Postoperative functional result and quality of life after oesophageal reconstruction based on the type of cervical anastomosis.

INTRODUCTION: The keystone of the rate of postoperative complications and functional outcome in oesophageal reconstruction is the technique method of performing cervical anastomosis.Despite new technologies and improved technique in specialized centres, post-anastomosis complications have not significantly improved. PURPOSE: The goal of our study is to analyse the causes that make anastomosis with the oesophagus hypopharynx a particular case. If anatomical and morphological aspects cannot be adjusted (poor histological structure and vascularity etc.), some important elements for performing a good anastomosis can be identified and corrected. MATERIAL AND METHOD: Between 1981-2014, 195 oesophageal reconstructions were performed in our clinic. Our study involved an analysis of 72 cases (2000-2014), based on a statistical evaluation by Kaplan-Meier method that considered as eries of factors (oesophagus hypopharynx as anastomotic partner, stomach, jejuno-ileum, colon as visceral partner,pharyngotomy type, T-L, T-T, L-L, L-T type anastomosis,number of anastomotic layers). RESULTS were compared with those obtained by standard clinical and laboratory investigation,analysing the post-therapeutic outcome using three criteria (clinical aspects of swallowing, barium swallow and endoscopy) and by subjective assessment by each patient of his her state and complaints, with effects on long-term functional outcome (dysphagia, reflux, pain, asthenia, weight loss, hoarseness). RESULTS: Statistical analysis determined that only some of the analysed factors proved to be valuable. The higher the level of the anastomosis, the more intense the impairment of the digestive function. The jejunum and left colon proved to bemost effective anastomotic partners. The best method for implantation seems to be T-T or T-L and the number of anastomosis layers has no influence on postoperative outcome. CONCLUSIONS: Acquired data can influence to some extent the operatory technique, with a lower complication rate.Unfortunately, laborious technical aspects and specific anatomical limitations make this goal difficult to achieve.

Monitoring the Laryngeal Nerves During Thyroidectomy. Initial 115 Cases Experience.

The lesions of the laryngeal nerves, despite low incidence, are the most severe long term complications after thyroidectomy. Visualization after careful dissection of the recurrent laryngeal nerve (RLN) is now the golden standard among thyroid surgeons. We assessed traditional landmarks for the identification of RLN and anatomic high risk situation. The study also presented our initial experience using neuro monitoring of RLN (IONM) during surgery. The results show a recognizable Zuckerkandl tubercle in 162 of the 222 cases (72,97%). After dissection RLN was found posterior from TZ in 154 cases (95,06%) and lateral from TZ in 8 cases (4,93%). The identification of the Zuckerkandl tubercle is a useful landmark for RLN localization. As concerning high risk situations we found 2 non recurrent laryngeal nerves (both on the right side). Extra laryngeal ramification of RLN is an anatomical reality with significant incidence (23,8% in our study) and major surgical involvement. Extra laryngeal ramification of RLN occurs more often between the cross point with inferior thyroid artery and larynx entry point. Monitoring the branches of RLN we obtain major EMG signal on the anterior one. The surgical meaning is that the anterior branch carries the most important motor fibers and we have to pay extra care in the correct identification and preservation of it. From a total of 222 visually identified RLN we have 215 nerves (96,84%) with positive EMG signal on monitoring. For 7 nerves (3,15%) we had no EMG signal. In 3 cases (2 total thyroidectomies and 1 lobectomy) involving 5 RLN there was a false negative result caused by electrode malposition or desoldering from endotracheal tube. Our initial experience shows that IONM is harmless, easy to handle and a useful tool for identifying the nerve and confirm its integrity. More extended studies are needed to show if intraoperative monitoring decreases the rate of RLN iatrogenic injury.

Surgical Treatment with Radiofrequencies for Outpatients with Surgical Benign Ano-Perianal Diseases.

