A case of surgical treatment for extensive corrosive stricture of esophagus and stomach after ingestion of strong hydroxide

A 29-year-old woman who swallowed oil cleaner (strong hydroxide: NaOH) by mistake received conservative therapy because of having neither mediastinitis nor peritonitis. She complained of dysphagia 1?month after ingestion. Upper gastrointestinal series showed severe stricture in the middle and lower thoracic esophagus and in the antrum of the stomach. Gastrostomy and jejunostomy were performed on the 87th day after ingestion. Transthoracic subtotal esophagectomy and total gastrectomy followed by esophageal reconstruction using the colon with microvascular anastomosis through a retrosternal route was performed on the 148th day after the ingestion. On open thoracotomy, although dense mediastinal adhesions were found around the esophagus, esophagectomy could be achieved successfully. She was discharged 22?days after the second surgery without postoperative complication.     

Outcomes of endoscopic and surgical resection for a second primary cancer in the residual cervical esophagus after thoracic esophagectomy

Patients who have received subtotal esophagectomy for thoracic esophageal cancer must be closely monitored for second primary malignancies. The purpose of this study is to review and assess patients who developed a second primary esophageal cancer in the residual cervical esophagus. Between 1996 and 2010, 10 patients were diagnosed in our hospital with esophageal squamous cell cancer in the residual cervical esophagus after undergoing thoracic esophagectomy and were treated with endoscopic or surgical resection. Data from these patients were reviewed retrospectively. Seven of the 10 patients (70%) had multiple primary carcinoma lesions at the time of their esophagectomy. A second primary cancer in the residual cervical esophagus was detected in eight patients during follow-up endoscopic examinations while the patients were still asymptomatic. Seven of the patients underwent endoscopic resection for a superficial cancer. None of those patients experienced any complications, and all are currently alive and cancer-free. The remaining three patients underwent resection of the cervical esophagus with regional lymph node dissection. Two of those patients experienced severe complications; one subsequently died (hospital death) from pneumonia, 12 months after surgery, while the other died from recurrence of his cancer. The third patient is alive and cancer-free. Early detection of a second primary malignancy in the residual cervical esophagus followed by endoscopic resection is the best treatment strategy for patients who previously received subtotal esophagectomy for thoracic esophageal cancer. Surgical resection puts patients at high risk of mortality or morbidity.     

Surgical resection of gastrointestinal stromal tumor of esophagus following preoperative imatinib treatment: a case report

We report a case of esophagectomy after a primary esophageal gastrointestinal stromal tumor (GIST) was preoperatively treated with imatinib mesylate. A 71-year-old woman was diagnosed with an esophageal submucosal tumor by upper gastrointestinal endoscopy at her health checkup. The tumor was located at the lower thoracic esophagus immediately above the esophagogastric junction and measured 4.5 cm in size. It was diagnosed as GIST of the esophagus for reasons of its high susceptibility to imatinib mesylate. Preoperative treatment with imatinib was performed in an attempt to preserve the esophagus. Although the tumor size was decreased by 36% after the 6-month treatment, transhiatal esophagectomy was required for complete resection, and esophageal preservation could not be accomplished.     

Ivor-Lewis esophagectomy for esophageal cancer after distal gastrectomy

We report the use of gastric remnant for esophageal substitution after distal gastrectomy in a 53-year-old man with esophageal cancer. This patient had a 4-month history of progressive dysphagia for solid food. An upper gastrointestinal endoscopy showed a 7.0 cm bulge tumor in the middle-lower esophagus, wherein the upper margin was located 28 cm from the dental arcade. Computed tomography (CT) of the chest revealed wall thickening in the middle-lower esophagus. In this case, radical en bloc esophagectomy with a two-field lymph node dissection was performed in the upper abdomen and mediastinum via a posterolateral right thoracotomy through the fifth intercostal space. Esophagogastric anastomosis was performed mechanically in the apex of the chest using a circular stapler. The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the right thoracic cavity. The patient was discharged on the 12th postoperative day without complications. The gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.     

