Thoracoscopic esophagectomy in the prone position for corrosive stricture after esophageal perforation due to balloon dilatation

An 18-year-old man was referred to our hospital because of chest pain after ingestion of a strong hydroxide in an attempted suicide. On post-ingestion day 25, an esophageal endoscopy and esophagram revealed at least three strictures, one each in the cervical, upper, and lower thoracic esophagus. In particular, the upper thoracic esophageal stricture was severe and was 5 cm long. Repeated balloon dilatation was employed, but resulted in perforation of the upper thoracic esophagus on the fourth attempt. On post-ingestion day 95, thoracoscopic esophagectomy in the prone position was performed. The esophagus was reconstructed using a subtotal gastric tube and cervical esophagogastric anastomosis in the supine position. Although the periesophageal adhesions were severe, esophagectomy was successfully performed. Anastomotic leakage developed after surgery, but the patient was discharged on postoperative day 47 on a regular diet.     

Successful 2nd reconstruction for failed ileocolonic interposition after esophagectomy

We report a 53-year-old woman who underwent successful 2nd reconstruction following ileocolonic necrosis after esophagogastrectomy. The patient had the initial operation for simultaneous esophageal and gastric cancer with subtotal esophagectomy and total gastrectomy after retrosternal ileocolic reconstruction. Proximal ileocolonic necrosis developed on the 7th postoperative day and massive bleeding from the left carotid artery occurred 2?days later. She was referred to our hospital after recovery from the last operation for restoration of discontinued esophageal substitute. Partial sternal resection was followed by implantation of a free jejunal graft between the remnant colon and the cervical esophagus. The transferred jejunum was covered by a left latissimus dorsi musculocutaneous flap. Postoperative course was uneventful and she was discharged 29?days after operation. For extended necrosis of an esophageal substitute after retrosternal reconstruction for esophageal surgery, this surgical procedure seems to result in less surgical stress with physiological and cosmetic benefit.     

Successful treatment of intractable esophagothoracic fistula using covered self-expandable stent

This report concerns the successful treatment with a covered self-expandable stent of an intractable thoracoesophageal fistula after total esophagectomy for esophageal cancer. Total esophagectomy was performed on a 68-year-old man who presented with a huge esophageal cancer in the lower esophagus. Massive leakage was observed on the 5th day postoperatively. Since high fever and coughing continued, he was diagnosed as having esophagothoracic fistula and pyothorax, after which fenestration of the right chest wall was performed. Although the patient's general condition was getting better, stenosis near the anastomosis (esophagogastrostomy) and the esophagothoracic fistula were resistant to treatment with balloon dilatation and repeated endoscopic mucotomy. Further treatment, consisting of glue or fibrin sealant injection was not effective. After a covered self-expandable stent had been placed endoscopically, however, the fistel was completely cured in 2 months. This new endoscopic approach thus represents a promising option for the treatment of intractable esophagothoracic fistula.     

Successful management of esophageal perforation due to an aortic arch aneurysm replacement

SUMMARY.  We present the successful management of an esophageal perforation after aortic arch aneurysm replacement in a 64-year-old patient. Four weeks after surgical repair of a perforated aortic arch aneurysm, a contained perforation of the thoracic esophagus on the prosthesis was detected. A subtotal esophagectomy and reconstruction by pull-up of the stomach together with the greater omentum and high intrathoracic esophagogastrostomy was performed. The aortic prosthesis was covered by omentum. After a prolonged postoperative course, the patient was discharged from the hospital on a full oral diet. She is well after 1 year without signs of infection.     

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.     

