Surgical treatment for esophageal carcinoma.

Advances in surgery as primary treatment for esophageal cancer are dependent upon early diagnosis, a systematic resection of periesophageal tissues by an en bloc resection, improved results of esophageal anastomoses with decreased risk and morbidity, and knowledge of the impact of staging on prognosis. More exact pathologic staging sets the stage for evaluation of adjuvant therapy protocols. Patients with favorable staging have a high chance that en bloc surgical resection is curative. For those with more advanced disease, surgery continues to offer a role through palliative resection or bypass to relieve severe dysphagia.

Pathophysiology of gastroesophageal reflux.

The factors controlling competence of the gastroesophageal junction have been carefully analyzed over the last decade. Although the presence of an anatomic sphincter guarding the lower esophagus has not been confirmed in humans, a manometrically defined high-pressure zone is present in the lower esophagus. The magnitude of sphincter pressure correlates well with the incidence of pathologic gastroesophageal reflux. Another important determinant of cardial competence is the length of intra-abdominal esophagus. The interaction of length and pressure in maintaining competence is demonstrated by several clinical and experimental studies. Twenty percent of refluxors have normal components of cardial competence. Several physical factors, namely components of Laplace's law, may govern control of reflux especially after antireflux repairs. The occurrence of esophagitis as a complication of gastroesophageal reflux is determined by the ability of the esophageal body to rid itself of an acid load as well as by factors that delay gastric emptying.

En bloc resection for neoplasms of the esophagus and cardia.

The principles of en bloc resection for carcinoma can be adapted to neoplasms of the esophagus. The techniques of the operation are described. Among the 80 patients undergoing radical resection, there were nine (11%) hospital deaths within 30 days of operation. The actuarial survival rate was 24% at 3 years and 18% at 5 years. There have been no recurrences of cancer more than 3 years after operation. Results have been significantly worse among 12 patients receiving preoperative radiation therapy than in 68 in whom operation was the first treatment (1 year survival rates, 17% versus 60%). There have been no significant differences in results based upon cell type or tumor location, but patients with diseased lymph nodes or full-thickness wall penetration of the tumor had a significantly poorer survival at 2 years than patients without these determinants of prognosis. Radical en bloc resection for carcinoma of the esophagus can be performed with a mortality rate no greater than that from the less extensive standard esophagectomy. A few patients may become long-term survivors after this operation despite unfavorable prognostic factors. The operation provides improved pathological staging as a guide to prognosis and need for subsequent adjuvant therapy.

Occult cervical nodal metastasis in esophageal cancer: preliminary results of three-field lymphadenectomy.

The extent of lymphadenectomy for carcinoma of the thoracic esophagus remains debatable. A prospective study was initiated in August 1994 to evaluate the patterns of nodal spread after esophagectomy with three-field lymph node dissection. The hospital mortality rate was 3.3%. Nodal metastases occurred in 73% (22/30) of patients. The most commonly affected nodal groups were the lesser curvature nodes (57%), parahiatal nodes (42%), and the right recurrent nodes (35%). Cervical nodal metastasis occurred in 10 patients (35%) irrespective of tumor location or T status. The cervical field of dissection was as likely as the mediastinum to be a site of nodal disease. These findings should be considered when the operative strategy for esophageal carcinoma is planned.

Hemodynamic characteristics of critical stenosis in canine coronary arteries.

To determine the hemodynamic characteristics of critical stenosis of coronary arteries, mean left circumflex coronary artery (LCCA) flow, myocardial peak reactive hyperemic response (PRHR), myocardial PO2 and PCO2 electrocardiograms, and aortic pressure were monitored at precise degrees of LCCA stenosis in 18 dogs. Stepwise LCCA constriction by a specially designed occluder resulted in a gradual drop in PRHR but little change in other variables. When PRHR was reduced 96 per cent, critical stenosis was achieved, and further constriction caused pronounced and sudden changes in all parameters. When critical stenosis occurred, LCCA diameter had been reduced by 74 plus or minus 2 per cent. Mean LCCA flow was reduced from a base-line level of 42 plus or minus 2 to 34 plus or minus 2 c.c. per minute. PO2 in the myocardium was reduced from 24 plus or minus 1.5 to 16 plus or minus 1.6 mm. Hg. PCO2 increased from 43 plus or minus 5 to 55 plus or minus mm. Hg. T waves in Lead II because isoelectric. The myocardium was well perfused and able to regulate flow through an artery narrowed up to 74 per cent. Beyond this point of critical stenosis, the vascular bed was maximally dilated and further narrowing caused ischemia. These findings indicate that PRHR may be useful at operation to determiine whether all significant lesions are bypassed and whether graft flow is adequate.

