Annals of the Royal College of Surgeons of England (1975) vol 56
Unresectable carcinoma
of
the
oesophagus G B Ong OBE FRCS
Professor of Surgery, University of Hong Kong
Summary One hundred and eighty-one patients with unresectable carcinoma of the oesophagus have been seen and treated during the past Io years. When the general condition of the patient was judged to be such that he was able to withstand a major operation a bypass procedure was adopted. No cases were rejected, but when the patient was in extremis oesophagostomy and gastrostomy only were performed. The results of treatment are presented and the difliculties encountered discussed.
Introduction Moynihan, in the Hunterian Oration delivered at the Royal College of Surgeons of England on i4th February I927, referring to the fight against disease, said: 'Man's life is warfare. The individual, the whole race, is beset by foes, unresting, relentless. Against them our defence, if we are ever to subdue them, must be carefully planned and diligently strengthened. But defence, however stubborn, is not enough. Attacks designed after scientific study of the enemy strongholds and methods, and launched with impassioned zeal, must never for one instant falter. Not all our attacks meet with success. Failure inspires us to fresh and still more eager endeavour'. Moynihan Lecture delivered on 3rd April I974
This constant struggle is as true today as it was 47 years ago. This is especially so in the case of the inoperable carcinoma of the oesophagus. Carcinoma of the oesophagus when first seen in Hong Kong is often in an advanced stage and resection may not be possible. Some patients may already have developed distant metastases. Poor respiratory function due to extensive pulmonary tuberculosis or aspiration pneumonia is frequently found. Older patients often have cardiac insufficiency or are actually in a state of cardiac failure. When the lesion has extended beyond the confines of the oesophagus, has infiltrated the bronchus giving rise to oesophagobronchial fistula, or has invaded the aorta attempts at resection will result in disaster. The resectability rate of mid-oesphageal carcinoma is relatively low. Mustard and Ibberson1 resected only 26o/% of their cases, though Sweet2 gave a figure of 65% resectability for mid-oesophageal lesions. Garlock and Klein3 found that in 42% of their cases the lesion could be removed. Ong and Kwong4 gave a similar figure of 45%/O. Hitherto, in cases which are not resectable either for curative or palliative purposes relief of the dysphagia by dilatation and insertion of an oesophageal tube has been widely practised. The results reported by Celestin5
4
GB
Ong
and O'Connor et al.6 have been optimistic. On the other hand Pringle and Winsey7, Bestler et al.8, Duvoisin et al.9, and Procter"0 have cast doubt on the value of this form of treatment. We have not been happy with the result of intubation in unresectable carcinoma of the oesophagus, for even in successful cases the patient can at best swallow semisolid food, and in order to wash down the bolus a large amount of fluid has to be taken with each act of swallowing. In I 964 I reported a personal series of I I cases" in the majority of which a bypass operation, using either colon, jejunum, or stomach, was performed. Since then, unless the general condition of the patient was so poor that no major operation was feasible, we have used the bypass operation for all unresectable carcinomas of the oesophagus.
All the patients on admisDysphagia sion had had dysphagia for 2-I4 months. The history usually started with a feeling of discomfort at the site of obstruction. This was quickly followed by inability to swallow solid food and consequently the patient subsisted on semisolid diet; ultimately he could swallow only fluids. If oesophagobronchial fistula was present, whenever the patient swallowed fluid a spasm of cough, followed by profuse expectoration of sputum and sometimes of the fluid ingested, would occur. With chest infection the amount of sputum brought up was between i2o and 240 ml daily. Many of these patients were admitted in a state of dehydration with dyspnoea and cyanosis. There had been Loss of body weight marked loss of body weight in every case, varying from 2.27 to as much as i8.2 kg, with an average of 6.8 kg. At the time of admission the average body weight was 42. I
Material From I964 to March I974 i8i patients with inoperable carcinoma of the oesophagus from the upper third to the cardia were seen and treated at the University Surgical Unit, Queen Mary Hospital, Hong Kong. There were 148 males and 33 females, giving a ratio of 4.5: The oldest patient was 83 years of age while the youngest was 38. The average age for males was 56 years and for females 66. The overall average age was 58.
(range 25.45-50) kg.
2
i.
In 28 cases (I5 5%) Level of lesion the tumour was situated in the upper third of the oesophagus-that is, from Di to D4. Mid-thoracic growths (D4-D8) were found in II9 cases (65.7 /,). In 2 cases (ii.6%) the growth was in the lower oesophagus (D8-Di 2) and was of squamous cell origin, while in 13 cases (7.2%) it was an adenocarcinoma from the cardiac portion of the stomach which had invaded the oesophagus giving rise to dysphagia. 1
Pulmonary infection Fifty-seven patients (3 I5%) were admitted with severe chest infection. (This does not include the 32 patients who had oesophagobronchial fistula.) Twentyfive recovered after intensive treatment with antibiotics and physiotherapy. However, the chest condition recurred following definitive operative treatment. In addition, 21 patients had suffered from active pulmonary tuberculosis and in 2 of these tubercle bacilli were demonstrated. These patients had to have chemotherapeutic cover before operation. In open cases one month of chemotherapy was given before the patient was subjected to operation. Metastases to lymph nodes Metastases were present in the lymph nodes in 35 patients (I9.3%). These lymph nodes were usually found in the left supraclavicular fossa and were quite obvious at the time of admission; in 5 cases they were found behind the
Unresectable carcinoma of the oesophagus right sternoclavicular joint. Hoarseness of the voice due to vocal cord paralysis occurred in 24 patients (13.2%/1). This never improved after irradiation, indicating lymphatic involvement and invasion of usually the left recurrent laryngeal nerve. Distant metastases Distant metastases were present in 27 patients (I5%). The liver was involved in i i cases, while the remainder had widespread metastases including the bones and skin. Oesophagobronchial fistula Thirty-two patients (i8%/,) were admitted with oesophagobronchial fistula. This included 9 patients who had had irradiation and had developed the fistula following treatment. The other 23 patients had developed oesophagobronchial fistula in the course of the illness and were admitted as such. The fistula was demonstrated either by barium swallow or at bronchoscopy. Preoperative irradiation Of the i8i patients, 9 had had preoperative irradiation at some stage. Most of them had never completed it and were referred to us because in the course of treatment they had developed oesophagobronchial fistula.
Preoperative management Most of these patients with advanced cancer of the oesophagus were in a poor nutritional state when admitted. As many of them had respiratory infection active treatment was necessary to prepare them for any subsequent operative treatment. Barium swallow was carried out whenever possible and if there was a suspicion of an oesophagobronchial fistula a water-soluble medium such as Gastrografin was used. If the patient was dyspnoeic and had a large amount of sputum tracheostomy was performed so that bronchial toilet could be carried out frequently.