Management of gastric epithelial neoplasia in patients requiring esophagectomy for esophageal cancer

Esophageal squamous cell carcinoma is occasionally associated with malignancies located in other regions of the alimentary tract, as well as in the head, neck, and upper respiratory tract. The stomach is most commonly used for reconstruction of the alimentary tract after esophagectomy for esophageal cancer. When synchronous tumors are located in the stomach, it is often unsuitable for use in esophageal reconstruction. In such cases, an invasive procedure involving anastomosis between the esophagus and the colon must be performed. However, this procedure is associated with a high incidence of mortality and morbidity. Seven patients with synchronous esophageal cancer and gastric epithelial neoplasia were encountered. First, endoscopic submucosal dissection (ESD) was performed for the gastric epithelial neoplasia. Then, following successful ESD, Ivor‐Lewis esophagectomy for esophageal cancer was planned 1 to 2 weeks later. A total of 11 gastric epithelial lesions were found in seven patients. En bloc resection by ESD was possible in all 11 lesions and histologically complete resection was achieved in all 11 lesions. Follow‐up endoscopy was done 1–2 weeks after ESD; six patients with well‐healing ulcers underwent esophagectomy the next day (8 or 15 days after ESD). In one patient with a poorly healed ulcer, a second follow‐up endoscopy was done 1 week later and then esophagectomy was performed the next day (22 days after ESD). Post‐surgical complications related to ESD, such as bleeding or mediastinal leak, were not seen in any of the seven patients. In patients with synchronous esophageal cancer and gastric epithelial neoplasia, ESD for gastric epithelial neoplasia followed by Ivor‐Lewis esophagectomy 1 to 2 weeks later is an effective choice of treatment.     

Leiomyosarcoma of the esophagus in a patient with chagasic megaesophagus: case report and literature review.

Leiomyosarcoma constitutes approximately 0.5% of the malignant neoplasias of the esophagus and its association with megaesophagus has not been described. We report on a case of a woman with dysphagia that was slowly progressive from the age of 19 due to chagasic megaesophagus. The woman was subjected to cardiomyotomy at the age of 49. She presented a rapid worsening of the dysphagia due to leiomyosarcoma at the age of 61, and was subjected to subtotal esophagectomy with cervical esophagogastroplasty. She developed pulmonary and hepatic metastases 14 months after surgery and died six months later.     

Sialadenoma Papilliferum of the Esophagus

Sialadenoma papilliferum is an extremely rare benign tumor of the esophagus. We report a 70-yr-old woman who was first thought to have adenocarcinoma in the distal esophagus. Transhiatal esophagectomy and left colon interposition were performed. The pathological diagnosis of Sialadenoma papilliferum of the esophagus arising in the submucosal gland ducts was confirmed after surgery.     

Malignant acanthosis nigricans with esophageal cancer

A 62-year-old woman was referred to our hospital with presenting pigmentation and/or dermal thickening in the nucha, face, axilla, abdomen, and hands. She also presented a history of weight loss of 4 kg during the previous 3 months. She was pathologically diagnosed as having acanthosis nigricans by skin biopsy. She subsequently underwent ¹⁸F-FDG-PET, CT, and upper gastrointestinal endoscopy, and then was diagnosed as having malignant acanthosis nigricans with squamous cell carcinoma in the esophagus at the clinical stage of T3, N0, M0, stage IIA in the UICC stage classification. She underwent subtotal esophagectomy through a left thoracotomy with thoracoabdominal two-field lymphadenectomy and esophageal reconstruction using a gastric tube through a retrosternal route. The postoperative course was uneventful, and she was discharged at 26 days after the surgery without any adjuvant therapy. At 6 months after the surgery, the dermal thickening and the pigmentation of the acanthosis nigricans were completely relieved. She is well without recurrence at 1 year to date after surgery. Although acanthosis nigricans is frequently associated with malignancy, malignant acanthosis nigricans with squamous cell carcinoma in the esophagus has been rare.     

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.     