En bloc esophagectomy improves survival for stage III esophageal cancer.

OBJECTIVE: The role of en bloc esophagectomy in the surgical treatment of patients with locally advanced esophageal cancer is not well defined. This report attempts to elucidate its impact on survival, in comparison with less extensive resection, among patients with stage III disease. METHODS: A prospectively established database was retrospectively analyzed. RESULTS: One hundred twenty-eight patients underwent esophagectomy for carcinoma of the thoracic esophagus between 1988 and 1996 (78 underwent en bloc resection and 50 underwent standard resection). The 30-day and hospital mortality rates were 3.9% and 5.4%, respectively, comparable for the two procedures. Fifty-four patients had stage III disease. Overall 4-year survival was 34.5% after en bloc resection, with a median survival of 27 months (n = 33), and 11% after standard resection (n = 21), with a median survival of 12 months (p = 0.007). Among patients with stage III disease undergoing a complete resection, 4-year survivals were 36.7% and 0% after en bloc and standard resections, respectively (p = 0.001). Eighty-six of 128 patients had nodal metastasis. Three-year survivals for patients with NI disease were 33.9% and 13% after en bloc and standard resections, respectively (p = 0.02). CONCLUSION: Among patients with stage III esophageal cancer, en bloc resection appears to significantly improve survival compared with lesser resections. This improvement in survival may be attributable to resection of nodal disease.

Thoracic esophageal diverticula. Why is operation necessary?

Diverticula of the thoracic esophagus are uncommon disorders. The indications for surgical intervention in asymptomatic or minimally symptomatic patients are unclear. Among 20 patients referred during a 20-year period, 6 were male and 14 female, with a median age of 65 years. Two had had previous diverticulectomies. Dysphagia was present in 9 (45%) and regurgitation in 11 (55%). Nine patients had severe nocturnal cough with symptoms of aspiration. In two of these nine and in three other patients (25%), pulmonary symptoms were the only manifestation of disease, with no or minimal esophageal symptoms. In one patient the diagnosis of the presence of bronchial asthma for several years was incorrect; one patient had massive aspiration before hernia repair, in one a bronchoesophageal fistula and lung abscess developed, and two had severe persistent cough. All patients had a diagnostic barium esophagogram and endoscopy. Operation was performed in 17 patients, whereas three others declined operation. There was one hospital death. Follow-up is complete on 17 of 19 patients until June 1991. All operative survivors but one are free of symptoms. Of three patients refusing operation, one died of aspiration pneumonia, another died of myocardial infarction, and one with severe dysphagia is living. Because of the prevalence of aspiration (45%) and the potential for life-threatening pulmonary complications in some patients (15%), we conclude that operative intervention should be undertaken in all patients with thoracic esophageal diverticula regardless of the presence or absence of symptoms.

Esophageal carcinoma with airway invasion. Evolution and choices of therapy.

In order to define the evolution of airway invasion by esophageal cancer, we reviewed 53 patients presenting with (group A) or without (group B) tracheoesophageal fistulae. Patients in group A were treated by esophageal bypass (4), esophageal diversion (4), expectant therapy (4), or esophageal prosthesis (1). The median survival was 4 months. Group B patients were treated by esophageal resection (18), esophageal bypass (4), or radiation therapy (13), depending on the extent of local disease. Bronchoscopy was a valuable tool for predicting resectability. Surgical resection, when possible, yielded better palliation. There were 4 long-term survivors in group B.

Massive hiatal hernias: the anatomic basis of repair.

OBJECTIVES: In the repair of giant hiatal hernias, controversy persists as to whether an antireflux repair is required and whether a Collis gastroplasty is necessary. This study was undertaken to determine the location of the gastroesophageal junction in giant hiatal hernias with an intrathoracic stomach, as well as the outcome after repair without a Collis gastroplasty. METHODS: Fifty-two patients were evaluated for a giant hiatal hernia, of whom 47 underwent surgical correction. Preoperative evaluation included esophagoscopy (n = 45), gastrointestinal series (n = 40), esophageal manometry (n = 20), and 24-hour pH testing (n = 13). The dominant clinical features were acute chest or abdominal pain (72%), heartburn (53%), and gastrointestinal bleeding (49%). The gastroesophageal junction was located in the mediastinum in 77% of patients, in the abdomen in 17%, and was not determined in 6%. Twenty-eight patients (59%) had clinical or objective evidence of reflux. Reduction with an antireflux repair without a gastroplasty was done in 47 (Belsey, n = 28; Nissen, n = 19). An excellent or good result was achieved in 38 patients (90%) with a median follow-up of 45 months. CONCLUSIONS: These results, obtained without a Collis gastroplasty, are equivalent to those obtained by an antireflux repair with an esophageal lengthening procedure. The frequent location of the gastroesophageal junction in the mediastinum suggests that these massive hernias often are the result of progressive enlargement of a sliding component. An antireflux repair is therefore necessary in the majority of patients.

