Cancer of the gastric tube reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer

Among 750 patients diagnosed with esophageal carcinoma in our department between 1972 and 1997, we reviewed our 10 cases in which cancer occurred within gastric tubes reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer. The interval between esophagectomy and cancer onset in the reconstructed gastric tube was relatively long (mean interval: 72 months). Five of our 10 subjects had gastric tube cancer detected at follow-up endoscopy. Four underwent total or partial gastric tube resection with open thoracotomy using colonic or jejunal reconstruction; 3 underwent endoscopic resection. To the best of our knowledge, this is the first report on patients undergoing total resection of gastric tubes reconstructed through the posterior mediastinal route after esophagectomy and rereconstruction using the pedicled colon for the gastric tube cancer.     

Video-assisted surgery for gastric carcinoma arising in a gastric tube reconstructed retrosternally

Advances in diagnostic and surgical techniques have improved the prognosis of esophageal cancer, but there is growing concern about gastric tube cancer after esophagectomy. Gastric carcinoma arising in tubes that were reconstructed retrosternally is usually resected through a median sternotomy; however, this is invasive and carries a risk of osteomyelitis after suture-line failure. We performed video-assisted gastric tube resection, eliminating the need for sternotomy by using a sternal lifting method, on a 71-year-old man who had previously undergone esophagectomy and reconstruction retrosternally. The tumor was a Borrmann type 1 advanced cancer located near the esophagogastric anastomosis. Neck collar and upper abdominal incisions were made, and the sternum was lifted using a Kent retractor to extend the retrosternal space. Under videoscope assistance, we stripped the adhesions around the gastric tube carefully and performed total gastric tube resection. For the reconstruction, the ileocolon was lifted through the retrosternal space, and an ileoesophagostomy and Roux-en-Y reconstruction were performed. Despite leakage from an esophago-ileoanastomosis on postoperative day 6, the patient recovered well without mediastinitis or osteomyelitis of the sternum. Thus, our surgical procedure provides a good surgical view, decreases surgical stress, and reduces the risk of fatal postoperative complications.     

Video-assisted thoracoscopic esophagectomy for esophageal cancer

BACKGROUND: The Ivor-Lewis procedure is a radical, invasive, and effective procedure for the resection of most esophageal cancers. To minimize invasiveness, we performed thoracoscopic and video-assisted esophagectomy and mediastinal dissection for esophageal cancer. METHODS: From November 1995 to June 1997, 23 patients with intrathoracic esophageal cancer, excluding T4 cancers, underwent thoracoscopic and video-assisted esophagectomy. Bilateral cervical dissections were performed as well as preparation of the gastric tube and transhiatal dissection of the lower esophagus. The cervical esophagus was cut using a stapler knife, and esophageal reconstruction was performed through the retrosternal route or anterior chest wall. Next, thoracoscopic mediastinal dissection and esophagectomy were performed. RESULTS: The mean volume of blood loss was 163 +/- 122 ml; mean thoracoscopic surgery duration, 111 +/- 24 min; mean postoperative day for patients to start eating, 8 +/- 3 days; and mean hospital stay, 26 +/- 8 days. No patient developed systemic inflammatory response syndrome postoperatively. Tracheal injury occurred and was repaired during the thoracoscopic approach in one patient. No patients died within 30 days after surgery. Postoperative complications included transient recurrent nerve palsy in five patients, pulmonary secretion retention requiring tracheotomy in two, and chylothorax in one. Five patients died of cancer recurrence within 1 year of surgery. CONCLUSIONS: Our surgical experience with thoracoscopic and video-assisted esophagectomy indicate that it is a feasible and useful procedure.     