INTRODUCTION: Nowadays, the occurrence of surgical benign ano-perianal diseases (SBAPD) is raising. Radiofrequency (RF) represents a surgical therapeutic method using high frequency radio waves to perform incisions, excisions and tissue coagulation. The main purpose of the study is to validate the possibility to use RF within the surgical treatment for outpatients with SBAPD; at the same time, a special consideration has been given to appreciate the efficiency of RF compared with other surgical methods. MATERIAL AND METHOD: The study presents the results accumulated in 11 years (December 2003 - December 2014) in "PROCTOLINE" International Medical Center; also, we have taken into account the accomplishments on 783 outpatients, submitted to RF surgery for 10 different types of SBAPD. Various RF surgeries (cuttings, excisions, coagulations, curettages etc.) have been performed under local anesthesia. RESULTS: The necessary time was usually less than 45 minutes, while the post-operatory duration for a total healing was in the range of 7 to 45 days. The percentage of minor complications was quite a small one (8,3%). Also, we might appreciate excellent post-treatment results (maximum value of 11 years); Typically, the patients return for periodic postoperative examination at first and fourth week after surgery. CONCLUSIONS: RF represents an efficient, rapid and secure method for the treatment of SBAPD; it may be used in ambulatory, only under local anesthesia, offering to the patient a minimal post-operatory discomfort, as well as a rapid, esthetic and functional recovery of wound. By comparison with "classical surgery", the complications are rather minor ones and their percentage occurs in a lesser one.

Evaluation of Neoadjuvant Radiochemotherapy Response (RCT) in Squamous Esophageal Cancer (ESC) and Implications in Therapeutic Conduct.

The multidisciplinary approach in ESC emerged as a result of efforts to maximize the treatment outcome of this disease.Surgical approach as the only therapeutic option is not always followed by a good distance survival. A concomitant neoadjuvant radiochemotherapy in ESC may result in a favourable outcome for responding patients, reducing the size of the tumor and the degree of lymph node damage increasing resectability and the R0 resection rate, improving prognosis. For non-responding patients or if the disease continues to progress under RCT therapy, the surgical time is delayed, adverse effects of radiochemotherapy are added and postoperative morbidity and mortality are increased. The imaging methods for the assessment of response have only limited value and metabolic response; only FDG-PET manages to come close to pathological response. Determining the response degree is very important for the establishment of the surgical conduct: planned or necessity surgery, or non-surgical palliative therapy.

Giant Esophageal GIST: Diagnostic and Therapeutic Challenge - Case Report.

GIST are rare mesenchymal tumors of the digestive tract (less than 1% of the digestive tract neoplasia). Of these, less than 1% are found in the esophagus. Surgery is the main treatment of GIST and is supported by targeted therapy with tyrosine kinase inhibitors like imatinibmesylate. We present the case of a female patient of 51 years, admitted in our clinic for a bulky tumor in the posterior mediastinum, diagnosed after investigations performed for fatigue for the great efforts. Clinical examination was unspecific. Chest X-ray and thoraco-abdominal CT identified a widening of the mediastinum through a posterior mediastinal tumor mass, determining a deviation to the left of the thoracic esophagus without causing not abledysphagia or respiratory symptoms. It was decided surgery by thoracotomy in V right intercostal space and total excision of the tumor was performed. Histopathology examination confirmed the preoperative suspicion of esophageal GIST. Prognosis is reserved, the risk of relapse is very high given the fact that the tumor was extracted fragmented. Currently the patient is under treatment with imatinib mesylate and entered into clinical and imaging follow-up program, according to clinical guidelines.

Lesions of the laryngeal nerves during thyroidectomy - what's new?

Lesions to the laryngeal nerves, despite their low incidence, are the most severe long term complications after thyroidectomy.Visualization after careful dissection of the recurrent laryngeal nerve (RLN) is now the gold standard among thyroid surgeons. The Zuckerkandl tubercle (TZ) is a constant landmark for the identification of the RLN. Recent studies show the occurrence of two or more branches of RLN before entering the larynx. Knowledge about their existence could prevent lesions. Some high risk surgical situations are evidenced, such as: non recurrent laryngeal nerve emerging high from the vagus and the superior laryngeal nerve type Cernea 2. Several examination procedures are mandatory for a complete postoperative evaluation: video laryngoscopy and laryngeal electromyography (LEMG) bring valuable objective and prognostic data. However, due to the unpredictability of the synkynesis process, the prognosis of recovery in RLN injuries remains difficult.

Intermesenteric appendicular abscess, a diagnostic challenge; case report and review.

