'cal Treatment of Carcinoma s and Cardiac Portion

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1 'cal Treatment of Carcinoma s and Cardiac Portion 850 Patients Xu Le-Tian, M.D., Sun Zhen-Fu, M.D., Li Ze-Jian, M.D., and Wu Lian-Hun, M.D. ABSTRACT From 1961 to 1978, 850 patients with carcinoma of the esophagus or cardiac portion of the stomach were operated on in the Capital Hospital of the Chinese Academy of Medical Sciences. Eightythree percent of the patients were men, and about 45% of the patients ranged from 51 through 60 years old. Just over half of the patients were seen when the lesion was at a late stage of development. The thirtyday postoperative mortality among 664 patients with a resected lesion was 10%. Leakage of the esophagogastric anastomosis was the chief cause of morbidity, and about half of the patients with this condition died. The 5-year survival among these 664 patients with a resected lesion was 22%. Retrospective review of the literature confirmed the possibility of further increasing resectability, further decreasing mortality, and providing greater long-term survival if early complete resection of the tumor can be carried out. Carcinoma of the esophagus and cardiac portion of the stomach is one of the most common cancers in North China. From 1961 to 1978, 850 patients with this form of cancer were operated on in the Capital Hospital, Chinese Academy of Medical Sciences. In this report, we present our findings in this group of patients. Clinical Material During a 17-year period, 850 patients with carcinoma of the esophagus or cardiac portion of the stomach underwent operation at the Capital Hospital, Peking. There were 707 men and 143 women, a ratio of about 5:l. The patients were in the following age groups: 28 through 30 years old, 7 patients; 31 through 40, 56 patients; 41 From the Department of Surgery, Capital Hospital, Peking, People's Republic of China. Accepted for publication Mar 18, Address reprint requests to Dr. Xu, Vice-head, Department of Surgery, Associate Professor, Capital Hospital, Peking, People's Republic of China. through 50, 235; 51 through 60, 386; 61 through 70, 158; and 71 through 74, 8. About 45% of the patients were between 51 and 61 years old. Slightly more than half of the patients were seen at a late stage in the development of the lesion: they had marked dysphagia on a semiliquid diet, loss of body weight, and an esophageal tumor greater than 5 cm. However, they had no contraindication to operation. The 850 patients were divided into three groups: Group 1 consisted of 67 patients in whom the lesion was in the upper third of the esophagus. Group 2 had 363 patients in whom the lesion was in the middle third of the esophagus. Group 3 consisted of 420 patients in whom the lesion was in the lower third of the esophagus or cardiac portion of the stomach. Results In 664 patients the tumor was resected (Table). Resectability was 98% for Group 1, 77% for Group 2, and 76% for Group 3 (average, 78% for all 850 patients). Thirty-day mortality among the patients undergoing resection was 24% (16 patients) in Group 1, 10% (29 patients) in Group 2, and 7% (22 patients) in Group 3. The average mortality for these 664 patients was 10%. Causes of death included leakage of the anastomosis, empyema, septicemia, heart failure, internal hemorrhage of the gastrointestinal tract, renal failure, respiratory failure, chylothorax, pneumonia, septic shock, and pyloric obstruction. The chief cause of death among patients with a resected lesion was leakage of the anastomosis (28167). Postoperative complications among patients who underwent resection included leakage of the anastomosis, empyema, wound infection, pneumothorax, pseudomembranous enterocolitis, injury to the recurrent laryngeal nerve, diaphragmatic hernia, stricture of the anastomosis, and pyloric obstruction. The incidence of leak- 542

