Surgical treatment of cancer of the esophagus and esophagogastric junction

Immediate and long-term results of surgical treatment of cancer of the esophagus and esophageal-gastric passage in 103 patients were analyzed. Ninety-nine extirpations of the esophagus with simultaneous isoperistaltic tubic esophagogastroplasty (95) and coloplasty (4), 4 Luis surgeries were performed. Hospital lethality was 4.9%, rate of postoperative complications - 47.6%. 5-year survival after surgery was 32.4+/-5,8%: in cancer of cervical or upper-thoracic part of the esophagus - 0, middle-thoracic part - 24.6+/-7.2%, lower-thoracic part - 56.5+/-11.9%, esophageal-gastric passage - 35.6+/-16.1%. Problems of surgical techniques, indications for transhiatal and transthoracic approaches to the esophagus, schemes of combined treatment are discussed.     

Palliative endoscopic dilatation in carcinoma of the esophagus and esophagogastric junction

The palliative effect of repeated endoscopic dilatation of malignant strictures of the esophagus and esophagogastric junction was prospectively evaluated in 41 patients. Dilatation was performed with Eder-Puestow technique in brief general anesthesia. Substantial improvement in swallowing ability was experienced after each treatment. The dysphagia recurred, however, and the dilatations were repeated at intervals of about 4 weeks. Most patients required less than or equal to three treatments during their remaining lifespan. There were few complications, the most prominent being perforation (in 5% of 128 sessions). Only short hospital stay was required, and 18 patients remained at home during the periods between dilatations. Endoscopic dilation of the esophagus and esophagogastric junction gives good palliation. The technique is simple, cheap and safe. It is suitable for lesions at any site, not time-consuming, available at almost all endoscopy units, and consequently to be recommended in this clinical setting.     

Hyperplastic polyps of the esophagus and esophagogastric junction: histologic and clinicopathologic findings.

Hyperplastic polyps of the esophagus and esophagogastric junction region (EGJ) are uncommon lesions characterized by hyperplastic epithelium (foveolar-type, squamous, or both) with variable amounts of inflamed stroma. They have been reported almost exclusively in the radiologic and clinical literature as occurring predominantly in association with gastroesophageal reflux disease (GERD). Comprehensive histologic and clinicopathologic evaluation of these polyps, their association with background mucosal pathology, and their association with Barrett's esophagus has not been previously performed. We studied 30 hyperplastic polyps from 27 patients and characterized the histologic, endoscopic, and clinical features of both the polyps and the background esophagus. Hyperplastic polyps were most common in the region of the EGJ (67%), followed by the distal esophagus (30%) and mid-esophagus (3%). Most (80%) were composed of predominantly cardiac-type mucosa, predominantly squamous mucosa (17%), or an admixture (3%). Intestinal metaplasia of the polyp was present in only 7% and low-grade dysplasia in only 3%. In the majority of cases (67%) hyperplastic polyps were associated with concurrent or recent ulcers or erosive esophagitis. In most cases (48%) esophageal injury was associated with GERD, but other potential etiologies included medications, infection, anastomotic or polypectomy sites, vomiting, and photodynamic therapy. Four patients (15%) had Barrett's esophagus, three of whom had or developed dysplastic Barrett's mucosa. These results underscore the pathogenesis of esophageal/EGJ region hyperplastic polyps as a mucosal regenerative response to surrounding mucosal injury. Careful clinical history and biopsy of the nonpolypoid mucosa are essential for determining the clinicopathologic context in which the polyps have developed.     

Preoperative high-dose radiation and chemotherapy in adenocarcinoma of the esophagus and esophagogastric junction

Background: Esophageal adenocarcinoma (EA) incidence is rising. Defining optimal management is essential because median survival after surgery alone is only 12 months. High-dose radiation (>5000 cGy) and chemotherapy (HDRCT) preoperatively for patients with EA has not been fully investigated. We evaluated tumor response, resectability, and survival following HDRCT in patients with localized EA. Methods: Thirty patients with American Joint Committee on Cancer (AJCC) clinical stage I or II EA were prospectively treated with HDRCT. The treatment consisted of 60 Gy radiation at 2 Gy per fraction with concurrent infusional 5-fluorouracil (5-FU) and a bolus of mitomycin C followed by esophagogastrectomy. The range of follow-up was 7 to 69 months, with a median of 31 months. Results: Twenty of 30 patients (67%) received full-course HDRCT. Severe esophagitis precluded full-dose radiation in 10 patients. Three patients developed neutropenia and fever requiring admission to a hospital. Two patients died preoperatively of treatment-related complications. Nine patients were not explored. Eighteen patients were resected with curative intent; the remaining three had metastatic disease at laparotomy. Seven of 18 resected patients (39%), or 7/30 (23%) of all patients treated, had a pathologic complete response. There was one operative death. Overall local control was seen in 25/30 patients (83%). Median overall survivals for resected and for all patients were 23 and 13 months, respectively. Conclusions: Preoperative HDRCT in patients with EA results in encouraging local tumor response and local control. Overall survival, however, may not be improved, and the treatment-related mortality of 10% is higher than reported with surgery alone or with preoperative chemotherapy.Presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