Treating gastric tube cancer with distal gastrectomy preserving the gastroepiploic artery

Total resection of the gastric tube with lymphadenectomy is standard and reliable treatment for gastric tube cancer. However the risk associated with totally removing a gastric tube previously reconstructed through the posterior mediastinal route is significant, given the need to lyse a significant number of adhesions in order to reach the mediastinum. As a less invasive procedure, we used distal gastrectomy to treat superficial gastric tube cancer in 2 patients. The distal gastric tube was mobilized and resected with preservation of the right gastroepiploic artery, and the Roux-en-Y gastrojejunostomy was used for reconstruction. This procedure was curative with less surgical stress.     

Metachronous gastric carcinoma from a gastric tube after radical surgery for esophageal carcinoma

BACKGROUND: Cases of metachronous gastric carcinoma arising from a gastric tube used for reconstruction have been increasing in long-term survivors of esophageal cancer in recent years. We investigated the characteristics of gastric tube carcinoma to determine the most appropriate approach to managing it. METHODS: Between 1980 and 1997, 508 patients underwent radical esophagectomy for esophageal carcinoma at Keio University Hospital. Reconstruction was performed with a gastric tube in 414 (81.5%) of them, and 8 of them developed a metachronous carcinoma in the gastric tube. The clinical and pathologic characteristics of the gastric tube carcinomas were evaluated in this study. RESULTS: Gastric cancer was detected during follow-up endoscopic examinations or in an upper gastrointestinal series in seven patients. All of the cancers were diagnosed as adenocarcinoma histopathologically. Endoscopic mucosal resection was performed in two patients, partial resection of the residual stomach was performed in three patients. One patient was treated by endoscopic mucosal resection as palliative therapy, since he had severe pulmonary emphysema. Total resection of the gastric tube was attempted in 2 advanced cases but was unsuccessful because of direct invasion of other organ by the cancer. The 5 patients who underwent curative resection are alive with no subsequent recurrence. CONCLUSIONS: Since early diagnosis permits less invasive treatment and curative treatment is difficult in advanced cases, strict postoperative examinations are important after radical esophagectomy to ensure early detection of metachronous gastric carcinoma arising from gastric tubes used for reconstruction.     

Laparoscopic intragastric surgery for gastric tube cancer following esophagectomy

As a result of the recent improvement of the prognosis of esophageal cancer, the reporting frequency of gastric tube cancer following esophageal cancer has increased. Gastric tube total resection following median sternotomy, a highly invasive surgical procedure, is applied to the cases of advanced gastric tube cancer, whereas endoscopic mucosal resection is selected for the cases of early gastric tube cancer. If endoscopic mucosal resection is not applicable for some reason, partial or total resection of the gastric tube following median sternotomy has been selected. We applied laparoscopic intragastric surgery to such a case: The patient, a 59-year-old man with esophageal cancer, had undergone subtotal esophagectomy followed by gastric tube reconstruction through the retrosternal route 6 years before. Since endoscopy revealed early gastric cancer in the body of the stomach, we tried to perform mucosal resection but failed because of anastomotic stenosis. However, we successfully performed intragastric surgery, in which a camera and forceps were inserted directly into the gastric tube. Thus, laparoscopic intragastric surgery is a useful technique in cases to which endoscopic mucosal resection is not applicable.     

食管切除术后管状胃不同上提径路的比较

目的 比较食管癌三切口手术后,管状胃经胸骨后和经食管床两种径路上提行胃食管颈部吻合的安全性和有效性.方法 回顾性分析2005年7月至2009年5月间107例行食管癌三切口手术患者的临床资料.结果 本组患者上提管状胃采用经胸骨后径路行胃食管颈部吻合者52例,经食管床径路者55例.两种径路吻合组在手术时间、术中出血量及胸管置管方面差异均无统计学意义（P＞0.05）.胸骨后径路组的住院时间[（12.9±9.4）d]长于食管床径路组[（9.9±5.4）d,P＜0.05].两组均无围手术期死亡病例.胸骨后径路组的吻合口瘘发生率（26.9%）明显高于食管床径路组（5.5%）（P＜0.01）;两组患者肺部感染、肺不张和心律失常等心肺并发症发生率差异无统计学意义（P＞0.05）.结论 经胸骨后和经食管床径路管状胃上提均为有效、安全的途径;但胸骨后径路术后吻合口瘘发生率较高.应个体化选择管状胃的上提径路.     

