Complications of abdominal right-thoracic (Ivor Lewis) esophagectomy

Esophageal resection and reconstruction are associated with significant operative and postoperative morbidity and mortality. Careful evaluation of the patient's cardiopulmonary status; proper preparation of the patient with smoking cessation, exercise, and cardiopulmonary rehabilitation; assessment of the stage of disease; selection of a suitable operative technique; and meticulous attention to technical details help reduce the incidence of complications and ensure a successful outcome in this technically challenging procedure.     

A case of unusual complication of diaphragmatic herniation of transverse colon following transhiatal esophagectomy

The authors report a rare complication observed after transhiatal esophagus extirpation performed for esophageal cancer. In this case the transverse colon herniated into the pleural cavity through the esophageal hiatus. Herniation completed on the 6.th. postoperative day and caused mechanical ileus. In the first few postoperative days, radiology pointed to a basal pulmonal infiltrate, later it resembled relaxation of the diaphragm, which was rather misleading. Recognition of the real situation was possible only on the 6.th.postoperative day. The patient was reoperated and the pathological state could be reversed. The esophageal hiatus was reconstructed. In the opinion of the authors the complication may have developed partly due to the opening of the left pleural cavity in the course of extrathoracal esophagectomy, and partly to the fact that the spleen was removed during operation. The outcome after reoperation was uneventful. The authors consider this as a rather rare and instructive case.     

Total thoracic esophagectomy for esophageal cancer

BACKGROUND: Many current methods of esophageal resection have drawbacks that result in inadequate proximal resection, inadequate lymphadenectomy, and difficult gastric and splenic access. We describe a technique that allows reliable and safe access to the chest, abdomen, and neck. STUDY DESIGN: From 1988 to 1995, 113 patients (82 men; mean age 65.3 +/- 4.5 years) with carcinoma of the esophagus or esophagogastric junction (middle third in 34, lower third in 41, and cardia in 38) underwent total thoracic esophagectomy. The histology was adenocarcinoma in 71 (62.8%), squamous cell carcinoma in 32 (28.3%), and undifferentiated carcinoma in 10 (8.9%) of the patients; 57 tumors (50.5%) were stage III. The esophagus and stomach were mobilized through a left thoracoabdominal incision. After completion of the esophageal resection, the fundus of the stomach was sutured to the esophageal stump to allow later delivery of the stomach into the neck. The esophagogastric anastomosis was performed with continuous single-layer absorbable suture through a left oblique cervical incision. RESULTS: The mean duration of the operation was 309.2 +/- 47.9 minutes. Hospital stay ranged from 5 to 49 days (median, 12 days). The perioperative mortality rate was 4.4%. Anastomotic leak occurred in six patients (5.3%), one of whom died. The proximal resection margin was microscopically free of tumor in all cases, and with a minimum followup period of 18 months, there has been no anastomotic recurrence in any patient. Actuarial survival at 1 year was 63.4% +/- 4.9%, at 3 years 41.4% +/- 5.9%, and at 5 years 22.7% +/- 6.3%. CONCLUSIONS: Total thoracic esophagectomy through the left chest with a separate left cervical incision allows clear access to the esophagus and stomach and good tumor clearance. This procedure may be performed with a low rate of anastomotic leakage, a very low mortality rate, and no anastomotic tumor recurrence.     

A comparison of transhiatal and transthoracic resection for oesophageal carcinoma

We compared the results of 327 transthoracic (TT) resections and 82 transhiatal (TH) resections for carcinoma of the oesophagus operated on between July 1982 and June 1991. Significantly more patients with carcinoma of the lower third of the oesophagus (54% versus 28%) and with increased pulmonary risks for surgery (61% versus 22%) were selected for the TH approach as compared with the TT approach. Results showed comparable intraoperative complications between the two groups. 5% of patients in the TH group required a thoracotomy for control of haemorrhage (3 patients) and repair of bronchial tear (1 patient) which occurred during the transmediastinal dissection. Postoperatively, mechanical ventilation requirement and complications involving the cardio-pulmonary systems were similar between the two groups. Anastomotic leakage occurred in 3% and 4%, respectively for the TH and TT patients (p = NS), whereas hoarseness occurred in 16% and 5%, respectively (p = 0.001). The 30-day mortality rates and hospital mortality rates were comparable between the two groups as were the overall survival rates. Our results suggested that while TH resection did not diminish the operative morbidity and mortality rates overall, it is appropriate for patients with increased pulmonary risks to be preferentially selected for this approach, and for tumours located in the upper and lower portion of the thoracic oesophagus where dissection of the tumour can be carried out mostly under vision.     

