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Palliative management of esophageal carcinoma
Palliative Management of Esophageal Carcinoma
Ronald H. R. Belsey, MD, FRCS, FRCSI, Bristol, England
It has been estimated by a medical economist that it costs the average patient $23,000 to die from cancer. If t he patient is dying from cancer of the esophagus, involving major surgery, the cost is likely to be nearer $33,000. The question being debated today is whether the patient is getting a fair return for this outlay or whether he is being swindled in a big way. It is generally agreed that death from this dread disease constitutes one of the more distressing and least comfortable ways of dying. Assuming that the primary duty of the physician or surgeon is to relieve suf.fering rather than to cure disease, then the whole subject of management demands review. Diagnosis when the growth is still curable, before distant metastases or unresectable local spread has occurred, is rare for the following reasons: The usual warning signs of pain or hemorrhage are uncommon. The esophagus can adapt to a considerable degree of stenosis before the patient experiences any subjective dysphagia. An obvious decline in the patient’s general condition may not occur until late in the course of the disease. Mass popoulation surveys by esophageal washing:, and endoscopy such as have been conducted in China in an effort to achieve earlier diagnosis are probably not feasible on economic or philosophical grounds in Western societies, nor as yet is there any evidence that a significant improvement in survival rates can be achieved by this approach. Owing to defects in the medical educational system, the profession is not yet sufficiently “esophagealminded” to be alerted to the necessity of endoscopic examination in virtually symptom-free patients as the only method of achieving early diagnosis at. a curable stage of the disease. Radiologic examination will reveal only advanced growths. Regrettably, a Fromthe Department of Surgery, Urwersity of Bristol, Bristol, England. Requests for reprints should be addressed to Ronald H. R. Belsey, MD, University of Bristol, Bristol, England Presented at the Fifth Annual Lyman A. Brewer Ill Cardiothoracic SymPoswm. Los Angeles, California, December 6 and 7, 1979.
Volume
139,
June 1990
radiologist’s report of “no esophageal abnormality seen” may promote an attitude of complacency in the clinician and delay the essential endoscopic examination until the tumor has advanced. Radiotherapy and chemotherapy have so far proved of little value in the management of this disease. The value of radical esophageal resections combined with mediastinectomy is currently being investigated; as yet there is no definite evidence that improved long-term survival rates offset the increase in operative risk that may result from complications related to the lymphatic system. Surgical resection followed by esophageal reconstruction remains the dominant element in the surgeon’s armamentarium for the management of this disease. The average resection rate reported is 40 percent. Our concern is not only with the late results in those patients in terms of survival and the quality of life, but equally with the fate of the 60 percent that are rejected from the resection program. The problem is largely philosophical. The higher the resection rate, the higher will he the operative mortality rate. It has been stated with justification that no surgeon concerned with statistics should undertake the treatment of cancer of the esophagus. This is one situation where compassion takes precedence over surgical vanity. Many take the view that any surgical treatment is essentiall:y palliative. The presence of distant metastases rules out any hope of long-term survival. In terms of local spread however, it has been found difficult. or impossible in practice to hazard a longterm prognosis. Every surgeon has had the experience of performing a resection where both local extension and lymphatic spread presented an apparently hopeless situation, only to find the patient alive and apparently free from recurrence 5 or more years later. Autopsy records on patients dying from esophageal carcinoma reveals that in 30 percent of
789
Belsey
cases the tumor is still confined to the esophagus with no evidence of distant metastases and is potentially curable or amenable to effective palliative treatment. Definition
of Palliation
The complications rather than the underlying growth are mainly responsible for the distress suffered by the patient. Dysphagia and significant malnutrition usually occur relatively late in the course of the disease. Pulmonary complications such as recurring aspiration pneumonitis will accompnay the onset of significant obstruction. Septic intoxication is a feature of large fungating neoplasms that are heavily infected by both aerobic and anaerobic flora. Anemia may result from slow bleeding from a fungating growth, together with malnutrition and septic intoxication. The presenting symptoms may be caused by distant metastases. The most dreaded complication is the development of a fistula between the lumen of the esophagus and either the trachea or a main bronchus. Palliation aims at the relief of all of the local complications until death occurs from metastases. The success or failure of the available methods for palliation will be reviewed in the light of this philosophy. Dilatation, repeated as necessary, may be the only method available to relieve dysphagia and possibly reduce pulmonary complications in elderly depleted patients. The extent of the resulting symptomatic relief is unpredictable; it may last from a few days to several weeks, depending on the type of growth present. Intubation with one of the numerous devices designed for this purpose may be combined with dilatation. Opinions vary widely on the value of intubation, depending on the interpretation of the term relief. For surgeons who demand restoration of the patient’s ability to eat and drink normally and with satisfaction as the only acceptable form of palliation, the results of intubation are inadequate. At best, the patient may be able to swallow fluids or soft substances such as ice cream, but obstruction of the tube even with milk curds is common, calling for frequent replacement or endoscopic clearance. Plastic tubes may disintegrate and pass through the stricture. Intubation for high strictures is rarely tolerated by the patient. If the distal end of the tube enters the stomach in a lower third stricture, severe and distressing reflux can occur. Intubation of middle third strictures involves a considerable risk of hemorrhage, the most common cause of death after intubation. Sepsis, anemia and the risk of a fistula into the airway are not relieved. The indications for intubation are