The appendicular origin of an intermesenteric abscess is rarely suspected prior to surgery, due to atypical clinical presentation and poor sensitivity of exploratory methods. A 43-year-old male was admitted for recent pain and mild tenderness in the epigastrium, slight emesis, leucocytosis (C-reactive protein was not determined), with no pathological findings on simple abdominal radiological examination (Rx). Abdominal ultrasound(US) and endoscopy were irrelevant. The abdomen became moderately tender, distended; diffuse enteric gas,slightly impaired bowel movement could be demonstrated by anew Rx. CT (oral contrast) was performed in the 3rd day:edematous infiltration of the mesentery and of a left-flank digestive loop (jejunal, sigmoidian?), small-size fluid collection(with extraluminal air-level) and paretic loops in the proximity, but normal wall-appearance of the caecum and its surrounding fat; the CT result was inconclusive (perforated diverticulosis or malignancy?). Barium enema: normal,including the caecum. Installation of vesperal fever, progressive mid-abdominal pain, tenderness and formation of a mass were the rationale for open mid-line laparotomy, discovering a large intermesenteric abscess, secondary to perforated gangrenous intermesenteric appendicitis. Surgical outcome of appendectomy was normal. A high index of suspicion may be suggested by: atypical clinical presentation (fever; ileus;presence or formation of a tender, periumbilical, mass) and CT findings (abscess; extraluminal air; ileus).

Motor criteria evaluation of iso-anisoperistaltic graft in oesophageal reconstruction -- an experimental study of isolated colic graft motility pattern in dogs.

In the medical literature there are more than one opinion in favour of the isoperistaltic interposed loop, considering it to render a higher propulsive activity and thus with much better functionality, with less intense symptoms of regurgitation,reflux or aspiration. Technically, however, due to anatomical relationships, anisoperistaltic graft interposition is more convenient. Is this detrimental to functionality? What is the best peristaltic model? At first sight, it seems that due to the local anatomy and surgical technique involved, we compromise at the expense of better functionality. To find the answer to these questions, starting from the typical pattern of colonic motility in the transverse and left colon, we need to identify new motor behaviour of the isolated colic segment. Because motor activity is generated by electric waves discharged from the area control centre, their electromyographic registration would allow finding the contractile pattern of a transplanted loop.

Therapeutic strategies in colonic cancer.

Colonic cancer is the most common malignancy of the digestive tract, representing 13% of all malignancies. The aim of the study is to evaluate the current therapeutic strategy in patients with CC. Mortality from the disease is declining in many Western countries; this may be the result of screening for CC, resection of adenomas, early detection of tumoral lesions and the use of individualized therapeutic strategies. The multimodal treatment of the disease includes different sequences such as: surgery, chemotherapy, radiotherapy,immunotherapy. Current advances in the research of mechanisms of carcinogenesis in CC make it possible to use genetic information in order to establish the prognostic and predictive factors for selecting the patients for individualized therapy. The current methods of CC evaluation allow the planning of individualized therapeutic strategies, which would lead to optimal results.

Transobturator urethral suspension surgical treatment of urinary incontinence in men.

INTRODUCTION: Urinary incontinence represents involuntary urethral loss of urine and represents a major health problem worldwide, mainly due to the psychosocial implications it determines. The surgical treatment of urinary incontinence in men is needed especially postoperatively, after radical retropubic prostatectomy, transurethral resection or vaporization of prostate, bladder neck incision etc. Surgical indications appear when all the other conservatory means of treatment have failed, including antimuscarinic medication or pelvic floor training. TECHNIQUE: The surgical procedure is similar to the one used for women, TOT to be more precise. The meshes are made of polypropylene, identical to those used for women or especially designed for urinary incontinence in men. The surgical technique can be "in-out" or "out-in" according to surgeon preferences. RESULTS: Postoperative recovery was fast and without major complications. The urethral catheter was removed 24 hours after the procedure and the patients were discharged 48-72 hours after surgery. After 30 days postoperative, urodynamics and abdominal echography showed no vesical residue. Success rate is about 80%. COMPLICATIONS: Intraoperative complications are minimal (urethral, vascular or vesical) and can be avoided in the hands of experienced surgeons. Mesh rejection and rupture or urethral erosion can occur as rare postoperative complications. CONCLUSIONS: Transobturator urethral suspension procedure proved to be efficient. It is a minimally invasive procedure, easy and with relatively short surgical time. Inbound time is short, making this procedure cost-effective.

Solitary ganglioneuromatosis of the descending colon, presenting as giant retroperitoneal tumour.

