Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients.

OBJECTIVE: To assess the effectiveness of transoral stapled diverticulum esophagostomy in relieving symptoms and decreasing outflow resistance at the pharyngoesophageal junction in patients with Zenker diverticulum. DESIGN: Cohort study. From April 1, 1992, until May 31, 1996, the operation was attempted in 95 patients. The median follow-up was 23 months (range, 13-48 months). SETTING: Tertiary care university hospital. PATIENTS: There were 74 men and 21 women, with a median age of 64 years (age range, 37-92 years). All complained of dysphagia and pharyngo-oral regurgitation, and 18 (20%) suffered from recurrent aspiration pneumonia. The median size of the pouch measured by flexible endoscopy was 4 cm (range, 2.5-8 cm). INTERVENTION: The septum between the diverticulum and the esophageal lumen was divided under general anesthesia using a linear endostapler introduced through a Weerda endoscope. In most patients, 2 applications of the endostapler with a modified anvil were used. Operative time averaged 23 minutes. MAIN OUTCOME MEASURES: Morbidity, symptom score, patient's satisfaction, videofluorographic barium transit, hypopharyngeal intrabolus pressure, upper esophageal clearance of radioisotope. RESULTS: A switch to open surgery was required in 3 patients (3.1%), due to difficult exposure of the common wall in 2 cases and a mucosal tear in the other. No postoperative morbidity or mortality was recorded. Oral feeding was started the following day and the median hospital stay was 3 days (range, 2-8 days). Five patients complained of persistent symptoms; 3 of them underwent another endosurgical operation, 1 underwent laser treatment by means of flexible endoscopy, and 1 eventually required open surgery. All patients are asymptomatic at the latest follow-up visit. Postoperative radiologic studies showed free flow of barium in all patients. Manometry showed a significant reduction of hypopharyngeal intrabolus pressure over preoperative values (P=.003). Radionuclide studies showed a significant reduction of upper esophageal residual activity at 1 minute compared with preoperative values (P=.006). CONCLUSIONS: Endosurgical approach to hypopharyngeal diverticula larger than 2 cm is safe and effective. Symptom relief, elimination of the pouch, and decreased outflow resistance at the pharyngoesophageal junction can be obtained without morbidity and with a short hospital stay.

Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty.

Redundancy of the interposed colon used as an esophageal substitute is a common finding in the long-term follow-up of these patients. When symptoms caused by food retention in the colonic loop occur, surgical correction is necessary to improve quality of life and to prevent aspiration. We report a technique to straighten the redundant colon that consists of a side-to-side colocolic anastomosis using a linear stapler. This obviates the need for a redo cologastric anastomosis. Compared with resection of the loop, the operation is quick, safe, and easy to perform, and it may decrease the risk of injury to the marginal vessels of the colon graft.

Videothoracoscopic enucleation of esophageal leiomyoma.

A new thoracoscopic technique to enucleate esophageal leiomyomas is described. The procedure has been successfully performed in 3 patients. All patients benefited by this new surgical approach due to the decreased operative trauma, reduced postoperative pain, quick recovery, and minute skin scars. Although further clinical experience and longer periods of follow-up are needed to evaluate the full benefits and limits of this new access, the early results of the thoracoscopic approach are promising.

Push-through intubation: effective palliation in 409 patients with cancer of the esophagus and cardia.

Between 1980 and 1989, 355 patients with cancer of the esophagus and 54 with cancer of the cardia underwent push-through intubation because of advanced tumor stage or medical contraindications to tumor resection. In 36 other patients (8.1%), the attempt at transtumoral intubation failed. The hospital mortality rate after intubation was 3.4%. The following complications were observed: hemorrhage in 2.0% of the patients, esophageal perforation in 4.9%, tube dislodgment in 12.7%, and tube obstruction in 4.4%. Early resumption of semisolid oral feeding was possible in 80% of the discharged patients. The actuarial 1-year survival rate was 7.7% and the median survival, 3.9 months. In conclusion, push-through intubation represents a valid therapeutic choice, which is indicated mainly for patients with a long, infiltrating, and circumferential stricture of the thoracic esophagus or cardia that is inoperable and for patients with an esophagorespiratory or esophagomediastinal fistula.