790
therefore very limited, and the greater a surgeon’s experience with more radical forms of palliation, the less he will resort to this attempt at palliation. Irradiation has rarely proved successful in achieving adequate palliation. The development of a tracheoesophageal fistula has frequently been hastened by irradiation in middle and upper third growths. Response of a lower third growth has frequently resulted in worsening of the dysphagia from undilatable stricture formation. Chemotherapy has proved equally unsuccessful. Gastrostomy creates an intolerable situation for both the patient and the relatives condemned to live with him. Few surgeons would consent to this barbaric procedure being performed on themselves in this context. Two options for palliation remain: palliative resection with reconstruction, and various bypass operations. Palliative
Resection
and Reconstruction
This description has been rejected by some writers on the grounds that resection implies more than palliation. The alternative philosophy claims that all resections should be regarded as palliative, with the occasional satisfactory long-term result and apparent cure as a bonus achieved largely by accident. Assuming that palliation implies relief not only of dysphagia but also of sepsis, hemorrhage, anemia, tendency to pulmonary aspiration and the risk of a fistula into the airway, then these objectives can be achieved only by resection of the tumor-bearing segment of the esophagus. Various technical details demand examination. If the resection is designed to relieve dysphagia, it is essential that the risk of further dysphagia resulting from local recurrence of the growth or anastomotic problems be eliminated. Local recurrence of the growth stems from the upward spread in the submucosal lymphatic plexus, the extent of which cannot be determined by endoscopic examination. Initially it was thought that at least 5 cm of normal esophagus above the upper limit of the growth should be resected. This proved inadequate. Apart from occasional recurrences at a higher level, examination of resected specimens revealed premalignant changes throughout the organ with sufficient frequency to warrant a change in policy. In most clinics the entire esophagus is now resected routinely, irrespective of the level of the growth. There are additional reasons for routine total esophagectomy that will become apparent when the problem of subsequent reconstruction is discussed. Adenocarcinoma of the fundus of the stomach with obstruction due to involvement of the lower esoph-
The American Journal of Surgery
Palliative Management of Esophageal Carcinoma
agus presents a different problem. Owing to the different method of local spread, the present trend is to perform total gastrectomy combined with resection of the lower half of the esophagus. A resection of this extent, wit,h esophageal reconstruction cannot be performed by the abdominal route. Tumors in the region of the cardia should be approached through the extended left, sixth interspace thoracotomy with peripheral detachment of the diaphragm. All obvious and resectable lymphatic extensions will be removed along with the esophagus. The position of irresectable deposits left behind will he marked with metal clips. Left or Right Thoracotomy? This choice is dictated by the level of the growth and the type of subsequent reconstruction contemplated. The practice varies in different clinics. In those where it is considered preferable to perform resection and reconstruction through a single extended thoracotomy incision, the left approach will be used more often, with the right approach reserved for middle-third growths adjacent to the aortic arch. When a separate laparotomy incision is preferred for preparation of the transplant with which the esophagus will be reconstructed, right thoracotomy will often be chosen. Preliminary 1:n most dilated by paCent to during the junostomy alimentation management
patients the stricture can be sufficiently bouginage before resection to enable the take a high protein fluid diet by mout,h period of preparation. A preliminary jemerely wastes valuable time. Parenteral has radically changed the preoperative of’ nutritional problems.
Procedures?
For the patient, a single operation that restores his ability to swallow and relieves the other complicat.ions is preferable to any multistage program. The alternatives are a preliminary bypass procedure fol’owed by esophageal resection at a later date, or primary resection with a feeding gastrostomy and cervical esophagostomy and secondary reconstruction. The latter program is more logical because the sooner the growth is removed, the smaller the risk of recurrence. There is little convincing evidence that staged procedures reduce the operative morbidity or mortality rate; in fact, some workers have found that the combined risk of two major operations exceeds t.hat of a single-stage procedure. Improvements in
139,
June
1990
Reconstructive
Technique
Partial esophagogastrectomy followed by intrathoracic esophagogastrostomy has been abandoned for the following reasons, except in cases in which only the shortest surgical procedure is justified due to the advanced stage of the disease and the hopeless prognosis. The operative morbidity and morta1it.y rates are higher than those of any other form of reconstruction, due to anastomotic fistulas and acute aspiration pneumonitis in the early postoperative period. Limited resection increases the risk of f’urther dysphagia due to local recurrence of the t.umor. In the event of the patient’s survival for longer I han a year, there is the added risk of severe peptic esophagitis due to refux and recurrent dysphagia from peptic stenosis. Attempts to construct a valvular esophagogastric anastomosis to prevent reflux have so far failed. Three techniques are available f’or reconstruction after total esophagectomy: the use of whole stomach and cervical esophagogastrostomy, interposition of an isoperistaltic segment of left colon, and interposition of an isoperistaltic segment of jejunum.
Feeding Jejunostomy?
Single Stage or Multistage
Volume
anesthesia, operative technique and pre- and postoperative care undoubtedly favor single-stage synchronous resection and reconstruction.
