Transhiatal Esophagectomy Without Thoracotomy for Carcinoma of the Thoracic

MARK B. ORRINGER, M.D.

Transhiatal esophagectomy (THE) without thoracotomy was From the Section of Thoracic Surgery, The University of performed in 100 patients with carcinoma of the thoracic esoph- Michigan Medical Centers, Ann Arbor, Michigan agus (7 upper, 45 mid, and 48 lower third). The esophagus was replaced with (96) or colon (4). Intraoperative com- plications included pneumothorax requiring a chest tube(s) (63) and membranous tracheal tear (2). Blood loss averaged 880 ml. Postoperative complications included transient recurrent laryn- also the appropriateness ofTHE as a "cancer operation." geal nerve paresis (31), anastomotic leak (5), and chylothorax Our approach to carcinoma involving the cervicothoracic (2). There were no intraoperative deaths or re-explorations for esophagus has been discussed previously.3 This report postoperative bleeding. Six hospital deaths resulted from as- reviews our experience with 100 patients with carcinoma piration pneumonia (2), retroperit6neal or mediastinal abscess involving the intrathoracic esophagus. The efficacy of (2), pulmonary embolus (1), and respiratory insufficiency (1). well as its to Postoperative hospitalization averaged 14 days. Actuarial sur- THE as a palliative procedure, as ability vival among the 94 operative survivors is 82% at 6 months, 52% achieve apparent cure in patients with esophageal car- at 12 months, 32% at 24 months, 22% at 36 months, and 17% cinoma, is emphasized. at 48 months. Ofthe operative survivors, 15% have lived 2 years or more and 10% are clinically disease free. THE is safe, as- sociated with a low morbidity, and achieves excellent palliation Materials and Methods and survival at least as good as that reported in many series of transthoracic esophagectomies for esophageal carcinoma. During the past 7 years, THE without thoracotomy, as described previously,"4 has been performed in 100 IN PATIENTS REQUIRING esophagectomy and visceral patients with carcinoma ofthe thoracic esophagus (7 upper esophageal substitution, the physiologic insult ofcom- thoracic, 45 middle third, and 48 distal third). Upper bined thoracic and abdominal incisions and the disastrous third tumors were defined as those extending from the an esophagogastric results of disruption of intrathoracic thoracic inlet to the level of the carina, or from approx- anastomosis remain the leading causes ofoperative mor- imately 19 cm to 25 cm from the upper incisors at en- bidity and mortality. Both ofthese problems are circum- doscopy. Middle third tumors involved the esophagus vented by the technique of transhiatal esophagectomy from the level the to a point approximately 5 a thoracotomy and utilizes a of carina (THE), which both avoids cm above the esophagogastric junction, roughly 25-35 cervical esophageal anastomosis. Since our preliminary cm from the incisors. Distal third tumors involved the report advocating THE,' we have used this operation in esophagus from 35 to 40 cm from the incisors. Histo- 190 patients requiring esophagectomy, 133 for carcinoma logically, all seven of the upper third carcinomas were and Our 57 for benign esophageal disease. growing facility squamous cell. Of the 45 middle third tumors, 38 (84%) with this technique, as well as the reduced perioperative were , and seven (16%) were have served as morbidity in these patients, justification adenocarcinomas. This distribution was reversed among for our current view that THE is the preferred approach in esophageal Con- the 48 distal esophageal tumors, where 41 (85%) were most patients requiring resection.2 adenocarcinomas and seven (15%) were squamous cell. troversy continues to surround the relative safety of this Among these 100 patients, 80 were men and 20 were operation, particularly in patients with carcinoma, and women, ranging in age from 38 to 92 years, with an average of 62 years. Twenty-one of these patients were Presented at the 104th Annual Meeting of the American Surgical 70 years of age or older. Dysphagia was the predominant Association, Toronto, Canada, April 25-27, 1984. presenting complaint in all but four patients, and the Reprint requests: Mark B. Orringer, M.D., Professor of Surgery, The University of Michigan Hospitals, Section of Thoracic Surgery, C7079, average duration of symptoms before diagnosis was 3 Box 32, Ann Arbor, MI 48109. months. Seventy-one patients had experienced weight loss Submitted for publication: April 30, 1984. that averaged 10.5 kg.

