Br. J. Surg. Vol. 63 (1976) 206-209
Resection and reconstruction for carcinoma of the thoracic oesophagus HIROSHI AKIYAMA, MAMORU HIYAMA AND C H l A K l HASHIMOTO* SUMMARY
The technique and results of oesophageal resection through a right thoracotomy and laparotomy with reconstruction utilizing the stomach via a re trosternal route are reported. Forty patients underwent this procedure, with no mortality. The average blood loss during operation was 424m1, and 72 per cent of this series underwent the operation without blood transfusion. I t is b e l i e d that this type of’one-stage operation for carcinoma of the oesophagus is reasonable .from the viewpoint of adequate resection of malignancies, and it can be perjormed with minimal surgical risk. With experience, perhaps it will become a standard method such as the Billroth I method in gastric surgery.
SINCEthe beginning of modern surgery, oesophageal operations, particularly reconstructive procedures, have been a major area of interest. The colon, stomach and small intestine are the organs most frequently used for oesophageal substitution. These organs can be brought up to the proximal cut end of the oesophagus for anastomosis through various routes, such as the presternal, restrosternal, intrathoracic or posterior mediastinal route. Surgeons should be capable of performing all types of oesophageal reconstruction, but since this procedure involves many fine techniques it is usually reserved for the specialist. However, a standard operative approach which is considered reasonable from the viewpoint of appropriate cancer surgery and entails minimal surgical risks for the aged and undernourished patients in which such surgery is usually necessary should be established. The present paper describes a method of oesophageal resection and reconstruction using the stomach through a retrosternal route for carcinoma of the thoracic oesophagus. The technique is simple and fulfils the criteria outlined above. The results obtained so far are reported. With increasing experience, this operation should be utilized and perfected and thus may become equivalent to the Billroth I procedure in gastric surgery. Patients During the period from 1971 to 1974, 270 cases of carcinoma of the upper alimentary canal including the hypopharynx, upper and lower oesophagus and cardia were admitted to the Toranomon Hospital, Tokyo. Of the 270 cases, 140 cases (51.9 per cent) underwent resection and reconstruction. In the majority of cases the stomach was utilized for reconstruction, as this organ is our first choice, rather than
206
the colon, for oesophageal substitution. Patients who fulfilled the following criteria were selected for the procedure described here: (1) a lesion located in the thoracic oesophagus, not in the hypopharynx or the cervical or abdominal oesophagus; (2) a resectable lesion; (3) a healthy stomach. Forty patients satisfied all these points and underwent this operation.
Technique The method is shown diagrammatically in Fig. 1. The operation involves the right chest, the upper abdomen and the neck. The general plan is as follows. The thoracic oesophagus and proximal stomach are resected. A pyloroplasty is also carried out. The stomach is brought up to the neck through a retrosternal tunnel. The cervical oesophagus is anastomosed to the stomach which is then located behind the sternum. The skin incision is placed at the right fifth intercostal space. It is essential to check that there is no direct invasion by the tumour of the surrounding vital organs before proceeding with the resection. The pleura is incised along the azygos vein, which is then ligated and transected, exposing the whole posterior mediastinum. Dissection of the posterior mediastinal lymph nodes is performed. The oesophageal branch of the vagus nerve is cut and lymph nodes at the bifurcation of the trachea and pulmonary hilum are removed. The pulmonary branch of the vagus nerve is preserved if possible. The paratracheal lymph nodes are removed bilaterally. It is important not to damage the recurrent laryngeal nerve on either side. The thoracic oesophagus is severed at a high level for a low lesion or at a level just above the cardia for a higher lesion (further resection is done later). The cut end of the oesophagus is temporarily closed by suture. The surgical margin should first be checked by direct vision by oesophagotomy (Akiyama et al., 1974). The lower mediastinum is also dissected including all the lymph nodes, particularly those at the oesophageal hiatus. Care should be taken not to damage the left pleura, but if the tumour has invaded the left pleura the affected area must be resected. The thoracic oesophagus with the tumour is left in the thorax, and the chest is closed. The abdomen is then opened by an upper median incision. Exploration for possible intra-abdominal metastases is performed. In some cases with suspicion of advanced abdominal metastases, this is the first step of the operation. These indications are further discussed later. The greater omentum is severed along
* Department of Surgery, Toranomon Hospital, 2, Akasaka, Aoi-cho, Minato-ku, Tokyo, Japan.
