- Email: [email protected]
Obstructing Lesions of the Esophagus
Obstructing Lesions of the Esophagus HERBERT D. ADAMS, M.D.
BENIGN LESIONS
Congenital Atresia of the Esophagus
In the newborn infant it is important to be aware that atresia of the esophagus is a relatively common congenital lesion and to recognize the characteristic symptoms and clinical signs so that a prompt diagnosis can be made, which is so essential to effective and satisfactory treatment. Excess mucus, episodes of cyanosis, inability to take fluid, regurgitation, vomiting and spasmodic coughing should at least suggest the presence of an atresia of the esophagus since this lesion must be recognized early before much aspiration has taken place and aspiration pneumonia has developed. Frequently, the diagnosis can be made on history and physical signs alone but usually an x-ray examination is necessary to establish this diagnosis definitely. This is best accomplished by instillation of a few drops of radiopaque medium through a small catheter, aspirating as much as possible of this after the roentgenogram has been taken. This roentgenologic study should demonstrate the size and level of the upper pouch and any fistula between this pouch and the tracheobronchial tree (Figs. I, a and b). In addition, almost all will show x-ray signs of atelectasis and varying degrees of aspiration pneumonia. A plane film of the abdomen is also of considerable value since the presence of air in the stomach and gastrointestinal tract is definite evidence of a fistula between the lower segment and the tracheobronchial tree. The absence of air in the gastrointestinal tract, however, does not always rule out such a communication. In the majority of these lesions, over 90 per cent, the esophagus ends in a high, blind pouch in the posterior superior mediastinum and the lower segment originates in a fistula from the membranous trachea or the carina or primary bronchus (Fig. 2). Accurate analysis of the type of lesion is, of course, very important primarily in the selection of the particular operation that will produce the best result with the lowest mortality in these delicate situations. A number of factors will very definitely influence the survival rate in
773
774
HERBERT
D.
ADAMS
Fig. 1. Congenital atresia of the esophagus of the commonest type. a, The upper pouch; note large amounts of gas in the intestinal tract, indicating a fistula between the lower segment and the tracheobronchial tree. b, Postoperative film; the atresia has been corrected and functioning continuity of the esophagus re-established.
this condition. One has already been mentioned-early and prompt diagnosis-since a delay in diagnosis and treatment, and the associated sepsis, pneumonia and deterioration in the nutritional status of the infant will result in a high mortality. Second, prematurity and a very low birth weight also increase the risk considerably. Third, the preoperative care and preparation of these patients are likewise of considerable importance in their survival and in obtaining satisfactory results. Once the diagnosis has been established nothing should be given orally, suction should be utilized regularly; the infant should be placed in an incubator with oxygen, the dehydration corrected, and administration of antibiotics started to control the associated infection and pneumonia. The fourth factor of great importance is the fact that other congenital malformations are present in a high percentage of these patients; at least 25 per cent will have significant, serious anomalies of other systems, such as cardiovascular, gastrointestinal, neurological and urological lesions. Fifth and finally, the details of the postoperative care are of extreme importancecontinuing with the oxygen, continuous special nursing care, suctioning, nothing by mouth for ten to 14 days and careful control of parenteral fluids and electrolytes. In infants whose birth weight is low and nutrition poor initially, the judicious use of gastrostomy so that feeding may be started within 48 hours or so after the operation may be helpful in these poor-risk patients. It is important to point out that gastrostomy alone should not be performed in those patients who have a tracheal or bronchoesophageal fistula since they will die of sepsis and pneumonia.
Obstructing Lesions of the Esophagus
775
CONGENITAL ATRESIA OF ESOPHAGUS COMMON TYPES
!
RARE TYPES
Fill;. 2. Common and rare types of congenital atresia of the esophagus; over 90 per cent are of the type (see 1) shown first in this drawing.
The accepted and preferred management of esophageal atresia with tracheo-esophageal fistula is primary anastomosis after the fistula has been divided and closed. Earlier in our experience with this condition this procedure was done by a retropleural approach, but at the present time these operations are carried out transpleurally under endotracheal cyclopropane. High mobilization of the upper pouch with closure of the
776
HERBERT
D.
ADAMS
fistula into the trachea is performed as soon as possible to provide better control of anesthesia and secretions, the lower segment is mobilized and a two-layered anastomosis is carried out. Primary anastomosis is usually possible, although extensive transpleural mobilization of both distal and proximal ends of the esophagus may be necessary to bring the two segments together without undue tension, using great care to maintain an adequate blood supply to the segments. A primary and uncomplicated esophageal anastomosis is rarely possible in patients with atresia not accompanied by a tracheopharyngeal fistula since these segments are usually widely separated. Likewise, infants who do not have air in their stomach usually have only a very rudimentary and short lower esophagus that will not permit primary anastomosis without mobilization of the stomach and its displacement into the thorax, which is not well tolerated by the newborn infant. In general, in infants with this type of congenital lesion, that is, without esophagotracheal fistula from either the upper or lower segments of the esophagus, it is best to do a gastrostomy and at that time carry out a retrograde bougienage to help determine the length of the lower segment. If it is very short, a cervical esophagostomy is done, with a second staged interposition of the large bowel to bridge this defect. As stated before, gastrostomy alone is rarely used except in the occasional case in which a fistula does not exist, and the esophageal ends are widely separated. The two stage procedure just described is the most satisfactory operation under these conditions. The best results in congenital atresia of the esophagus, therefore, depend upon early diagnosis, careful preoperative management, a very careful estimate of the type of lesion present so that the proper operative procedure can be applied, and extreme care in the postoperative management. The great majority of these lesions are associated with esophagotracheal fistula and therefore are suitable for closure of the fistula and primary anastomosis of the esophagus. Chemical or Caustic Strictures
Another type of benign stricture of the esophagus is caused by the ingestion of caustic chemicals. This type invariably goes through an acute phase with various complications and frequently terminates in a true cicatricial stricture of the esophagus involving a considerable length of this structure (Fig. 3). The quantity and type of chemical swallowed and the immediate care will determine the degree of the initial damage to the esophagus. The administration of antibiotics will also help to prevent progressive damage and additional stricturing from superimposed infection. Steroid treatment during the acute phase may also be of aid in reducing the ultimate tendency toward the more severe degrees of stricture. Following the emergency administration of antidotes or neutralizers of
Obstructing Lesions of the Esophagus
777
Fig. 3. Caustic stricture (a) in a child and (b) in an adult; both required esophageal resection.
the particular chemical ingested and treatment of shock or systemic reactions, the esophagus should be put at rest by simple gastrostomy. Such a gastrostomy should be simply the insertion of a number 24 to 30 mushroom catheter in the anterior surface of the distal third of the stomach by means of a double inverting purse-string catgut suture. In closing the peritoneum with interrupted catgut sutures the suture immediately above and below the tube should include the wall of the stomach to bring it up to the undersurface of the peritoneum (Fig. 4, C). This is done so that the tube can be removed or replaced easily, especially for retrograde periodic dilatations over a string if necessary. Complicated types of gastrostomy should be avoided and even the simple type just described should be carried out with great care to avoid poor healing, leakage and complications that are difficult to manage. With the proper immediate care and judicial dilatations of the stricture a good result can be obtained in many cases, but in intractable cases subsequent operations become necessary. Thoraco-abdominal resection of a destroyed and functionless esophagus and replacement with the stomach, colon, or jejunum, according to the surgeon's preference, should be performed. In our experience replacement with the stomach has been satisfactory. Because of the problem of postoperative reflux and esophagitis, however, a vagotomy and pyloroplasty must be done simultaneously if the stomach is used. The use of the colon as a replacement has also proved very satisfactory. Peptic Esophagitis
Peptic esophagitis of varying degrees may produce obstruction and
778
HERBERT
D.
