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.     

A decade of experience with transthoracic and transhiatal esophagectomy

BACKGROUND: Morbidity and mortality remain significant for transthoracic (TT) and transhiatal (TH) esophagectomy. We report a case-specific approach employing either resection to minimize perioperative morbidity and mortality. METHODS: All primary esophageal resections performed for benign and malignant esophageal disease were reviewed over a 10-year period. The operative approach was tailored to the location and extent of disease and the physiologic reserve of the patient. RESULTS: In all, 115 patients underwent esophagectomy for benign (25) and malignant (90) disease. Fifty-six TT and 59 TH resections were performed. Four emergent TT cases did not have reconstruction. There was 1 hospital mortality. Perioperative transfusion was avoided in 65 patients. Respiratory complications occurred in 15. Three patients had a cervical anastomotic leak requiring open wound drainage. No association between resection type and complication was evident. CONCLUSIONS: The judicious use of both TT and TH esophagectomy resulted in an operative mortality of less than 1%, reduced operative blood loss, and a relatively low rate of perioperative complications.     

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.     

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.     

Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy

HYPOTHESIS: Minimally invasive esophagectomy can be performed as safely as conventional esophagectomy and has distinct perioperative outcome advantages. DESIGN: A retrospective comparison of 3 methods of esophagectomy: minimally invasive, transthoracic, and blunt transhiatal. SETTING: University medical center. PATIENTS: Eighteen consecutive patients underwent combined thoracoscopic and laparoscopic esophagectomy from October 9, 1998, through January 19, 2000. These patients were compared with 16 patients who underwent transthoracic esophagectomy and 20 patients who underwent blunt transhiatal esophagectomy from June 1, 1993, through August 5, 1998. MAIN OUTCOME MEASURES: Operative time, amount of blood loss, number of operative transfusions, length of intensive care and hospital stays, complications, and mortality. RESULTS: Patients who had minimally invasive esophagectomy had shorter operative times, less blood loss, fewer transfusions, and shortened intensive care unit and hospital courses than patients who underwent transthoracic or blunt transhiatal esophagectomy. There was no significant difference in the incidence of anastomotic leak or respiratory complications among the 3 groups. CONCLUSION: Minimally invasive esophagectomy is safe and provides clinical advantages compared with transthoracic and blunt transhiatal esophagectomy.     

Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients

OBJECTIVE: Debate continues as to whether transhiatal esophagectomy results in lower morbidity and mortality than transthoracic esophagectomy. Most data addressing this issue are derived from single-institution studies. To investigate this question from a nationwide multicenter perspective, we used the Veterans Administration National Surgical Quality Improvement Program to prospectively analyze risk factors for morbidity and mortality in patients undergoing transthoracic esophagectomy or transhiatal esophagectomy from 1991 to 2000. METHODS: Univariate and multivariate analyses were performed on 945 patients (mean age, 63 +/- 10 years). There were 562 transthoracic esophagectomies and 383 transhiatal esophagectomies in 105 hospitals, with complete 30-day outcomes recorded. RESULTS: There were no differences in recorded preoperative variables between the groups that might bias any comparisons. Overall mortality was 10.0% (56/562) for transthoracic esophagectomy and 9.9% (38/383) for transhiatal esophagectomy (P =.983). Morbidity occurred in 47% (266/562) of patients after transthoracic esophagectomy and in 49% (188/383) of patients after transhiatal esophagectomy (P =.596). Risk factors for mortality common to both groups included a serum albumin value of less than 3.5 g/dL, age greater than 65 years, and blood transfusion of greater than 4 units (P <.05). When comparing transthoracic esophagectomy with transhiatal esophagectomy, there was no difference in the incidence of respiratory failure, renal failure, bleeding, infection, sepsis, anastomotic complications, or mediastinitis. Wound dehiscence occurred in 5% (18/383) of patients undergoing transhiatal esophagectomy and only 2% (12/562) of patients undergoing transthoracic esophagectomy (P =.036). CONCLUSIONS: These data demonstrate no significant differences in preoperative variables and postoperative mortality or morbidity between transthoracic esophagectomy and transhiatal esophagectomy on the basis of a 10-year, prospective, multi-institutional, nationwide study.     

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.     

Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures

BACKGROUND: Transhiatal and transthoracic esophagectomy are common approaches for esophageal resection. The literature is limited regarding the combined thoracoscopic and laparoscopic approach to esophagectomy. The aim of this study was to evaluate the outcomes of combined thoracoscopic and laparoscopic esophagectomy for the treatment of benign and malignant esophageal disease. STUDY DESIGN: We performed a retrospective chart review of 46 consecutive minimally invasive esophagectomies performed between August 1998 and September 2002. Indications for esophagectomy were carcinoma (n = 38), Barrett's esophagus with high-grade dysplasia (n = 3), and recalcitrant stricture (n = 5). Of 38 patients with carcinoma 23 (61%) had neoadjuvant therapy. The main outcome measures were operative time, blood loss, length of intensive care unit and hospital stay, conversion rate, morbidity, mortality, pathology, disease recurrence, and survival. RESULTS: Approaches to esophagectomy were thoracoscopic and laparoscopic esophagectomy (n = 41), thoracoscopic and laparoscopic Ivor Lewis resection (n = 3), abdominal only laparoscopic esophagogastrectomy (n = 1), and hand-assisted laparoscopic transhiatal esophagectomy (n = 1). Minimally invasive esophagectomy was successfully completed in 45 (97.8%) of 46 patients. The mean operative time was 350 +/- 75 minutes and the mean blood loss was 279 +/- 184 mL. The median length of intensive care unit stay was 2 days and median length of stay was 8 days. Major complications occurred in 17.4% of patients and minor complications occurred in 10.8%. Late complications were seen in 26.1% of patients. The overall mortality was 4.3%. Among the 38 patients who underwent esophagectomy for cancer the 3-year survival was 57%. In a mean followup of 26 months there was no trocar site or neck wound recurrences. CONCLUSIONS: A thoracoscopic and laparoscopic approach to esophagectomy is technically feasible and safe for the treatment of benign and malignant esophageal disease. With a mean followup of 26 months thoracoscopic and laparoscopic esophagectomy appears to be an oncologically acceptable surgical approach for the treatment of esophageal cancer.     

Transhiatal esophagectomy for treatment of benign and malignant esophageal disease

Since our initial 1978 report, we have performed transhiatal esophagectomy (THE) in 1085 patients with intrathoracic esophageal disease: 285 (26%) benign lesions and 800 (74%) malignant lesions (4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was possible in 97% of patients in whom it was attempted; reconstruction was performed at the same operation in all but six patients. The esophageal substitute was positioned in the original esophageal bed in 98%, stomach being used in 782 patients (96%) and colon in those with a prior gastric resection. Hospital mortality was 4%, with three deaths due to uncontrollable intraoperative hemorrhage. Major complications included anastomotic leak (13%), atelectasis/pneumonia prolonging hospitalization (2%), recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration (< 1% each). There were five reoperations for mediastinal bleeding within 24 hours of THE. Intraoperative blood loss averaged 689 ml. Altogether, 78% of the patients had no postoperative complications. Actuarial survival of the cancer patients mirrors that reported after transthoracic esophagectomy. Late functional results are good or excellent in 80%. Approximately 50% have required one or more anastomotic dilatations. With intensive preadmission pulmonary and physical conditioning, use of a side-to-side staple technique (which has reduced the cervical esophagogastric anastomotic leak rate to less than 3%), and postoperative epidural anesthesia, the need for an intensive care unit stay has been eliminated and the length of hospital stay was reduced to 7 days. We concluded that THE can be achieved in most patients requiring esophageal resection for benign and malignant disease and with greater safety and less morbidity than the traditional transthoracic approaches.     

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial

OBJECTIVE: To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival. BACKGROUND: A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available. METHODS: A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy. RESULTS: After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02). CONCLUSION: There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.     

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.     

Adenocarcinoma of the distal esophagus and gastric cardia. Comparison of results of transhiatal esophagectomy and thoracoabdominal esophagogastrectomy

Between 1965 and 1984, 72 patients underwent operation for adenocarcinoma of the distal esophagus or gastric cardia. A standard transthoracic esophagogastrectomy and esophagogastrostomy was performed in 43 and a transhiatal esophagectomy without thoracotomy and partial proximal gastrectomy was performed in 29. There was no significant difference between the two groups in age, sex, or TNM tumor staging. The perioperative complication rate was 86% in the esophagogastrectomy patients and 48% in the transhiatal esophagectomy patients (p less than 0.05). Mortality was higher in the esophagogastrectomy group (14%) than in the transhiatal esophagectomy group (7%). Average operative blood loss was greater in the esophagogastrectomy patients (2,510 versus 1,187 ml). Average postoperative hospitalization was longer for the esophagogastrectomy patients (22.2 days versus 12.3 days). Both differences are statistically significant (p less than 0.05). Late results, as evaluated by life-table analysis, showed no significant difference in survival between the two groups of patients. Because the morbidity and mortality rates of transhiatal esophagectomy are as low as or lower than those for esophagogastrectomy, late survival is as good, and palliation is superior (less suture-line tumor recurrence and reflux esophagitis), we believe that transhiatal esophagectomy is the preferred operative approach in patients with adenocarcinoma of the distal esophagus or gastric cardia.     

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.     

Minimally invasive transhiatal esophagectomy: lessons learned

Background Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned. Methods A retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival. Results Eighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36–79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1–3), and 1 for high-grade dysplasia in Barrett’s. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180–450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10–39). The median number of nodes harvested was 10 (range = 2–26). At a median follow-up of 13 months (range = 4–42), 13 patients were alive. Conclusions Minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.     