5
Oesophagoscopy and bronchoscopy were carried out as a routine under general anaesthesia so that biopsy could be performed and a histological diagnosis obtained.
Operative treatment Oesophagostomy and gastrostomy If the general condition of the patient was poor owing to chest infection or oesophagobronchial fistula, immediately after oesophagoscopy and bronchoscopy tracheostomy was carried out together with gastrostomy and oesophagostomy. The oesophagus was brought out posterior to the sternomastoid or after division of the posterior attachment of this muscle and then stitched to the skin. This would prevent the saliva from trickling down the trachea through the tracheostomy opening. The distal part of the divided oesophagus was closed. Gastrostomy was performed by making a small incision cutting through all layers of the abdominal wall. A Witzel type of gastrostomy was performed. This has been described previously'2. This procedure was carried out on 15 of the i8I patients as a semi-emergency operation. Feeding through the gastrostomy was carried out soon after the operation and a high-calorie liquid diet, obtained by passing normal food through a blender, was given. Out of these I5 patients, only one improved to such an extent that a definitive bypass, using the stomach, could be performed. Bypass operations Primary bypass operation was carried out in each of the remaining i66 cases, a single bypass in go and a double bypass in 76. A single bypass is one in which one end of an isolated jejunal or isoperistaltic colonic loop is anastomosed to the stomach and the other to the divided cervical oesophagus. For a double bypass, in addition to these anastomoses a Roux-en-Y
6
G B Ong
operation is performed at the divided abdominal portion of the lower oesophagus (Fig. i). T'his latter operation was designed originally for patients with oesophagobronchial fistula13. For colonic bypass the Colonic bypass terminal ileum is utilized for the upper anastomosis and the right side of the transverse colon anastomosed to the stomach in the abdominal part of the procedure. Restoration of colonic continuity is accomplished by making an end-to-end ileocolostomy. The isolated colon is placed behind the stomach and transverse mesocolon so that its vascular pedicle lies in the lesser sac. The anastomosis is done with catgut or linen thread suture. Transthoracic bypass with Jejunal bypass jejunum was done for all lower oesophageal lesions. The length of jejunum required to bypass the obstruction usually requires division of only one main jejunal vessel. This loop is delivered into the thorax by making an opening in the diaphragm. The oesophagus
A
is transected above the growth and the lower end closed. An end-to-end anastomosis is then made. For anastomosis in the neck preparation of a jejunal loop uisually requires division of 3 or 4 main jejunal vessels. The arteries and veins are dissected out and ligated separately. The leaves of the mesentery are peeled off. This manoeuvre allows the intestine to straighten out14'11. When the smallintestinal loop has been prepared the two leaves of the mesentery are brought together again by interrupted sutures (Fig. 2). This serves as a protection of the vessels supplying the isolated intestine. Like the large intestine, it is brought up into the neck with the vascular pedicle lying in the lesser sac. The stomach was used for Stomach bypass a single bypass operation on 5 occasions. In 2 cases the reversed gastric tube as described by Heimlich and Winfield"5 and Heimlich16 was used, being placed subcutaneously in one and retrostemally in the other. In the re-
B
C
Diagram showing the methods of double bypass. (A) jejunum; (B) colon; and (C) stomach.
FIG. I
Unresectable carcinoma of the oesophagus
7
FIG. 2 (A) Loop of jejunum being prepared for bypass. The leaves of the mesentery are peeled of. (B) After straightening the jejunal loop the leaves of the mesentery are brought together by interrupted sutures. (C) The jejunum is now straightened and reaches the larynx (pointer).
maimnng 3 cases the stomach, after mobilization, was delivered into the right pleural cavity. The oesophagus distal to the growth was then freed and the fundus of the stomach was anastomosed to the oesophagus well above the tumour. The whole of the stomach, after mobilization, was used for bypassing the lesion in 56 patients. This operation was originally carried out by Kirschnere7 and had recently been performed for malignant oesophageal lesions"8. It was especially useful in cases with oesophagobronchial fistula. The technique is as follows. Mobilization of the stomach is done as far as the duodenum. An extensive Kocher's manoeuvre is necessary to enable the stomach to be brought up into the neck. Should there
be difficulty in making the stomach reach the neck it can be lengthened by gently kneading and stretching it. Pyloromyotomy is also done in order to prevent gastric retention, which would result in postoperative regurgitation and aspiration of the stomach contents. The stomach is divided at the cardia, which is closed with continuous catgut. A Roux-en-Y anastomosis between the divided abdominal oesophagus and the jejunum is then made. This anastomosis is made with a continuous catgut suture and any defects are then reinforced with a few interrupted stitches. Leakage does not occur at this point as no food passes through it. The enteroenterostomy is made at least I8 in. (46 cm) away from this suture line. This length of jejunum between the two anasto-
8
G B Onig
wvill prevent reflux of intestinal contents tion, aspiration of sputum through the into the lower oesophagus, with aspiration tracheostomy being carried out every I5-20 minutes throughout the 24 hours. into the lungs if there is a fistula. A nasogastric tube was inserted in each The route case at the conclusion of the operation and Routes taken at bypass taken for the bypass can be either subcuta- the stomach kept empty. When colon or jeneous or retrostemal. The preparation of this junum had been used for bypass this tube tunnel is best done with a large pair of scis- was placed in the lumen of the intestinal loop sors of the Abel type. In doing this the to keep it empty. If the blood supply of an perforating branches of the internal mam- isolated loop of intestine was marginal demary vessels may be damaged; should this compression was essential, as an increase of happen the skin should be slit open and the intraluminal pressure could compromise its bleeding vessels exposed and ligated. blood supply. The nasogastric tube could be The proximal end of the stomach or small taken out when peristalsis returned, which or large intestine is anchored to two pieces usually took place within 24-48 hours. of gauze. By pulling on these through the Oral feeding with fluid was usually given tunnel the mobilized stomach or intestine can about the 5th or 6th postoperative day probe brought up into the neck. vided the Gastrografin swallow showed that The retrostemal route gives rise to no there was no leakage. If leakage was present difficulty. While working in the neck the cer- the nasogastric tube was used as a feeding vical muscles are detached from their sternal tube so that the intravenous drip could be insertions. By blunt dissection the whole hand dispensed with as soon as possible. can be inserted into the anterior mediastinum Blood transfusions were given whenever from the abdomen. Provided the dissection necessary. If there was leakage and the conis done very close to the back of the sternum dition of the patient was poor parenteral no troublesome complication will be encoun- hyperalimentation would often result in tered. Tcars in the mediastinal pleura are marked improvement. Frequent blood culfrequent, but drainage of the pleural cavity tures were made to rule out fungal infection, will prevent tension pneumothorax. which was sometimes met with, especially When the growth is high or lymph nodes when broad-spectrum antibiotics had been are palpable at the root of the neck it is given for a long period. If candida was grown better to place the transplant subcutaneously from the blood hyperalimentation was since a retrosternal transplant may be com- stopped and a fungicide given. pressed by expansion of the growth or lymph node metastases, with recurrence of dysResults phagia". Of the I8 i patients, 128 Survival Postoperative care As most of these patients were in a weak state (71X%) survived operation. These included I0 postoperative complications were relatively patients who underwent oesophagostomy and common and postoperative care was all-im- gastrostomy for either oesophagobronchial portant. Antibiotics were given for chest in- fistula, very severe pulmonary infection, or fection, especially in the presence of an poor general condition, one of whom suboesophagobronchial fistula. Tracheostomy was sequently improved to such an extent that a carried out on patients with sputum reten- bypass operation was possible. The average moses
Unresectable carcinoma of the oesophagus
9
survival time for these i o patients was 2 months. Among the i i 9 patients who survived the bypass operation the longest survival time was I 8 months and the shortest i month, with an average of 4 months. Among the I 2 patients (6.6%) who are still alive the longest survival is 8 months.
