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Reappraisal of esophagogastrectomy for esophageal malignancy
Reappraisal of Esophagogastrectomy for Esophageal Malignancy V. A. Piccone, MD, Brooklyn, New York H. H. LeVeen, MD, Brooklyn, New York N. Ahmed, Brooklyn, New York S. Grosberg, MD, Brooklyn, New York
Esophageal carcinoma is one of the most difficult malignancies to cure, and almost as frustrating to palliate. It constitutes 1 per cent of all cancer in North America. The typical lesion is a squamous carcinoma. The proximity to adjacent structures and the lack of a separating membrane account for the propensity to contiguous spread. The distensibility of the esophagus when the tumor is limited to a part of the circumference delays the onset of obstruction until the tumor is far advanced. Thus, therapy is often palliative rather than curative. The rationale for the shift from treatment almost exclusively by surgery in the 1949-1956 era to treatment mainly by radiotherapy in the 1965-1975 era was based on the high surgical mortality [1-31 reported in studies that predated the extensive modern radiotherapy experience and were related to the early surgical trials. The continuing lack of prospective randomized studies comparing radiation and surgery perpetuates the unhappy dependency on retrospective analysis and historical comparisons. Nevertheless, our four-
teen year clinical experience with radical surgery as the primary therapy allows reevaluation of esophagogastrectomy in light of the surgical technology of the 1960s and 1970s. We are reporting the present experience because the data indicate, within the limits of retrospective analysis, that current surgical therapy offers better palliation than does radiation therapy alone, especially for midthird lesions.
From the Departments of Medicine and Surgery, Brooklyn Veterans AdministrationHospital and Downstate Medical Center, State University of New York, Brooklyn, New York. Reprint requests should be addressed to V. A. Piccone, MD, Dapartment Of Medicine, Brooklyn Veterans Administration Hospital, 300 Poly Place, Brooklyn, New York 11209. Presented at the Nineteenth Annual Meeting of the Society for Surgery of the Alimentary Tract, Las Vegas, Nevada, May 23-24, 1973.
32
Material and Methods Eighty-nine patients were referred for radical surgical treatment of esophageal carcinoma from July 1965to May 1978. The clinical problem was obstructive esophageal malignancy without spread to superficial regional nodes, lung, bones, or other distant areas and without vocal cord paralysis, pleural effusion, or ascites. Patients with disseminated malignancy were provided less formidable, but less effective, palliative procedures and are not the subject of this report. The most frequent symptoms were progressive dysphagia and weight loss. Dysphagia was usually of at least two months’ duration, and weight loss prior to hospital admission averaged 20 pounds. The average age was 62.2 years, and all patients were in the sixth to eighth decades. Excessive use of alcohol and tobacco was common. The esophagus appeared abnormal on fluoroscopic contrast visualization with Gastrografine or barium in all eightynine patients, and the findings usually were suggestive of malignancy. The definitive diagnosis was established by esophagoscopy and biopsy in most patients, although acquisition of a surgical specimen was necessary in some instances. Thorough preoperative evaluation revealed no distant metastases, except for eighteen patients with radionuclide liver scans suggestive of hepatic involvement. Liver scans which were inconclusive or only suggestive of metastases did not exclude radical surgery because of the frequent false-positive result in cirrhotic patients. The pathology of these esophageal lesions is summarized in Table I. The usual preponderance of epidermoid carcinoma is evident. However, the thirteenth reported primary malignant melanoma and the first primary plasmacytoma demonstrate the minimal potential for diverse histopathology. Midesophageal lesions seemed more frequent than in most studies, because patients with upper gastric carcinomas and malignancies of the cervical esophagus were not referred to the thoracic surgical service. Most adenocarcinomas were located in the lower esophagus close to the gastroesophageal junction. Direct invasion of contiguous structures or lymphatic spread to regional nodes was
The American Journal 01 Surgery
Esophagogastrectomy
TABLE I
Histopathologic Type and Distribution-Esophageal
Malignancies No. of Patients with Esophageal Lesions
Histologic Type
Upper Third
Middle Third
Lower Third
Squamous cell carcinoma Adenocarcinoma Anaplastic carcinoma Malignant melanoma (primary) Plasmacytoma (primary) Mixed (squamous and adenocarcinoma)
2 1 0 0 0 0
43 2 5 0 0 1
20 7 0
Total
3
51
29
in almost all patients (stage IV), indicating the advanced nature of the disease at the time of initial clinical presentation. present
1 1 0
Total 65 (78%) 10 (12%) 5 (6%) 1(1.2%) 1(1.2%) 1(1.2%) 83
cuff of stomach up onto the esophagus to cover the anastomosis and to prevent reflux, and sutures of the stomach up to the pleura and neighboring fascia to prevent tension on the anastomosis. (Figure 1C.)
Operative Technic
Radical resection and restoration of gastrointestinal continuity by intrathoracic esophagogastrostomy was performed using the combined abdominal and right thoracic approach described by Lewis [4], except that both stages were completed in a single operation. The right thoracotomy allowed extension of the esophageal resection as high as necessary without being hampered by the aortic arch and eliminated the need for an incision of the diaphragm or costal arch. Modification for high intrathoracic esophageal lesions included continuation of the dissection through the thoracic outlet and performance of the esophagogastrostomy through a cervical incision. The first stage was performed with the patient supine and using a high midline incision extended upward alongside the xiphoid. After abdominal exploration, the stomach was freed of its omental attachments and prepared for transposition by carefully preserving the right gastric and gastroepiploic arteries. (Figure 1A.) The spleen was removed only if there was extension of the tumor to the spleen or if the nodes in the gastrosplenic ligament were involved with tumor. Mobilization of the duodenum from the inferior vena cava and the aorta provided excellent upward mobility of the duodenum and head of the pancreas. Pyloroplasty was performed only if the pylorus was abnormally narrowed. The left gastric artery was divided at its origin after stripping off involved lymph nodes, so that communications with the right‘gastric artery were preserved. Residual tumor was left in the celiac area if a large cluster of nodes made removal difficult. A 1 cm incision in the fibrous insertion of the diaphragmatic crura, anterior to the esophagus, insured adequate drainage of the stomach. The thoracic part of the operation was performed using a standard right posterolateral thoracotomy with subperiosteal resection of the fourth rib. The esophagus was excised to a distance of 4 cm above palpable tumor. (Figure 1B.) For midesophageal lesions care is necessary in dissecting the tumor from the membranous portion of the trachea and bronchi, the pulmonary veins, the left atrium, and the aorta. Esophagogastrostomy was performed using the apex of the cardia, a two layer anastomosis, a telescoped
Volume 137, January 1979
Results
Resectability. Excision of the esophagus and reconstruction by esophagogastrostomy was accomplished in eighty-one of the eighty-nine patients. The overall resectability rate was thus 93 per cent. All tumors in the middle and upper third of the esophagus were successfully resected despite invasion of contiguous structures in 60 per cent and nodal involvement in 75 per cent. Resection was less predictively accomplished for the thirty-five patients with lower third lesions. Intervention was limited to a feeding gastrostomy in six patients because of tumor spread along the lesser curvature, invasion of the posterior peritoneum, and multiple hepatic metastases not evident prior to operation. Esophagogastrectomy was extended to include hemipancreatectomy, transverse colectomy, and splenectomy in two other patients, so that the resectability rate by standard esophagogastrectomy for lower third lesions was only 77 per cent (27 of 35). Operative Mortality. (Table II.) The thirty day mortality for the eighty-one patients undergoing esophagogastrectomy and reconstruction by intrathoracic esophagogastrostomy, the standard procedure, was 4.9 per cent. Inclusion of the two deaths in the patients with extended radical procedures would increase the mortality to 7.2 per cent. Resection of midthird lesions was accomplished with a 3.9 per cent mortality. The mortality for resection of twenty-seven lower third lesions was 7.4 per cent, excluding the two extended radical procedures. The causes of death are listed in Table III. Anastomotic Disruption. Postoperative contrast visualizations before commencement of oral feedings approximately twelve days after surgery proved anastomotic integrity in all patients with uncom-
33
Piccone et al
r
Figure 1. Technical details of the esophagogastrectomy.
