The management of extensive corrosive esophageal strictures: Do not dilate and procrastinate

Corrosive strictures of the esophagus are difficult to treat, however, prompt and appropriate management of corrosive burns to the esophagus can prevent the formation of strictures. In a developing country like India, where facilities for early treatment are not easily available, strictures are an ineviatable consequence. If the strictures are extensive, dilatational therapy proves ineffective and offers no substantial benefit to the patients. Twenty patients with extensive corrosive strictures of the esophagus were surgically managed; by esophageal bypass in 13 and esophagectomy in 7. Surgical treatment restored normal swallowing in all the patients. The common post-operative complications to occur were: pulmonary complications, anastomotic leak and stricture, gastric outlet obstruction and reflux esophagitis. For extensive corrosive strictures of the esophagus, we advocate early surgical treatment rather than prolonged dilatational therapy.     

食管内翻拔脱术治疗食管癌贲门癌19例分析

目的　探讨食管内翻拔脱术在食管癌、贲门癌外科治疗中的地位。方法　 19例食管癌、贲门癌病人接受了食管内翻拔脱术 ,其中食管鳞癌 15例 ,颈段 3例 ,胸中段 6例 ,胸下段 6例 ;贲门腺癌 4例。 0期 1例 ;Ⅰ期 4例 ;Ⅱa期 4例 ;Ⅱb期 1例 ;Ⅲ期 9例。 3例因有上消化道手术史行结肠代食管。结果　 19例均获切除 ,食管切缘阴性 ,无手术死亡。术后声音嘶哑 1例 ,心律失常1例 ,双侧胸腔积液 1例 ,左侧气胸伴左膈下脓肿 1例 ,5例出现小的颈部吻合口瘘。结论　食管内翻拔脱术扩大了食管癌、贲门癌的手术适应证 ,使某些常规手术高危患者重新获得手术机会。     

Esophageal reconstruction with intraoperative dilatation of the hypopharynx for the management of chronic corrosive esophageal strictures.: A technical tip

Chronic corrosive strictures of the upper cervical esophagus and hypopharynx resulting from ingestion of caustic substances are a challenging surgical entity when repeated endoscopic dilatations fail to yield satisfactory results. Restoring the continuity of the upper digestive tract by esophageal substitution at healthy tissue margins not only compromises the integrity of the swallowing mechanism, but also often requires the performance of a tracheostomy in order to ensure avoidance of recurrent aspirations. We describe three cases of corrosive upper cervical esophageal strictures treated with intraoperative dilatation of the proximal hypopharyngeal stump and concurrent ‘stenting’ of the pharyngeal anastomosis with the conduit replacing the esophagus. All patients tolerated the procedure well. Avoidance of both impairment of deglutition and respiratory complications, as well as restoration of normal esophageal function, was successfully accomplished.     

Esophageal cancer from the german point of view

Although there are no differences worth mentioning between esophageal cancer in Japan and in Europe regarding epidemiology, tumor stages at the beginning of therapy and surgical selection. In Japan, early esophageal squamous cell carcinoma is more often diagnosed than in Europe where esophageal adenocarcinoma, especially that of the endobrachyesophagus, is becoming more and more relevant. For a long time, the limiting factor for the prognosis of esophageal cancer was the postoperative lethality. However, by carefully analysing the factors influencing this operative lethality over the last few years, the lethality following esophagectomy has been decreased to approximately 15 per cent. In fact, in some specialized centers, the lethality is now less than 10 per cent and in selected patient groups even 3 per cent has been reached. It is only through this achievement that the prognosis for esophageal cancer has been able to be markedly improved. The results of this analysis can be detailed as follows: 1) The preoperative definition of tumor stage by CT or MRI is not reliable, the validity being between 45 per cent and 73 per cent. Therefore, no therapeutical decisions can be made on the basis of these diagnostic procedures. Hopefully the intraluminal ultrasound will improve this situation in the future. 2) The analysis of preoperative nutritional status did not allow a definition of risk groups. 3) Decisive improvements were able to be achieved by the standardising of surgical procedures and indications. Enbloc resection is indicated for all intrathoracic squamous cell carcinomas and accounts for a high percentage of RO-resections. The blunt dissection is especially appropriate for distal adenocarcinomas. 4) Endobronchial onesided ventilation during the operation and prophylatic assisted ventilation have both decreased the pulmonary risk considerably. A further improvement in the prognosis of esophageal carcinoma can possibly be achieved by the preoperative identification of advanced tumors (T₃/T₄) and preoperatively treating these tumor types accordingly. From our own experience, we believe combined radio-chemotherapy could be successful.     