Ganglioneuroma (GN) is a benign neoplasia of the autonomous nervous system, colonic GN is uncommon in adults. There are three subgroups: polypoid GN, ganglioneuromatous polyposis and diffuse ganglioneuromatosis. Ganglioneuromatosis is highly-associated to neurofibromatosis type 1 (NF1) and multiple endocrine neoplasia type 2b (MEN2B). A 68-year-old female, with a discrete retarded emission of stools, was admitted for a large tumor in the left flank; CT scan, urography and barium enema demonstrated a large retroperitoneal mass, presumed as sarcoma. Open surgery discovered a 16 10 11 cm solid and encapsulated tumor, attached to the retroperitoneal descending colon, with no macroscopic mucosal involvement; the pathologic diagnosis of the resected specimen (en-bloc tumorectomy with limited colectomy) was intramural colonic ganglio-neuromatosis. Anamnesis, physical examination and complete endoscopic explorations showed no evidence of personal bearing or familial aggregation of genetic syndromes. In adults, association of transmural ganglioneuromatosis to NF1 or MEN2B is not mandatory; presentation often mimics obstructive carcinoma and positive diagnosis is provided by pathological examination of the resected specimen. In this peculiar case, the loose tissue of the retroperitoneal space favoured a slow development of intramural ganglioneuromatosis, presenting as a gigantic retroperitoneal mass with no radiological evidence of its colonic origin.

Surgical virtual reality - highlights in developing a high performance surgical haptic device.

Just like simulators are a standard in aviation and aerospace sciences, we expect for surgical simulators to soon become a standard in medical applications. These will correctly instruct future doctors in surgical techniques without there being a need for hands on patient instruction. Using virtual reality by digitally transposing surgical procedures changes surgery in are volutionary manner by offering possibilities for implementing new, much more efficient, learning methods, by allowing the practice of new surgical techniques and by improving surgeon abilities and skills. Perfecting haptic devices has opened the door to a series of opportunities in the fields of research,industry, nuclear science and medicine. Concepts purely theoretical at first, such as telerobotics, telepresence or telerepresentation,have become a practical reality as calculus techniques, telecommunications and haptic devices evolved,virtual reality taking a new leap. In the field of surgery barrier sand controversies still remain, regarding implementation and generalization of surgical virtual simulators. These obstacles remain connected to the high costs of this yet fully sufficiently developed technology, especially in the domain of haptic devices.

Paraneoplastic syndrome in primitive retroperitoneal tumours.

INTRODUCTION: Retroperitoneal tumours represent a particular oncological pathology. No other human pathology is so deceiving and scarce in specific clinical symptoms as these tumours. Usually borrowing the symptoms of nearby organs they are discovered in advanced or incurable stages. MATERIAL AND METHOD: We have tried to present to you the challenge of diagnosing some retroperitoneal tumours. One of the rarest signs was by far the paraneoplastic syndrome or the secretion of active biological substances. The study group is composed of histopatologically diagnosed patients. The vast majority were selected from urology and general surgery wards, but there were cases from gynaecology, neurosurgery and even from endocrinology and gastroenterology. RESULTS: Paraneroplastic syndrome represents the secretion of various substances by the tumour, substances that make changes at bioumoral level. In our study we found 3 cases of 32 patients (9,37%) with paraneoplastic syndrome. What is to be noticed is that because of this syndrome the diagnosis was more difficult and was indirectly referred to a retroperitoneal tumour. We would like to present these cases and their particularities. CONCLUSIONS: Every case was a surgical and diagnostic challenge. Biologic active substance secretion or the paraneoplastic syndrome makes the clinical picture even more complicated for primitive retroperitoneal tumours. The clinical symptoms of these tumours require a more careful approach of these patients. Close co-operation with other medical specialties in cases such as ours is mandatory.

Clinical importance of the determinant-based classification of acute pancreatitis severity.

PURPOSE: This classification should eliminate the confusion in terminology occurring over the last 20 years with direct implications in clinical practice. METHOD: The study was based on the web-based consultation of experts worldwide. 528 invitations were sent and 240 responses received from 49 countries from all continents. RESULTS: In an attempt to eliminate many confusions of the old classification, definitions that have built-in modern concepts of the disease have been issued, clinical evaluation of these severity has been improved and a standardized reporting data to objectively evaluate new treatments and to facilitate the communication of data between centers has been created. DISCUSSIONS: An ideal classification should reflect the whole area of clinical and paraclinical changes for one patient, at a given time. In the chosen classification, the main variable that characterizes the degree of severity is only the transitory or persistent organ dysfunction(s) failure(s). CONCLUSIONS: The most significant contribution to this update is redefining local complications based on their content,existence or non-existence of the wall, the place of their appearance and their evolution over time (local determinants).Systemic determinants take into account the presence of organ failures (transient or persistent). The presence of determinant factors has a cumulative effect.