which was encountered in a patient who was treated with cyclophosphamide in an attempt to check the rapid spread of the disease, though it was the disease rather than the cytotoxic drug that was the cause of weight loss. Three patients of this group had extensive pulmonary tuberculosis, while i i patients had metastases to the lymph nodes and liver.
Ability to eat after operation Seventynine of the II9 survivors were able to eat normal diet and a further 35 to take soft food after the operation. Another 3 patients have just been operated on and are expected to eat normally. Barium swallow showed a normal passage in every case, but 2 patients were regarded as failures as they required tube feeding owing to persistent leakage at the neck anastomosis. Cineradiographic examination showed no regurgitation of intestinal contents into the bronchus. Passage through the loop of intestine or stomach was free. The transplanted portions of the gastrointestinal tract functioned well. The large or small intestine did contract, but the stomach did not seem to do so. There was little or no difference whether the transplant was placed subcutaneously or retrosternally. This could be demonstrated by intraluminal pressure studies.
Postoperative complications Leakage at the cervical anastomosis occurred in 69 cases (4I%). The reason for the frequency of this complication was not clear. The percentage was certainly highest (29/6I; 48%) when the stomach was pulled into the neck, but the blood supply of the stomach in each instance was more than adequate and there was never any tension. The proportion with leakage was lower (33/84; 39%/0) when the jejunum was used and lowest (7/2I; 33%) with colonic anastomosis. Leakage, whatever type of transplant was used, always occurred on the lateral aspect of the anastomosis. Generally it healed spontaneously, repair being necessary in only o cases.
Effect on body weight Thirty-eight patients gained more than I.82 kg after discharge and in 3 of these the maximum weight gained was i6.82, 8.64, and 6.82 kg respectively (Fig. 3). The average weight gained in this group was 2.95 kg. Sixty-five patients gained less than 1.82 kg but maintained the same weight up to the time of discharge from hospital. When they began to lose weight ,again it was a sign of extensive spread of the disease and the end was close. Twenty-five patients steadily lost weight despite their ability to swallow normally. The FIG. 3 Patient with double bypass, (A) bemaximum loss of body weight was I5.45 kg, fore operation and (B) six months later.
10
G B Ong
Pulmonary infection due to aspiration of oesophageal contents occurred after operation in 89 cases (54%). The majority of these patients had had infection before the operation. It had subsided after vigorous treatment but recurred after operation. Wound sepsis occurred in 31 cases (i9%). The infection was in the abdominal wound, from the infected gastrostomy opening, in every case. Metabolic and electrolyte imbalance occurred in I 4 patients who at the time of admission were dehydrated and moribund. After correction of the imbalance they were operated upon but subsequently developed the same complication. Gangrene of the transplanted loop occurred after operation in 6 cases as a result of venous obstruction. In all 6 it was a jejunal loop, and when transplanted it was healthy and bled well. Within 24 hours it became turgid and peristalsis was absent. In the meantime tachycardia and restlessness had developed. Removal of the intestinal loop was carried out in 2 cases but both patients died shortly afterwards. Damage to the venous return during preparation of the intestine was the cause in these 2 cases. In the remaining cases it was angulation of the bowel preventing good venous drainage. Of the i 8i Postoperative deaths patients treated, 53 (29.3%) died within the postoperative period. Of these 53, 5 were among the I3 patients who had oesophagobronchial fistula and underwent only oesophagostomy and gastrostomy. Of the remaining 48, 26 had a double bypass and 22 had a single one. Chest infection caused the greatest number of these deaths (40/53; 75.5%/). Many of these infections were inevitable and some of them were terminal. Two deaths were due to peritonitis and infection at the site of anastomosis respectively and could probably
have been avoided had greater care had been practised at the time of operation. Gangrene of the intestinal loop accounted for 6 deaths, haemorrhage for 3, and heart failure for 2. Of the I I 3 patients who Late deaths have died during the follow-up period after bypass operation, 54 were admitted terminally to the Queen Mary Hospital. Forty of these 54 could take normal diet up to the very end; postmortem examination showed multiple secondaries in the liver, bones, and lungs in i 8 and chest infection in 22, I3 of whom had oesophagobronchial fistula. The remaining I 4 patients had terminal dysphagia, which was due to metastatic lymph nodes compressing the bypass in 3, cachexia in 4, anorexia in 6, and dyspnoea due to a tumour compressing the trachea in one
(Fig. 4).
Fifty-nine patients died at home. The last follow-up before their deaths showed that 29 patients were eating well but had clinical evidence of either secondaries or chest infection. Twelve patients complained of dysphagia, but barium examination revealed patency of the intestinal loop. Eighteen patients were either cachectic or had anorexia.
Lessons learned The resectability Relief of dysphagia rate in advanced carcinoma of the oesophagus is at best in the region of 45-50%/O. Many of these growths, although resectable, are not curable as distant metastases may be present. Resection, whenever possible, ought to be carried out even for palliation as this will give relief to the dysphagia. When the lesion is unresectable owing to infiltration or for any other cause radiotherapy is often resorted to. But when the growth has penetrated the bronchial tree radiotherapy tends to produce
Unresectable carcinoma of the oesophagus
II
FIG. 4 Patient with Kirschner operation who died suddenly of asphyxiation: (A) before operation, (B) after operation, and (C) postmortem specimen showing left main bronchus completely occluded by tumour. oesophagobronchial fistula, the result of which is even worse than the disease itself. The insertion of an oesophageal tube, popularized many years ago by Souttar"9 and more recently by Celestin5, gives only partial relief to the symptom of dysphagia. Even when successfully treated the patient can eat food only in puree or liquid form, attempts to ingest solid food often causing obstruction, necessitating clearance through an oesophagoscope. Furthermore, obstruction of the tube will occur when the tumour grows above it. During the introduction of the tube dilatation with the oesophageal bougie can at times cause rupture. When in position the tube may erode through the oesophageal wall and the trachea and this may give rise to tracheo-oesophageal fistula (Fig. 5). It may also slip through the growth and be passed out per rectum.
