The recurrence pattern of esophageal carcinoma after transhiatal resection

BACKGROUND: There is much controversy about the optimal resection for carcinoma of the esophagus. Little is known about the pattern of recurrence after transhiatal resection for esophageal carcinoma. STUDY DESIGN: We retrospectively reviewed the charts of 149 patients who underwent transhiatal esophagectomy for carcinoma of the mid or distal esophagus or gastroesophageal junction between June 1993 and June 1997. Recurrence was classified as locoregional or distant recurrence. Nine patients with macroscopically evident tumor left after resection and three patients (2.0%) who died in the hospital were excluded from the analysis. This left 137 patients; 105 men and 32 women with a median age 65 years (range 37 to 84 years). RESULTS: There were 95 adenocarcinomas (69.3%) and 42 squamous cell carcinomas (30.7%). Overall the median followup was 24.0 months (range 1.4 to 69.2 months). For patients alive at the end offollowup without recurrence, the median followup was 36.5 months (range 23.6 to 69.2 months). Seven patients died of other causes. The median interval between operation and recurrence was 11 months (range 1.4 to 62.5 months) for patients who had recurrence, with no significant difference in interval between locoregional and systemic recurrence. Seventy-two of the 137 patients (52.6%) developed recurrent disease. Thirty-two patients (23.4%) developed locoregional recurrence only, 21 patients (15.3%) developed systemic recurrence only, and 19 patients (13.9%) had a combination of both. In only 8.0% of all patients was there recurrence in the cervical lymph nodes. The most frequent sites of distant recurrence were liver (37.5%), bone (25.0%), and lung (17.5%). Recurrence was related to postoperative lymph node status (p<0.001) and the radicality of the operation (p<0.001) in multivariate analysis. Recurrence was not associated with localization or histologic type of the tumor. CONCLUSIONS: Recurrence after transhiatal resection is an early event. Almost 40% of patients developed locoregional recurrent disease. For this patient group a more extended procedure may be of benefit, especially in the patients (23.4%) with locoregional recurrence in whom this is the only site of recurrent disease. But the potential benefit of a more extended procedure has to be balanced against a possible increase in perioperative morbidity and mortality.     

Laparoscopic transhiatal esophagectomy for esophageal cancer

BACKGROUND: Traditional esophagectomy may be associated with mortality, considerable morbidity, and lengthy recovery. It is often performed in cancer patients who are typically older, have associated comorbidities, and are often malnourished, all factors that increase surgical risk. Minimally invasive esophagectomy has the potential advantages of being a less traumatic procedure with an easier postoperative recovery and fewer wound and pulmonary complications. METHODS: A retrospective analysis of patients who underwent laparoscopic transhiatal esophagectomy was performed. Assessed parameters included patient demographics and operative data, pathology results, and long-term follow-up of at least 12 months. RESULTS: Twenty-two patients underwent laparoscopic transhiatal esophagectomy; 19 had esophageal cancer. Two patients were operated on for Barrett esophagus, and 1 patient had achalasia. The majority of patients were men (82%), and the mean age was 59 years (range 15 to 74 years); 1 patient (4.5%) was converted to open surgery. The average operative time was 380 minutes (range 285 to 525 minutes), and the average blood loss was 220 mL; only 3 patients required transfusion. The median hospital stay was 8 days (range 5 to 46 days). Postoperative mortality occurred in 1 patient (4.5%), and postoperative complications developed in 6 patients (27.2%). In the 19 cancer patients, the average number of harvested nodes was 14.3 (range 10 to 19). The average follow-up was 30 months (range 12 to 48 months). The overall survival for cancer patients was 61% (11 of 19), and disease-free survival was 39% (7/19). CONCLUSIONS: Esophagectomy is a major surgery with considerable morbidity and potential mortality. Minimally invasive esophagectomy is a feasible approach that can be safely performed by surgeons with extensive experience in that field. Advantages include less intraoperative blood loss, a smaller incision, and a potentially faster postoperative recovery. In cancer patients, immediate oncologic goals of adequate margins and lymph node dissection can be achieved, and long-term outcome appears to be similar to that found with open approaches.     