The vascularization pattern of the colon and surgical decision in esophageal reconstruction with colon. A selective SMA and IMA arteriographic study.

INTRODUCTION: No matter the reconstructive technique, the fundamental concepts in visceral reconstruction have as main grounds the mandatory vascular support for the graft replacement. Individual vascular particularities can influence or even oblige the surgeon to choose a certain procedure. This is why the vascularization is beyond doubt the dominant factor in mobilizing the colon for reconstruction. MATERIAL AND METHOD: Our arteriographic study entails an investigation upon the vascularization pattern of the two main sources that participate in the arterial irrigation of the colon via the emerging vessels: superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). We did not consider certain patients upon a specific criterion; also, we did not exclude any patients due to various reasons. We took into account 49 patients as study group, all of them having registered into the clinic for a reconstructive technique, throughout the years from 2000 to 2010. From 1981 to 2012 there have been 187 reconstructive techniques performed due to post caustic pathology. From a total of 49 patients, 11 had suffered major abdominal surgeries, 5 of which had had unsuccessful reconstructive attempts. RESULTS: Out of the 49 patients on whom we have performed the exploration, arteriography showed a favorable situation for reconstruction in 31 of them. In the other 18 patients anomalies or atypical distributions were identified, in 5 of the SMA and in 13 of the IMA, respectively. Operative decision was modified in 22 patients. One important thing to note from the point of view of the segment to be moved: we had no graft necrosis in patients with preoperative arteriographic examination. CONCLUSIONS: Due to the need for good mobilization, arterial ligations should be adjusted and modified depending on the particular vascular distribution, to maintain a sufficient blood flow in the marginal artery, in order to reach the colic sections and the straight arteries near them.

Superior socio-medical alternative to feeding gastrostomy and jejunostomy in advanced esophago-gastric junction adenocarcinoma.

INTRODUCTION: The diagnosis of esophago gastric junction adenocarcinoma often occurs when the neoplastic process is surprised in advanced stages and blocks the esophageal-gastric junction causing dysphagia, stages in which curative therapy is more likely impossible to be accomplished. In these cases, the treatment goal is mainly to provide feeding capacity as naturally as possible and to start the adjuvant oncological treatment. The use of endoscopic esophageal prostheses provides the patient with the possibility to be fed orally and with a good social integration, but due to the technical incapacity to cross the tumoral stenosis with the endoscope, or due to the endoscopist s concerns regarding the sensitive areas (poles of the esophagus), there are reluctances in respect to this method (on average 20%). MATERIAL AND METHOD: We conducted a retrospective study aimed to determine the optimal therapeutic modality depending on the evolutive stages of the disease and to analyse the justification of the original procedure of laparogastroscopic esophageal stenting through tumoral drilling as a technical alternative to the reluctances or failures of endoscopic prosthesis and as a biological and social solution to the disabling gastrostomy for patients with advanced esophageal-gastric junction adenocarcinoma. RESULTS AND DISCUSSIONS: Staging was disarming, most patients were diagnosed in advanced stages, fact also supported by literature. Regarding esophageal stenting by transtumoral drilling, the results are significant especially in terms of postoperative morbidity CONCLUSIONS: Although our study regarding laparogastroscopic stenting by transtumoral drilling in esophago-gastric junction adenocarcinoma is limited, this original procedure brought us satisfaction whenever we used this approach.

Molecular factors and criteria for predicting the response to neoadjuvant treatment in patients with esophageal squamous cell carcinoma (ESCC) -- responder/non-responder.

