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Management of Carcinoma of the Cervical Esophagus
MANAGEMENT OF CARCINOMA OF THE CERVICAL ESOPHAGUS DANELY P. SLAUGHTER, M.D., F.A.C.S.* AND ERWIN H. ROESER, M.D.t
Carcinoma of the cervical esophagus is not as frequent as cancer elsewhere in this organ; therefore few surgeons have extensive experience with such lesions. The surgical attack has been awkward until recent concepts of reconstruction were developed. Thus, most attempts at treatment have been through methods of irradiation, with only occasional success. Actually, surgical cure of cancer in the cervical esophagus is more feasible than in the thoracic portion because of the much wider lateral dissection and excision that can be accomplished in the neck. Adjacent organs, such as the larynx, trachea and thyroid, may be sacrificed and the regional node areas in both sides of the neck may be removed if indicated. The removal of such a wide "cancer field" is not possible in the tubular dissection required for excision of the thoracic esophagus. ETIOLOGY AND SYMPTOMATOLOGY
No specific agents or factors have been reported predisposing to the development of carcinoma of the esophagus, except the infrequent association with leukoplakia and Plummer-Vinson syndrome. Considerable mention has been made of the role played by various forms of chronic irritation in the development of new growths in the oral cavity. Among these are included intraoral sepsis, smoking, thermal irritation, and syphilis. It is reasonable to assume that they may playa similar role in the causation of epithelial change in the cervical esophagus. In this respect it is interesting to note that of sixteen cases of carcinoma of the esophagus with a second primary neoplasm reported by Watson,30 87.5 per cent had a primary intraoral carcinoma. This would appear to be more than a chance relationship. Actually, a lesion of considerable size may be present in the cervical esophagus before marked symptoms are manifested. The symptoms at first are indefinite and vague, and usually cause the patient little concern. They may be only a sense of throat irritation or slight discomfort in swallowing, not an uncommon From the University of Illinois College of Medicine, Chicago. * Assistant Professor of Surgery and Director of Tumor Clinic, University of Illinois College of Medicine, Research and Educational Hospitals; Attending Surgeon, St. Francis Hospital, Evanston, Illinois. t Clinical Assistant in Surgery, University of Illinois College of Medicine.
,85
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DANELY P. SLAUGHTER, ERWIN H. ROESER
experience to most of us, which is discarded by the patient as a mild upper respiratory infection, excessive smoking, or fatigue. Although dysphagia is the most commonly associated symptom of carcinoma of the esophagus, it is a late manifestation of disease when the primary neoplasm is in the cervical esophagus. Here the esophageal wall is thin, flexible, and devoid of sensory nerve fibers. To cause obstruction to the passage of food may require a lesion involving a considerable segment of the esophageal wall. Pain and discomfort in the neck are usually late and from fixation or pressure on contiguous cervical structures. DIAGNOSIS
The early diagnosis of carcinoma of the cervical esophagus is a direct expression of the index of suspicion on the part of the medical examiner. A differential diagnosis from foreign body injury to the mucosa, globus hystericus, Plummer-Vinson syndrome and thyroid disorders should be made with reasonable dispatch after appropriate study. Examination should start with external neck palpation to discern the presence of goiter, cervical rib, lymph node hypertrophy, metastases, retropharyngeal abscess and contiguous esophageal tumors. Intraoral inspection may reveal leukoplakia, and the presence of multicentric epithelial change should be kept in mind. The integrity of the recurrent laryngeal nerves should be checked. Recently we have had three patients come to our attention who have had a high cervical transection or obliteration of one vagus nerve and manifested difficulty in swallowing and paresis of the laryngeal muscles. An x-ray of the cervical spine may show sufficient osteoarthritis in the aged with weight loss to be a cause of external esophageal pressure. Fluoroscopic study of the esophagus with a thick barium suspension is most important. Lateral views may be pathognomonic of an intraluminal defect. In all irregularities of the mucosal pattern and intraluminal projections it becomes mandatory to proceed further with direct esophagoscopy and biopsy study of any suspicious· change in the epithelium. Fluoroscopic study is expedient but not always conclusive. Once microscopic assay confirms toe presence of tumor, the appropriate modality of therapy should be instituted. TREATMENT
X-Ray Therapy. The treatment of cervical espphageal carcinoma by irradiation has been a most unhappy chapter. An appreciation of the natural history of epidermoid cancer in this structure may explain treatment failures. Life expectancy without treatment is about five to eight months from the onset of symptoms. There is no report of a large series of cases treated by irradiation alone. However, Watson30 reviewed
CARCINOMA OF CERVICAL ESOPHAGUS
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seventy-eight cases of cervical esophageal carcinomas, twenty-eight of which were treated by radiation as the sole modality of therapy. In this group only four patients were living ten to fifty-six months later. In another group of twenty-seven cases in which the mode of therapy was gastrostomy plus irradiation, only six patients were living four to nineteen months later. Lenz l4 has treated four cases of postcricoid epithelioma by irradiation alone. One patient is living and well thirteen years after treatment. The other three lived from three months to six years before dying of recurrent disease. Metastases to lymph nodes are fairly early and may well be bilateral. The nodes most commonly involved are the deep jugular, supraclavicular and prevertebral. In Watson's80 group, 22 per cent had discernible nodes on their initial examination. Symptoms of esophageal obstruction may be ameliorated in 75 per cent of the cases from irradiation alone. Life expectancy in this group is about fourteen months. Gastrostomy actually increases the expectancy very little, since the patient still dies from aspiration pneumonia, sudden hemorrhage, carcinomatosis or cachexia. As yet we have treated no cases with the betatron, and it is doubtful if there will be any significant increase in survival rate. Esophageal carcinoma is a radiosensitive and, hence, a potentially curable tumor when favorable factors of the disease are combined with diligently planned irradiation. The studious work of Guisezll .in the repeated use of curietherapy on esophageal carcinomas has yielded encouraging results