34
plicated malignant obstruction, thus eliminating disruption as a cause of operative (30 day) death. The anastomosis probably leaked in a patient with achalasia who underwent resection because of hemorrhage and infection. An unsuspected concomitant esophageal carcinoma had eroded into the chest wall, exposing ribs and causing hemorrhage. Empyema complicated the postoperative course, and during the second month gastric contents appeared in the chest tube drainage. Continued leakage and infection eventually resulted in death. Postoperative x-ray films showed an apparent narrowing of the lower esophagus in most patients with the telescoped type of esophagogastric anastomosis. However, narrowed distal esophagus was distensible and did not cause dysphagia. This narrowed appearance was seen in late survivors as long as six years after surgery. (Figure 2.) Need for Pyloroplasty. Gastric retention did not complicate deletion of pyloroplasty. Radiologically detected delay in gastric emptying occurred in three patients, but later studies showed a return to more rapid gastric emptying in two patients. The third patient was recently resected and has not been studied at a later interval. Two patients have complaints consistent with reflux esophagitis. The 12 hour gastric analyses of five survivors are seen in Table IV. Palliation and Quality of Life. Dysphagia was relieved and oral alimentation restored in the 95 per cent of patients who survived the standard esophagogastrectomy. Appetite returned to normal only in the small number of long-term survivors who also maintained normal weight. Most patients continued to lose weight and before the introduction of intravenous hyperalimentation, lost an average of 18 pounds during the first postoperative month. Prehepatic intravenous hyperalimentation [5], used during the past three years, has reduced weight loss during the first postoperative month substantially; some patients have gained weight. Intravenous hyperalimentation is optimal in these patients, since the inadequate oral ingestion guarantees essential fats and trace elements, thus minimizing hyperalimentation problems. The excellent palliation of surgery is evident in the complete absence of aspiration pneumonia, tracheoesophageal fistula, esophageal or anastomotic stricture, erosion into aorta, or recurrent malignant obstruction. Most of the patients, who would have died of aspiration pneumonia if treated by radiation alone, eventually died of distant metastases. The patients who died within three months were for the most part those with hepatic metastases, and
The American Journal oi Surgery
Esophagogastrectomy
TABLE II
Postoperative (30 day) Mortality to Procedure Performed Location of Tumor
Esophagogastrectomy Upper third Middle third Lower third Total Esophagogastrectomy, hemipancreatectomy, transverse colectomy and splenectomy Lower third Gastrostomy Lower third
according
Deaths
o/3 2151 (3.9%) 2129 (6.9%) 4f63 4.6%
212 (100%) 016
these patients did not receive major benefits from surgery. Excellent palliation was achieved in the 70 per cent who survived beyond three months. All who lived beyond one year but who were not cured enjoyed uncomplicated oral alimentation for the remainder of their lives, and like almost all resected patients, died of distant metastases. The six patients who lived beyond five years enjoyed uncomplicated oral alimentation. Survival. The survival curves are shown in Figure 3. Five late survivors died of unassociated medical problems, and two five year survivors died of a cerebrovascular accident and a myocardial infarction. The mean survival was 10.9 months. The survival of patients with liver metastases was 3.5 months. The mean survival of patients with spread to contiguous structures and regional lymph nodes, but without hepatic involvement, was 9 months.
TABLE III
Postoperative
(30 dav) Mortalitv-Causes No. of Patients
Causes Pulmonary complications Pulmonary embolism Cardiac arrest Necrotizing hemorrhagic pancreatitis Hepatic metastases and progressive liver failure Anastomotic leak Note: POD = postoperative
Interval from Surgery
2 1 1 1
POD POD POD POD
2 and 4 9 14 14
1
POD 14
0 day.
In addition, experience with several types of indwelling tubes was gained [IO]. By the late 196Os, comparative studies were beginning to suggest better palliation from surgery than from radiotherapy even with midthird lesions [II]. Moreover, the effect of combined radiotherapy and surgery [12] on longevity seemed minimal at best, and the general results of treating esophageal malignancy remained grim. Today, palliative treatment remains the primary goal, and the comparison is still basically between radiotherapy and surgery. Esophagectomy and intrathoracic esophagogastrostomy in these eighty-three patients provided better palliation than did radiotherapy alone. Esophageal obstruction was relieved in all of the 95
Comments
Treatment of esophageal malignancy has been characterized by slow change and dismal results. The first large scale trials of surgery realized a 20 to 50 per cent mortality [I-3], and the mortality for midthird lesions was especially high. However, the shift to radiation therapy, which quite naturally followed in the 195Os, provided little cause for optimism. Obstruction was often not relieved, and lethal tracheoesophageal fistulas were common. The need for better palliation and longer survival remained obvious. Pearson [6] commented that the results of radiotherapy were distinguished only by being less disastrous than primary surgical treatment. The results of radiation therapy became more reproducible with the introduction of megavoltage radiation. At the same time the operative mortality was becoming lower because of rapid advances in thoracic surgery. The improved safety of surgery prompted trial of colon bvpass [7], extrapleural anterior esophagogastrostomy [S], and gastric tubes [9].