Reconstruction in oesophageal carcinoma
Fig. 1. Scheme of the resection and reconstruction for carcinoma of the thoracic oesophagus utilizing the stomach through a retrosternal route.
the greater curvature of the stomach, preserving the right gastro-epiploic artery. The left gastro-epiploic artery and the short gastric arteries are severed and the greater curvature of the stomach is freed towards the oesophageal hiatus. Lymph node dissection at the origin of the coeliac artery and along the common hepatic artery is carried out. The coronary vein and the left gastric artery are severed and tied at their origin. The thoracic oesophagus with the tumour or the cut end of the oesophagus is pulled through the oesophageal hiatus into the abdomen. The oesophagus and stomach is extended and placed on the chest. The proximal stomach including the lymph nodes at the right and left paracardia and the upper part of the lesser curvature is removed together with the oesophagus. Pyloroplasty is performed as a routine procedure. Finally, a neck incision is made along the anterior border of the sternocleidomastoid muscle and the cut end of the oesophagus is pulled out of the neck (Fig. 2). To create the retrosternal tunnel a flat malleable intestinal retractor with a hole in one side (Akiyama and Hiyama, 1974) is used. A tape is threaded through the hole in the retractor. A wide superior orifice of the anterior mediastinum is obtained by dividing both the sternohyoid and sternothyroid muscles. The tape anchored to the retractor is attached to the stomach, which is then brought up to the neck by pulling the tape through the retrosternal tunnel. This can normally be done without difficulty. The cervical oesophagus and the stomach are anastomosed in two layers. Accurate approximation of the epithelium is a very important factor for primary healing of the anastomosis (Akiyama, 1973). A nasogastric tube is inserted for suction, and later to allow tube feeding until oral ingestion is resumed. Results Of the 40 cases who underwent this procedure, there were no operative or hospital deaths. The total operative mortality of resection and reconstruction for .malignant lesions of the hypopharynx to the oesophagogastric junction between 1971 and 1974 was
Fig. 2. Operation photograph showing the stomach, after resection of the oesophageal tumour, cardia and upper lesser curvature, placed on the chest. Its suitability for oesophageal substitution is evident. The stomach is pulled up to the neck through a retrosternal tunnel. The cervical oesophagus is ready for anastomosis.
1.4 per cent. Thus, resection and reconstruction of the thoracic oesophagus by the stomach using a retrosternal route with cervical oesophagogastrostomy in one stage is a safe procedure as demonstrated by its negative mortality rate. As regards postoperative complications, only minor ones developed, including temporary vocal cord paralysis ( I case, spontaneously healed), a small salivary fistula ( I case, spontaneously healed) and stenosis due to compression by a large bony process on the posterior surface of manubrium of the sternum (1 case, the bony process was resected and the oesophagus and stomach were reanastomosed). Oral ingestion of food was resumed on the ninth postoperative day and all the cases were able to eat a normal diet after recovery. Figs. 3 and 4 show postoperative barium swallow films. The most frequent postoperative complaints are diarrhoea and some fullness of the stomach, but these usually disappear after a few months. Long term results are not yet available. However, 57 per cent of the series are alive and well at the present time.
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Hiroshi Akiyama et al.
Fig. 4. Postoperative barium swallow film showing the stomach situated in the retrosternal space.
Fig. 3. Barium swallow film after oesophageal reconstruction utilizing the stomach through a retrosternal route. Arrow indicates the cervical oesophagogastrostomy.
The blood loss during operation ranged between 107 and 996 ml, with an average of 424 ml. If a patient is not seriously anaemic preoperatively, the operation can be performed without blood transfusion. In this series 72 per cent of the cases did not require blood during the operation.
