Results of the surgical treatment of diseases of the esophagus and cardia]

The experience with treatment of 21 patients with diseases of the esophagus is presented. Of them, 16 were operated on for cancer of the esophagus and cardia. The author considers the operative interventions performed with the use of a combined abdominothoracic approach as the most rational ones in cancer of the abdominal esophagus.     

Esophageal extirpation with one-stage esophagoplasty

In the period from 1980 to June, 1989 the authors conducted operations on 128 patients for extirpation of the esophagus with one-stage esophagoplasty by means of an isoperistaltic tube formed from the greater curvature of the stomach. Fifty-four of these patients had benign esophageal strictures, 74 had malignant lesions of the esophagus. The authors claim this operation to be the operation of choice in carcinoma of the lower third of the esophagus and in carcinoma of the cardia extending to the thoracic esophagus. It may be carried out in carcinoma of the thoracic esophagus at any level, in benign strictures of the thoracic esophagus, and in stage IV cardiospasm in patients in whom operations had been performed earlier on the cardia. The abdominocervical approach can be supplemented by right thoracotomy in carcinoma of the midthoracic part of the esophagus. Four patients (3%) died after the operation. The authors recommend wider use of the operation.     

胸、腹腔镜联合食管癌手术的临床分析

目的:探讨胸腹腔镜联合手术治疗食管癌的可行性和疗效,并总结相关临床经验。方法:2010年3月至2010年8月采用胸腔镜联合腹腔镜施行7例食管癌切除术,肿瘤均位于食管中上段,行胃体游离并经食管床上提胃体(管状胃)行食管胃颈部吻合术。结果:所有患者均顺利完成腔镜手术,无中转开胸病例,手术时间平均260min,术中平均出血200ml。平均清扫淋巴结12.8枚。术后下床活动时间平均3d,术后平均住院12d。术后1例发生吻合口漏,无其他并发症发生。患者均康复出院,术后随访2～8个月,均恢复良好。结论:胸、腹腔镜联合食管切除术较常规食管癌手术患者创伤小,术后康复快,且淋巴结清扫彻底,值得临床推广。     

同时性多原发食管癌

目的 探讨同时性多原发食管癌的临床特点、诊断和治疗.方法 采用回顾性研究的方法,对收治的32例同时性多原发食管癌的临床资料进行总结、分析.结果 全组食管双原发灶30例,三原发灶2例,共66个病灶,其中位于颈段22个,胸上段10个,胸中段19个,胸下段15个.66个病灶中,鳞癌65个,腺癌1个.32例中术前确诊26例.32例均采用手术治疗,其中4例行探查手术,1例行姑息切除手术,余27例行完全性切除手术.术后病理食管残端阳性2例.术后出现并发症8例.术后随访28例,1、3和5年生存率分别为76.9％、43.3％和14.8％.结论 完善的术前检查可显著提高同时性多原发食管癌的确诊率,手术是其较好治疗方法.     

The technic of esophageal extirpation with one-stage esophagoplasty using a stomach tube]

The article deals with the technical aspects of operation for extirpation of the esophagus through a cervico-abdominal approach in carcinoma (133 operations) and benign esophageal strictures (117 operations) with one-stage plastics by means of an isoperistaltic tube formed from the greater curvature of the stomach. The relative safety (2.8% of patients died) and high efficacy of the described operation allow it to be recommended for wide introduction into the practice of institutions engaged in surgery of the esophagus.     

Use of mini-invasive procedures in esophageal surgery.

The authors have applied the advantages of mini-invasive surgery to the treatment of esophageal diseases. The technical possibilities of esophageal dissection have been investigated in patients with cancer of the intrathoracic esophagus. The mini-invasive techniques have been applied in the clinical setting to perform the esophagectomy through a trans-hiatal approach or by means of thoracoscopy. Performing the esophagectomy through the trans-hiatal approach allows an accurate mediastinal dissection and lymphadenectomy of the paraesophageal nodes. Performing the esophagectomy by means of thoracoscopy requires division of the azygos vein. In our experience better to divide the esophagus high in the chest. At present, trans-hiatal esophagectomy with mini-invasive procedures seems to be the technique of choice. However, the approach based on thoracoscopy will gain popularity with the development of more sophisticated instruments. In selected cases, it could be advantageous to use both techniques.     