ADAMS
Fig. 4. The technique of simple gastrostomy. A, Location of abdominal and gastric incisions. B, Insertion of mushroom catheter in the stomach by a double purse-string. C, Closure of the peritoneum bringing the stomach wall up to its under surface.
dysphagia. This is commonly associated with hiatus hernia and reflux and particularly with the ulcer diathesis, with or without a demonstrable peptic ulcer. This esophagitis may be only mild and produce minimal distress and dysphagia. We have seen a number of patients, however, in whom the esophagitis was so severe that dysphagia was marked and an acute stricture of the lower esophagus was present (Fig. 5). The treatment consists of rigid ulcer management and careful esophageal dilatations under the protection of antibiotics. We have not seen this particular type of esophagitis with acute stricture progress to the
Obstructing Lesions of the Esophagus
779
Fig. Fig.5.5.Peptic Pepticesophagiti esophagitiswith with characteristic characteristic stricture stricture associassociated ated with with ulcer ulcer diathesis; diathesis; satissatisfactorily byaarigid rigidulcer ulcer factorilytreated treatedby regimen anddilatation. dilatation. regimenand
Fig. 6. Peptic esophagitis associated with ulcer diathesis and hiatus hernia. Recurrences satisfactorily treated by dilatations for many years, but eventually hemigastrectomy, vagotomy and repair of hiatus hernia were required.
780
HERBERT
D.
ADAMS
permanent cicatricial type which requires resection, except in those instances in which it is associated with hiatus hernia and recurrent ulceration of the distal portion of the esophagus. In recurring severe degrees of reflux esophagitis associated with hiatus hernia and ulcer diathesis (Fig. 6), operation should be advised before permanent, advanced, cicatricial changes have taken place in the lower esophagus and cardia. Various operations have been used to correct this condition-hemigastrectomy, vagotomy and repair of the hiatus hernia; pyloroplasty, vagotomy and repair of hiatus hernia; and interposition of the colon. It is most important to correct the ulcer diathesis as well as the reflux in these severe cases if good permanent results are to be obtained. For this reason we have selected hemigastrectomy, vagotomy and repair of hiatus hernia as the procedure of choice in this complex situation. Achalasia of the Esophagus
Achalasia or malfunctioning esophagus is a broad term. The condition may be caused by a variety of lesions involving the lower esophagus and cardia. These different etiologic lesions must be carefully distinguished if the correct treatment is to be carried out and good and lasting results obtained. When an accurate appraisal of the causative factor of the achalasia has not been made there is considerable confusion regarding the surgical procedure of choice and wide variation in the results obtained by a given operative procedure. Most of the operations now used are effective when applied in properly selected cases but the real difficulty and poor results have come from classifying all cases of the achalasia as due to cardiospasm and applying one procedure, such as myotomy, in the treatment of all patients. True cardiospasm, without ulceration and without advanced cicatricial changes which may develop and eventually become intractable after many years of successful dilatation, may be well handled by periodic dilatation, including the use of the Plummer dilator (Fig. 7). This treatment has been reported effective in 65 to 85 per cent of the cases; the details of this procedure are given under a separate heading by Dr. Lathrop. In the more refractory cases and in patients who, for one reason or another, do not want or cannot continue periodic dilations indefinitely, a myotomy (Heller operation) at the esophagogastric junction is indicated (Fig. 8). This procedure should not be used, however, when ulceration or advanced organic cicatricial stricture of the lower end of the esophagus is present. If the results of myotomy are to be permanently successful, the hiatal hernia produced by this operation must be carefully repaired or subsequent reflux esophagitis will compromise the result. In addition, in our experience it is important to study the patient adequately to rule out an associated ulcer diathesis. If this is present, vagotomy and pyloroplasty should be performed in addition to the
Obstructing Lesions of the Esophagus
781
Fig. 7. Achalasia due to cardiospasm, successfully treated by dilatations.
Fig. 8. Heller operation. Myotomy at the esophagogastric junction. Note most of the myotomy is on the esophageal side of the esophagogastric junction.
782
HERBERT
D.
ADAMS
Fig. 9. a, Achalasia caused by a congenital aganglionic segment of the lower esophagus, treated by resection and pyloroplasty. b, Postoperative chest film following resection of the large redundant and saccular section of the esophagus, with correction of the dilatation and poor function of the upper segment.
myotomy or serious difficulties will be encountered and the symptoms will eventually recur. Under these conditions an abdominal approach is preferable so that pyloroplasty can be properly done simultaneously. From this discussion it is apparent that the Heller operation has definite deficiencies which it is well to emphasize: (1) failure to repair the resulting hiatus hernia; (2) subsequent reflux esophagitis and recurrence of symptoms and (3) failure to correct the associated ulcer diathesis or to recognize advanced, irreversible, organic changes in the distal esophagus or cardia. When such a true cicatricial stricture is present only resection of the distal end of the esophagus and cardia, esophagogastric anastomosis, vagotomy and pyloroplasty will give a good lasting result. Finally, the true mega-e8ophagu8 is commonly placed in this category of achalasia, that is, the tremendously dilated and saccular, the functionally totally disorganized esophagus (Fig. 9). In our experience this should be considered an entirely separate entity. Its etiology is similar to that of Hirschsprung's disease of the colon and the obstruction is the result of a congenital aganglionic segment of the lower end of the esophagus which acts as a nonfunctioning obstructing segment, causing in time the extreme degrees of esophageal dilatation seen in these cases. This condition is exactly the same as that seen in the colon due:to an identical aganglionic segment in the rectum. These cases can be readily distinguished from cardiospasm by the huge saccular dilatations and the fact that the obstructing segment can be readily dilated and a large esophagoscope passed through it without resistance; and at the same time the
Obstructing Lesions of the Esophagus
783
dilatation accomplishes only the most transient, if any, improvement in the dysphagia. This is in marked contrast to cardiospasm in which definite and proportionate improvement is obtained in the dysphagia, depending on the degree of the dilatation. Another important mechanical factor must also be clearly recognized, that is the huge, tortuous, lower saccular esophagus lying completely across the right diaphragm and extending to the right chest wall in many cases which, when filled with liquid and food, distorts, angulates and obstructs the outflow tract through the cardia, much as a large diverticulum may obstruct the esophagus at other levels (Fig. 10). To correct both of these important obstructing factors, that is, the aganglionic nonfunctioning segment and the obstruction produced by the weight of this huge sacculation, the operation that has produced the best and most lasting results in our hands has been resection of the lower half of the esophagus including this huge lower sacculation, an esophagogastric anastomosis immediately below the arch of the aorta, vagotomy and pyloroplasty. In these cases the pylorus has usually been so far to the right that the esophageal resection has been carried out through a transthoracic approach and the chest closed. The patient is then moved
Fig. 10. Line drawing of a case of achalasia (shown in Fig. 9, a) to illustrate segment of esophagus that was resected (shaded area).