Discussion Numerous approaches to reconstructing the thoracic oesophagus have been detailed in the literature (Garlock, 1938; Sweet, 1945; Nakayama and Hirota, 1962; Petrov, 1964; Heimlich, 1966). However, a simple procedure with minimal risks has not been reported. Right thoracotomy is an established approach to reach the entire length of the thoracic oesophagus and posterior mediastinurn. It is of importance to visualize the whole posterior mediastinum for radical lymph node dissection. When a lesion is so advanced that it is strongly suspected to have extensive intraabdominal metastases, especially in the liver and retroperitoneal or para-aortic lymph nodes, exploratory 208
laparotomy is performed first to exclude inoperable cases. Advanced cases include tumours with markedly irregular ulceration, multicentric lesions and nonulcerated massive tumours which are histologically poorly differentiated. Otherwise, thoracotomy is the first procedure, but with this approach intra-abdominal information can also be obtained through an incision made in the right diaphragm. Needless oesophagectomies have been avoided in some cases by finding liver metastasis at a ‘right-sided transthoracic exploratory laparotomy’. By closing the chest immediately after completion of the posterior mediastinal dissection, the amount of time that the chest is open is reduced. This is one of the advantages obtained by adopting a retrosternal route in the oesophageal reconstruction. The stomach has frequently been used to replace the oesophagus (Garlock, 1938; Sweet, 1945), and Nakayama and Hirota (1962) markedly lowered the operative mortality rate by using the stomach through a presternal route and by dividing the operation into three stages. The stomach has many advantages for oesophageal substitution. It is large enough to bring up to the neck or even up to the hypopharynx (Ong and Lee, 1960; Le Quesne and Ranger, 1966; Akiyama et al., 1971), it has elasticity and a good intramural blood supply and only one anastomosis is necessary for completion of the oesophageal reconstruction. In other words, simplicity is the great advantage. Postoperative complaints are minimal after this procedure. Despite frequent descriptions of these advantages, a practical technique of utilizing the stomach has not
Reconstruction in oesophageal carcinoma been established. It is important to realize that intraabdominal lymph node dissection along the coeliac artery, the upper part of the lesser curvature and the paracardiac regions of the stomach is mandatory. Fortunately, after resection of the cardia and upper part of the lesser curvature (after completion of intraabdominal lymph node dissection) the form of the residual stomach is very suitable for oesophageal substitution. It is tailor-made for this purpose and is also of a sufficient size to bring up through a retrosternal route. Some efforts have been made to redesign the stomach (Heimlich, 1966), but probably the unmodified stomach with its normal peristalsis is most suitable for oesophageal substitution. The retrosternal route is an excellent route through which the oesophageal substitution can be brought up to the neck. It is simple to create, shorter than a presternal route and has a better cosmetic appearance. In addition, the area where local recurrence may occur is avoided. Oesophageal reconstruction with a segment of colon (Petrov, 1964) is also a useful method, but it contains many anastomoses and is a time-consuming procedure. Subsequently, our first choice for oesophageal substitution is always the stomach, reserving the colon for when the stomach cannot be utilized. In conclusion, this procedure is simple to perform for oesophageal replacement while satisfying all the necessary requirements for cancer surgery.
References
and HIYAMA M. (1974) A simple esophageal bypass operation by the high gastric division. Surgery 75, 674-68 I. AKIYAMA H., KOGURE T. and ITAI Y. (1974) Role of esophagotomy in the surgical treatment of esophageal cancer. Int. Surg. 59, 478482. AKIYAMA H., SATO Y. and TAKAHASHI F. (1971) Immediate pharyngogastrostomy following total esophagectomy by blunt dissection. Jap. J . Surg. 1, 225-231. GARLOCK J. H. (1938) The surgical treatment of carcinoma of the thoracic esophagus with a report of three successful cases. Surg. Gynecol. Obstet. 66, 534-548. HEIMLICH H. J. (1966) Elective replacement of the oesophagus. Br. J. Surg. 53,913-916. LE QUESNE L. P. and RANGER D. (1966) Pharyngolaryngectomy with immediate pharyngogastric anastomosis. Br. J . Surg. 53, 105-109. NAKAYAMA K. and HIROTA K. (1962) Experience of about 3000 cases with cancer of the esophagus and the cardia. Aust. NZ. J . Surg. 31, 222-230. ONG G. B. and LEE T. c. (1960) Pharyngogastric anastomosis after oesophago-pharyngectomy for carcinoma of the hypopharynx and cervical oesophagus. Br. J. Surg. 48, 193-200. PETROV B. A. (1964) Retrosternal artificial esophagus created from colon. Surgery 55, 520-523. SWEET R. H. (1945) Transthoracic resection of the esophagus and stomach for carcinoma. Ann. Surg. 121, 272-284.
AKIYAMA H.
(1973) Esophageal anastomosis. Arch. Surg. 107, 512-514.
