Mechanisms for the development of esophageal atresia.

BACKGROUND: There is no universally accepted theory to explain esophageal embryology and the abnormal development that produces esophageal atresia. METHODS: The impact of Adriamycin administration on the pathogenesis of esophageal atresia was studied in the rat model of VATER association, from embryonic day (ED) 10 to ED 13. RESULTS: Tissues in the ED10 Adriamycin-exposed embryos displayed less cell proliferation as shown by the reduced population of MIB-5-labelled cells. Cell apoptosis that is characteristic of the normal ED 12 lateral epithelial folds of the foregut (the prospective site of tracheoesophageal septation) was absent in the foregut of the Adriamycin-exposed embryo. Histologic examination of the ED 11-exposed embryo showed the presence of abnormal notochord that was stretched, split, or tethered to the foregut. This contrasts with the normal embryo in which the notochord was localized in close vicinity of the ventral part of the neural tube and separated from the foregut by ample amount of mesenchyme. The abnormal localization of the notochord was accompanied by the lack of down-regulation of the sonic hedgehog (Shh) activity in the prospective site of future tracheoesophageal separation in the exposed ED 12 embryo. CONCLUSION: The authors proposed that the ectopic location of the notochord leads to the disruption in Shh signalling that may underpin the development of esophageal atresia.     

颈椎前路内固定术后中远期食管并发症

 目的 探讨颈椎前路内固定术后中远期食管并发症的发生率及其诊疗策略。方法 对2001年1月至2011年12月2316例行颈椎前路内固定手术患者发生的中远期食管并发症情况进行回顾性分析。食管中远期并发症包括术后2周以上发生的食管穿孔、食管气管瘘、食管皮下瘘、食管憩室、食管胸膜瘘及食管狭窄等。结果 共4例患者发生中远期食管并发症,发生率为0.17%(４/２３1６),其中食管穿孔发生率为0.09%(2例)。病例1为31岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后7年发现食管憩室合并食管穿孔。手术取出内固定,清创后切除憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例2为46岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后3年发现食管憩室。手术取出内固定,切除食管憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例3为58岁女性患者,自体髂骨移植融合加钢板内固定(C6)术后5年出现食管憩室。手术取出内固定,切除食管憩室,胸锁乳突肌肌瓣修补食管。病例4为56岁女性患者,钛网植骨融合加钢板内固定(C6)术后3年出现食管穿孔。手术取出内固定,清创后胸锁乳突肌肌瓣修补食管。4例患者术后食管并发症均获得成功治疗,恢复良好。结论 颈椎前路内固定术后中远期食管并发症的发生率较低,X线片、消化道造影及消化道内镜检查是主要的诊断方法,手术是其主要的治疗手段。     

颈段食管癌施行保留咽和喉手术为主的综合治疗远期疗效

目的探讨以胸外科为主的多学科综合治疗对颈段食管癌的远期疗效。方法回顾性分析北京大学肿瘤医院胸外科单一手术组2000年3月至2011年3月间施行以胸外科保留咽、喉手术为主的多学科综合治疗的41例颈段食管癌患者的临床及随访资料．并与同期同一手术组治疗的480例非颈段食管癌进行比较。结果41例颈段食管癌患者中男28例,女13例,平均年龄62岁。接受术前化疗30例．术后化疗25例,手术前后均予以化疗21例,术后放疗6例。除4例仅行探查手术外,另37例行食管癌根治性切除颈部吻合,其中1例围手术期死亡。接受根治性切除术并顺利出院的36颈段食管癌患者术后1、3、5和8年累计生存率分别为96．8％、52．6％、35．1％和35．1％：而同期接受根治性切除术并顺利出院的457例非颈段食管癌患者的1年、3年、5年和8年累计生存率分别为85．0％、54．3％、45．0％和36．7％;两组差异无统计学意义（19〉0．05）。结论以胸外科为主的多学科综合治疗颈段食管癌能够获得较为满意的远期疗效。     

