric artery in patients 2 and 3. Patient 2 died of pneumonia 18 months later, but the other patients have been well, without recurrence of the cancer after surgery. In conclusion, mediastinoscopy-assisted transhiatal esophagectomy has some benefits for elderly esophageal cancer patients who experience preoperative complications.     

Surgical treatment for poor-risk patients with carcinoma of the esophagus

During the period between 1979 and 1988, 145 patients with cancer of the esophagus were admitted to our department. They were examined for the preoperative risk factors associated with multiple organ function and classified into three groups according to the risk score. Special attention was paid to postoperative pulmonary complications, mortality and the long term results of surgery in the poor-risk patients and the findings analyzed in reference to the operative procedures. The resection rate for the poor-risk group was 41 per cent, however, esophagectomy was only able to be combined with a right thoracotomy and abdominal approach in 26 per cent of the patients in this group. Postoperative pulmonary complications developed in 64 per cent of the poor-risk patients who underwent a transthoracic esophagectomy and in only 25 per cent of those who received a transhiatal esophagectomy, although there was no significant difference in the overall survival rate beteeen these two subgroups. The present observations therefore raised the possibility that transhiatal esophagectomy may improve the results of surgical treatment for poor-risk patients with esophageal cancer.     

Surgical treatment for poor-risk patients with carcinoma of the esophagus

During the period between 1979 and 1988, 145 patients with cancer of the esophagus were admitted to our department. They were examined for the preoperative risk factors associated with multiple organ function and classified into three groups according to the risk score. Special attention was paid to postoperative pulmonary complications, mortality and the long term results of surgery in the poor-risk patients and the findings analyzed in reference to the operative procedures. The resection rate for the poor-risk group was 41 per cent, however, esophagectomy was only able to be combined with a right thoracotomy and abdominal approach in 26 per cent of the patients in this group. Postoperative pulmonary complications developed in 64 per cent of the poor-risk patients who underwent a transthoracic esophagectomy and in only 25 per cent of those who received a transhiatal esophagectomy, although there was no significant difference in the overall survival rate between these two subgroups. The present observations therefore raised the possibility that transhiatal esophagectomy may improve the results of surgical treatment for poor-risk patients with esophageal cancer.     

Immune responses and prediction of major infection in patients undergoing transhiatal or transthoracic esophagectomy for cancer

OBJECTIVE: To investigate alterations in immune responses after transhiatal versus transthoracic esophageal resection and to evaluate the role of preoperative immune functions in predicting postoperative infectious complications. SUMMARY BACKGROUND DATA: Impaired immune defense is associated with a decreased resistance to infection. Patients undergoing esophageal resection via a transhiatal or transthoracic approach are prone to develop infectious complications. There are no randomized data on immune responses after two major surgical interventions. METHODS: The study group consisted of 20 patients who were randomly allocated to a limited transhiatal or extended transthoracic esophagectomy for cancer. Blood samples were taken before the operation and at regular intervals thereafter from day 1 to day 10. Monocyte and T-helper type 1 (Th1) and type 2 (Th2) lymphocyte functions were assessed in stimulated whole blood cultures. RESULTS: Both surgical groups had severely depressed in vitro production of interleukin (IL)-12, IL-10, interferon-gamma, IL-2, IL-4, and IL-13 on postoperative day 1. Depression of Th2-type cytokine production was more profound after transthoracic than after transhiatal esophagectomy (IL-4, P=.005; IL-13,P=.007). Postoperative reduction in Th1-type cytokine production was similar between the two groups (interferon-gamma, P=.40; IL-2, P=.06). Irrespective of the surgical approach, patients who developed major infectious complications after surgery presented with a diminished T-cell cytokine production before the operation compared to those who had a relatively uneventful recovery (IL-4, P=.045; interferon-gamma, P=.064). In regression analysis, the occurrence of postoperative major infection was best predicted by increased duration of anesthesia ( P<.0001) and low preoperative interferon-gamma production ( P=.006). CONCLUSIONS: Both transhiatal and transthoracic esophagectomy induced severely depressed monocyte and T-lymphocyte cytokine production. The extent of the surgical procedure had a differential immunosuppressive impact on Th2-type but not on Th1-type cell activity, indicating that the two Th pathways were downregulated through distinct mechanisms. Preoperative interferon-gamma determination would be useful to anticipate the occurrence of postoperative major infectious complications.     