Longterm favorable results of limited hepatic resections for patients with hepatocellular carcinoma: 20 years of experience

BACKGROUND: Recently, anatomic resection has been, in theory, considered preferable for eradicating portal venous tumor extension and intrahepatic metastasis in hepatocellular carcinoma (HCC). We have reported the effectiveness of limited hepatic resection for cirrhotic patients with HCC. STUDY DESIGN: A retrospective study was carried out in 321 patients who underwent curative hepatic resection (anatomic resection, n=201; limited resection, n=120) as the initial treatment for solitary HCC<5 cm in our institution in the period 1985 to 2004 (median followup period 5.1 years). RESULTS: Anatomic resection did not influence overall and recurrence-free survival rates after hepatic resection. In the liver damage A group (n=215), both 5-year overall and recurrence-free survival rates in the anatomic resection group were considerably better than those in the limited resection group (87% versus 76%, p=0.02, and 63% versus 35%, p<0.01, respectively). In the liver damage B group (n=106), both 5-year overall and recurrence-free survival rates in the anatomic resection group were substantially worse than those in the limited resection group (48% versus 72%, p<0.01, and 28% versus 43%, p=0.01, respectively). The results of multivariate analysis revealed that anatomic resection was a notably poor factor in promoting recurrence-free survival in patients with liver damage B. CONCLUSIONS: Anatomic resection should be recommended for noncirrhotic patients (liver damage A) with HCC. Longterm results of limited hepatic resection proved its validity for cirrhotic patients (liver damage B) with HCC.     

食管癌和食管胃结合部癌术后复发与再发癌的手术疗效

目的 探讨食管癌和食管胃结合部癌术后复发与再发癌的手术疗效.方法 回顾性分析2002年4月至2012年10月河北医科大学第四医院收治的15例食管癌和食管胃结合部癌术后复发或再发癌患者的临床资料.12例复发癌患者确诊距第1次手术平均时间为28个月(8～ 66个月),3例再发癌患者确诊距第1次手术平均时间为196个月(60 ～288个月).对吻合口局部复发患者,如果切除复发癌后残胃大小足够重建食管,则用残胃重建食管.复发癌切除后残余胃不足以重建食管或需同时进行全胃切除,则根据患者的身体状况采用结肠或空肠代食管.术后对所有患者每半年随访1次,随访时间截至患者死亡或2012年12月31日.术后2年内每半年进行1次胸腹部CT与上消化道造影检查,术后2年每年进行1次胸腹部CT与上消化道造影检查,对于可疑患者进行胃镜检查.根据患者第2次术后临床病理分期,采用Kaplan-Meier方法计算生存率,生存分析采用Log-rank检验.结果 15例手术患者中,10例贲门腺癌术后吻合口复发患者,4例行复发癌切除+残胃与食管胸内吻合术,4例行结肠代食管术,2例行空肠代食管术;3例贲门腺癌术后再发食管鳞癌患者,2例行肿瘤切除+结肠代食管术,1例行食管下段癌与残胃切除+食管空肠Roux-en-Y吻合术;2例食管癌术后吻合口复发患者,行复发癌切除+颈部食管胃吻合术.患者平均手术时间为460 min(390～540 min);术中平均出血量为430 ml(200～700 ml);术后发生ARDS、肺部感染、颈部切口感染各1例;死亡2例,其中1例为突发心肌梗死,另1例为术后出现顽固性低蛋白血症合并肺部感染死亡;平均住院时间为29.5 d(25 ～36 d).15例再手术患者中,Ⅰa期1例、Ⅰb期1例、Ⅱa期4例、Ⅱb期4例、Ⅲa期5例.13例获得随访的患者中,6例Ⅰ、Ⅱa期患者中位生存时间为25个月,7例Ⅱb、Ⅲ期患者中位生存时间为16个月,两者比较,差异有统计学意义(x2=8.91,P＜0.05).结论 食管癌、食管胃结合部癌术后复发与再发癌患者再手术治疗在技术上安全可行,可使患者生存获益.但再手术风险较大,要严格掌握手术适应证.     

Repair of interrupted aortic arch: results after more than 20 years

Background. This study focused on the influence of concomitant anomalies, the individual surgical approach, and the probability for reinterventions.

Methods. Between 1975 and 1999, 94 patients with interrupted aortic arch were evaluated for short- and long-term results after surgical treatment.

