The regurgitation prophylaxis after the distal esophagus resection

The clinical use of esophagogastroplasty with antireflux gastroesophageal anastomosis was analyzed basing on the data of 11 operated patients. All patients had benign strictures of the esophagus were operated on transhiatally. The long-term and early results demonstrated the efficacy of the sphincter-valve gastroesophageal anastomosis in prevention of reflux after distal esophagus resection and primary esophagogastroplasty.     

Treatment of perforation in the healthy esophagus: analysis of 12 cases

Background Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice. Materials and methods We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out. Results Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis—more than 24 h after the perforation event—seems to be the only factor correlated with fatal outcome (p = 0.045). Conclusions The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.     

Prevention and treatment of pleuropulmonary complications after simultaneous reconstructive operations on the esophagus in esophageal cancer]

Pleuropulmonary complications in 50 patients who underwent operation for esophageal carcinoma with simultaneous esophagogastroplasty were most frequent (59%) and serious and accounted for up to 60% of all causes of early postoperative mortality. In operations through a transthoracic approach these complications occur more frequently (75%) than in operations without thoracotomy (48%). The possible causes and measures for the prevention of pleuropulmonary complications in the pre-, intra-, and postoperative periods are discussed. Particular attention is focused on the acute respiratory insufficiency syndrome during resection of the esophagus without thoracotomy. It is concluded that this serious pathological condition can be avoided by a complex of preventive and therapeutic measures carried out in all stages of treatment.     

Surgical treatment of esophageal carcinoma complicated by fistulas.

OBJECTIVES: The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant esophageal fistulas is about 13%. The range of treatment modalities proposed by different authors varies from palliation to active and, if possible, radical surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas. METHODS: Thirty-five patients (aged 28--67) with malignant esophageal fistulas of different localizations were operated over a period from 1990 to 2000. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and 11 cases, respectively. The malignant fistula with the mediastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, two, five, four and three cases, respectively. Subtotal esophagectomy and esophagogastroplasty were performed in 18 patients; subtotal esophagectomy with intrapleural coloesophagoplasty was performed in one case; proximal gastric and lower thoracic esophageal resection from the left-side abdominothoracic approach was performed in three cases. Esophagogastric bypass anastomoses were formed in ten patients. Gastrostomy was performed in three patients. RESULTS: The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resection, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3--31), the 2-year survival rate was 21% after combined esophagectomies. CONCLUSIONS: The goal of surgery for esophageal cancer with various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymphadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surgery or gastrostomy. We consider that en-bloc combined resection of esophageal cancer complicated by fistula can be done with a low mortality.     

Surgical treatment of cancer of the esophagus and esophagogastric junction

Immediate and long-term results of surgical treatment of cancer of the esophagus and esophageal-gastric passage in 103 patients were analyzed. Ninety-nine extirpations of the esophagus with simultaneous isoperistaltic tubic esophagogastroplasty (95) and coloplasty (4), 4 Luis surgeries were performed. Hospital lethality was 4.9%, rate of postoperative complications - 47.6%. 5-year survival after surgery was 32.4+/-5,8%: in cancer of cervical or upper-thoracic part of the esophagus - 0, middle-thoracic part - 24.6+/-7.2%, lower-thoracic part - 56.5+/-11.9%, esophageal-gastric passage - 35.6+/-16.1%. Problems of surgical techniques, indications for transhiatal and transthoracic approaches to the esophagus, schemes of combined treatment are discussed.     

The palliative value of surgical resection for carcinoma of the esophagus

The authors review their experience with primary resection for carcinoma of the esophagus and compare the palliative results with those of a recently reported series of similar patients treated with radiotherapy alone. Between 1971 and 1977, 104 patients with carcinoma of the esophagus underwent resection as the primary therapy. The operative mortality was 7.7% (1.7% in the latter half of the series). At least 80% of the 104 patients had complete, continuing palliation of their dysphagia. Radiotherapy in a similar group of patients reported resulted in an 8% mortality from complications of the treatment and there was local recurrence of the tumour, usually associated with dysphagia, in 80%. The authors conclude that the palliation achieved with surgical resection is substantially better than that achieved with radical radiotherapy applied to a similarly staged group of patients with carcinoma of the esophagus.     