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.     

Transhiatal blunt esophagectomy for carcinoma of the esophagus.

Transhiatal blunt esophagectomy has been reported as a safe and effective procedure for the palliation of carcinoma of the esophagus. Avoidance of a thoracotomy eliminates the morbidity associated with this procedure, and creation of a cervical esophagogastric anastomosis avoids the catastrophic sequelae of an intrathoracic anastomotic leak. Moreover, use of the procedure for palliation does not preclude excellent 1-year survival rates. We report early results in five consecutive patients with esophageal carcinoma who underwent transhiatal blunt esophagectomy. Five patients had 22 complications, including one with a fascial dehiscence, pyloroplasty leak, and localized mediastinal abscess requiring a second laparotomy. One patient died in the hospital postoperatively of massive aspiration pneumonitis. Our results compare favorably with those reported in the literature. We believe that transhiatal blunt esophagectomy avoids the morbidity and mortality of a thoracotomy and an intrathoracic anastomosis, yet remains a major gastrointestinal operative procedure with all of its attendant risks.     

An audit of surgical outcomes of esophageal squamous cell carcinoma.

OBJECTIVE: Esophageal squamous cell carcinoma and adenocarcinoma were increasingly recognized as two entities with different biologic behaviors and prognosis. Surgical risks and oncologic benefits of transthoracic and transhiatal esophagectomy for esophageal squamous cell carcinoma patients are not confessed. METHODS: Between 1994 and 2005, 216 esophageal squamous cell carcinoma patients underwent esophagectomy were enrolled and analyzed retrospectively. RESULTS: One hundred sixty-six patients underwent transthoracic esophagectomy and 50 patients underwent transhiatal esophagectomy. The overall hospital mortality and postoperative complication rates were 9.7 and 49%, respectively. The amount of intra-operative blood loss or transfusion, postoperative complication rate, lengths of hospital stay and hospital mortality rate were not significantly different between both groups. However, shorter operative time was noticed in transhiatal group (p<0.001). The overall 5-year survival rate was 16.8%. ESCC patients underwent either transthoracic or transhiatal esophagectomy had comparable long-term survival. The pTNM stage was independent prognostic factor for patients underwent transthoracic esophagectomy. However, location of tumor (p=0.009) and pathologic tumor length (p=0.012) were predictors of prognosis for patients underwent transhiatal esophagectomy. CONCLUSIONS: For esophageal squamous cell carcinoma patients, no significant differences in postoperative mortality or morbidity rates were observed between transthoracic and transhiatal esophagectomy. However, traditional pTNM staging system might underestimate the severity of esophageal squamous cell carcinoma patients who underwent transhiatal esophagectomy. The information of dissimilar prognostic factors for transhiatal or transthoracic esophagectomies will be helpful in tailoring more individualized adjuvant therapy to optimize esophageal squamous cell carcinoma patient's outcome.     

Laparoscopic transhiatal esophagectomy: outcomes

Background Laparoscopic transhiatal esophagectomy, indicated for benign and malignant esophageal diseases, is a complex operation, often associated with a high rate of morbidity and mortality. During the past decade this technique has became well accepted among specialized surgeons for the treatment of esophageal cancer, avoiding thoracotomy and reducing open access complications. The aim of the present study was to retrospectively analyze patients with esophageal cancer who underwent laparoscopic transhiatal esophagectomy. Methods From November 1993 to August 2006, 78 patients underwent laparoscopic transhiatal esophagectomy. There were 68 cases of esophageal cancer (57 males and 21 females, age range = 28–73 years) with a predominant rate of squamous cell carcinoma (60.2%). Results The conversion rate was 6.4%. The mean operative time was 153 min with a 12.8% rate of cervical leak and a postoperative (30-day) mortality rate of 5.1%. The four-year survival rate was 19% as determined within a subgroup of 21 patients whose followup during the period was possible. Conclusions Laparoscopic transhiatal esophagectomy is a safe alternative for experienced professionals. This access can improve mortality, hospital stay, and other outcomes when compared with open methods.     