Cervical
Esophagofundostomy
One advantage of the cervical anastomosis over the intrathoracic one is a lower incidence of anastomotic fistulas, possibly due to neutralization of the negative intrathoracic pressure by compression from the surrounding cervical organs and the reduced risk of fatal septic complications should a leak occur. Another advantage is a lower incidence of’ reflux esophagitis and peptic stenosis above the anastomosis. Three routes are available for the transplanted stomach: mediastinal, pleural and retrosternal. The mediastinal and retrosternal routes are preferable because the tendency to gastric distention is restrained by the confines of these routes; distention may be prominent when the intrapleural route is used, leading to some degree of pulmonary embarassment. The mediastinal route should not be used if residual tumor in the mediastinum imposes t.he risk of recurrent obstruction of the esophageal replacement. A furt,her advantage of this technique is the single anastomosis needed to restore continuity. After resection of the esophagus through the extended left
791
Belsey
sixth interspace thoracotomy, the cardia is closed and pyloromyotomy performed to prevent gastric stasis, an effective drainage procedure that incurs less risk of troublesome duodenal reflux. The fundus of the stomach is then brought up through the hiatus and then by the mediastinal or transpleural route to the base of the neck, where it is anchored to the stump of the resected esophagus. The thoracotomy is then closed, the patient is turned onto his back, and through an oblique left cervical incision the remainder of the esophagus is resected and an anastomosis is performed between the pharyngoesophageal junction and a separate opening in the highest point of the gastric fundus. The cervical dissection can be greatly assisted by freeing the esophagus as high as possible from inside the left thorax by gentle finger dissection. In no case in my experience was any technical difficulty encountered in bringing the fundus up to the neck, even in cases in which the stomach appeared to be contracted as a result of chronic starvation from esophageal obstruction. When the retrosternal route is employed, the fundus can be anchored to the base of the neck by two sutures passed out through the skin and tied by the anesthetist. After the thoracotomy is closed, the upper anastomosis is concluded in the manner already described. In view of the ease with which this reconstruction can be achieved, there appears to be no indication for the more complicated reconstruction with a reversed gastric tube by the Gavriliu technique, involving the possibility of late functional problems from the antiperistaltic nature of the proximal part of the reconstruction. Reconstruction by cervical esophagofundostomy is not possible if the upper part of the stomach has been resected on account of malignant involvement of the lesser curve. Left Colonic Interposition Reconstruction with left colon has advantages over other techniques. It is mandatory that the segment of colon be interposed in the isoperistaltic fashion. The colon may not be peristaltic, but it is a powerful unidirectional propulsive organ with a highly developed sense of responsibility. Attempts to reconstruct with antiperistaltic segments have inevitably led to severe functional problems and dysphagia. Despite the necessity for three anastomoses, in a series of 360 reconstructions for various obstructive lesions the operative mortality rate (5 percent) and the incidence of significant anastomotic fistulas (1 percent) were lower than with any other reconstructive technique. The blood supply from the left
792
colic artery is robust and rarely prone to anatomic variations. The close relation between the marginal artery and the viscus results in a direct channel with no redundancy or kinking as is frequently encountered with jejunum. Sufficient viscus is available to replace the entire esophagus together with the pharynx and stomach when necessary, without tension. Left colon is trained to deal with solid boluses and is therefore functionally more efficient as an esophageal substitute than right colon or other organs. The benign nature of colonic secretion probably explains the low incidence of anastomotic problems and freedom from the risk of postoperative esophagitis. The only contraindications to left colonic interposition are severe intrinsic colonic disease and the mesenteric endarteritis occasionally encountered in patients with systemic hypertension. Reconstruction with left colon is therefore the method of choice in a situation where, despite the apparent palliative nature of the treatment, the patient may survive longer than 2 years. When contraindicated, the alternative procedure is cervical esophagogastrostomy. The technique of the procedure has been described elsewhere. The essential points are as follows: Adequate exposure must be obtained through the extended left sixth interspace thoracotomy. The left colic artery should be inspected and its suitability for sustaining the transplant determined. The descending colon should be mobilized to facilitate the colocolic anastomosis. An estimated adequate length of colon for the reconstruction should be separated, which may involve division of the left branch of the middle colic artery followed by colocolic anastomosis between the transverse and descending colon. An antireflux cologastric anastomosis should be performed on the posterior aspect of the stomach near the greater curve one third of the distance from the closed cardia to the pylorus distally, to maintain an 8 to 10 cm segment of transplant in the high pressure region below the diaphragm. All three routes are available for positioning the transplant; however, it is essential that kinking or other obstruction of the blood supply to the transplant, especially the venous return, be carefully avoided. Redundancy of the colon above the diaphragm must be avoided, especially if the mediastinal or transpleural route has been used. After completion of the proximal anastomosis, any redundant transplant is gently drawn downward and replaced in the abdomen, where it will cause no embarrassment; the seromuscular layer of the colon is then anchored for half its circumference to the margin of the diaphragmatic hiatus to discourage its return to the thoracic cavity.
The American Journal of Surgery
Palliative Management of Esophageal Carcinoma
Jejunal Interposition The advantages of the interposition of an isoperistaltic segment of jejunum for reconstruction are (1) active peristalsis and (2) the rarity of intrinsic jejunal disease to contraindicate its use. The disadvantage of jejunum for esophageal replacement lies in the anatomy of the vascular supply. *Jejunum is suitable for a short reconstruction, but if a long or total reconstruction is attempted a tight “bowstring” vascular pedicle will be accompanied by a long loop of redundant viscus above the diaphragm and considerable attendant risk of mechanical obstruction and stasis. If no alternative to the use of ,jejunum is available, on account of intrinsic disease of the colon or previous interference with the stomach, then the redundant loop should be excised immediately without damage to the main vascular pedicle and continuity restored by an additional end-t o-end anastomosis. The main indication for jejunal int.erposition is reconstruction by means of a Roux-Y esophagojejunostomy after total gastrectomy and partial esophagectomy for carcinoma of the cardia. Bypass Techniques
for Relieving
Obstruction
In certain cases in which the tumoris unresectable due to local extensions, a bypass procedure may be the only method of achieving adequate relief of dysphagia. The obstruction may be eliminated and the risk of further aspiration pneumonitis reduced, but the other complications such as sepsis, hemorrhage and the risk of the dreaded tracheoesophageal f’i$,tula are unaffected. I’alliation is therefore incomp1et.e. Unresectable tumors of t,he cardia can be i)>,passed by Roux-Y esophagojejunostomy, with a side-to-end anastomosis as high above the tumor as possible, the jejunal limb being brought up through a :;eparate opening in the central tendon of the diaphragm. Mid-third tumors can be bypassed by mobilizing the stomach and performing a side-to-side anastomosis above the tumor through a right thoracototny. An ‘&peristaltic segment of left colon can he employed to bypass a tumor situated at any level ar.d is undoubtedly the organ of choice when the tumor is in the upper third. It must be stressed, however, that bypass procedures are indicated only when palliative resection is technically impossible. Distant Metastases:
a Contraindication?