784
HERBERT
D.
ADAMS
Fig. 11 Fig. 12 Fig. 11. Gross specimen of segment resected showing the obstructing aganglionic segment immediately above the cardia and the tremendous hypertrophy of the esophagus proximal to this segment. Fig. 12. Characteristic x-ray appearance of an esophageal web.
to the prone position and a pyloroplasty meticulously carried out through a right upper rectus, paramedian, abdominal incision. In cases of mega-esophagus (similar to megacolon) there is congenital absence of Auerbach's plexus in the lower end of the esophagus, confirmed by microscopic studies of operative specimens, and this portion of the esophagus therefore acts as an obstructing nonfunctioning segment (Fig. 11). Most of these patinets have had this condition all their life and in many instances have reached young adulthood before they finally sought medical advice and help with their problem. They have been able to adjust their eating so that enough food gets through the cardia to maintain nourishment in spite of this greatly dilated esophagus. As a group they become very unhappy individuals, shunning society, and enduring considerable distress, but adjust to these problems until eventually food and fluid begins to spill over into their lungs especially during their sleep and extensive chronic pneumonitis develops. Several
Obstructing Lesions of the Esophagus
785
of these patients have come to us primarily because of the resulting associated dyspnea that has distressed them. Once this tremendous dilatation of the true mega-esophagus develops, especially if an associated aspiration pneumonitis begins, the surgical correction of this condition becomes urgent. The treatment of choice in these cases is careful preparation by decompression and aspiration of the esophagus, and eventual extensive resection, as described. In several of our patients the esophagus was so tremendously dilated and so much associated pneumonitis was present that it was necessary to put the esophagus totally at rest by gastrostomy and to improve the patient's general condition and nutrition for some months before surgical resection was undertaken. Miscellaneous Obstructing Lesions of the Esophagus
A number of rare forms of benign lesions produce symptoms of esophageal obstruction. First there are webs at different levels of the esophagus which eventually produce symptoms sufficiently severe to require treatment. They can be demonstrated on the roentgenogram (Fig. 12). Treatment consists of simple partial excision and division of the webs through the esophagoscope. Another lesion that is occasionally seen is the esophagus lined with gastric mucosa in its distal two-thirds with obstruction at the proximal junction. Usually, it is not associated with frank ulceration and is managed satisfactorily by dilatation and diet. Finally there is the so-called Schatski ring usually associated with a hiatus hernia; it may be a web at the cardio-esophageal junction, but it is a controversial lesion. Benign Tumors
Probably the most common obstructive lesion of the esophagus is tumor. Such tumors may be the result of extension and secondary to a primary lesion in some other organ closely related anatomically to the esophagus, such as the bronchus, or they may be primary in the esophagus itself. The commonest form of primary tumor of the esophagus, of course, is carcinoma. Occasionally, however, benign tumors are found and because of their rarity and their amenability to permanent cure they are of considerable interest. Benign tumors not only are rare but their recognition at times is difficult owing to the lack of symptoms and signs. They are of prime surgical importance because of the necessity to distinguish them from malignant lesions of the esophagus, because of their potential malignancy and finally because symptoms associated with such tumors may be relieved and cured by operation. Clinically, benign esophageal tumors are of two types: (1) mucosal and (2) extramucosal or intramural tumors. Mucosal tumors arise from either the mucosa or submucosa, and may be sessile or pedunculated (Fig. 13). They include the polyps, adenoma, and papilloma. Intramural tumors arise from the extramucosal layers of the esophageal wall and are less common than the mucosal types. They are, in order of frequency, the
786
HERBERT
D.
ADAMS
Fig. Fig. 13. 13. Pedunculated Pedunculated esophageal esophageal polyp. polyp.
Typicalappearance appearanceofofleiomyoma leiomyomaofofthe themid midesophagus. esophagus.This Thispatient patientwas was Fig. 14. 14. a,a, Typical Fig. Leiomyomaofoflower loweresophagus. esophagus.This Thislesion lesionproduced producedsymptoms. symptoms. asymptomatic. b,b, Leiomyoma asymptomatic.
Obstructing Lesions of the Esophagus
787
myomas (leiomyomas and lipomyomas), cysts, lipoma and of approximately equal frequency, the neurofibromas, osteochondromas, giant cell tumors and aberrant thyroid. These tumors grow slowly and outward and therefore do not tend to occlude the lumen unless the mass encircles the esophagus or becomes extremely large (Fig. 14). Pedunculated tumors occur predominantly in the upper fourth of the esophagus and are most frequently seen in men. Malignant degeneration probably is uncommon but it does occur. The signs and symptoms depend on the type of tumor and its location in the esophagus. Thus, when the tumor is situated in the lower esophagus symptoms may be absent or those of compression and obstruction; when it is in the upper mediastinum the symptoms are those of venous obstruction and tracheal compression, and may be accompanied by paralysis of the recurrent laryngeal nerve. Thus, the more common complaints are intermittent dysphagia, substernal pain, regurgitation including even regurgitation of a long pedunculated polyp, cough, dyspnea and hoarseness. However, the symptoms offer little in distinguishing these lesions from malignant tumors in the same area and in making a correct diagnosis. X-ray studies and endoscopic examination are required to differentiate the cause of similar symptoms found with other benign obstructing lesions (Fig. 15) of the esophagus and those of carcinoma. The importance of esophagoscopic confirmation of the x-ray findings is illustrated by the x-ray evidence of a large, obstructing tumor in the lower esophagus with a pedicle arising high in the esophagus. Extramucosal tumors when viewed through the esophagoscope show extramural encroachment on the lumen but they are covered by intact
Fig. 15. a, Large mediastinal mass, an esophageal cyst, compressing the esophagus. b, Cyst wall lined with orderly ciliated, pseudostratified, columnar epithelium (X400).
788
HERBERT~D. ~ADAMS
Fig. 16. Operative sketch of mobilization of the esophagus from the mediastinum for removal of an intramural leiomyoma.
normal epithelium. It is well to emphasize the hazard of biopsy with this type of tumor since such a procedure may open up the mediastinum or the tumor to infection, complicating the subsequent removal or because of the possibility of opening into a para-esophageal aneurysm. Carcinoma can practically be ruled out by the presence of intact, normal appearing mucosa. The treatment of benign esophageal tumors is surgical and the procedure is relatively simple in most instances. The pedunculated intraluminar tumors can usually be removed through the esophagoscope or by utilizing the electrocoagulating snare. A cervical or transthoracic esophagotomy may be required for their removal. Intramural lesions may be shelled out by splitting the muscularis, but if they encircle the esophagus or are of great size, resection and anastomosis are necessary. These intramural tumors may occur at practically any level in the esophagus and are best approached through the right thorax. The esophagus at the level of the tumor is carefully mobilized and the tumor resected under direct vision (Fig. 16). Fibromas and leiomyomas are intramural and encapsulated; they can be carefully dissected out of the muscular wall of the esophagus without any extensive damage to the muscularis and usually without opening the mucosal layer. The muscularis is then carefully reconstructed with fine interrupted silk. Under these conditions very little risk is involved and the patient should obtain a permanent cure and complete relief of his symptoms.