in a few selected cases. External therapy is limited by the inability to deliver a uniform tumorocidal dose in most cases. Submucosal extensions of the tumor are frequently completely missed in the field of therapy. Intraluminal curietherapy employing a radium bougie has met universal failure and ·frequently is complicated by fatal perforation. The authors have used interstitial irradiation through an esophagoscope or open thoracotomy with only palliative results. Surgical Management. Until recently cervical esophagus carcinoma has been predominantly treated. by irradiation. However, this lesion was first surgically resected by Czerny 6 in 1877. At that time he resected a segment of esophagus 6 cm. in length. The distal orifice was left open in the lower neck as an expedient to feeding. The patient not only survived the operative procedure, but lived fifteen months before dying of recurrent cancer. Mikulicz 16 in 1884 also resected the cervical esophagus and, in addition, completed a plastic skin repair which permitted eating solid food for a short time. His patient died sixteen months later of recurrent disease. Von Hacker29 in 1908 further advanced the operative attack on this tumor by an en bloc excision of both larynx and esophagus. Reports of long-term surgical survivals are first noted in 1934 by Evans, 8 who reported a twenty-three year survival, and by Trotter8 in 1937,
88
DANELY P. SLAUGHTER, ERWIN H. ROESER
who reported a ten year survival after surgical excision of carcinoma of the cervical esophagus. An excellent review of the surgical development of the treatment of carcinoma of the cervical esophagus is reported by Watson and Poo1.30 The primary design of any surgical attack on cervical esophageal carcinoma is for its complete extirpation at the sacrifice of contiguous cervical structures if necessary. Due to current developments in the ancillary surgical sciences, especially anesthesia, antibiotics and fluid balance, an aggressive and radical approach to this lesion is now possible and fulfills the prerequisite of a cancer operation. The primary tumor may be widely resected in continuity with its regional lymphatic drainage, as with an associated radical neck dissection, with a surprisingly low mortality. Interest in reconstructing the cervical gullet has been somewhat lacking, due to the previously high incidence of recurrence. The literature is replete with reports of challenging ingenuity in attempts to re-establish pharyngeal-gastric continuity .. In general there have developed four surgical technics for the ablation of this lesion. Esophagotomy with Local Resection and Primary Restoration of Luminal Continuity. This is the simplest approach. A suitable incision may be made along the anterior border of the sternocleidomastoid muscle and the esophagus mobilized in the usual manner. Preferably a rectangular flap of skin and platysma with its base laterally is developed, so that, in the event a more formidable esophageal resection is necessary, the flap may be employed in an immediate plastic repair. This procedure offers only a minimal resection of the esophagus, but has an occasional indication in instances of an early tumor limited to the mucosa. The authors have employed this procedure in the excision of a pedunculated adenocarcinoma with excellent results. The following case is reported because of its unusual character, and to illustrate that adenocarcinoma can occur primarily in the esophagus. Such tumors arise from the mucus-secreting glands located in the submucosa. CASE REPORT. S. K, about 50 years of age, was born and reared in Germany. During late childhood she contracted tuberculosis, and there subsequently developed multiple cervical nodes and sinuses. She was given a course of unfiltered x-ray therapy to the involved cervical nodes. Four years ago multiple areas of radionecrosis of the skin were excised and replaced with skin grafts. In July of 1949 she rf;lgurgitated her food on several occasions, and flecks of bright red blood were n9ted. On two occasions several tablespoonfuls of dark clotted blood· were regurgitated. A fluoroscopy of the stomach and colo~ was reported as
CARCINOMA OF CERVICAL ESOPHAGUS
was effected. A small drain was placed
to the area of the esophagotomy. The postoperative convalescence was without event, and the wound healed primarily in spite of the presence of severe latent radiation damage. It was judged reasonable to excise this tumor locally because of its discreteness and low grade malignant potential.
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DANELY P. SLAUGHTER, ERWIN H. ROESER
Surgical Construction of Artificial Esophagus by Mobilizing Parts of Alimentary Tract. In the surgeon's attempt to restore esophageal continuity after resection, the host of procedures developed bear witness to. their frequent failures. The frequency of caustic strictures of the esophagus and the resourceful ingenuity of the responsible surgeon have led to numerous developments in re-establishing esophageal continuity. Antethoracic and plastic skin tubes advocated by Mikulicz,16 Eggers,7 Trotter,28 Bricker,S Stevenson,2S Torek27 and von Hacker29 all have the inherent disadvantage of cicatrical stenosis. To answer this problem,
~,
----"Tt
i
/5ubcut. jejunum __ -j
i
J.
I
if)
Fig. 27.
Fig. 28.,
Fig. 27. The Carrol-Beck-Halpern cutaneous tube connecting cervical esophagus with stomach. Flap of stomach wall has been fashioned into a tube and anastomosis made extraperitoneally. Fig. 28. The Yudin artificial esophagus employing jejunum tunneled subcutaneously under skin.
attempts were made to bring up subcutaneously in the anterior thoracic wall various parts of the alimentary tract. In this regard the following have been mobilized: stomach, colon, and jejunum by Kirschner,13 Vulliet and Kelling,3S and Yudin,s4 respectively. Of these procedures, Yudin's34 modification of Roux's principle (Figs. 27, 28) has been the most satisfactory. He subcutaneously tunneled the jejunum from abdomen to neck for a direct esophageal anastomosis of mucosa to mucosa;. The pitfalls and l~itations of the tunneling procedures have been excessive fat in th~ mesentery, narrowness of mesentery, and poor' distribution of the arterial arcades. Complications have been narroWing
CARCINOMA OF CERVICAL ESOPHAGUS
91
of stoma, ulceration, fistula and late intestinal necrosis from retrograde thrombosis. Local Resection and Primary Repair Employing Cervical Skin 'Flap. Next of significant import was a procedure developed by Watson30 and Wookey31 in 1942, and later Brunschwig.4 The previous authors independently developed a technic of local resection of the cervical esophagus and primary repair of the gullet defect employing a rectangular cervical skin flap (Fig. 29). In this procedure a rectangular flap of skin
Cut edqe of 'thyroid
I
Recurrent larynQeal n. Fig. 29. Modified Wookey procedure using rectangular skin flap. Lobe of thyroid removed for exposure.