Too often in the past surgeons have opened the abdomen, confirmed the presence of hepatic metast.ases and promptly closed the ahdomen again. This
Volume
139, June 1990
policy maly help the surgeon’s statistics, but it does not help -the patient who is then condemned to an undignified demise in great misery. This situation again has philosophical overtones, but compassion demands that the surgeon attempt. to relieve the major complications by one of the palliative procedures already discussed to enable the patient at least to die naturally and with dignity, in the company of his friends. If the patient dies during the attempt, nothing is lost other than the surgeon’s vanity. In a co-nsecutive series of 901 cases of esophageal carcinoma reported from Bristol, palliative resection and reconstruction were performed in 76 percent of the patients, which indicates that many patients with advanced disease and distant metastases were accepted for palliation. Only moribund patients destined to die within a few days of admission were denied; some of them were helped hy simple dilatation. The operative mortality rate in that series was 24 percent, which many surgeons would regard as completely unacceptable. However, among the 76 percent who survived the operat,ion, the average length of survival was 24 months, during which time the patients could swallow normally or with minimal difficulty and were grateful. This is palliation. Management of Trachea- or Bronchoesophageal Fistulas This is, undoubt,edly the most dreaded complication that can occur in this disease. LJntil recently nothing could be done to help t,hese patients other than to hasten their demise from drowning with increasing doses of morphine. This complication may arise in patients with localized disease and no distant metastases and may in fact he responsible for the presenting symptoms. When a malignant tumor is found to he invading the major air passages, irradiation will merely accelerate the development of a fistula. If palliative resection and reconstruction are performed in this situation with residual tumor left in the wall of the trachea, then post.operative irradiation can be given to prevent or delay airway ohstruction without the attendant risk of fistula formation. This constitutes one of t,he few indications for irradiation in the management of this disease. Once a fistula has developed, irradiation will only worsen the situation by increasing the size of the fistula. Intuhation may provide marginal help hut is not the answer to the problem. Only disconnection and isolating the segment of’ esophagus where the fistula is located, followed by a bypass procedure, will restore the ahility t.o drink without drowning. The residual tumor may then respond IO irradiation for
793
Belsey
a time. Mucus secreted by the esophageal glands can be evacuated by coughing or by the ciliary action of the airway mucosa. As no esophageal resection is planned, thoracotomy is unnecessary. At laparotomy an isoperistaltic transplant of left colon is prepared, of sufficient length to reach the neck. The cardia is divided and both the esophagus and the stomach are closed. The cologastric anastomosis is performed on the posterior aspect of the stomach by the technique previously described, to prevent tension or kinking of the vascular pedicle of the colon transplant, which can occur if the anastomosis is performed on the anterior aspect. The proximal end of the transplant is closed temporarily. A retrosternal tunnel is established. Through a cervical incision the upper esophagus is divided and the lower end closed and dropped back into the mediastinum, thus creating a closed esophageal segment draining through the fistula into the trachea and entirely disconnected from the upper gastrointestinal tract. The proximal end of the colon transplant is then brought up through the retrosternal tunnel and anastomosed end-to-end with the cervical esophagus. The quantity of mucus secreted by the esophageal glands is small and will not compromise the airway. Anastomotic
Technique
In palliation for carcinoma of the esophagus, where relief of obstruction plays such a major role, the prevention of recurrent obstruction from anastomotic complications is just as important as the pre-
794
vention of obstruction from further spread of the tumor. Attempted palliation is useless if the patient returns 3 months later with further dysphagia resulting from an anastomotic stricture. Anastomotic technique is therefore a matter of considerable importance to the patient. There is now ample proof that a single layer anastomosis with mucosal inversion, as dictated by the principle of tissue apposition without tissue strangulation by excessive suturing, involves less risk of stenosis from traumatic fibrosis and is superior to the multilayer anastomoses popular in the past. Provided a nonirritant suture material is used to reduce fibrous reaction, it probably matters little which of the numerous varieties of sutures available is used. In the Chicago and Bristol series, monofilament stainless steel wire has been preferred because of its completely inert nature and its noninterference with the healing process if local infection occurs. However, the single layer principle is probably more important than the nature of suture material. Summary The surgical treatment of esophageal carcinoma is palliative surgery in 90 percent of cases. Much can be done by the motivated surgeon to ease the suffering of the patients and to help them die with dignity. In this context, compassion is more important than surgical statistics. Age, depletion resulting from complications and distant metastases are no longer contraindications to palliative surgery as defined herein.