+ Obstructing Lesions of the Esophagus
789
CARCINOMA
The commonest obstructing tumor is carcinoma which may occur at all levels, but the surgical approach, surgical management and technical details vary considerably according to the level involved. If the diagnosis is made at an operable stage, carcinoma of the esophagus can be safely resected at any level, including the superior thoracic strait, and the continuity of the intestinal tract re-established by displacing the stomach or colon into the thorax and even into the cervical region for esophagogastric or colonic anastomosis. We believe that esophagoscopy should be done in all cases for biopsy and grading, and any evidence of inoperability determined by direct vision. All patients with lesions at higher levels should also have bronchoscopy to rule out invasion of the bronchus or the trachea which would make the tumor definitely inoperable. In general, the prognosis in carcinoma of the esophagus is so poor, the absolute survival rate is so small and even survival rates based on resectable cases are so low that there has been considerable controversy whether surgery for carcinoma of the esophagus is ever curative, and that almost always it is palliative. Only two forms of treatment are available at this time: resection or some form of radiotherapy or some combination of the two. If radiotherapy is selected as a primary form of therapy, the esophagus should be put at rest temporarily and the patient's nutrition kept up by the use of a simple gastrostomy as previously described. We do not believe, however, that there is a pl!1-ce for any form of palliative surgery other than resection, such as a gastrostomy merely to prolong the patient's life or the utilization of bypassing tubes. In general, all of the lesions involving the upper thoracic esophagus and those in the superior thoracic strait are of considerably greater seriousness than those of the lower levels because of the magnitude of the procedure and, even more important, because of the extreme disturbance of the cardiopulmonary function associated with these procedures. We no longer fear the complications of infection and leakage from the anastomosis but serious problems arise which are associated with extensive disturbance of the cardiac function and greatly reduced pulmonary function in cases in which the carcinoma is situated high in the esophagus. In all of these high resections the possibility of right sided cardiac failure during the immediate postoperative period must be kept in mind since it is impossible to estimate the patient's cardiac reserve. The entire mediastinum must necessarily be dissected, with considerable manipulation of the arch of the aorta and the base of the heart; the displacement of the stomach or colon into the chest; paralysis of the diaphragm, and the frequent necessity of opening both thoraces at the same time in order to remove these high lesions. As a result a profound physiologic disturbance is produced.
790
HERBERT
D.
ADAMS
a
b Fig. 17. High resection of the esophagus for carcinoma of the superior thoracic strait. Esophagogastric anastomosiS iIi the neck.
When carcinomas are located in the superior thoracic strait and low cervical region the patients are placed on the operating table on their right side, the left side up, in the usual chest position. The left arm is wrapped with sterile towels and the neck is included in the draping of the sterile thoracic field. The arm is then displaced posteriorly and the lower left region of the neck is opened through a low cervical incision to determine the operability and to free tbis portion of the esopbagus down into the superior mediastinum as far as possible. If the lesion has not extended to the structures of the neck, the thorax is opened through a posterolateral incision, the esophagus is dissected out of the mediastinum above the arch and tbe involved esophagus at this level is mobilized and freed to join the dissection from above. If the lesion can be completely mobilized from above and below in this manner the remainder of the esopbagus is freed from tbe mediastinum, the diaphragm is opened widely and the stomach is totally mobilized, preserving the right gastroepiploic artery and right gastric artery. The esopbagus is immediately transected above the cardia and the cardia closed. The inner end of the left clavicle and the first rib are resected through the cervical incision to permit the stomach to be displaced by the most direct route through the anterior chest into the neck (Fig. 17) for an esophagopharyngeal anastomosis to tbe top of the fundus. The right colon may also be used for this purpose. For lesions in the upper thoracic portion of the esophagus at the level of tbe arch and hilar structures of the lung, a posterolateral transthoracic approach is carried out. This can be done through either tbe right or left
Obstructing Lesions of the Esophagus
791
thorax. We prefer the left thoracic approach since this permits a more accurate mobilization of the exact amount of stomach needed in this particular case, and preservation of the greatest possible amount of circulation of the stomach. The only advantage of the right-sided approach is that technical difficulties associated with the arch of the aorta are reduced, but we have been able to work out the details of our technique on the left side to compensate for this very satisfactorily. With the exception of lesions very low in the esophagus, in order to obtain adequate margin above the lesion it is always necessary to resect the esophagus above the arch of the aorta and to make the anastomosis in the chest as high as possible (Fig. 18), bringing the stomach anterior and superior to the arch of the aorta for a very careful two-layer anastomosis of the stomach and esophagus. Lesions of the distal portion of the esophagus (Fig. 19) and cardia are best approached through a posterolateral incision with transthoracic, transdiaphragmatic exposure. It is our feeling that a more complete cancer operation with wider block dissection can be performed from this approach than with the patient in position for the abdominothoracic approach. When lesions involve the cardia, considerable resection of the stomach, especially along its lesser curvature, and a routine splenectomy
Fig. 18. Resection of esophagus for carcinoma of the mid esophagus with esophagogastric anastomosis above and anterior to the arch of the aorta.
792
HERBERT
D.
ADAMS
Fig. 19. Filling defect due to carcinoma in the lower esophagus.
are required in order to remove as widely as possible all of the tumor, the gastric mesenteries and the included lymphatics. When such an extensive resection has been performed it is necessary to tailor the remaining distal segment of the stomach carefully for a primary anastomosis with the esophagus several inches above the diaphragm (Fig. 20). Again I wish to stress that after high resections there is a marked physiological disturbance which is of great significance in the postoperative management. The stomach is almost totally displaced into the thorax, the stomach itself is extensively denervated by high vagotomy, its blood supply is disturbed and greatly reduced and it is, therefore, prone to dilatation as it lies across the pericardium. If dilatation in this particular position is allowed to occur, severe cardiorespiratory disturbance will result which may be so profound as to cause the death of the patient. Therefore, in resections at this level the Levin tube which is placed down to the obstructing lesion before operation is passed through the anastomosis to the level of about the mid stomach opposite the pericardium at the time the posterior rows of the anastomosis are completed. This tube is kept on suction long enough following the operation to avoid any gastric dilatation. Contrary to past teachings we have not seen any complications arising as a result of the tube lying across the line of anastomosis. The results of such operations and survival rates, of course, have been
Obstructing Lesions of the Esophagus
793
Fig. 20. a and b, Resection of the cardia and distal esophagus for carcinoma. c, Tailoring of the antrum for esophagogastric anastomosis.
unsatisfactory in everyone's hands. At the present time the absolute five year survival rate is 4.8 per cent and the five year survival rate based on resected cases is 7.5 per cent. We have already reported our dissatisfaction with the results and have attempted to improve our figures by resecting these usually extensive lesions and giving supervoltage x-ray therapy after operation. Our survival figures continue to improve somewhat as a result of this combination. Therefore, we continue to use this combined therapy in most cases of resection for carcinoma of the esophagus.