Post-esophagectomy chylothorax successfully treated with the combination of thoracic duct clipping and octreotide administration

We herein describe the case of a 61-year-old man with stage II esophageal cancer who experienced chylothorax after esophagectomy. He was successfully treated with thoracic duct clipping and octreotide administration. Previously the patient had had a head and neck cancer treated with multimodality treatment: neoadjuvant chemoradiation therapy, operation, and adjuvant CRT. Then, esophagectomy with lymph node dissection without resection of the thoracic duct was performed via a right thoraco-abdominal approach. On postoperative day 1, enteral nutrition was started. On day 5, the chest tube drainage increased to 2000?ml per day. On day 7, the drainage fluid increased to 3000?ml per day, and its color turned cloudy white. We then performed lymphoscintigraphy and diagnosed the patient as having chylothorax. Immediately we administered intermittent subcutaneous octreotide 100???g?×?3 per day; however, it could not stop the leakage. On day 13, we performed an operation: a fat-rich supplement was administered through the jejunostomy tube before the operation, the thoracic duct injury was readily identified, and we clipped the thoracic duct in the superior mediastinum, followed by 300???g per day octreotide treatment. On day 16, however, 400?ml per day of chyle leaked from the drain again, and we increased the dose of octreotide to 600???g per day. On day 18, the drainage stopped, and the patient was discharged on day 38. Octreotide administration combined with surgical treatment should be considered as a treatment option for chylothorax, which is a rare complication of esophagectomy.     

Preoperative chemoradiotherapy and surgery for locally advanced esophageal basaloid squamous carcinoma: report of successful

A 58-year-old Japanese man complained of dysphagia, and esophagography and endoscopy showed a 7.5-cm-long protruding tumor in his middle esophagus. Biopsy diagnosed the lesion as basaloid squamous carcinoma. We assessed the tumor as T3N0M0 stage II. Preoperative chemoradiotherapy was started, consisting of 3 weeks of intravenous chemotherapy with 10 mg/day cisplatin and 750 mg/day 5-fluorouracil and concurrent total 45-Gy external irradiation applied to the tumor. We evaluated the effectiveness as a partial response and performed curative resection with radical esophagectomy 23 days after the completion of chemoradiotherapy. The pathological findings showed necrosis and degeneration over two-thirds of the tumor. Postoperatively, he returned to physical labor and has had no evidence of recurrence for 5 years. Although basaloid squamous carcinoma of the esophagus is associated with poor prognosis because of its highly malignant potential, preoperative chemoradiotherapy followed by radical esophagectomy may allow for the possibility of improving the prognosis of a fatal process.     

Small cell carcinoma of the esophagus: a case report.

Primary small cell carcinoma of the esophagus, which is similar in appearance and behavior to its counterpart of the lung, is a rare tumor. We describe a 77 year-old woman whose esophagram revealed a well-defined mass in the lower third of the thoracic esophagus. A biopsy specimen showed an infiltration of small malignant cells. The individual cells were oval- or spindle-shaped with hyperchromatic nuclei and scant cytoplasm. Synaptophysin staining was positive. The mass was diagnosed as a small cell carcinoma of the esophagus. She underwent an esophagectomy with esophagogastric anastomosis. We discuss the treatment of small cell carcinoma of the esophagus.     

Observations of the fibrosing process in paraquat lung injury by chest X-ray and CT

A 42-year-old woman with a known history of paraquat ingestion was admitted to our hospital on the 10th day after ingestion complaining of dyspnea and general fatigue. Steroid therapy and low dose oxygen therapy were administered. She recovered and was discharged on the 190th day after paraquat ingestion. A chest X-ray film on admission disclosed a bilateral ground-glass shadow. As time passed, a reticular shadow with a loss of lung volume leaving a peripherally clear zone appeared on chest X-rays and shrank gradually toward the peri-hilar area during the course. CT of the lung clearly demonstrated progress of the pulmonary fibrosing process. In the early phase of paraquat poisoning, CT revealed diffuse high density areas dominant in the posterior part of the lungs with a subpleural intact area. The high density area was sharply demarcated from the subpleural intact area. As time passed, the high density area shrank toward the central zone, causing bullous changes in the subpleural area. The dominant fibrotic change in the intermediate and central zones seems to be one of the characteristic findings in paraquat induced pulmonary fibrosis.     