Volume 137, January 1979
Figure 2. Contrast visualization of the esophagogastric anastomosis demonstrating the reflection of the stomach up info the esophagus, in fhls instance similar fo normal the esophagogastrlc junction.
35
Piccone
et al
TABLE IV
12 Hour Gastric Analysis After Esophagogastrectomy Total Volume (cc)
Free Hematocrit
Patient
Interval from Surgery
b-w$l)
@WV
FL PS JC WT HD
5yr2mo 6yr3mo 2mo 2mo 2mo
90 75 350 300 400
4o” 5o” 0 0 0
65“ 7o” loo 16’ 2o”
Total Acidity
per cent of patients who were resectable, whereas radiation is generally credited with relieving obstruction in only 70 per cent of patients [13,14]. The thirty day mortality of 7 per cent for surgery, a figure taken as representative of today’s technology, is less than that occurring from the aspiration pneumonia and tracheoesophageal fistulas associated with radiotherapy. The additional serious morbidity of radiation therapy, including nonfatal aspiration pneumonia (15 per cent), nonfatal tracheoesophageal fistulas (10 per cent), mediastinal perforation (13 per cent), radiation myelitis of the spinal cord, stricture, hemorrhage, and constrictive pericarditis [13,14], are far more frequent than postoperative atelectasis, pneumonia, and embolism. Although surgical patients rarely realize a return of appetite, they enjoy unimpaired oral alimentation for the remainder of their lives and die of distant metastases [II]. Radiotherapy is saddled with far more frequent recurrent malignant obstruction, final reliance on gastrostomy, and the high incidence of death by pneumonia from aspiration or tracheoesophageal fistulas. The palliative value of esophageal resection and intrathoracic esophagogastrostomy in these eightythree patients was also more satisfactory than in our previous experience with resection and anterior colon bypass gastrostomy and the various esophageal tubes. Esophageal resection and colon bypass has a surgical mortality of 15 to 25 per cent [15,16], has three anastomoses at risk, and poses the problems of inadequate vasculature, less dependable anastomotic healing, and greater chance of infection [I&16]. Reversed gastric tubes of the Gavriliu type often leak at the anastomosis, and many patients die before completion of both stages. Prosthetic tubes (Celestin and Meckler) have a relatively high mortality (to 14 per cent) [IO] and are complicated by obstructing food, erosion into adjacent structures, migration, and tumor overgrowth in an additional 25 per cent of patients. The survival time is only half as long as with resection, and food ingestion is limited to fluids that can pass through the tube. Gastrostomy does little
36
Figure 3. Long-term survival for esophagogastrectomy.
to relieve aspiration of saliva. Substernal gastric bypass probably has a special role in prevention of gastric reflux through malignant tracheoesophageal fistulas [17] but in general is not preferred, because removal of the main tumor mass may alter the response of the host to the tumor. Resection with intrathoracic esophagogastrostomy had almost no serious physiologic complications and was optimal for the group who survived beyond the first two postoperative months. The reduction in surgical mortality for midthird lesions is the most striking difference between the most recent and the earlier surgical reports. Nakayama [8], Mosely [2], Collis [29], Sweet [21], and Lortat-Jacob, Maillard, and Fekete [20] reported surgical mortalities of midthird lesions to be two and three times those of lower third lesions. Surgical mortalities of up to 50 per cent offered little choice but to favor radiotherapy. The 3.9 per cent mortality in the present report is an acceptable surgical mortality and confirms that reported by others [I 11, and we believe it to be representative of current surgical technology. The second important change in the operative treatment of midthird lesions is the dramatic increase in the resectability rate. The often stated objection to separate abdominal and right thoracic incisions was the futility of exploring the chest to find a tumor that would not permit even palliative removal after all the technical details of the abdominal operation. To the contrary, the thoracic esophagus could always be removed in the fifty-one patients with midthird lesions encountered in our experience. The high resectability rate of 100 per cent reflects the realization that residual tumor is best left on the membranous portion of the trachea or major bronchi to avoid inadvertent opening into the airway. This not only allows resection but is safe and seems to have prevented the gastroesophageal fistulas seen in the natural course of the disease or associated with radiotherapy. Right thoracotomy contributed to the
The American Journal of Surgery
Esophagogastrectomy
successful management of midthird lesions by providing easy access to the midintrathoracic esophagus during resection and the upper third for reconstruction. The resectability rate was higher for midthird lesions because lower third lesions sometimes directly involved the liver, diaphragm, and retroperitoneal structures. The low surgical mortality of the past decade, the high resectability rate of 100 per cent, the low rate of anastomotic leakage that can be achieved, the usual success in restoring oral alimentation, and the low incidence of serious complications usually associated with radiotherapy are compelling reasons for a shift to surgical therapy for midesophageal lesions. The true extent of esophageal cancer at the time of diagnosis, wherein the tumor is confined to esophagus in only 20 per cent of patients, seems to preclude improvements in survival until some therapy for disseminated disease becomes available. The survival curves of this and other recent studies are difficult to validly compare because of the different extents of tumor. Pearson’s [18] radiotherapy study did not include patients with tumor infiltrating the trachea and bronchi, those with remote lymphatic metastases, or patients with demonstrable liver metastases, whereas the present study was primarily concerned with palliative relief of obstruction and therefore included patients with far advanced disease. The short survival of the patient resected in the face of liver metastases does not justify such major surgery, and insertion of an indwelling tube would be appropriate. In the absence of hepatic involvement, survival after surgery alone or radiotherapy alone appears similar. The improved quality of life following surgery is dramatically different and a compelling advantage. Summary
Esophagogastrectomy performed in eighty-three patients with a thirty day mortality of 7 per cent, a resectability rate of 93 per cent, and no anastomotic leakage, provided dependable relief of malignant obstruction and restored oral alimentation in all surviving patients. Long-term survival was unchanged. The successful resection of all midthird lesions with a 3.9 per cent mortality reflects the capability of current surgery and suggests that surgical palliation of midthird esophageal tumors is preferable to radiotherapy alone. References 1.
MacManusJE,
Paine JR, Dunn J, Merdinger W: Carcinoma of the esophagus; report of cases: 1947 to 1953. Surgery40: 510. 1956.