Salvage esophagectomy through a transhiatal approach for cancer of the thoracic esophagus after left pneumonectomy for lung cancer

Here we report on a 54-year-old man who had undergone left pneumonectomy for a primary lung cancer 25 years earlier and who underwent salvage blunt esophagectomy for a recurrent esophageal cancer after definitive chemoradiotherapy. The patient received chemoradiotherapy for a cancer in the upper thoracic esophagus at the clinical stage IA (T1bN0M0) because of a past history of left pneumonectomy for lung cancer, and the esophageal cancer showed complete response. At 1 year after chemoradiotherapy, local recurrence was found in the upper thoracic esophagus. Although chemotherapy using docetaxel was administered, this was not effective. Transhiatal esophagectomy as salvage surgery was successfully done by a combination of laparo-mediastinoscopy assisted blunt dissection with the eversion stripping method. The postoperative course was uneventful. The patient died of lung and brain metastasis at 23 months after the salvage surgery. Transhiatal esophagectomy may be an option as a salvage esophagectomy in cases with a history of major lung surgery.     

Transabdominal ligation of the thoracic duct as treatment of choice for postoperative chylothorax after esophagectomy

Postoperative chylothorax after injury of the thoracic duct during esophagectomy is a rare but severe complication which may lead to serious problems such as loss of fat and proteins, and immunodeficiency. Without treatment mortality can rise to over 50%. From 1988 to 2005, we treated 10 patients with postoperative chylothorax after 409 resections of the esophagus (2.4%). Of these 10 patients nine underwent transthoracic esophagectomy with gastric pull-up to enable an intrathoracic (n = 7) or cervical (n = 2) anastomosis and one patient received a transhiatal esophagectomy with gastric pull-up and cervical anastomosis. The average amount of postoperative chylus was 2205 mL (200-4500 mL) per day. After a median postoperative interval of 10 days, relaparotomy and transhiatal double ligation of the thoracic duct was performed in nine out of 10 patients. One patient could be managed conservatively. The average amount of chylus was reduced to 151 mL per day (90.5%). Seven patients had no complications, and three suffered from postoperative pneumonia. Two of the patients with pneumonia recovered, and one died. Discharge from hospital, after ligation of the thoracic duct, was possible after a median time of 18 days (11-52). Ligation of the thoracic duct via relaparotomy appeared to be a simple and safe method to treat postoperative chylothorax.     

CASE OF A SEVERE AND LONG BENIGN STRICTURE OF THE ESOPHAGUS

A unique case of a severe and long benign stricture of the esophagus was experienced by the authors. A 50‐year‐old alcoholic man was admitted to our hospital complaining of dysphagia as well as severe and continuous retrosternal burning pain of acute onset after abrupt vomiting. His previous medical history included alcoholic liver dysfunction, renal dysfunction, Klinefelter’s syndrome and a surgically treated duodenal ulcer. Ingestion of foreign body or acid/alkali substances was excluded. Although histopathologic examination of the endoscopic biopsy specimen was reported to be an esophageal squamous cell carcinoma, endoscopic findings and a barium esophagogram were not typical for a malignant disease. Since this study demonstrated a smooth surface of the lumen in spite of it being approximately 10 cm long, severe stricture of the esophagus was diagnosed. Because the stricture was very long and severe, and was not conservatively treatable, it was decided, after obtaining informed consent, that surgical resection of the esophagus would be performed. Subtotal esophagectomy with lymph node dissection and colonic interposition was carried out. During surgery, the patient was diagnosed as having liver cirrhosis. Histopathologic examination of the surgically resected specimen revealed a 10 cm‐long narrowing of the middle and lower thoracic esophagus with thick walls, particularly in the inner circular muscle layer, without malignancy. Unfortunately, the patient’s postoperative course was followed by cervical leakage. He subsequently died of multiple organ failure on the sixteenth postoperative day. It is worth keeping in mind that esophageal benign stricture with longitudinal ulceration can be induced by esophageal submucosal dissection, as seen in the present case.     

Cervical lymphadenectomy is beneficial for patients with carcinoma of the upper and mid-thoracic esophagus

The role of cervical lymphadenectomy for thoracic esophageal cancer is controversial. This study evaluated the impact of cervical lymphadenectomy on the cervical lymph node metastasis (LNM) and survival rates of patients with esophageal cancer. We analyzed 199 patients who received radical esophagectomy with three-field lymphadenectomy. The overall 5-year survival rate was 49.4%. Cervical LNM was found in 36 (18.1%) out of the 199 patients. The 5-year survival rates of the patients with cervical LNM from upper and mid-esophageal cancers were 71.4% and 35.9%, respectively. However, none of the patients with cervical LNM from lower esophageal cancer survived more than 4 years after esophagectomy. The overall survival of patients with five or more metastatic nodes (5.9%) was significantly worse than that of patients with less than five positive nodes (45.5%). Cervical lymphadenectomy is beneficial for patients with carcinoma of the upper and mid-thoracic esophagus, and with less than five positive nodes.     

