The Surgical Management of Patients with Carcinoma of the Midthoracic Esophagus Julius W. Garvey, MD, FRCS (C), FACS Stony Brook, New York
Clinical and pathological findings in 15 patients with carcinoma of the midthoracic esophagus were analyzed. The author concluded that preoperative radiotherapy reduces tumor size and improves resectability. Longer follow-up is required to determine whether or not preoperative radiotherapy improves survival rates in these patients.
Carcinoma of the esophagus is one of the most prevalent gastrointestinal cancers afflicting man. Despite modern advances in technique and ancillary support, surgery alone cures five to ten percent of affected patients. Radiotherapy alone cures even less. of the combination Recently, preoperative radiotherapy and surgery has been used, with reports of improvement in survivals and cures.'-:' However, a generous estimate of only 10 to 20 percent of these patients can expect cure by current therapeutic modalities. It seems likely that a cure will be achieved when an etiology is determined or as a result of advances in immunologic understanding. The problem facing the therapist in 80 to 90 percent of patients with carcinoma of the esophagus is to provide adequate palliation, that is, relief of dysphagia. Adequate palliation is achieved by any means that will pro-
From the Division of Cardio-Thoracic Surgery, Long Island Jewish-Hillside Medical Center, and Queens Hospital Center Affiliation, and the State University of New York at Stony Brook, New York. Requests for reprints should be addressed to Dr. Julius W. Garvey, Department of Cardiothoracic Surgery, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432.
vide normal or near normal swallowing with minimal morbidity and mortality. There is near universal agreement that surgical extirpation is the best treatment for carcinoma of the lower third of the esophagus. There remains disagreement to which we subscribe that carcinoma of the cervical esophagus is best treated by radiotherapy. Treatment of carcinoma of the midthoracic esophagus engenders even more disagreement. '2'24 We feel that with midthoracic lesions, adequate palliation and attempts to cure are best achieved by either surgical extirpation where feasible or by-pass of the obstruction. With this philosophy, a two-pronged thrust of maximal palliation and occasional cure, we have proceeded with aggressive surgical therapy for midthoracic esophageal lesions.
Material and Results Fifteen patients with midthoracic lesions were treated surgically at Harlem Hospital during the three-year period July 1967 to June 1970. There were 11 men and four women, which conforms to the usual male/ female ratio. They ranged in age from 44 to 71, the majority being in their fifties or sixties. All patients were black (Table 1), and the presenting symptom
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 2, 1978
in all was moderate to severe dysphagia. All of the lesions were located in the midthoracic esophagus and were histologically proven squamous cell carcinomas. Nine lesions were treated by esophagogastrectomy and esophagogastrostomy (EG) and six by colon bypass. (CBP). There were no postoperative mortalities in the EG group, but two occurred in the CBP group (33 percent). The mortality of both groups was 13 percent which compares favorably with other reports. There was one pleural effusion in the EG group, a complication rate of 11 percent. One pleural effusion and two cervical leaks occurred in the CBP survivors for a complication rate of 75 percent, a group complication rate of 30 percent. One of the deaths in the CBP group was related to an intra-abdominal anastomotic leak which caused sepsis and subsequent death on the 18th postoperative day. The other death was the result of an heroic attempt to palliate a patient who presented with a tracheoesophageal (TE) fistula and aspiration pneumonia. A bypass was done, but the esophagogastric junction was not tied off and the patient continued to aspirate postoperatively. He died from massive aspiration and pneumonia on the third postoperative day. In the CBP group one patient had her bypass in two stages, the cervical esophagocolostomy being done a month after the initial substernal transposition of the colon. At the time, the viability of the proximal colon was doubtful. She had an uneventful postoperative course, but her hospital stay was 54 days. The shortest hospital stay 113
Table 1. Carcinoma of the Midthoracic Esophagus Harlem Hospital 1967-1970
Age 40 50 60 70
- 49 - 59 - 69 - 79
Black Black Males Females Pathology 2 5 3 1
1 2 1 0
Squamous Squamous Squamous Squamous
in the CBP group was 24 days, for the patient with bilateral pleural effusions. The longest was 92 days, for one of the patients with an anastomatic leak. The average hospital stay for this group was 65 days. In the EG group, the shortest hospital stay was 13 days, the longest 37-for the patient with pleural effusion. Most of the EG group were discharged in about 14 days. The others stayed longer for social reasons, for an averge of 23 days. Palliation of dysphagia is described as excellent when the patient had no symptoms as to swallowing and eating. A patient with a good result could swallow and eat well, but had symptoms such as regurgitation, belching, fullness, diarrhea, or dysphagia. When these symptoms were severe enough to incapacitate the patient or require dilatation, the result was considered poor. In the EG group, seven had excellent, one had good, and one had poor results. Overall, eight had excellent, three had good and two had poor results. The overall survival time for both groups at the time of review was 13 months. In the EG group alone it was 15 months. The patient who survived longest was alive and free of disease at 43 months. Thirty-eight months after esophageal surgery, he had a left partial mandibulectomy and radical neck dissection for squamous cell carcioma of the floor of the mouth. The shortest survival time was five months. This patient was untraceable and was therefore presumed dead. In the CBP group, the average survival time was eight months, the shortest two months. The one who lived longest died at 20 months when an attempt was made to resect his lesion. There were no survivors in this group. 114
Only three patients had curative resections and all were in the EG group, surviving for 43, 32, and 5 months respectively. Four surviving CBP's received postoperative radiotherapy. This was 5,000 to 6,000 R rotation therapy with the "Co machine, given over a sixweek period. In the EG group, one patient received similar therapy preoperatively and two postoperatively.