Reoperation for failed antireflux operations.

UNLABELLED: Experience with gastroesophageal reflux in patients without prior operations has yielded understanding of pathophysiology, surgical techniques, and results. Less is known about patients with failed antireflux operations. This report of 61 patients undergoing repeat antireflux procedures addresses this issues. Not included are patients with gastroesophageal reflux after ulcer operations or with inappropriate antireflux operations for motility disorders. Group A patients (n = 34) had only one previous operation, Group B (n = 19) had two, and Group C (n = 8) had three or more. Group C had significantly (p less than 0.05) more dysphagia and less heartburn than Group A. This observation correlated with findings from manometry, pH testing, and endoscopy, which showed progressively worse esophageal body function and a greater incidence of severe esophagitis and esophageal leak, but less gastroesophageal reflux, in Group C than B and in Group B compared to A. Operative mortality was 4.9%. Repeat antireflux operations in the 58 survivors were as follows: Group A included 25 standard antireflux procedures and seven bowel interpositions, and 75% were transthoracic. Group B included 16 antireflux procedures and one bowel interposition, and 82% were transthoracic. Group C included four antireflux procedures and three interpositions, and all were transthoracic. Clinical results were excellent or good in 85% in Group A, 66% in Group B, and only 42% in Group C (A versus C, p less than 0.05). Surgical complications increased from 27% in Group A to 75% in Group C (p less than 0.05). CONCLUSIONS: Patients with one prior operation and recurrent gastroesophageal reflux are similar to patients with no prior operations. Results of repeat antireflux operations deteriorate with increasing operations because of impaired esophageal function and progressive tissue destruction. Therefore, second reoperations must be definitive and resection and reconstruction with healthy tissue considered. A transthoracic approach is preferable for first reoperations and mandatory after multiple antireflux procedures.

Evaluation of brush cytology as an independent technique for detection of esophageal carcinoma.

In this study the accuracy of indirect brush cytology for detection of esophageal carcinoma is evaluated against current standard methods of diagnosis and is compared with the known accuracy rate of endoscopically directed brush cytology. A standard endoscopic nylon brush placed inside a nasogastric tube was used in 203 patients with various esophageal problems. Correct diagnosis was made in 78% of cancers, 95% of potentially premalignant cases, and 100% of cases of normal esophageal mucosa with both indirect and directed brushing procedures. The technique meets most requirements of a new screening procedure as being simple, safe (no complications), relatively inexpensive, and acceptable to patients (98% compliance). Currently it is employed to monitor high-risk esophageal conditions and post-treatment courses of patients with pharyngoesophageal tumors for local recurrence or a new primary lesion in the esophagus.

Technique, indications, and clinical use of 24 hour esophageal pH monitoring.

The technique of 24 hour esophageal pH monitoring (24 hour pH test) is described. Experience with the 24 hour pH test in 393 patients with suspected esophageal disease has shown the clinical usefulness of the test in objectively determining the presence of gastroesophageal reflux. The test was effective in evaluating atypical symptoms of gastroesophageal reflux such as respiratory symptoms and chest pain and, in children, failure to thrive and recurrent pneumonia. The 24 hour pH test was particularly useful in evaluating patients who were referred with other abdominal or thoracic disease and had, in addition, symptoms suggestive of gastroesophageal reflux on history. The test helped to unsnarl the cause of recurrent symptoms after an esophageal myotomy for achalasia or an antireflux procedure. Of 179 patients with typical symptoms of gastroesophageal reflux, 27% had normal 24 hour test results and were subsequently diagnosed as having another cause for their symptoms. Of 146 patients who had normal findings on esophagoscopy, 54% were shown to have abnormal gastroesophageal reflux on 24 hour pH monitoring, indicating lack of sensitivity of endoscopy to detect reflux. In addition, the 24 hour pH test identified patterns of abnormal reflux and indicated those patients most at risk for development of stricture. The test is well tolerated by the patients, simple to use, and dependable when performed and read as described. The clinical use of the 24 hour pH test brings objectivity to the evaluation of exophageal disease that has hitherto not been available.