Surgical complications do not affect longterm survival after esophagectomy for carcinoma of the thoracic esophagus and cardia

BACKGROUND: Surgical resection is the only real chance of cure for carcinoma of the esophagus and esophagogastric junction, although it carries considerable postoperative morbidity and mortality. The longterm prognosis for patients undergoing operation depends largely on the pathologic stage of the disease. The real impact of postoperative complications on survival is still under evaluation. STUDY DESIGN: A retrospective analysis was performed on patients with squamous cell carcinoma and adenocarcinoma of the thoracic esophagus and esophagogastric junction, undergoing surgical resection between January 1992 and December 2002. For the 522 patients considered for esophagogastroplasty, we analyzed comorbidities, preoperative staging, neoadjuvant treatments, surgical data, histopathology, postoperative surgical or medical complications, and survival. RESULTS: Surgical complications occurred in 85 of 522 patients (16.3%); their survival rate was entirely similar to that of the group of patients without surgical complications (p=0.9). The survival rate was worse for patients with concurrent surgical and medical complications. Analysis of the 99 patients (19%) who had only medical complications postoperatively revealed a survival rate comparable (p=0.9) with that of the 338 patients (63.7%) with an uneventful postoperative course. The median postoperative hospital stay was 14 days for all 522 patients, and 18 days for patients with medical or surgical postoperative complications. Multivariate analysis of the predictive factors showed that surgical complications do not affect longterm prognosis. CONCLUSIONS: Surgical complications have no negative impact on survival rates, which seem to depend exclusively on the pathologic stage of the tumor.     

Results of simultaneous resection and plastic surgery of the esophagus with extra-cavitary cervical esophagostomy in esophageal cancer in its thoracic part

The work analyses the results of one-stage resection and plastics of the esophagus with a tube formed from the greater curvature of the stomach and creation of an ++extra-cavitary anastomosis on the neck in combined and surgical treatment of carcinoma of the thoracic esophagus in 279 patients. Various complications occurred in 181 (64.8%) patients. The mortality was 19.3% (16.8% among patients who underwent radical operation and 25.6% among those treated by a palliative operation). The number of complications in the groups of surgical and combined treatment was approximately equal. The results of 5-year survival were better in the group with combined treatment. Postponed + extra-cavitary anastomosis was formed in 65.2% of cases. One-stage resection and plastics of the esophagus with ++extra-cavitary anastomosis is an adequate operation from the oncological standpoint in the treatment of carcinoma of the thoracic esophagus. Its further perfection is necessary for improvement of the immediate and late-term results of treatment.     

Subtotal esophagectomy with simultaneous retromediastinal plastic surgery using gastric pedicled flap without thoracotomy

Thirty-three operations for subtotal esophagectomy with one-stage plastics with a gastric pedicle without thoracotomy were carried out between 1985 and 1988. The indications for the operation were as follows: carcinoma of the esophagus (17) and of cardioesophageal localization (7), cicatricial stricture of the esophagus (6), IV degree cardiospasm (2), unspecific esophageal ulcer (1). The esophagus was resected through a laparotomo-transdiaphragmatic-cervical access, the graft formed from the greater curvature of the stomach was passed in the posterior mediastinum with the establishment of a cervical esophagogastroanastomosis. Postoperative complications occurred in 29 patients: incompetence of the anastomosis (26), mediastinitis and pyothorax, (4), peritonitis (2), pneumonia (4). Six patients died. With the performance of intrapleural esophagogastroplasty the mortality rate fell from 25 to 18.2%. The authors claim that subtotal esophagectomy with posteromediastinal gastroplasty without thoracotomy is a less traumatic and safer operative intervention.     

A variant of functionally active esophagogastric anastomosis in the surgery of stenosing lesions of the esophagus

A method of forming a cervical are flux esophgeal-gastric anastomosis has been developed allowing to exclude or considerably decrease the effect of esophago-gastro-pharingeal reflux on the esophageal stump mucosa after subtotal resection of the esophagus and performing one-moment esophagogastroplasty. A muscular constrictor and a circular invagination valve formed in the area of the esophagogastroanastomosis represent a single mechanism having the functional properties approximating the natural esophagocardial passage which prevents the reflux of the stomach contents into the esophagus stump and is a guarantee of prophylactics of reflux-esophagitis and stenosis of the created anastomosis.     

Laparoscopic esophagogastroplasty: a minimally invasive alternative to esophagectomy in the surgical management of megaesophagus with axis deviation

Introduction

The results of cardiomyotomy in patients of achalasic megaesophagus with axis deviation are not satisfactory, and several authors have advocated an esophagectomy in these patients. We describe the technical details and outcomes of a novel technique of laparoscopic esophagogastroplasty for end-stage achalasia.

Methods

Patients with end-stage achalasia, characterized by tortuous megaesophagus were selected. The surgery was performed in supine position using five abdominal ports. The steps included mobilization of the gastroesophageal junction and lower intrathoracic esophagus, straightening and anchoring the pulled intrathoracic esophagus into the abdomen, and a side-side esophagogastroplasty.