and platysma based on the lesser side of the tumor prominence is developed. The esophagus is mobilized, and tapes are placed around it for traction. The pharynx may now be divided below the hyoid bone and the esophagus transected a suitable distance below the tumor. If nodes are discernibly involved, one continues with an en bloc resection of the esophagus and radical neck dissection. If the larynx or postcricoid space is involved, the larynx is likewise condemned and laryngectomy performed. In this case the trachea is freed and divided below the cricoid with a sterile intratracheal tube with inflatable cuff inserted into the
92
DANELY P. SLAUGHTER, ERWIN H. ROESER
distal trachea. A tracheostomy is always performed at the end of the procedure. Once the diseased tissue is removed, the skin flap is placed across the prevertebral space and sutured into position by interrupted catgut sutures (Fig. 30). The upper edge of the skin flap is sutured to the cut
Skin flap 5utured to proximal and di stal ILnds of (Z $opha Q'lLal orifices
\ Fig. 30. Skin flap is sutured to hypopharynx above and esophagus below. Note incomplete closure of tube and skin graft to defected area (Inset).
end of the pharynx and the lower edge to the esophagus. The closure is not completed because of the gross contamination of the surgical field, and a lateral sinus or cleft is left which is easily closed at a second stage. A Levin tube is inserted transnasally into the stomach. The remaining raw surface is covered with a split thickness skin graft. To date this procedure is the most practical yet devised for this tumor site, since it is accompanied by a low mortality, lends itself well to the radical resec-
CARCINOMA OF CERVICAL ESOPHAGUS
93
tions frequently necessary, establishes a primary reconstruction of the gullet, and may be completed in a short hospital stay. This procedure, however, cannot be employed when the site of the tumor is low in the neck near the thoracic inlet, since adequate resection will require excision of the upper mediastinal esophagus. Bricker3 has recently cir-' cumvented this situation by devising pedicled, inverted skin tubes which he has successfully interposed between the mediastinal esophagus or stomach distally, and the proximal esophageal stump. Cervical Gastroesophagostomy. Adams and Phemisterl initiated the fourth phase of the surgical attack on cervical esophageal carcinoma by their original work on cardioesophagectomy. Garlock,9 Sweet25 • 26 and Churchil15 further advanced this procedure by their progressively higher cardioesophageal anastomoses following resection of the thoracic esophagus. In 1948 Garlock1o and Sweet,24 both confronted with an esophageal carcinoma at the thoracic inlet, mobilized the stomach sufficiently to effect an anastomosis above the level of the tumor. Since then Wylie and Frazell,32 Brewer,2 Scott,21 Nissen l7 and others have accomplished the same procedure. It is interesting to note that Kirschner13 in 1920 performed a cervical gastroesophagostomy by mobilizing the stomach, as is so popular today, and tunneled the same subcutaneously across the thorax to the neck. The transthoracic route was purposely avoided. The procedure advocated by Garlock lO and Sweet21 is one of both merit and magnitude. These authors give a rather detailed description of their technic and the reader is referred to their work for particulars. Common to most of the reported cases has been the problem of bronchial secretions, pneumonia and coughing. Vigorous and persistent tracheobronchial aspirations usually were necessary. The authors have found it extremely expedient to employ a tracheostomy for this purpose alone when there has been extensive transthoracic manipulation or mobilization of the stomach. The need for tracheal and bronchial aspirations may then be performed simply by catheter suction by the attendant nurse at any hour of the day and as frequently as indicated. It is also advantageous to explore the cervical tumor first through a neck incision. Once the operability is determined, the wound is covered with a towel and the patient placed for thoracotomy. The eighth intercostal space has been excellent. This would at first seem low, but the actual anastomosis is performed in the cervical area and the lower thoracotomy incision facilitates mobilization of the stomach and esophagus (Fig. 31). Recently there has been comment on the ultimate position of the stomach. Some have felt that it should be placed posterior to the aorta. This not only gives 2 or 4 cm. more in length, but the aortic arch itself
94
DANELY P. SLAUGHTER, ERWIN H. ROESER
may actually act as a valve and help to reduce gastric reflux. It would seem that some regurgitation of gastric contents may be from the absence of sphincter, atony of the stomach (vagus interruption) and positive pressure during coughing, but this has not been of great concern. Care should be exercised to preserve and identify the recurrent nerve and thoracic duct. The vagi may be cut below the level of bifurcation of the trachea. A generous cuff of omentum left on the stomach will aid in maintaining blood supply to the stomach and may also be used to reinforce the anastomosis. Closure of the mediastinal pleura about
Fig. 31. Diagramatic outline of cervical gastroesophagostomy. Cardia has been closed and fundus of stomach brought up into neck for anastomosis through separa te incision.
the stomach at the thoracic inlet will tend to isolate the cervical region from the thorax. It would seem prudent to obtain a preoperative x-ray of the stomach to determine its size, since it is doubtful if a small or contracted stomach can be mobilized sufficiently for a cervical anastomosis. In this event the Roux en-Y procedure employing the jejunum transthoracically to the neck might be of use. Reynolds 1.9 and Rienhoff20 have employed it in lower thoracic esophageal anastomoses with good results. Reynolds18 has also been compelled in one instance of an old left pulmonary tuberculosis with thoracoplasty to use a right thoracotomy incision for resection of a high esophageal lesion. It was possible
CARCINOMA OF CERVICAL ESOPHAGUS
95
to mobilize the stomach, bringing it up through the right chest, and perform a. cervical esophagogastric anastomosis successfully. The excellent work of Shapiro and Robillard22 has demonstrated that the blood supply to the esophagus is really a "shared vasculature." The surgeon's past anatomic appreciation of the blood supply to this structure has been that of a regional or segmental supply, and moderate mobilizations were feared with the danger of gangrene. Actually the blood supply is richer than generally believed. In the event of a contracted or foreshortened stomach, it would seem reasonable to leave the lower esophagus attached to the stomach and brought up through the chest into the neck for an end-to-end anastomosis. This has been done. It is desirable to arrest diaphragmatic motion to prevent both pull on the anastomosis and episodes of increased positive pressure on the stomach. To destroy the phrenic nerve we have adopted the policy of routinely removing a segment of the nerve rather than merely crushing the nerve with a hemostat. Catheter drainage in both the apex and costal phrenic angle assures adequate expansion of the lung and drainage. For the preoperative and postoperative care pertinent to this procedure one is referred to the work of Haight12 and Maier.15 REFERENCES 1. Adams, W. E. and Phemister, D. B.: Carcinoma of the Lower Thoracic
2.