282 Vol. 200 * No. 3 TRANSHIATAL ESOPHAGECTOMY WITHOUT THORACOTOMY 283 The preoperative assessment included a barium swallow TABLE 1. TNM Classification for Postsurgical Resection Staging ofEsophageal Carcinoma* examination and esophagoscopy with biopsy in all pa- tients. Those with mid or upper third tumors underwent Definitions bronchoscopy to assess possible tracheobronchial inva- Primary tumor (T) T1-Tumor invading mucosa or submucosa but not muscularis sion. High grade obstructing tumors were dilated enough T2-Tumor invading but not through muscularis to enable passage of a feeding tube, and enteral alimen- T3-Tumor invading entire thickness of muscularis into tation was instituted via the nasogastric tube in all patients adjacent tissue Regional lymph nodes (N) unable to swallow an adequate caloric intake. Intravenous No-Regional nodes not involved hyperalimentation was not used routinely in any patient. N,-Unilateral regional nodes involved When warranted by dehydration, marked weight loss, or N2-Bilateral regional nodes involved N3-Extensive multiple regional nodes involved pulmonary sepsis secondary to aspiration from the Distant (M) esophageal obstruction, up to 2 weeks were invested before Mo-No distant metastasis surgery administering adequate calories through a feeding MI-Distant metastasis Classification tube, encouraging ambulation, and delivering intensive Stage I-T1, No, Mo pulmonary physiotherapy in association with a program Stage II-TI, N1, N2; MO T2, NO-N2; MO oftotal abstinence from cigarette smoking. Approximately Stage III-T3, any N, MO Any T, N3, MO Stage IV-Any T, any N, Ml 1 unit of blood was transfused before surgery for every 10 lbs of weight loss the patient had experienced. * Modified from the Manualfor Staging of Cancer, second edition. After THE, the stomach was used to replace the esoph- American Joint Committee on Cancer. Edited by Beahrs P and Myers MH. J. B. 61-72. agus in 96 of these patients, the four requiring long seg- Lippincott Co., Philadelphia, PA, 1983; ment colonic interposition having undergone prior gastric resection for peptic ulcer disease. The esophageal sub- racotomy for intrathoracic hemorrhage either during the stitute was positioned in the posterior mediastinum in operation or in the acute postoperative period. the original esophageal bed in 94 patients, four patients undergoing placement of the stomach and two the colon in the retrosternal position due to concern that residual Complications posterior mediastinal tumor might subsequently result in recurrent obstruction. Intraoperative. Entry into one or both pleural cavities was apparent on routine inspection ofthe pleura Sampling ofaccessible subcarinal, paraesophageal, and through the hiatus after completion of the esophagectomy in 63 celiac axis lymph nodes was routine, but no attempt was patients and was treated with placement ofa chest tube(s) made to perform an en bloc wide resection of the esoph- before positioning the esophageal substitute in the chest. agus and its contiguous lymph node bearing tissues. In Two patients required a splenectomy because of intra- 53% ofthese patients, as assessed by the operative findings, operative injury to the spleen. Two tracheal lacerations local tumor invasion or distant lymph node metastases occurred during resection of midesophageal carcinomas. precluded a "curative" resection. In 47%, however, gross One, involving the high membranous trachea, was ex- total removal ofall palpable or visible tumor and adjacent posed and repaired through a partial upper sternal split. lymph nodes was achieved and was felt to represent a membranous was man- potentially curable procedure. Nevertheless, postsurgical The other, involving the carina, aged by guiding the endotracheal tube through the left tumor node metastasis (TNM) staging ofthese carcinomas mainstem bronchus, administering one based upon histologic examination of the resected spec- imen (Table 1) indicated that only five patients had Stage as a substernal gastric bypass was completed, and then I carcinomas (Table 2). In 76 patients the carcinomas were transmurally invasive into periesophageal tissue on TABLE 2. Postsurgical Resection Staging of 100 Intrathoracic histologic examination, and in another eight patients, al- Esophageal Carcinomas though the tumor was invading the esophageal muscle but had not penetrated it completely, extensive regional Tumor Site or distant lymph node metastases were present (Stage III Upper Middle Distal or Stage IV tumors). Third Third Third Total TNM Stage Results I 0 3 2 5 II 0 6 5 11 III 4 30 37 71 There