Esophagogastrectomy: The influence of stapled versus hand-sewn anastomosis on outcome

Successful anastomosis is essential for favorable esophagogastrectomy outcomes. Before July 2002, almost all esophagogastric anastomoses at our institution were hand-sewn. We then began using linear stapled anastomotic techniques. This review compares patient outcomes with both techniques. From July 2001 to June 2004, 280 consecutive esophagogastrectomy patients (235 men and 45 women) were reviewed (median age, 65 years). The anastomosis was intrathoracic in 206 patients (74%) and cervical in 74 (26%). Anastomoses were hand-sewn in 205 patients (73%) and linear stapled in 75 (27%). Stapled anastomoses were intrathoracic in 33 patients (16%) and cervical in 42 (57%). Anastomotic leaks occurred in 30 patients (11%); 26 (12.7%) in the hand-sewn and 4 (5.3%) in the linear stapled group (P = .008). Leaks were asymptomatic in 17 patients (57%). Dilatation was required in 70 hand-sewn anastomoses (34%) and in 11 stapled (14.6%) (P = .001). Hand-sewn anastomoses were more likely to leak and require dilatation; odds ratios and 95% confidence intervals were 5.35 (1.67–19.27) and 3.58 (1.66–8.34), respectively. A linear stapled anastomosis is safe and associated with both a significantly lower leak rate and the need for dilatation compared with hand-sewn anastomosis. This nonrandomized series suggests that linear stapled anastomosis is the preferred technique regardless of anastomotic location. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

A laparoscopy-assisted surgical approach to esophageal carcinoma

BACKGROUND: Surgical resection is the treatment of choice for esophageal carcinoma. Over the past decade, laparoscopy has proven an accurate staging modality for detecting peritoneal carcinosis and small metastatic liver deposits unsuspected at preoperative investigation. This has led to a change in surgical strategy in up to 20% of patients. In addition, by means of laparoscopic techniques, it is possible to mobilize the stomach and perform a safe transhiatal mediastinal dissection at least up to the level of the inferior pulmonary veins. PATIENTS AND METHODS: Laparoscopy-assisted esophagectomy was attempted in 43 patients over the past 3 years. The esophagectomy was performed via laparoscopy combined with right thoracotomy (group A) or with left cervicotomy and transmediastinal endodissection (group B). RESULTS: The overall conversion rate to laparotomy was 11.6%. No hospital deaths occurred. The morbidity rate was 20% in group A and 30.7% in group B. The mean hospital stay was 11 in group A and 10 days in group B. Five patients died between 11 and 19 months after surgery with recurrent disease. No port-site metastases were recorded during follow-up. CONCLUSIONS: This approach has proven feasible and safe in the medium-term follow-up. Further experience and a longer follow-up are needed to assess the impact of these procedures on long-term survival.     

伸展型食管支架治疗食管良恶性狭窄

报告两种伸展型支架治疗食管、贲门良恶性狭窄１２２例次结果。其中包括食管、贲门术后吻合口狭窄、晚期食管癌贲门癌、食管癌放疗后狭窄、食管化学烧伤后狭窄、食管癌性食管气管瘘和贲门失弛症者，效果良好。置管术可在内镜、Ｘ线下或剖胸探查术中进行，能有效地解除梗阻，提高病人生活质量。结论：伸展型支架较传统置管术操作简单，疗效肯定，并发症少，是食管外科的有效方法之一。     

Endoscopic resection of carcinoma in situ of the esophagus accompanied by esophageal varices

Summary A case of carcinoma in situ of the esophagus accompanied by esophageal varices was treated by endoscopic mucosal resection using a transparent tube (EMRT) following eradication of the varices via injection sclerotherapy (EIS). Intravariceal injection sclerotherapy was performed for esophageal varices, and after eradication of the varices had been achieved, half of the circumferential esophageal mucosal resection of the cancer lesion was carried out. No serious complication such as perforation or mass bleeding was observed. Cancer-involved mucosa was completely resected and all specimens contributed well to accurate histopathological study, being diagnosed as intraepithelial squamous-cell carcinoma. The artificial ulcer recovered completely, showing no stenotic changes. Our conclusion from this experience is that EIS + EMRT is a valuable and minimally invasive treatment for patients exhibiting this disease, providing an accurate histopathological diagnosis.     