3. 4.
5. 6. 7.
8. 9.
10.
Esophagus: Report of a Successful Resection and Esophagogastrostomy. J. Thoracic Surg. 7:621, 1938. Brewer, L. A., III: One-Stage Resection of Carcinoma of the Cervical Esophagus with Subpharyngeal Esophagogastrostomy. Ann. Surg. 130:1, 1949. Bricker, E. and Burford, T. H.: Use of Pedicle Tube Flap in Carcinoma of Upper Esophagus. Presented at Annual Meeting of the American Association for Thoracic Surgery (June 1) 1948. Brunschwig, A. and Camp, E.: One-stage Resection of Total Cervical Esophagus, Larynx, Base Tongue, Hypopharynx, Cervical Trachea and Bilateral Cervical Lymph Node Chains for Carcinoma Primary in Cervical Exophagus-Reconstruction of Cervical Esophagus. Laryngoscope. 57:305312,1944. Churchill, E. D. and Sweet, R. H.: Transthoracic Resection of Tumors of the Stomach and Esophagus. Ann. Burg. 115:897, 1942. Czerny, J.: Neue Operationen. Zentrabl. f. Chir. 4:433-434, 1877. Eggers, C.: Carcinoma of the Upper Esophagus and Pharynx. Ann. Burg. 81: 695, 1925. Evans, A.: Quoted by Turner. Recent Advances in the Treatment of Carcinoma of the Esophagus from the Surgical and Radiological Aspects. Proc. Roy. Boc. Med. 27:7-17,1934. Garlock, J. H.: Re-establishment of Esophagogastric Continuity Following Resection of Esophagus for Carcinoma of Middle Third. Surg., Gynec. & Obst. 78:23, 1944. Garlock, J. H.: Resection of Thoracic Esophagus for Carcinoma Located
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11.
12. 13. 14. 15. 16. 17. 18. 19.
20.
21.
22. 23. 24. 25. 26. 27. 28. 29.
30. 31. 32.
33. 34.
DANELY P. SLAUGHTER, ERWIN H. ROESER
above the Arch of Aorta: Cervical Esophagogastrostomy. Surgery. 24:1, 1948. Guisez, J.: Plusieurs cas de cancers de l'oesophage traites avec succes par,la radium therapie. Bull. et Mem. Soc. d. Chirurgiens de Parie. 22: 751-760, 1930. Haight, C.: Intratracheal Suction in the Management of Postoperative Pulmonary Complications. Ann. Surg. 107:218, 1938. Kirschner, M.: Ein neues Verfohern der Oesophagoplastik. Arch. f. klin. Chirungie. 114:606, 1920. Lenz, M.: Personal communication. Maier, H. C.: Preoperative, Operative and Postoperative Care in Esophareal Resection. Surgery. 23:884-892, 1947. Mikulicz, J.: Ein Fall von Resection des carcinomatosen Esophagus mit plastischen Ersatz des exciderdten Stiickes. Prag. med. Wchnschr. 11 :93,1896. Nissen, R.: Cervical Esophagogastrostomy Following Resection of SupraAortic Carcinoma of the Esophagus. Ann. Surg. 130:21, 1949. Reynolds, J.: Personal communication. Reynolds, J. and Yo un;!; , J.: Use of the Roux en Y in Extending the Operability of Carcinoma of Stomach and Lower-End of Esophagus. Surgery. 24:246, 1948. Rienhoff, W. F., Jr.: Intrathoracic Esophagojejunostomy for Lesions of the Upper Third of the Esophagus. South. M. J. 39:928, 1946. Scott, W. H., Jr., and Hanlon, C. R.: Simultaneous Cervical and Thoracic Approach for Resection of Carcinoma in the Upper Fourth of the Esopha;!;us. Ann. Surg. 131 :186, 1950. Shapiro, A. L. and Robillard, G. L.: The Esophageal Arteries. Ann. Surg. 131 :171, 1950. Stevenson, T. W.: Reconstruction of the Esophagus by a Skinlined Tube. Surg., Gynec. & Obst. 84:197-202, 1947. Sweet, R. H.: Carcinoma of the Superior Mediastinal Segment of the Esophagus. Surgery. 24:939, 1948. Sweet, R. H.: Surgical Management of Carcinoma of the Midthoracic Esophagus. New England J. Med. 23:31, 1945. Sweet, R. H.: The Treatment of Carcinoma of the Esophagus and Cardiac End of the Stomach by Surgical Extirpation. Surgery. 23:952, 1948. Torek, F.: Carcinoma of the Larynx, Trachea and Esophagus. Ann. Surg. 84:889,1926. Trotter, J.: Carcinoma of Cervical Esophagus. Lancet. 1:73, 1937. Von Hacker, V.: Ueber Resection und Plastic am Halsabschmitt der Speiserohreins besondere beim Carcinoma. Verhandl. d. deutsch. Gesillsch. f. Chir. Berl. 37:359--425, 1908. Watson, W. L. and Pool, J. L.: Cancer of Cervical Esophagus. Surgery. 23: 893-905, 1948. Wookey, H.: The Surgical Treatment of Carcinoma of the Pharynx and Upper Esophagus. Surg., Gynec. & Obst. 75:499, 1942. Wylie, R. H. and Frazell, E. L.: Cervical Esophagogastric Anastomosis Following Subtotal Resection of the Esophagus for Carcinoma. Ann. Surg. 130:1, 1949. Volliet and Kelling; Quoted by Yudin. Surgical Construction of 80 Cases of Artificial Esophagus. Surg., Gynec. & Obst. 78:561, 1944. Yudin, S. S.; Surgical Construction of 80 Cases of Artificial Esophagus. Surg., Gynec. & Obst. 78:561, 1944. .
