Choice of the method in the surgical treatment of cancer of the thoracic part of the esophagus

The optimal approaches to the choice of the surgical treatment of carcinoma of the thoracic esophagus are discussed from analysis of 425 operations. Louis' operation providing for a convenient approach for a rather high resection of the esophagus with one-stage esophagogastric anastomosis is recommended in localization of the tumor in the inferior third of the esophagus. Garlock's operation is indicated only in low localization of the carcinoma (diaphragmatic and supradiaphragmatic segments). In carcinoma of the middle third of the esophagus Dobromyslov-Torek's operation is indicated only for elderly and debilitated patients; in the remaining cases a one-stage intervention (Louis' operation) is recommended. An original modification of esophagogastric anastomosis is suggested.     

Combined gastrectomy with extensive lymph node excision in the surgical treatment of cancer of the stomach

The authors discuss experience in combined gastrectomy in 206 patients with gastric carcinoma. They encountered 72 various postoperative complications which were not fatal. Fourteen patients died, which made up a total postoperative mortality of 6.8%. The most frequent and threatening complication was incompetence of the esophago-intestinal++ anastomosis, which occurred in 17 cases (8.3%) and was the cause of death of 6 patients (42.9%). The incidence of purulent and pleuropulmonary complications was 19.9 and 3.4%, respectively. Extensive lymphadenectomy was performed in combined gastrectomy in 40 cases, which accounted for 42.6% of all combined interventions. The incidence of complication was lowest in this group of patients (15%), and there were only 2 fatal outcomes (5%). The authors believe that total gastrectomy with omentectomy, splenectomy, resection of the lower esophagus, and extensive lymphadenectomy is the method of choice in surgical treatment of gastric carcinoma.     

Experience in the surgical treatment of patients with cancer of the proximal stomach

The results of surgical treatment of 116 patients with cancer of the proximal part of the stomach are analysed; in 63 of the patients the tumor had spread to the esophagus. Combined gastrectomy was performed in 87 patients, combined proximal resection of the stomach--in 2 patients. In 73 patients the operation was carried out through a transperitoneal approach. The authors describe an original method of compression esophago-intestinal anastomosis established through a transperitoneal approach with a suturing apparatus of their design. The operation was performed on 14 patients. Comparative analysis of the results of surgical treatment with the use of different methods for creating the anastomosis allows the suggested method to be recommended when a transpleural approach is contraindicated.     

Experience in esophagogastroplasty in surgical and combined treatment of patients with cancer of the thoracic esophagus

The results of surgical and combined treatment of 79 patients with cancer of the thoracic esophagus are discussed. All underwent resection of the esophagus. One-stage esophagogastroplasty was carried out in 44 patients, in 35 patients resection of the esophagus was the first stage of treatment, esophagogastroplasty was undertaken 6-8 weeks later. The authors describe their techniques of separating the upper part of the esophagus, forming the gastric tube and inserting it through the posterior mediastinum. Postoperative mortality was 15.9% in one-stage and 22.8% in postponed esophagogastroplasty. Completeness of treatment in both groups in relation to the total number of patients subjected to resection of the esophagus was 86.5 and 48.1%, respectively. Preoperative radiotherapy influenced neither the incidence of complications nor the mortality.     

食管腐蚀性烧伤后严重狭窄的外科治疗

目的探讨食管腐蚀性烧伤后狭窄的外科治疗经验及胃或横结肠代食管重建手术的应用价值。方法对98例食管腐蚀性烧伤后狭窄的患者中72例广泛食管狭窄、病变超过食管中段以上者采用横结肠代食管、保留结肠左动脉升支、胸骨后顺蠕动吻合,其中横结肠咽腔吻合18例,横结肠食管颈部吻合54例,胸段食管旷置不切除;26例狭窄位于中下段,经胸切除瘢痕段食管用胃重建食管,胃食管胸内吻合。结果结肠食管重建72例中,术后死亡4例（5．56％）,发生颈部吻合口瘘14例（19．44％）,后期出现颈部吻合口狭窄7例,经治疗后均痊愈。胃重建食管26例无手术死亡,术后发生胸内吻合口狭窄3例,经扩张治愈。结论食管腐蚀性烧伤后狭窄在伤后20～24周可积极采取食管重建术,根据食管狭窄段严重程度及位置决定是否行狭窄段食管切除、选择食管重建替代物及吻合的位置。可采用横结肠食管颈部吻合或结肠咽腔吻合术,胸内胃食管吻合术。     