Limited operation for patients with T1 esophageal cancer

BACKGROUND/AIMS: Transhiatal esophagectomy without thoracotomy has been introduced as a minimally invasive operation to prevent postoperative complications in patients with relatively early-stage esophageal cancer who have preoperative pulmonary or cardiovascular complications or who are in a high age bracket. However, this procedure for patients with esophageal cancer remains controversial, especially as regards curative surgery because complete intrathoracic lymphadenectomy cannot be performed in this operation. Thus, cancer recurrence after this operation has been considered to be high. To evaluate the benefits of this less invasive surgery for patients with T1 esophageal cancer, the prognoses of patients who underwent transhiatal esophagectomy without thoracotomy were compared with those of patients who underwent traditional esophagectomy with thoracotomy. METHODS: Between 1989 and 1998, 33 patients with T1 esophageal cancer were operated on in our hospital. We introduced transhiatal esophagectomy without thoracotomy in 19 patients who were over 70 years old or who had preoperative complications (transhiatal group). The remaining 14 patients were treated with the transthoracic procedure (transthoracic group). These 33 patients were followed up at our hospital until the end of 1999. The postoperative complications and prognoses in the two groups were compared. RESULTS: We were able to reduce the operation time using the transhiatal procedure. Even though no significant difference was detected, there were fewer postoperative pulmonary complications with this procedure (11%) than with the transthoracic procedure (21%). The incidences of in-hospital mortality did not differ between the two groups. Cancer recurrence was detected in 5 of 19 patients (26%) in the transhiatal group and in 5 of 14 patients (36%) in the transthoracic group; no difference was observed (P=0.562). The 5-year survival rate (58%) of the transhiatal group was no different from that of the transthoracic group (62%, P=0.69). CONCLUSIONS: Complete intrathoracic lymphadenectomy cannot be performed along with transhiatal esophagectomy; however, the prognoses of patients who were treated with this procedure were no different from those of patients who were treated with transthoracic esophagectomy. Thus, transhiatal esophagectomy without thoracotomy might be a justifiable operation for compromised patients with T1 esophageal cancer.     

同时发生的食管胃重复癌的外科治疗

目的探讨同时发生的食管、胃重复癌的外科治疗方法及效果.方法1985年1月至2005年1月收治同时发生的食管、胃重复癌12例,均为男性,平均年龄56.8岁.全组均行手术治疗,成功完成同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道10例,食管内翻拔脱并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道1例,手术探查1例.结果全组无围术期死亡.术后颈部吻合口瘘2例,不全肠梗阻1例,均经保守治疗后痊愈;术后腹部切口裂开1例,二期缝合治愈.9例获得随访,1、3、5年生存率分别100%、44.4%、22.2%.结论同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道是根治同时发生的食管、胃重复癌安全有效的外科治疗方法.     

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.     

综合治疗食管多原发癌22例

目的 探讨食管多原发癌的治疗策略及疗效。方法回顾性分析2000年3月至2011年3月间北京大学临床肿瘤医院胸外科收治的22例食管多原发癌患者的临床病理资料．并与同期、同一手术组收治的471例单发食管癌患者的预后进行比较。结果22例食管多原发癌手术采用剖胸食管切除者18例,经裂孔食管切除者4例;接受术前化疗者8例,术后化疗者15例,其中手术前、后均予化疗者6例。471例单发食管癌患者手术采用剖胸食管切除者423例,经裂孔食管切除者60例：接受术前化疗者148例,术后化疗者267例,其中手术前后均予化疗者101例。22例多原发癌患者3年生存率为41．9％．中位生存期为29．2个月：471例单发食管癌患者的3年生存率为54．7％,中位生存期46．8个月;两组比较差异无统计学意义（P=0．051）。结论食管多原发癌治疗效果较差：广泛的食管切除在此类患者中有重要的意义．同时辅以积极的全身综合治疗．     

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.     

Transhiatal esophagectomy for benign and malignant conditions

BACKGROUND: Experience with transhiatal esophagectomy (THE) for both benign and malignant diseases of the esophagus as practiced over an 18-year period is presented. METHODS: Between 1982 and 2000, 411 consecutive patients underwent THE for both benign (n = 44) and malignant (n = 367) diseases of esophagus. Surviving patients were followed up for a mean of 30.4 months. RESULTS: The overall operative mortality was 11% which had reduced to 6% for the last 111 patients. Operative mortality in the benign group was less than 5%. Respiratory complications were the most frequent cause of morbidity and mortality. Nonfatal anastomotic leaks occurred in 14%. The overall actuarial survival rates at 2, 5, and 10 years for carcinoma patients were 54%, 38%, and 18% respectively. The 2- and 5-year actuarial survival rates for postcricoid cancers were 83% and 64%, respectively. CONCLUSIONS: Transhiatal esophagectomy is safe and effective, and its results including long-term outcome are comparable with most published series.