Results. Interrupted aortic arch was associated mainly with a ventricular septal defect (85%) and left ventricular outflow tract obstruction (LVOTO, 13%). Mean follow-up was 6.7 years (median 6.9 years, 628.4 patient years). A single-stage operation was performed in 76 cases. Early mortality for two-stage procedures was 37% and late mortality was 26%, compared with single-stage procedures, with an early mortality of 12% and a late mortality of 20%, respectively. Early mortality in patients with additional LVOTO was 42% and late mortality was 50%. Freedom from reoperation at 5 years was 62%, and at 10 years was 49%. Reinterventions were performed mainly for residual arch stenosis, also with bronchus or tracheal compression, or LVOTO.

Conclusions. Arch continuity and repair of associated anomalies can be achieved with an acceptable overall risk in this often complex entity. Associated anomalies play an important role in the outcome. Single-stage repair with primary anastomosis of the arch should be the surgical goal. The long-term probability for reoperation is high.     

Surgical treatment for malignant lesions of the distal part of the esophagus and the esophagogastric junction

The treatment of 364 patients with carcinoma of the distal part of the esophagus and the esophagogastric junction is reported. Eighty-two percent of the patients were subjected to operation and the resect ability rate was 52%. At operation 230 patients had lymph node metastases and 115 patients had distant metastases to abdominal organs. The resection rate was significantly higher in patients with squamous cell carcinoma than in patients with adenocarcinoma, and about two-thirds of the resections were considered as curative treatment. The operative mortality rate for the entire period was high (24%), but the mortality decreased in the last 10-year period. The 5-year survival rate after resection was in the same level as in other series; the survival rate for patients with squamous cell carcinoma was considerably higher than for patients with adenocarcinoma.If surgical resection is not feasible, surgical bypass of the obstructing lesion is indicated. This alternative procedure gives satisfactory palliation in the majority of patients.

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Resumen Este informe se refiere al tratamiento de 364 pacientes con carcinoma de la porción distal del esófago y de la unión cardioesofágica. El 82% de los pacientes fué sometido a operación y la tasa de resección fué de 52%. En la operación se encontró que 230 pacientes tenían metástasis a ganglios linfáticos y que 115 tenían metástasis a órganos abdominales.La tasa de resección fué significativamente mayor en pacientes con carcinoma escamocelular que en los pacientes con adenocarcinoma, y alrededor de 2/3 de las resecciones fueron consideradas como tratamiento curativo. La mortalidad operatoria para la totalidad del período fué alta (24%), pero disminuyó en los últimos 10 anos. La tasa de supervivencia a cinco años después de la resección fué del mismo nivel que en otras series; la supervivencia fué considerablemente mayor en pacientes con carcinoma escamocelular que en los pacientes con adenocarcinoma.Cuando la resección quirúrgica no es practicable, está indicada una esofagogastrostomía de tipo bypass o la intubación. Estos procedimientos proveen una paliación satisfactoria en la mayoría de los pacientes al mejorar la calidad de la vida, la cual es bastante superior cuando el paciente puede corner y beber.

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Résumé Les auteurs font état du traitement de 364 malades atteints de cancer de la partie distale de l'oesophage et de la jonction oesophagogastrique. Quatre-vingt deux pour cent (82%) des malades ont été opérés, le taux de résection ne dépassant pas 52%. Lors de l'intervention 230 de ces sujets présentaient des métastases lymphatiques et 115 présentaient des métastases à distance au niveau des organes abdominaux. Le taux de résection fut plus élevé chez les sujets qui présentaient un cancer squameux par rapport à ceux qui présentaient un adénocarcinome. Environ 2/3 des résections furent considérés comme curatives. La mortalité opératoire au total s'est élevée à 24% mais son taux a sensiblement décru au cours des 10 dernières années. Le taux de survie à 5 ans est le même que celui publié dans d'autres séries. Il est à noter que le taux de survie chez les patients atteints de cancer squameux fut nettement plus élevé que celui des sujets porteurs d'un adénocarcinome.Si la résection chirurgicale est impossible il est indiqué d'établir un court-circuit digestif au-dessus de la lésion ou d'intuber celle-ci. Ces méthodes donnent une rémission satisfaisante dans la majorité des cas.

     

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食管胃结合部腺癌(AEG)无论从发病机制还是生物学行为上,均不同于食管癌和胃癌,外科治疗时常需考虑是否行联合脏器切除术,尤其是脾脏切除。然而,行脾脏切除术对此类病人术后存活率的影响目前尚存在一定争议。因此,临床上行手术AEG治疗时,应首先明确肿瘤的不同分型、慎重考虑手术的难易程度、全面综合评估原发灶与脾脏的关系及脾门淋巴结的状态,再决定是否行联合脾脏等脏器切除术。