The highest permissible levels of resection of the esophagus in cancer during surgery with intrathoracic or cervical esophagogastric anastomoses

The levels of esophageal resection for squamous carcinoma were determined in 84 patients by measuring the distance from the incisors to the ring of the esophagogastric anastomosis during esophagoscopy. The radicalism of the operations was evaluated from the difference in the distance between the incisors and the upper border of the tumor and the distance between the incisors and the anastomosis. The mean levels of the highest possible resections of the esophagus were at a distance of 33.5 +/- 2.8, 23.6 +/- 2.0, and 20.4 +/- 2.0 cm from the incisors, respectively, in Garlock's operation, Lewis' operation, and Dobromyslov-Torek's operation with esophagoplasty using an antiperistaltic gastric pedicle. It is suggested that the choice of the method of surgical treatment should be based on comparison of the determined levels of the highest possible resection of the esophagus with the endoscopic assessment of the level of the upper border of the tumor in the esophagus.     

胸内食管胃吻合口瘘25例临床分析

目的 报告食管癌贲门癌根治术后发生胸内食管胃吻合口瘘治疗经验。方法 1984～1998年,共施行食管癌贲门癌根治术,胸内食管胃手工吻合术1065例,发生吻合口瘘28例,发生率2.6%,3例放弃治疗。主动脉弓上吻合19例,弓下吻合6例。前期17例采用保守治疗,后期8例再次开胸手术。结果 前期17例采用保守治疗,死亡12例,死亡率70.6％;后期8例采用再次开胸手术,死亡1例,死亡率降为12.5％。两种治疗方法临床差别显著。结论 胸部X线检查,口服美兰,食管造影是早期诊断吻合口瘘的主要手段,只要患者全身和局部情况允许,再次开胸手术是治疗成功的关键。     

Treatment of perforation in the healthy esophagus: analysis of 12 cases

Background Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice. Materials and methods We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out. Results Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis—more than 24 h after the perforation event—seems to be the only factor correlated with fatal outcome (p = 0.045). Conclusions The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.     

�����ݸ���ʳ��θ�Ĥ�Ǻ����������Ű�103������

目的　探讨治疗贲门癌的手术新入路及吻合方法。方法　广东省揭阳市人民医院普通外科 1997年1月至 2 0 0 3年 7月经腹切开膈肌脚入路 ,行胃浆肌瓣覆盖 食管胃黏膜吻合 10 3例。结果　全组病例无死亡、无吻合口瘘 ,亦无食管切缘癌残留。术后并发症发生率 4 82 %。结论　经腹切开膈肌脚 ,行胃浆肌瓣覆盖 食管胃黏膜吻合术 ,操作在腹腔进行 ,创伤及生理干扰较小 ;能有效地预防吻合口漏 ;既能切除足够的食管 ,又能扩大淋巴结的清除范围 ,适用于浸润食管长度 <2cm的贲门癌的手术治疗。     

Esophagogastrectomy for carcinoma: current hospital mortality and morbidity rates.

Between January 1, 1970, and March 1, 1979, 153 patients with carcinoma of the esophagus or cardia were seen at the Lahey Clinic; 124 (81%) underwent surgical exploration and 102 (82.3%) were found amendable to resection. This report concerns the 82 patients operated on by the senior author, 72 of whom (87.8%) had surgical resection. A variety of resective techniques were used but currently esophagogastrectomy and esophagogastrostomy is preferred, a left thoracotomy being used for low lying lesions; upper thoracic and cervical lesions are approached through a combined abdominal and right thoracic approach or esophagectomy with cervical esophagogastrostomy and without thoracotomy is used. Two deaths occurred within 30 days of operation, a hospital mortality rate of 2.8%. Significant complications developed in 11 patients (15.3%). The average survival was 20.8 months, and satisfactory long-term relief of dysphagia was achieved in 91.2% of patients. An aggressive surgical approach to the management of patients with carcinoma of the esophagus or cardia is justified, for esophagogastrectomy and esophagogastrostomy is applicable to the majority of patients; can now be performed at low risk with a reasonable period of hospitalization; and provides satisfactory long-term palliation.     