Surgical and endoscopic palliation of esophageal carcinoma.

We reviewed the records of 732 patients with advanced esophageal carcinoma to determine the efficacy of palliative therapy. Palliative resection was performed in 156 patients. Hospital mortality was 9.6%, 1-year survival was 29.1%, and median survival was 7.8 months. Excellent or good palliative results were obtained in 78% of operative survivors. Bypass procedures were performed in 49 patients: hospital mortality was 20.4%, with a median survival of 6.2 months. Excellent or good palliative results were obtained in 71% of operative survivors. Intubation of the tumor was performed in 254 patients. Thirty-day mortality was 10.2%, and median survival was 4.0 months. No patient received excellent palliation. Neodymium:yttrium-aluminum-garnet laser therapy or photodynamic therapy was performed in 50 patients. No procedure-related deaths were recorded, and median survival was 4.1 months. Excellent or good results were obtained in 83% of patients. Lesser procedures were performed in 106 patients, and 117 had only staging examinations. Although surgical palliation of esophageal cancer with resection or bypass provides good results, the cost is high. Improvements in palliative results require reduction in operative mortality, increased accuracy of preoperative staging, continuing use of laser therapy, and increased use of chemotherapy alone or in combination with radiotherapy and operation.

Indications for esophagectomy in nonmalignant Barrett's esophagus: a 10-year experience.

Between 1978 and 1988, 88 patients were referred for the surgical treatment of nonmalignant Barrett's esophagus. Nineteen patients required esophageal resection. Male/female ratio was 13:6; age range was 13 to 84 years (mean age, 49.8 years; median age, 40 years). Preoperative studies demonstrated strictures in 11 patients and ulcers in 7. Penetrating Barrett's ulcer resistant to treatment was the indication for resection in 5 patients. Ulcers penetrated to the pericardium (1 patient), pulmonary vein (1), lung (1), and mediastinum (2). Other indications for resection included undilatable strictures (2), previous operations (4), high-grade dysplasia (3), parietal cells lining the esophagus (1), patient's refusal of long-term surveillance (2), and the inability to exclude adenocarcinoma preoperatively (2). Reconstruction was achieved by colon interposition (15) or esophagogastrostomy (4), with one postoperative death. Mean follow-up was 41 months and was 100% complete. Of the 18 patients, 3 have occasional regurgitation but none have any dysphagia or weight loss. Esophageal resection is indicated in a select group of patients with Barrett's esophagus. Absolute indications include a deep penetrating ulcer confirmed intraoperatively, high-grade dysplasia, strong suspicion of cancer, and multiple previous operations. Relative indications include strictures not responding to dilation and young patients refusing long-term surveillance.

Surgical therapy of esophageal leiomyoma.

