Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation

OBJECTIVE

Postoperative chylothorax remains an uncommon but potentially life-threatening complication of esophagectomy for cancer, and the ideal management is still controversial. The aim of the study was to compare the outcomes of patients treated nonoperatively with those of patients promptly undergoing reoperation.

METHODS

From 1980 to 1998, 1787 esophagectomies for esophageal or cardia cancer were performed, and 19 (1.1%) patients had postoperative chylothorax. We analyzed type of operation, surgical approach, delay of diagnosis of chylothorax, daily chest tube output, type of management, major complications, death, hospital stay, and final outcome.

RESULTS

Of the 19 patients with chylothorax, 11 were initially managed nonoperatively (group A): 4 (36%) patients had spontaneous resolution of chylothorax, and the other 7 required reoperation for the persistence of a high-volume output. There were three infectious complications and one postoperative death in this group. No reliable predictive criteria of successful versus unsuccessful nonoperative management could be found. The 8 most recent patients underwent early reoperation (group B). All patients recovered, and no major complications possibly related to chylothorax or hospital deaths were observed. They were discharged after a median of 22 days (range, 12-85 days) compared with a median of 36 days (range, 21-64 days) for patients of group A.

CONCLUSIONS

Early thoracic duct ligation is the treatment of choice for chylothorax occurring after esophagectomy. Reoperation should be performed immediately after the diagnosis is made to avoid the complications related to nutritional and immunologic depletion caused by prolonged nonoperative treatment.

Laparoscopic treatment of lymphocele after kidney transplantation

BACKGROUND

Laparoscopic treatment of pelvic lymphocele secondary to kidney transplant has gained popularity in the last few years, although lesions of the urinary tract (ureter, renal pelvis, and bladder) have been reported frequently. To evaluate the result of this treatment and the associated risk of urinary tract lesions, we reviewed our experience and reports in the medical literature on open and laparoscopic surgery.

METHODS

From 1991 to 1999, we laparoscopically treated 12 patients (7 men and 5 women; median age, 43 years; range, 17-59 years) with symptomatic pelvic lymphocele causing a deterioration of renal function because of compression on the ureter in 10 of the 12 patients and lymphocele compression of the iliac vein in the other 2 patients. In nine patients, the lymphocele wall was opened and sutured to the peritoneum to keep the window open. In two patients, an omentoplasty was performed, and in the remaining patient, both techniques were used. All patients were followed up clinically with ultrasound and biochemistry for a median period of 33 months (range, 1-96 months). Using Medline, we reviewed the medical literature from 1980 to 1998 and collected 252 cases in which operations had been performed to drain an internal lymphocele secondary to kidney transplantation.

RESULTS

Laparoscopic treatment was successful in 11 of the 12 patients. One patient was converted to open surgery because of a lesion in the transplanted ureter. One patient needed repeat laparoscopy 24 hours after the operation because of bleeding from the peritoneal window. The median duration of the operation was 120 min (range, 70-200 min), and the median postoperative hospital stay was 5 days (range, 2-12 days). None of the patients needed to discontinue oral cyclosporine assumption. The serum creatinine level dropped significantly after surgery (p < 0. 05). No symptomatic recurrences were observed. Of the 252 patients found in the medical literature, in 129 the procedure was performed with open surgery and in 123 laparoscopically (our 12 patients included). The prevalence of iatrogenic lesions to the urinary tract increased threefold with the use of laparoscopic surgery (from 1.6% in open surgery to 7% in laparoscopy). The recurrence rate of symptomatic lymphocele, however, decreased from 15% to 4%.

CONCLUSIONS

Laparoscopic drainage of posttransplantation lymphocele is a relatively simple method for treating this complication, although it bears the burden of an increased incidence of urinary tract lesions, as confirmed by a review of the literature. The major advantage of the laparoscopic approach is the absence of postoperative ileus with the opportunity to continue the enteral immunosuppressive regimen and a lower recurrence rate. These data suggest that laparoscopic lymphocele treatment might be considered the therapy of choice, provided the iatrogenic lesions of the urinary tract diminish as more experience with this technique is gained.