Successful management of esophageal necrosis after thoracic endovascular aortic repair for ruptured traumatic aortic aneurysm

A 65-year-old man reported nausea and anorexia after falling down a flight of stairs. Computed tomography (CT) showed a ruptured descending thoracic aortic aneurysm, and emergency thoracic endovascular aortic repair (TEVAR) was performed. However, after resuming food intake, the patient developed a fever. CT scan showed severe pneumomediastinum and a mediastinal abscess, and the patient was diagnosed with esophageal perforation. Emergency esophagectomy was performed, with an esophageal fistula made at the cervix. Jejunostomy was then performed to enable enteral nutrition. Histological examination showed substantial necrosis at the middle intrathoracic esophagus, and the patient was diagnosed with esophageal necrosis leading to perforation. Five months after the esophagectomy, gastric conduit reconstruction through the retrosternal route was performed. The patient was able to resume food intake, and survived more than 1 year after this surgery. Here, we describe the successful management of this rare case of esophageal necrosis after TEVAR for ruptured traumatic aortic aneurysm.     

Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer

This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand‐assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA‐preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.     

Mediastinoscopy-assisted esophagectomy for thoracic esophageal cancer after right thoracotomy for lung cancer: report of two cases

We herein report two cases of thoracic esophageal cancer operated on by mediastinoscopy-assisted esophagectomy (MAE) via the neck and the esophageal hiatus after right thoracotomy for primary lung cancer. Case 1 was a 78-year-old man who had undergone a lower lobectomy of the right lung 5 years earlier and had also undergone a pleuroparietopexy for postoperative chylothorax via right thoracotomy again. A squamous cell carcinoma of the middle thoracic esophagus was detected by endoscopy. Although radiotherapy was performed on the patient, the esophageal tumor was locally recurrent. Thus, MAE was performed because it would have been difficult to approach the esophageal tumor by right thoracotomy again, and the patient was successfully treated. Case 2 was a 71-year-old-man who had undergone an upper lobectomy of the right lung 5 years earlier. For a squamous cell carcinoma located between the middle and lower esophagus, MAE was performed. Metastatic lymph nodes surrounding the middle and lower thoracic esophagus were sufficiently dissected. Although esophageal cancer patients with metachronous lung cancer are rare, therapeutic issues for these patients remain. MAE via the neck and the esophageal hiatus for esophageal cancer patients who had previously undergone a lobectomy of the right lung may be considered a tool for surgical approach. Furthermore, MAE may be considered to be a salvage operation such as in case 1.     

Laparoscopic transhiatal approach for resection of an adenocarcinoma in long-segment Barrett's esophagus

Barrett's esophagus(BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcinoma arising in long-segment BE(LSBE) associated with a hiatal hernia that was successfully treated with a laparoscopic transhiatal approach(LTHA) without thoracotomy. The patient was a 42-year-old male who had previously undergone laryngectomy and tracheal separation to avoid repeated aspiration pneumonitis. An ulcerative lesion was found in a hiatal hernia by endoscopy and superficial esophageal cancer was also detected in the lower thoracic esophagus. The histopathological diagnosis of biopsy samples from both lesions was adenocarcinoma. There were difficulties with the thoracic approach because the patient had severe kyphosis and muscular contractures from cerebral palsy. Therefore, we performed subtotal esophagectomy by LTHA without thoracotomy. Using hand-assisted laparoscopic surgery, the esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. A hernial sac was identified on the cranial side of the right crus of the diaphragm and carefully separated from the surrounding tissues. Abruption of the thoracic esophagus was performed up to the level of thearch of the azygos vein via LTHA. A cervical incision was made in the left side of the permanent tracheal stoma, the cervical esophagus was divided, and gastric tube reconstruction was performed via a posterior mediastinal route. The operative time was 175 min, and there was 61 m L of intra-operative bleeding. A histopathological examination revealed superficial adenocarcinoma in LSBE. Our surgical procedure provided a good surgical view and can be safely applied to patients with a hiatal hernia and kyphosis.     