Results

Four patients with megaesophagus due to end-stage achalasia underwent this procedure. The average duration of surgery was 177.5 (range, 120–240) min. All patients could be ambulated on the first postoperative day. Oral feeding was initiated by the third postoperative day, and all patients had significant improvements in their dysphagia scores. All patients had excellent cosmetic results and were discharged by the fifth postoperative day. An upper gastrointestinal contrast study done at 6 weeks after surgery did not show any hold up of contrast, and there was decrease in the convolutions and diameter of the esophagus. At a mean follow-up of 10.5 (range, 3–15) months, all patients are euphagic without significant symptoms of gastroesophageal reflux.

Conclusions

Laparoscopic esophagogastroplasty is an effective option for relieving dysphagia in megaesophagus due to achalasia with axis deviation and is a reasonable alternative before subjecting to a major and potentially morbid esophagectomy.     

Surgical treatment of carcinoma of the hypopharynx and cervical esophagus]

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arose after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 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 (84.9%) and palliative in 23 (14.1%). In 33 cases of laryngo-pharyngo-cervical segmentary esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 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 refusing 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 with patients operated for carcinoma of the hypopharynx than with 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)     

Neoadjuvant radiochemotherapy in the treatment of esophageal squamous carcinoma:Preliminary results in a series of 15 patients

The purpose of this study is to analyze the experience of the Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute (Bucharest) regarding the results of neoadjuvant radiochemotherapy in the squamous carcinoma of the esophagus. During 01.01.2001-09.07.2003, 15 patients with squamous carcinoma of the esophagus were treated using neoadjuvant radiochemotherapy (RCT); 13 patients (86%) underwent esophageal resection (in 2 patients resection was not possible due to the mediastinal invasion). Complete histological response (the lack of malignant tissue on the esophagectomy specimens) was noted in 5 cases. The morbidity and mortality rates were 48%, respectively 6%. RCT increases the resectability in esophageal cancer and decreases the postoperative morbidity and mortality.     

Cancer 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 patients with a carcinoma of the cervical esophageal region arising after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 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 segmental laryngo-pharyngo-cervical esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent total laryngo-pharyngo esophagectomy and the gastrointestinal 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 refusing laryngectomy with a 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 with patients operated for carcinoma of the hypopharynx than with 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)     

Choice of the method of isoperistaltic tubular esophagogastroplasty completion based on intraoperative assessment of vascularization of gastric transplant

Intraoperative assessment of vascularization of isoperistaltic tubular gastric transplant using angiotensiometry and Doppler flowmetry was performed at 136 patients undergone extirpation of esophagus with esophagogastroplasty. The main criteria of gastric transplant convenience for anastomosis with esophagus were: clear intramural pulse on all circle of gastric transplant by flowmetry data; intramural arterial pressure according to angiotensiometry data have to be not less 80 mm Hg, and the ratio of venous to arterial pressure has not to be more 50%. At inadequate criteria the surgery must be finished with cervical esophago- and gastrostoma.     

Diagnosis and treatment of esophageal leyomyoma

Radical operations for benign esophageal leyomyoma were performed in 50 patients in 1976-2006 in the clinic. Highly informative roentgenologic, endoscopic and ultrasonographic (including intraesophageal) methods were applied in the disease diagnosis, permitting to establish the diagnosis, as a rule, accurately before the operation. The diagnosis was verified definitely, basing on intraoperative revision data and the results of express-histologic investigation of the tumor excised. Extramucosal enucleation of benign leyomyoma with plastic closure of esophageal muscle defect or its suturing was done in 33 (66%) patients. Subtotal esophageal resection was performed in 11 (22%) patients, reconstructive operations--in 10 (20%), including in 5 (10%)--retrosternal esophagocolonoplasty, in 2 (4%)--intrathoracic esophagogastroplasty and in 1 (2%)--retrosternal esophagojejunoplasty. In 2 (4%) patients with small benign leyomyoma the esophageal wall portion resection was performed using suturing apparatus and in 1 (2%)--gastrostomy. Postoperative mortality had constituted 2%. Results of treatment were studied in 46 (92%) patients in 1-18 yrs, 4.8 at average. There were no recurrences. The result was estimated as good in 39 (78%) patients and fair--in 7 (14%).     