Volume 137, January 1979
2. Moseley RV: Squamous carcinoma of the esophagus. Surg Gynecol Obstet 126: 1242, 1966. 3. Mullard KS: Carcinoma of oesophagus treated by excision. Lancet 1: 677, 1970. 4. Lewis I: Surgical treatment of carcinoma of esophagus with special reference to new operation for growth of middle third. Br J Surg 2: 18, 1946. 5. Piccone VA, LeVeen H, Berlyne G, et al: Prehepatic hyperalimentation. J Surg Res (In press.) 6. Pearson JG: Cancer of the gastrointestinal tract. II. Esophagus: treatment-localized and advanced. Value of radiation therapy. JAMA 227: 161, 1974. 7. Belsey R: Reconstruction of the esophagus with left colon. J Thorac Cardiovasc Surg 49: 33, 1965. a. Nakayama K: Radical operations for carcinoma of the esophagus and cardiac end of the stomach. J Int Co// Surg 2 1: 5 1, 1954. 9. Gavriliu D, Georaescu L: Esotagoplastic viscerala directa. Chirurgie 4: 104, 1955. 10. Girardet RE, Ransdell HT Jr, Wheat MW Jr: Palliative intubation in the management of esophageal carcinoma. Ann Thorac Surg ia: 417, 1974. 11. Wilson E, Plested G, Carey JS: Esophagogastrectomy versus radiation therapy for midesophageal carcinoma. Ann Thorac Surg 10: 195, 1970. 12. Guernsey JM, Doggett RL 3rd, Kohatsu S, et al: Combined treatment of cancer of the esophagus. Am J Surg 117: 157, 1969. 13. Frazier AB, Levitt SH, DeGiorgi LS: Effectiveness of radiation therapy in the treatment of carcinoma of the esophagus. A retrospective study. Am J Roentgen01 106: 630, 1970. 14. Lewinsky, BS, Annes GP, Mann SG, et al: Carcinoma of the esophagus: an analysis of results and of treatment techniques. Radio/ C/in 44: 192, 1975. 15. El-Domeiri A, Martini M, Beattie EJ Jr: Esophageal reconstruction by colon interposition. Arch Surg 100: 356, 1970. 16. Nicks R: Colonic replacement of the oesophagus. Some observations on infarction and wound leakage. Br J Surg 54: 124, 1967. 17. Orringer MB, Sloan H: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J Thorac Cardiovasc Surg 70: 636, 1975. ia. Pearson JG: The present status and future potential of radiotherapy in the management of esophageal cancer. Cancer 39: 882, 1977. 19. Collis JL: Carcinoma of the oesophagus; the case for surgical excision. Lancef 2: 613, 1957. 20. Lortat-Jacob J, Maillard J, Fekete F: A procedure to prevent reflux after esophagogastric resection; experience with 17 patients, Surgery 50: 600, 196 1. 21. Sweet RH: The results of radical surgical extirpation in the treatment of carcinoma of the esophagus and cardia with five year survival statistics. Surgery 94: 46, 1952.
Discussion
Bernard Gardner (Brooklyn, NY): I support the authors’ attitudes toward the use of these operations for palliation of these patients. We have a series of thirty patients in whom we have performed either esophagogastrectomies or total gastrectomies for proximal gastric cancer, seventeen of whom had liver metastases at the time of operation, Of this particular series, twenty-eight patients left the hospital alive, and the palliation obtained by being able to feed them in a normal way is of tremendous value in their overall management. Our long-term survival rate is, as you would suspect, not very high. We have only six patients who have survived free
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Piccone et al
of disease for four years; but certainly in this particular location, either the lower esophagus or proximal stomach, the use of the Celestin tube is not very helpful. Resection of the tumor, on the other hand, yields excellent palliation. John Terblanche (Cape Town, South Africa): In the black South African, the disease, which is both very common and presents late, occurs predominantly in the middle third of the esophagus. In that setting I do not believe that the palliative resections described today are as valuable as simple intubation procedures. In large series with palliative resections in our country, the results have not been as good as can be achieved with the much lesser procedures of either pulsion or traction intubation. With regard to technical details, we prefer to perform the anastomosis in the neck. It makes the complication of leakage, when it occurs, less of a problem, and it is usually easy to get the stomach up into the right side of the neck. We support the view that pyloroplasty is unnecessary and, in fact, other groups in South Africa have demonstrated that bile reflux is a problem in patients in whom pyloroplasty is performed. David B. Skinner (Chicago, IL): I concur with the hypothesis about the palliative management of esophageal carcinoma. I have just a few questions. You showed us a slide indicating the regional node and surrounding tissue involvement in fifty patients. How did you select them out of the total group of eighty-nine? In how many patients did you have to perform any postoperative dilatation of the anastomosis for recurrences? You mentioned leaving gross tumor behind in the mediastinum, and yet claimed that none of these patients had recurrent dysphagia. How was that mediastinal tumor controlled? Hiram C. Polk, Jr (Louisville, KY): Would you comment about any special characteristics of the anastomosis which might have been associated with such a high clinical success rate?
38
V. A. Piccone (closing): The technic for the esophagogastric anastomosis was standard. The telescoping of the stomach up onto the esophagus provides additional protection against leakage. Adequate mobilization of the stomach permits cuffing onto the esophagus on both the anterior and posterior surfaces without tension. With regard to Dr. Gardner’s remarks, I would note that back around 1965 when we were planning prospectively, he suggested that we use the Lewis-Ivor operation which he learned in California. Dr. Terblanche favors intubation over resection. The 3.9 per cent mortality for resecting midthird esophageal lesions is far superior to the one month 10 to 14 per cent mortality for intubation described in the literature. After resection, patients can swallow ordinary foods; they do not have to take liquids or blended diets They less frequently aspirate. Their survival is double that of intubated patients. They have no erosion of surrounding structures. They have no regrowth of tumor, and they have no migration of the tube. For these reasons, resection and restoration of the gastroesophageal continuity by surgery is the optimal method of treating midthird lesions. As to Dr. Skinner’s question, the new slide showing the most recent results on lymph node involvement and invasion of the contiguous structures was not ready for the presentation, but the statistics are exactly the same as they were when this series was presented with fifty cases. Residual tumor was often left when the esophagus was dissected from surrounding structures, but recurrent dysphagia from progressive encroachment by residual local disease did not occur. The cut edge of the esophagus was always free of tumor on frozen sections at the time of surgery, so recurrent dysphagia from direct esophageal involvement was not encountered. I do not know why tracheoesophageal or tracheogastric fistulas did not develop in our patients, because residual tumor was left close to the tracheal bifurcation or right main bronchus in many patients. Although one might expect erosion of residual tumor into transposed stomach, it just did not happen. In the course of radiotherapy, certainly, when there is invasion of this area, radiation often is complicated by a tracheoesophageal fistula. We had no real problem with control of residual local disease. It was always a problem of distant metastases.