2 543 Xu et al: Surgical Treatment of Carcinoma of the Esophagus Operations and Results in 850 Patients with Carcinoma of the Esophagus and Cardiac Portion of the Stomach Patients with Carcinoma of Patients with Patients with Lower Third Carcinoma of Carcinoma of and Cardiac Operation and Upper Third Middle Third Portion Totals Results (N = 67) (N = 363) (N = 420) (N = 850) OPERATION Resection 66 (98%) 280 (77%) 318 (76%) 664 (78%) Exploratory thoracotomy Palliative loob esophagogastros tomy RESULTS Thirty-day mortalityc 16 (24%) 29 (10%) 22 (7%) 67 (10%) Leakage of 8 (12%) 26 (9%) 18 (6%) 52 (8%) anastomosisc Death after leakage (54%) Five-year survival % Mortality of 7% after exploratory thoracotomy. bmortality of 4% after palliative esophagogastrostomy. Applies to patients undergoing resection. age of the anastomosis was 12% in Group 1,9% in Group 2, and 6% in Group 3 (see Table). The average incidence of this complication among the 664 patients with a resectable lesion was 8%, and just over half of the patients with this complication (54%) died (28 out of 52). To relieve esophageal obstruction and prolong survival in some of the 186 patients with a nonresectable lesion, we performed palliative esophagogastrostomy (bypass operation). Average survival among the 100 patients operated on in this manner was eight months; operative mortality was 4%. The thirty-day operative mortality among the 86 patients who underwent exploratory thoracotomy was 7%. Pathological examinations were done of the 664 tumors resected. Macroscopically, the resected lesions were medullary, ulcerative, or scirrhous in character or mushroom or polypoid in form. Microscopically, the tumors in the upper and middle thirds of the esophagus (Groups 1 and 2) were chiefly squamous cell carcinoma, plus four instances of carcinosarcoma. In the lower third of the esophagus and cardiac portion of the stomach (Group 3), adenocarcinoma and undifferentiated cell carcinoma were the predominant types. Postoperative irradiation at a dose of 5,000 rads was used only in patients with mediastinal lymphadenopathy after resection of squamous cell carcinoma. Chemotherapy was used routinely in patients with metastasis to lymph nodes after resection of adenocarcinoma or undifferentiated cell carcinoma. Agents used included 5-fluorouracil, Cytoxan (cyclophosphamide), mitomycin C, and bleomycin, and were given alternately or in combination. Recurrence of carcinoma of the esophagus usually was found in the mediastinal and retroperitoneal lymph nodes. Clinical manifestations of recurrence were loss of body weight, poor appetite, hoarseness, supraclavicular adenopathy, ascites, and cachexia. The five-year survival for the 664 patients with a resected tumor was 22%. The best results occurred in the group of patients with carcinoma of the middle third of the esophagus (Group 2) and the worst results, in the group with carcinoma of the upper third of the esophagus (Group 1).

544 The Annals of Thoracic Surgery Vol 35 No 5 May 1983 Comment In 1938, Adams and Phemister [l] performed a successful resection of carcinoma of the lower esophagus using esophagogastrostomy.

3 544 The Annals of Thoracic Surgery Vol 35 No 5 May 1983 Comment In 1938, Adams and Phemister [l] performed a successful resection of carcinoma of the lower esophagus using esophagogastrostomy. On April 26, 1940, in Peking the same kind of operation was done successfully by Wu and Loucks 161. In March, 1951, Hwang [2] performed a cervical esophagogastrostomy in Shanghai. Since then, esophagectomy has become one of the most common thoracic operations in North China. By a mass survey reported in 1959, the incidence of carcinoma of the esophagus in a population of 17 million was found to be 7.11 per 100,000 population. The etiology for this high incidence of esophageal carcinoma in North China is still not clear. Diagnosis, Indications, and Contraindications to Operation In the vast majority of our 850 patients, the diagnosis was established without difficulty by barium meal esophagogram and by the complaint of progressive difficulty in swallowing. Correct diagnosis of carcinoma of the middle third of the esophagus was established at operation by frozen biopsy in 1 patient with a preoperative diagnosis of diverticulum of the esophagus and in 1 patient with leiomyoma. Correct diagnosis of benign stricture of the lower esophagus as a complication of reflux esophagitis was established after resection of the lesion in 2 patients with a preoperative diagnosis of carcinoma of the esophagus. Some patients were referred from local hospitals in North China where the cytological diagnosis was obtained with a net-covered balloon catheter. The catheter is swallowed by the patient and pulled out after inflation of the balloon to catch the specimen. With this method, a cytological diagnosis can be made and the level of the lesion localized by multiple segmental examinations. The chief complaint of a patient seen early with esophageal carcinoma was pain or discomfort during swallowing rather than dysphagia. Typical signs of esophageal carcinoma on esophagogram were disarrangement of the lineal figure of the mucous membrane, stricture, a filling defect, or ulceration. In our hospital, rigid or fiberoptic endoscopic examination was advised only for patients with a questionable diagnosis. We believe in an active approach (i.e., surgical intervention) to treat carcinoma of the esophagus and cardiac portion of the stomach. Only when there is hoarseness, metastasis to a supraclavicular lymph node, a palpable mass below the xiphoid process, an esophagotracheal or bronchial fistula, obvious ascites, or cachexia are contraindications to operation considered. Dehydration, disturbances in blood electrolytes, or malnutrition can be corrected by infusion, transfusion, or hyperalimentation. The presence of one or a combination of these conditions does not necessarily mean the lesion is unresectable. Preoperative Preparation We give importance to the preoperative evaluation of patients. Electrocardiograms, renal and liver function tests, and blood electrolytes are examined routinely. In patients with chronic obstructive pulmonary disease or pulmonary tuberculosis, chest roentgenograms are advisable. Analysis of blood gases and pulmonary function tests are done if necessary. In patients with marked obstruction of the esophagus, washing the esophagus with a solution of 0.9% sodium chloride may minimize edema in the mucous membrane and infection. Oral hygiene should be corrected and periodontal infection controlled before operation. Bronchitis should be controlled and smoking should be stopped at least one week before operation. Focal infection of the oral cavity and upper respiratory tract were the most important sources of postoperative infection among our patients. Therefore, the preventive use of antibiotics (penicillin and streptomycin) should begin three days before operation. Operative Methods For carcinoma of the cardiac portion of the stomach and lower end of the esophagus, we used two types of infraaortic esophagogastrostomy: end-to-side and end-to-end anastomosis through a posterolateral thoracotomy with resection of the seventh rib without pyloro-