[First-line chemo-radiotherapy neoadjuvant treatment in locally advanced (T4) epidermoid carcinoma of the esophagus]

In the period 1993-1997 we performed two phase II pilot studies of first-line chemo-radiotherapy in patients with locally advanced (T4) SCC of the esophagus. The first protocol (3 cycles of DDP-VP16 + 45 Gy) was used in 37 patients: toxicity was not negligible; a clinical tumor downstaging was obtained in 54% of cases; an R0 resection surgery was performed in 40% of patients. The overall median survival of the whole group of 37 patients was 11 months, while it was > 36 months for patients undergoing R0 resection. The second protocol (4 cycles of DDP-5FU + 45 Gy) was used in 25 patients: a clinical tumor downstaging was obtained in 55% of cases, and R0 resection surgery was performed in 45% of patients. The overall median survival of the whole group was 11 months. To date, all patients but one (who died after 13 months) are alive with a median follow up of 13 months. The prognosis of both groups of patients was improved compared to patients with T4 SCC of the esophagus who did not undergo chemo and/or radiotherapy. The survival advantage was especially evident for those who were able to undergo an R0 resection. First line chemo-radiotherapy should be considered the standard treatment for locally advanced esophageal SCC.

[Anastomotic stenoses correlated with the use of mechanical staplers in the surgery of esophageal cancer]

From 1990 to 1995, 187 patients underwent esophagectomy and esophagogastrostomy with the anastomosis performed inside the chest using a circular stapler. Twenty-three patients (12.3%) developed an anastomotic stricture. The incidence of anastomotic stricture was inversely related to the diameter of the stapler. Also concomitant cardiovascular diseases, morpho-functional disorders of the tubulized stomach (possible related to duodeno-gastric reflux) and neoadjuvant chemotherapy were recognized as significant risks factors. Endoscopic dilations were safe and effective in the treatment of anastomotic strictures.

First-line chemotherapy improves the resection rate and long-term survival of locally advanced (T4, any N, M0) squamous cell carcinoma of the thoracic esophagus: final report on 163 consecutive patients with 5-year follow-up

OBJECTIVE

The objective of this prospective, nonrandomized study was to evaluate the immediate and long-term results of first-line chemotherapy and possible surgery in locally advanced, presumably T4 squamous cell esophageal cancer.

SUMMARY BACKGROUND DATA

Locally advanced esophageal cancer is rarely operable and has a dismal prognosis. For this reason, neoadjuvant cytoreductive treatments are more and more frequently used with the aim of downstaging the tumor, increasing the resection rate, and possibly improving survival.

METHODS

From January 1983 to December 1991, 163 consecutive patients with a presumedly T4 squamous cell carcinoma of the thoracic esophagus (group A) received on average 2.5 cycles (range, 1-6) of first-line chemotherapy with cisplatin (100 mg/m2 on day 1) and 5-fluorouracil (1000 mg/m2 per day, in continuous infusion from day 1 through day 5). Chemotherapy was followed by surgery when adequate downstaging of the tumor was obtained.

RESULTS

Chemotherapy toxicity was WHO grade 0 to 2 in 80% of cases, but 3 toxic deaths (1.9%) occurred. Restaging suggested a downstaging of the tumor in 101 of 163 patients (62%), but only 85 patients (52%) underwent resection surgery; it was complete or R0 in 52 (32%) and incomplete or R1-2 in 33. Overall postoperative mortality was 11.7% (10 of 85), morbidity 41% (35 of 85). Complete pathologic response was documented in 6 patients, and significant downstaging to pStage I, IIA, or IIB occurred in 25 more patients. The overall 5-year survival was 11 % (median, 11 months). After resection surgery, the 5-year survival was 20% (median, 16 months); none of the nonresponders survived 4 years after palliative treatments without resection (median survival, 5 months). The 5-year survival rate of the 52 patients undergoing an R0 resection was 29% (median, 23 months). Stratifying patients according to the R, pT, pN, and pStage classifications, the survival curves were comparable to the corresponding data obtained in the 587 group B patients with "potentially resectable" esophageal cancer who underwent surgery alone during the same period. Furthermore, the results were improved in comparison with 136 previous or subsequent patients with a locally advanced tumor who did not undergo neoadjuvant treatments (group C). In these patients, the R0 resection rate was 7%, and the overall 5-year survival was 3% (median, 5 months).