BACKGROUND: Surgical enucleation is the treatment of choice in selected patients with esophageal leiomyoma. The video-thoracoscopic approach can potentially cause less patient discomfort postoperatively and reduce the hospital stay and recovery period. STUDY DESIGN: A retrospective evaluation of 66 patients who underwent surgical therapy for esophageal leiomyoma over a 27-year period was done. The main symptoms were dysphagia in 35 (53 percent) patients, heartburn or regurgitation, or both, in 11 (17 percent) patients, and retrosternal pain in ten (15 percent) patients. Associated esophageal disorders were found in 19 patients (some patients had more than one disorder): hiatal hernia in 15 (23 percent), epiphrenic diverticulum in four (6 percent), and achalasia in three (5 percent). The operation consisted of leiomyoma enucleation in 63 patients, and esophageal resection in three. In six patients, the enucleation was successfully performed by video-thoracoscopy combined with intraoperative esophagoscopy. The muscle layer of the esophagus was approximated in the majority of the patients after tumor enucleation. RESULTS: There was no operative mortality. The incidence of intraoperative esophageal perforation was greater in patients who had previously undergone endoscopic biopsy (p < 0.01). In one patient, a pseudodiverticulum developed after thoracoscopic enucleation, requiring reoperation with approximation of the muscle layer for relief of dysphagia. The length of hospital stay was shorter in patients undergoing the video-assisted operation (p < 0.05). The median follow-up period was 53 months (range, 12 to 248 months). No recurrence of leiomyoma was observed. Overall, seven (11 percent) patients complained of heartburn or epigastric pain, or both, which was responsive to antisecretory drugs, but only three had such symptoms induced by the operation. In two patients the symptoms appeared after combined treatment of an epiphrenic diverticulum, and in one patient after simple leiomyoma enucleation. CONCLUSIONS: Enucleation of esophageal leiomyoma is a safe and effective operation. The video-thoracoscopic approach combined with intraoperative esophagoscopy allows performance of this procedure with the added advantage of shortening hospital stay. The muscle layer of the esophagus should be approximated to avoid decreasing the propulsive activity of the esophageal body. This may improve the long-term outcome of the operation by preserving the acid-clearing mechanism of the esophagus and reducing the incidence of postoperative reflux esophagitis.

Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?

The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.

Epidermal growth-factor receptors and erbb2 protein expression in esophageal cancer and normal mucosa.

The epidermal growth factor receptor (EGFr) and the erbB2 protein (p185) concentrations were assessed in 31 esophageal cancer specimens and in the corresponding normal mucosa, in order to investigate the possible links with the main clinical and pathological parameters. Detectable and high affinity EGFr was found in 27/31 cancer and in 18/31 normal tissue samples. EGFr concentrations were not significantly different between cancer and normal tissue, although a trend toward higher levels in cancer was found. No relationships were found with histologic type, tumor bulk, lymph node status, pathologic stage, ploidy and type of surgical resection. A significant negative correlation between EGFr levels and overall survival was found. Detectable levels of p185 were found in all the tissues examined, but the expression was higher in adenocarcinoma than in squamous cell carcinoma samples. The EGFr role in malignant transformation still has to be established, but the determination could be of clinical use. As for p185, its role in the onset of esophageal cancer could be confined to the subgroup of the adenocarcinomas.

Laparoscopic approach to esophageal achalasia.

Certain technical details are considered important to ease the laparoscopic performance of a Heller myotomy combined with a Dor antireflux procedure for esophageal achalasia. A special emphasis is given to intraoperative esophagoscopy combined with a mild balloon distension of the esophagogastric junction. These maneuvers prove helpful in identifying the esophagogastric region, easing the myotomy, and controlling its completeness.

TAF test in primary esophageal carcinoma: comparison with other tumor markers.

An ELISA method for the determination of circulating specific HSV-TAA antibodies has recently become available (TAF test). The presence of TAF was tested in serum of 154 patients with primary esophageal carcinoma, collected in three institutions. The overall TAF-test positivity rate was 57.1%, being significantly lower in stage IV than in stage III patients. The concordance rate between TAF and CEA, ferritin, TPA, SCC and TATI was low, suggesting that TAF is probably independent of the other tumor markers evaluated. The clinical role of TAF-test determination in patients with esophageal carcinoma is currently under evaluation.

Perioperative blood transfusion adversely affects prognosis of patients with stage I non-small-cell lung cancer.