were no intraoperative deaths. Measured intra- IV 3 6 4 13 operative blood loss ranged from 125 to 250 ml and Total 7 45 48 100 averaged 881 ml (Table 3). No patient required a tho- 284 ORRINGER Ann. Surg. * September 1984 TABLE 3. Intraoperative Blood Loss with Transhiatal Esophagectomy from mediastinal or retroperitoneal abscess (2), and re- Blood Loss (ml) spiratory insufficiency secondary to severe chronic ob- structive pulmonary disease (1). One of the two patients Site Number Range Average who aspirated retained intrathoracic gastric contents did a Upper third 7 300-2500 943 so when she received cleansing purgatives after having Middle third 45 125-2000 766 normal postoperative barium swallow on the tenth post- Lower third 48 260-2500 976 operative day. The two deaths from sepsis occurred in Total 100 125-2500 881 patients with extensive midthird carcinomas. In one, be- cause of residual posterior mediastinal tumor after frac- turing the primary mass away from the prevertebral fascia, repositioning the patient for a right thoracotomy through the stomach was positioned retrosternally. A subsequent which the tracheal tear was closed. Both of these latter anastomotic leak was drained but the patient succumbed two patients had uneventful postoperative courses. to respiratory insufficiency and sepsis. At postmortem Postoperative. Left recurrent laryngeal nerve paresis examination, there was a large posterior mediastinal ab- with resulting hoarseness occurred in 31 patients. The scess. The second patient underwent palliative THE in hoarseness resolved spontaneously within 2 to 12 weeks the presence of hepatic metastases found at operation. of operation in all but four patients, three of whom re- After surgery, he developed deep thrombophlebitis ofthe quired Teflon injection ofthe paralyzed vocal cord. This leg, progressive ascites, and sepsis. At autopsy a large complication was initially thought to be an unavoidable retroperitoneal abscess was found. Retrospectively, disease consequence of blunt transhiatal dissection, which was was too extensive in both ofthese latter patients to persist postulated to traumatize the recurrent laryngeal nerve with the esophagectomy. The patient who succumbed to where it loops beneath the aortic arch in the chest. In severe chronic obstructive pulmonary disease could not our last consecutive 31 patients, however, meticulous be weaned from the ventilator after surgery, underwent avoidance of any retractor against the tracheoesophageal a tracheostomy, and was able to swallow soft foods until groove during the cervical portions of the operation has she developed pneumonia and died after a 3-month hos- resulted in a striking decrease in the incidence of post- pitalization. operative hoarseness, which has occurred in two patients. Follow-up Two patients, both with upper third esophageal carci- THE an av- nomas, developed a chylothorax that ultimately required The 94 survivors of were discharged after 14 a limited thoracotomy and ligation of the thoracic duct erage hospitalization of days. Seventy patients (74%) 11 to 14 days after operation, for control. There were five cervical esophagogastric were discharged between anastomotic leaks, three in 92 patients (3%) in whom the and 10 (11%) between 15 to 21 days. Thus, 85% of the were within 3 weeks of stomach was positioned in the posterior mediastinum in operative survivors discharged the original esophageal bed, and two in four patients (50%) operation. Postoperative radiation and/or recommended for patients who were be- in whom the stomach was positioned substernally. were generally lieved to have had palliative resections. Such adjuvant therapy was typically administered under the direction Mortality of physicians located near the patients' homes following There were six hospital deaths for an overall mortality their discharge from our medical center. Thus, 23 patients of six per cent. The causes of death included pulmonary (25%) received postoperative chemotherapy, 16 patients embolus (1), massive aspiration pneumonia (2), sepsis (17%) , and seven patients (7%) both radiation and chemotherapy. The remaining 48 patients (51%) received no postoperative adjuvant therapy. TABLE 4. Actuarial Survival Following Transhiatal Esophagectomy The current status of all 94 patients is known, and for Intrathoracic Esophageal Carcinoma their actuarial survival is shown in Table 4. Overall, at Per cent Survival After Operation the time of this report, 52% have lived 12 months; 32%, 24 months; 22%, 36 months; and 17%, 48 months. Be- 6 12 24 36 48 cause postoperative