Transhiatal esophagectomy: a safe alternative for selected patients.

One hundred one consecutive patients underwent an esophagectomy with gastric interposition for benign and malignant processes from January 1982 through July 1990. Seventy-seven underwent transhiatal esophagectomy and 24, transthoracic esophagectomy. Multivariate analysis was performed comparing the hospitalization experience of the two groups. There was no significant difference found between the mean intraoperative blood loss for transhiatal esophagectomy (770 +/- 105 mL) and that of transthoracic esophagectomy (700 +/- 175 mL). There was a significant difference between operative time, with transhiatal esophagectomy averaging 5.4 hours and transthoracic esophagectomy averaging 7.3 hours. Postoperative stay was not significantly different although there was a wide range of values for the transthoracic esophagectomy group. An 8% operative mortality was experienced by both groups. There were a significant number of minor anastomotic leaks at the cervical anastomotic level for the transhiatal esophagectomy group, but all responded to nonoperative management. The highest morbidity and mortality were seen in the subgroup of transhiatal esophagectomies done for laryngocervical malignancies. The lowest morbidity and mortality were seen in the subgroup of 12 patients who underwent transhiatal esophagectomy for nonmalignant esophageal conditions. Transhiatal esophagectomy appears to be a safe alternative for early intrathoracic esophageal malignancies at any level, for bulky distal esophageal lesions, and for benign conditions requiring total esophagectomy.     

Section V: techniques of esophageal resection

Esophagectomy the treatment of choice for esophageal cancer, is a procedure which, nationwide, carries a mortality rate of 10% and a morbidity rate of 50%. The five-year survival rate for esophagectomy for cancer remains at 20%. With great care in surgical planning, technique, and patient care, the mortality rate has been lowered to 3% at several large academic centers. The methods of esophagectomy including Ivor-Lewis, transhiatal, left thoracoabdominal, and cervical exenteration are discussed. The technique of tri-incisional esophagectomy is detailed in this chapter. This technique combines the best aspects of the Ivor-Lewis and transhiatal approaches, those being a cervical anastomosis (avoiding an intrathoracic leak, minimizing reflux, and allowing for a complete esophagectomy) and transthoracic dissection of the esophagus (allowing for a safe dissection and complete lymphadenectomy).     

Postoperative pulmonary complication and surgical treatment of esophageal cancer in aged patients--evaluation of preoperative risk factors and postoperative management

Because of the recent improvement in surgical technique and perioperative management, surgical treatment for esophageal cancer has become more extensive and thus even aged poor-risk patients can be operated on. However, transthoracic esophagectomy is still associated with a high rate of postoperative pulmonary complications. We analysed the preoperative findings and postoperative treatment in aged patients. During the decade starting from 1980, 151 patients with esophageal cancer were admitted to our clinic, there were 44 aged patients over 70 years. They were examined for preoperative risk factors associated with multiple organ functions. Our special attention was paid to postoperative pulmonary complications and hemodynamics that were monitored using the Swan-Ganz catheter. In the aged patients, there were highly abnormal finding in preoperative examinations, especially in cardiac, pulmonary and renal functions. Moreover, their cardiac index levels were lower and pulmonary vascular resistance levels were higher than those of the younger group. Postoperative pulmonary complications were induced frequently in the poor-risk patients who underwent transthoracic esophagectomy. However, the patients who were received infusion of dopamine and dobutamine were able to keep hemodynamic balance in the early postoperative period. Most patients with esophageal cancer are relatively old and have often multiorgan dysfunction. Transhiatal esophagectomy is a safe operation that is suitable for the treatment of aged poor-risk patients who can not tolerate thoracotomy. Choice of a surgical procedure for them should be carefully determined according to the systemic preoperative assessment of risk factors. Postoperative fluid therapy and respiratory management should be performed more strictly in the aged patient.     