Relationship of a hiatal hernia to the function of the body of the esophagus and the gastroesophageal junction.

One hundred two patients referred to our Esophageal Function Laboratory without endoscopic evidence of esophagitis were divided into two groups on the basis of the presence of a hiatal hernia on endoscopic examination. Fifty-three patients had a hiatal hernia and 49 did not. Both groups and 30 normal volunteer subjects had esophageal manometry and 24 hour esophageal pH monitoring. The incompetency of the cardia in patients with a hiatal hernia was dependent upon loss of components responsible for the antireflux mechanism, mainly a decrease in distal esophageal sphincter pressure and a decrease in the length of the sphincter exposed to the positive-pressure environment of the abdomen. These deficiencies were not related to the presence of a hiatal hernia and were similar to those of patients with an incompetent cardia without a hiatal hernia. Patients with a hiatal hernia and an incompetent cardia had significantly more esophageal exposure to refluxed acid than without a hiatal hernia. On the basis of the number of reflux episodes that lasted 5 minutes or longer and radioisotope transit studies, this increased acid exposure was due to both a loss of competency of the cardia and poor esophageal clearance secondary to the presence of a hiatal hernia. Reduction of the hernia and anchoring the distal esophagus into the abdomen not only may improve the antireflux mechanism, but corrects the clearance abnormality as well. The presence of a hiatal hernia has a detrimental effect on the clearance function of the body of the esophagus and may aggravate the effects of gastroesophageal reflux due to an incompetent cardia.

The role of adjuvant therapy after resection of T1 N1 M0 and T2 N1 M0 non-small cell lung cancer.

Thirty-four consecutive patients with non-small cell lung cancer plus N1 nodal metastases (eight with T1 N1 M0 and 26 with T2 N1 M0) were retrospectively reviewed. Nineteen had adenocarcinoma, 11 had squamous disease, and four had large cell carcinoma. Eleven patients had surgical resection alone (32.3%), with a median survival of 13 months. Seven patients (20.6%) had resection followed by radiation therapy, with a median survival of 19.2 months. Sixteen patients (47.1%) had resection followed by radiation therapy and chemotherapy, consisting of cyclophosphamide, doxorubicin, methotrexate, and procarbazine. Median survival for the latter group was 45.5 months, significantly greater than for those treated with resection alone (p less than 0.005). We did not observe any relationship between survival and age, cell type, number or location of diseased hilar nodes, distance of tumor from the resected bronchial margin, tumor size, the presence or absence of visceral pleural involvement, or the type of resection performed. Resection in combination with adjuvant radiation therapy and chemotherapy offers improved median survival over resection alone in patients with T1 N1 M0 and T2 N1 M0 non-small cell lung cancer.

Regional accuracy of computed tomography of the mediastinum in staging of lung cancer.

To determine the regional accuracy of computed tomography of the mediastinum in staging lung cancer, we compared the results of preoperative computed tomographic staging to pathologic findings in lymph nodes taken at mediastinoscopy and/or thoracotomy in 61 patients. Twenty-two patients had adenocarcinoma, 24 had squamous cell carcinoma, eight had large cell tumors, and seven had small cell cancer or mixed cellular types. Sixteen patients had Stage I, eight had Stage II, and 37 had Stage III disease. Thirteen patients had mediastinoscopy only, and the remaining 48 patients had thoracotomy. Computed tomographic staging of the mediastinum as a whole had an accuracy of 88% with a negative predictive index of 96.1%. In examining the differential regional accuracy within the mediastinum we found results in the aortopulmonary window to be inferior to those of other regions, with an accuracy of 80% and a negative predictive index of 83.3%. The reliability of computed tomographic scan staging varied relative to cell type. The accuracy rate in adenocarcinoma was 94.7% compared to 70.6% in squamous cell carcinoma. Computed tomography is accurate for staging the mediastinum in lung cancer, and this accuracy holds over the regions of the mediastinum except the aortopulmonary window. Computed tomography is more accurate for staging adenocarcinoma than squamous cell cancer.

Gallium-67 scanning for carcinoma of the lung.