adjuvant therapy was not adminis- mos mos mos mos mos tered using a randomized design, and because the therapy Site Number was not standardized, the effect ofadjuvant therapy upon Upper third 7 71 54 survival in this group is difficult to determine. Statistically, Middle third 40 77 41 21 17 Lower third 47 88 62 48 31 26 however, there was no significant difference in survival between those who received postoperative adjuvant che- Total 94 82 52 32 22 17 motherapy, radiation therapy, or both and those who did Vol. 200 . No. 3 TRANSHIATAL ESOPHAGECTOMY WITHOUT THORACOTOMY 285 not. All but three patients who have died since THE have TABLE 5. The Effect of Tumor Stage on 12- and 24-Month Survival Following Transhiatal Esophagectomy for Intrathoracic had documented or clinically presumptive evidence of Esophageal Carcinoma-94 Patients widespread metastatic esophageal carcinoma. As expected, the stage of the resected tumor proved to Per cent Survival Tumor be an important determinant ofsurvival in these patients, Stage Number 12 Mos 24 Mos those with Stage I and II tumors living considerably longer than those with Stage III and IV disease (Table 5). Since I and II 15* 83 54 III 68 48 28 most of the middle third tumors were squamous carci- IV I 1 34 0 nomas, and most of the distal third tumors were ade- nocarcinomas, however, a more meaningful statistical * Stage I and II tumors are considered together because of the small number of patients with Stage I disease (5). These differences in 12- analysis compares the effect of tumor stage, as well as and 24-month survival between the three stage groups are statistically tumor location, upon survival (Table 6). Approximately significant (p-value 0.0069). 50% of patients with Stage I and II tumors of both the middle and distal esophagus survived 24 months. The 12-month and 24-month survival of patients with Stage cervical anastomotic suture line recurrence prior to their III tumors, however, was considerably better for distal deaths from carcinomatosis. Fifteen patients (16%) have third as compared to middle third carcinomas. acknowledged experiencing some postoperative regurgi- Fourteen ofthe 94 operative survivors (15%) have lived tation of intrathoracic gastric contents, primarily on as- 24 months or more. Among these "long-term" survivors, suming the recumbent position shortly after eating. No three have died of metastatic disease after 29, 31, and 38 patient, however, has developed pulmonary complications months, one died oflymphoma after 29 months, and one of reflux, and none has complained of heartburn. Tran- died of a myocardial infarction after 24 months. This sient postvagotomy diarrhea, generally well-controlled latter patient was an 80-year-old woman who underwent with diphenoxylate, has occurred in 41 (44%) of these THE for a Stage III distal third adenocarcinoma arising patients. No patient has had difficulty with emptying of in a Barrett's esophagus and received chemotherapy after the intrathoracic stomach following . surgery for 1 year. She had no residual tumor at post- mortem examination. Another patient died of a stroke Discussion after 39 months and was clinically tumor-free at the time of his death. One patient has metastatic adenocarcinoma In performing THE, after mobilization of the visceral from his esophagogastric junction primary after 54 esophageal substitute (generally stomach) is complete, re- months. The remaining patients are alive and clinically sectability of the esophagus is determined by palpation tumor-free after 30, 34, 41, 60, 68, 72, and 81 months, through the diaphragmatic hiatus. The surgeon must be respectively. The first three of these seven patients had prepared to perform a thoracotomy or esophageal bypass midthird esophageal carcinomas (Stages I, II, and III, if extensive fixation of the tumor-containing portion of respectively), and the latter four had distal third esophageal the esophagus to adjacent structures is encountered. adenocarcinomas (Stages III, III, II, and I, respectively). Following discharge from the patients who hospital, TABLE 6. The Effect of Tumor Stage and Location on 12- and 24- have undergone THE for carcinoma are seen in follow- Month Survival Following Transhiatal Esophagectomy for up after 2 weeks, then at 3-month intervals for 2 years, Intrathoracic Esophageal Carcinoma in 87 Patients* and yearly thereafter. Outpatient Hurst-Maloney bougi- Middle Third enage ofthe cervical anastomosis is utilized very liberally Carcinomas Distal Third Carcinomas if any complaint of cervical dysphagia is elicited in post- operative