Unified approach to carcinoma of the esophagus

Esophagogastrectomy as palliative treatment for esophageal carcinoma: results obtained in the setting of a thoracic surgery residency program

The palliative treatment of esophageal carcinoma has included intubation, bypass, dilation, irradiation, and esophagogastrectomy. The last has been criticized by some on the basis of high operative morbidity and mortality. To assess the success of this method at our institution, we reviewed the 60 consecutive resections performed for carcinoma of the esophagus from January, 1972, through June, 1983. Forty-six patients had squamous cell tumors and 14, adenocarcinomas. There were 47 men and 13 women, and the mean age was 59.9 years (range, 38.5 to 78.9 years). The most frequent preoperative findings included dysphagia (55), weight loss (34), chest pain (22), and vomiting (49). Fifty (83%) out of the 60 resections were performed by the resident staff under the supervision of an attending surgeon. Four patients died within 30 days of operation, an operative mortality of 6.7%. Immediate causes of death included respiratory failure, myocardial infarction, hemorrhage, and renal failure. One of the patients who died and 3 of the survivors had an anastomotic leak. There were 27 additional complications in 24 patients: respiratory problems (8), arrhythmias (5), pleural effusion (4), gastric outlet obstruction (2), wound infection (2), and 1 each of pulmonary embolus, acute brain syndrome, congestive heart failure, myocardial infarction, chylothorax, and empyema. The one-, two-, three-, and five-year actuarial survival rates were 46%, 27%, 10%, and 5%, respectively. Mean survival for the 46 patients dead at the time of this study was 13.5 months. Outpatient follow-up data were available on 53 (95%) of the operative survivors and showed an absence of dysphagia in 87.5% during most of the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiological anatomy of the right gastroepiploic artery

Most gastroplasties performed to replace the esophagus are vascularized by the right gastroepiploic artery alone. Its origin, course and anatomical relations are classical and subject to little variation. Conversely, its mode of termination and relations to the left gastroepiploic artery have received quite different descriptions in the literature. This report describes the radiological anatomy of the right gastroepiploic artery based on arteriograms in 50 subjects. The right gastroepiploic artery was much larger (diameter 1.7 to 2.6 mm at its origin) than the left (absent in 3 cases) in our series. Direct end-to-end anastomosis of these two arteries, as described in classical reports, was found in only 23.5% of cases.

Carcinoma of the cervical esophagus: changing therapeutic trends

Carcinoma of the cervical esophagus is a lethal tumor because of its advanced stage at the time of diagnosis. The records of 71 patients with this disease treated at Memorial Sloan-Kettering Cancer Center from 1965 through 1980 have been reviewed herein. Epidermoid carcinoma was the prevailing histologic finding, and extramural penetration was present in 77 percent of the evaluable patients. Tracheal invasion and vocal cord paralysis were noted in 35 and 24 percent of the patients, respectively and were predictive of significantly decreased survival. Primary radiotherapy in doses greater than 5,000 rads produced short lived responses in 13 of 21 patients (62 percent). Surgery was performed in 45 patients (63 percent), including 35 esophagectomies for cure and palliative procedures in the 10 other patients. There were five operative deaths (11 percent), but only two followed esophageal resection (5.6 percent). Locoregional treatment failure, present in 46 of 52 evaluable patients (88 percent) at last follow-up, continues to be a major problem. Overall, the 5 year survival rate was 9.6 percent. The longest survival and best palliation was achieved with aggressive resection and immediate reconstruction using the transposed stomach (gastric pullup).

Pessimism concerning palliative bypass procedures for established malignant esophagorespiratory fistulas: a report of 18 patients

Eighteen patients with established malignant esophagorespiratory fistulas due to primary esophageal cancer were managed by substernal gastric bypass and isolation of the cancerous esophageal segment. Seven fistulas were esophagotracheal and 11 were esophagobronchial. Ten patients died in the hospital between two days and six weeks after operation. Eight patients left the hospital, surviving an average of 3 1/2 months, but 2 patients lived 5 and 7 months, respectively. Unrelenting respiratory infection and clinical inanition caused 7 hospital deaths in patients reestablished on oral alimentation with their fistulas disconnected. Anastomotic leaks occurred in 5 patients; three of these leaks closed. In the other 2 patients, cervicomediastinal sepsis and bilateral pneumonia with respiratory failure caused death. One patient died of anoxic cardiac arrest 48 hours postoperatively. Fifteen of the 18 patients resumed oral alimentation, but the overall results of palliative surgical therapy achieved in this series were not observably worthwhile for the majority.

Retrosternal gastric bypass for inoperable esophageal cancer: a report of 71 patients

Palliative substernal gastric bypass was performed in 71 patients with unresectable cancer of the intrathoracic esophagus. Fifty-six patients (78.9%) left the hospital, 53 eating normally and 3 on a soft diet. There were 15 hospital deaths (21%), 8 due to respiratory failure and pulmonary sepsis with tracheoesophageal fistulization. The remaining 7 deaths were due to aspiration and respiratory failure in 2 patients, anastomotic leakage with sepsis in 2, subphrenic abscess and septicemia in 1, mediastinitis in 1, and intestinal obstruction in 1. Anastomotic leakage occurred in 17 patients (23.9%), 5 of whom died. Wound infections developed in 28 patients (39.4%), 3 with mediastinal esophagocutaneous fistulas. Reestablishment of unimpeded swallowing, relief of respiratory aspiration, isolation of cancerous tracheobronchial infiltration, and freedom from incident-prone endoesophageal tubes were achieved in all patients leaving the hospital. Information is presented on 25 patients who were available for follow-up.

Use of circumferential stapler in reconstruction following resections for carcinoma of the cardia

The use of the End-to-End Anastomosis (EEA) circumferential stapler for reconstruction following resection of the esophagus and stomach for carcinoma of the cardia is reported here in 9 consecutive patients with fifteen anastomoses performed with this unit. The technical aspects of the EEA stapler are emphasized. Two frequent problems associated with this type of operation namely, stenosis or leak at the suture line, are completely avoided by the use of this stapler unit. Its use is recommended.