Fibrovascular esophageal polyp as a diagnostic challenge

Fibrovascular polyps are rare benign esophageal tumors that usually arise from the proximal third of the esophagus. We present the case of a 48-year-old man with a history of dysphagia and 7-kg weight loss over a period of 2 months. A barium swallow showed a distended esophagus with a tumor extending from the upper esophageal sphincter to the cardia. On a thoracic computed tomographic scan, a homogeneous intramural mass with a density of 22 Hounsfield units was seen, which extended throughout the entire esophagus. Fiberoptic endoscopy confirmed the presence an intramural tumor beginning at the upper esophageal sphincter and reaching to the cardia. The tumor was completely covered with mucosa, except for an ulcerated area at its distal end, which herniated into the stomach. On endoscopic ultrasound, the tumor appeared to grow submucosally and to respect the muscularis propria. Endoscopic biopsies from the ulcerated distal aspect of the tumor suggested a leiomyoma. None of the imaging modalities used revealed evidence of a polyp or intraluminal esophageal tumor. Rather, a potentially malignant extensive intramural tumor was suspected, and an esophagectomy was performed. Only at the time of removal of the specimen did it become evident that the tumor mass was located intraluminally with a pedicle in the region of the upper esophageal sphincter. The final pathological diagnosis was a giant fibrovascular polyp of the esophagus.     

Therapeutic effectiveness of chemoradiotherapy for carcinosarcoma of the esophagus: two case reports and a review of the literature

Esophageal carcinosarcoma is an extremely rare tumor, and surgery is the mainstay of treatment. We report two patients with carcinosarcoma of the esophagus who received neoadjuvant chemoradiotherapy and underwent curative resection. Patient 1 was a 50-year-old man with a type 2 lesion in the upper thoracic esophagus; clinical stage was T3 or partial T4N1M0. After chemoradiotherapy the tumor and the lymph nodes become smaller, and subtotal esophagectomy was performed. Patient 2 was a 66-year-old man with a protruding lesion in the lower thoracic esophagus. Preoperative chemoradiotherapy was administered, and he had a partial response. However, surgery was postponed because of pneumonia; 11 months later, tumor enlargement was confirmed and we then performed subtotal esophagectomy. The therapeutic role and effectiveness of both chemotherapy and radiotherapy remain unclear. We reviewed 26 previously reported cases of esophageal carcinosarcoma treated by chemotherapy, radiotherapy, or both. These findings suggest that preoperative chemoradiotherapy may be effective for downstaging the primary tumor in patients with advanced esophageal carcinosarcoma.     

胸段食管癌的微创手术治疗(附145例报告)

目的 探讨手辅助电视胸腔镜（HVATS）行胸段食管癌切除术的可行性及优缺点。方法 施行HVATS食管癌切除胃食管颈部吻合术124例、食管癌切除胃食管右胸内吻合术21例。结果 两组患者均能够达到常规手术切除效果,手术创伤小、恢复快,无围术期死亡。结论 在HVATS下采用胃食管颈部吻合术或右胸内吻合术能够实现对胸段食管任何位置的肿瘤进行根治性手术治疗。     

Esophageal schwannoma with tracheal compression

An esophageal schwannoma was found in a 73-year-old woman with cough, exertional dyspnea, and progressive dysphagia. Chest imaging showed an upper mediastinal mass (apex, right thoracic cavity) with direct lower tracheal compression. Esophagography and esophagoscopy revealed a tumor in the cervical and upper thoracic esophagus; it was resected from the upper thoracic esophagus followed by cervical esophageal repair. Histology showed oval-to-fusiform cells with palisading and lymphocytic stromal infiltration (immunohistochemistry, S-100 protein-positive). The patient was well one year afterward.     

Esophageal intramural pseudodiverticulosis associated with esophageal perforation

We report a rare case of esophageal intramural pseudodiverticulosis with lower esophageal stricture which perforated into the peritoneal cavity after the patient vomited. A 61-year-old man was admitted with severe chest and epigastric pain after dysphagia and vomiting. Under a diagnosis of upper gastrointestinal perforation, laparotomy was performed. The anterior wall of the abdominal esophagus was found to have ruptured, and proximal gastrectomy with abdominal esophagectomy was performed. His-tological examination revealed esophageal intramural pseudodiverticulosis with esophageal stricture distal to the site of rupture, and postoperative endoscopy showed diffuse pseudodiverticulosis in the remaining esophagus. The patient is free of symptoms 5 years after the surgery. This case suggests that careful treatment may be indicated in patients with esophageal intramural pseudodiverticulosis with stricture and elevated intraluminal pressure, to minimize the possibility of severe complications such as esophageal perforation. Received: June 7, 1999 / Accepted: January 28, 2000     