胃浆肌瓣包套的食管胃吻合术

目的 探讨预防食管,贲门癌手术后吻合口瘘和狭窄,返流性食管炎发生的方法。方法 对２７３例贲门癌,食管下段癌患者,随机分为治疗组１４５例,对照组１２８例,并分别采用胃浆肌瓣包套的食管胃吻合术及传统的食管胃二层同心圆吻合术。结果 治疗组无吻合口瘘及吻合口狭窄,返流性食管炎１０例。     

Clinical biology and surgical therapy of intramucosal adenocarcinoma of the esophagus

BACKGROUND: Mucosal ablation and endoscopic mucosal resection have been proposed as alternatives to surgical resection as therapy for intramucosal adenocarcinoma (IMC) of the esophagus. Acceptance of these alternative therapies requires an understanding of the clinical biology of IMC and the results of surgical resection modified for treatment of early disease. STUDY DESIGN: Retrospective review of 78 patients (65 men, 13 women; median age 66 years) with IMC who were treated with progressively less-extensive surgical resections (ie, en bloc, transhiatal, and vagal-sparing esophagectomy) from 1987 to 2005. RESULTS: The tumor was located in a visible segment of Barrett's esophagus in 65 (83%) and in cardia intestinal metaplasia in 13 (17%). A visible lesion was present in 53 (68%) and in all but 4 the lesion was cancer. In those patients with visible Barrett's, the tumor was within 3 cm of the gastroesophageal junction in 66% and within 1 cm in 37%. Esophagectomy was en bloc in 23, transhiatal in 31, vagal-sparing in 20, and transthoracic in 4. Operative mortality was 2.6%. Vagal-sparing esophagectomy had less morbidity, a shorter hospital stay, and no mortality. Of the patients who had en bloc resection, a median of 41 nodes were removed. One patient had one lymph node metastasis on hematoxylin and eosin staining and two others, normal on hematoxylin and eosin staining, had micrometastases on immunohistochemistry. Actuarial survival at 5 years was 88% and was similar for all types of resections. Two patients died from systemic metastases and seven from noncancer causes. CONCLUSIONS: IMC occurred in cardia intestinal metaplasia and in Barrett's esophagus. Two-thirds of patients with IMC had a visible lesion. Most tumors occurred near the gastroesophageal junction. Node metastases were uncommon, questioning the need for lymphadenectomy. A vagal-sparing technique had less morbidity than other forms of resection and no mortality. Survival after all types of resection was similar. Outcomes of endoscopic techniques should be compared with this benchmark.     

Duodenoesophageal reflux and the development of esophageal adenocarcinoma in rats.

BACKGROUND. The carcinogenic effect of duodenoesophageal reflux, gastroesophageal reflux, and nitrosamines was studied in the rat esophagus. METHODS. Twenty male Sprague-Dawley rats underwent esophagogastroplasty to produce gastroesophageal reflux and 60 underwent duodenoesophageal anastomosis to produce duodenoesophageal reflux. Forty-three animals underwent no operation and acted as controls. Carcinogens known to produce squamous tumors in the rat esophagus (2,6-dimethylnitrosomorpholine [DMNM] or methyl-n-amylnitrosamine [MNAN]) were tested in each group. RESULTS. The rate of squamous carcinoma was 25% for rats with DMNM alone, 30% for rats with MNAN alone, and 20% for rats with induced gastroesophageal reflux plus DMNM. The rate of malignant change rose to 80% in rats with induced duodenoesophageal reflux and DMNM and 67% with duodenoesophageal reflux and MNAN. With duodenoesophageal reflux, 50% of tumors were adenocarcinoma, in contrast to 100% squamous differentiation of tumors in rats given the carcinogens with esophagogastroplasty or no operation. CONCLUSION. The presence of duodenoesophageal reflux increased the frequency and changed the histologic type of esophageal cancer in nitrosamine-treated rats. This indicates that duodenoesophageal reflux plays a role in the development of esophageal adenocarcinoma.     

Cancer of esophagus and esophagogastric junction: analysis of results of 1,025 resections after 5 to 20 years

Resection was carried out in 1,025 of 1,654 patients with cancer of the esophagus or esophagogastric junction at the Peking Medical College Hospitals in China from 1953 through 1973. All cancers of the esophagus were squamous cell carcinomas except for five adenocarcinomas. A lesion localized within the esophageal wall was found in 55% and lymph node metastasis in 41.3% of the patients undergoing resection. All cancers of the esophagogastric junction were adenocarcinomas. The tumor had invaded beyond the boundaries of the stomach in 76.7% of these patients, and positive nodes were found in 61% of the patients. The rate of resectability was 81.2% for esophageal cancer and 74% for cancer of the esophagogastric junction. Surgical mortality after resection was 4.9% (50/1,025). The 5-year survival after resection was 20.9% (214/1,025). Better results were found following complete resection: 24% (210/875) for all patients, 28.2% (162/575) for patients with cancer of the esophagus, and 16% (48/300) for patients with cancer of the esophagogastric junction. Late survival at 10, 15, and 20 years after resection of esophageal cancer was 20%, 12%, and 7.4%, respectively. The favorable prognostic factors after resection of esophageal cancer were tumor of the lower third of the esophagus, the absence of lymph node involvement, and the presence of a localized lesion. The 5-year survival for patients with cancer of the lower third of the esophagus was 32.7%. It was 64.2% for patients with a localized lesion with negative nodes in this subgroup.