Solitary Nodal Recurrence in the Dorsal Area of the Thoracic Aorta After a Curative Resection of Esophageal Cancer: Report of Two Cases

Although locoregional recurrence is often observed in the cervicothoracic area even after an esophagectomy with three-field lymph node dissection (3FL), recurrence in the mediastinal lymph nodes is relatively rare. We experienced two cases of solitary recurrence in a posterior mediastinal node (No 112-ao) after a curative resection for thoracic esophageal cancer. The lymph node recurrence was located in the connective tissue adjacent to the left posterior wall of the thoracic aorta, and thus could not have been removed by the conventional approach of an esophagectomy through a right thoracotomy. These two patients underwent surgical removal of the tumor through left thoracotomy, and survived for 5 years and 1 year without recurrence, respectively. Because the rate of metastasis in this area appears to be low, it is not always necessary to perform complete nodal dissection of the left side of the descending aorta at the initial surgery in cases of thoracic esophageal cancer. However, our experience suggests the importance of periodic computed tomography scans to check for any nodal recurrence in this area, since a surgical resection may be effective when the recurrence is detected as a solitary metastasis.     

Second primary carcinoma in the gastric tube constructed as an esophageal substitute after esophagectomy

BACKGROUND: The prognosis of esophageal carcinoma has improved, but along with this improvement, concern has increased about the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after esophagectomy. We describe our experience in the diagnosis and treatment of gastric tube carcinoma. STUDY DESIGN: We retrospectively examined 31 cases of gastric tube carcinoma; these cases occurred in 26 patients who received esophagectomy between September 1968 and October 2000. RESULTS: Surgical resection was performed in 10 patients. Gastrectomy with regional lymph node dissection was performed in 7 patients and partial resection of the stomach without lymph node dissection in 3 patients. In 6 patients leakage was encountered after gastrectomy; 3 of these patients died of multiple organ failure. Only one of the gastrectomy patients is alive without disease. Over the past 7 years, 15 patients with 20 lesions have been treated by endoscopic mucosal resection (EMR). Three of these patients required additional operation because of massive submucosal invasion by the tumor. One complication occurred at EMR, but it was successfully treated by conservative therapy. All patients treated by EMR alone were alive with neither local nor distant metastasis during a median followup period of 27.5 months. Of those patients who received surgical resection initially and were diagnosed as inoperable, all 10 had not received periodic checkups and had some symptoms. In contrast, of 15 patients who underwent EMR, all 20 lesions were found by annual followup endoscopic examination in the absence of symptoms. CONCLUSIONS: EMR for gastric tube carcinoma is safe and has few complications, in contrast to surgical resection of the gastric tube, which places a severe burden on the patient and has high morbidity and mortality. Early detection of the tumor by annual endoscopic examination is recommended for achieving good outcomes in gastric tube carcinoma after esophagectomy.     

Predictive value of blood flow in the gastric tube in anastomotic insufficiency after thoracic esophagectomy