BENIGN LESIONS
Congenital Atresia of the Esophagus
In the newborn infant it is important to be aware that atresia of the esophagus is a relatively common congenital lesion and to recognize the characteristic symptoms and clinical signs so that a prompt diagnosis can be made, which is so essential to effective and satisfactory treatment. Excess mucus, episodes of cyanosis, inability to take fluid, regurgitation, vomiting and spasmodic coughing should at least suggest the presence of an atresia of the esophagus since this lesion must be recognized early before much aspiration has taken place and aspiration pneumonia has developed. Frequently, the diagnosis can be made on history and physical signs alone but usually an x-ray examination is necessary to establish this diagnosis definitely. This is best accomplished by instillation of a few drops of radiopaque medium through a small catheter, aspirating as much as possible of this after the roentgenogram has been taken. This roentgenologic study should demonstrate the size and level of the upper pouch and any fistula between this pouch and the tracheobronchial tree (Figs. I, a and b). In addition, almost all will show x-ray signs of atelectasis and varying degrees of aspiration pneumonia. A plane film of the abdomen is also of considerable value since the presence of air in the stomach and gastrointestinal tract is definite evidence of a fistula between the lower segment and the tracheobronchial tree. The absence of air in the gastrointestinal tract, however, does not always rule out such a communication. In the majority of these lesions, over 90 per cent, the esophagus ends in a high, blind pouch in the posterior superior mediastinum and the lower segment originates in a fistula from the membranous trachea or the carina or primary bronchus (Fig. 2). Accurate analysis of the type of lesion is, of course, very important primarily in the selection of the particular operation that will produce the best result with the lowest mortality in these delicate situations. A number of factors will very definitely influence the survival rate in
773
774
HERBERT
D.
ADAMS
Fig. 1. Congenital atresia of the esophagus of the commonest type. a, The upper pouch; note large amounts of gas in the intestinal tract, indicating a fistula between the lower segment and the tracheobronchial tree. b, Postoperative film; the atresia has been corrected and functioning continuity of the esophagus re-established.
this condition. One has already been mentioned-early and prompt diagnosis-since a delay in diagnosis and treatment, and the associated sepsis, pneumonia and deterioration in the nutritional status of the infant will result in a high mortality. Second, prematurity and a very low birth weight also increase the risk considerably. Third, the preoperative care and preparation of these patients are likewise of considerable importance in their survival and in obtaining satisfactory results. Once the diagnosis has been established nothing should be given orally, suction should be utilized regularly; the infant should be placed in an incubator with oxygen, the dehydration corrected, and administration of antibiotics started to control the associated infection and pneumonia. The fourth factor of great importance is the fact that other congenital malformations are present in a high percentage of these patients; at least 25 per cent will have significant, serious anomalies of other systems, such as cardiovascular, gastrointestinal, neurological and urological lesions. Fifth and finally, the details of the postoperative care are of extreme importancecontinuing with the oxygen, continuous special nursing care, suctioning, nothing by mouth for ten to 14 days and careful control of parenteral fluids and electrolytes. In infants whose birth weight is low and nutrition poor initially, the judicious use of gastrostomy so that feeding may be started within 48 hours or so after the operation may be helpful in these poor-risk patients. It is important to point out that gastrostomy alone should not be performed in those patients who have a tracheal or bronchoesophageal fistula since they will die of sepsis and pneumonia.
Obstructing Lesions of the Esophagus
775
CONGENITAL ATRESIA OF ESOPHAGUS COMMON TYPES
!
RARE TYPES
Fill;. 2. Common and rare types of congenital atresia of the esophagus; over 90 per cent are of the type (see 1) shown first in this drawing.
The accepted and preferred management of esophageal atresia with tracheo-esophageal fistula is primary anastomosis after the fistula has been divided and closed. Earlier in our experience with this condition this procedure was done by a retropleural approach, but at the present time these operations are carried out transpleurally under endotracheal cyclopropane. High mobilization of the upper pouch with closure of the
776
HERBERT
D.
ADAMS
fistula into the trachea is performed as soon as possible to provide better control of anesthesia and secretions, the lower segment is mobilized and a two-layered anastomosis is carried out. Primary anastomosis is usually possible, although extensive transpleural mobilization of both distal and proximal ends of the esophagus may be necessary to bring the two segments together without undue tension, using great care to maintain an adequate blood supply to the segments. A primary and uncomplicated esophageal anastomosis is rarely possible in patients with atresia not accompanied by a tracheopharyngeal fistula since these segments are usually widely separated. Likewise, infants who do not have air in their stomach usually have only a very rudimentary and short lower esophagus that will not permit primary anastomosis without mobilization of the stomach and its displacement into the thorax, which is not well tolerated by the newborn infant. In general, in infants with this type of congenital lesion, that is, without esophagotracheal fistula from either the upper or lower segments of the esophagus, it is best to do a gastrostomy and at that time carry out a retrograde bougienage to help determine the length of the lower segment. If it is very short, a cervical esophagostomy is done, with a second staged interposition of the large bowel to bridge this defect. As stated before, gastrostomy alone is rarely used except in the occasional case in which a fistula does not exist, and the esophageal ends are widely separated. The two stage procedure just described is the most satisfactory operation under these conditions. The best results in congenital atresia of the esophagus, therefore, depend upon early diagnosis, careful preoperative management, a very careful estimate of the type of lesion present so that the proper operative procedure can be applied, and extreme care in the postoperative management. The great majority of these lesions are associated with esophagotracheal fistula and therefore are suitable for closure of the fistula and primary anastomosis of the esophagus. Chemical or Caustic Strictures
Another type of benign stricture of the esophagus is caused by the ingestion of caustic chemicals. This type invariably goes through an acute phase with various complications and frequently terminates in a true cicatricial stricture of the esophagus involving a considerable length of this structure (Fig. 3). The quantity and type of chemical swallowed and the immediate care will determine the degree of the initial damage to the esophagus. The administration of antibiotics will also help to prevent progressive damage and additional stricturing from superimposed infection. Steroid treatment during the acute phase may also be of aid in reducing the ultimate tendency toward the more severe degrees of stricture. Following the emergency administration of antidotes or neutralizers of
Obstructing Lesions of the Esophagus
777
Fig. 3. Caustic stricture (a) in a child and (b) in an adult; both required esophageal resection.
the particular chemical ingested and treatment of shock or systemic reactions, the esophagus should be put at rest by simple gastrostomy. Such a gastrostomy should be simply the insertion of a number 24 to 30 mushroom catheter in the anterior surface of the distal third of the stomach by means of a double inverting purse-string catgut suture. In closing the peritoneum with interrupted catgut sutures the suture immediately above and below the tube should include the wall of the stomach to bring it up to the undersurface of the peritoneum (Fig. 4, C). This is done so that the tube can be removed or replaced easily, especially for retrograde periodic dilatations over a string if necessary. Complicated types of gastrostomy should be avoided and even the simple type just described should be carried out with great care to avoid poor healing, leakage and complications that are difficult to manage. With the proper immediate care and judicial dilatations of the stricture a good result can be obtained in many cases, but in intractable cases subsequent operations become necessary. Thoraco-abdominal resection of a destroyed and functionless esophagus and replacement with the stomach, colon, or jejunum, according to the surgeon's preference, should be performed. In our experience replacement with the stomach has been satisfactory. Because of the problem of postoperative reflux and esophagitis, however, a vagotomy and pyloroplasty must be done simultaneously if the stomach is used. The use of the colon as a replacement has also proved very satisfactory. Peptic Esophagitis
Peptic esophagitis of varying degrees may produce obstruction and
778
HERBERT
D.