Endoscopically treated esophageal lipoma presenting with recurrent dysphagia after esophagectomy for esophageal carcinoma

We have reported a case of endoscopically treated lipoma of the cervical esophagus. The patient was referred to our hospital with a chief complaint of dysphagia and underwent an esophagectomy through right thoracotomy, followed by esophagogastrostomy for superficial esophageal cancer 3¹/₂ months before. However, this benign lesion was not revealed by preoperative check‐up. He again complained of dysphagia after esophagectomy and lipoma of the cervical esophagus was confirmed. Esophageal lipomas are relatively rare in the digestive tract; however, lipoma of the cervical esophagus can cause upper airway obstruction in the case of regurgitation of the tumor. Therefore, this disease must be considered in the examination of the patient with dysphagia.     

Selective three-field lymphadenectomy for thoracic esophageal squamous carcinoma

The purpose of this study was to examine metastasis in different nodal stations and the extent of lymphadenectomy for esophageal carcinoma. Eighty-seven thoracic esophageal squamous carcinoma patients underwent esophagectomy with two-field or three-field lymphadenectomy based on cervical ultrasonography. Thirty-five patients (40.2%) with ultrasonography-detected cervical nodes underwent cervical dissection. Significantly more patients with primary tumors in the upper thoracic esophagus had cervical dissection than patients with tumors in the middle and lower esophagus (66.7%vs. 30.2%, P=0.002). Metastasis to cervical, superior mediastinal, mid-mediastinal, and abdominal nodes were 19.5%, 25.3%, 23%, and 24.1%, respectively. Cervical metastasis was 29.2%, 20.8%, and 10% for upper, middle, and lower thoracic esophageal tumors. Regional lymphadenopathy was found in 48 patients (55.2%) and was significantly related to cervical metastasis (31.3%vs. 5.1%, P=0.002). It was significantly less in upper (37.5%) than in middle (62.3%) and lower (60%) thoracic esophageal tumors (P=0.041). When cervical metastasis was included into regional lymphadenopathy, the difference was no longer significant (45.8%vs. 63.5%, P=0.135). Cervical dissection was associated with significantly more morbidities (60%vs. 34.6%, P=0.020), especially recurrent laryngeal nerve palsy (22.9%vs. 9.6%, P=0.089). Recurrent laryngeal nerve palsy was related significantly to anastomotic leakage (53.8%vs. 13.5%, P=0.001). There was no significant difference between the 2-year survivals for patients with or without cervical metastasis (50.0 vs. 72.0%, P=0.094). We conclude that cervical metastasis is of a similar rate as metastasis to mediastinal or abdominal nodes. Cervical nodes should be taken as regional lymph nodes for thoracic esophageal cancer. Cervical dissection is associated with increased morbidity and should be reserved for patients who may benefit from the procedure. Selective three-field dissection based on ultrasonography is helpful in reducing surgical morbidity while increasing the completeness of resection.     

Esophageal reconstruction with remnant stomach:A case report and review of literature

The number of patients developing esophageal cancer after gastrectomy has increased.However,gastric remnant is very rarely used for reconstruction in esophageal cancer surgery because of the risk of anastomotic leakage resulting from insufficient blood flow.We present a case of esophageal cancer using gastric remnant for esophageal substitution after distal gastrectomy in a 57-year-old man who presented with a 1-month history of mild dysphagia and a background history of alcohol abuse.Gastroscopy showed a 1.2 cm × 1.0 cm bulge tumor of the lower third esophagus with the upper margin located 39 cm from the dental arcade.Computed tomography of the chest showed lower third esophageal wall thickening.The patient underwent en bloc radical esophagectomy with a two-field lymph node dissection of the upper abdomen and mediastinum via a left-sided posterolateral thoracotomy through the seventh intercostal space.The upper end of the esophagus was resected 5 cm above the tumor.The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the left thoracic cavity.The patient started a liquid diet on postoperative day 8 and was discharged on the 10 th postoperative day without complications.In this report,we demonstrate that the gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.