Carcinoma of the cervical esophagus is not as frequent as cancer elsewhere in this organ; therefore few surgeons have extensive experience with such lesions. The surgical attack has been awkward until recent concepts of reconstruction were developed. Thus, most attempts at treatment have been through methods of irradiation, with only occasional success. Actually, surgical cure of cancer in the cervical esophagus is more feasible than in the thoracic portion because of the much wider lateral dissection and excision that can be accomplished in the neck. Adjacent organs, such as the larynx, trachea and thyroid, may be sacrificed and the regional node areas in both sides of the neck may be removed if indicated. The removal of such a wide "cancer field" is not possible in the tubular dissection required for excision of the thoracic esophagus. ETIOLOGY AND SYMPTOMATOLOGY
No specific agents or factors have been reported predisposing to the development of carcinoma of the esophagus, except the infrequent association with leukoplakia and Plummer-Vinson syndrome. Considerable mention has been made of the role played by various forms of chronic irritation in the development of new growths in the oral cavity. Among these are included intraoral sepsis, smoking, thermal irritation, and syphilis. It is reasonable to assume that they may playa similar role in the causation of epithelial change in the cervical esophagus. In this respect it is interesting to note that of sixteen cases of carcinoma of the esophagus with a second primary neoplasm reported by Watson,30 87.5 per cent had a primary intraoral carcinoma. This would appear to be more than a chance relationship. Actually, a lesion of considerable size may be present in the cervical esophagus before marked symptoms are manifested. The symptoms at first are indefinite and vague, and usually cause the patient little concern. They may be only a sense of throat irritation or slight discomfort in swallowing, not an uncommon From the University of Illinois College of Medicine, Chicago. * Assistant Professor of Surgery and Director of Tumor Clinic, University of Illinois College of Medicine, Research and Educational Hospitals; Attending Surgeon, St. Francis Hospital, Evanston, Illinois. t Clinical Assistant in Surgery, University of Illinois College of Medicine.
,85
86
DANELY P. SLAUGHTER, ERWIN H. ROESER
experience to most of us, which is discarded by the patient as a mild upper respiratory infection, excessive smoking, or fatigue. Although dysphagia is the most commonly associated symptom of carcinoma of the esophagus, it is a late manifestation of disease when the primary neoplasm is in the cervical esophagus. Here the esophageal wall is thin, flexible, and devoid of sensory nerve fibers. To cause obstruction to the passage of food may require a lesion involving a considerable segment of the esophageal wall. Pain and discomfort in the neck are usually late and from fixation or pressure on contiguous cervical structures. DIAGNOSIS
The early diagnosis of carcinoma of the cervical esophagus is a direct expression of the index of suspicion on the part of the medical examiner. A differential diagnosis from foreign body injury to the mucosa, globus hystericus, Plummer-Vinson syndrome and thyroid disorders should be made with reasonable dispatch after appropriate study. Examination should start with external neck palpation to discern the presence of goiter, cervical rib, lymph node hypertrophy, metastases, retropharyngeal abscess and contiguous esophageal tumors. Intraoral inspection may reveal leukoplakia, and the presence of multicentric epithelial change should be kept in mind. The integrity of the recurrent laryngeal nerves should be checked. Recently we have had three patients come to our attention who have had a high cervical transection or obliteration of one vagus nerve and manifested difficulty in swallowing and paresis of the laryngeal muscles. An x-ray of the cervical spine may show sufficient osteoarthritis in the aged with weight loss to be a cause of external esophageal pressure. Fluoroscopic study of the esophagus with a thick barium suspension is most important. Lateral views may be pathognomonic of an intraluminal defect. In all irregularities of the mucosal pattern and intraluminal projections it becomes mandatory to proceed further with direct esophagoscopy and biopsy study of any suspicious· change in the epithelium. Fluoroscopic study is expedient but not always conclusive. Once microscopic assay confirms toe presence of tumor, the appropriate modality of therapy should be instituted. TREATMENT
X-Ray Therapy. The treatment of cervical espphageal carcinoma by irradiation has been a most unhappy chapter. An appreciation of the natural history of epidermoid cancer in this structure may explain treatment failures. Life expectancy without treatment is about five to eight months from the onset of symptoms. There is no report of a large series of cases treated by irradiation alone. However, Watson30 reviewed
CARCINOMA OF CERVICAL ESOPHAGUS
87
seventy-eight cases of cervical esophageal carcinomas, twenty-eight of which were treated by radiation as the sole modality of therapy. In this group only four patients were living ten to fifty-six months later. In another group of twenty-seven cases in which the mode of therapy was gastrostomy plus irradiation, only six patients were living four to nineteen months later. Lenz l4 has treated four cases of postcricoid epithelioma by irradiation alone. One patient is living and well thirteen years after treatment. The other three lived from three months to six years before dying of recurrent disease. Metastases to lymph nodes are fairly early and may well be bilateral. The nodes most commonly involved are the deep jugular, supraclavicular and prevertebral. In Watson's80 group, 22 per cent had discernible nodes on their initial examination. Symptoms of esophageal obstruction may be ameliorated in 75 per cent of the cases from irradiation alone. Life expectancy in this group is about fourteen months. Gastrostomy actually increases the expectancy very little, since the patient still dies from aspiration pneumonia, sudden hemorrhage, carcinomatosis or cachexia. As yet we have treated no cases with the betatron, and it is doubtful if there will be any significant increase in survival rate. Esophageal carcinoma is a radiosensitive and, hence, a potentially curable tumor when favorable factors of the disease are combined with diligently planned irradiation. The studious work of Guisezll .in the repeated use of curietherapy on esophageal carcinomas has yielded encouraging results in a few selected cases. External therapy is limited by the inability to deliver a uniform tumorocidal dose in most cases. Submucosal