The Amerkan Journal of Surgery
Esophageal carcinoma is one of the most difficult malignancies to cure, and almost as frustrating to palliate. It constitutes 1 per cent of all cancer in North America. The typical lesion is a squamous carcinoma. The proximity to adjacent structures and the lack of a separating membrane account for the propensity to contiguous spread. The distensibility of the esophagus when the tumor is limited to a part of the circumference delays the onset of obstruction until the tumor is far advanced. Thus, therapy is often palliative rather than curative. The rationale for the shift from treatment almost exclusively by surgery in the 1949-1956 era to treatment mainly by radiotherapy in the 1965-1975 era was based on the high surgical mortality [1-31 reported in studies that predated the extensive modern radiotherapy experience and were related to the early surgical trials. The continuing lack of prospective randomized studies comparing radiation and surgery perpetuates the unhappy dependency on retrospective analysis and historical comparisons. Nevertheless, our four-
teen year clinical experience with radical surgery as the primary therapy allows reevaluation of esophagogastrectomy in light of the surgical technology of the 1960s and 1970s. We are reporting the present experience because the data indicate, within the limits of retrospective analysis, that current surgical therapy offers better palliation than does radiation therapy alone, especially for midthird lesions.
From the Departments of Medicine and Surgery, Brooklyn Veterans AdministrationHospital and Downstate Medical Center, State University of New York, Brooklyn, New York. Reprint requests should be addressed to V. A. Piccone, MD, Dapartment Of Medicine, Brooklyn Veterans Administration Hospital, 300 Poly Place, Brooklyn, New York 11209. Presented at the Nineteenth Annual Meeting of the Society for Surgery of the Alimentary Tract, Las Vegas, Nevada, May 23-24, 1973.
32
Material and Methods Eighty-nine patients were referred for radical surgical treatment of esophageal carcinoma from July 1965to May 1978. The clinical problem was obstructive esophageal malignancy without spread to superficial regional nodes, lung, bones, or other distant areas and without vocal cord paralysis, pleural effusion, or ascites. Patients with disseminated malignancy were provided less formidable, but less effective, palliative procedures and are not the subject of this report. The most frequent symptoms were progressive dysphagia and weight loss. Dysphagia was usually of at least two months’ duration, and weight loss prior to hospital admission averaged 20 pounds. The average age was 62.2 years, and all patients were in the sixth to eighth decades. Excessive use of alcohol and tobacco was common. The esophagus appeared abnormal on fluoroscopic contrast visualization with Gastrografine or barium in all eightynine patients, and the findings usually were suggestive of malignancy. The definitive diagnosis was established by esophagoscopy and biopsy in most patients, although acquisition of a surgical specimen was necessary in some instances. Thorough preoperative evaluation revealed no distant metastases, except for eighteen patients with radionuclide liver scans suggestive of hepatic involvement. Liver scans which were inconclusive or only suggestive of metastases did not exclude radical surgery because of the frequent false-positive result in cirrhotic patients. The pathology of these esophageal lesions is summarized in Table I. The usual preponderance of epidermoid carcinoma is evident. However, the thirteenth reported primary malignant melanoma and the first primary plasmacytoma demonstrate the minimal potential for diverse histopathology. Midesophageal lesions seemed more frequent than in most studies, because patients with upper gastric carcinomas and malignancies of the cervical esophagus were not referred to the thoracic surgical service. Most adenocarcinomas were located in the lower esophagus close to the gastroesophageal junction. Direct invasion of contiguous structures or lymphatic spread to regional nodes was
The American Journal 01 Surgery
Esophagogastrectomy
TABLE I
Histopathologic Type and Distribution-Esophageal
Malignancies No. of Patients with Esophageal Lesions
Histologic Type
Upper Third
Middle Third
Lower Third
Squamous cell carcinoma Adenocarcinoma Anaplastic carcinoma Malignant melanoma (primary) Plasmacytoma (primary) Mixed (squamous and adenocarcinoma)
2 1 0 0 0 0
43 2 5 0 0 1
20 7 0
Total
3
51
29
in almost all patients (stage IV), indicating the advanced nature of the disease at the time of initial clinical presentation. present
1 1 0
Total 65 (78%) 10 (12%) 5 (6%) 1(1.2%) 1(1.2%) 1(1.2%) 83
cuff of stomach up onto the esophagus to cover the anastomosis and to prevent reflux, and sutures of the stomach up to the pleura and neighboring fascia to prevent tension on the anastomosis. (Figure 1C.)
Operative Technic
Radical resection and restoration of gastrointestinal continuity by intrathoracic esophagogastrostomy was performed using the combined abdominal and right thoracic approach described by Lewis [4], except that both stages were completed in a single operation. The right thoracotomy allowed extension of the esophageal resection as high as necessary without being hampered by the aortic arch and eliminated the need for an incision of the diaphragm or costal arch. Modification for high intrathoracic esophageal lesions included continuation of the dissection through the thoracic outlet and performance of the esophagogastrostomy through a cervical incision. The first stage was performed with the patient supine and using a high midline incision extended upward alongside the xiphoid. After abdominal exploration, the stomach was freed of its omental attachments and prepared for transposition by carefully preserving the right gastric and gastroepiploic arteries. (Figure 1A.) The spleen was removed only if there was extension of the tumor to the spleen or if the nodes in the gastrosplenic ligament were involved with tumor. Mobilization of the duodenum from the inferior vena cava and the aorta provided excellent upward mobility of the duodenum and head of the pancreas. Pyloroplasty was performed only if the pylorus was abnormally narrowed. The left gastric artery was divided at its origin after stripping off involved lymph nodes, so that communications with the right‘gastric artery were preserved. Residual tumor was left in the celiac area if a large cluster of nodes made removal difficult. A 1 cm incision in the fibrous insertion of the diaphragmatic crura, anterior to the esophagus, insured adequate drainage of the stomach. The thoracic part of the operation was performed using a standard right posterolateral thoracotomy with subperiosteal resection of the fourth rib. The esophagus was excised to a distance of 4 cm above palpable tumor. (Figure 1B.) For midesophageal lesions care is necessary in dissecting the tumor from the membranous portion of the trachea and bronchi, the pulmonary veins, the left atrium, and the aorta. Esophagogastrostomy was performed using the apex of the cardia, a two layer anastomosis, a telescoped
Volume 137, January 1979
Results
Resectability. Excision of the esophagus and reconstruction by esophagogastrostomy was accomplished in eighty-one of the eighty-nine patients. The overall resectability rate was thus 93 per cent. All tumors in the middle and upper third of the esophagus were successfully resected despite invasion of contiguous structures in 60 per cent and nodal involvement in 75 per cent. Resection was less predictively accomplished for the thirty-five patients with lower third lesions. Intervention was limited to a feeding gastrostomy in six patients because of tumor spread along the lesser curvature, invasion of the posterior peritoneum, and multiple hepatic metastases not evident prior to operation. Esophagogastrectomy was extended to include hemipancreatectomy, transverse colectomy, and splenectomy in two other patients, so that the resectability rate by standard esophagogastrectomy for lower third lesions was only 77 per cent (27 of 35). Operative Mortality. (Table II.) The thirty day mortality for the eighty-one patients undergoing esophagogastrectomy and reconstruction by intrathoracic esophagogastrostomy, the standard procedure, was 4.9 per cent. Inclusion of the two deaths in the patients with extended radical procedures would increase the mortality to 7.2 per cent. Resection of midthird lesions was accomplished with a 3.9 per cent mortality. The mortality for resection of twenty-seven lower third lesions was 7.4 per cent, excluding the two extended radical procedures. The causes of death are listed in Table III. Anastomotic Disruption. Postoperative contrast visualizations before commencement of oral feedings approximately twelve days after surgery proved anastomotic integrity in all patients with uncom-
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Piccone et al
r
Figure 1. Technical details of the esophagogastrectomy.