Of the patients treated by intubation by Pringle and Winsey7 50%° could swallow only liquid and did not leave the hospital. In our series I I9 patients out of I66 undergoing bypass operations were discharged from hospital-that is, 71.7%. The mortality of 28.3% could have been lower if the patients who were operated on had been better selected, but many of them were already in a dying condition. Even as it is, the mortality rate is comparable to that reported by Sweet', who carried out resection for mid-oesophageal lesions in 36 cases and had 9 deaths, a mortality of 25%. Those patients who Quality of life were successfully treated not only could eat normal diet but also gained weight. Sometimes they could lead a normal active life. Some could even return to their former occupation. The following case illustrates this.
12
G B Ong
hazardous and fraught with complicamost frequent of which was chest infection. Most patients, even without oesophagobronchial fistula, had some degree of chest infection, dammed-up secretion above the obstructed oesophagus often being aspirated and causing pneumonia. When the lesion was complicated by oesophagobronchial fistula the pulmonary infection became desperate and was usually a terwere
tions, the
minal event.
Leakage at the neck anastomosis was the next most frequent complication and the reason for this is obscure. In one case previously
Plastic oesophageal tube eroding oesophagus (short arrow) and penetrating left main bronchus (long arrow).
FIG. 5
A Chinese man aged 59 whose body wcight on admission was only 4I kg was shown on barium swallow to have an oesophagobronchial fistula (Fig. 6). He choked with each act of swallowing, was constantly coughing, and was expectorating up ml of sputum a day. A double bypass operato tion was performed from which he made an uneventful recovery, with reduction in sputum to negligible amounts, and was able to swallow normal diet at the time of discharge one month later. By this time he had gained 3.I8 kg in weight. He continued to do well and 6 months later he had regained his normal body weight and was able to go back to work. A year later he had gained I6.82 kg since the time of admission and his weight was then 57.73 kg (Fig. 7). From then on his weight was maintained until I8 months after the operation, when metastatic lymph nodes became palpable in the neck, but he was able to swallow to the very last. He was finally admitted to another hospital where he died. No postmortem examination was carried out. ioo
reported18 the leak in the neck was below the point of anastomosis and occurred just before the patient's death; at postmortem examination it was found that the stomach was paper-thin becauise of terminal tissue breakdown. It is possible that sepsis may play a part in prodtucing leakage. Another possibility is that it results from the fact that the divided oesophagus is brought out subcutaneously and the anastomosis made in the gutter formed after the left sternomastoid muscle is divided and the free end attached to the prevertebral muscles. Hence the lateral part of the anastomosis is protected only by the skin of the neck. However, in the last 6 cases closure was accomplished with interrupted catgut and just before the neck was closed the sternomastoid was sutured to the stemohyoid muscle, but this reinforcement of the suture line did not seem to overcome the difficulty. Further stuidies will be required to elucidate this failure of technique.
Conclusion In this series of 18I cases of unresectable carcinoma of the oesophagus I67 bypass operations were carried out (i 66 primary, I after preliminary oesophagostomy and gasHigh rate of complications The by- trostomy). Intubation with either the pulsion pass operations performed on these patients or traction type of oesophageal tube was not
Unresectable carcinoma of the oesophagus
A Barium swallow
I3
B oesophagobronchial
fistula. of patient with malignant (B) Postoperative oesophagogram. Note there is now no reflux into the bronchus.
FIG. 6 (A)
~~~~~~~~~~~~~~~~~~ ...-~~~ * «Y. :, ..: . .. . ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
FIG. 7
(A) Patient
on
discharge. (B) Six months later. (C) One year later.
14
G B Ong
performed. These patients were not selected 5 Celestin, L, R (I959) Annals of the Royal College of Surgeons of England, 25, i65. and attempts were made to treat even the 6 O'Connior, T, Watson, R, Lepley, D jr, and dying. Weisel, W (I963) Archives of Surgery, 87, 275. The results have been encouraging, for 7 Pringle, R, and Winsey, H S (i973) Journal of even some of the moribund patients recovered the Royal College of Surgeons of Edinbuirgh, and lived their remaining days in comfort. i8, i88. They could eat even normal solid food and 8 Bestler, J M, Frazer, J P, and Yarington, C T jr some returned to their former occupation (1966) Laryngoscope, 76, 65I. as labourers. 9 Duvoisin, G E, Ellis, F H jr, and Payne, W S (I967) Suirgical Clinics of North America, 47, The mortalitv rate is still high, but some 827. causes of death are avoidable. An improveD S C (I968) South African Journal ment in the correct application of operative io Procter, of Surgery, 6, 137. techniques, of which Moynihan was a past ii Ong, G B (i964) British Journal of Surgery, master, could see the lowering and perhaps 5', 53elimination of such complications as leakage 1 2 Ong, G B (I97I) in Current Problems in Surat the site of the anastomosis. gery, cd. M Ml Ravitch. Chicago, Year Book
References Mustard, R A, and Ibberson, 0 (1956) Annals of Surgery, 144, 927. 2 Sweet, R H (I957) Proceedings of American College of Surgeons Clinical Congress, Atlantic City, N.J., October I957. (Also in Surgery of the Esophagus, ed. R WV Postlethwait and W C Sealy, p. 305. Springfield, Ill., Thomas.) 3 Garlock, J H, and Klein, S H (I954) Annals of Surgery, 139, I9. 4 Ong, G B, anid Kwong, K H (I969) Journal of the Royal College of Surgeons of Edinburgh, 14, 3. X
13 14
I5 i6
17 i8
I9
Medical Publishers. Ong, G B, and Kwong, K H (1970) Surgery, 67, 293. Allison, P R, and Da Silva, L T (I953) British Journal of Surgery, 41, I73. Heimlich, 1I J, and Winfield, J M (I955) Surgery, 37, 549. Heimlich, II J (I966) British Journal of Surgery, 53, 9I3Kirschner, M B (I920) Langenbecks Archiv fur klinische Chirurgie, II4, 6o6. Ong, G B (1973) British Journal of Surgery, Go, 221. Souittar, H S (1924) British Medical Journal, I, 782.