CONCLUSION

Although nonrandomized, these results suggest that in locally advanced esophageal carcinoma, first-line chemotherapy increases the resection rate and improves the overall long-term survival. In responding patients who undergo R0 resection surgery, the prognosis depends on the final pathologic stage and not on the initial pretreatment stage.

bcl-2 and p53 immunophenotypes in pre-invasive, early and advanced oesophageal squamous cancer

AIMS

An inverse correlation between bcl-2 and p53 expression has been reported in several types of epithelial tumour. The role of bcl-2 and p53 in the development of oesophageal squamous carcinoma has yet to be established. The expression of bcl-2 and p53 proteins has been evaluated in the multistage oesophageal tumorigenesis, which progresses from normal mucosa to dysplasia (squamous intraepithelial lesion, SIL), to invasive early and advanced oesophageal squamous cancer.

METHODS AND RESULTS

Sixty-four cases of squamous oesophageal cancer, coexisting with SIL in 18 cases, were immunohistochemically analysed for any overexpression of bcl-2 and p53 proteins. Any association of bcl-2 and p53 protein expression with patient survival was also analysed. We observed bcl-2 expression that decreased significantly during the progression of oesophageal carcinogenesis. A decreasing frequency in the expression of bcl-2 in advanced oesophageal squamous cancer coincided with frequent p53 overexpression. bcl-2 expression was correlated with patient survival by univariate analysis. The association disappeared after adjusting for tumour stage, p53 overexpression showed no association with patient survival by either univariate or multivariate analysis.

CONCLUSIONS

The down-regulation of bcl-2 and upregulation of p53 in advanced oesophageal squamous cancer suggest that bcl-2 and p53 proteins may interact in the progression of oesophageal squamous cancer.

Oesophageal and cardia function in patients with paraoesophageal hiatus hernia

BACKGROUND

The decision to add an antireflux procedure when a paraoesophageal hernia is repaired is still controversial. The aim of this study was to investigate oesophageal and cardia function in these patients to verify whether fundoplication was needed.

METHODS

Eighteen patients with paraoesophageal hernia were evaluated by oesophageal manometry, 24-h pH monitoring, endoscopy and barium swallow. All patients underwent surgery including antireflux fundoplication. Fourteen patients with sliding hernia plus reflux disease and 16 healthy volunteers formed the control groups.

RESULTS

Patients with paraoesophageal hernia had a shorter lower oesophageal sphincter and a greater acid exposure than healthy controls (P < 0.05). Fifteen of 18 patients had either abnormal acid exposure and/or a defective lower oesophageal sphincter at manometry. Postfundoplication symptoms were observed in only one of 16 patients at 6 months' follow-up.

CONCLUSION

Since 15 of 18 patients had abnormal acid exposure or were considered prone to developing gastro-oesophageal reflux disease because of a defective lower oesophageal sphincter, this study strongly supports the need to add an antireflux operation to hernia repair.

Prevalence, management and outcome of early adenocarcinoma (pT1) of the esophago-gastric junction. Comparison between early cancer in Barrett's esophagus (type I) and early cancer of the cardia (type II)

The study compares, in true adenocarcinoma of the cardia and in adenocarcinoma in Barrett's esophagus, the prevalence of early cancers and their outcome in those patients suitable for resection surgery. From 1980 to 1993, 26 of 350 (7.4%) resected adenocarcinomas of the esophago-gastric junction were pathologically staged as early cancer or pT1. The prevalence of early cancer was 3.7% (11/294) for true cancer of the cardia and 27% (15/56) for cancer in Barrett's esophagus (P < 0.001). Ten of the 15 latter cancers were diagnosed during endoscopic surveillance for benign Barrett's esophagus. Among early cancers, there were four mucosal and 22 submucosal tumours; of the latter, eight had lymph node metastasis and seven neoplastic permeation of lympho-hematic vessels. The most frequently used surgical procedure was esophago-gastric resection and gastric pull-up. Postoperative morbidity was 15.4%, and hospital mortality 3.8%. Excluding postoperative deaths, the overall 5-year survival rate was 79% for early cancer of the cardia and 83% for early cancer in Barrett's esophagus (log rank test = 0.0214, P = 0.88). Overall, the survival rate was 100% in the absence of lymph node metastasis and 43% in the presence of node metastasis (log rank test = 15.811, P = 0.0001). Only one of five patients with both node metastasis and vessel infiltration survived longer than 5 years. In conclusion, the prevalence of early cancer was significantly greater for cancer in Barrett's esophagus than for true cancer of the cardia. Prognosis of the two types of tumour after resection surgery was the same and depended on lymph node status and neoplastic permeation of lympho-hematic vessels.