4 545 Xu et al: Surgical Treatment of Carcinoma of the Esophagus plasty. The advantage of end-to-side infraaortic esophagogastrostomy is that the suture line is placed near the blood supply of the stoma of the stomach. But there may be tension in the suture line if too much of the stomach and esophagus is resected. The advantage of end-to-end infraaortic esophagogastrostomy is that the alignment of the anastomosis is good. However, there is a weak point in the triangular suture area at the site of anastomosis, and there is a possibility of stricture after completion of the anastomosis. For carcinoma of the lower and middle thirds of the esophagus, we used two types of supraaortic esophagogastrostomy through a posterolateral thoracotomy with resection of the sixth rib: a telescopelike anastomosis and scarfwrapping-like anastomosis. In the telescopic anastomosis, there are two layers of suture for both the anterior and posterior walls of the anastomosis. The inner layer is a wholethickness stitch through both sides of the stomach and the esophagus. The outer layer is a stitch between the fibromuscular layer of the esophagus and the seromuscular layer of the fundus of the stomach. The telescoped portion of the esophagus is from 3 to 5 cm in length. The anterior wall of the stomach inferior to the anastomosis is slung and fixed to the dome of the pleural cavity. A similar procedure to prevent reflux after esophagogastric resection was reported by Lortat-Jacob and colleagues [3] in In the scarf-wrapping-like anastomosis, the first layer of interrupted stitches is placed through the whole thickness of the esophagus and the fundus of the stomach. The anastomosis line is then wrapped by the fundus of the stomach as with a scarf. The anterior wall of stomach inferior to the anastomosis is approximated together and sutured longitudinally. The incidence of leakage after anastomosis by these two methods was about the same, and no significant differences were observed in our patients. However, if the leakage caused infection, it was easily localized and encapsulated after the scarf-wrapping-like anastomosis. For carcinoma of the upper third of the esophagus, we used stomach or colon as a substi- tute for esophagus. We employed a one-stage, three-phase procedure: right posterolateral thoracotomy for isolation of more advanced carcinoma of the esophagus, left paramedial laparotomy for isolation of the stomach, and right cervical incision for esophagogastrostomy. We also used a one-stage, two-phase procedure: left posterolateral thoracotomy for isolation of the stomach and esophagus, and left cervical incision for esophagogastrostomy. The advantage of using stomach as a substitute for esophagus is that only a single anastomosis is done. The great surgical trauma that occurs when three incisions are made should be considered carefully. The possibility of obstruction at the hiatus of the diaphragm when a right-sided approach is used should be prevented by enlargement of the hiatus of the diaphragm. The advantages of using colon as a substitute for esophagus are that the patient has a normally functioning stomach below the diaphragm, and that the colon is acid resistant and has a good blood supply. However, the incidence of Escherichia coli infection is quite high. Etiological Factors of Leakage of Anastomosis The mortality was high after resection of esophageal carcinoma in 9,673 reported cases [4]. It ranged from 19 to 40%, with a gradual decrease in recent years. Better results were reported elsewhere: mortality of 5.7% in 839 patients with resected lesions [5]. One of the most dangerous and most frequent complications was leakage from the suture line. The wideranging results of resection of esophageal carcinoma that are reported by different authors using various operative methods in patients with quite different conditions depend partly on factors involving the patient and partly on the skill and experience of the surgeons. Excluding the first category of factors, four from the second category were considered to be the chief causes of leakage after esophagogastrostomy. The first is the blood supply of the tissue around the suture line. A poor blood supply may occur when there is too much devascularization of the esophagus during operation. That part of the esophagus not to be resected must be minimally separated from connected structures