Unresectable carcinoma
of
the
oesophagus G B Ong OBE FRCS
Professor of Surgery, University of Hong Kong
Summary One hundred and eighty-one patients with unresectable carcinoma of the oesophagus have been seen and treated during the past Io years. When the general condition of the patient was judged to be such that he was able to withstand a major operation a bypass procedure was adopted. No cases were rejected, but when the patient was in extremis oesophagostomy and gastrostomy only were performed. The results of treatment are presented and the difliculties encountered discussed.
Introduction Moynihan, in the Hunterian Oration delivered at the Royal College of Surgeons of England on i4th February I927, referring to the fight against disease, said: 'Man's life is warfare. The individual, the whole race, is beset by foes, unresting, relentless. Against them our defence, if we are ever to subdue them, must be carefully planned and diligently strengthened. But defence, however stubborn, is not enough. Attacks designed after scientific study of the enemy strongholds and methods, and launched with impassioned zeal, must never for one instant falter. Not all our attacks meet with success. Failure inspires us to fresh and still more eager endeavour'. Moynihan Lecture delivered on 3rd April I974
This constant struggle is as true today as it was 47 years ago. This is especially so in the case of the inoperable carcinoma of the oesophagus. Carcinoma of the oesophagus when first seen in Hong Kong is often in an advanced stage and resection may not be possible. Some patients may already have developed distant metastases. Poor respiratory function due to extensive pulmonary tuberculosis or aspiration pneumonia is frequently found. Older patients often have cardiac insufficiency or are actually in a state of cardiac failure. When the lesion has extended beyond the confines of the oesophagus, has infiltrated the bronchus giving rise to oesophagobronchial fistula, or has invaded the aorta attempts at resection will result in disaster. The resectability rate of mid-oesphageal carcinoma is relatively low. Mustard and Ibberson1 resected only 26o/% of their cases, though Sweet2 gave a figure of 65% resectability for mid-oesophageal lesions. Garlock and Klein3 found that in 42% of their cases the lesion could be removed. Ong and Kwong4 gave a similar figure of 45%/O. Hitherto, in cases which are not resectable either for curative or palliative purposes relief of the dysphagia by dilatation and insertion of an oesophageal tube has been widely practised. The results reported by Celestin5
4
GB
Ong
and O'Connor et al.6 have been optimistic. On the other hand Pringle and Winsey7, Bestler et al.8, Duvoisin et al.9, and Procter"0 have cast doubt on the value of this form of treatment. We have not been happy with the result of intubation in unresectable carcinoma of the oesophagus, for even in successful cases the patient can at best swallow semisolid food, and in order to wash down the bolus a large amount of fluid has to be taken with each act of swallowing. In I 964 I reported a personal series of I I cases" in the majority of which a bypass operation, using either colon, jejunum, or stomach, was performed. Since then, unless the general condition of the patient was so poor that no major operation was feasible, we have used the bypass operation for all unresectable carcinomas of the oesophagus.
All the patients on admisDysphagia sion had had dysphagia for 2-I4 months. The history usually started with a feeling of discomfort at the site of obstruction. This was quickly followed by inability to swallow solid food and consequently the patient subsisted on semisolid diet; ultimately he could swallow only fluids. If oesophagobronchial fistula was present, whenever the patient swallowed fluid a spasm of cough, followed by profuse expectoration of sputum and sometimes of the fluid ingested, would occur. With chest infection the amount of sputum brought up was between i2o and 240 ml daily. Many of these patients were admitted in a state of dehydration with dyspnoea and cyanosis. There had been Loss of body weight marked loss of body weight in every case, varying from 2.27 to as much as i8.2 kg, with an average of 6.8 kg. At the time of admission the average body weight was 42. I
Material From I964 to March I974 i8i patients with inoperable carcinoma of the oesophagus from the upper third to the cardia were seen and treated at the University Surgical Unit, Queen Mary Hospital, Hong Kong. There were 148 males and 33 females, giving a ratio of 4.5: The oldest patient was 83 years of age while the youngest was 38. The average age for males was 56 years and for females 66. The overall average age was 58.
(range 25.45-50) kg.
2
i.
In 28 cases (I5 5%) Level of lesion the tumour was situated in the upper third of the oesophagus-that is, from Di to D4. Mid-thoracic growths (D4-D8) were found in II9 cases (65.7 /,). In 2 cases (ii.6%) the growth was in the lower oesophagus (D8-Di 2) and was of squamous cell origin, while in 13 cases (7.2%) it was an adenocarcinoma from the cardiac portion of the stomach which had invaded the oesophagus giving rise to dysphagia. 1
Pulmonary infection Fifty-seven patients (3 I5%) were admitted with severe chest infection. (This does not include the 32 patients who had oesophagobronchial fistula.) Twentyfive recovered after intensive treatment with antibiotics and physiotherapy. However, the chest condition recurred following definitive operative treatment. In addition, 21 patients had suffered from active pulmonary tuberculosis and in 2 of these tubercle bacilli were demonstrated. These patients had to have chemotherapeutic cover before operation. In open cases one month of chemotherapy was given before the patient was subjected to operation. Metastases to lymph nodes Metastases were present in the lymph nodes in 35 patients (I9.3%). These lymph nodes were usually found in the left supraclavicular fossa and were quite obvious at the time of admission; in 5 cases they were found behind the
Unresectable carcinoma of the oesophagus right sternoclavicular joint. Hoarseness of the voice due to vocal cord paralysis occurred in 24 patients (13.2%/1). This never improved after irradiation, indicating lymphatic involvement and invasion of usually the left recurrent laryngeal nerve. Distant metastases Distant metastases were present in 27 patients (I5%). The liver was involved in i i cases, while the remainder had widespread metastases including the bones and skin. Oesophagobronchial fistula Thirty-two patients (i8%/,) were admitted with oesophagobronchial fistula. This included 9 patients who had had irradiation and had developed the fistula following treatment. The other 23 patients had developed oesophagobronchial fistula in the course of the illness and were admitted as such. The fistula was demonstrated either by barium swallow or at bronchoscopy. Preoperative irradiation Of the i8i patients, 9 had had preoperative irradiation at some stage. Most of them had never completed it and were referred to us because in the course of treatment they had developed oesophagobronchial fistula.
Preoperative management Most of these patients with advanced cancer of the oesophagus were in a poor nutritional state when admitted. As many of them had respiratory infection active treatment was necessary to prepare them for any subsequent operative treatment. Barium swallow was carried out whenever possible and if there was a suspicion of an oesophagobronchial fistula a water-soluble medium such as Gastrografin was used. If the patient was dyspnoeic and had a large amount of sputum tracheostomy was performed so that bronchial toilet could be carried out frequently.