It has been speculated that blood transfusion might adversely affect prognosis in cancer patients by immunosuppression. To avoid the confounding affect of advanced disease, we tested this hypothesis in 117 patients with stage I non-small-cell lung cancer. Mean and median follow-up were 49.7 months and 47 months, respectively. Patients who died during the postoperative period were not included. Perioperative transfusion was defined as administration of whole blood or packed cells within 30 days of operation. The overall cumulative 5-year disease-free survival rate was 67%. In patients with transfusion, it was 53% and in patients without transfusion it was 81% (p = 0.0055). A multivariate analysis was performed that included patient age, race, sex, cell type, extent of operation (pneumonectomy versus lobectomy/segmentectomy), operative blood loss, admission hematocrit, discharge hematocrit, and the presence or absence of perioperative transfusion. The only variable that significantly correlated with 5-year disease-free survival was the presence or absence of perioperative transfusion (p = 0.0278), and this effect was not related to the number of transfusions. Retrospective analysis of long-term results of patients surviving curative operation for stage I lung cancer shows that any perioperative transfusion significantly worsens the patient's prognosis and suggests very strongly that this association is due to an adverse effect of the transfusion rather than the transfusion serving as a marker for another risk factor.

Disconnection of the ampulla of Vater: a new technique for reconstruction.

We report the case of a 42 year-old patient who had undergone gastric resection and Billroth I reconstruction for a duodenal ulcer 15 years earlier. The patient was admitted to our Department for a high output biliopancreatic fistula which developed after another gastric resection with Billroth II reconstruction which was performed for a peptic stricture of the gastroduodenal anastomosis. At laparotomy, a complete disconnection of the ampulla of Vater was found, with the duodenal stump oversewn 5 cm distally to the papillary area. After plasty of the biliary and pancreatic ducts, a direct anastomosis between the new ampulla and a Roux-en-Y jejunal loop was performed. The post-operative course was uneventful. The details of the surgical technique are reported.

Surgical therapy in patients with failed antireflux repairs.

BACKGROUND/AIMS: Failure of antireflux surgery may be due to errors in patient selection, errors in the choice of the operation, or technical errors in the performance of the operation. The purpose of this work was to review a series of patients surgically treated for a failed antireflux procedure over the past two decades. MATERIALS AND METHODS: Seventy patients (62%) out of 113 consecutive individuals presenting with symptoms after one or more operations for gastroesophageal reflux disease underwent reoperation. Five patients had been operated on laparoscopically. The indications for reoperation were based on severity of symptoms and results of objective investigation. Surgical therapy was tailored to the individual patient based on pathophysiological abnormalities and on the results of intraoperative assessment. RESULTS: Reflux symptoms and dysphagia represented the major complaint in 62.8% and 35.7% of patients, respectively. The most common pathophysiological abnormality was an incompetent lower esophageal sphincter. Intraoperative assessment showed a disrupted or misplaced repair in 77% of the patients. The most common reoperation performed was a partial or total fundoplication (54.3%), followed by antrectomy and Roux-en-Y anastomosis (25.7%). There was no mortality. Postoperative morbidity rate was 8.5%. At a median follow-up of 48 months, 87% of patients were scored as Visick 1-2 and 90% declared themselves satisfied with the results of reoperation. CONCLUSIONS: Management of patients with failed antireflux procedures is challenging. However, detailed physiological evaluation and a surgical approach tailored to residual anatomy and function of the foregut can provide excellent results.

Duodeno-gastro-esophageal reflux after gastric surgery: surgical therapy and outcome in 42 consecutive patients.

BACKGROUND/AIMS: Duodeno-gastro-esophageal reflux is a common event after gastric surgery and can result in severe symptoms and mucosal injury. Medical therapy is largely ineffective. The most common remedial operation consists of a long isoperistaltic Roux-en-Y limb in order to shunt duodenal contents away from the gastric pouch and the esophagus. METHODOLOGY: Between 1980 and 1996, 42 patients underwent duodenal diversion after gastric surgery. The presence of severe symptoms and/or endoscopic esophagitis unresponsive to medical therapy was considered an indication for surgery. Functional studies were performed in selected patients in an attempt to objectively document the presence of excessive duodeno-gastro-esophageal reflux. A 40-60 cm Roux-en-Y limb was constructed in all patients. RESULTS: There was no post-operative mortality. The median follow-up was 28 months (range: 5-114). Symptoms related to delayed gastric emptying persisted in 5 patients (11.9%). Overall, 32 patients (76%) had a Visick I-II score. Best results (90%) were achieved in patients with previous total gastrectomy. CONCLUSIONS: Roux-en-Y duodenal diversion should be reserved for patients with intractable symptoms and documented reflux, and is mostly effective after total gastrectomy. Patients with a residual stomach are less likely to benefit from the procedure, probably because an underlying motor disorder plays a major role in the pathogenesis of the symptoms than does the reflux of duodenal contents.