AKIYAMA H.
209
Resection and reconstruction for carcinoma of the thoracic oesophagus HIROSHI AKIYAMA, MAMORU HIYAMA AND C H l A K l HASHIMOTO* SUMMARY
The technique and results of oesophageal resection through a right thoracotomy and laparotomy with reconstruction utilizing the stomach via a re trosternal route are reported. Forty patients underwent this procedure, with no mortality. The average blood loss during operation was 424m1, and 72 per cent of this series underwent the operation without blood transfusion. I t is b e l i e d that this type of’one-stage operation for carcinoma of the oesophagus is reasonable .from the viewpoint of adequate resection of malignancies, and it can be perjormed with minimal surgical risk. With experience, perhaps it will become a standard method such as the Billroth I method in gastric surgery.
SINCEthe beginning of modern surgery, oesophageal operations, particularly reconstructive procedures, have been a major area of interest. The colon, stomach and small intestine are the organs most frequently used for oesophageal substitution. These organs can be brought up to the proximal cut end of the oesophagus for anastomosis through various routes, such as the presternal, restrosternal, intrathoracic or posterior mediastinal route. Surgeons should be capable of performing all types of oesophageal reconstruction, but since this procedure involves many fine techniques it is usually reserved for the specialist. However, a standard operative approach which is considered reasonable from the viewpoint of appropriate cancer surgery and entails minimal surgical risks for the aged and undernourished patients in which such surgery is usually necessary should be established. The present paper describes a method of oesophageal resection and reconstruction using the stomach through a retrosternal route for carcinoma of the thoracic oesophagus. The technique is simple and fulfils the criteria outlined above. The results obtained so far are reported. With increasing experience, this operation should be utilized and perfected and thus may become equivalent to the Billroth I procedure in gastric surgery. Patients During the period from 1971 to 1974, 270 cases of carcinoma of the upper alimentary canal including the hypopharynx, upper and lower oesophagus and cardia were admitted to the Toranomon Hospital, Tokyo. Of the 270 cases, 140 cases (51.9 per cent) underwent resection and reconstruction. In the majority of cases the stomach was utilized for reconstruction, as this organ is our first choice, rather than
206
the colon, for oesophageal substitution. Patients who fulfilled the following criteria were selected for the procedure described here: (1) a lesion located in the thoracic oesophagus, not in the hypopharynx or the cervical or abdominal oesophagus; (2) a resectable lesion; (3) a healthy stomach. Forty patients satisfied all these points and underwent this operation.
Technique The method is shown diagrammatically in Fig. 1. The operation involves the right chest, the upper abdomen and the neck. The general plan is as follows. The thoracic oesophagus and proximal stomach are resected. A pyloroplasty is also carried out. The stomach is brought up to the neck through a retrosternal tunnel. The cervical oesophagus is anastomosed to the stomach which is then located behind the sternum. The skin incision is placed at the right fifth intercostal space. It is essential to check that there is no direct invasion by the tumour of the surrounding vital organs before proceeding with the resection. The pleura is incised along the azygos vein, which is then ligated and transected, exposing the whole posterior mediastinum. Dissection of the posterior mediastinal lymph nodes is performed. The oesophageal branch of the vagus nerve is cut and lymph nodes at the bifurcation of the trachea and pulmonary hilum are removed. The pulmonary branch of the vagus nerve is preserved if possible. The paratracheal lymph nodes are removed bilaterally. It is important not to damage the recurrent laryngeal nerve on either side. The thoracic oesophagus is severed at a high level for a low lesion or at a level just above the cardia for a higher lesion (further resection is done later). The cut end of the oesophagus is temporarily closed by suture. The surgical margin should first be checked by direct vision by oesophagotomy (Akiyama et al., 1974). The lower mediastinum is also dissected including all the lymph nodes, particularly those at the oesophageal hiatus. Care should be taken not to damage the left pleura, but if the tumour has invaded the left pleura the affected area must be resected. The thoracic oesophagus with the tumour is left in the thorax, and the chest is closed. The abdomen is then opened by an upper median incision. Exploration for possible intra-abdominal metastases is performed. In some cases with suspicion of advanced abdominal metastases, this is the first step of the operation. These indications are further discussed later. The greater omentum is severed along
* Department of Surgery, Toranomon Hospital, 2, Akasaka, Aoi-cho, Minato-ku, Tokyo, Japan.