5
Oesophagoscopy and bronchoscopy were carried out as a routine under general anaesthesia so that biopsy could be performed and a histological diagnosis obtained.
Operative treatment Oesophagostomy and gastrostomy If the general condition of the patient was poor owing to chest infection or oesophagobronchial fistula, immediately after oesophagoscopy and bronchoscopy tracheostomy was carried out together with gastrostomy and oesophagostomy. The oesophagus was brought out posterior to the sternomastoid or after division of the posterior attachment of this muscle and then stitched to the skin. This would prevent the saliva from trickling down the trachea through the tracheostomy opening. The distal part of the divided oesophagus was closed. Gastrostomy was performed by making a small incision cutting through all layers of the abdominal wall. A Witzel type of gastrostomy was performed. This has been described previously'2. This procedure was carried out on 15 of the i8I patients as a semi-emergency operation. Feeding through the gastrostomy was carried out soon after the operation and a high-calorie liquid diet, obtained by passing normal food through a blender, was given. Out of these I5 patients, only one improved to such an extent that a definitive bypass, using the stomach, could be performed. Bypass operations Primary bypass operation was carried out in each of the remaining i66 cases, a single bypass in go and a double bypass in 76. A single bypass is one in which one end of an isolated jejunal or isoperistaltic colonic loop is anastomosed to the stomach and the other to the divided cervical oesophagus. For a double bypass, in addition to these anastomoses a Roux-en-Y
6
G B Ong
operation is performed at the divided abdominal portion of the lower oesophagus (Fig. i). T'his latter operation was designed originally for patients with oesophagobronchial fistula13. For colonic bypass the Colonic bypass terminal ileum is utilized for the upper anastomosis and the right side of the transverse colon anastomosed to the stomach in the abdominal part of the procedure. Restoration of colonic continuity is accomplished by making an end-to-end ileocolostomy. The isolated colon is placed behind the stomach and transverse mesocolon so that its vascular pedicle lies in the lesser sac. The anastomosis is done with catgut or linen thread suture. Transthoracic bypass with Jejunal bypass jejunum was done for all lower oesophageal lesions. The length of jejunum required to bypass the obstruction usually requires division of only one main jejunal vessel. This loop is delivered into the thorax by making an opening in the diaphragm. The oesophagus
A
is transected above the growth and the lower end closed. An end-to-end anastomosis is then made. For anastomosis in the neck preparation of a jejunal loop uisually requires division of 3 or 4 main jejunal vessels. The arteries and veins are dissected out and ligated separately. The leaves of the mesentery are peeled off. This manoeuvre allows the intestine to straighten out14'11. When the smallintestinal loop has been prepared the two leaves of the mesentery are brought together again by interrupted sutures (Fig. 2). This serves as a protection of the vessels supplying the isolated intestine. Like the large intestine, it is brought up into the neck with the vascular pedicle lying in the lesser sac. The stomach was used for Stomach bypass a single bypass operation on 5 occasions. In 2 cases the reversed gastric tube as described by Heimlich and Winfield"5 and Heimlich16 was used, being placed subcutaneously in one and retrostemally in the other. In the re-
B
C
Diagram showing the methods of double bypass. (A) jejunum; (B) colon; and (C) stomach.
FIG. I
Unresectable carcinoma of the oesophagus
7
FIG. 2 (A) Loop of jejunum being prepared for bypass. The leaves of the mesentery are peeled of. (B) After straightening the jejunal loop the leaves of the mesentery are brought together by interrupted sutures. (C) The jejunum is now straightened and reaches the larynx (pointer).
maimnng 3 cases the stomach, after mobilization, was delivered into the right pleural cavity. The oesophagus distal to the growth was then freed and the fundus of the stomach was anastomosed to the oesophagus well above the tumour. The whole of the stomach, after mobilization, was used for bypassing the lesion in 56 patients. This operation was originally carried out by Kirschnere7 and had recently been performed for malignant oesophageal lesions"8. It was especially useful in cases with oesophagobronchial fistula. The technique is as follows. Mobilization of the stomach is done as far as the duodenum. An extensive Kocher's manoeuvre is necessary to enable the stomach to be brought up into the neck. Should there
be difficulty in making the stomach reach the neck it can be lengthened by gently kneading and stretching it. Pyloromyotomy is also done in order to prevent gastric retention, which would result in postoperative regurgitation and aspiration of the stomach contents. The stomach is divided at the cardia, which is closed with continuous catgut. A Roux-en-Y anastomosis between the divided abdominal oesophagus and the jejunum is then made. This anastomosis is made with a continuous catgut suture and any defects are then reinforced with a few interrupted stitches. Leakage does not occur at this point as no food passes through it. The enteroenterostomy is made at least I8 in. (46 cm) away from this suture line. This length of jejunum between the two anasto-
8
G B Onig
wvill prevent reflux of intestinal contents tion, aspiration of sputum through the into the lower oesophagus, with aspiration tracheostomy being carried out every I5-20 minutes throughout the 24 hours. into the lungs if there is a fistula. A nasogastric tube was inserted in each The route case at the conclusion of the operation and Routes taken at bypass taken for the bypass can be either subcuta- the stomach kept empty. When colon or jeneous or retrostemal. The preparation of this junum had been used for bypass this tube tunnel is best done with a large pair of scis- was placed in the lumen of the intestinal loop sors of the Abel type. In doing this the to keep it empty. If the blood supply of an perforating branches of the internal mam- isolated loop of intestine was marginal demary vessels may be damaged; should this compression was essential, as an increase of happen the skin should be slit open and the intraluminal pressure could compromise its bleeding vessels exposed and ligated. blood supply. The nasogastric tube could be The proximal end of the stomach or small taken out when peristalsis returned, which or large intestine is anchored to two pieces usually took place within 24-48 hours. of gauze. By pulling on these through the Oral feeding with fluid was usually given tunnel the mobilized stomach or intestine can about the 5th or 6th postoperative day probe brought up into the neck. vided the Gastrografin swallow showed that The retrostemal route gives rise to no there was no leakage. If leakage was present difficulty. While working in the neck the cer- the nasogastric tube was used as a feeding vical muscles are detached from their sternal tube so that the intravenous drip could be insertions. By blunt dissection the whole hand dispensed with as soon as possible. can be inserted into the anterior mediastinum Blood transfusions were given whenever from the abdomen. Provided the dissection necessary. If there was leakage and the conis done very close to the back of the sternum dition of the patient was poor parenteral no troublesome complication will be encoun- hyperalimentation would often result in tered. Tcars in the mediastinal pleura are marked improvement. Frequent blood culfrequent, but drainage of the pleural cavity tures were made to rule out fungal infection, will prevent tension pneumothorax. which was sometimes met with, especially When the growth is high or lymph nodes when broad-spectrum antibiotics had been are palpable at the root of the neck it is given for a long period. If candida was grown better to place the transplant subcutaneously from the blood hyperalimentation was since a retrosternal transplant may be com- stopped and a fungicide given. pressed by expansion of the growth or lymph node metastases, with recurrence of dysResults phagia". Of the I8 i patients, 128 Survival Postoperative care As most of these patients were in a weak state (71X%) survived operation. These included I0 postoperative complications were relatively patients who underwent oesophagostomy and common and postoperative care was all-im- gastrostomy for either oesophagobronchial portant. Antibiotics were given for chest in- fistula, very severe pulmonary infection, or fection, especially in the presence of an poor general condition, one of whom suboesophagobronchial fistula. Tracheostomy was sequently improved to such an extent that a carried out on patients with sputum reten- bypass operation was possible. The average moses
Unresectable carcinoma of the oesophagus
9
survival time for these i o patients was 2 months. Among the i i 9 patients who survived the bypass operation the longest survival time was I 8 months and the shortest i month, with an average of 4 months. Among the I 2 patients (6.6%) who are still alive the longest survival is 8 months.