颈椎前路手术并发食管瘘的原因及处理

 目的 探讨颈椎前路手术并发食管瘘的原因及处理对策。方法 回顾性分析2004年1月至2011年12月采用颈椎前路手术治疗2348例颈椎疾患患者资料,其中5例发生食管瘘,男3例,女2例;年龄14~48岁,平均34岁;颈椎外伤3例,颈椎病1例,颈椎结核1例。1例患者术中发现食管瘘,给予修补;另4例均为术后发现,行清创探查引流术,其中1例探查时发现食管瘘口遂给予修补,1例仅行清创探查术,1例清创探查术后二期行内固定取出术,1例清创探查术后二期行内固定取出及肌瓣填塞术。给予禁食、营养支持、伤口引流及抗生素治疗;定期吞服亚甲蓝,观察漏口情况。结果 经过9～61周治疗,所有患者食管瘘口愈合,恢复进食。随访6～48个月,无一例发生食管瘘复发、颈椎失稳及迟发感染;吞咽功能均良好;患者原有颈部疾患治疗效果均满意,颈椎外伤患者Frankel分级平均提高1级,颈椎病患者JOA评分由术前9分提高至术后15分。结论 采用食管瘘口修补、肌瓣填塞以及引流手术,并严格禁食禁水、营养支持,必要时取出内固定物,多数颈椎前路手术并发食管瘘的患者能获得满意的疗效。术中仔细轻柔操作是预防食管瘘发生的关键。     

Esophageal adenocarcinomas in heterotopic gastric mucosa: review and report of a case with complete response to neoadjuvant radiochemotherapy

Adenocarcinomas are exceedingly rare in the cervical esophagus (26 reported cases), where squamous cell cancer (SCC) is the predominant tumor type. Esophageal heterotopic gastric mucosa (HGM) - a frequent remnant of incomplete replacement of the original columnar epithelium during the embryonic period - is suspected as cellular origin of cervical esophageal adenocarcinomas. As in any rare tumor entity, no standard treatment strategy is available for cervical esophageal adenocarcinomas. We herein report about the case of a 52-year-old man with a locally advanced, irresectable cervical esophageal adenocarcinoma originating in HGM. We decided on a neoadjuvant therapy (48.6 Gy + 5-FU/cisplatin) derived from experiences with SCC. Restaging showed an extraordinary good clinical response of the previously irresectable tumor. Subsequently the patient underwent limited cervical esophageal resection, lymphadenectomy and interposition of a free jejunal loop for reconstruction. Postoperative histopathological work-up of the specimen showed no residual tumor tissue, but unchanged HGM. This is the first case with complete response of a rare cervical esophageal adenocarcinoma to a neoadjuvant protocol. On 3-year follow-up the patient is doing fine with no complaints of dysphagia and no evidence of local or systemic recurrence.     

保留喉功能的非开胸食管钝性剥脱术治疗颈段食管癌

目的探讨保留喉功能的非开胸食管钝性剥脱术治疗颈段食管癌的临床经验。方法总结分析1997年8月至2005年11月间,采用保留喉功能非开胸食管钝性剥脱术对28例颈段食管癌患者进行治疗的临床资料。结果28例患者术前均确诊为颈段食管鳞状细胞癌。其中12例单纯接受手术治疗(单纯手术组),16例术前或术后接受放疗(综合治疗组)。治疗期间,全组无1例发生大出血、气管撕裂及围手术期死亡;6例(21.4%)出现并发症,其中吻合口瘘2例,喉返神经损伤4例。全组患者5年总体生存率50.3%;单纯手术组5年生存率25.7%,综合治疗组5年生存率66.1%;综合治疗组明显优于单纯手术组(χ2=4.07,P=0.0438)。结论保留喉功能的非开胸食管钝性剥脱术治疗颈段食管癌是可行的,联合放射治疗可以明显提高患者的术后生存率。     

Current management of cervical esophageal cancer

Background  

Pharyngo-laryngo-esophagectomy (PLE) has been regarded as a standard treatment for cervical esophageal cancer, but the morbidity and mortality rates associated with PLE are substantial. Chemoradiation (CTRT) is widely used to treat esophageal cancer; however, its role in managing cervical esophageal cancer has not been fully elucidated. It was hypothesized that up-front CTRT could be an effective alternative treatment option to PLE. The purpose of this study was to compare the outcomes of patients with cervical esophageal cancer treated with these two methods.     

