Esophagectomy: Definitive Treatment for Esophageal Neuromotor Dysfunction

Twenty-two patients with a history of between one and four (average of two) unsuccessful prior esophageal operations for neuromotor dysfunction were treated with esophageal resection and replacement. Eleven (50%) had recurrent reflux esophagitis in association with various disorders of motility: esophageal spasm in 4, achalasia in 3, scleroderma in 2, and esophageal atresia in 2. Eight (36%) had primary esophageal spasm and 3 (14%) had achalasia. Esophageal obstruction, regurgitation, and severe spasm were the most common manifestations of the inability to swallow normally. Transthoracic or transhiatal (blunt) esophagectomies were performed in 5 and 17 patients, respectively. The stomach, with a cervical esophagogastric anastomosis, was used for esophageal substitution in 15 patients. Six patients underwent a long-segment colonic interposition, and 1 patient with achalasia underwent a distal esophagectomy and short-segment colonic interposition. One patient undergoing transthoracic esophagectomy for achalasia died from unrecognized intraoperative bleeding into the opposite chest. There were no other operative deaths. Additional complications included transient hoarseness in 8 patients, chylothorax in 1, and anastomotic leak in 1. After an average follow-up of 25 months for the 21 surviving patients, ability to eat is regarded as good in 18 (85%), fair in 1 (5%), and poor in 2 (10%).In patients with incapacitating esophageal neuromotor disease, a more radical operative approach—esophagectomy—may be safer and more reliable than attempting another procedure and risking another failure. Esophagectomy ensures definitive elimination of the esophageal problem and as optimal an ability to eat as possible. Our experience suggests that the stomach, with a cervical esophagogastric anastomosis, offers a better functional esophageal substitute than does a colonic interposition.     

Definitive Chemoradiotherapy and Salvage Esophagectomy for Esophageal Cancer Associated With Multiple Lung Metastases: A Case Report

The prognosis of esophageal cancer with distant metastasis is dismal. We report a 70-year-old man with esophageal cancer and multiple lung and lymph node metastases. Complete response was achieved following definitive chemoradiotherapy. Twenty-four months after the initial chemoradiotherapy, local recurrence was detected but there was no evidence of distant metastasis. Therefore, the patient underwent salvage esophagectomy. The surgery was well tolerated without any postoperative complications. The patient is still alive 48 months after the salvage surgery. Our experience suggests that salvage esophagectomy is an important component of multimodal therapy for the recurrence of esophageal cancer.Key words: Esophageal cancer, Chemoradiotherapy, Salvage surgeryThe prognosis of esophageal cancer has improved in recent years, but remains poor despite curative resection.¹ The prognosis is extremely dismal in patients with distant metastasis. The Radiation Therapy Oncology Group (RTOG) trial 85-01 showed that chemoradiotherapy (CRT) improved outcomes, with a 5-year overall survival rate of 26% compared with 0% following radiotherapy alone. Moreover, residual cancer was less common following CRT (26%) than following radiotherapy alone (37%).² However, local recurrence occurs in 37% of patients after definitive CRT.³ Salvage esophagectomy is one strategy for residual cancer or local recurrence after definitive CRT. Of note, when R0 resection is achieved, long-term survival can be expected.⁴⁻⁶ On the other hand, this is an invasive procedure associated with high morbidity and mortality⁶ and the patient''s prognosis is extremely poor after R1/R2 resection.⁴⁻⁶ Therefore, salvage esophagectomy should only be performed if complete removal of the tumor is expected.Here, we report a rare case with esophageal cancer and multiple lung metastases, in which complete response (CR) was achieved after definitive CRT and salvage esophagectomy was effective for the local recurrence.     

Postoperative Pneumonia is Associated with Long-Term Oncologic Outcomes of Definitive Chemoradiotherapy Followed by Salvage Esophagectomy for Esophageal Cancer

Background or Purpose

As we previously indicated, postoperative pneumonia has a negative impact on the overall survival after planned esophagectomy. However, the impact of postoperative pneumonia after salvage esophagectomy on long-term oncologic outcomes still remains unclear. This study aimed to indicate the association between postoperative pneumonia and long-term outcomes of definitive chemoradiotherapy followed by salvage esophagectomy. Furthermore, we determined a prediction model for overall survival (OS) and disease-free survival (DFS) using a survival classification and regression tree (CART).

Methods

Ninety-three patients who underwent CRT followed by esophagectomy for thoracic esophageal cancer were identified for this study. Forty-nine patients and 44 patients were included in the salvage and neoadjuvant groups, respectively. We investigated the association between postoperative pneumonia and long-term oncologic outcomes following salvage esophagectomy.