Esophageal carcinoma and achalasia: prevalence, incidence and results of treatment.

UNLABELLED: Between 1980 and 1988, we treated 1,521 patients with squamous cell carcinoma of the esophagus and 336 patients with adenocarcinoma of the gastric cardia. Between 1967 and 1988, 244 patients with esophageal achalasia were also observed. Among 1,857 patients with cancer, achalasia was present in 21 cases (1.1%). In 18 patients the mean and median interval between the diagnosis of achalasia and cancer was 11.5 and 8 years, respectively. In 3 cases achalasia was detected during the work-up for esophageal cancer. The previous treatment for achalasia administered elsewhere was as follows: balloon dilatation in 6 cases, myotomy and Nissen repair in 2, and distal esophageal resection in 1. Thirteen patients (61.9%) underwent resection, resulting in 1 postoperative death, and a mean and median survival of 23.3 and 13 months, respectively. Push intubation was performed in 4 cases, chemotherapy in 2, a by-pass procedure in 1, endoscopic Nd:YAG laser in 1, while 1 further patient did not receive any treatment for the carcinoma, but only balloon dilatation of the LES. The mean follow-up of the 244 patients with primary esophageal achalasia was 44.6 months (range 1-108), and only 1 patient developed an esophageal cancer, giving an incidence of 18.6 cases per 100,000 per year. CONCLUSIONS: in our experience, achalasia is present in a minority of patients with esophageal cancer, and larger prospective controlled trials are needed to assess the true incidence of malignant degeneration in the achalasic patient.

Primary multiple epithelioid leiomyosarcoma of the liver.

Sarcomas represent only 1-2% of primary malignant tumors of the liver. We report the twenty first case of primary hepatic leiomyosarcoma in the literature. Metastases from gastrointestinal tract, female genital system and lung have to be excluded before confirming diagnosis of a primary neoplasm. Extensive involvement of the liver parenchyma contraindicated surgery, the treatment of choice when the tumor is solitary or multiple but located in one lobe. Chemotherapy, as employed in our patient, is the alternative therapeutic option in inoperable cases, but its role has to be clarified.

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)

Prognostic significance of ploidy determination in rectal cancer.

Between 1965 and 1981, 154 patients with potentially curable rectal adenocarcinoma underwent surgical treatment at the University of Chicago Medical Center. In 134 cases, enough histological material was available to perform determinations of DNA content by the cytophotometric method (n = 108), or by the flow cytometric technique (n = 109). In 83 cases, DNA content was analyzed in the same specimen with both techniques, and in 77 of these cases the sections obtained from the paraffin blocks were contiguous. When using flow cytometry, 62% of stage B and 74% of stage C lesions were classified as aneuploid on the basis of a DNA index greater than 1. This correlation was statistically significant (p = 0.002). Patients with diploid tumors had an actuarial five-year survival equal to 62% in comparison with a 46-51% five-year survival for patients with aneuploid tumors. This difference was not statistically significant and it was explained by the tendency for aneuploid tumors to be in an advanced histopathological stage.

Evaluation of leiomyoma of the esophagus with endoscopic ultrasonography.

Fourteen patients with suspected leiomyoma of the esophagus were studied by endoscopic ultrasonography, computed tomography, endoscopy and barium swallow. The results were correlated with the histology of the resected specimens: in 2 patients with a peduncolated leiomyoma originating from the second echographic layer, endoscopic resection was performed. Endoscopic ultrasonography was superior to other imaging techniques in detection and staging of leiomyoma because it can determine the layer of origin, the direction of the growth and the consistency of the tumor.