extensions of the tumor are frequently completely missed in the field of therapy. Intraluminal curietherapy employing a radium bougie has met universal failure and ·frequently is complicated by fatal perforation. The authors have used interstitial irradiation through an esophagoscope or open thoracotomy with only palliative results. Surgical Management. Until recently cervical esophagus carcinoma has been predominantly treated. by irradiation. However, this lesion was first surgically resected by Czerny 6 in 1877. At that time he resected a segment of esophagus 6 cm. in length. The distal orifice was left open in the lower neck as an expedient to feeding. The patient not only survived the operative procedure, but lived fifteen months before dying of recurrent cancer. Mikulicz 16 in 1884 also resected the cervical esophagus and, in addition, completed a plastic skin repair which permitted eating solid food for a short time. His patient died sixteen months later of recurrent disease. Von Hacker29 in 1908 further advanced the operative attack on this tumor by an en bloc excision of both larynx and esophagus. Reports of long-term surgical survivals are first noted in 1934 by Evans, 8 who reported a twenty-three year survival, and by Trotter8 in 1937,
88
DANELY P. SLAUGHTER, ERWIN H. ROESER
who reported a ten year survival after surgical excision of carcinoma of the cervical esophagus. An excellent review of the surgical development of the treatment of carcinoma of the cervical esophagus is reported by Watson and Poo1.30 The primary design of any surgical attack on cervical esophageal carcinoma is for its complete extirpation at the sacrifice of contiguous cervical structures if necessary. Due to current developments in the ancillary surgical sciences, especially anesthesia, antibiotics and fluid balance, an aggressive and radical approach to this lesion is now possible and fulfills the prerequisite of a cancer operation. The primary tumor may be widely resected in continuity with its regional lymphatic drainage, as with an associated radical neck dissection, with a surprisingly low mortality. Interest in reconstructing the cervical gullet has been somewhat lacking, due to the previously high incidence of recurrence. The literature is replete with reports of challenging ingenuity in attempts to re-establish pharyngeal-gastric continuity .. In general there have developed four surgical technics for the ablation of this lesion. Esophagotomy with Local Resection and Primary Restoration of Luminal Continuity. This is the simplest approach. A suitable incision may be made along the anterior border of the sternocleidomastoid muscle and the esophagus mobilized in the usual manner. Preferably a rectangular flap of skin and platysma with its base laterally is developed, so that, in the event a more formidable esophageal resection is necessary, the flap may be employed in an immediate plastic repair. This procedure offers only a minimal resection of the esophagus, but has an occasional indication in instances of an early tumor limited to the mucosa. The authors have employed this procedure in the excision of a pedunculated adenocarcinoma with excellent results. The following case is reported because of its unusual character, and to illustrate that adenocarcinoma can occur primarily in the esophagus. Such tumors arise from the mucus-secreting glands located in the submucosa. CASE REPORT. S. K, about 50 years of age, was born and reared in Germany. During late childhood she contracted tuberculosis, and there subsequently developed multiple cervical nodes and sinuses. She was given a course of unfiltered x-ray therapy to the involved cervical nodes. Four years ago multiple areas of radionecrosis of the skin were excised and replaced with skin grafts. In July of 1949 she rf;lgurgitated her food on several occasions, and flecks of bright red blood were n9ted. On two occasions several tablespoonfuls of dark clotted blood· were regurgitated. A fluoroscopy of the stomach and colo~ was reported as
CARCINOMA OF CERVICAL ESOPHAGUS
was effected. A small drain was placed
to the area of the esophagotomy. The postoperative convalescence was without event, and the wound healed primarily in spite of the presence of severe latent radiation damage. It was judged reasonable to excise this tumor locally because of its discreteness and low grade malignant potential.
90
DANELY P. SLAUGHTER, ERWIN H. ROESER
Surgical Construction of Artificial Esophagus by Mobilizing Parts of Alimentary Tract. In the surgeon's attempt to restore esophageal continuity after resection, the host of procedures developed bear witness to. their frequent failures. The frequency of caustic strictures of the esophagus and the resourceful ingenuity of the responsible surgeon have led to numerous developments in re-establishing esophageal continuity. Antethoracic and plastic skin tubes advocated by Mikulicz,16 Eggers,7 Trotter,28 Bricker,S Stevenson,2S Torek27 and von Hacker29 all have the inherent disadvantage of cicatrical stenosis. To answer this problem,
~,
----"Tt
i
/5ubcut. jejunum __ -j
i
J.
I
if)
Fig. 27.
Fig. 28.,
Fig. 27. The Carrol-Beck-Halpern cutaneous tube connecting cervical esophagus with stomach. Flap of stomach wall has been fashioned into a tube and anastomosis made extraperitoneally. Fig. 28. The Yudin artificial esophagus employing jejunum tunneled subcutaneously under skin.
attempts were made to bring up subcutaneously in the anterior thoracic wall various parts of the alimentary tract. In this regard the following have been mobilized: stomach, colon, and jejunum by Kirschner,13 Vulliet and Kelling,3S and Yudin,s4 respectively. Of these procedures, Yudin's34 modification of Roux's principle (Figs. 27, 28) has been the most satisfactory. He subcutaneously tunneled the jejunum from abdomen to neck for a direct esophageal anastomosis of mucosa to mucosa;. The pitfalls and l~itations of the tunneling procedures have been excessive fat in th~ mesentery, narrowness of mesentery, and poor' distribution of the arterial arcades. Complications have been narroWing
CARCINOMA OF CERVICAL ESOPHAGUS
91
of stoma, ulceration, fistula and late intestinal necrosis from retrograde thrombosis. Local Resection and Primary Repair Employing Cervical Skin 'Flap. Next of significant import was a procedure developed by Watson30 and Wookey31 in 1942, and later Brunschwig.4 The previous authors independently developed a technic of local resection of the cervical esophagus and primary repair of the gullet defect employing a rectangular cervical skin flap (Fig. 29). In this procedure a rectangular flap of skin
Cut edqe of 'thyroid
I
Recurrent larynQeal n. Fig. 29. Modified Wookey procedure using rectangular skin flap. Lobe of thyroid removed for exposure.