Esophageal perforation after anterior cervical surgery: a review of the literature for over half a century with a demonstrative case and a proposed novel algorithm

Purpose

To review relevant data for the management of esophageal perforation after anterior cervical surgery.

Methods

A case of delayed esophageal perforation after anterior cervical surgery has been presented and the relevant literature between 1958 and 2014 was reviewed. A total of 57 papers regarding esophageal perforation following anterior cervical surgery were found and utilized in this review.

Results

The treatment options for esophageal perforation after anterior cervical surgery were discussed and a novel management algorithm was proposed.

Conclusion

Following anterior cervical surgery, patients should be closely followed up in the postoperative period for risk of esophageal perforation. Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury. Review of the literature revealed that conservative treatment is advocated for early and small esophageal perforations. Surgical treatment may be considered for large esophageal defects.

     

Isolated cervical esophageal reconstruction for rare esophageal tumors

BACKGROUND: Isolated defects in the cervical esophagus in patients who have not undergone total laryngectomy are uncommon. We report 2 cases of rare esophageal tumors requiring reconstruction of the cervical esophagus after tumor resection. METHODS AND RESULTS: The patients were a 51-year-old woman with an esophageal granular cell tumor and a 54-year-old woman with an esophageal schwannoma. Both defects were reconstructed with a radial forearm flap. A small subclinical leak developed in 1 patient and healed spontaneously within 2 weeks. At 1 year and 2 years of follow-up, both patients were consuming a normal diet and had normal voices. CONCLUSIONS: A thin and well-vascularized flap such as the radial forearm flap is essential for reconstructing an isolated cervical esophageal defect so as to maximize functional outcome.     

A new instrument for insertion of anvil head for circular stapled anastomosis]

Difficulty associated with the insertion of the anvil head into the esophageal stump, caused by narrowing of the cervical esophagus, is a big problem for staple anastomosis during esophageal reconstruction. Postoperative cervical stricture also has been a major complication of esophagogastric anastomosis using a circular stapler. The stricture results from esophageal laceration caused by the anvil insertion. To avoid these complications, we designed a new retractor with triple-flap arms, which spreads out in a concentric circle from 20 mm to 35 mm in diameter. This instrument is useful for gently expanding the cervical esophagus without lacerations, and facilitates an anvil insertion into the stump of esophagus. In the 8 patients in whom this instrument was applied for dilation, none of the patients suffered from any stricture. Our clinical result indicates the usefulness of this new instrument for avoiding esophageal laceration and preventing stricture of esophageal anastomosis performed by circular stapler.     

Cervical esophageal hemangioma combined with thyroid cancer

Hemangiomas that arise in cervical esophagus are extremely rare, representing 3.3% of all benign esophageal tumors. Although endoscopic mucosal resection (EMR) and potassium titanyl phosphate/yttrium aluminum garnet (KTP/YAG) laser therapy have been used with success for small tumors, the safety and efficacy in the case of large tumors remains uncertain. We report the successful resection of cervical esophageal hemangioma through a cervical esophagotomy in a patient with thyroid cancer who needed a cervical collar incision.     

Surgical repair of long-segment cervical esophageal injury with a sternocleidomastoid myocutaneous flap

We present a useful technique for the surgical management of long-segment cervical esophageal tears using a sternocleidomastoid flap with overlying skin patch. The flap is easily accessible, customizable, and offers the ability to repair long segments of cervical and upper thoracic esophageal injuries.     