follow-up. Thus, of the 94 operative survivors, Per cent Per cent 42 (45%) have undergone such outpatient dilations for Survival Survival cervical dysphagia, generally between 1-3 times during Tumor 12 24 12 24 the first six postoperative months, but only six have de- Stage Number Mos Mos Number Mos Mos veloped true fibrotic anastomotic strictures necessitating I and II 8 71 53 7 100 50 regular bougienage. One patient with postoperative re- III 26 29 12 38 60 42 current laryngeal nerve paralysis experienced severe sec- IV 6 33 0 2 0 0 ondary cricopharyngeal motor dysfunction and never re- * The seven patients with upper third carcinomas are excluded from gained his ability to swallow by the time of his death this analysis due to their small number. The differences in 12- and 24- from metastases after 5 months. All but these latter seven month survival between the three stage groups ofmiddle third carcinomas are not quite statistically significant (p-value 0.1197). For distal third patients have been able to swallow an unrestricted diet tumors, however, the differences between the three stage groups are comfortably. Two patients developed dysphagia from significant (p-value 0.0019). 286 ORRINGER Ann. Surg. September 1984 Among our last 104 consecutive patients with carcinoma adequate esophageal resection and formal lymph node of the intrathoracic esophagus, however, THE has been dissection to patients with potentially curable tumors.7'8 possible in 100, local tumor extension necessitating stan- However, few American or European surgeons subscribe dard transthoracic esophagectomy or esophageal bypass to the concept of radical esophagectomy with a formal in four. It is conceivable that our relatively high resect- en bloc dissection of contiguous lymph node bearing tis- ability rate using the technique of THE is related to the sues, pleura, and abdominal lymphatics.9Y0 In the vast general socioeconomic level and availability of medical majority of patients with esophageal carcinoma, the goal care for our patients, relatively few presenting with severe ofesophagectomy is palliation, not cure, and if the latter cachexia and huge tumors. Nevertheless, in our expeni- should somehow be achieved, it is more a function of ence, even relatively large intrathoracic esophageal car- individual tumor biology and host resistance rather than cinomas are resectable through the hiatus, if necessary the extent ofthe resection performed. Skinner has recently fracturing the tumor away from the prevertebral fascia reported his results of "radical esophagectomy and en or other adjacent mediastinal structures. The addition of bloc dissection" in the treatment of 80 patients with car- a partial upper sternal split facilitates dissection under cinoma of the esophagus and cardia.'0 His 29 patients direct vision ofupper third esophageal carcinomas, which with midesophageal tumors had a 3-year actuarial survival may be adherent to but not invading the trachea.5 of 14%, while the 37 patients with lower third tumors It is apparent from our experience with both benign had a 3-year survival of 33%. These data do not differ and malignant esophageal disease that the normal stomach appreciably from the 3-year actuarial survival in our pa- readily reaches above the level ofthe clavicles for a tension- tients undergoing THE without attention to a formal free cervical esophagogastric anastomosis. Regardless of lymph node dissection- 17% for middle third tumors the visceral esophageal substitute used, the posterior me- and 31% for distal third tumors. diastinal route in the original esophageal bed is the pre- With the notable exception of a few recently reported ferred location because: (1) it is the shortest distance be- series in which the hospital mortality has been less than tween the and ; (2) subsequent esophageal 5%, 11-13 esophageal resection and reconstruction for car- dilations, if required, are made difficult by the anterior cinoma carries a mortality that is generally between 15- displacement of the anastomosis that occurs when the 40%.14,5 Giuli and Gignoux, presenting the results in stomach or colon are positioned substernally in the an- 2400 patients with esophageal carcinoma operated upon terior mediastinum; and (3) the incidence ofanastomotic in multiple European hospitals, report a mortality for leak is increased when a cervical esophagogastric anas- esophagectomy of 30%.16 Similarly, Earlam and Cunha- tomosis is positioned in the anterior neck as opposed to Melo, in an extensive literature review, report a hospital the more posterior location in the esophageal bed.6 