The American Journal of Surgery
Ronald H. R. Belsey, MD, FRCS, FRCSI, Bristol, England
It has been estimated by a medical economist that it costs the average patient $23,000 to die from cancer. If t he patient is dying from cancer of the esophagus, involving major surgery, the cost is likely to be nearer $33,000. The question being debated today is whether the patient is getting a fair return for this outlay or whether he is being swindled in a big way. It is generally agreed that death from this dread disease constitutes one of the more distressing and least comfortable ways of dying. Assuming that the primary duty of the physician or surgeon is to relieve suf.fering rather than to cure disease, then the whole subject of management demands review. Diagnosis when the growth is still curable, before distant metastases or unresectable local spread has occurred, is rare for the following reasons: The usual warning signs of pain or hemorrhage are uncommon. The esophagus can adapt to a considerable degree of stenosis before the patient experiences any subjective dysphagia. An obvious decline in the patient’s general condition may not occur until late in the course of the disease. Mass popoulation surveys by esophageal washing:, and endoscopy such as have been conducted in China in an effort to achieve earlier diagnosis are probably not feasible on economic or philosophical grounds in Western societies, nor as yet is there any evidence that a significant improvement in survival rates can be achieved by this approach. Owing to defects in the medical educational system, the profession is not yet sufficiently “esophagealminded” to be alerted to the necessity of endoscopic examination in virtually symptom-free patients as the only method of achieving early diagnosis at. a curable stage of the disease. Radiologic examination will reveal only advanced growths. Regrettably, a Fromthe Department of Surgery, Urwersity of Bristol, Bristol, England. Requests for reprints should be addressed to Ronald H. R. Belsey, MD, University of Bristol, Bristol, England Presented at the Fifth Annual Lyman A. Brewer Ill Cardiothoracic SymPoswm. Los Angeles, California, December 6 and 7, 1979.
Volume
139,
June 1990
radiologist’s report of “no esophageal abnormality seen” may promote an attitude of complacency in the clinician and delay the essential endoscopic examination until the tumor has advanced. Radiotherapy and chemotherapy have so far proved of little value in the management of this disease. The value of radical esophageal resections combined with mediastinectomy is currently being investigated; as yet there is no definite evidence that improved long-term survival rates offset the increase in operative risk that may result from complications related to the lymphatic system. Surgical resection followed by esophageal reconstruction remains the dominant element in the surgeon’s armamentarium for the management of this disease. The average resection rate reported is 40 percent. Our concern is not only with the late results in those patients in terms of survival and the quality of life, but equally with the fate of the 60 percent that are rejected from the resection program. The problem is largely philosophical. The higher the resection rate, the higher will he the operative mortality rate. It has been stated with justification that no surgeon concerned with statistics should undertake the treatment of cancer of the esophagus. This is one situation where compassion takes precedence over surgical vanity. Many take the view that any surgical treatment is essentiall:y palliative. The presence of distant metastases rules out any hope of long-term survival. In terms of local spread however, it has been found difficult. or impossible in practice to hazard a longterm prognosis. Every surgeon has had the experience of performing a resection where both local extension and lymphatic spread presented an apparently hopeless situation, only to find the patient alive and apparently free from recurrence 5 or more years later. Autopsy records on patients dying from esophageal carcinoma reveals that in 30 percent of
789
Belsey
cases the tumor is still confined to the esophagus with no evidence of distant metastases and is potentially curable or amenable to effective palliative treatment. Definition
of Palliation
The complications rather than the underlying growth are mainly responsible for the distress suffered by the patient. Dysphagia and significant malnutrition usually occur relatively late in the course of the disease. Pulmonary complications such as recurring aspiration pneumonitis will accompnay the onset of significant obstruction. Septic intoxication is a feature of large fungating neoplasms that are heavily infected by both aerobic and anaerobic flora. Anemia may result from slow bleeding from a fungating growth, together with malnutrition and septic intoxication. The presenting symptoms may be caused by distant metastases. The most dreaded complication is the development of a fistula between the lumen of the esophagus and either the trachea or a main bronchus. Palliation aims at the relief of all of the local complications until death occurs from metastases. The success or failure of the available methods for palliation will be reviewed in the light of this philosophy. Dilatation, repeated as necessary, may be the only method available to relieve dysphagia and possibly reduce pulmonary complications in elderly depleted patients. The extent of the resulting symptomatic relief is unpredictable; it may last from a few days to several weeks, depending on the type of growth present. Intubation with one of the numerous devices designed for this purpose may be combined with dilatation. Opinions vary widely on the value of intubation, depending on the interpretation of the term relief. For surgeons who demand restoration of the patient’s ability to eat and drink normally and with satisfaction as the only acceptable form of palliation, the results of intubation are inadequate. At best, the patient may be able to swallow fluids or soft substances such as ice cream, but obstruction of the tube even with milk curds is common, calling for frequent replacement or endoscopic clearance. Plastic tubes may disintegrate and pass through the stricture. Intubation for high strictures is rarely tolerated by the patient. If the distal end of the tube enters the stomach in a lower third stricture, severe and distressing reflux can occur. Intubation of middle third strictures involves a considerable risk of hemorrhage, the most common cause of death after intubation. Sepsis, anemia and the risk of a fistula into the airway are not relieved. The indications for intubation are
