Reconstruction after cervical esophagectomy using a free jejunal graft

Reconstruction after cervical esophagectomy using a free jejunal graft and forming an additional "vocal canal" are described. It is necessary to pay attention to several points, for example, selection of the jejunal graft, selection of the cervical vessels for anastomosis, technique of hypopharyngeal-jejunal anastomosis, and postoperative management of the anastomotic vessels. These contribute to the improvement of patient quality of life. Forming an additional "vocal canal" in patients who underwent radical surgery is particularly desirable. In this article, we introduce our operative method.     

Free jejunal graft for hypopharyngeal and esophageal reconstruction

Aims This study assessed the techniques of the free jejunal graft for the reconstruction of hypopharynx or cervical esophagus and discussed the main aspects related to those procedures.Methods and results By using free jejunal grafts, we reconstructed 54 hypopharyngeal and cervical esophageal cancers. In this study, 23 out of 54 patients had a malignant tumor located in the hypopharynx and 31 in the cervical esophagus (27 primary cases and four secondary cases). Despite the multi-step and time-consuming procedure, we did not incur any trans-operative complication. Furthermore, we undertook the larynx preserving cervical esophagectomy and free jejunal graft reconstruction in six patients with cervical esophageal cancer, and those patients acquired a good quality of life.Conclusion For the reconstruction of hypopharynx or cervical esophagus, the free jejunal graft is a very useful technique and improves the patients quality of life.     

Metachronous gastric carcinoma from a gastric tube after radical surgery for esophageal carcinoma

BACKGROUND: Cases of metachronous gastric carcinoma arising from a gastric tube used for reconstruction have been increasing in long-term survivors of esophageal cancer in recent years. We investigated the characteristics of gastric tube carcinoma to determine the most appropriate approach to managing it. METHODS: Between 1980 and 1997, 508 patients underwent radical esophagectomy for esophageal carcinoma at Keio University Hospital. Reconstruction was performed with a gastric tube in 414 (81.5%) of them, and 8 of them developed a metachronous carcinoma in the gastric tube. The clinical and pathologic characteristics of the gastric tube carcinomas were evaluated in this study. RESULTS: Gastric cancer was detected during follow-up endoscopic examinations or in an upper gastrointestinal series in seven patients. All of the cancers were diagnosed as adenocarcinoma histopathologically. Endoscopic mucosal resection was performed in two patients, partial resection of the residual stomach was performed in three patients. One patient was treated by endoscopic mucosal resection as palliative therapy, since he had severe pulmonary emphysema. Total resection of the gastric tube was attempted in 2 advanced cases but was unsuccessful because of direct invasion of other organ by the cancer. The 5 patients who underwent curative resection are alive with no subsequent recurrence. CONCLUSIONS: Since early diagnosis permits less invasive treatment and curative treatment is difficult in advanced cases, strict postoperative examinations are important after radical esophagectomy to ensure early detection of metachronous gastric carcinoma arising from gastric tubes used for reconstruction.     

Coronary artery bypass graft after esophagogastrectomy.

A 71-year-old male with a history of retrosternal gastric bypass, after a resected esophageal carcinoma, developed angina pectoris due to stenosis of the left main trunk and the left anterior descending artery. The patient was treated with off-pump beating-heart coronary artery bypass approached via left thoracotomy. Two free conduits arising from the left internal mammary artery were utilized for this particular case, since the aortocoronary bypass was impossible due to the severely calcified aorta. Postoperative angiography confirmed good coronary flow and the patient has been symptom free for 6 months.     

New canine model for free jejunal graft studies

The need to more fully understand the function and physiology of the free jejunal graft prompted us to develop a new canine model. Twelve dogs were used to transplant a free jejunal graft in the neck with proximal and distal stomas exteriorized to the skin. The techniques used, complications encountered, and the potential for acute and chronic studies with this animal model are presented.     

Pharyngolaryngectomy reconstruction by revascularized free jejunal graft

The results of reconstruction after total pharyngolaryngectomy using a free revascularized jejunal graft in 72 patients are presented. There was a low hospital mortality (2.8%), a short average time until swallowing (13 days) and a short average postoperative hospital stay (20 days). Twelve patients had resections more extensive than the standard total pharyngolaryngectomy. Sixteen patients (22.2%) suffered some graft complication, but only five (two early graft losses, one late graft loss, one fistula and one stricture) required further reconstructive surgery. Abdominal complications were minimal. There were no complications attributable to post-operative radiotherapy. Swallowing of solids and liquids is good and is maintained long-term. These results are compared with those reported for other methods of reconstruction. This comparison supports a contention that jejunal autograft is the reconstruction of choice after pharyngolaryngectomy.     

Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma

Background

To identify factors affecting postoperative course and survival after esophagectomy for cancer and reasons for improved survival over time.