Gallium-67 citrate scanning was prospectively evaluated in 55 patients who had lung lesions suspected to be primary carcinoma on chest x-ray films and in whom subsequent histologic diagnosis was obtained. Of 47 patients with histologically proved carcinoma of the lung, 44 (94 per cent) had a positive 67Ga scan. No patient with a positive scan had a benign lesion, so that the positive scan accuracy rate was 100 per cent. All 8 patients with a benign lesion and 3 patients with a malignant lesion had negative scans, for a negative scan accurary rate of 72 per cent for benign lesions. These results give statistical validity for the usefulness of the 67Ga scan in diagnosing carcinoma of the lung (p less than 0.001). Tumor cell type had little effect on the sensitivity of 67Ga scan. The 67Ga scan was equally useful in the evaluation of peripheral and central lesions. There was little difference amount T1, T2, and T3 classified lesions in their ability to take up 67Ga. The 67Ga scan was competitive with mediastinoscopy in assessing mediastinal lymph node metastases and provides a noninvasive method of assessing hilar lymph node metastases. There was a good correlation between the clinical staging of patients with lung cancer based on a chest x-ray film and 67Ga scanning and the staging after surgical treatment based on the histology of the resected specimens.

Dysplasia in Barrett's esophagus.

In a retrospective histological study, resected specimens obtained from 23 patients with adenocarcinoma in Barrett's esophagus (Group I) and endoscopic multiple (step) biopsies from 38 patients without carcinoma in Barrett's esophagus (Group II) were investigated for dysplastic changes. Dysplasia was most frequently found in the type of mucosa comprising intestinal metaplasia. There seem to be two pathways to dysplasia in Barrett's esophagus. In Group I dysplasia was found in 18 out of 23, and in Group II in 2 out of 38 patients. In Barrett's esophagus, dysplasia may be considered not only a precursor of carcinoma, but also a marker for coexisting carcinoma.

Results of changing trends in the surgical management of complications of diverticular disease.

During the past decade, primary resection with anastomosis has gained acceptance in the surgical treatment of complications arising from diverticular disease of the colon. We have reviewed our experience during the past 10 years to determine whether this approach has clinical validity. Of 673 patients followed over a 10-year period, 93 (14%) required operation. Operative indications were generally limited to urgent complications of the disease: abscess (36), bleeding (18), perforation (10), obstruction (10), and fistula (5). A small group of patients underwent operation for recurrent symptoms (7) and for the suspicion of coexistent carcinoma (8). Initial operative management included resection with anastomosis (44), resection and colostomy (26), and diverting colostomy (23). The overall incidence of complications was significant; the most common complication was infectious in nature: abscess (7), fistula (9), wound infection (11), dehiscence (2), and sepsis (5). Complications were more numerous in patients who did not receive primary resection of the diseased segment 2.1 versus 1.1 complications per patient, respectively), and the duration of hospitalization was significantly greater in this group as well. The perioperative mortality rate of our surgical patients was 6.4%; none of these deaths were associated with resection and anastomosis. These data indicate that resection with primary anastomosis is a sound approach in properly selected patients with urgent complications of diverticular disease, and that aggressive surgical management can yield results that are better than those obtained from the use of colostomy alone.

In situ kidney preservation for transplantation with use of profound hypothermia (5 to 20 degrees C.) with an intact circulation.

Twenty-seven anesthetized dogs were surface cooled at 4 to 6 degrees C. or 15 to 20 degrees C. Circulation was provided by the mechanical ventricular assist in 23 dogs. After 24 or 48 hours of in situ preservation, the kidneys were transplanted into the necks or iliac fossas of anephric recipients. Renal function was preserved in the cadaver for up to 48 hours at 15 to 20 degrees C. by maintaining a pulsatile circulation. Further cooling to 4 to 6 degrees C. caused progressive deterioration in renal function. The nonperfused kidneys kept in situ at 4 to 6 degrees C. did not produce any urine after transplantation. If the practical problems of total body cooling are solved, in situ preservation of multiple organs in the cadaver would increase the number of available organs for transplantation.

Duodenogastric reflux and reflux esophagitis.

Twenty-seven patients with gastroesophageal reflux were prospectively investigated to define the role of duodenogastric reflux in the development of reflux esophagitis. Duodenogastric reflux was detected and quantified by pH monitoring of the gastric environment 5 cm distal to the distal esophageal sphincter. Alkaline duodenogastric reflux was identified by the occurrence of spontaneous, intense gastric alkalinization during fasting periods. Patients with reflux with esophagitis were distinguished from those without esophagitis by having fewer of these episodes and, consequently, more acid stomachs than had patients without esophagitis. As previously shown, refluxers with esophagitis also had more frequent acid gastroesophageal reflux and prolonged gastric emptying. These findings suggest that refluxers with esophagitis have a functional gastropyloric disturbance resulting in delayed gastric emptying, decreased frequency of alkaline duodenogastric reflux episodes, and more frequent acid gastroesophageal reflux than do refluxers without esophagitis.