大肠癌并发急性肠梗阻的外科治疗（附62例分析）

为探讨大肠癌并发急性肠梗阻的外科治疗方法及效果．回顾性分析62例大肠癌并发急性肠梗阻行急症手术治疗的临床资料,其中右半结肠癌并梗阻23例,左半结肠癌和直肠癌并梗阻39例。结果显示,62例均行手术治疗,其中行一期切除吻合45例（右半结肠一期切除吻合16例,左半结肠一期切除吻合29例）。回横结肠吻合7例．Hartmann术4例,单纯造瘘手术2例,Miles术4例。术后发生吻合口漏2例。肺部感染3例,创口感染5例（其中切口裂开2例）,并发症发生率为19．4％。死亡2例,1例（3．2％）死于多器官功能衰竭．1例死于心力衰竭。除死亡2例外,其他病例均通过非手术治疗治愈。结果表明,结、直肠癌并发急性结肠梗阻的治疗要根据患者的全身情况和肿瘤的局部情况来进行综合判定．适应症掌握恰当,一期肿瘤切除和吻合术是安全的。     

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.     

Garlock's operation in cancer of the esophagus

Experience in 88 Garlock-type operations carried out in carcinoma of the esophagus allows a certain opinion to be formed on the advantages and shortcomings of this surgical intervention. In esophageal carcinoma with its proximal boundary within the range of the retropericardial segment of the esophagus, a left abdominothoracic approach (Garlock's operation) is adequate in resection of the esophagus in conformity with the oncological principles and allows the formation of the esophagogastric anastomosis at the level of the arch of the aorta without particular technical difficulties. Reduction of the time needed for the operation, determination of the resectability of the esophageal tumor before mobilization of the stomach are obvious advantages of the abdominothoracic approach.     

Successful combined resection of carcinoma of the esophagus and adrenal metastasis: Report of a case

We report herein the case of a 56-year-old man who underwent successful combined resection of carcinoma of the esophagus and an adrenal metastasis. The patient presented with carcinoma of the thoracic esophagus, and an adrenal tumor was incidentally detected by computed tomography(CT). Complete removal of the carcinoma was accomplished along with a combined resection of the thoracic esophagus and left adrenal gland. Surgery was followed by the administration of anticancer chemotherapeutic agents. He is currently doing well with a grade 1 performance status and no signs of recurrence 22 months after his operation. To our knowledge, no previous report of the successful simultaneous resection of esophageal carcinoma and an adrenal metastasis has been documented in the literature.     

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.     

食管破裂诊断及外科手术方式的选择——附36例临床分析

目的探讨食管破裂的诊断与手术方式。方法 1980-01—2012-06间共收治36例食管破裂与穿孔患者。保守治疗2例,手术治疗34例。单纯食管破裂修补术、食管破裂修补加肋间肌瓣、膈肌瓣、带蒂大网膜覆盖破裂口8例;破裂食管切除、Ⅰ期食管胃胸内或颈部吻合术3例;纵膈引流、胸腔引流或食管"T"管引流加空肠造瘘6例;食管旷置或颈部食管造瘘,加纵膈、胸腔引流及空肠造瘘,Ⅱ期消化道重建2例,其中1例为经胸骨后管状胃与颈部食管吻合;颈部食管旁切开引流术及食管支架置入术各1例。贲门失弛缓症、食管癌、食管癌术后吻合口狭窄扩张或支架置入时破裂5例:姑息性食管癌切除、吻合口狭窄部切除再游离胃行颈部吻合术4例,食管破裂修补术加破裂食管对侧Heller手术1例。合并多发性肋骨骨折肺深部裂伤、脾破裂胃破裂、车祸胸部贯通伤伴胸壁皮肤Ⅱ度烧伤各1例:行肺裂伤修补,胸腹联合切口行脾切除胃破裂修补术加胃空肠造瘘,1例伤后6d,确诊食管破裂,行食管破裂修补及肋间肌瓣加固。1例食管异物40 d,致食管-主动脉瘘(AEF),左心转流下阻断主动脉,修补主动脉破口,切除胸段食管行颈部食管胃吻合,获成功。食管胸中段化学性烧伤致穿孔1例,I期行胸段食管切除食管胃颈部吻合术。食管破裂修补术后再瘘3例:行胸腔廓清、上下胸腔引流及空肠造瘘。结果治愈27例,其中3例并吻合口狭窄,经扩张后好转。死亡9例。结论选择合理方式治疗食管破裂至关重要。要综合考虑食管破裂的原因、部位、时间、大小、原发疾病、并发症、纵隔及胸腔感染情况。     