790
therefore very limited, and the greater a surgeon’s experience with more radical forms of palliation, the less he will resort to this attempt at palliation. Irradiation has rarely proved successful in achieving adequate palliation. The development of a tracheoesophageal fistula has frequently been hastened by irradiation in middle and upper third growths. Response of a lower third growth has frequently resulted in worsening of the dysphagia from undilatable stricture formation. Chemotherapy has proved equally unsuccessful. Gastrostomy creates an intolerable situation for both the patient and the relatives condemned to live with him. Few surgeons would consent to this barbaric procedure being performed on themselves in this context. Two options for palliation remain: palliative resection with reconstruction, and various bypass operations. Palliative
Resection
and Reconstruction
This description has been rejected by some writers on the grounds that resection implies more than palliation. The alternative philosophy claims that all resections should be regarded as palliative, with the occasional satisfactory long-term result and apparent cure as a bonus achieved largely by accident. Assuming that palliation implies relief not only of dysphagia but also of sepsis, hemorrhage, anemia, tendency to pulmonary aspiration and the risk of a fistula into the airway, then these objectives can be achieved only by resection of the tumor-bearing segment of the esophagus. Various technical details demand examination. If the resection is designed to relieve dysphagia, it is essential that the risk of further dysphagia resulting from local recurrence of the growth or anastomotic problems be eliminated. Local recurrence of the growth stems from the upward spread in the submucosal lymphatic plexus, the extent of which cannot be determined by endoscopic examination. Initially it was thought that at least 5 cm of normal esophagus above the upper limit of the growth should be resected. This proved inadequate. Apart from occasional recurrences at a higher level, examination of resected specimens revealed premalignant changes throughout the organ with sufficient frequency to warrant a change in policy. In most clinics the entire esophagus is now resected routinely, irrespective of the level of the growth. There are additional reasons for routine total esophagectomy that will become apparent when the problem of subsequent reconstruction is discussed. Adenocarcinoma of the fundus of the stomach with obstruction due to involvement of the lower esoph-
The American Journal of Surgery
Palliative Management of Esophageal Carcinoma
agus presents a different problem. Owing to the different method of local spread, the present trend is to perform total gastrectomy combined with resection of the lower half of the esophagus. A resection of this extent, wit,h esophageal reconstruction cannot be performed by the abdominal route. Tumors in the region of the cardia should be approached through the extended left, sixth interspace thoracotomy with peripheral detachment of the diaphragm. All obvious and resectable lymphatic extensions will be removed along with the esophagus. The position of irresectable deposits left behind will he marked with metal clips. Left or Right Thoracotomy? This choice is dictated by the level of the growth and the type of subsequent reconstruction contemplated. The practice varies in different clinics. In those where it is considered preferable to perform resection and reconstruction through a single extended thoracotomy incision, the left approach will be used more often, with the right approach reserved for middle-third growths adjacent to the aortic arch. When a separate laparotomy incision is preferred for preparation of the transplant with which the esophagus will be reconstructed, right thoracotomy will often be chosen. Preliminary 1:n most dilated by paCent to during the junostomy alimentation management
patients the stricture can be sufficiently bouginage before resection to enable the take a high protein fluid diet by mout,h period of preparation. A preliminary jemerely wastes valuable time. Parenteral has radically changed the preoperative of’ nutritional problems.
Procedures?
For the patient, a single operation that restores his ability to swallow and relieves the other complicat.ions is preferable to any multistage program. The alternatives are a preliminary bypass procedure fol’owed by esophageal resection at a later date, or primary resection with a feeding gastrostomy and cervical esophagostomy and secondary reconstruction. The latter program is more logical because the sooner the growth is removed, the smaller the risk of recurrence. There is little convincing evidence that staged procedures reduce the operative morbidity or mortality rate; in fact, some workers have found that the combined risk of two major operations exceeds t.hat of a single-stage procedure. Improvements in
139,
June
1990
Reconstructive
Technique
Partial esophagogastrectomy followed by intrathoracic esophagogastrostomy has been abandoned for the following reasons, except in cases in which only the shortest surgical procedure is justified due to the advanced stage of the disease and the hopeless prognosis. The operative morbidity and morta1it.y rates are higher than those of any other form of reconstruction, due to anastomotic fistulas and acute aspiration pneumonitis in the early postoperative period. Limited resection increases the risk of f’urther dysphagia due to local recurrence of the t.umor. In the event of the patient’s survival for longer I han a year, there is the added risk of severe peptic esophagitis due to refux and recurrent dysphagia from peptic stenosis. Attempts to construct a valvular esophagogastric anastomosis to prevent reflux have so far failed. Three techniques are available f’or reconstruction after total esophagectomy: the use of whole stomach and cervical esophagogastrostomy, interposition of an isoperistaltic segment of left colon, and interposition of an isoperistaltic segment of jejunum.
Feeding Jejunostomy?
Single Stage or Multistage
Volume
anesthesia, operative technique and pre- and postoperative care undoubtedly favor single-stage synchronous resection and reconstruction.