34
plicated malignant obstruction, thus eliminating disruption as a cause of operative (30 day) death. The anastomosis probably leaked in a patient with achalasia who underwent resection because of hemorrhage and infection. An unsuspected concomitant esophageal carcinoma had eroded into the chest wall, exposing ribs and causing hemorrhage. Empyema complicated the postoperative course, and during the second month gastric contents appeared in the chest tube drainage. Continued leakage and infection eventually resulted in death. Postoperative x-ray films showed an apparent narrowing of the lower esophagus in most patients with the telescoped type of esophagogastric anastomosis. However, narrowed distal esophagus was distensible and did not cause dysphagia. This narrowed appearance was seen in late survivors as long as six years after surgery. (Figure 2.) Need for Pyloroplasty. Gastric retention did not complicate deletion of pyloroplasty. Radiologically detected delay in gastric emptying occurred in three patients, but later studies showed a return to more rapid gastric emptying in two patients. The third patient was recently resected and has not been studied at a later interval. Two patients have complaints consistent with reflux esophagitis. The 12 hour gastric analyses of five survivors are seen in Table IV. Palliation and Quality of Life. Dysphagia was relieved and oral alimentation restored in the 95 per cent of patients who survived the standard esophagogastrectomy. Appetite returned to normal only in the small number of long-term survivors who also maintained normal weight. Most patients continued to lose weight and before the introduction of intravenous hyperalimentation, lost an average of 18 pounds during the first postoperative month. Prehepatic intravenous hyperalimentation [5], used during the past three years, has reduced weight loss during the first postoperative month substantially; some patients have gained weight. Intravenous hyperalimentation is optimal in these patients, since the inadequate oral ingestion guarantees essential fats and trace elements, thus minimizing hyperalimentation problems. The excellent palliation of surgery is evident in the complete absence of aspiration pneumonia, tracheoesophageal fistula, esophageal or anastomotic stricture, erosion into aorta, or recurrent malignant obstruction. Most of the patients, who would have died of aspiration pneumonia if treated by radiation alone, eventually died of distant metastases. The patients who died within three months were for the most part those with hepatic metastases, and
The American Journal oi Surgery
Esophagogastrectomy
TABLE II
Postoperative (30 day) Mortality to Procedure Performed Location of Tumor
Esophagogastrectomy Upper third Middle third Lower third Total Esophagogastrectomy, hemipancreatectomy, transverse colectomy and splenectomy Lower third Gastrostomy Lower third
according
Deaths
o/3 2151 (3.9%) 2129 (6.9%) 4f63 4.6%
212 (100%) 016
these patients did not receive major benefits from surgery. Excellent palliation was achieved in the 70 per cent who survived beyond three months. All who lived beyond one year but who were not cured enjoyed uncomplicated oral alimentation for the remainder of their lives, and like almost all resected patients, died of distant metastases. The six patients who lived beyond five years enjoyed uncomplicated oral alimentation. Survival. The survival curves are shown in Figure 3. Five late survivors died of unassociated medical problems, and two five year survivors died of a cerebrovascular accident and a myocardial infarction. The mean survival was 10.9 months. The survival of patients with liver metastases was 3.5 months. The mean survival of patients with spread to contiguous structures and regional lymph nodes, but without hepatic involvement, was 9 months.
TABLE III
Postoperative
(30 dav) Mortalitv-Causes No. of Patients
Causes Pulmonary complications Pulmonary embolism Cardiac arrest Necrotizing hemorrhagic pancreatitis Hepatic metastases and progressive liver failure Anastomotic leak Note: POD = postoperative
Interval from Surgery
2 1 1 1
POD POD POD POD
2 and 4 9 14 14
1
POD 14
0 day.
In addition, experience with several types of indwelling tubes was gained [IO]. By the late 196Os, comparative studies were beginning to suggest better palliation from surgery than from radiotherapy even with midthird lesions [II]. Moreover, the effect of combined radiotherapy and surgery [12] on longevity seemed minimal at best, and the general results of treating esophageal malignancy remained grim. Today, palliative treatment remains the primary goal, and the comparison is still basically between radiotherapy and surgery. Esophagectomy and intrathoracic esophagogastrostomy in these eighty-three patients provided better palliation than did radiotherapy alone. Esophageal obstruction was relieved in all of the 95
Comments
Treatment of esophageal malignancy has been characterized by slow change and dismal results. The first large scale trials of surgery realized a 20 to 50 per cent mortality [I-3], and the mortality for midthird lesions was especially high. However, the shift to radiation therapy, which quite naturally followed in the 195Os, provided little cause for optimism. Obstruction was often not relieved, and lethal tracheoesophageal fistulas were common. The need for better palliation and longer survival remained obvious. Pearson [6] commented that the results of radiotherapy were distinguished only by being less disastrous than primary surgical treatment. The results of radiation therapy became more reproducible with the introduction of megavoltage radiation. At the same time the operative mortality was becoming lower because of rapid advances in thoracic surgery. The improved safety of surgery prompted trial of colon bvpass [7], extrapleural anterior esophagogastrostomy [S], and gastric tubes [9].