ADAMS
Fig. 4. The technique of simple gastrostomy. A, Location of abdominal and gastric incisions. B, Insertion of mushroom catheter in the stomach by a double purse-string. C, Closure of the peritoneum bringing the stomach wall up to its under surface.
dysphagia. This is commonly associated with hiatus hernia and reflux and particularly with the ulcer diathesis, with or without a demonstrable peptic ulcer. This esophagitis may be only mild and produce minimal distress and dysphagia. We have seen a number of patients, however, in whom the esophagitis was so severe that dysphagia was marked and an acute stricture of the lower esophagus was present (Fig. 5). The treatment consists of rigid ulcer management and careful esophageal dilatations under the protection of antibiotics. We have not seen this particular type of esophagitis with acute stricture progress to the
Obstructing Lesions of the Esophagus
779
Fig. Fig.5.5.Peptic Pepticesophagiti esophagitiswith with characteristic characteristic stricture stricture associassociated ated with with ulcer ulcer diathesis; diathesis; satissatisfactorily byaarigid rigidulcer ulcer factorilytreated treatedby regimen anddilatation. dilatation. regimenand
Fig. 6. Peptic esophagitis associated with ulcer diathesis and hiatus hernia. Recurrences satisfactorily treated by dilatations for many years, but eventually hemigastrectomy, vagotomy and repair of hiatus hernia were required.
780
HERBERT
D.
ADAMS
permanent cicatricial type which requires resection, except in those instances in which it is associated with hiatus hernia and recurrent ulceration of the distal portion of the esophagus. In recurring severe degrees of reflux esophagitis associated with hiatus hernia and ulcer diathesis (Fig. 6), operation should be advised before permanent, advanced, cicatricial changes have taken place in the lower esophagus and cardia. Various operations have been used to correct this condition-hemigastrectomy, vagotomy and repair of the hiatus hernia; pyloroplasty, vagotomy and repair of hiatus hernia; and interposition of the colon. It is most important to correct the ulcer diathesis as well as the reflux in these severe cases if good permanent results are to be obtained. For this reason we have selected hemigastrectomy, vagotomy and repair of hiatus hernia as the procedure of choice in this complex situation. Achalasia of the Esophagus
Achalasia or malfunctioning esophagus is a broad term. The condition may be caused by a variety of lesions involving the lower esophagus and cardia. These different etiologic lesions must be carefully distinguished if the correct treatment is to be carried out and good and lasting results obtained. When an accurate appraisal of the causative factor of the achalasia has not been made there is considerable confusion regarding the surgical procedure of choice and wide variation in the results obtained by a given operative procedure. Most of the operations now used are effective when applied in properly selected cases but the real difficulty and poor results have come from classifying all cases of the achalasia as due to cardiospasm and applying one procedure, such as myotomy, in the treatment of all patients. True cardiospasm, without ulceration and without advanced cicatricial changes which may develop and eventually become intractable after many years of successful dilatation, may be well handled by periodic dilatation, including the use of the Plummer dilator (Fig. 7). This treatment has been reported effective in 65 to 85 per cent of the cases; the details of this procedure are given under a separate heading by Dr. Lathrop. In the more refractory cases and in patients who, for one reason or another, do not want or cannot continue periodic dilations indefinitely, a myotomy (Heller operation) at the esophagogastric junction is indicated (Fig. 8). This procedure should not be used, however, when ulceration or advanced organic cicatricial stricture of the lower end of the esophagus is present. If the results of myotomy are to be permanently successful, the hiatal hernia produced by this operation must be carefully repaired or subsequent reflux esophagitis will compromise the result. In addition, in our experience it is important to study the patient adequately to rule out an associated ulcer diathesis. If this is present, vagotomy and pyloroplasty should be performed in addition to the
Obstructing Lesions of the Esophagus
781
Fig. 7. Achalasia due to cardiospasm, successfully treated by dilatations.
Fig. 8. Heller operation. Myotomy at the esophagogastric junction. Note most of the myotomy is on the esophageal side of the esophagogastric junction.
782
HERBERT
D.
ADAMS
Fig. 9. a, Achalasia caused by a congenital aganglionic segment of the lower esophagus, treated by resection and pyloroplasty. b, Postoperative chest film following resection of the large redundant and saccular section of the esophagus, with correction of the dilatation and poor function of the upper segment.
myotomy or serious difficulties will be encountered and the symptoms will eventually recur. Under these conditions an abdominal approach is preferable so that pyloroplasty can be properly done simultaneously. From this discussion it is apparent that the Heller operation has definite deficiencies which it is well to emphasize: (1) failure to repair the resulting hiatus hernia; (2) subsequent reflux esophagitis and recurrence of symptoms and (3) failure to correct the associated ulcer diathesis or to recognize advanced, irreversible, organic changes in the distal esophagus or cardia. When such a true cicatricial stricture is present only resection of the distal end of the esophagus and cardia, esophagogastric anastomosis, vagotomy and pyloroplasty will give a good lasting result. Finally, the true mega-e8ophagu8 is commonly placed in this category of achalasia, that is, the tremendously dilated and saccular, the functionally totally disorganized esophagus (Fig. 9). In our experience this should be considered an entirely separate entity. Its etiology is similar to that of Hirschsprung's disease of the colon and the obstruction is the result of a congenital aganglionic segment of the lower end of the esophagus which acts as a nonfunctioning obstructing segment, causing in time the extreme degrees of esophageal dilatation seen in these cases. This condition is exactly the same as that seen in the colon due:to an identical aganglionic segment in the rectum. These cases can be readily distinguished from cardiospasm by the huge saccular dilatations and the fact that the obstructing segment can be readily dilated and a large esophagoscope passed through it without resistance; and at the same time the
Obstructing Lesions of the Esophagus
783
dilatation accomplishes only the most transient, if any, improvement in the dysphagia. This is in marked contrast to cardiospasm in which definite and proportionate improvement is obtained in the dysphagia, depending on the degree of the dilatation. Another important mechanical factor must also be clearly recognized, that is the huge, tortuous, lower saccular esophagus lying completely across the right diaphragm and extending to the right chest wall in many cases which, when filled with liquid and food, distorts, angulates and obstructs the outflow tract through the cardia, much as a large diverticulum may obstruct the esophagus at other levels (Fig. 10). To correct both of these important obstructing factors, that is, the aganglionic nonfunctioning segment and the obstruction produced by the weight of this huge sacculation, the operation that has produced the best and most lasting results in our hands has been resection of the lower half of the esophagus including this huge lower sacculation, an esophagogastric anastomosis immediately below the arch of the aorta, vagotomy and pyloroplasty. In these cases the pylorus has usually been so far to the right that the esophageal resection has been carried out through a transthoracic approach and the chest closed. The patient is then moved
Fig. 10. Line drawing of a case of achalasia (shown in Fig. 9, a) to illustrate segment of esophagus that was resected (shaded area).