Mediastinoscope-assisted transhiatal esophagectomy for esophageal cancer

Background: Transthoracic esophagectomy (TTE) is a radical strategy for treatment of esophageal cancer, and the morbidity and mortality are high. Transhiatal esophagectomy (THE) is advantageous because it avoids thoracotomy and has a shorter surgical time, but risk of intraoperative morbidity stresses the surgeon and lymph node sampling is not possible. Methods: Mediastinoscope-assited transhiatal esophagectomy (MATHE) was performed in 42 patients with esophageal cancer. Patients with superficial esophageal cancer and medical risk were included. Feasibility and efficacy of this procedure are discussed by examining short- and long-term morbidity, mortality, and survival. Results: With the mediastinoscope, esophagectomy was performed safely under direct vision. There was only a small amount of bleeding, and surgical time was short. Little morbidity and no deaths were recorded. Conclusion: MATHE is a safe and minimally invasive technique that allows direct visualization of mediastinal structures Lymph node sampling was feasible because of clear visualization of the mediastinum.     

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.     

Indicators of prognosis after hepatic resection for colorectal secondaries.

From 1960 to 1988, 266 patients underwent resection of colorectal secondaries to the liver with curative intent. All patients were followed until April 1, 1990, or death, with a median follow-up time of 52 months. Nine patients with minimal macroscopic residual disease and 38 patients with all gross tumor removed but positive margins showed a poor prognosis with a median survival time of 13.3 months, the longest being 42 months. Of the 219 patients having potentially curative resection, 12 patients died postoperatively (5.5%). Actuarial 5, 10 and 20-year survival for the remaining 207 patients was 39%, 28%, and 18%, respectively. At April 1, 1990, 77 patients were alive with no evidence of disease for up to 24 years, and 12 patients had died without recurrence. The following factors were associated with less favorable crude survival: presence and extent of mesenteric lymph node involvement (p = 0.0003), grade III/IV primary tumor (p = 0.035), synchronous diagnosis of metastases (p = 0.017), satellite metastases (p = 0.0003), limited resection margins (p = 0.019), and nonanatomic procedures (p = 0.013). With respect to disease-free survival, grading of the primary (p = 0.055) and the extent of clear margins (p = 0.019) failed to achieve statistical significance. Two other criteria are commonly recommended as absolute contraindications to hepatic resection: extrahepatic disease and the presence of four or more independent metastases. A radical excision of all detectable disease may rarely be possible in these circumstances. Nevertheless, within the curative settings, no significant predictive value regarding either overall or disease-free survival was found in this series. Three corresponding "high risk" patients are alive without disease at 5 to 11 years from hepatic resection. These patients with more advanced intrahepatic or concomitant limited extrahepatic disease require a particularly thorough diagnostic work up. As no superior therapeutic alternative is currently available, an aggressive surgical approach may occasionally be justified, and may, in a small portion, result in definite tumor control.     

Tracheal injury during transhiatal esophagectomy without thoracotomy. Anesthesiologic management

A patient with carcinoma of the lower third of esophagus suffered an extensive tracheal tear during transhiatal esophagectomy without thoracotomy, with severe impairment of ventilatory and hemodynamic status. A right thoracotomy was required for the repair of the tracheal lesion, which extended to the origin of left bronchus. During the maneuvers for bronchial intubation, the hypoxia worsened and cardiac arrest caused by ventricular fibrillation appeared. The arrhythmia was reverted. Operative mortality of transhiatal esophagectomy without thoracotomy is 8%. Pneumothorax is the most common operative complication. Tracheal laceration is reported in 1% of cases; usually it is not severe and is easily treated, although it can have significant severity and result in death as in the present case. After the operation, the patient persisted hemodynamically unstable, developing a new gasometric deterioration and bilateral pleural effusion, with impairment of coagulation. The patient died 39 hours after operation. The anesthetic management of peroperative tracheal tear is reviewed.     