mortality of 33.3% in 83,783 esophagectomies.'7 THE The most frequent complications oftranshiatal esoph- without thoracotomy is clearly less ofa physiologic insult agectomy are relatively minor. A pleural tear occurs in to the debilitated patient with esophageal carcinoma than nearly two-thirds of the patients, but a chest tube has the traditional combined thoracic and abdominal ap- seemed a small price to pay for avoidance of a thora- proach used for esophageal resection and reconstruction. cotomy. Recurrent laryngeal nerve injury can be a dev- Twenty-one per cent of our patients were 70 years ofage astating complication after esophagectomy, not only be- or older, and seven of these were between 75 to 92 years cause of the resulting hoarseness but also because of im- of age. In more than one-half of these elderly patients, paired swallowing and secondary aspiration that may because of marked debility, a thoracotomy would not occur. This complication, however, can usually be averted even have been considered. Our overall hospital mortality by avoiding cervical retraction on the tracheoesophageal of six per cent, as well as the fact that 85% ofour patients groove. The only major complications of THE we have surviving operation left the hospital within 3 weeks of encountered are intraoperative tracheal laceration (2 pa- operation, attest to the merits ofTHE in providing efficient tients) and postoperative chylothorax (2 patients), both and relatively safe palliation in the patient with carcinoma in patients with middle or upper third esophageal car- of the thoracic esophagus. cinomas. Uncontrollable thoracic bleeding has not oc- curred in any of our patients. Clearly, however, the po- Acknowledgment tential for such complications ofesophagectomy, regard- The author is indebted to Kenneth E. Guire, M.S., Senior Research less of the operative approach, emphasizes the need for Associate, University of Michigan School of Public Health, for his sta- a sound knowledge of thoracic surgical anatomy and tistical analysis of this data. technique. The fact that a thoracotomy is unnecessary in most patients undergoing an esophagectomy does not References mitigate the requirement of thoracic surgical training. 1. Orringer MB, Sloan H. Esophagectomy without thoracotomy. J THE for carcinoma has been criticized for denying an Thorac Cardiovasc Surg 1978; 76:643-654. Vol. 200 * No. 3 TRANSHIATAL ESOPHAGECTOMY WITHOUT THORACOTOMY 287 2. Orringer MB, Orringer JS. Transhiatal esophagectomy without 10. Skinner DB. En bloc resection for neoplasms of the esophagus and thoracotomy-a dangerous operation? J Thorac Cardiovasc Surg cardia. J Thorac Cardiovasc Surg 1983; 85:59-71. 1983; 85:72-80. 11. Akiyama H, Tsurumaru M, Kawamura T, Ono Y. Principles of 3. Orringer MB, Sloan H. Anterior mediastinal tracheostomy-indi- surgical treatment for carcinoma of the esophagus: analysis of cations, techniques, and clinical experience. J Thorac Cardiovasc lymph node involvement. Ann Surg 1981; 194:438-446. Surg 1979; 78:850-859. 12. Ellis FH Jr, Gibb SP. Esophagogastrectomy for carcinoma: current 4. Orringer MB. Transhiatal blunt esophagectomy without thoracot- hospital mortality and morbidity rates. Ann Surg 1979; 190:699- omy. In Cohn LH, ed. Modern Techniques in Surgery-Car- 705. diothoracic Surgery. Installment IX. Mt. Kisco, NY: Futura Publishing Co, 1983; 1-21. 13. Piccone VA, LeVeen HH, Ahmed N, Groberg S. Reappraisal of 5. Orringer MB. Partial median sternotomy: anterior approach to the esophagogastrectomy for esophageal malignancy. Am J Surg 1979; upper thoracic esophagus. J Thorac Cardiovasc Surg 1984; 137:32-38. 87: 124-129. 14. Ellis FH Jr. Carcinoma of the esophagus. Cancer 1983; 33:264- 6. Orringer MB. Substernal gastric bypass ofthe excluded esophagus- 281. results of an ill-advised operation. Surg, in press. 15. Postlethwait RW. Complications and deaths after operations for 7. Parker EF. Discussion ofOrringer MB and Sloan H. Esophagectomy esophageal carcinoma. J Thorac Cardiovasc Surg 1983; 85:827- without thoracotomy. J Thorac Cardiovasc Surg 1978; 76:652- 831. 653. 16. Giuli R, Gignoux M. Treatment of carcinoma of the esophagus- 8. Skinner DB. Discussion of Orringer and Sloan H. Esophagectomy retrospective study of 2400 patients. Ann Surg 1980; 192:44- without thoracotomy. J Thorac Cardiovasc Surg 1978; 76:652. 52. 9. Logan A. The surgical treatment of carcinoma of the esophagus 17. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma. and cardia. J Thorac Cardiovasc Surg 1963; 46:150-161. I. A critical review of surgery. Br J Surg 1980; 67:381-390.