Methods

Complete esophageal resection was attempted for middle and lower third esophageal carcinomas in 386 consecutive patients between January 1982 and January 2002. Two study periods were analyzed: 1982 to 1993 and 1994 to 2002. Prognostic factors were identified by multivariate analysis and the two periods compared.

Results

Hospital mortality rate decreased from 5.4% to 2.9% (p = 0.245). Both anastomotic leakage and pulmonary complications rates decreased from 9.8% to 2.2% (p = 0.001) and 24.1% to 19.3% (p = 0.295), respectively. An increased proportion of patients had R0 resection in the latter period, 78.5% versus 67.0%, (p = 0.028). Five-year survival rate after R0 resection increased from 29% to 46% (p = 0.001), with a decreased recurrence rate from 65.8% to 44.3% (p = 0.002). Three favorable prognostic factors were identified: low pT stage, pN0 stage, and operation during the 1994 to 2002 study period.

Conclusions

Short-term outcome and survival of patients with resected esophageal cancer have improved over time. Advances in perioperative technique, staging methods, and surgical management combined with higher patient selection and use of neoadjuvant chemoradiation may be responsible for this progress.     

Ivor Lewis esophagogastrectomy for esophageal cancer

Background. To examine the efficacy of the Ivor Lewis esophagogastrectomy for esophageal carcinoma prior to the widespread use of preoperative chemotherapy and irradiation, we reviewed our experience.

Methods. We reexamined the cases of 220 consecutive patients who underwent an Ivor Lewis esophagogastrectomy for esophageal cancer from January 1992 through December 1995.

Results. There were 196 men (89.1%) and 24 women. Median age was 65 years (range, 29 to 85 years). The results of pathological study showed adenocarcinoma in 188 patients (85.5%), squamous cell carcinoma in 31 (14.1%), and leiomyosarcoma in 1 patient (0.5%). Postsurgical staging was as follows: stage 0 in 10 patients, stage I in 19, stage IIa in 38, stage IIb in 28, stage III in 111, and stage IV in 14. The operative mortality rate was 1.4% (3 patients), and complications occurred in 83 patients (37.7%). Follow-up was 98.6% complete. Median survival for operative survivors was 1.9 years (range, 32 days to 8.7 years). The overall 5-year survival rate was 25.2%; it was 80% for patients in stage 0, 94.4% for those in stage I, 36.0% for those in stage IIa, 14.3% for patients in stage IIb, 10% for those in stage III and 0% for patients in stage IV.

Conclusions. Ivor Lewis esophagogastrectomy for esophageal cancer is a safe operation. Long-term survival is stage dependent. The low survival associated with advanced cancers should stimulate the search for effective neoadjuvant therapy.     

Pharyngoesophageal bypass using a free jejunal graft for corrosive stricture

The management of corrosive strictures of the esophagus involving the pharynx and/or larynx continues to be a challenge to surgeons. This paper presents a case of a corrosive stricture extending from the hypopharynx to the cervical esophagus associated with complete obstruction of the larynx, which was successfully treated by pharyngoesophageal bypass using a free jejunal graft. Postoperative recovery was smooth without any complications, and swallowing was restored. Three months after the bypass operation, the patient underwent laryngoplasty. Although aspiration occurred immediately after the laryngoplasty, six months later the was again able to tolerate the oral intake of semisolid food without any need for supplementary nutritional support. Reconstruction of a short segment of the pharyngoesophageal stricture by a free jejunal graft restores almost normal swallowing provided that dilatation of the lower esophagus is achieved.     

Value of radiotherapy after radical surgery for esophageal carcinoma: a report of 495 patients

BACKGROUND: Despite three decades of debate, no conclusion has been reached concerning the effectiveness of postoperative radiotherapy for resected esophageal carcinoma. From 1986 through 1997, a prospective randomized study was carried out with 495 patients in an attempt to define the value of this therapeutic modality. METHODS: A total of 495 patients with esophageal cancer who had undergone radical resection were randomized by the envelope method into a surgery-alone group (S) of 275 patients and a surgery plus radiotherapy group (S + R) of 220 patients. Radiation treatment was started 3 to 4 weeks after the operation. The portals encompassed the entire mediastinum and bilateral supraclavicular areas. A midplane dose of 50 to 60 Gy in 25 to 30 fractions was delivered over 5 to 6 weeks. RESULTS: The overall 5-year survival rate was 31.7% for the S group and 41.3% (p = 0.4474) for the S + R group. The 5-year survival rates of patients who were lymph node positive were 14.7% and 29.2% (p = 0.0698), respectively. Five-year survival rates of stage III patients were 13.1% and 35.1% (p = 0.0027), respectively. CONCLUSIONS: Postoperative prophylactic radiotherapy improved the 5-year survival rate in esophageal cancer patients with positive lymph node metastases and in patients with stage III disease compared with similar patients who did not receive radiation therapy. These results were almost significant for patients with positive lymph node metastases and highly significant for patients with stage III disease.