Image analysis of DNA cytometry for assessing prognosis after resection of esophageal cancer]

Esophagus cancer is a heterogeneous disease with considerable differences in malignant behaviour. Some relevant factors for prognosis are known. In this study we analyzed DNA-ploidy as a potential prognostic parameter in esophagus carcinoma. Paraffin embedded histological material from 50 patients with an esophagus cancer, obtained by resection, were selected for analysis. Tumor areas within the paraffin material were identified by HE-stained reference sections. One 50 microns section was dewaxed, rehydrated and mechanically and enzymatically treated to a suspension of 10,000 cells/ml. 1 ml of the suspension, containing bare nuclei with small rests of cytoplasma was centrifuged on glass slides. The fixed nuclei were air-dried and stained by Feulgen-SITS technique, which allows quantitative measurement of DNA. The DNA analysis was carried out with a computer-controlled single cell cytophotometry (Leytas 2, Leitz, Wetzlar). In contrast to the flow cytometry with image cytometry only tumors cells were measured. Overlapping nuclei, dirt and other artefacts as well as inflammatory cells were efficiently eliminated. With the DNA image cytometry we could differentiate between diploid and hypotriploid, hypertriploid aneuploid tumors. Best prognosis had diploid and hypotriploid tumors, the worst hypertriploid carcinomas. In the multivariate analysis the DNA-content of the tumor cells in esophagus cancer was the only prognostic parameter. DNA-content of tumor cells may become considerably clinical relevant in esophagus cancer for the decision to perform a resection or palliative treatment. In patients with hypertriploid tumors an adjuvant oncological therapy may increase the prognosis.     

Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer

Background

Most published minimally invasive esophagectomy techniques involve a multiple field approach, including laparoscopic and thoracoscopic esophageal mobilization. Laparoscopic transhiatal esophagectomy (LTE) should potentially reduce the complications associated with thoracotomy. This study aims to compare outcomes of LTE with open transhiatal esophagectomy (OTE) and en-bloc esophagectomy (EBE).

Methods

Retrospective chart review was performed on all patients who had an LTE for cancer between July 2008 and July 2012 at our institution. Data was compared with an historic cohort of patients who underwent OTE and EBE at the same institution from July 2002 to July 2008.

Results

There were 33 patients with LTE, compared with 60 patients with OTE and 139 with EBE. The presence of minor operative complications was similar (p = 0.36), but major complications were significantly less common in the LTE group (12, 23 and 33 %, respectively; p = 0.04). The median number of blood transfusions during hospitalization was significantly lower in the LTE group (0, 2.5 and 3, respectively; p = 0.005). Median tumor size was significantly smaller (1.5, 2.2, and 3 cm, respectively; p = 0.03), but the LTE group had a significantly higher percentage of patients with neoadjuvant treatment (39, 14 and 29 %, respectively; p = 0.008). Median lymph node yield for LTE was lower (24, 36 and 48, respectively; p < 0.0001), but the percentage of patients with positive nodes was similar (33, 33 and 39 %, respectively; p = 0.69). Mortality was equivalent among the groups (0, 2 and 4 %, respectively; p = 0.38). The median LOS for the LTE group was significantly lower (10, 13 and 15 days, respectively; p < 0.0001). Overall survival was not different between the three groups (p = 0.65), with median survival at 24 months of 70, 65 and 65 %, respectively.

Conclusion

LTE can be performed safely with less major complications and shorter hospital stay than open esophagectomy. The reduced lymph-node harvest did not impact overall survival.     