DISCUSSION may have from his extensive experience with the management of ad- enocarcinoma of the cardia and the esophagus. DR. ROBERT E. CONDON (Milwaukee, Wisconsin): I want to confine Dr. Stem, I am reminded by our President's Address this morning my remarks to the surgical management of the difficult problem of that sometimes we are slow to adopt useful new operations. I remind adenocarcinoma of the cardia and of the distal esophagus. you all that this operation was introduced halfa century ago by George Carcinoma of the cardia generally presents, as does squamous esoph- Grey Turner and, although Professor Turner continued to use it oc- ageal cancer, with symptoms, primarily, of obstruction. The biology of casionally throughout his active professional lifetime, it has only been the lesion is that of a gastric cancer, with a poor response to radiation more recently that surgeons such as Dr. Orringer and Dr. Akiyama have and no effective chemotherapy, leaving surgical therapy as the only brought this useful operation back into our consciousness. means of palliation and perhaps cure. I believe there is a place for this operation, and I support its use for When seen, these patients usually have very bulky lesions and they the indications that Dr. Orringer has outlined. often have already involved the adjacent diaphragm, but metastases to the and to the distal lymph nodes occur much later in the course of the disease and, therefore, meaningful palliation is a true surgical DR. WILLIAM E. NEVILLE (Newark, New Jersey): After Dr. Ravitch's potential. Presidential Address, I may be treading on perilous ground for the future, The unique feature ofadenocarcinoma ofthe cardia is that it regularly but I arise with mixed emotions to discuss this fine paper by Dr. Orringer. spreads submucosally in the esophagus, and so unless an extensive On the one hand, this operation is a tribute to his surgical dexterity, esophageal resection is undertaken, the disease will not be satisfactorily but on the other hand, it is not one which I would do, nor would I let controlled. my residents do. The typical approach to the management of adenocarcinoma of the All of us who perform esophagectomy for cancer of the esophagus cardia has been to do a resection ofthe proximal stomach and the distal realize how difficult it is to perform an adequate cancer operation with esophagus, with an esophagogastrostomy in the chest conducted through the chest open. Now we are supposed to do this blindly, by feel. Ad- a left thoracotomy. That approach has two problems: (1) it does not mittedly, there are certain technical mnaneuvers that can be expeditiously encompass all of the submucosal spread of the disease; and (2) if you performed blindly by all of us, in the dark, but this is done for pleasure, get an anastomotic leak in the chest, the potential for disaster is certainly and in situations where we are well versed in the anatomy. (Laughter) present. Further, if the patient survives more than 6 months, reflux In the operation for , none of these amenities are esophagitis is a problem. available. Because of these considerations, we abandoned this more traditional Another factor enters into the universal acceptance ofthis operation, approach 4 years ago and switched to total thoracic esophagectomy in and that is the impact this can have on malpractice lawyers. His list of continuity with resection ofthe upper half to two-thirds of the stomach complications are indefensible in court because this is not the standard for carcinoma of the cardia. We have done it in the manner as outlined technique, nor the state of art, which one should employ for cancer of by Dr. Orringer and in the last 4 years we have treated 22 patients. We the esophagus at the moment. I personally know offive cases undergoing have had no operative mortality. We have reconstructed all of these litigation at the present time due to an exsanguinating hemorrhage in- patients by mobilizing the distal stomach remnant to the neck, then traoperatively from avulsion of the aortic wall during removal of the conducting a cervicoesophagogastrostomy. esophagus. I personally have turned down two of them for being an The 4-year survival is 25%, and the postoperative course in these expert witness for the defendant because I could not see my way clear. patients is certainly more benign than it is after a thoracotomy. The On the other hand, what he says, very clearly, is true: In his hands consequences of an anastomotic leak in the neck are trivial compared it is safe. The survival is almost as good as that reported for transthoracic to the problem of an anastomotic leak in the chest. esophagectomy. It may be that this is the way to go on patients who We have found that use ofa two-team approach, one team doing the for some reason or another cannot tolerate a thoracotomy. However, cervical portion of the operation and another doing the abdominal por- in these circumstances, I firmly believe that the method of choice is to tion, has markedly shortened our operative time. The same concept bypass the esophagus extrathoracically, and let the patient eat normally that we use in resecting the in an abdominoperineal resection- for what little time he has left. it has done more than cut the time in half. It has cut it to about one- A question to Dr. Orringer that was not brought out in the abstract third. is: What is his role in preoperative therapy or chemotherapy? In our I would like to ask Dr. Orringer if he uses the two-team approach institution, Ben Rush and I give the patient the benefit of preoperative for the management of his patients, and for any amplifying remarks he x-ray and collaborate-which was brought out by the previous discus-