Discussion It is obvious in comparing the above results that the EG's did better. There was no conscious bias in choosing EG or CBP except that, generally, the higher and bulkier lesions were treated by bypass. With this demonstrated difference, we tended to favor EG where
feasible. The two instances where we still feel colon bypass can play a role are (1) for palliation of a TE fistula where the esophagogastric junction should be ligated or transected and (2) for the patient who preoperatively has involvement of his trachea or bronchus and is an acceptable surgical risk. The four survivors of the CBP group received postoperative radiotherapy. In the EG group, those thought to have localized lesions received postoperative radiotherapy. Those with distant metastases received none. The reports of Parker' and Nakayama' seem to indicate that preoperative radiotherapy is worthwhile. We do not hestitate to cut across tumor in the mediastinum, neither do intra-abdominal metastases contraindicate palliative resection. The only absolute contraindication to surgery is widespread metastases or severe concomitant disease. We resect the lesion wherever surgically possible. All cases have been done through the right chest with a separate abdominal incision and the anastomosis done high in the thorax above the azygous vein. All cases have a pyloromyotomy or pyloroplasty-the Ivor Lewis operation.57 One recent modification is to do a Nissen wraparound at the esophagogastrostomy site, to create an artificial sphincter and prevent reflux. We believe that indwelling tubes have a place in palliation but are no substitute for surgery, which gives better
palliation and may cure the patient. These tubes should be used only when worthwhile palliation is possible-not when death is imminent. With our aggressive approach, not many patients fall between these limits. The disadvantages of the use of these tubes are well documented in the literature.8 When indicated, we prefer a Celestin or Fell tube." Gastrostomy or jejunostomy alone as methods of palliation are not used by us. The addition of an abdominal stoma makes the patient more miserable and does not relieve his dysphagia or prevent regurgitation, aspiration, or pneumonia. We have continued to apply these principles since the above study was concluded. We have made two additions-preoperative hyperalimentation and preoperative radiotherapy. If the patient does not respond to hyperalimentation per os, by tube or vein, and reverse his catabolic state, then a major procedure is not contemplated and radiotherapy is completed to 6,000 Rads. Preoperative radiotherapy consists of 3,000 Rads given in two weeks and the patient rested for one week and then an esophagogastrectomy done. We have not followed our patients long enough to determine whether preoperative radiotherapy improves survival. However, it does reduce tumor size and hence improves resectability.
Literature Cited 1. Parker EF, Gregorie HB Jr, Arrants RE, et al: Carcinoma of esophagus. Ann Surg 171 :746-751, 1970 2. Gunnlangsson GH, Wychulis AR, Roland C, et al: Analysis of the records of 1,657 patients with carcinoma of the esophagus and cardia of the stomach. Surg Gynecol Obstet 130:9971005, 1970 3. Nakayama K, Oribate H, Yamaguchi K: Surgical treatment combined with preoperative concentrated irradiation for esophageal cancer. Cancer 20:778-888, 1967 4. Hankins JR, Cole FN, Ward A, et al: Carcinoma of the esophagus: The philosophy for palliation. Ann Thorac Surg 14:189-197, 1972 5. Lewis l: Surgical treatmrent of carcinoma of the esophagus with special reference to a new operation for growth of the middle third. Br J Surg 34:18-31, 1946 6. Fisher DR, Brawley RK, Kieffer RF: Esophago-gastrostomy in the treatment of carcinoma of the distal two-thirds of the esophagus. Ann Thorac Surg 14:658-670, 1972 7. Carey JS, Plested WG, Hughes RK: Esophago-gastrectomy. Ann Thorac Surg 14:59-68, 1972 8. Duvoisin GE, Ellis FH Jr, et al: The value of palliative prostheses in malignant lesions of the esophagus. Surg Clin North Am 47:827-831, 1967 9. Fell SC, Grunwald RP, Hurwitt ES: Palliation of esophageal carcinoma by prosthetic intubation. J Thorac Cardiovasc Surg 51 :272-278, 1966
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 2, 1978
Clinical and pathological findings in 15 patients with carcinoma of the midthoracic esophagus were analyzed. The author concluded that preoperative radiotherapy reduces tumor size and improves resectability. Longer follow-up is required to determine whether or not preoperative radiotherapy improves survival rates in these patients.