Anastomotic insufficiency is considered to be one of the most serious complications associated with esophageal reconstruction. The purposes of this study were to identify (1) the relationship between anastomotic insufficiency and tissue blood flow (TBF) in the gastric tube in the perioperative period, and (2) the effects of intravenous prostaglandin E1 (PGE1) on TBF in the gastric tube. The study group consisted of 44 patients who were to undergo esophagectomy for esophageal cancer. Intraoperative and postoperative TBF on the serosal side of the gastric tube were measured by laser-Doppler tissue blood flowmetry. The TBF of the Leakage(+) group (n = 5) was poorer than that of the Leakage(?) group (n = 39) during the intraoperative and postoperative periods. There was a significant difference in TBF between the two groups at postoperative day (POD) 3. There was a tendency in the PGE1(+) group (n = 18) to exhibit richer blood flow through the anastomosis than the PGE1(?) group (n = 26), intraoperatively, but the difference was not significant. Two of five Leakage(+) cases were also in the PGE1(+) group. There was no relationship between intraoperative medication with PGE1 and incidence of leakage. The TBF of three-field lymph node dissection and reconstruction of the retrosternal route group (n = 21) was poorer than that of the two-field lymph-node dissection and reconstruction of the posterior mediastinal route group (n = 23). The TBF in the gastric tube after esophagectomy may be a predictor of anastomotic insufficiency. However, PGE1 treatment in the intraoperative period alone is not effective in preventing anastomotic insufficiency.     

同时发生的食管胃重复癌的外科治疗

目的探讨同时发生的食管、胃重复癌的外科治疗方法及效果.方法1985年1月至2005年1月收治同时发生的食管、胃重复癌12例,均为男性,平均年龄56.8岁.全组均行手术治疗,成功完成同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道10例,食管内翻拔脱并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道1例,手术探查1例.结果全组无围术期死亡.术后颈部吻合口瘘2例,不全肠梗阻1例,均经保守治疗后痊愈;术后腹部切口裂开1例,二期缝合治愈.9例获得随访,1、3、5年生存率分别100%、44.4%、22.2%.结论同期食管次全切除并全胃切除,结肠代食管并空肠“P”袢代胃重建消化道是根治同时发生的食管、胃重复癌安全有效的外科治疗方法.     

食管癌切除术后不同重建途径吻合口瘘的原因及预防

目的了解食管癌切除术后经不同径路重建,发生吻合口瘘的情况;探讨系统性淋巴结清扫后,经胸骨后胃代食管颈部吻合口瘘发生率较高的原因及预防方法。方法1105例行食管癌切除术的患者,229例经左胸行胸内吻合(A组),716例经右胸食管床胃代食管行颈部吻合(B组),160例予以系统性淋巴结清扫术后经胸骨后行颈部吻合(C组)。分析比较不同手术径路的3组患者术后吻合口瘘发生的情况。结果吻合口瘘发生率分别为:A组5/229(2.2%)、B组85/716(11.9%)、C组31/160(19.4%),C组吻合口瘘发生率显著高于A、B组(P<0.01和P<0.05)。比较C组不同重建方式吻合口瘘发生率显示,手工吻合与器械吻合(22.2%与11.6%,P=0.133)、全胃重建与管状胃重建(25%与15.6%,P=0.146)间吻合口瘘发生率无明显差异,而延长胃肠减压管留置时间至术后7d,吻合口瘘发生率由23.3%降至9.1%(P<0.05)。结论胸骨后胃代食管吻合口瘘发生率较高的主要原因,是前纵隔内的胃体受压、冲击吻合口所致;通过延长胃肠减压管留置时间能有效减少瘘的发生。     

Abdominal incisional hernia occurring after an esophagectomy reconstructed with a gastric tube through an antesternal route: Report of a case

A Japanese man, who had undergone a subtotal esophagectomy reconstructed with a gastric tube through an antesternal route for esophageal carcinoma 16 years previously, was admitted to our hospital because of an abdominal incisional hernia. The abdominal incisional hernia was in his upper abdomen and was difficult to push back into the intraabdominal cavity by hand. The hernia was successfully repaired by operation. We thus conclude that an abdominal incisional hernia is a rare but important late-phase complication occurring after an esophagectomy reconstructed with either an antesternal or retrosternal route, and an operation should be the treatment of choice.     