Reconstruction in oesophageal carcinoma
Fig. 1. Scheme of the resection and reconstruction for carcinoma of the thoracic oesophagus utilizing the stomach through a retrosternal route.
the greater curvature of the stomach, preserving the right gastro-epiploic artery. The left gastro-epiploic artery and the short gastric arteries are severed and the greater curvature of the stomach is freed towards the oesophageal hiatus. Lymph node dissection at the origin of the coeliac artery and along the common hepatic artery is carried out. The coronary vein and the left gastric artery are severed and tied at their origin. The thoracic oesophagus with the tumour or the cut end of the oesophagus is pulled through the oesophageal hiatus into the abdomen. The oesophagus and stomach is extended and placed on the chest. The proximal stomach including the lymph nodes at the right and left paracardia and the upper part of the lesser curvature is removed together with the oesophagus. Pyloroplasty is performed as a routine procedure. Finally, a neck incision is made along the anterior border of the sternocleidomastoid muscle and the cut end of the oesophagus is pulled out of the neck (Fig. 2). To create the retrosternal tunnel a flat malleable intestinal retractor with a hole in one side (Akiyama and Hiyama, 1974) is used. A tape is threaded through the hole in the retractor. A wide superior orifice of the anterior mediastinum is obtained by dividing both the sternohyoid and sternothyroid muscles. The tape anchored to the retractor is attached to the stomach, which is then brought up to the neck by pulling the tape through the retrosternal tunnel. This can normally be done without difficulty. The cervical oesophagus and the stomach are anastomosed in two layers. Accurate approximation of the epithelium is a very important factor for primary healing of the anastomosis (Akiyama, 1973). A nasogastric tube is inserted for suction, and later to allow tube feeding until oral ingestion is resumed. Results Of the 40 cases who underwent this procedure, there were no operative or hospital deaths. The total operative mortality of resection and reconstruction for .malignant lesions of the hypopharynx to the oesophagogastric junction between 1971 and 1974 was
Fig. 2. Operation photograph showing the stomach, after resection of the oesophageal tumour, cardia and upper lesser curvature, placed on the chest. Its suitability for oesophageal substitution is evident. The stomach is pulled up to the neck through a retrosternal tunnel. The cervical oesophagus is ready for anastomosis.
1.4 per cent. Thus, resection and reconstruction of the thoracic oesophagus by the stomach using a retrosternal route with cervical oesophagogastrostomy in one stage is a safe procedure as demonstrated by its negative mortality rate. As regards postoperative complications, only minor ones developed, including temporary vocal cord paralysis ( I case, spontaneously healed), a small salivary fistula ( I case, spontaneously healed) and stenosis due to compression by a large bony process on the posterior surface of manubrium of the sternum (1 case, the bony process was resected and the oesophagus and stomach were reanastomosed). Oral ingestion of food was resumed on the ninth postoperative day and all the cases were able to eat a normal diet after recovery. Figs. 3 and 4 show postoperative barium swallow films. The most frequent postoperative complaints are diarrhoea and some fullness of the stomach, but these usually disappear after a few months. Long term results are not yet available. However, 57 per cent of the series are alive and well at the present time.
207
Hiroshi Akiyama et al.
Fig. 4. Postoperative barium swallow film showing the stomach situated in the retrosternal space.
Fig. 3. Barium swallow film after oesophageal reconstruction utilizing the stomach through a retrosternal route. Arrow indicates the cervical oesophagogastrostomy.
The blood loss during operation ranged between 107 and 996 ml, with an average of 424 ml. If a patient is not seriously anaemic preoperatively, the operation can be performed without blood transfusion. In this series 72 per cent of the cases did not require blood during the operation.