Robot-assisted thoracoscopic esophagectomy for a giant upper esophageal leiomyoma

SUMMARY.  This is the first report of a thoracoscopic esophagectomy for a giant leiomyoma of the upper esophagus aided by a robotic system. A 37-year-old man presented with progressive dysphagia and nocturnal aspiration. Endoscopic ultrasound and CT scan of the chest revealed an upper esophageal tumor of 9 × 4 cm arising from the muscularis mucosae. A fine needle aspiration showed clustering of mesenchymal cells, confirming the diagnosis of a stromal cell tumor. A mesenchymal malignancy was suspected because the tumor was located in the upper esophagus and was arising from the muscularis mucosae, both uncommon for a leiomyoma. Moreover, tumor size, an indicator of potential malignancy if >3 cm, was 9 cm. Therefore, an esophagectomy was performed thoracoscopically with the formation of a gastric conduit via laparotomy and a hand-sewn end-to-side cervical anastomosis. The thoracoscopic phase was performed with support of the da Vinci™ robotic system, which allowed for an excellent 3-dimensional view and a precise dissection of the esophagus along the vital mediastinal structures. The duration of the thoracoscopic part was 115 min and that of the total procedure was 270 min. Blood loss during the thoracoscopic phase was 50 mL; total blood loss was 200 mL. The patient was ventilated for 1 day; his total intensive care stay was 2 days. He left the hospital in good condition on the 11th postoperative day. Histopathological examination combined with immunohistochemistry revealed a leiomyoma of 9.0 × 5.0 × 2.5 cm. After 3 years of follow-up, the patient is in good health.     

Mixed spindle and epithelioid cell type gastrointestinal stromal tumor of the esophagus: a case report

Fewer than 1 % of gastrointestinal stromal tumors (GISTs) are of the esophagus. This report describes a 63-year-old female diagnosed with mixed spindle/epithelioid cell GIST of the esophagus. She was admitted to our hospital with symptoms of nausea and hematemesis. Preoperative imaging showed a huge submucosal tumor in the lower thoracic and abdominal esophagus. Pathologic examination of an endoscopic biopsy sample suggested squamous cell carcinoma. She underwent subtotal esophagectomy and reconstruction with a gastric tube. Postoperative pathological diagnosis revealed a mixed spindle/epithelioid cell type GIST. The tumor measured 8 × 6 cm, with 30–50 mitotic counts per high power field, immunohistochemical positivity for C-kit (CD117) and CD34 and high risk by modified Fletcher classification. Adjuvant chemotherapy with imatinib mesylate was started 3 months after surgery. Preoperative pathological examination, including staining for CD117 and CD34, of biopsy samples of apparently stromal tumors may be required to rule out rare subtypes of GIST.     

Primary malignant melanoma of the esophagus successfully treated by an esophagectomy followed by systemic chemotherapy

Primary malignant melanoma of the esophagus is a rare disease that tends to demonstrate an extremely poor prognosis. We herein describe a case of primary malignant melanoma of the esophagus that was successfully treated. The tumor was incidentally detected by a barium swallow examination performed during a routine medical checkup. The tumor was resected by a transhiatal radical esophagectomy. Histologically, the tumor metastasized to one of the perigastric lymph nodes, although tumor invasion was confined to the submucosa at the primary site. Immunohistochemically, the tumor cells were strongly positive for S100 protein and HMB-45. Postoperatively, systemic chemotherapy consisting of DTIC, ACNU, and VCR was administered. The patient has survived without recurrence for 12 months after these treatments. A transhiatal esophagectomy followed by systemic chemotherapy may therefore be an effective treatment for potentially curable primary melanoma of the esophagus.     

Surgical management of carcinoma of the hypopharynx and cervical esophagus.

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 with a carcinoma of the cervical esophageal region that developed after laryngectomy for laryngeal cancer. The mean age of the patients was 57.5 years (range: 41-73). One hundred and sixty-seven patients underwent surgical exploration (operability rate 59.5%), and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). In 33 cases a laryngopharyngo-cervical segmental esophagectomy with free intestinal loop transplantation was performed, with an operative mortality of 6.1%. One hundred and three patients underwent laryngo-pharyngo-total esophagectomy, and the digestive tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus who refused laryngectomy, with an hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded in patients operated on for carcinoma of the hypopharynx than in patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs. 26% and 43% vs. 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.