Future perspectives on the standardization of surgical treatment for esophageal cancer

The Japanese Society for Esophageal Diseases published guidelines for the treatment of esophageal cancer in December 2002. Radical surgery is indicated for T1N1 and T2,3 disease without M1 metastasis to other organs, which consists of transthoracic esophagectomy through the right chest with mediastinal and abdominal (two-field), and cervical if necessary (three-field) resection, lymphadenectomy, and esophageal reconstruction by pulling up the stomach. The survival benefit of cervical lymphadenectomy remains controversial. A randomized, controlled trial (RCT) comparing two-field and three-field resection is needed to evaluate the efficacy of cervical lymphadenectomy. In the West, especially in the USA, surgeons prefer transhiatal esophagectomy, which is illogical in cancer surgery, rather than transthoracic esophagectomy. A recent Dutch RCT comparing transhiatal and transthoracic esophagectomy reported lower morbidity and a trend toward improved long-term survival in the transhiatal group. Minimally invasive surgery for esophageal cancer is common in clinical practice today. However, there is little evidence showing that less-invasive procedures are superior to radical surgery. Further investigation is needed to determine the efficacy of thoracoscopic esophagectomy and laparoscopic mobilization of the stomach for esophageal replacement. The efficacy of neoadjuvant chemotherapy and chemoradiotherapy also remains controversial. However, the effectiveness of adjuvant chemotherapy after surgery on disease-free survival was confirmed by the Japanese Clinical Oncology Group RCT.     

Surgical treatment after the failed antireflux operation

Eighty-seven adults have undergone reoperation for recurrent gastroesophageal reflux or complications of prior antireflux procedures. Operations performed included the transthoracic Collis-Nissen procedure (59), Collis-Belsey repair (14), Nissen fundoplication (one), repair of acute postoperative paraesophageal hernia (one), division of obstructing crural suture (one), and esophageal resection (23). Among the 73 patients undergoing an additional hiatal hernia repair, there were two postoperative deaths. Follow-up averages 28 months. Subjectively, results have been excellent or good (no or mild reflux symptoms or dysphagia) in 47 (67%); fair in eight (12%), who have moderate dysphagia or reflux symptoms controlled medically; and poor in 15 (21%), 12 of whom have required additional operations. Early postoperative esophageal dilations were required in 25 patients (36%) and regular dilations in seven (10%). Among the 23 patients undergoing esophageal resection, four had a distal esophagectomy and short-segment colon interposition and 19 had a transhiatal esophagectomy without thoracotomy; stomach was used for esophageal replacement in 14 and colon in five. There were no operative deaths. Follow-up averages 17 months. Thirteen patients have had esophageal dilations (nine early and four regularly), and one has clinically significant reflux. Overall, subjective results are good or excellent in 64 (76%). The results of "redo hiatal hernia operation" are far from ideal. Optimal surgical treatment after the failed antireflux operation requires careful analysis of the existing anatomy and experience to decide when esophageal resection is a safer and more reliable approach than another hiatal hernia repair.     