Thorakoskopisch-assistierte En-bloc-Ösophagektomie

We report outcomes of en bloc esophageal resection with a thoracoscopically assisted laparotomy approach. The operation data were as follows: 41 thoracoscopically assisted procedures, 41 intrathoracic anastomoses, conversion rate 0, 100% R0 resection rate, 25 (15–52) lymph node retrievals, leak rate 2, and one mortality. From these results we conclude that minimally invasive esophagectomy with high intrathoracic anastomosis is a safe procedure. The R0 resection rate, lymph node retrieval, and operating time are comparable with those of the open abdominothoracic approach.     

Synchronous double carcinoma of the left lung and esophagus; report of a case

A 75-year-old man, who was followed for the atypical epithelium of the stomach, was diagnosed as esophageal carcinoma. Further examination revealed left lung tumor that was suspected of lung carcinoma. Radical operation of the esophageal carcinoma was performed. On 41st postoperative day, after open biopsy for the left lung tumor, left upper lobectomy was performed. Pathological diagnosis was moderately differentiated squamous cell carcinoma of the esophagus and well differentiated adenocarcinoma of the lung. Synchronous double carcinoma of the lung and the esophagus is rare.     

电视胸腔镜食管癌切除术的临床体会

目的：总结电视胸腔镜食管癌切除术的临床经验。方法：回顾分析2012年4月至2013年4月为11例食管癌患者行电视胸腔镜食管癌切除术的临床资料。其中男10例,女1例,48～73岁,平均（63.7±11.1）岁;胸上段食管癌2例,胸中段食管癌9例。术前病理均确诊为鳞状细胞癌。采用胸腔镜游离胸段食管并清扫淋巴结,开腹游离胃并行食管胃颈部吻合。结果：10例成功完成胸腔镜手术,1例因胸腔严重粘连中转小切口完成手术。胸部手术时间平均（81±21.3）min,术中出血量100～350 ml;术后住院10～15 d。共清扫淋巴结119枚,平均每例清除（10.8±3.5）枚。术后发生颈部吻合口漏1例、声音嘶哑1例。结论：电视胸腔镜食管癌切除术在技术上是安全、可行的,避免了传统手术胸、腹部的较大切口,保持了胸壁的完整性,减轻了患者术后疼痛,术后康复快,并发症少,具有很好的微创效果;但术前应认真把握手术适应证。     

Palliative methods permitting oral feeding in patients with carcinoma of the esophagus (author's transl)]

405 patient with carcinoma of the esophagus were operated on the unit from 1st January 1972 to 15th February 1977. Among these 405 patients, 55 underwent prolonged esophageal intubation and 24 a palliative operation. We considered successively the various methods of prolonged intubation and the various types of palliative operation possible. At the end of this study, it appears that palliative surgery for carcinoma of the esophagus owing to the severity of the operation and the high post-operative mortality and the doubtful functional results, should be reserved for eso-respiratory fistulas, per-operative loss of esophageal blood supply, and the contra-indications to prolonged intubation. On the other hand, it seems that the indications for prolonged intubation should be enlarged at the expense of those for gastrectomy, excluding however stenosing or too extensive carcinomas and carcinoma of the upper.     

Two surgical cases of synchronous double carcinoma of the lung and esophagus and review of 10 documented cases in Japan]

Synchronous double carcinoma of the lung and the esophagus is extremely rare disease. In Japan, 13 cases have reported by Abo and only 10 clinical cases have been documented so far. We describe two cases of synchronous double carcinoma of the lung and the esophagus. Case 1. A 74-year-old man was admitted to our hospital because of the abnormal shadow of the chest X-ray film. Left upper lobectomy was carried out for the lung carcinoma. Because of dysphagia after surgery, upper GI series and endoscopic biopsy were performed, and midesophageal carcinoma was revealed. Radical operation of the esophageal carcinoma was performed 2 months after the first operation. Pathological diagnosis of the lung tumor and the esophageal tumor were well differentiated adenocarcinoma and moderately differentiated squamous cell carcinoma respectively and both of them were early cancer. After 22 months of the second operation, he is doing well. Case 2. a 66-year-old man was operated on because of the esophageal carcinoma in other hospital. Abnormal shadow appeared in his X-ray film 10 months after operation. Although he received chemotherapy as metastatic lung cancer, bronchoscopic examination revealed it adenocarcinoma. We performed segmental lobectomy to him 17 months after the first operation. Pathological diagnosis was large cell carcinoma of the lung. He is also doing well 18 months after the second operation.     