which was encountered in a patient who was treated with cyclophosphamide in an attempt to check the rapid spread of the disease, though it was the disease rather than the cytotoxic drug that was the cause of weight loss. Three patients of this group had extensive pulmonary tuberculosis, while i i patients had metastases to the lymph nodes and liver.
Ability to eat after operation Seventynine of the II9 survivors were able to eat normal diet and a further 35 to take soft food after the operation. Another 3 patients have just been operated on and are expected to eat normally. Barium swallow showed a normal passage in every case, but 2 patients were regarded as failures as they required tube feeding owing to persistent leakage at the neck anastomosis. Cineradiographic examination showed no regurgitation of intestinal contents into the bronchus. Passage through the loop of intestine or stomach was free. The transplanted portions of the gastrointestinal tract functioned well. The large or small intestine did contract, but the stomach did not seem to do so. There was little or no difference whether the transplant was placed subcutaneously or retrosternally. This could be demonstrated by intraluminal pressure studies.
Postoperative complications Leakage at the cervical anastomosis occurred in 69 cases (4I%). The reason for the frequency of this complication was not clear. The percentage was certainly highest (29/6I; 48%) when the stomach was pulled into the neck, but the blood supply of the stomach in each instance was more than adequate and there was never any tension. The proportion with leakage was lower (33/84; 39%/0) when the jejunum was used and lowest (7/2I; 33%) with colonic anastomosis. Leakage, whatever type of transplant was used, always occurred on the lateral aspect of the anastomosis. Generally it healed spontaneously, repair being necessary in only o cases.
Effect on body weight Thirty-eight patients gained more than I.82 kg after discharge and in 3 of these the maximum weight gained was i6.82, 8.64, and 6.82 kg respectively (Fig. 3). The average weight gained in this group was 2.95 kg. Sixty-five patients gained less than 1.82 kg but maintained the same weight up to the time of discharge from hospital. When they began to lose weight ,again it was a sign of extensive spread of the disease and the end was close. Twenty-five patients steadily lost weight despite their ability to swallow normally. The FIG. 3 Patient with double bypass, (A) bemaximum loss of body weight was I5.45 kg, fore operation and (B) six months later.
10
G B Ong
Pulmonary infection due to aspiration of oesophageal contents occurred after operation in 89 cases (54%). The majority of these patients had had infection before the operation. It had subsided after vigorous treatment but recurred after operation. Wound sepsis occurred in 31 cases (i9%). The infection was in the abdominal wound, from the infected gastrostomy opening, in every case. Metabolic and electrolyte imbalance occurred in I 4 patients who at the time of admission were dehydrated and moribund. After correction of the imbalance they were operated upon but subsequently developed the same complication. Gangrene of the transplanted loop occurred after operation in 6 cases as a result of venous obstruction. In all 6 it was a jejunal loop, and when transplanted it was healthy and bled well. Within 24 hours it became turgid and peristalsis was absent. In the meantime tachycardia and restlessness had developed. Removal of the intestinal loop was carried out in 2 cases but both patients died shortly afterwards. Damage to the venous return during preparation of the intestine was the cause in these 2 cases. In the remaining cases it was angulation of the bowel preventing good venous drainage. Of the i 8i Postoperative deaths patients treated, 53 (29.3%) died within the postoperative period. Of these 53, 5 were among the I3 patients who had oesophagobronchial fistula and underwent only oesophagostomy and gastrostomy. Of the remaining 48, 26 had a double bypass and 22 had a single one. Chest infection caused the greatest number of these deaths (40/53; 75.5%/). Many of these infections were inevitable and some of them were terminal. Two deaths were due to peritonitis and infection at the site of anastomosis respectively and could probably
have been avoided had greater care had been practised at the time of operation. Gangrene of the intestinal loop accounted for 6 deaths, haemorrhage for 3, and heart failure for 2. Of the I I 3 patients who Late deaths have died during the follow-up period after bypass operation, 54 were admitted terminally to the Queen Mary Hospital. Forty of these 54 could take normal diet up to the very end; postmortem examination showed multiple secondaries in the liver, bones, and lungs in i 8 and chest infection in 22, I3 of whom had oesophagobronchial fistula. The remaining I 4 patients had terminal dysphagia, which was due to metastatic lymph nodes compressing the bypass in 3, cachexia in 4, anorexia in 6, and dyspnoea due to a tumour compressing the trachea in one
(Fig. 4).
Fifty-nine patients died at home. The last follow-up before their deaths showed that 29 patients were eating well but had clinical evidence of either secondaries or chest infection. Twelve patients complained of dysphagia, but barium examination revealed patency of the intestinal loop. Eighteen patients were either cachectic or had anorexia.
Lessons learned The resectability Relief of dysphagia rate in advanced carcinoma of the oesophagus is at best in the region of 45-50%/O. Many of these growths, although resectable, are not curable as distant metastases may be present. Resection, whenever possible, ought to be carried out even for palliation as this will give relief to the dysphagia. When the lesion is unresectable owing to infiltration or for any other cause radiotherapy is often resorted to. But when the growth has penetrated the bronchial tree radiotherapy tends to produce
Unresectable carcinoma of the oesophagus
II
FIG. 4 Patient with Kirschner operation who died suddenly of asphyxiation: (A) before operation, (B) after operation, and (C) postmortem specimen showing left main bronchus completely occluded by tumour. oesophagobronchial fistula, the result of which is even worse than the disease itself. The insertion of an oesophageal tube, popularized many years ago by Souttar"9 and more recently by Celestin5, gives only partial relief to the symptom of dysphagia. Even when successfully treated the patient can eat food only in puree or liquid form, attempts to ingest solid food often causing obstruction, necessitating clearance through an oesophagoscope. Furthermore, obstruction of the tube will occur when the tumour grows above it. During the introduction of the tube dilatation with the oesophageal bougie can at times cause rupture. When in position the tube may erode through the oesophageal wall and the trachea and this may give rise to tracheo-oesophageal fistula (Fig. 5). It may also slip through the growth and be passed out per rectum.