Esophagectomy for esophageal cancer

This review considers the esophagectomy techniques in the treatment of esophageal cancer and provides the guidelines for optimizing the patients' chances at cure, minimizing the risk of mediastinal enteric leak (which carries a mortality rate as high as 50%) and minimizing associated pulmonary insufficiency and infection. The 4 most commonly used routes for resection and replacement include a transhiatal, transthoracic (Ivor-Lewis), tri-incisional (right chest then simultaneous abdominal and left neck), and left chest (distal tumors). Each of these techniques will be described as will the use of colon and jejunum for esophageal replacement. The healthy stomach is the preferred conduit for esophageal replacement. The stomach is well vascularized, easily reaches to the neck, and requires only a single anastomosis for re-establishing intestinal continuity. When the stomach is not available (usually because of prior surgery or disease) the choice of conduits include colon and jejunum. With respect to minimally invasive esophagectomy for esophageal cancer, several groups have significant experience with this and report excellent results. This is an evolving technique but holds much promise for improving the quality of life of patients with cancer without compromising their survival. In locally advanced middle third tumors, thoracotomy and dissection under direct vision's desirable and improves the safety of the operation. The same may apply to tumors receiving neoadjuvant therapy. For tumors of the distal esophagus, transhiatal, tri-incisional, and Ivor-Lewis resection are probably equally as safe, and appear to result in equivalent long-term survival. An intrathoracic anastomotic leak is disastrous, carrying a mortality rate of up to 50%. Any surgeon who performs esophagectomy with an intrathoracic anastomosis must do so with a low incidence of leakage, certainly under 5%. Consideration should be given to a cervical placement if there are factors increasing the risk such as the use of induction therapy.     

Treatment of adenocarcinoma of the lower esophagus and cardia: resection with or without thoracotomy?

STUDY AIM: In the treatment of adenocarcinoma of the cardia and lower oesophagus, the choice of the approach (with or without thoracotomy) to perform a proximal oesogastrectomy (POG) is still debated. The aim of this retrospective study was to compare mortality, morbidity and long-term survival in a series of patients operated on with or without thoracotomy. PATIENTS AND METHOD: From January 1991 to June 1997, 59 patients (mean ages: 65 +/- 10 years, range: 30-83) underwent POG through a transthoracic (n = 31) or a transhiatal approach (n = 28). All patients underwent both coeliac and left gastric lymphadenectomy. A mediastinal subaortic lymphadenectomy was only performed in patients who had a transthoracic approach. Both groups were comparable concerning age, weight and height, and tumoral staging according to preoperative imaging and pathologic examination. The transhiatal group included more high-risk patients (respiratory insufficiency, ASA score = 3) (NS). RESULTS: Resection was palliative in four patients in the transthoracic group and two patients in the transhiatal group. Operative mortality was 9% in the transthoracic group and 0% in the transhiatal group (NS). Pulmonary complications were as frequent with and without thoracotomy (35% versus 32% respectively). Global (curative and palliative resections) 3-year actuarial survival was similar in both groups (transthoracic: 39% versus transhiatal: 46%, NS), as well as survival after curative resection (44% versus 49% respectively, NS). The operative approach did not influence survival in patients N+ (22% versus 17% respectively, NS) and in patients N- (86% versus 77% respectively, NS). CONCLUSION: These results suggest that, for adenocarcinoma of the cardia and lower oesophagus, the theoretical carcinologic benefit of mediastinal lymphadenectomy can be balanced with an higher operative risk related to the transthoracic approach.     

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.     

Changes of serum cytokine levels after thoracoscopic esophagectomy

We introduced thoracoscopic esophagectomy with extended lymphadenectomy for reduction of respiratory dysfunction and less surgical intervention in July 1995. In this study, we investigated the changes in serum interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-lra) levels in 8 patients (TS Group) who underwent thoracoscopic esophagectomy with extended lymphadenectomy and compared them with the changes in patients who underwent conventional thoracotomy (CT Group). The duration of the operation and intrathoracic procedure in the TS group were significantly longer than in the CT group. However, the amount of blood loss and intrathoracic blood loss of the TS group were not significantly higher than in the CT group. The number of dissected lymph nodes was not significantly larger. The serum IL-6 levels reached maximum levels 3 hours from the end of operation. In the TS group, the changes in IL-6 levels were significantly larger (p<0.05). On the other hand, the changes in CRP levels were also significantly larger (p<0.01). Significant correlation was observed between the duration of the intrathoracic procedure and the maximum levels of IL-6. On the other hand, serum IL-lra levels were not significantly. At present, these results suggest that the surgical intervention of thoracoscopic esophagectomy are more larger than that of conventional thoracotomy. We think that the length of intrathoracic procedure of thoracoscopic esophagectomy may make more large surgical stress.