Clinical and Pathological Characteristics of Carcinosarcoma of the Esophagus: Report of Four Cases

Carcinosarcoma of the esophagus is a rare malignant neoplasm composed of both carcinomatous and sarcomatous elements. Four out of 850 patients with carcinoma of the esophagus or the cardiac portion of the stomach undergoing operation at Capital Hospital, Beijing, had carcinosarcoma of the esophagus. They ranged from 50 to 58 years old, but only 45% of all 850 patients with carcinoma were in the age group from 51 through 60 years old. All 4 patients with carcinosarcoma of the esophagus were men.On barium swallow esophagogram, the 4 patients had a characteristic intraluminal polypoid lesion in the middle third of the esophagus. Such lesions of the esophagus also can occur in patients with benign fibrovascular polyps, leiomyoma, and the polypoid form of esophageal carcinoma and esophageal melanoma. The last two can be differentiated from carcinosarcoma only by pathological examination after excision.After radical excision and esophagogastrostomy, the 4 patients were followed up for 19, 4, 4, and 3 years. They were in good condition without recurrence.     

Surgical treatment of esophageal carcinoma complicated by fistulas.

OBJECTIVES: The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant esophageal fistulas is about 13%. The range of treatment modalities proposed by different authors varies from palliation to active and, if possible, radical surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas. METHODS: Thirty-five patients (aged 28--67) with malignant esophageal fistulas of different localizations were operated over a period from 1990 to 2000. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and 11 cases, respectively. The malignant fistula with the mediastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, two, five, four and three cases, respectively. Subtotal esophagectomy and esophagogastroplasty were performed in 18 patients; subtotal esophagectomy with intrapleural coloesophagoplasty was performed in one case; proximal gastric and lower thoracic esophageal resection from the left-side abdominothoracic approach was performed in three cases. Esophagogastric bypass anastomoses were formed in ten patients. Gastrostomy was performed in three patients. RESULTS: The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resection, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3--31), the 2-year survival rate was 21% after combined esophagectomies. CONCLUSIONS: The goal of surgery for esophageal cancer with various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymphadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surgery or gastrostomy. We consider that en-bloc combined resection of esophageal cancer complicated by fistula can be done with a low mortality.     

Treatment of esophageal achalasia (cardiospasm) with diaphragmatic graft: report of 44 patients

Results with the use of a diaphragmatic graft in the surgical relief of achalasia are reported for 44 patients. The operative technique involves construction of a pedicle flap of diaphragm the size of the muscular defect on the lower segment of the esophagus and suture of the transplanted diaphragmatic pedicle to the site of the esophageal muscular defect. Immediate operative results were good; there was only one complication, a case of pneumonia that was cured. Patients were followed from 3 months to 19 years. Two patients were lost to follow-up. Excellent results were obtained in 39 patients; 3 patients still had nausea and heartburn, but were better than before operation. This procedure has three advantages: (1) it prevents occurrence of fistula and diverticulum at the site of the esophageal muscular defect; (2) it effectively eliminates formation of restenosis due to scar and reflux esophagitis; and (3) it allows the cardia to recover its normal function and the esophagus to return to normal size at the site of operation.     

Temporary double exclusion of the perforated esophagus using absorbable staples.

A new method for double exclusion of the esophagus is presented. Temporary closure of the cervical and intraabdominal esophagus using absorbable staples allows effective healing of esophageal perforations. The procedure should be routinely combined with drainage of the periesophageal abscess. Complete recanalization of the esophagus occurs 1 to 2 weeks after operation.     