784
HERBERT
D.
ADAMS
Fig. 11 Fig. 12 Fig. 11. Gross specimen of segment resected showing the obstructing aganglionic segment immediately above the cardia and the tremendous hypertrophy of the esophagus proximal to this segment. Fig. 12. Characteristic x-ray appearance of an esophageal web.
to the prone position and a pyloroplasty meticulously carried out through a right upper rectus, paramedian, abdominal incision. In cases of mega-esophagus (similar to megacolon) there is congenital absence of Auerbach's plexus in the lower end of the esophagus, confirmed by microscopic studies of operative specimens, and this portion of the esophagus therefore acts as an obstructing nonfunctioning segment (Fig. 11). Most of these patinets have had this condition all their life and in many instances have reached young adulthood before they finally sought medical advice and help with their problem. They have been able to adjust their eating so that enough food gets through the cardia to maintain nourishment in spite of this greatly dilated esophagus. As a group they become very unhappy individuals, shunning society, and enduring considerable distress, but adjust to these problems until eventually food and fluid begins to spill over into their lungs especially during their sleep and extensive chronic pneumonitis develops. Several
Obstructing Lesions of the Esophagus
785
of these patients have come to us primarily because of the resulting associated dyspnea that has distressed them. Once this tremendous dilatation of the true mega-esophagus develops, especially if an associated aspiration pneumonitis begins, the surgical correction of this condition becomes urgent. The treatment of choice in these cases is careful preparation by decompression and aspiration of the esophagus, and eventual extensive resection, as described. In several of our patients the esophagus was so tremendously dilated and so much associated pneumonitis was present that it was necessary to put the esophagus totally at rest by gastrostomy and to improve the patient's general condition and nutrition for some months before surgical resection was undertaken. Miscellaneous Obstructing Lesions of the Esophagus
A number of rare forms of benign lesions produce symptoms of esophageal obstruction. First there are webs at different levels of the esophagus which eventually produce symptoms sufficiently severe to require treatment. They can be demonstrated on the roentgenogram (Fig. 12). Treatment consists of simple partial excision and division of the webs through the esophagoscope. Another lesion that is occasionally seen is the esophagus lined with gastric mucosa in its distal two-thirds with obstruction at the proximal junction. Usually, it is not associated with frank ulceration and is managed satisfactorily by dilatation and diet. Finally there is the so-called Schatski ring usually associated with a hiatus hernia; it may be a web at the cardio-esophageal junction, but it is a controversial lesion. Benign Tumors
Probably the most common obstructive lesion of the esophagus is tumor. Such tumors may be the result of extension and secondary to a primary lesion in some other organ closely related anatomically to the esophagus, such as the bronchus, or they may be primary in the esophagus itself. The commonest form of primary tumor of the esophagus, of course, is carcinoma. Occasionally, however, benign tumors are found and because of their rarity and their amenability to permanent cure they are of considerable interest. Benign tumors not only are rare but their recognition at times is difficult owing to the lack of symptoms and signs. They are of prime surgical importance because of the necessity to distinguish them from malignant lesions of the esophagus, because of their potential malignancy and finally because symptoms associated with such tumors may be relieved and cured by operation. Clinically, benign esophageal tumors are of two types: (1) mucosal and (2) extramucosal or intramural tumors. Mucosal tumors arise from either the mucosa or submucosa, and may be sessile or pedunculated (Fig. 13). They include the polyps, adenoma, and papilloma. Intramural tumors arise from the extramucosal layers of the esophageal wall and are less common than the mucosal types. They are, in order of frequency, the
786
HERBERT
D.
ADAMS
Fig. Fig. 13. 13. Pedunculated Pedunculated esophageal esophageal polyp. polyp.
Typicalappearance appearanceofofleiomyoma leiomyomaofofthe themid midesophagus. esophagus.This Thispatient patientwas was Fig. 14. 14. a,a, Typical Fig. Leiomyomaofoflower loweresophagus. esophagus.This Thislesion lesionproduced producedsymptoms. symptoms. asymptomatic. b,b, Leiomyoma asymptomatic.
Obstructing Lesions of the Esophagus
787
myomas (leiomyomas and lipomyomas), cysts, lipoma and of approximately equal frequency, the neurofibromas, osteochondromas, giant cell tumors and aberrant thyroid. These tumors grow slowly and outward and therefore do not tend to occlude the lumen unless the mass encircles the esophagus or becomes extremely large (Fig. 14). Pedunculated tumors occur predominantly in the upper fourth of the esophagus and are most frequently seen in men. Malignant degeneration probably is uncommon but it does occur. The signs and symptoms depend on the type of tumor and its location in the esophagus. Thus, when the tumor is situated in the lower esophagus symptoms may be absent or those of compression and obstruction; when it is in the upper mediastinum the symptoms are those of venous obstruction and tracheal compression, and may be accompanied by paralysis of the recurrent laryngeal nerve. Thus, the more common complaints are intermittent dysphagia, substernal pain, regurgitation including even regurgitation of a long pedunculated polyp, cough, dyspnea and hoarseness. However, the symptoms offer little in distinguishing these lesions from malignant tumors in the same area and in making a correct diagnosis. X-ray studies and endoscopic examination are required to differentiate the cause of similar symptoms found with other benign obstructing lesions (Fig. 15) of the esophagus and those of carcinoma. The importance of esophagoscopic confirmation of the x-ray findings is illustrated by the x-ray evidence of a large, obstructing tumor in the lower esophagus with a pedicle arising high in the esophagus. Extramucosal tumors when viewed through the esophagoscope show extramural encroachment on the lumen but they are covered by intact
Fig. 15. a, Large mediastinal mass, an esophageal cyst, compressing the esophagus. b, Cyst wall lined with orderly ciliated, pseudostratified, columnar epithelium (X400).
788
HERBERT~D. ~ADAMS
Fig. 16. Operative sketch of mobilization of the esophagus from the mediastinum for removal of an intramural leiomyoma.
normal epithelium. It is well to emphasize the hazard of biopsy with this type of tumor since such a procedure may open up the mediastinum or the tumor to infection, complicating the subsequent removal or because of the possibility of opening into a para-esophageal aneurysm. Carcinoma can practically be ruled out by the presence of intact, normal appearing mucosa. The treatment of benign esophageal tumors is surgical and the procedure is relatively simple in most instances. The pedunculated intraluminar tumors can usually be removed through the esophagoscope or by utilizing the electrocoagulating snare. A cervical or transthoracic esophagotomy may be required for their removal. Intramural lesions may be shelled out by splitting the muscularis, but if they encircle the esophagus or are of great size, resection and anastomosis are necessary. These intramural tumors may occur at practically any level in the esophagus and are best approached through the right thorax. The esophagus at the level of the tumor is carefully mobilized and the tumor resected under direct vision (Fig. 16). Fibromas and leiomyomas are intramural and encapsulated; they can be carefully dissected out of the muscular wall of the esophagus without any extensive damage to the muscularis and usually without opening the mucosal layer. The muscularis is then carefully reconstructed with fine interrupted silk. Under these conditions very little risk is involved and the patient should obtain a permanent cure and complete relief of his symptoms.