5 546 The Annals of Thoracic Surgery Vol 35 No 5 May 1983 in order to preserve as much of the blood supply as possible. The characteristic segmental distribution of the blood supply to the esophagus and the weak point of this supply should be considered during esophagogastrostomy. Poor blood circulation also can occur when venous return to the gastric stoma is obstructed after resection and when irreversible damage to the musculomucous structure of the esophagus is done by manual retraction. Ties that are too tight and the placing of too many stitches (stitch distance, less than 0.5 cm) may either restrict the blood supply or cut through the postoperatively swollen mucous membrane and result in necrosis along the suture line. A good blood supply is very important for tissue healing following anastomosis. The second chief cause of leakage after esophagogastrostomy is tension along the suture line, with its effect on blood supply. An unsatisfactory anastomosis that results in tension along the suture line might cause cutting through of the stitches, infection, and leakage. In patients with advanced cardiac carcinoma or carcinoma of the fundus involving the cardiac portion of the stomach, much of the stomach was excised and the short, narrowing gastric stoma was anastomosed to the esophagus, usually with some degree of tension along the suture line. To lengthen the gastric tube and minimize tension along the suture line, complete isolation of the pylorus and pars superior of the duodenum was necessary. In the vast majority of patients, there was some loose connective tissue around these areas. Also, the topmost point of the fundus should be selected for anastomosis, and excessive isolation and resection of the esophagus should be avoided. The third major factor in leakage involves the effectiveness of gastrointestinal decompression. Following operation, it should be checked constantly to rule out any possibility of malpositioning of the tube, kinking of the tube, leakage of the tube, or weak suction power. A distended stoma of the stomach usually increases the tension along the suture line and causes leakage of gastric fluid into the pleural space. The fourth factor leading to leakage was in- adequate exposure for a supraaortic esophagogastrostomy. A prominent aortic knob and emphysematous lung both interfere with the successful construction of an anastomosis through an ordinary posterolateral thoracotomy with resection of the sixth rib. In such cases, resection of the sixth rib and cutting down the fifth rib at its posterior end may be helpful. Leakage of Anastomosis Rupture of the anterior wall of the anastomosis usually has a sudden manifestation early on the second or third postoperative day. Patients have a high, spiking fever, intoxication, and septic shock due to E. coli infection. The prognosis is usually ominous even after drainage. A small leak due to an unmatched approximation of the mucous membrane or to infection of a stitch has an insidious manifestation usually, occurring 'on the sixth to eighth postoperative day. Patients have a low-grade fever or have fever after liquids. Symptoms of intoxication are not very serious. The infection can be localized and encapsulated, and then controlled after drainage. Phlegmonous mediastinitis has an acute, serious clinical manifestation because there is a plentiful blood circulation and numerous nerve plexuses in this region. The infection can extend upward to the neck or downward to the retroperitoneal space. The cause of death is usually septicemia or septic shock. The basic principle of management of leakage of esophagogastrostomy is to drain the infection and provide nutritional support to the patient. If the infection can be controlled by broadspectrum antibiotics, nutritional support becomes the most important problem. We prefer to use parenteral hyperalimentation through catheterization of the subclavian vein at the acute stage of infection and then, for prolonged nutritional support, feed through tube jejunostomy after the recovery of intestinal function. In conclusion, we believe that based on the reports in the literature during the past half century, the great majority of authors consider resection of the tumor and reestablishment of gastrointestinal continuity to be the most effective therapeutic measure for treatment of carcinoma

6 547 Xu et al: Surgical Treatment of Carcinoma of the Esophagus of the esophagus or cardiac portion of the stomach. Although a comparatively low resectability, high postoperative mortality and morbidity, and relatively low long-term survival have been reported previously, our recent retrospective review confirms the possibility of increasing the resectability, decreasing the mortality and morbidity, and increasing the long-term survival. Early diagnosis and complete resection of the tumor by a well-trained surgical team may achieve even better results. In some instances, radiotherapy and chemotherapy can be beneficial postoperatively. We extend our gratitude to Herbert Sloan, M.D., for his helpful advice and encouragement in the preparation of this paper. References 1. Adams WE, Phemister DB: Carcinoma of the lower thoracic esophagus: report of successful resection and esophagogastrostomy. J Thorac Surg 7621, Hwang CS: Resection of the esophagus and cervical esophago-gastrostomy. Chung Hua I Hsueh Tsa Chih 37207, Lortat-Jacob JL, Maillard JN, Fekete F: A procedure to prevent reflux after esophagogastric resection: experience with 17 patients. Surgery 50:600, Postlethwait RW: Surgery of the Esophagus. New York, Appleton-Century-Crofts, 1979, pp Wu YK: Thoracic Surgery, Peking, China, The Publisher of People s Public Health, 1974, pp Wu YK, Loucks HH: Resection of the esophagus for carcinoma. J Thorac Surg 11:516, 1942

Cancer of Esophagus and Esophagogastric Junction: Analysis of Results of 1,025 Resections after 5 to 20 Years

Cancer of Esophagus and Esophagogastric Junction: Analysis of Results of 1,025 Resections after 5 to 20 Years Yun Kan Lu, M.D., Yueh Min Li, M.D., and Yue Zhi Gu, M.D. ABSTRACT Resection was carried out