Gastric tube perforation after esophagectomy for esophageal cancer

We searched for cases of perforation of the gastric tube after esophagectomy for esophageal cancer by reviewing the literature. Only 13 cases were found in the English literature, and serious complications were seen in all cases, especially in cases of posterior mediastinal reconstruction. However, in the Japanese literature serious complications were also frequently seen in retrosternal reconstruction. Gastric tubes are at a higher risk of developing an ulcer than the normal stomach, including an ulcer due to Helicobacter pylori infection, insufficient blood supply, gastric stasis, and bile juice regurgitation. H. pylori eradication and acid-suppressive medications are important preventive therapies for ordinary gastric ulcers, but for gastric tube ulcers the effects of such treatments are still controversial. We tried to determine the most appropriate treatment to avoid serious complications in the gastric tubes, but we could not confirm an optimal route because each had advantages and disadvantages. However, at least in cases with severe atrophic gastritis due to H. pylori infection or a history of frequent peptic ulcer treatment, the antesternal route is clearly the best. Many cases of gastric tube ulcers involve no pain, and vagotomy may be one of the reasons for this absence of pain. Therefore, periodic endoscopic examination may be necessary to rule out the presence of an ulcer.     

Right gastro-omental artery reconstruction after pancreaticoduodenectomy for subtotal esophagectomy and gastric pull-up

IntroductionThere are no reports on vessel reconstruction of right gastro-omental artery deficits due to pancreatic tumor resection. Here, we describe successful arterial reconstruction using the middle colic artery in a patient who had undergone esophageal reconstruction with a gastric tube and whose right gastro-omental artery had been resected.Presentation of caseA 70-year-old man underwent subtotal esophagectomy and reconstructive surgery with a retrosternal gastric tube for esophageal cancer. A follow-up computed tomography (CT) scan revealed a tumor on the pancreatic head that was adjacent to the right gastro-omental artery. Pancreaticoduodenectomy (PD) was subsequently performed. The gastro-omental artery was resected along with the tumor, creating a 7-cm deficit. The anastomosis was performed between the right branch of the middle colic artery and the distal end of the right gastro-omental artery. No complications that involved blood flow to the reconstructed esophagus were postoperatively observed. Four months after surgery, the blood flow to the gastric tube was confirmed by a contrast CT scan.DiscussionWe reconstructed the right gastro-omental artery using the middle colic artery, and not a vein graft, as that would have required vessel anastomosis at two locations. The middle colic artery branches on the posterior surface of the pancreas, which is located close to the right gastro-omental artery.ConclusionThe middle colic artery provides sufficient blood supply to the pulled-up gastric tube. PD can be performed even in patients who have undergone esophageal reconstruction.     

The route of reconstruction following esophagectomy

The route of reconstruction following esophagectomy.Retrosternal reconstruction shows an increased rate of postoperative non-surgical complications and a slightly increased mortality compared to posterior mediastinal reconstruction. Radionuclid transit through the gastric tube is significantly longer in either way of reconstruction compared to normal controls. Tracerretention is significantly increased after retrosternal reconstruction. This however has no impact on the patients' quality of life. We therefore recommend posterior mediastinal reconstruction provided that curative resection is definitely achieved in order to avoid possible complications by local recurrence. In the palliative situation we would rather choose the retrosternal route of reconstruction as the functional disadvantages had no negative effect on quality of life and the general disadvantages seem to be neglectable in this situation. The same is true if adjuvant radiation of the tumorbed is planned. Pyloroplasty in our opinion is unnecessary. The presternal route of reconstruction is underrepresented in the literature. In our experience it has no indication.     

Strangulation of the reconstructive gastric tube by the azygos arch

Graft necrosis after esophageal reconstruction is a rare but disastrous complication associated with a high mortality rate. Azygos arch strangulation of the graft is an unusual cause of graft necrosis. We report two cases of postesophagectomy gastric tube reconstruction complicated by azygos arch strangulation and graft ischemia. In one patient, graft necrosis resulted and a reconstruction was performed later with a colon interposition. In the other patient, the azygos arch was divided and the graft was preserved. We recommend dividing the azygos arch routinely during transthoracic or thoracoscopic esophagectomy if the reconstruction graft is to be brought up through the posterior mediastinal route to help avoid this problem.     