Cervical
Esophagofundostomy
One advantage of the cervical anastomosis over the intrathoracic one is a lower incidence of anastomotic fistulas, possibly due to neutralization of the negative intrathoracic pressure by compression from the surrounding cervical organs and the reduced risk of fatal septic complications should a leak occur. Another advantage is a lower incidence of’ reflux esophagitis and peptic stenosis above the anastomosis. Three routes are available for the transplanted stomach: mediastinal, pleural and retrosternal. The mediastinal and retrosternal routes are preferable because the tendency to gastric distention is restrained by the confines of these routes; distention may be prominent when the intrapleural route is used, leading to some degree of pulmonary embarassment. The mediastinal route should not be used if residual tumor in the mediastinum imposes t.he risk of recurrent obstruction of the esophageal replacement. A furt,her advantage of this technique is the single anastomosis needed to restore continuity. After resection of the esophagus through the extended left
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sixth interspace thoracotomy, the cardia is closed and pyloromyotomy performed to prevent gastric stasis, an effective drainage procedure that incurs less risk of troublesome duodenal reflux. The fundus of the stomach is then brought up through the hiatus and then by the mediastinal or transpleural route to the base of the neck, where it is anchored to the stump of the resected esophagus. The thoracotomy is then closed, the patient is turned onto his back, and through an oblique left cervical incision the remainder of the esophagus is resected and an anastomosis is performed between the pharyngoesophageal junction and a separate opening in the highest point of the gastric fundus. The cervical dissection can be greatly assisted by freeing the esophagus as high as possible from inside the left thorax by gentle finger dissection. In no case in my experience was any technical difficulty encountered in bringing the fundus up to the neck, even in cases in which the stomach appeared to be contracted as a result of chronic starvation from esophageal obstruction. When the retrosternal route is employed, the fundus can be anchored to the base of the neck by two sutures passed out through the skin and tied by the anesthetist. After the thoracotomy is closed, the upper anastomosis is concluded in the manner already described. In view of the ease with which this reconstruction can be achieved, there appears to be no indication for the more complicated reconstruction with a reversed gastric tube by the Gavriliu technique, involving the possibility of late functional problems from the antiperistaltic nature of the proximal part of the reconstruction. Reconstruction by cervical esophagofundostomy is not possible if the upper part of the stomach has been resected on account of malignant involvement of the lesser curve. Left Colonic Interposition Reconstruction with left colon has advantages over other techniques. It is mandatory that the segment of colon be interposed in the isoperistaltic fashion. The colon may not be peristaltic, but it is a powerful unidirectional propulsive organ with a highly developed sense of responsibility. Attempts to reconstruct with antiperistaltic segments have inevitably led to severe functional problems and dysphagia. Despite the necessity for three anastomoses, in a series of 360 reconstructions for various obstructive lesions the operative mortality rate (5 percent) and the incidence of significant anastomotic fistulas (1 percent) were lower than with any other reconstructive technique. The blood supply from the left
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colic artery is robust and rarely prone to anatomic variations. The close relation between the marginal artery and the viscus results in a direct channel with no redundancy or kinking as is frequently encountered with jejunum. Sufficient viscus is available to replace the entire esophagus together with the pharynx and stomach when necessary, without tension. Left colon is trained to deal with solid boluses and is therefore functionally more efficient as an esophageal substitute than right colon or other organs. The benign nature of colonic secretion probably explains the low incidence of anastomotic problems and freedom from the risk of postoperative esophagitis. The only contraindications to left colonic interposition are severe intrinsic colonic disease and the mesenteric endarteritis occasionally encountered in patients with systemic hypertension. Reconstruction with left colon is therefore the method of choice in a situation where, despite the apparent palliative nature of the treatment, the patient may survive longer than 2 years. When contraindicated, the alternative procedure is cervical esophagogastrostomy. The technique of the procedure has been described elsewhere. The essential points are as follows: Adequate exposure must be obtained through the extended left sixth interspace thoracotomy. The left colic artery should be inspected and its suitability for sustaining the transplant determined. The descending colon should be mobilized to facilitate the colocolic anastomosis. An estimated adequate length of colon for the reconstruction should be separated, which may involve division of the left branch of the middle colic artery followed by colocolic anastomosis between the transverse and descending colon. An antireflux cologastric anastomosis should be performed on the posterior aspect of the stomach near the greater curve one third of the distance from the closed cardia to the pylorus distally, to maintain an 8 to 10 cm segment of transplant in the high pressure region below the diaphragm. All three routes are available for positioning the transplant; however, it is essential that kinking or other obstruction of the blood supply to the transplant, especially the venous return, be carefully avoided. Redundancy of the colon above the diaphragm must be avoided, especially if the mediastinal or transpleural route has been used. After completion of the proximal anastomosis, any redundant transplant is gently drawn downward and replaced in the abdomen, where it will cause no embarrassment; the seromuscular layer of the colon is then anchored for half its circumference to the margin of the diaphragmatic hiatus to discourage its return to the thoracic cavity.
The American Journal of Surgery
Palliative Management of Esophageal Carcinoma
Jejunal Interposition The advantages of the interposition of an isoperistaltic segment of jejunum for reconstruction are (1) active peristalsis and (2) the rarity of intrinsic jejunal disease to contraindicate its use. The disadvantage of jejunum for esophageal replacement lies in the anatomy of the vascular supply. *Jejunum is suitable for a short reconstruction, but if a long or total reconstruction is attempted a tight “bowstring” vascular pedicle will be accompanied by a long loop of redundant viscus above the diaphragm and considerable attendant risk of mechanical obstruction and stasis. If no alternative to the use of ,jejunum is available, on account of intrinsic disease of the colon or previous interference with the stomach, then the redundant loop should be excised immediately without damage to the main vascular pedicle and continuity restored by an additional end-t o-end anastomosis. The main indication for jejunal int.erposition is reconstruction by means of a Roux-Y esophagojejunostomy after total gastrectomy and partial esophagectomy for carcinoma of the cardia. Bypass Techniques
for Relieving
Obstruction
In certain cases in which the tumoris unresectable due to local extensions, a bypass procedure may be the only method of achieving adequate relief of dysphagia. The obstruction may be eliminated and the risk of further aspiration pneumonitis reduced, but the other complications such as sepsis, hemorrhage and the risk of the dreaded tracheoesophageal f’i$,tula are unaffected. I’alliation is therefore incomp1et.e. Unresectable tumors of t,he cardia can be i)>,passed by Roux-Y esophagojejunostomy, with a side-to-end anastomosis as high above the tumor as possible, the jejunal limb being brought up through a :;eparate opening in the central tendon of the diaphragm. Mid-third tumors can be bypassed by mobilizing the stomach and performing a side-to-side anastomosis above the tumor through a right thoracototny. An ‘&peristaltic segment of left colon can he employed to bypass a tumor situated at any level ar.d is undoubtedly the organ of choice when the tumor is in the upper third. It must be stressed, however, that bypass procedures are indicated only when palliative resection is technically impossible. Distant Metastases:
a Contraindication?