Comparison of extended esophagectomy through mini-thoracotomy/laparotomy with conventional thoracotomy/laparotomy for esophageal cancer

Objective: In order to assess the usefulness of esophagectomy through mini-thoracotomy/laparotomy as a minimally invasive surgical procedure for esophageal cancer, we compared the results to those of conventional right thoracotomy/laparotomy. Methods: From 1998 to 2002, 40 patients with thoracic esophageal cancer were prospectively assigned to two groups. Twenty patients underwent esophagectomy through mini-thoracotomy/laparotomy (M-group), while the other 20 had conventional thoracotomy/laparotomy (C-group). Surgical complications, the duration of the systemic inflammatory response syndrome (SIRS), postoperative pain, cytokine responses, and respiratory function were compared between the two groups. Results: There was no difference of morbidity between the M- and C-groups after surgery. There were also no differences between the two groups with respect to the operating time, bleeding, and number of dissected lymph nodes. The duration of SIRS was shorter in the M-group than in the C-group (p=0.055). Use of morphine was lower in the M-group than in the C-group with patient-controlled anesthesia (p=0.002) .The interleukin-6 level of the M-group was lower than that of the C-group at 3, 6 hours, and 3 days after the operation. Recovery of vital capacity by the M-group was better than by the C-group after the operation. Postoperative hospital stay of the M-group was significantly shorter than that of the C-group (p=0.014). Long-term survival was not different in the two groups. Conclusion: Mini-thoracotomy/laparotomy reduces invasiveness and pain compared with conventional thoracotomy/laparotomy for esophagectomy without causing any differences of morbidity or long-term survival.     

胃浆肌瓣覆盖式食管胃吻合术的临床应用

为预防食管胃吻合口的并发症，我们设计一种新的吻合方法，即胃浆肌瓣覆盖式食管胃吻合术。采用新吻合方法行食管贲门癌切除术120例，贲门失弛缓症食管部分切除术42例，手术无死亡，术后未发生吻合口瘘。术后半年内38例行头低脚高位食管钡餐检查，吻合口为2.0～2.2cm者6例，1.5～2.0cm者30例，1.0～1.5cm者2例，未见返流现象。术后半年至3年行食管镜检和活检30例中，食管粘膜正常者28例，仅2例有轻度粘膜充血水肿。认为此方法有实用价值。     

Lower Esophageal Sphincter- and Vagus-Preserving Proximal Partial Gastrectomy for Early Cancer of the Gastric Cardia

Purpose Proximal gastrectomy and lymph node dissection are often performed for T1 cancer of the gastric cardia; however, direct esophagogastrostomy is frequently complicated by reflux esophagitis. We describe a simple technique for preventing esophageal reflux and discuss its results. Methods This technique is indicated for T1 cancer of the gastric cardia without lymphadenopathy. Partial resection, including the lesion, is performed, preserving the vagus nerve and lower esophageal sphincter (LES). Lymph node dissection is done around the left gastric, celiac, and splenic arteries. The esophagus is then anastomosed to the anterior wall in the center of the remnant stomach. Results We evaluated the results of this procedure in eight patients. X-ray films showed no esophageal reflux in either the supine or the right decubitus position. None of the patients complained of reflux or other dyscrasic symptoms, and none had any feeling of microgastria. One patient had some localized erosion near the anastomosis. Conclusions This simple and safe technique does not result in post-gastrectomy syndrome or microgastria, and the risk of leaving cancer cells is minimal.     

Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for barrett’s esophagus

Endoscopic surveillance is recommended for patients with Barrett’s esophagus to detect high-grade dys-plasia (HGD) or cancer. We studied the outcome of esophagectomy in a cohort of patients who devel-oped HGD or cancer between 1995 and 2003 while under surveillance for Barrett’s. Outcomes were measured by analysis of clinical records, symptom questionnaire, and SF-36 (version 2). In 34 patients, mean surveillance time was 48 months (range, 4–132); the mean number of endoscopies was 10 (range, 3–30). Preoperative diagnosis was HGD in 9 patients (26.5%), carcinoma in situ in 16 (47%), and ad-enocarcinoma in 9 (26.5%). There was no esophagectomy-related mortality; 10 patients (29%) had com-plications. At mean follow-up of 46 months (range, 13–108), SF-36 (version 2) results showed quality of life scores equal to or better than those of healthy individuals. Incidence and severity scores (VAS 1–10) for postoperative symptoms were reflux, 59% (2.8); dysphagia, 28% (3.7); bloating, 45% (2.6); nausea, 28% (2.1); and diarrhea, 55% (2.5). Twenty-nine patients (85%) have no clinical, radiographic, or en-doscopic evidence of recurrent esophageal cancer or metastasis. One patient has metastatic disease. En-doscopic surveillance in Barrett’s patients yields malignant lesions at an early, generally curable, stage. Esophagectomy is curative in the great majority and can be accomplished with minimal mortality and excellent quality of life. This work was supported in part by the Mary and Dennis Wise Fund and in part by an educational grant from United States Surgical Corpo-ration, Tyco Healthcare.     

Effect of Slip Time in Forming Neo‐Esophageal Stenosis After Replacement of a Thoracic Esophagus With Nitinol Artificial Esophagus

Attempts have been made to investigate the effect of slip time of nitinol artificial esophagus for forming neo‐esophageal stenosis after replacement of a thoracic esophagus with nitinol artificial esophagus in 20 experimental pigs. The pigs whose slip time was less than 90 days postoperatively had severe dysphagia (Bown's III) immediately after they were fed, and the dysphagia aggravated gradually later on (Bown's III–IV). The pigs whose slip time was more than 90 days postoperatively had mild/moderate dysphagia (Bown's I–II) immediately after they were fed, and the dysphagia relieved gradually later on (Bown's II‐I‐0). The ratios between the diameter of neo‐esophagus in different slip time and normal esophagus were 25% (at 2 months postoperatively), 58% (at 4 months postoperatively), and 93% (at 6 months postoperatively), respectively. The relationship between nitinol artificial esophagus slip time and neo‐esophageal stenosis showed a positive correlation. After replacement of a thoracic esophagus with nitinol artificial esophagus, the artificial esophageal slip time not only affected the original diameter of the neo‐esophagus immediately, but also affected the neo‐esophageal scar stricture forming process later on. The narrowing of neo‐esophagus is caused by overgrowth of scar tissue. But there is the positive correlation between artificial esophagus slip time and neo‐esophageal stenosis, so this can be a way of overcoming neo‐esophageal stenosis by delaying slip time of artificial esophagus.     

不开胸食管剥脱术在颈段食管癌中的治疗价值

目的探讨不开胸食管剥脱术治疗颈段食管癌的效果。方法自1995年7月至2004年12月对21例颈段食管癌患者行不开胸食管剥脱术并Ⅰ期行胃咽吻合或胃食管端侧吻合术。结果本组病人的手术切除率100%。手术后发生各类并发症8例,其中吻合口瘘3例,肺部感染3例,伤口裂开1例,气胸1例。18例患者术后有不同程度的胃液反流。1例住院期间因胃大出血死亡。除2例失访外其余患者获得随访27个月～12年,13例存活超过1年,6例存活超过3年,3例存活超过5年。结论不开胸食管剥脱术手术简单,效果满意,适用于颈段食管癌。食管剥脱术后行胃代食管者胃液反流严重,手术方式有待进一步改善。     

Obstructing esophageal hematoma mimicking cancer: A case report and experimental study

In this paper the 10th case of esophageal hematoma, a rare variant of the Mallory-Weiss syndrome, is reported. The radiographic study strongly suggested an obstructing neoplasm, however, this hematoma disappeared within five days and this same rapid disappearance was noted in dogs in which esophageal hematomas were induced. Fiberoptic esophagoscopy provides a clue to the diagnosis since the mural hematoma is differentiated from carcinoma by its dark color.     

A case of pseudosarcoma associated with type 3 squamous cell carcinoma of the esophagus: Report of a case

(Received for publication on Feb. 5, 1998; accepted on Jan. 7, 1999)