Carcinoma of the esophagus is one of the most prevalent gastrointestinal cancers afflicting man. Despite modern advances in technique and ancillary support, surgery alone cures five to ten percent of affected patients. Radiotherapy alone cures even less. of the combination Recently, preoperative radiotherapy and surgery has been used, with reports of improvement in survivals and cures.'-:' However, a generous estimate of only 10 to 20 percent of these patients can expect cure by current therapeutic modalities. It seems likely that a cure will be achieved when an etiology is determined or as a result of advances in immunologic understanding. The problem facing the therapist in 80 to 90 percent of patients with carcinoma of the esophagus is to provide adequate palliation, that is, relief of dysphagia. Adequate palliation is achieved by any means that will pro-
From the Division of Cardio-Thoracic Surgery, Long Island Jewish-Hillside Medical Center, and Queens Hospital Center Affiliation, and the State University of New York at Stony Brook, New York. Requests for reprints should be addressed to Dr. Julius W. Garvey, Department of Cardiothoracic Surgery, Queens Hospital Center, 82-68 164th Street, Jamaica, NY 11432.
vide normal or near normal swallowing with minimal morbidity and mortality. There is near universal agreement that surgical extirpation is the best treatment for carcinoma of the lower third of the esophagus. There remains disagreement to which we subscribe that carcinoma of the cervical esophagus is best treated by radiotherapy. Treatment of carcinoma of the midthoracic esophagus engenders even more disagreement. '2'24 We feel that with midthoracic lesions, adequate palliation and attempts to cure are best achieved by either surgical extirpation where feasible or by-pass of the obstruction. With this philosophy, a two-pronged thrust of maximal palliation and occasional cure, we have proceeded with aggressive surgical therapy for midthoracic esophageal lesions.
Material and Results Fifteen patients with midthoracic lesions were treated surgically at Harlem Hospital during the three-year period July 1967 to June 1970. There were 11 men and four women, which conforms to the usual male/ female ratio. They ranged in age from 44 to 71, the majority being in their fifties or sixties. All patients were black (Table 1), and the presenting symptom
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 2, 1978
in all was moderate to severe dysphagia. All of the lesions were located in the midthoracic esophagus and were histologically proven squamous cell carcinomas. Nine lesions were treated by esophagogastrectomy and esophagogastrostomy (EG) and six by colon bypass. (CBP). There were no postoperative mortalities in the EG group, but two occurred in the CBP group (33 percent). The mortality of both groups was 13 percent which compares favorably with other reports. There was one pleural effusion in the EG group, a complication rate of 11 percent. One pleural effusion and two cervical leaks occurred in the CBP survivors for a complication rate of 75 percent, a group complication rate of 30 percent. One of the deaths in the CBP group was related to an intra-abdominal anastomotic leak which caused sepsis and subsequent death on the 18th postoperative day. The other death was the result of an heroic attempt to palliate a patient who presented with a tracheoesophageal (TE) fistula and aspiration pneumonia. A bypass was done, but the esophagogastric junction was not tied off and the patient continued to aspirate postoperatively. He died from massive aspiration and pneumonia on the third postoperative day. In the CBP group one patient had her bypass in two stages, the cervical esophagocolostomy being done a month after the initial substernal transposition of the colon. At the time, the viability of the proximal colon was doubtful. She had an uneventful postoperative course, but her hospital stay was 54 days. The shortest hospital stay 113
Table 1. Carcinoma of the Midthoracic Esophagus Harlem Hospital 1967-1970
Age 40 50 60 70
- 49 - 59 - 69 - 79
Black Black Males Females Pathology 2 5 3 1
1 2 1 0
Squamous Squamous Squamous Squamous
in the CBP group was 24 days, for the patient with bilateral pleural effusions. The longest was 92 days, for one of the patients with an anastomatic leak. The average hospital stay for this group was 65 days. In the EG group, the shortest hospital stay was 13 days, the longest 37-for the patient with pleural effusion. Most of the EG group were discharged in about 14 days. The others stayed longer for social reasons, for an averge of 23 days. Palliation of dysphagia is described as excellent when the patient had no symptoms as to swallowing and eating. A patient with a good result could swallow and eat well, but had symptoms such as regurgitation, belching, fullness, diarrhea, or dysphagia. When these symptoms were severe enough to incapacitate the patient or require dilatation, the result was considered poor. In the EG group, seven had excellent, one had good, and one had poor results. Overall, eight had excellent, three had good and two had poor results. The overall survival time for both groups at the time of review was 13 months. In the EG group alone it was 15 months. The patient who survived longest was alive and free of disease at 43 months. Thirty-eight months after esophageal surgery, he had a left partial mandibulectomy and radical neck dissection for squamous cell carcioma of the floor of the mouth. The shortest survival time was five months. This patient was untraceable and was therefore presumed dead. In the CBP group, the average survival time was eight months, the shortest two months. The one who lived longest died at 20 months when an attempt was made to resect his lesion. There were no survivors in this group. 114
Only three patients had curative resections and all were in the EG group, surviving for 43, 32, and 5 months respectively. Four surviving CBP's received postoperative radiotherapy. This was 5,000 to 6,000 R rotation therapy with the "Co machine, given over a sixweek period. In the EG group, one patient received similar therapy preoperatively and two postoperatively.