Video-assisted transsternal radical esophagectomy: three-field lymphadenectomy without thoracotomy for esophageal cancer

To reduce the invasiveness of radical esophagectomy, we developed a new approach: video-assisted transsternal radical esophagectomy (VATRE). This article presents the operative techniques and our initial results. In our new procedure, cervical U-shaped and longitudinal sternoabdominal incisions are made, and a complete midline sternotomy is carried out. Lymph node clearance from the neck to the upper mediastinum and from the lower mediastinum to the upper abdomen is performed under direct vision. In the middle mediastinum, a video-assisted technique is used to dissect the lymph nodes. After esophageal resection and three-field lymphadenectomy, reconstruction is performed. One-lung ventilation is unnecessary. We have performed this procedure in two cases. These patients had no major complications and recovered more rapidly than patients undergoing conventional transthoracic esophagectomy. Our initial experience shows that VATRE is a technically feasible and less invasive procedure for cancer surgery, and it enables us to easily perform three-field lymphadenectomy.     

Successful treatment of esophageal cancer with transhiatal esophagectomy after heart transplantation

A 55-year-old heart transplant recipient with reflux esophagitis presented for routine endoscopic surveillance of an area of Barrett's metaplasia initially seen 3 years previously. Esophagogastroduodenoscopy revealed adenocarcinoma at 33 cm from the incisors. The preoperative clinical stage was T₁N₀M₀ by endoscopic ultrasound. Transhiatal esophagectomy was performed with R0 resection of the cancer, and the patient recovered uneventfully. Pathologic examination confirmed esophageal adenocarcinoma (T₁N₀M₀) in Barrett's mucosa. The patient is doing well, and has no evidence of disease after 18 months.     

Pull-through esophagectomy without thoracotomy for esophageal carcinoma.

Seventeen consecutive patients underwent pull-through esophagectomy using blunt dissection from laparotomy and cervical incisions for carcinoma of the esophagus. Fifteen patients had a middle-third lesion while 2 patients had a distal-third lesion. The gastrointestinal tract was reconstructed using primary gastroesophagostomy in 15 patients and colon interposition in 2. Both the colon and stomach were placed through the posterior mediastinum. The surgical technique and results are described in detail. There were two major complications. One patient died of massive gastric hemorrhage on the eighth postoperative day in spite of emergency operation. Another patient sustained a tear of the membranous trachea at the time of blunt dissection. This was repaired through a right thoracotomy without difficulty. Esophagectomy using blunt dissection offered excellent palliation and resulted in little morbidity in our series. The shortened operating time, minimal blood loss, total lack of postoperative chest pain, minimal pulmonary complications, and the benefit of a cervical anastomosis are several advantages compared with the present surgical approaches.     

胸腔镜辅助食管内翻拔脱术治疗胸上、中段食管癌(附8例报告)

目的:探讨用简捷的术式治疗胸上、中段食管癌,减少术后并发症。方法:为8例食管癌患者施行胸腔镜辅助食管内翻拔脱术,分析手术操作过程、并发症及术后患者的康复情况等。结果:8例患者均采用胸腔镜辅助食管内翻拔脱术完成手术,1例发生吻合口漏,1例发生对侧气胸,经对症治疗治愈。结论:此术式治疗胸上、中段食管癌优于传统手术。     

Total esophagectomy without thoracotomy for cancer

Total extrathoracic esophagectomy was performed in 16 patients with neoplasms arising in the thoracic and cervical esophagus and the hypopharynx. The procedure was combined with posterior mediastinal gastric pull up in all but two patients who had previous gastrectomy and were managed with colon interposition. Splenectomy was avoided in all patients. Although, in the presence of TNM stage III and IV disease, the procedure was performed mostly for palliation, it resulted in only two deaths and it led to rapid initiation of oral alimentation. Extrathoracic esophagectomy constitutes a safe and simple alternative to other ablative or palliative procedures in the treatment of hypopharyngeal and esophageal malignancies.     

影响肝癌切除术预后的多因素分析

肝癌的研究在近年来取得了很大的进展,越来越多的病人获得长期生存[1].然而,从总的人群来看,肝癌的长期生存率仍然很低.笔者回顾性分析196例肝癌切除病人的临床资料,旨在探寻影响肝癌预后的危险因素.     