Results

Patients from the salvage group tended to have a lower OS compared to neoadjuvant group (median survival: salvage, 24 months vs neoadjuvant, 43 months, p?=?0.117). Multivariate analyses revealed that postoperative pneumonia adversely affected both OS (p?<?0.001) and DFS (p?=?0.044) after salvage esophagectomy. We generated the prediction model for OS and DFS in the salvage group using survival CART. Postoperative pneumonia was the most important parameter for predicting the OS.

Discussion

The present study demonstrates the long-term outcomes and risk factors for mortality of salvage esophagectomy. To improve OS after salvage surgery, the development of a means of decreasing pulmonary complications is needed.

     

Salvage Lymphadenectomy of the Right Recurrent Nerve Node with Tracheal Involvement After Definitive Chemoradiation Therapy for Esophageal Squamous Cell Carcinoma: Report of Two Cases

Thoracic esophageal cancers frequently metastasize to the right recurrent nerve nodes (RRNNs). In fact, huge RRNNs invading the trachea sometimes remain after definitive chemoradiation therapy (CRT), despite complete remission of the primary lesion. We performed salvage lymphadenectomy of a large RRNN combined with partial resection of the trachea in two patients. Using an anterior approach, we removed part of the sternum, clavicle, and the first and second costal cartilage; then, we removed the RRNNs with combined resection of the lateral quarter circumference of the trachea, the esophageal wall, and the recurrent nerve. Reconstruction was done with a musculocutaneous patch of major pectoral muscle to cover the tracheal defect. The only minor complication was venous thrombosis in one patient. Thus, combined removal of the RRNN and trachea was performed safely as a salvage operation after definitive CRT for esophageal squamous cell carcinoma.     

Long-Term Quality of Life After Esophagectomy for Esophageal Cancer

BackgroundSurgery, as part of a multimodal approach, offers the greatest chance of cure for esophageal cancer. However, esophagectomy is often perceived as having a lasting impact on quality of life (QOL), biasing some physicians and patients toward nonoperative management. A comprehensive understanding of the dynamic changes in patient-centered outcomes is therefore important for decision making. Our objective was to determine the long-term QOL after esophagectomy.MethodsData were obtained from a prospectively collected (2006-2015) esophagectomy database at a high-volume center, and patients surviving 3 or more years were identified. Health-related QOL was evaluated using the Functional Assessment of Cancer Therapy-Esophageal Module (FACT-E) at diagnosis and every 3 to 6 months, and was stratified according to operative approach, stage, and complications. In addition, QOL scores were compared with normative population values.ResultsOf 480 patients, 47% (n = 226) survived 3 or more years and 70% (158 of 226) completed the health-related QOL assessments. Time of follow-up was 5.1 ± 2.8 years. After a reduction at 1 to 3 months, FACT-E increased from a baseline of 126 (95% CI, 121-131) to 133 (95% CI, 127-139) at 12 months, and to 147 (95% CI, 142-153) by 5 years. There was no difference in long-term FACT-E with respect to the surgical approach, clinical and pathologic stage, or postoperative complications. At long-term follow-up (more than 3 years), QOL did not differ significantly from the normative population reference values.ConclusionsThe long-term QOL of esophagectomy patients surviving at least 3 years is improved when compared with the time of diagnosis and does not differ from the general population.     

Selective Lymphadenectomy for Salvage Esophagectomy in Patients with Esophageal Squamous Cell Carcinoma

Annals of Surgical Oncology - Extensive lymph node dissection increases the risk of postoperative complications, especially in salvage surgery, after definitive chemoradiotherapy (≥ 50 Gy) in...     