Resection of carcinoma in the cervical esophagus following prior removal of a thoracic esophageal carcinoma — A case report—

We report herein, a rare case of a patient who, having undergone resection of a thoracic esophageal cancer, underwent removal of a cervical esophageal cancer, for which a free jejunal graft with microvascular anastomoses was utilized. The tumor in the cervical esophagus had originated from a second primary squamous cell cancer, which had occurred synchronously but had unfortunately escaped detection before the first operation. Due to the high incidence of other multicentric neoplasma or metastatic skip lesions accompanying esophageal carcinoma, careful evaluation during preoperative examinations in order to avoid overlooking another lesion, especially in the cervical portion of the esophagus is imperative.     

选择性颈胸腹三野淋巴结清扫治疗胸段食管鳞癌

目的 研究胸段食管鳞癌的淋巴结转移规律，探讨合适的淋巴结清扫范围。方法 87例接受食管次全切除术的胸段食管鳞癌患者，根据术前食管腔内超声和颈部超声检查结果，选择性进行胸腹二野或颈胸腹三野淋巴结清扫。结果 超声发现颈部淋巴结肿大并行三野清扫35例（40．2％，三野清扫组），其中原发肿瘤位于胸上段食管者的比例（16／24例，66．7％）显著高于中、下段肿瘤者（19／63例，30．2％）（P=0．002）。三野清扫术扫除淋巴结13．7组／例，显著多于二野清扫组（52例，59．8％）的10．5组／例（P〈0．001）。术后病理检测三野清扫组转移淋巴结1．5组／例，也显著多于二野清扫组的0．8组／例（P〈0．01）。颈淋巴结转移（pM1-LN）17例（占全组19．5％，占三野清扫组48．6％），有区域淋巴结转移者的颈淋巴结转移比例（15／48例，31．3％）显著高于无区域淋巴结转移者（2／39例，5．1％）（P〈0．01）。上、中、下纵隔及上腹部的淋巴结转移率分别为25．3％、23．O％、5．7％和24．1％，颈淋巴结转移与上纵隔（P〈0．01）及中纵隔（P〈0．01）淋巴结转移显著相关，但与下纵隔及上腹部淋巴结转移无关。三野清扫组术后并发症发生率（60．0％）显著高于二野清扫组（34．6％，P=0．020）。喉返神经损伤发生率两组差异无统计学意义（P〉0．05）；但喉返神经损伤者吻合口瘘发生率（7／13例，53．8％）显著高于无喉返神经损伤者（10／74例，13．5％，P=0．001）。术后死亡率两组差异无统计学意义（P〉0．05）。结论 应对肿瘤位于胸上段食管、或上纵隔及中纵隔淋巴结已发生转移的食管癌患者在超声指导下进行选择性颈胸腹三野淋巴结清扫术，以降低手术风险、提高手术根治效果。     

Resection of carcinoma in the cervical esophagus following prior removal of a thoracic esophageal carcinoma--a case report

We report herein, a rare case of a patient who, having undergone resection of a thoracic esophageal cancer, underwent removal of a cervical esophageal cancer, for which a free jejunal graft with microvascular anastomoses was utilized. The tumor in the cervical esophagus had originated from a second primary squamous cell cancer, which had occurred synchronously but had unfortunately escaped detection before the first operation. Due to the high incidence of other multicentric neoplasma or metastatic skip lesions accompanying esophageal carcinoma, careful evaluation during preoperative examinations in order to avoid overlooking another lesion, especially in the cervical portion of the esophagus is imperative.     

Clinical implications of cervical lymph node metastasis patterns in thoracic esophageal cancer.