Discussion It is obvious in comparing the above results that the EG's did better. There was no conscious bias in choosing EG or CBP except that, generally, the higher and bulkier lesions were treated by bypass. With this demonstrated difference, we tended to favor EG where
feasible. The two instances where we still feel colon bypass can play a role are (1) for palliation of a TE fistula where the esophagogastric junction should be ligated or transected and (2) for the patient who preoperatively has involvement of his trachea or bronchus and is an acceptable surgical risk. The four survivors of the CBP group received postoperative radiotherapy. In the EG group, those thought to have localized lesions received postoperative radiotherapy. Those with distant metastases received none. The reports of Parker' and Nakayama' seem to indicate that preoperative radiotherapy is worthwhile. We do not hestitate to cut across tumor in the mediastinum, neither do intra-abdominal metastases contraindicate palliative resection. The only absolute contraindication to surgery is widespread metastases or severe concomitant disease. We resect the lesion wherever surgically possible. All cases have been done through the right chest with a separate abdominal incision and the anastomosis done high in the thorax above the azygous vein. All cases have a pyloromyotomy or pyloroplasty-the Ivor Lewis operation.57 One recent modification is to do a Nissen wraparound at the esophagogastrostomy site, to create an artificial sphincter and prevent reflux. We believe that indwelling tubes have a place in palliation but are no substitute for surgery, which gives better
palliation and may cure the patient. These tubes should be used only when worthwhile palliation is possible-not when death is imminent. With our aggressive approach, not many patients fall between these limits. The disadvantages of the use of these tubes are well documented in the literature.8 When indicated, we prefer a Celestin or Fell tube." Gastrostomy or jejunostomy alone as methods of palliation are not used by us. The addition of an abdominal stoma makes the patient more miserable and does not relieve his dysphagia or prevent regurgitation, aspiration, or pneumonia. We have continued to apply these principles since the above study was concluded. We have made two additions-preoperative hyperalimentation and preoperative radiotherapy. If the patient does not respond to hyperalimentation per os, by tube or vein, and reverse his catabolic state, then a major procedure is not contemplated and radiotherapy is completed to 6,000 Rads. Preoperative radiotherapy consists of 3,000 Rads given in two weeks and the patient rested for one week and then an esophagogastrectomy done. We have not followed our patients long enough to determine whether preoperative radiotherapy improves survival. However, it does reduce tumor size and hence improves resectability.
Literature Cited 1. Parker EF, Gregorie HB Jr, Arrants RE, et al: Carcinoma of esophagus. Ann Surg 171 :746-751, 1970 2. Gunnlangsson GH, Wychulis AR, Roland C, et al: Analysis of the records of 1,657 patients with carcinoma of the esophagus and cardia of the stomach. Surg Gynecol Obstet 130:9971005, 1970 3. Nakayama K, Oribate H, Yamaguchi K: Surgical treatment combined with preoperative concentrated irradiation for esophageal cancer. Cancer 20:778-888, 1967 4. Hankins JR, Cole FN, Ward A, et al: Carcinoma of the esophagus: The philosophy for palliation. Ann Thorac Surg 14:189-197, 1972 5. Lewis l: Surgical treatmrent of carcinoma of the esophagus with special reference to a new operation for growth of the middle third. Br J Surg 34:18-31, 1946 6. Fisher DR, Brawley RK, Kieffer RF: Esophago-gastrostomy in the treatment of carcinoma of the distal two-thirds of the esophagus. Ann Thorac Surg 14:658-670, 1972 7. Carey JS, Plested WG, Hughes RK: Esophago-gastrectomy. Ann Thorac Surg 14:59-68, 1972 8. Duvoisin GE, Ellis FH Jr, et al: The value of palliative prostheses in malignant lesions of the esophagus. Surg Clin North Am 47:827-831, 1967 9. Fell SC, Grunwald RP, Hurwitt ES: Palliation of esophageal carcinoma by prosthetic intubation. J Thorac Cardiovasc Surg 51 :272-278, 1966
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 2, 1978