Effects of en bloc esophagectomy on nutritional and immune status in patients with esophageal carcinoma

We tested the hypothesis that extravascular adenosine induces the release of vasodilatory products from endothelial cells lining skeletal muscle vessels. Endothelium-intact (n = 35) and -denuded (n = 5) dog semitendinosus intramuscular arteries were isolated, cannulated, and placed in 100-mL baths containing Krebs-Henseleit bicarbonate buffer (Krebs) at 37 degrees C and gassed with 95% O2--5% CO2. Each vessel, as well as a parallel tubing segment (avascular control), was perfused at 3.5 +/- 0.2 mL/min (inflow pressure 94 +/- 2 mmHg; 1 mmHg = 133.3 Pa) with Krebs containing 100 microM phenylephrine, 6% dextran, and 15 units/mL superoxide dismutase. Perfusate from all segments dripped onto endothelium-denuded dog femoral artery rings. The addition of 10 microM acetylcholine to the perfusate to test the functional integrity of endothelium-intact donor segments did not alter resistance in vessel segments or change force in rings. The addition of 100 microM adenosine to the extravascular bath decreased resistance 1.5 +/- 0.4 mmHg.mL-1.min-1 in vessel segments but was without effect on downstream rings. When acetylcholine was retested in the presence of extravascular adenosine, a relaxation (16 +/- 6%) occurred in rings receiving perfusate from endothelium-intact segments but not endothelium-denuded or tubing segments. This relaxation was eliminated by N omega-nitro-L-arginine (10 microM), a nitric oxide synthase inhibitor, and was attenuated to 4 +/- 1% by 8-phenyltheophylline (10 microM), an adenosine receptor antagonist. Thus adenosine, in conjunction with acetylcholine, acting through a receptor-mediated event, resulted in the release of nitric oxide from the endothelium of perfused intramuscular arteries, indicating the potential for extravascular conditions to influence the release of endothelium-derived products.     

Extrathoracic esophagectomy in the treatment of esophageal cancer

Extrathoracic esophagectomy has the potential of improving the results of resectional therapy for carcinoma of the esophagus by eliminating the need for thoracotomy and decreasing postoperative pulmonary complications. This report compares the operative and functional results of blunt extrathoracic esophagectomy and substernal reversed gastric tube reconstruction in patients with esophageal cancer to results in 10 consecutive nonrandomized control patients treated by standard esophagogastrectomy. Extrathoracic esophagectomy was associated with greater pulmonary dysfunction than standard esophagogastrectomy. While there was no significant difference in survival in the two groups, three patients in the standard esophagogastrectomy group (mean survival 9.0 months) and none in the extrathoracic esophagectomy group (mean survival 7.4 months) developed anastomotic recurrence. Extrathoracic esophagectomy evidently does not afford patients with esophageal carcinoma better palliation than standard esophagogastrectomy.     

A new surgical management of esophageal stenosis without esophagectomy

In many cases, reflux esophagitis following surgical treatment for esophageal stenosis is caused by the recurrence of that after esophagectomy and esophogogastrostomy. We performed a new management without esophagectomy for a 66-year-old man with sliding hiatal hernia and esophageal stenosis induced by reflux esophagitis. A Expanding Metalic Stent (MES) was inserted to the stenotic portion of the esophagus, and then Collis-Nissen's procedure was done through left thoracotomy and phrenotomy. The postoperative course was satisfactory, and no gastroes-ophageal reflux was detected with the use of 24h pH-monitoring of the esophagus after surgery.     

The role of esophagectomy in the management of esophageal perforations

BACKGROUND: Despite the many advancements made in thoracic surgery, the management of patients with esophageal perforation remains problematic and controversial. METHODS: Between 1985 and 1995, 27 esophagectomies were performed for perforation of the thoracic esophagus. A retrospective review of the records of these patients was carried out, and a scoring scale developed by Elebute and Stoner to grade the severity of sepsis was applied. RESULTS: Among the 27 patients undergoing esophagectomy for a perforation, the interval between rupture and esophagectomy was less than 24 hours in only 11 patients (40.7%). Postoperative surgical complications occurred in 4 patients (14.8%) and nonsurgical complications, in 7 (25.9%). The hospital mortality rate was 3.7% (1/27). In 14 patients, primary reconstruction was performed in the bed of the excised esophagus. There were no anastomotic leaks in this subgroup. This suggests that an anastomosis between viable, well-vascularized tissues is more important for successful healing than avoidance of some degree of contamination of the adjacent mediastinum. On follow-up, which averages 41 months, 73% of patients (16/22) have neither symptoms nor complaints. CONCLUSIONS: Esophageal resection definitively eliminates the source of intrathoracic sepsis, the perforation, and the affected esophagus. Reconstruction carried out in one stage does not increase operative morbidity. Esophageal resection and reconstruction is a valid approach even in cases of spontaneous perforation in which the diagnosis is markedly delayed.     

Neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy or surgery for operable thoracic esophageal carcinoma

PURPOSE: A prospective clinical trial was undertaken to investigate the feasibility of concurrent chemoradiotherapy for esophageal carcinomas. MATERIALS AND METHODS: Between June 1989 and May 1996, forty patients with operable squamous cell carcinoma of the thoracic esophagus (Stage 0 to III: UICC 1987), ages 45 to 78 years (mean: 64), were enrolled in a study of neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy (CRT group) or surgery (CRT-S group). Neoadjuvant chemoradiotherapy consisted of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 Fr/day) through 10-MVX rays, with 2 courses of cisplatin (80-100 mg/body, mean: 60 mg/m2, Day 1, bolus injection) and 5-fluorouracil (500-1000 mg/body/day, mean: 400 mg/m2, Days 1-4, continuous infusion). After completion of neoadjuvant chemoradiotherapy, an intermediate clinical response was assessed by barium swallow, esophagoscopy with/without biopsy, EUS in most cases, thoracic and upper abdominal CT scan, and cervical US. Definitive chemoradiotherapy was performed in patients when regression of more than 75% was evident (CRT Group), and esophageal resection was indicated in those who remained at less than 75% (CRT-S Group). In CRT Group, a cumulative dose of 60-70 Gy for Tis, T1 and 65-75 Gy for T2-T4 tumor with high-dose-rate intraluminal brachytherapy and a total of 3 courses of chemotherapy were planned. In CRT-S Group, intraoperative radiotherapy for abdominal lymphatic system and postoperative supraclavicular irradiation were added. RESULTS: At the time of intermediate assessment, complete response (CR) was observed in 16 patients, a partial response (PR) in 22, and no change (NC) in 2. Thirty responding patients (CR, 16; PR, 14) entered the CRT Group, and 10 nonresponding patients (PR, 8; NC, 2) were followed by surgery (CRT-S Group). Radiotherapy was completed satisfactorily, but chemotherapy was suspended in 26 patients (65%) because of acute toxicity. Clinical CR rate at the completion of treatment showed 90% in CRT Group, and pathologic CR rate 10% in CRT-S Group. The overall median survival was 45 months, survival at 1, 2, and 3 years being 100%, 72%, and 56%, respectively. Local-regional failure was observed in 7 patients (all in CRT Group), distant failure in 6 (3 in CRT Group, 3 in CRT-S Group) and local-regional with distant failure in 1 (CRT Group). Four patients with local-regional recurrence in the CRT Group were salvaged by surgery. Overall survival at 2 and 3 years for CRT vs. CRT-S Group was 72%, 64% vs. 75%, 38%, respectively. No treatment-related mortality was observed. The rate of the 'esophagus conservation' was 65% (Stage 0: 1 of 1, 100%; Stage I: 11 of 12, 92%; Stage II: 8 of 17, 47%; Stage III: 6 of 10, 60%). CONCLUSION: Our results demonstrated that almost all early disease (Stage 0-I) and about half of advanced disease (Stage II-III) could be conserved, their esophagus treated by the multidisciplinary approach centering on high-dose radiotherapy and concurrent chemotherapy.     

Development of synchronous bilateral lung cancers after esophagectomy for esophageal cancer: report of a case

It is well known that squamous cell carcinoma of the esophagus can be associated with carcinoma of other organs. We report herein the rare case of a 60-year-old man who developed synchronous bilateral lung cancers after undergoing esophagectomy for esophageal cancer. Staged bilateral lobectomy was successfully performed to minimize respiratory complications 3 years after his esophagectomy. This case report serves to demonstrate that aggressive and careful surgical approach with adequate followup offers the chance of long-term survival for patients with multiple primary cancers.     