and platysma based on the lesser side of the tumor prominence is developed. The esophagus is mobilized, and tapes are placed around it for traction. The pharynx may now be divided below the hyoid bone and the esophagus transected a suitable distance below the tumor. If nodes are discernibly involved, one continues with an en bloc resection of the esophagus and radical neck dissection. If the larynx or postcricoid space is involved, the larynx is likewise condemned and laryngectomy performed. In this case the trachea is freed and divided below the cricoid with a sterile intratracheal tube with inflatable cuff inserted into the
92
DANELY P. SLAUGHTER, ERWIN H. ROESER
distal trachea. A tracheostomy is always performed at the end of the procedure. Once the diseased tissue is removed, the skin flap is placed across the prevertebral space and sutured into position by interrupted catgut sutures (Fig. 30). The upper edge of the skin flap is sutured to the cut
Skin flap 5utured to proximal and di stal ILnds of (Z $opha Q'lLal orifices
\ Fig. 30. Skin flap is sutured to hypopharynx above and esophagus below. Note incomplete closure of tube and skin graft to defected area (Inset).
end of the pharynx and the lower edge to the esophagus. The closure is not completed because of the gross contamination of the surgical field, and a lateral sinus or cleft is left which is easily closed at a second stage. A Levin tube is inserted transnasally into the stomach. The remaining raw surface is covered with a split thickness skin graft. To date this procedure is the most practical yet devised for this tumor site, since it is accompanied by a low mortality, lends itself well to the radical resec-
CARCINOMA OF CERVICAL ESOPHAGUS
93
tions frequently necessary, establishes a primary reconstruction of the gullet, and may be completed in a short hospital stay. This procedure, however, cannot be employed when the site of the tumor is low in the neck near the thoracic inlet, since adequate resection will require excision of the upper mediastinal esophagus. Bricker3 has recently cir-' cumvented this situation by devising pedicled, inverted skin tubes which he has successfully interposed between the mediastinal esophagus or stomach distally, and the proximal esophageal stump. Cervical Gastroesophagostomy. Adams and Phemisterl initiated the fourth phase of the surgical attack on cervical esophageal carcinoma by their original work on cardioesophagectomy. Garlock,9 Sweet25 • 26 and Churchil15 further advanced this procedure by their progressively higher cardioesophageal anastomoses following resection of the thoracic esophagus. In 1948 Garlock1o and Sweet,24 both confronted with an esophageal carcinoma at the thoracic inlet, mobilized the stomach sufficiently to effect an anastomosis above the level of the tumor. Since then Wylie and Frazell,32 Brewer,2 Scott,21 Nissen l7 and others have accomplished the same procedure. It is interesting to note that Kirschner13 in 1920 performed a cervical gastroesophagostomy by mobilizing the stomach, as is so popular today, and tunneled the same subcutaneously across the thorax to the neck. The transthoracic route was purposely avoided. The procedure advocated by Garlock lO and Sweet21 is one of both merit and magnitude. These authors give a rather detailed description of their technic and the reader is referred to their work for particulars. Common to most of the reported cases has been the problem of bronchial secretions, pneumonia and coughing. Vigorous and persistent tracheobronchial aspirations usually were necessary. The authors have found it extremely expedient to employ a tracheostomy for this purpose alone when there has been extensive transthoracic manipulation or mobilization of the stomach. The need for tracheal and bronchial aspirations may then be performed simply by catheter suction by the attendant nurse at any hour of the day and as frequently as indicated. It is also advantageous to explore the cervical tumor first through a neck incision. Once the operability is determined, the wound is covered with a towel and the patient placed for thoracotomy. The eighth intercostal space has been excellent. This would at first seem low, but the actual anastomosis is performed in the cervical area and the lower thoracotomy incision facilitates mobilization of the stomach and esophagus (Fig. 31). Recently there has been comment on the ultimate position of the stomach. Some have felt that it should be placed posterior to the aorta. This not only gives 2 or 4 cm. more in length, but the aortic arch itself
94
DANELY P. SLAUGHTER, ERWIN H. ROESER
may actually act as a valve and help to reduce gastric reflux. It would seem that some regurgitation of gastric contents may be from the absence of sphincter, atony of the stomach (vagus interruption) and positive pressure during coughing, but this has not been of great concern. Care should be exercised to preserve and identify the recurrent nerve and thoracic duct. The vagi may be cut below the level of bifurcation of the trachea. A generous cuff of omentum left on the stomach will aid in maintaining blood supply to the stomach and may also be used to reinforce the anastomosis. Closure of the mediastinal pleura about
Fig. 31. Diagramatic outline of cervical gastroesophagostomy. Cardia has been closed and fundus of stomach brought up into neck for anastomosis through separa te incision.
the stomach at the thoracic inlet will tend to isolate the cervical region from the thorax. It would seem prudent to obtain a preoperative x-ray of the stomach to determine its size, since it is doubtful if a small or contracted stomach can be mobilized sufficiently for a cervical anastomosis. In this event the Roux en-Y procedure employing the jejunum transthoracically to the neck might be of use. Reynolds 1.9 and Rienhoff20 have employed it in lower thoracic esophageal anastomoses with good results. Reynolds18 has also been compelled in one instance of an old left pulmonary tuberculosis with thoracoplasty to use a right thoracotomy incision for resection of a high esophageal lesion. It was possible
CARCINOMA OF CERVICAL ESOPHAGUS
95
to mobilize the stomach, bringing it up through the right chest, and perform a. cervical esophagogastric anastomosis successfully. The excellent work of Shapiro and Robillard22 has demonstrated that the blood supply to the esophagus is really a "shared vasculature." The surgeon's past anatomic appreciation of the blood supply to this structure has been that of a regional or segmental supply, and moderate mobilizations were feared with the danger of gangrene. Actually the blood supply is richer than generally believed. In the event of a contracted or foreshortened stomach, it would seem reasonable to leave the lower esophagus attached to the stomach and brought up through the chest into the neck for an end-to-end anastomosis. This has been done. It is desirable to arrest diaphragmatic motion to prevent both pull on the anastomosis and episodes of increased positive pressure on the stomach. To destroy the phrenic nerve we have adopted the policy of routinely removing a segment of the nerve rather than merely crushing the nerve with a hemostat. Catheter drainage in both the apex and costal phrenic angle assures adequate expansion of the lung and drainage. For the preoperative and postoperative care pertinent to this procedure one is referred to the work of Haight12 and Maier.15 REFERENCES 1. Adams, W. E. and Phemister, D. B.: Carcinoma of the Lower Thoracic
2.