Volume 137, January 1979
Figure 2. Contrast visualization of the esophagogastric anastomosis demonstrating the reflection of the stomach up info the esophagus, in fhls instance similar fo normal the esophagogastrlc junction.
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Piccone
et al
TABLE IV
12 Hour Gastric Analysis After Esophagogastrectomy Total Volume (cc)
Free Hematocrit
Patient
Interval from Surgery
b-w$l)
@WV
FL PS JC WT HD
5yr2mo 6yr3mo 2mo 2mo 2mo
90 75 350 300 400
4o” 5o” 0 0 0
65“ 7o” loo 16’ 2o”
Total Acidity
per cent of patients who were resectable, whereas radiation is generally credited with relieving obstruction in only 70 per cent of patients [13,14]. The thirty day mortality of 7 per cent for surgery, a figure taken as representative of today’s technology, is less than that occurring from the aspiration pneumonia and tracheoesophageal fistulas associated with radiotherapy. The additional serious morbidity of radiation therapy, including nonfatal aspiration pneumonia (15 per cent), nonfatal tracheoesophageal fistulas (10 per cent), mediastinal perforation (13 per cent), radiation myelitis of the spinal cord, stricture, hemorrhage, and constrictive pericarditis [13,14], are far more frequent than postoperative atelectasis, pneumonia, and embolism. Although surgical patients rarely realize a return of appetite, they enjoy unimpaired oral alimentation for the remainder of their lives and die of distant metastases [II]. Radiotherapy is saddled with far more frequent recurrent malignant obstruction, final reliance on gastrostomy, and the high incidence of death by pneumonia from aspiration or tracheoesophageal fistulas. The palliative value of esophageal resection and intrathoracic esophagogastrostomy in these eightythree patients was also more satisfactory than in our previous experience with resection and anterior colon bypass gastrostomy and the various esophageal tubes. Esophageal resection and colon bypass has a surgical mortality of 15 to 25 per cent [15,16], has three anastomoses at risk, and poses the problems of inadequate vasculature, less dependable anastomotic healing, and greater chance of infection [I&16]. Reversed gastric tubes of the Gavriliu type often leak at the anastomosis, and many patients die before completion of both stages. Prosthetic tubes (Celestin and Meckler) have a relatively high mortality (to 14 per cent) [IO] and are complicated by obstructing food, erosion into adjacent structures, migration, and tumor overgrowth in an additional 25 per cent of patients. The survival time is only half as long as with resection, and food ingestion is limited to fluids that can pass through the tube. Gastrostomy does little
36
Figure 3. Long-term survival for esophagogastrectomy.
to relieve aspiration of saliva. Substernal gastric bypass probably has a special role in prevention of gastric reflux through malignant tracheoesophageal fistulas [17] but in general is not preferred, because removal of the main tumor mass may alter the response of the host to the tumor. Resection with intrathoracic esophagogastrostomy had almost no serious physiologic complications and was optimal for the group who survived beyond the first two postoperative months. The reduction in surgical mortality for midthird lesions is the most striking difference between the most recent and the earlier surgical reports. Nakayama [8], Mosely [2], Collis [29], Sweet [21], and Lortat-Jacob, Maillard, and Fekete [20] reported surgical mortalities of midthird lesions to be two and three times those of lower third lesions. Surgical mortalities of up to 50 per cent offered little choice but to favor radiotherapy. The 3.9 per cent mortality in the present report is an acceptable surgical mortality and confirms that reported by others [I 11, and we believe it to be representative of current surgical technology. The second important change in the operative treatment of midthird lesions is the dramatic increase in the resectability rate. The often stated objection to separate abdominal and right thoracic incisions was the futility of exploring the chest to find a tumor that would not permit even palliative removal after all the technical details of the abdominal operation. To the contrary, the thoracic esophagus could always be removed in the fifty-one patients with midthird lesions encountered in our experience. The high resectability rate of 100 per cent reflects the realization that residual tumor is best left on the membranous portion of the trachea or major bronchi to avoid inadvertent opening into the airway. This not only allows resection but is safe and seems to have prevented the gastroesophageal fistulas seen in the natural course of the disease or associated with radiotherapy. Right thoracotomy contributed to the
The American Journal of Surgery
Esophagogastrectomy
successful management of midthird lesions by providing easy access to the midintrathoracic esophagus during resection and the upper third for reconstruction. The resectability rate was higher for midthird lesions because lower third lesions sometimes directly involved the liver, diaphragm, and retroperitoneal structures. The low surgical mortality of the past decade, the high resectability rate of 100 per cent, the low rate of anastomotic leakage that can be achieved, the usual success in restoring oral alimentation, and the low incidence of serious complications usually associated with radiotherapy are compelling reasons for a shift to surgical therapy for midesophageal lesions. The true extent of esophageal cancer at the time of diagnosis, wherein the tumor is confined to esophagus in only 20 per cent of patients, seems to preclude improvements in survival until some therapy for disseminated disease becomes available. The survival curves of this and other recent studies are difficult to validly compare because of the different extents of tumor. Pearson’s [18] radiotherapy study did not include patients with tumor infiltrating the trachea and bronchi, those with remote lymphatic metastases, or patients with demonstrable liver metastases, whereas the present study was primarily concerned with palliative relief of obstruction and therefore included patients with far advanced disease. The short survival of the patient resected in the face of liver metastases does not justify such major surgery, and insertion of an indwelling tube would be appropriate. In the absence of hepatic involvement, survival after surgery alone or radiotherapy alone appears similar. The improved quality of life following surgery is dramatically different and a compelling advantage. Summary
Esophagogastrectomy performed in eighty-three patients with a thirty day mortality of 7 per cent, a resectability rate of 93 per cent, and no anastomotic leakage, provided dependable relief of malignant obstruction and restored oral alimentation in all surviving patients. Long-term survival was unchanged. The successful resection of all midthird lesions with a 3.9 per cent mortality reflects the capability of current surgery and suggests that surgical palliation of midthird esophageal tumors is preferable to radiotherapy alone. References 1.
MacManusJE,
Paine JR, Dunn J, Merdinger W: Carcinoma of the esophagus; report of cases: 1947 to 1953. Surgery40: 510. 1956.