Of the patients treated by intubation by Pringle and Winsey7 50%° could swallow only liquid and did not leave the hospital. In our series I I9 patients out of I66 undergoing bypass operations were discharged from hospital-that is, 71.7%. The mortality of 28.3% could have been lower if the patients who were operated on had been better selected, but many of them were already in a dying condition. Even as it is, the mortality rate is comparable to that reported by Sweet', who carried out resection for mid-oesophageal lesions in 36 cases and had 9 deaths, a mortality of 25%. Those patients who Quality of life were successfully treated not only could eat normal diet but also gained weight. Sometimes they could lead a normal active life. Some could even return to their former occupation. The following case illustrates this.
12
G B Ong
hazardous and fraught with complicamost frequent of which was chest infection. Most patients, even without oesophagobronchial fistula, had some degree of chest infection, dammed-up secretion above the obstructed oesophagus often being aspirated and causing pneumonia. When the lesion was complicated by oesophagobronchial fistula the pulmonary infection became desperate and was usually a terwere
tions, the
minal event.
Leakage at the neck anastomosis was the next most frequent complication and the reason for this is obscure. In one case previously
Plastic oesophageal tube eroding oesophagus (short arrow) and penetrating left main bronchus (long arrow).
FIG. 5
A Chinese man aged 59 whose body wcight on admission was only 4I kg was shown on barium swallow to have an oesophagobronchial fistula (Fig. 6). He choked with each act of swallowing, was constantly coughing, and was expectorating up ml of sputum a day. A double bypass operato tion was performed from which he made an uneventful recovery, with reduction in sputum to negligible amounts, and was able to swallow normal diet at the time of discharge one month later. By this time he had gained 3.I8 kg in weight. He continued to do well and 6 months later he had regained his normal body weight and was able to go back to work. A year later he had gained I6.82 kg since the time of admission and his weight was then 57.73 kg (Fig. 7). From then on his weight was maintained until I8 months after the operation, when metastatic lymph nodes became palpable in the neck, but he was able to swallow to the very last. He was finally admitted to another hospital where he died. No postmortem examination was carried out. ioo
reported18 the leak in the neck was below the point of anastomosis and occurred just before the patient's death; at postmortem examination it was found that the stomach was paper-thin becauise of terminal tissue breakdown. It is possible that sepsis may play a part in prodtucing leakage. Another possibility is that it results from the fact that the divided oesophagus is brought out subcutaneously and the anastomosis made in the gutter formed after the left sternomastoid muscle is divided and the free end attached to the prevertebral muscles. Hence the lateral part of the anastomosis is protected only by the skin of the neck. However, in the last 6 cases closure was accomplished with interrupted catgut and just before the neck was closed the sternomastoid was sutured to the stemohyoid muscle, but this reinforcement of the suture line did not seem to overcome the difficulty. Further stuidies will be required to elucidate this failure of technique.
Conclusion In this series of 18I cases of unresectable carcinoma of the oesophagus I67 bypass operations were carried out (i 66 primary, I after preliminary oesophagostomy and gasHigh rate of complications The by- trostomy). Intubation with either the pulsion pass operations performed on these patients or traction type of oesophageal tube was not
Unresectable carcinoma of the oesophagus
A Barium swallow
I3
B oesophagobronchial
fistula. of patient with malignant (B) Postoperative oesophagogram. Note there is now no reflux into the bronchus.
FIG. 6 (A)
~~~~~~~~~~~~~~~~~~ ...-~~~ * «Y. :, ..: . .. . ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
FIG. 7
(A) Patient
on
discharge. (B) Six months later. (C) One year later.
14
G B Ong
performed. These patients were not selected 5 Celestin, L, R (I959) Annals of the Royal College of Surgeons of England, 25, i65. and attempts were made to treat even the 6 O'Connior, T, Watson, R, Lepley, D jr, and dying. Weisel, W (I963) Archives of Surgery, 87, 275. The results have been encouraging, for 7 Pringle, R, and Winsey, H S (i973) Journal of even some of the moribund patients recovered the Royal College of Surgeons of Edinbuirgh, and lived their remaining days in comfort. i8, i88. They could eat even normal solid food and 8 Bestler, J M, Frazer, J P, and Yarington, C T jr some returned to their former occupation (1966) Laryngoscope, 76, 65I. as labourers. 9 Duvoisin, G E, Ellis, F H jr, and Payne, W S (I967) Suirgical Clinics of North America, 47, The mortalitv rate is still high, but some 827. causes of death are avoidable. An improveD S C (I968) South African Journal ment in the correct application of operative io Procter, of Surgery, 6, 137. techniques, of which Moynihan was a past ii Ong, G B (i964) British Journal of Surgery, master, could see the lowering and perhaps 5', 53elimination of such complications as leakage 1 2 Ong, G B (I97I) in Current Problems in Surat the site of the anastomosis. gery, cd. M Ml Ravitch. Chicago, Year Book
References Mustard, R A, and Ibberson, 0 (1956) Annals of Surgery, 144, 927. 2 Sweet, R H (I957) Proceedings of American College of Surgeons Clinical Congress, Atlantic City, N.J., October I957. (Also in Surgery of the Esophagus, ed. R WV Postlethwait and W C Sealy, p. 305. Springfield, Ill., Thomas.) 3 Garlock, J H, and Klein, S H (I954) Annals of Surgery, 139, I9. 4 Ong, G B, anid Kwong, K H (I969) Journal of the Royal College of Surgeons of Edinburgh, 14, 3. X
13 14
I5 i6
17 i8
I9
Medical Publishers. Ong, G B, and Kwong, K H (1970) Surgery, 67, 293. Allison, P R, and Da Silva, L T (I953) British Journal of Surgery, 41, I73. Heimlich, 1I J, and Winfield, J M (I955) Surgery, 37, 549. Heimlich, II J (I966) British Journal of Surgery, 53, 9I3Kirschner, M B (I920) Langenbecks Archiv fur klinische Chirurgie, II4, 6o6. Ong, G B (1973) British Journal of Surgery, Go, 221. Souittar, H S (1924) British Medical Journal, I, 782.