食管癌切除术后胃窦幽门十二指肠运动的变化

目的　通过监测食管癌切除术后患者消化间期胃窦、幽门、十二指肠移行性复合运动波(MMC)的变化 ,探讨胸部胃对固体食物排空延缓的发生机制。　方法　食管癌切除术后第 7～ 11天 ,通过 8通道袖套式测压导管监测患者胃窦、幽门、十二指肠的运动。　结果　幽门、十二指肠检出 2 8个MMC周期 ;胃窦检出 12个MMC周期 ,其中 4次MMCⅢ相活动后于十二指肠MMCⅢ活动的发生。MMC周期平均持续时间 :胃窦 (49 2± 10 5 )min ,幽门 (46 5± 10 4 )min ,十二指肠 (45 9± 10 0 )min ;MMCⅢ相平均持续时间 :胃窦 (6 7± 3 5 )min ,幽门 (10 0± 3 5 )min ,十二指肠 (8 0± 3 9)min。MMCⅢ相收缩波的平均振幅 :胃窦 (83± 30 )mmHg,幽门 (6 0± 12 )mmHg ,十二指肠 (5 5± 4 )mmHg。结论　胃窦MMCⅢ相活动次数及其收缩波平均振幅的减小 ,胃窦、幽门、十二指肠MMCⅢ时相的不协调运动是胸部胃对固体食物排空延缓的重要原因之一。     

Esophageal resection by cervico-abdominal approach without thoracotomy

The authors report their experience with transhiatal esophageal resection accumulated during the period between January 1978 and March 1990. Indications for the procedure included cancer of the gastric cardia (26.3%), cancer of the hypopharynx (3.8%), cancer of the esophagus (59.2%), and benign esophageal disease (9.8%). Esophageal substitution was performed using a tubulized stomach (63.6%), ileo-cecocoloplasty (28.5%), left colon (7.6%), and jejunum (0.3%). The majority of patients with neoplastic disease were found to be in an advanced stage (67.3% of esophageal cancer patients and 69.7% of cancer of the cardia patients with stage III disease). The mean intra-operative volume of blood transfused varied between 533 and 1,220 ml. Sixteen patients required hospitalization in the intensive care unit. The mean length of post-operative hospitalization varied between 16.8 and 20.6 days. Operative complications included hemorrhage (0.3%) and tracheal injury (0.6%). Operative (30 day) mortality was 5.8%. Causes of death included respiratory insufficiency (35.2%), pulmonary sepsis (23.5%), abdominal sepsis (17.8%), and others (undefined, 23.5%). The 5 year survival was 48.5% for cancer of the gastric cardia, 57.1% for cancer of the hypopharynx and 11.8% for esophageal cancer.     

Gender differences in prognosis after esophagectomy for esophageal cancer

Purpose

The purpose of this study was to clarify the gender differences in the prognosis, as well as mortality and morbidity, of patients who have undergone esophagectomy for esophageal cancer.

Methods

The clinical results of esophagectomy were compared between 975 male and 156 female patients with esophageal cancer.

Results

The male to female ratios of cervical and thoracic esophageal cancer were 1.87 and 7.38, respectively (P < 0.01). The incidence of preoperative comorbidities was 32.4 and 17.4 %, respectively, and the rates of both tobacco and alcohol abuse were significantly lower in the females than in the males. The mortality rate was lower in the females (3.8 %) than in the males (5.7 %), although the differences were not significant. The overall survival was significantly better in the female than in the male patients (P = 0.039). The 5- and 10-year overall survival rates were 32.6 and 20.5 % in the males and 39.5 and 32.5 % in the females, respectively. A multivariate analysis revealed gender to be an independent prognostic factor. However, no significant differences were recognized in disease-specific survival.

Conclusions

These results suggest that the prognosis of females with esophageal cancer is better than that of males after esophagectomy, most likely due to multiple clinical factors, such as a more favorable lifestyle and general status.