UNLABELLED: Regarding the mortality causes, esophageal squamous cell carcinoma (ESCC) is on the 7th place in the US and the 6th place in the world, with 5 year overall survival rate of 14%, which is still modest in comparison to other digestive neoplasia. Multiples strategies were involved to improve this percentage, associating surgical procedures and chemo- and radio- oncologic therapies. The distant results showed sensitive improvement, after introduction of multimodality neoadjuvant therapies. MATERIAL AND METHOD: Fifty-seven patients diagnosed with ESCC were evaluated between 2006 and 2010, male preponderance (77%), average age of 55. A multimodality therapeutic protocol was used: first - radio-chemotherapy (RCT), second - surgery and/or third - chemo- or radiotherapy. Four weeks post RCT all patients were evaluated to determine the response to neoadjuvant treatment followed by surgery - esophageal resection. Histopathological (HP) and immunohistochemical (IHC) analysis of the pathological specimens were performed in order to identify the molecular predictors with responsive or non responsive character; the studied markers were p53 (Dako 1:50), Ki-67 (Biogenex, 1:20), c-erbB-2 (Dako, 1:250). Based on these results, the working model used to determine the response to neoadjuvant therapy was tumor regression grade (TRG). RESULTS: After HP and IHC examination, the patients were included in two groups: responders and non responders (tumor cells > 10%). Complete neoplasia sterilization was achieved in 5 of the patients. CONCLUSIONS: We are able to state that the identification of potential predictive markers along with HP and IHC results represents a great perspective alternative in the ESCC therapy outcome. The detection of molecular type aggressiveness of the neoplastic process allows therapeutic orientation or guidance to certain therapy sequences or even to specific molecular targeted treatments.

[Surgical treatment of esophageal diverticula]. / Tratamentul chirurgical al diverticulilor esofagieni.

The aim of this paper is to evaluate the methods and therapeutic principles of esophageal diverticula pathology. We analyze the main pathological mechanisms which establish the therapeutic attitude linked with a complex pretherapeutic evaluation. In our study we enrolled 12 patients operated between 2001-2009 for esophageal diverticula with different topography. In this period of time there were much more patients diagnosed with this pathology, but the need for surgery was establish very tight regarding the actual practical guide which impose the identification and interception of physiological mechanisms by the surgical procedure. We highlight the particular technical details, as well as the important differences of postoperatory complications according to the topography of the diverticula pouch.

[Factors involved in the pathogenesis of acute pancreatitis]. / Factori implicati în patogeneza pancreatitei acute.

Pathophysiological and molecular research have marked the understanding of the primary events taking place in triggering acute pancreatitis, although the early diagnosis of pancreas diseases in general, continues to be a source of frustration in modem medicine. This presents the news about pathogenesis (co-localization theory, auto-activation theory of the tripsynogen), location of early events (acinar pancreatic cells which are the "key" involved: muscarinic receptors, acinar membrane, role of ionized calcium, the phenomenon of apoptosis), extracellular events in initiation of acute pancreatitis with the granting of a central place to enzyme activation and systemic inflammatory response. Aspects of early microvascular changes, disturbances of ischemia-reperfusion and systemic microvascular abnormalities are so important that justifies therapeutic concept of microcirculatory protection. Participation of monocyte/macrophage system, excessive activation of leukocytes that involving activation and release of lysosomal enzymes and oxygen free radicals associated with ischemia-reperfusion mechanism are defining for pathogenesis of acute pancreatitis.

[Principles of treatment in locally advanced esophageal squamous cancer]. / Principii de tratament in cancerul esofagian scuamos avansat local.

The diagnosis established in the symptomatic phase of this disease, most often occurs at advanced stage neoplasia. The purpose of this article is to establish the place and method of surgical and radio-chemo therapy in advanced loco-regional squamous esophageal neoplasm (stage IIB-III). Surgical treatment establishes the best results over long periods of time, however, this is done keeping in mind acceptable morbidity and mortality conditions. Multimodal treatment is encompassed in general efforts to achieve optimal results along with increasing the quantity and quality of life. Neoadjuvant radiochemotherapy (CRT) increases practitioners' possibility of resecting tumors, decreasing their size, and establishing proper means of local (radiotherapy) and systemic (chemotherapy) control. Great efforts are made in finding markers which lead to correct diagnosis and treatment options that will further permit nonresponsive radio and chemo therapy treated patients from experiencing unwanted toxicity. The role of adjuvant therapy is that of decreasing recurrence in patients with residual mediastinal disease after palliative surgical resection. Palliative treatment consists of improving dysphagia, and the quality of life using surgical, endoscopic, photodynamic, laser, radio and chemotherapy as alternatives.