Discussion Numerous approaches to reconstructing the thoracic oesophagus have been detailed in the literature (Garlock, 1938; Sweet, 1945; Nakayama and Hirota, 1962; Petrov, 1964; Heimlich, 1966). However, a simple procedure with minimal risks has not been reported. Right thoracotomy is an established approach to reach the entire length of the thoracic oesophagus and posterior mediastinurn. It is of importance to visualize the whole posterior mediastinum for radical lymph node dissection. When a lesion is so advanced that it is strongly suspected to have extensive intraabdominal metastases, especially in the liver and retroperitoneal or para-aortic lymph nodes, exploratory 208
laparotomy is performed first to exclude inoperable cases. Advanced cases include tumours with markedly irregular ulceration, multicentric lesions and nonulcerated massive tumours which are histologically poorly differentiated. Otherwise, thoracotomy is the first procedure, but with this approach intra-abdominal information can also be obtained through an incision made in the right diaphragm. Needless oesophagectomies have been avoided in some cases by finding liver metastasis at a ‘right-sided transthoracic exploratory laparotomy’. By closing the chest immediately after completion of the posterior mediastinal dissection, the amount of time that the chest is open is reduced. This is one of the advantages obtained by adopting a retrosternal route in the oesophageal reconstruction. The stomach has frequently been used to replace the oesophagus (Garlock, 1938; Sweet, 1945), and Nakayama and Hirota (1962) markedly lowered the operative mortality rate by using the stomach through a presternal route and by dividing the operation into three stages. The stomach has many advantages for oesophageal substitution. It is large enough to bring up to the neck or even up to the hypopharynx (Ong and Lee, 1960; Le Quesne and Ranger, 1966; Akiyama et al., 1971), it has elasticity and a good intramural blood supply and only one anastomosis is necessary for completion of the oesophageal reconstruction. In other words, simplicity is the great advantage. Postoperative complaints are minimal after this procedure. Despite frequent descriptions of these advantages, a practical technique of utilizing the stomach has not
Reconstruction in oesophageal carcinoma been established. It is important to realize that intraabdominal lymph node dissection along the coeliac artery, the upper part of the lesser curvature and the paracardiac regions of the stomach is mandatory. Fortunately, after resection of the cardia and upper part of the lesser curvature (after completion of intraabdominal lymph node dissection) the form of the residual stomach is very suitable for oesophageal substitution. It is tailor-made for this purpose and is also of a sufficient size to bring up through a retrosternal route. Some efforts have been made to redesign the stomach (Heimlich, 1966), but probably the unmodified stomach with its normal peristalsis is most suitable for oesophageal substitution. The retrosternal route is an excellent route through which the oesophageal substitution can be brought up to the neck. It is simple to create, shorter than a presternal route and has a better cosmetic appearance. In addition, the area where local recurrence may occur is avoided. Oesophageal reconstruction with a segment of colon (Petrov, 1964) is also a useful method, but it contains many anastomoses and is a time-consuming procedure. Subsequently, our first choice for oesophageal substitution is always the stomach, reserving the colon for when the stomach cannot be utilized. In conclusion, this procedure is simple to perform for oesophageal replacement while satisfying all the necessary requirements for cancer surgery.
References
and HIYAMA M. (1974) A simple esophageal bypass operation by the high gastric division. Surgery 75, 674-68 I. AKIYAMA H., KOGURE T. and ITAI Y. (1974) Role of esophagotomy in the surgical treatment of esophageal cancer. Int. Surg. 59, 478482. AKIYAMA H., SATO Y. and TAKAHASHI F. (1971) Immediate pharyngogastrostomy following total esophagectomy by blunt dissection. Jap. J . Surg. 1, 225-231. GARLOCK J. H. (1938) The surgical treatment of carcinoma of the thoracic esophagus with a report of three successful cases. Surg. Gynecol. Obstet. 66, 534-548. HEIMLICH H. J. (1966) Elective replacement of the oesophagus. Br. J. Surg. 53,913-916. LE QUESNE L. P. and RANGER D. (1966) Pharyngolaryngectomy with immediate pharyngogastric anastomosis. Br. J . Surg. 53, 105-109. NAKAYAMA K. and HIROTA K. (1962) Experience of about 3000 cases with cancer of the esophagus and the cardia. Aust. NZ. J . Surg. 31, 222-230. ONG G. B. and LEE T. c. (1960) Pharyngogastric anastomosis after oesophago-pharyngectomy for carcinoma of the hypopharynx and cervical oesophagus. Br. J. Surg. 48, 193-200. PETROV B. A. (1964) Retrosternal artificial esophagus created from colon. Surgery 55, 520-523. SWEET R. H. (1945) Transthoracic resection of the esophagus and stomach for carcinoma. Ann. Surg. 121, 272-284.
AKIYAMA H.
(1973) Esophageal anastomosis. Arch. Surg. 107, 512-514.
AKIYAMA H.
209