Ⅱ型和Ⅲ型食管胃结合部腺癌诊疗的研究进展

Ⅱ型和Ⅲ型食管胃结合部腺癌是一种特殊类型癌,兼具食管癌与胃癌特点,其在分期、分型及诊疗方式上存在诸多争论.目前公认的分型方法是Siewert分型,尚缺乏独立的TNM分期,其发病原因与胃食管反流、幽门螺杆菌感染、Barrett食管密切相关,治疗上以根治性手术联合围手术期放化疗、靶向治疗等在内的综合治疗为主.     

Primary disordered motor activity of the esophagus (diffuse spasm). Diagnosis and treatment

Primary disordered motor activity (PDMA) of the esophagus is characterized by abnormal motor activity in the lower two-thirds of the esophagus. Twenty-one patients with this syndrome were studied by history, roentgenography, endoscopy, manometry, and at operation. The results of a new and more radical approach to esophageal myotomy are evaluated.Pain, dysphagia, and weight loss are characteristic of PDMA. Motor spasm is seen roentgenographically, the esophageal wall is thickened, and with longstanding disease a retention esophagus develops. Manometry showed a very severe motor disorder in the lower two-thirds of the esophagus. Postoperative manometric studies were of value in distinguishing PDMA from achalasia, as proximal esophageal peristalsis was more recognizable. At operation muscle hyperplasia and spasm were found. A myotomy from the stomach to 10 cm. above the aortic arch was done, and it was found necessary to add a Collis gastroplasty to control reflux. With this approach all patients have had relief of pain and dysphagia.     

A case report of synchronous double cancer of the lung and esophagus

A 69-year-old man was admitted to our department with complaint of difficult swallowing. Upper gastrointestinal examination showed esophageal cancer and squamous cell carcinoma of the middle thoracic esophagus was revealed histologically. Chest X-ray showed the atelectasis of the B-3 region of right upper lobe of the lung. Further examinations revealed histologically squamous cell carcinoma growing from B-3 bronchus. Finally, he was diagnosed as synchronous double carcinoma of the lung and the esophagus. Simultaneous operation was performed on May 20, 1988. First, right upper lobectomy of the lung and wedged resection of right main bronchus were performed. Esophagectomy and antesternal esophageal reconstruction using the gastric tube was added. The postoperative course was satisfactory without any severe complications. The synchronous double cancer of the lung and the esophagus is rare. Our case indicates that simultaneous resection of both cancer and esophageal reconstruction can be safely performed.     

Effect of antireflux operation on Barrett's mucosa

Regression of Barrett's epithelium after antireflux operations remains a controversial topic. We evaluated the effect of antireflux procedures in patients with Barrett's esophagus on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Of the 241 patients with Barrett's esophagus treated at the Lahey Clinic from 1973 to 1989, 37 patients underwent an antireflux operation. Regression was defined as histological evidence of regenerating squamous mucosa that completely or partially replaced the columnar epithelium. Improvement in lower esophageal sphincter pressure to 12 mm Hg or greater occurred in 19 of 26 patients (73%) who had perioperative manometry. Symptomatic relief of esophagitis occurred in 34 of 37 patients (92%). Four patients had partial regression with regenerating squamous mucosa juxtaposed with areas of columnar epithelium. Carcinoma developed in 3 of 37 patients (8.1%). One patient had recurrence of severe symptoms of reflux esophagitis before development of carcinoma. Patients with Barrett's esophagus who have undergone a successful antireflux operation with symptomatic relief and evidence of improvement in lower esophageal sphincter pressures rarely show regression of Barrett's mucosa and may still be at risk for development of carcinoma. Therefore, the indications for antireflux operation in Barrett's esophagus should remain the same as for other patients with gastroesophageal reflux, but yearly endoscopic and histological surveillance should be continued postoperatively.     

Total esophagectomy and descending colon bypass for squamous cell carcinoma of the esophagus

Twenty patients with carcinoma of the esophagus were treated with descending colon bypass and combined radiation and chemotherapy. The results obtained are described. In ten patients, total esophagectomy was also performed with a significant prolongation of life and well-being. The advantages as well as the disadvantages of using the descending colon for esophageal bypass are described. The merits of treating esophageal carcinoma in a sequence of stages, including use of the descending colon for bypass radiation therapy, and total esophagectomy are reviewed.