3. 4.
5. 6. 7.
8. 9.
10.
Esophagus: Report of a Successful Resection and Esophagogastrostomy. J. Thoracic Surg. 7:621, 1938. Brewer, L. A., III: One-Stage Resection of Carcinoma of the Cervical Esophagus with Subpharyngeal Esophagogastrostomy. Ann. Surg. 130:1, 1949. Bricker, E. and Burford, T. H.: Use of Pedicle Tube Flap in Carcinoma of Upper Esophagus. Presented at Annual Meeting of the American Association for Thoracic Surgery (June 1) 1948. Brunschwig, A. and Camp, E.: One-stage Resection of Total Cervical Esophagus, Larynx, Base Tongue, Hypopharynx, Cervical Trachea and Bilateral Cervical Lymph Node Chains for Carcinoma Primary in Cervical Exophagus-Reconstruction of Cervical Esophagus. Laryngoscope. 57:305312,1944. Churchill, E. D. and Sweet, R. H.: Transthoracic Resection of Tumors of the Stomach and Esophagus. Ann. Burg. 115:897, 1942. Czerny, J.: Neue Operationen. Zentrabl. f. Chir. 4:433-434, 1877. Eggers, C.: Carcinoma of the Upper Esophagus and Pharynx. Ann. Burg. 81: 695, 1925. Evans, A.: Quoted by Turner. Recent Advances in the Treatment of Carcinoma of the Esophagus from the Surgical and Radiological Aspects. Proc. Roy. Boc. Med. 27:7-17,1934. Garlock, J. H.: Re-establishment of Esophagogastric Continuity Following Resection of Esophagus for Carcinoma of Middle Third. Surg., Gynec. & Obst. 78:23, 1944. Garlock, J. H.: Resection of Thoracic Esophagus for Carcinoma Located
96
11.
12. 13. 14. 15. 16. 17. 18. 19.
20.
21.
22. 23. 24. 25. 26. 27. 28. 29.
30. 31. 32.
33. 34.
DANELY P. SLAUGHTER, ERWIN H. ROESER
above the Arch of Aorta: Cervical Esophagogastrostomy. Surgery. 24:1, 1948. Guisez, J.: Plusieurs cas de cancers de l'oesophage traites avec succes par,la radium therapie. Bull. et Mem. Soc. d. Chirurgiens de Parie. 22: 751-760, 1930. Haight, C.: Intratracheal Suction in the Management of Postoperative Pulmonary Complications. Ann. Surg. 107:218, 1938. Kirschner, M.: Ein neues Verfohern der Oesophagoplastik. Arch. f. klin. Chirungie. 114:606, 1920. Lenz, M.: Personal communication. Maier, H. C.: Preoperative, Operative and Postoperative Care in Esophareal Resection. Surgery. 23:884-892, 1947. Mikulicz, J.: Ein Fall von Resection des carcinomatosen Esophagus mit plastischen Ersatz des exciderdten Stiickes. Prag. med. Wchnschr. 11 :93,1896. Nissen, R.: Cervical Esophagogastrostomy Following Resection of SupraAortic Carcinoma of the Esophagus. Ann. Surg. 130:21, 1949. Reynolds, J.: Personal communication. Reynolds, J. and Yo un;!; , J.: Use of the Roux en Y in Extending the Operability of Carcinoma of Stomach and Lower-End of Esophagus. Surgery. 24:246, 1948. Rienhoff, W. F., Jr.: Intrathoracic Esophagojejunostomy for Lesions of the Upper Third of the Esophagus. South. M. J. 39:928, 1946. Scott, W. H., Jr., and Hanlon, C. R.: Simultaneous Cervical and Thoracic Approach for Resection of Carcinoma in the Upper Fourth of the Esopha;!;us. Ann. Surg. 131 :186, 1950. Shapiro, A. L. and Robillard, G. L.: The Esophageal Arteries. Ann. Surg. 131 :171, 1950. Stevenson, T. W.: Reconstruction of the Esophagus by a Skinlined Tube. Surg., Gynec. & Obst. 84:197-202, 1947. Sweet, R. H.: Carcinoma of the Superior Mediastinal Segment of the Esophagus. Surgery. 24:939, 1948. Sweet, R. H.: Surgical Management of Carcinoma of the Midthoracic Esophagus. New England J. Med. 23:31, 1945. Sweet, R. H.: The Treatment of Carcinoma of the Esophagus and Cardiac End of the Stomach by Surgical Extirpation. Surgery. 23:952, 1948. Torek, F.: Carcinoma of the Larynx, Trachea and Esophagus. Ann. Surg. 84:889,1926. Trotter, J.: Carcinoma of Cervical Esophagus. Lancet. 1:73, 1937. Von Hacker, V.: Ueber Resection und Plastic am Halsabschmitt der Speiserohreins besondere beim Carcinoma. Verhandl. d. deutsch. Gesillsch. f. Chir. Berl. 37:359--425, 1908. Watson, W. L. and Pool, J. L.: Cancer of Cervical Esophagus. Surgery. 23: 893-905, 1948. Wookey, H.: The Surgical Treatment of Carcinoma of the Pharynx and Upper Esophagus. Surg., Gynec. & Obst. 75:499, 1942. Wylie, R. H. and Frazell, E. L.: Cervical Esophagogastric Anastomosis Following Subtotal Resection of the Esophagus for Carcinoma. Ann. Surg. 130:1, 1949. Volliet and Kelling; Quoted by Yudin. Surgical Construction of 80 Cases of Artificial Esophagus. Surg., Gynec. & Obst. 78:561, 1944. Yudin, S. S.; Surgical Construction of 80 Cases of Artificial Esophagus. Surg., Gynec. & Obst. 78:561, 1944. .