Too often in the past surgeons have opened the abdomen, confirmed the presence of hepatic metast.ases and promptly closed the ahdomen again. This
Volume
139, June 1990
policy maly help the surgeon’s statistics, but it does not help -the patient who is then condemned to an undignified demise in great misery. This situation again has philosophical overtones, but compassion demands that the surgeon attempt. to relieve the major complications by one of the palliative procedures already discussed to enable the patient at least to die naturally and with dignity, in the company of his friends. If the patient dies during the attempt, nothing is lost other than the surgeon’s vanity. In a co-nsecutive series of 901 cases of esophageal carcinoma reported from Bristol, palliative resection and reconstruction were performed in 76 percent of the patients, which indicates that many patients with advanced disease and distant metastases were accepted for palliation. Only moribund patients destined to die within a few days of admission were denied; some of them were helped hy simple dilatation. The operative mortality rate in that series was 24 percent, which many surgeons would regard as completely unacceptable. However, among the 76 percent who survived the operat,ion, the average length of survival was 24 months, during which time the patients could swallow normally or with minimal difficulty and were grateful. This is palliation. Management of Trachea- or Bronchoesophageal Fistulas This is, undoubt,edly the most dreaded complication that can occur in this disease. LJntil recently nothing could be done to help t,hese patients other than to hasten their demise from drowning with increasing doses of morphine. This complication may arise in patients with localized disease and no distant metastases and may in fact he responsible for the presenting symptoms. When a malignant tumor is found to he invading the major air passages, irradiation will merely accelerate the development of a fistula. If palliative resection and reconstruction are performed in this situation with residual tumor left in the wall of the trachea, then post.operative irradiation can be given to prevent or delay airway ohstruction without the attendant risk of fistula formation. This constitutes one of t,he few indications for irradiation in the management of this disease. Once a fistula has developed, irradiation will only worsen the situation by increasing the size of the fistula. Intuhation may provide marginal help hut is not the answer to the problem. Only disconnection and isolating the segment of’ esophagus where the fistula is located, followed by a bypass procedure, will restore the ahility t.o drink without drowning. The residual tumor may then respond IO irradiation for
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a time. Mucus secreted by the esophageal glands can be evacuated by coughing or by the ciliary action of the airway mucosa. As no esophageal resection is planned, thoracotomy is unnecessary. At laparotomy an isoperistaltic transplant of left colon is prepared, of sufficient length to reach the neck. The cardia is divided and both the esophagus and the stomach are closed. The cologastric anastomosis is performed on the posterior aspect of the stomach by the technique previously described, to prevent tension or kinking of the vascular pedicle of the colon transplant, which can occur if the anastomosis is performed on the anterior aspect. The proximal end of the transplant is closed temporarily. A retrosternal tunnel is established. Through a cervical incision the upper esophagus is divided and the lower end closed and dropped back into the mediastinum, thus creating a closed esophageal segment draining through the fistula into the trachea and entirely disconnected from the upper gastrointestinal tract. The proximal end of the colon transplant is then brought up through the retrosternal tunnel and anastomosed end-to-end with the cervical esophagus. The quantity of mucus secreted by the esophageal glands is small and will not compromise the airway. Anastomotic
Technique
In palliation for carcinoma of the esophagus, where relief of obstruction plays such a major role, the prevention of recurrent obstruction from anastomotic complications is just as important as the pre-
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vention of obstruction from further spread of the tumor. Attempted palliation is useless if the patient returns 3 months later with further dysphagia resulting from an anastomotic stricture. Anastomotic technique is therefore a matter of considerable importance to the patient. There is now ample proof that a single layer anastomosis with mucosal inversion, as dictated by the principle of tissue apposition without tissue strangulation by excessive suturing, involves less risk of stenosis from traumatic fibrosis and is superior to the multilayer anastomoses popular in the past. Provided a nonirritant suture material is used to reduce fibrous reaction, it probably matters little which of the numerous varieties of sutures available is used. In the Chicago and Bristol series, monofilament stainless steel wire has been preferred because of its completely inert nature and its noninterference with the healing process if local infection occurs. However, the single layer principle is probably more important than the nature of suture material. Summary The surgical treatment of esophageal carcinoma is palliative surgery in 90 percent of cases. Much can be done by the motivated surgeon to ease the suffering of the patients and to help them die with dignity. In this context, compassion is more important than surgical statistics. Age, depletion resulting from complications and distant metastases are no longer contraindications to palliative surgery as defined herein.
The American Journal of Surgery