+ Obstructing Lesions of the Esophagus
789
CARCINOMA
The commonest obstructing tumor is carcinoma which may occur at all levels, but the surgical approach, surgical management and technical details vary considerably according to the level involved. If the diagnosis is made at an operable stage, carcinoma of the esophagus can be safely resected at any level, including the superior thoracic strait, and the continuity of the intestinal tract re-established by displacing the stomach or colon into the thorax and even into the cervical region for esophagogastric or colonic anastomosis. We believe that esophagoscopy should be done in all cases for biopsy and grading, and any evidence of inoperability determined by direct vision. All patients with lesions at higher levels should also have bronchoscopy to rule out invasion of the bronchus or the trachea which would make the tumor definitely inoperable. In general, the prognosis in carcinoma of the esophagus is so poor, the absolute survival rate is so small and even survival rates based on resectable cases are so low that there has been considerable controversy whether surgery for carcinoma of the esophagus is ever curative, and that almost always it is palliative. Only two forms of treatment are available at this time: resection or some form of radiotherapy or some combination of the two. If radiotherapy is selected as a primary form of therapy, the esophagus should be put at rest temporarily and the patient's nutrition kept up by the use of a simple gastrostomy as previously described. We do not believe, however, that there is a pl!1-ce for any form of palliative surgery other than resection, such as a gastrostomy merely to prolong the patient's life or the utilization of bypassing tubes. In general, all of the lesions involving the upper thoracic esophagus and those in the superior thoracic strait are of considerably greater seriousness than those of the lower levels because of the magnitude of the procedure and, even more important, because of the extreme disturbance of the cardiopulmonary function associated with these procedures. We no longer fear the complications of infection and leakage from the anastomosis but serious problems arise which are associated with extensive disturbance of the cardiac function and greatly reduced pulmonary function in cases in which the carcinoma is situated high in the esophagus. In all of these high resections the possibility of right sided cardiac failure during the immediate postoperative period must be kept in mind since it is impossible to estimate the patient's cardiac reserve. The entire mediastinum must necessarily be dissected, with considerable manipulation of the arch of the aorta and the base of the heart; the displacement of the stomach or colon into the chest; paralysis of the diaphragm, and the frequent necessity of opening both thoraces at the same time in order to remove these high lesions. As a result a profound physiologic disturbance is produced.
790
HERBERT
D.
ADAMS
a
b Fig. 17. High resection of the esophagus for carcinoma of the superior thoracic strait. Esophagogastric anastomosiS iIi the neck.
When carcinomas are located in the superior thoracic strait and low cervical region the patients are placed on the operating table on their right side, the left side up, in the usual chest position. The left arm is wrapped with sterile towels and the neck is included in the draping of the sterile thoracic field. The arm is then displaced posteriorly and the lower left region of the neck is opened through a low cervical incision to determine the operability and to free tbis portion of the esopbagus down into the superior mediastinum as far as possible. If the lesion has not extended to the structures of the neck, the thorax is opened through a posterolateral incision, the esophagus is dissected out of the mediastinum above the arch and tbe involved esophagus at this level is mobilized and freed to join the dissection from above. If the lesion can be completely mobilized from above and below in this manner the remainder of the esopbagus is freed from tbe mediastinum, the diaphragm is opened widely and the stomach is totally mobilized, preserving the right gastroepiploic artery and right gastric artery. The esopbagus is immediately transected above the cardia and the cardia closed. The inner end of the left clavicle and the first rib are resected through the cervical incision to permit the stomach to be displaced by the most direct route through the anterior chest into the neck (Fig. 17) for an esophagopharyngeal anastomosis to tbe top of the fundus. The right colon may also be used for this purpose. For lesions in the upper thoracic portion of the esophagus at the level of tbe arch and hilar structures of the lung, a posterolateral transthoracic approach is carried out. This can be done through either tbe right or left
Obstructing Lesions of the Esophagus
791
thorax. We prefer the left thoracic approach since this permits a more accurate mobilization of the exact amount of stomach needed in this particular case, and preservation of the greatest possible amount of circulation of the stomach. The only advantage of the right-sided approach is that technical difficulties associated with the arch of the aorta are reduced, but we have been able to work out the details of our technique on the left side to compensate for this very satisfactorily. With the exception of lesions very low in the esophagus, in order to obtain adequate margin above the lesion it is always necessary to resect the esophagus above the arch of the aorta and to make the anastomosis in the chest as high as possible (Fig. 18), bringing the stomach anterior and superior to the arch of the aorta for a very careful two-layer anastomosis of the stomach and esophagus. Lesions of the distal portion of the esophagus (Fig. 19) and cardia are best approached through a posterolateral incision with transthoracic, transdiaphragmatic exposure. It is our feeling that a more complete cancer operation with wider block dissection can be performed from this approach than with the patient in position for the abdominothoracic approach. When lesions involve the cardia, considerable resection of the stomach, especially along its lesser curvature, and a routine splenectomy
Fig. 18. Resection of esophagus for carcinoma of the mid esophagus with esophagogastric anastomosis above and anterior to the arch of the aorta.
792
HERBERT
D.
ADAMS
Fig. 19. Filling defect due to carcinoma in the lower esophagus.
are required in order to remove as widely as possible all of the tumor, the gastric mesenteries and the included lymphatics. When such an extensive resection has been performed it is necessary to tailor the remaining distal segment of the stomach carefully for a primary anastomosis with the esophagus several inches above the diaphragm (Fig. 20). Again I wish to stress that after high resections there is a marked physiological disturbance which is of great significance in the postoperative management. The stomach is almost totally displaced into the thorax, the stomach itself is extensively denervated by high vagotomy, its blood supply is disturbed and greatly reduced and it is, therefore, prone to dilatation as it lies across the pericardium. If dilatation in this particular position is allowed to occur, severe cardiorespiratory disturbance will result which may be so profound as to cause the death of the patient. Therefore, in resections at this level the Levin tube which is placed down to the obstructing lesion before operation is passed through the anastomosis to the level of about the mid stomach opposite the pericardium at the time the posterior rows of the anastomosis are completed. This tube is kept on suction long enough following the operation to avoid any gastric dilatation. Contrary to past teachings we have not seen any complications arising as a result of the tube lying across the line of anastomosis. The results of such operations and survival rates, of course, have been
Obstructing Lesions of the Esophagus
793
Fig. 20. a and b, Resection of the cardia and distal esophagus for carcinoma. c, Tailoring of the antrum for esophagogastric anastomosis.
unsatisfactory in everyone's hands. At the present time the absolute five year survival rate is 4.8 per cent and the five year survival rate based on resected cases is 7.5 per cent. We have already reported our dissatisfaction with the results and have attempted to improve our figures by resecting these usually extensive lesions and giving supervoltage x-ray therapy after operation. Our survival figures continue to improve somewhat as a result of this combination. Therefore, we continue to use this combined therapy in most cases of resection for carcinoma of the esophagus.