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2. Moseley RV: Squamous carcinoma of the esophagus. Surg Gynecol Obstet 126: 1242, 1966. 3. Mullard KS: Carcinoma of oesophagus treated by excision. Lancet 1: 677, 1970. 4. Lewis I: Surgical treatment of carcinoma of esophagus with special reference to new operation for growth of middle third. Br J Surg 2: 18, 1946. 5. Piccone VA, LeVeen H, Berlyne G, et al: Prehepatic hyperalimentation. J Surg Res (In press.) 6. Pearson JG: Cancer of the gastrointestinal tract. II. Esophagus: treatment-localized and advanced. Value of radiation therapy. JAMA 227: 161, 1974. 7. Belsey R: Reconstruction of the esophagus with left colon. J Thorac Cardiovasc Surg 49: 33, 1965. a. Nakayama K: Radical operations for carcinoma of the esophagus and cardiac end of the stomach. J Int Co// Surg 2 1: 5 1, 1954. 9. Gavriliu D, Georaescu L: Esotagoplastic viscerala directa. Chirurgie 4: 104, 1955. 10. Girardet RE, Ransdell HT Jr, Wheat MW Jr: Palliative intubation in the management of esophageal carcinoma. Ann Thorac Surg ia: 417, 1974. 11. Wilson E, Plested G, Carey JS: Esophagogastrectomy versus radiation therapy for midesophageal carcinoma. Ann Thorac Surg 10: 195, 1970. 12. Guernsey JM, Doggett RL 3rd, Kohatsu S, et al: Combined treatment of cancer of the esophagus. Am J Surg 117: 157, 1969. 13. Frazier AB, Levitt SH, DeGiorgi LS: Effectiveness of radiation therapy in the treatment of carcinoma of the esophagus. A retrospective study. Am J Roentgen01 106: 630, 1970. 14. Lewinsky, BS, Annes GP, Mann SG, et al: Carcinoma of the esophagus: an analysis of results and of treatment techniques. Radio/ C/in 44: 192, 1975. 15. El-Domeiri A, Martini M, Beattie EJ Jr: Esophageal reconstruction by colon interposition. Arch Surg 100: 356, 1970. 16. Nicks R: Colonic replacement of the oesophagus. Some observations on infarction and wound leakage. Br J Surg 54: 124, 1967. 17. Orringer MB, Sloan H: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J Thorac Cardiovasc Surg 70: 636, 1975. ia. Pearson JG: The present status and future potential of radiotherapy in the management of esophageal cancer. Cancer 39: 882, 1977. 19. Collis JL: Carcinoma of the oesophagus; the case for surgical excision. Lancef 2: 613, 1957. 20. Lortat-Jacob J, Maillard J, Fekete F: A procedure to prevent reflux after esophagogastric resection; experience with 17 patients, Surgery 50: 600, 196 1. 21. Sweet RH: The results of radical surgical extirpation in the treatment of carcinoma of the esophagus and cardia with five year survival statistics. Surgery 94: 46, 1952.
Discussion
Bernard Gardner (Brooklyn, NY): I support the authors’ attitudes toward the use of these operations for palliation of these patients. We have a series of thirty patients in whom we have performed either esophagogastrectomies or total gastrectomies for proximal gastric cancer, seventeen of whom had liver metastases at the time of operation, Of this particular series, twenty-eight patients left the hospital alive, and the palliation obtained by being able to feed them in a normal way is of tremendous value in their overall management. Our long-term survival rate is, as you would suspect, not very high. We have only six patients who have survived free
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Piccone et al
of disease for four years; but certainly in this particular location, either the lower esophagus or proximal stomach, the use of the Celestin tube is not very helpful. Resection of the tumor, on the other hand, yields excellent palliation. John Terblanche (Cape Town, South Africa): In the black South African, the disease, which is both very common and presents late, occurs predominantly in the middle third of the esophagus. In that setting I do not believe that the palliative resections described today are as valuable as simple intubation procedures. In large series with palliative resections in our country, the results have not been as good as can be achieved with the much lesser procedures of either pulsion or traction intubation. With regard to technical details, we prefer to perform the anastomosis in the neck. It makes the complication of leakage, when it occurs, less of a problem, and it is usually easy to get the stomach up into the right side of the neck. We support the view that pyloroplasty is unnecessary and, in fact, other groups in South Africa have demonstrated that bile reflux is a problem in patients in whom pyloroplasty is performed. David B. Skinner (Chicago, IL): I concur with the hypothesis about the palliative management of esophageal carcinoma. I have just a few questions. You showed us a slide indicating the regional node and surrounding tissue involvement in fifty patients. How did you select them out of the total group of eighty-nine? In how many patients did you have to perform any postoperative dilatation of the anastomosis for recurrences? You mentioned leaving gross tumor behind in the mediastinum, and yet claimed that none of these patients had recurrent dysphagia. How was that mediastinal tumor controlled? Hiram C. Polk, Jr (Louisville, KY): Would you comment about any special characteristics of the anastomosis which might have been associated with such a high clinical success rate?
38
V. A. Piccone (closing): The technic for the esophagogastric anastomosis was standard. The telescoping of the stomach up onto the esophagus provides additional protection against leakage. Adequate mobilization of the stomach permits cuffing onto the esophagus on both the anterior and posterior surfaces without tension. With regard to Dr. Gardner’s remarks, I would note that back around 1965 when we were planning prospectively, he suggested that we use the Lewis-Ivor operation which he learned in California. Dr. Terblanche favors intubation over resection. The 3.9 per cent mortality for resecting midthird esophageal lesions is far superior to the one month 10 to 14 per cent mortality for intubation described in the literature. After resection, patients can swallow ordinary foods; they do not have to take liquids or blended diets They less frequently aspirate. Their survival is double that of intubated patients. They have no erosion of surrounding structures. They have no regrowth of tumor, and they have no migration of the tube. For these reasons, resection and restoration of the gastroesophageal continuity by surgery is the optimal method of treating midthird lesions. As to Dr. Skinner’s question, the new slide showing the most recent results on lymph node involvement and invasion of the contiguous structures was not ready for the presentation, but the statistics are exactly the same as they were when this series was presented with fifty cases. Residual tumor was often left when the esophagus was dissected from surrounding structures, but recurrent dysphagia from progressive encroachment by residual local disease did not occur. The cut edge of the esophagus was always free of tumor on frozen sections at the time of surgery, so recurrent dysphagia from direct esophageal involvement was not encountered. I do not know why tracheoesophageal or tracheogastric fistulas did not develop in our patients, because residual tumor was left close to the tracheal bifurcation or right main bronchus in many patients. Although one might expect erosion of residual tumor into transposed stomach, it just did not happen. In the course of radiotherapy, certainly, when there is invasion of this area, radiation often is complicated by a tracheoesophageal fistula. We had no real problem with control of residual local disease. It was always a problem of distant metastases.
The Amerkan Journal of Surgery