Endoscopic ultrasonography for preoperative staging of esophageal carcinoma

OBJECTIVE: The objective was to determine the frequency with which regression or progression of disease without treatment occurred in women diagnosed with squamous cell cervical carcinoma in situ (CIS) during pregnancy. METHODS:. A retrospective chart review of all women evaluated at the University of Iowa Colposcopy Clinic diagnosed with CIS during pregnancy from 1987 through 1992 was used. Thirty-four women were evaluated during pregnancy, of which 26 also had postpartum evaluation. All pathology reports of initial cytology and biopsies, as well as colposcopic impressions, were reviewed and compared to the same evaluations postpartum. RESULTS: Of the 26 women evaluated both antepartum and postpartum, only 1 was treated (cone biopsy) during pregnancy. She had disease suspicious for microinvasion. She was disease free postpartum. Of the remaining 25, 20 (80%) had persistent disease, 2 (8%) had either missed disease or progressive disease postpartum, and 3 (12%) resolved without treatment at postpartum evaluation. No statistical significance was found between route of delivery and persistence (P = 0.34). No statistical significance was found between smoking and persistence of disease (P = 1.0). In 46% of women the initial cytology was CIN I or II, and the initial colposcopic impression was found to underestimate the severity of the disease in 35% of cases. Two women were found to have invasive disease postpartum. CONCLUSIONS: There is a high persistence rate of CIS complicating pregnancy. Given the relatively high rate of underestimation of disease severity by both cytology and colposcopic impression, the use of routine biopsy at the time of colposcopy is recommended. Invasive disease may be encountered on postpartum evaluation.     

Combined lung resection for advanced thoracic esophageal carcinoma

We performed lung resection together with esophagectomy in 2 patients with advanced thoracic esophageal cancer. Both patients survived more than 2 years with no evidence of disease. The first case was a 60-year-old man who had a cancer lesion in middle of the intra-thoracic esophagus (Im) and the right lower lobe of the lung was involved. In March 1989, right lower lobectomy of the lung was performed with esophagectomy. Pathologic examination showed well differentiated squamous cell carcinoma invading the lung parenchyma and intrapulmonary lymph node. Postoperatively, 44 Gy of radiation and Peplomycin cancer chemotherapy was performed. The patient survived 51 months after surgery and died of chronic myelogenous leukemia. The second case was a 60-year-old man who underwent thoracic esophagectomy with resection of the involved pericardium and right lung in February 1992. Pathologic examination showed N3 lymph node metastasis. Postoperatively, the patient received 48 Gy of radiation and was free from cancer after 30 months. In conclusion, better surgical results are expected in cases of advanced thoracic esophageal cancer with lung involvement which can be completely resected en bloc with the primary tumor even in a3 cases than in those with aortic or tracheobronchial involvement.     

食管癌后程三维适形放疗的临床疗效评价

Objective:The aim of our study was to evaluate the clinical results and acute side effects of late course three-dimensional conformal radiotherapy (3DCRT) for esophageal carcinoma.Methods:From January 2004 to October 2006,70 patients with esophageal carcinoma received late course 3DCRT.Their clinical data were analyzed retrospectively.The short-term clinical results,acute side effects,local control rates and survival rates were evaluated.Results:The complete response rate was 62.9%,partial response rate was 35.7%,and the overall response rate was 98.6%.The 1-,2- and 3-year local control rates were 77.1%,51.4% and 45.7%,respectively.The 1-,2- and 3-year overall survival rates were 75.7%,54.3% and 38.6%,respectively.The median survival time was 26 months.Conclusion:The technique of late course 3DCRT is an effective treatment for esophageal carcinoma and tend to improve the overall survival rate.     

Esophageal perforation following use of esophageal airway

The esophageal airway has gained increasing acceptance in airway management during cardiopulmonary resuscitation, and its enthusiastic advocates are urging expansion of its use. A fatal case of esophageal perforation following the use of an esophageal airway is presented. Possible contributing factors are discussed. A modified esophageal airway which seems safer and more versatile, effective, and economic is described.     

Biobehavioral outcomes following psychological interventions for cancer patients.

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Programming for occupational outcomes following traumatic brain injury.

Examines the occupational outcomes reported from 3 traumatic brain injury (TBI) rehabilitation models: comprehensive neuropsychological rehabilitation, comprehensive neuropsychological rehabilitation and occupational trials, and supported work. It is argued that programming for occupational entry or reentry must include precise specification of barriers to rehabilitation outcome goals and systematic planning for skill generalization and maintenance. The Barriers Profile and the New Medico Barriers to Anticipated Rehabilitation Outcomes Scale are offered as tools to assist interdisciplinary treatment teams in identifying the number and magnitude of personal and environmental barriers to occupational resettlement; their use is illustrated with a case example. Procedures for enhancing generalization and maintenance of treatment goals are discussed. A comment by T. Kay follows. (PsycINFO Database Record (c) 2010 APA, all rights reserved)