OBJECTIVE. The authors attempt to clarify the clinical implications of cervical lymph node metastases from thoracic esophageal cancers. SUMMARY BACKGROUND DATA. Cervical lymph node metastases from thoracic esophageal cancer have been considered to be incompatible with curative resection. However, recent studies have demonstrated that cure is achievable in patients with such metastases. METHODS. Patterns of esophageal cancer metastasis to the cervical nodes and long-term results after tumor resection were investigated in 23 patients undergoing bilateral cervical lymphadenectomy for treatment of thoracic esophageal cancer. RESULTS. The number of positive nodes per patient was significantly greater (p < 0.05) in lower esophageal cancers (median: 15) than in upper or mid esophageal cancers (median: 2.5). Simultaneous metastases to three nodal regions (the neck, mediastinum, and abdomen) were significantly more common (p < 0.001) in lower esophageal tumors (88.9%) than in upper and mid esophageal lesions (7.1%). Although the overall 5-year survival rate was 16.5%, long-term survival was achieved only in patients with upper or mid esophageal cancer.     

Esophageal erosion 9 years after anterior cervical plate implantation

BACKGROUND: Anterior cervical discectomy and fusion is 1 of the most common spinal procedures performed. Most complications are observed during the intraoperative or immediate postoperative period. Long-term complications are not often described. A review of literature revealed 5 years as the longest complication interval. We present a case of esophageal erosion 9 years after initial surgery that was successfully treated. CASE DESCRIPTION: We describe a case of a 42-year-old woman who presented with recurrent pneumonia secondary to esophageal erosion almost 1 decade after anterior cervical spine surgery. This is the longest documented delay in presentation of esophageal erosion published to date. The diagnosis was made during EGD and the treatment consisted of plate removal and esophagus repair. The pertinent literature is reviewed and the therapeutic implications are discussed. CONCLUSIONS: In this report, we describe an uncommon case of esophageal erosion 9 years after anterior cervical plating. In cases of hardware migration even many years after surgery or in patients with intrinsic esophageal disease, potential esophageal damage should be considered.     

Tear of the cervical esophagus following hyperextension from manual traction: case report

Cervical esophageal disruption is a known complication of hyperextension injuries of the cervical spine. A patient was seen at our institution after nonprofessional manipulation of the cervical spine. There was no apparent cervical spine injury. Following diagnosis, the neck was explored and the esophageal tear repaired and drained. The patient recovered uneventfully.     

Management of corrosive esophageal burns in 149 cases

OBJECTIVES: We sought to present our experience in the management of esophageal burns. METHODS: From April 1976 through October 2003, 149 patients with corrosive esophageal burns were included in this study. Treatment modalities consisted of modified intraluminal stenting in 28, colon interposition in 71, gastric transposition in 25, repair of cervical stricture with platysma myocutaneous flap in 17, and miscellaneous operations in 12 patients. Eleven of these patients underwent the above procedures twice at our institute. The remaining 7 patients were treated with conservative therapy. RESULTS: Twenty-three patients recovered from intraluminal stenting, and 5 experienced stricture after stent removal. One of the 5 patients with failed stents responded to bougienage, and the remaining 4 patients required esophageal reconstruction later. Of the 71 colon interpositions, 5 patients died postoperatively, and complications consisted of proximal anastomotic fistula in 17, anastomotic stenosis in 6, and abdominal incision dehiscence in 2 patients. Postoperative complications in the 25 patients with gastric transpositions comprised anastomotic stricture in 2 patients and empyema in 1 patient. There was a cervical leak in 1 of the 17 patients undergoing the repair of cervical esophageal or anastomotic stricture with a platysma myocutaneous flap. One of the patients in the group undergoing 12 miscellaneous procedures died 8 months after surgical intervention. All the survivors currently eat regular diets. CONCLUSIONS: Intraluminal stenting can prevent the formation of caustic esophageal stricture. The location of the cicatricial esophagus dictates whether to perform concomitant esophagectomy during esophageal reconstruction. Platysma myocutaneous flap repair is an excellent method for the treatment of severe cervical esophageal or anastomotic stricture.