Colon interposition for esophageal replacement: a single-center experience

Background Gastric tube interposition has become the method of choice for esophageal replacement after esophagectomy. Colon interposition, on the other hand, is widely considered to be a method of last resort, associated with high morbidity and mortality. The present study reviews our experience with colon interposition for esophageal replacement.Patients Nineteen consecutive patients undergoing colon interposition for esophageal replacement between 1 January 1994 and 31 July 2001 were reviewed. Outcome was compared with international publications on colon interposition as well as with our results following gastric tube interposition (fundus rotation gastroplasty).Results Fourteen men and five women with a median age of 68 years (range 44–78) underwent colon interposition for benign (n=9) and malignant (n=10) lesions. Eighteen patients underwent trans-hiatal esophagectomy with cervical anastomosis, and one patient underwent thoraco-abdominal esophagectomy with intrathoracic anastomosis. Surgical morbidity was 36.8% (7/19). Anastomotic insufficiency and fatal mediastinal bleeding occurred in one patient each (5.3%). No cases of graft necrosis were observed, and no re-operations were necessary. In-hospital mortality was 15.8% (3/19), twice due to surgical complications (abdominal sepsis, mediastinal bleeding) and once due to pulmonary and cardiac failure. As a late complication, four patients (21.1%) developed anastomotic strictures that necessitated repeated endoscopic dilatation.Conclusions Gastric tube interposition remains the method of choice for esophageal replacement. Colon interposition, however, is a valuable alternative with a good long-term function. Early mortality, however, remains a matter of serious concern.     

Chyluria after ligation of the thoracic duct: a rare complication after thoracoscopic-assisted esophagectomy for esophageal cancer

Chyluria is leakage of lymphatic fluid into the urine, following trauma to or obstruction of the lymphatic system. We herein report a rare case of chyluria after esophagectomy for esophageal cancer. A 69-year-old male complaining of epigastric pain and reflux symptoms was diagnosed with advanced esophageal cancer and regional lymph node metastases. After receiving neoadjuvant chemotherapy to control the regional lymph node metastases, the patient underwent transthoracic excision of the esophagus assisted by thoracoscopy, with excision of the azygos vein and thoracic duct, esophagostomy and tube gastrostomy. On postoperative day 22, the urine appeared ivory white in color, and urine tests showed a high triglyceride level, thus confirming the diagnosis of chyluria. The chyluria decreased temporarily after switching the patient from enteral nutrition (EN) to parental nutrition, but it emerged again after the resumption of EN. Lymphangiography at that stage showed the flow of lipiodol into the pelvis of the left kidney. Resolution of the chyluria was noted after lymphangiography. He underwent esophageal reconstruction with a gastric tube through an anterior mediastinal route, and was discharged 36 days after the second operation. He was thereafter followed up at the outpatient clinic with radiotherapy.     

Surgical therapy of advanced esophageal cancer. A critical appraisal

Thirty-five patients with advanced esophageal carcinoma underwent esophagogastrectomy. Of these, 13 patients underwent esophagogastrectomy through midline celiotomy and right thoracotomy incisions (Group 1), and 20 patients underwent extrathoracic esophagectomy with either reversed gastric tube (Group 2) or isoperistaltic tube reconstruction (Group 3). Morbidity was significantly greater in patients who underwent extrathoracic esophagectomy due to more severe pulmonary complications and anastomotic fistulas. Because of these complications, a longer interval to solid food ingestion occurred in the extrathoracic esophagectomy group. Long-term survival was not affected by the operative procedure utilized. Extrathoracic esophagectomy with cervical anastomosis is associated with more complications than an intrathoracic anastomosis, resulting in inferior palliation for patients with advanced esophageal carcinoma.