Salvage Lymphadenectomy for Recurrent Esophageal Cancer After Chemoradiotherapy

Although salvage esophagectomies are widely performed, reports on salvage lymphadenectomy (SL) are few. We review our SL cases to clarify the indications. Fifty-five patients with esophageal cancer underwent chemoradiotherapy or radiotherapy, including 3 patients with single lymph node (LN) recurrences and one with allochronic double cervical node recurrence. Our department removed 5 recurrent LNs from these 4 patients. In Case 1, right supraclavicular LN was judged to be metastatic and R0 resection was carried out; he is alive without recurrence. In Case 2, we found, allochronically, metastases in his left cervical paraesophageal LN and left supraclavicular LN; residual tumors were R1 in both lesions. He is alive despite esophageal recurrence. In Case 3, a lymphadenectomy was performed on his thoracic para-aortic LN; however, tumor was removed incompletely, and he died 4 months after SL from disease progression. In Case 4, a subcarinal LN was thought to be metastatic, and was removed but no malignant tissues detected. He died 17 months after SL from pneumonia. Our experiences suggest that some patients survive relatively long with SL. Moreover, molecular examination of resected lesions could guide subsequent therapies. SL might be more widely used for these patients if not otherwise contraindicated.Key words: Esophageal cancer, salvage lymphadenectomy, Salvage surgery, Esophagectomy, ChemoradiotherapyEsophageal cancer is the eighth most common form of cancer worldwide, and is one of the most difficult malignancies to cure.¹ Excluding cases with severe concomitant diseases, surgery is the best modality to cure esophageal cancer.² However, many patients with esophageal cancer have concomitant diseases that are associated with alcohol and tobacco consumption, such as chronic obstructive pulmonary disease, liver cirrhosis, and synchronous cancers of the lung or head and neck region.³ For patients with such concomitant diseases, chemoradiotherapy (CRT) is usually performed to cure esophageal cancer. For unresectable advanced-stage tumors, CRT is also used, and sometimes has favorable results. The Radiation Therapy Oncology Group trial (RTOG 85-01) has established CRT without surgery as one standard for definitive treatment.⁴ Many patients and oncologists have accepted the nonsurgical approach with CRT as definitive therapy for esophageal carcinoma. Although complete response (CR) rates are high and short-term survival is favorable after definitive CRT, locoregional disease persists or recurs in 40–60% of patients.⁵ From Japan, a phase II study of CRT for Stage II–III esophageal squamous cell carcinoma (JCOG9906)⁶ found a CR rate of 62.2%, with 34.2% patients having residual or locoregional recurrence without distant metastasis after CRT.For resectable residual or recurrent lesions after definitive CRT, surgical excision is the only curative modality. Therefore, such operations are called salvage surgery. In Japan, salvage surgery is defined as a procedure for recurrent or residual cancer after definitive CRT (RT > 50 Gy)⁷ and thought to be the only curative method. Conversely, salvage surgery is widely considered elsewhere to be a type of palliative surgery—the excision of tissue to reduce the risk of death due to physiologic derangement. Although salvage esophagectomy is performed in many institutions in Japan,^8–13 reports on salvage lymphadenectomy (SL) are still few.^14,15 In this article, we review our SL cases, and examine indications for this kind of surgery.     

27例食管癌切除术后胃排空障碍

为探讨食管癌术后胃排空障碍合理的治疗方法及预防措施，对１９８２～１９９５年间２７例食管癌术后胃排空障碍病人的临床资料进行回顾性分析。食管胃颈部吻合者２２例，胸内吻合者５例。占同期食管癌手术２４２７例的１．１％。１８例功能性胃排空障碍病人中１５例经保守治愈，３例死亡；９例机械性胃排空障碍病人经手术治愈。结论：食管癌术后胃排空障碍好发于食管胃颈部吻合者，多为功能性，少数为机械性。因治疗方法不同需强调二者的鉴别诊断。术中精细适度各项操作，可减少机械性胃排空障碍的发生     

Results of Surgical Salvage after Failed Chemoradiation Therapy for Epidermoid Carcinoma of the Anal Canal

Background The standard treatment for epidermoid carcinoma of the anal canal consists of combined radiation and chemotherapy. For patients who present with persistent or locally recurrent disease, salvage abdominoperineal resection is the treatment of choice. The purpose of this study is to review our experience with salvage surgery in this group of patients. Methods From 1990–2002, 31 patients underwent radical salvage surgery with curative intent after failure of initial sphincter-conserving therapy, and the medical records of these patients were retrospectively reviewed. Clinicopathologic variables were determined and comparisons performed with the Cox proportional hazards model. Survival was calculated by the Kaplan–Meier method. Results Eleven patients underwent radical salvage surgery for persistent disease and 20 patients for recurrent disease. The median follow-up time was 29 months. The actuarial 5-year overall survival was 64%. Twelve patients developed recurrent disease after radical salvage surgery. Patients who received an initial radiation dose of less than 55 Gy had a significantly worse survival than those who received at least 55 Gy as part of their initial treatment (5-year overall survival 37.5% vs. 75%; age-adjusted hazard ratio 8.2 [95% CI: 1.1–59.8], P = .037). The presence of positive lymph nodes at presentation also adversely affected survival (P < .05). Factors that were not found to have an impact on survival included the presence of persistent versus recurrent disease, tumor (T) stage, and margin status of resection. Conclusions Long-term survival following salvage surgery for persistent or locally recurrent epidermoid carcinoma of the anal canal can be achieved in the majority of patients. However, patients who initially present with node-positive disease and patients who receive a radiation dose of less than 55 Gy as part of their initial chemoradiation therapy regimen have a worse prognosis after radical salvage surgery.