Surgical treatment of advanced thyroid carcinoma invading the trachea

Operative methods, in relation to the completeness of resection and surgical results, and postoperative complications, in relation to operative methods, were discussed in 60 patients with advanced thyroid carcinoma in whom tumor invading the trachea was resected along with thyroid carcinoma. Laryngotracheal anastomosis was performed in 41 patients and tracheotracheal anastomosis in 19 patients. Complete resection was performed in 22 patients in the former group and in 12 patients in the latter group. Three-, 5-, and 10-year survival rates in patients undergoing complete resection were 87.0%, 78.1%, and 78.1%, respectively. Those for patients undergoing incomplete resection were 64.9%, 43.7%, and 24.3%, respectively. The locations of remaining tumor were the tracheal stump in patients in whom resection was incomplete. In four patients with esophageal invasion, the muscular layer of the esophagus was resected. Three of these patients had good postoperative results. Postoperative complications consisted of stenosis at the anastomosis in two patients, temporary mis-swallowing in three patients, temporary lower pharyngeal stenosis in one patient, temporary vocal cord edema in one patient, and tetany in two patients.     

对不同部位结肠癌性肠梗阻术式选择的临床研究

目的探讨不同部位结肠癌性肠梗阻的术式选择。方法回顾性分析我院2007年7月至2012年12月期间手术治疗76例结肠癌性肠梗阻的临床资料。结果Ⅰ期肿瘤切除60例,占78.9%(60/76),其中Ⅰ期吻合55例,占91.7%(55/60)。左半结肠癌占60%(33/55),其中Ⅰ期左半结肠切除吻合术51.5%(17/33),I期扩大右半结肠切除吻合术27.3%(9/33),经内镜支架置入过渡后行I期左半结肠切除吻合术18.2%(6/33);Hartmann手术5例,占6.5%(5/76),Ⅰ期单纯造瘘9例(5例Ⅱ期切除),总切除率78.9%(60/76),术后并发吻合口漏1例,治愈75例,住院死亡1例(1.3%)。结论对结肠癌急性结肠梗阻应综合分析,选择适当术式,个体化治疗。     

结直肠癌急性梗阻的外科处理(附62例报告)

目的:探讨急性结肠梗阻的处理方法.方法:回顾性总结了62例急性结肠梗阻的手术处理方法和治疗效果.结果:右半结肠梗阻21例,全部行一期切除吻合术;其余41例低位梗阻患者中31例行一期切除吻合,4例行Miles术,3例行Hatmann术,2例行单纯造口术,1例行短路加造口术,术后低位梗阻一期切除吻合患者中2例出现吻合口瘘,经治疗痊愈,无死亡病例.结论:对于梗阻时间短,肠壁水肿轻的急性左半结肠癌梗阻患者,结合术中结肠灌洗,进行一期切除吻合是安全的.     

Circular myotomy as an aid to resection and end-to-end anastomosis of the esophagus.

Segments ranging from 40 to 70% of the thoracic esophagus were resected in 80 mongrel dogs. End-to-end anastomosis was effected after circular myotomy either proximal or distal, or both proximal and distal, to the anastomosis. Among dogs undergoing resection of 60% of the esophagus, distal myotomy enabled 6 of 8 animals to survive, and combined proximal and distal myotomy permitted 8 of 10 to survive. Cineesophagography was performed in a majority of the 50 surviving animals and showed no appreciable delay of peristalsis at the myotomy sites. When these sites were examined at postmortem examination up to 13 months after operation, 1 dog showed a small diverticulum but none showed dilatation or stricture. It is concluded that circular myotomy holds real promise as a means of extending the clinical application of esophageal resection with end-to-end anastomosis.