Prognosis of early squamous cell carcinoma of the esophagus after surgical therapy

Between 1980 and 1995, 91 (13.7%) out of 666 patients were determined by pathologic staging to have a superficial squamous-cell esophageal carcinoma of the thoracic esophagus. The male to female ratio was 3.3:1, and the mean age 60 years. Postoperative mortality was 4.3%. The median follow-up was 48 months (range 3-179). Survival was significantly decreased with increased depth of tumour invasion and presence of nodal metastases (P=0.03). Recurrent disease was prevalent in patients with submucosal tumours compared to those with mucosal tumours (P < 0.05). Only intra-epithelial and intramucosal carcinomas deserve the definition of 'early' tumours. Given the relative inaccuracy of current staging modalities and the low morbidity and mortality rates associated with surgical resection, surgery appears to be the mainstay of treatment of superficial squamous-cell esophageal cancer.

p53 alterations but no human papillomavirus infection in preinvasive and advanced squamous esophageal cancer in Italy

Geographic differences in exposure to suspected carcinogens have been identified in esophageal carcinogenesis, and both p53 alterations and human papillomavirus (HPV) infection have been reported in esophageal squamous carcinoma (ESC) from high-risk areas, including China and South Africa. The status of p53 alterations and HPV infection in ESC has not been determined in northern Italy, where the incidence of ESC is low. Formalin-fixed paraffin-embedded esophageal samples containing normal, dysplastic, and carcinomatous tissue from 18 patients were examined for p53 protein accumulation with immunohistochemistry, p53 mutation (exons 5-8) with PCR-single-strand conformation polymorphism analysis and DNA sequencing, and HPV infection with PCR using general primers to amplify the L1 gene. Accumulation of p53 protein was observed in both precancerous and carcinomatous lesions. p53 mutations were rare in dysplastic lesions but were detected in 9 of 18 carcinomas, a finding consistent with reports from other geographic areas. Examination of the p53 mutation spectrum revealed no hot spot mutation. In contrast, HPV was not found in any of these 18 cases. This is consistent with the findings from other low ESC risk areas in which HPV infection may not play a crucial role in esophageal oncogenesis, whereas the high risk of ESC in China and South Africa may be attributed to frequent HPV infection.

[Prosthetic bilateral laparoscopic hernioplasty. Extra-peritoneal approach]

The use of prosthetic mesh in inguinal hernia repairs is becoming increasingly popular. In recent years different laparoscopic procedures for prosthetic repair of inguinal hernias have been developed. The authors describe their initial experience with a totally extra-peritoneal prosthetic approach in laparoscopic repair of bilateral inguinal hernias. From November 1993 to May 1994, ten consecutive patients with bilateral primary inguinal hernias underwent laparoscopic repair under general anesthesia. A totally extra-peritoneal approach has been performed beginning through a 2 centimeter vertical midline sub-umbilical incision. Two additional trocars have been inserted on the midline: a 10/12 mm one halfway between the umbilicus and the pubis and 5 mm one 2 cm above the pubis. Average operative time was 141 minutes. Two cases were converted to traditional open Stoppa procedure because of holes made in the peritoneum during blunt dissection of the hernia sac. In the remaining 8 cases a polypropylene mesh of about 8 cm in height and 13 cm in length have been placed on each hernia site. No major complications have been observed and recovery was quick in all cases. In conclusion we think that laparoscopic hernia repair through a totally extra-peritoneal approach is technically feasible for general surgeons trained in laparoscopic surgery. Nevertheless the operation in costly and the patient's benefit in terms of rapid recovery, complications and recurrences has not yet been demonstrated in controlled prospective trials.

[Cholecysto-colic fistula: laparoscopic treatment]

Cholecystocolic fistula is an unusual complication of biliary tract disease and it may defeat laparoscopic treatment. We recently was a patient who, while undergoing laparoscopic cholecystectomy, was found to have a fistula between the gallbladder and the transverse colon. The fistula was transected with a 3 cm endoscopic linear stapling device and uneventful laparoscopic cholecystectomy was performed. This report shows that, with increasing experience, no absolute contraindications exist to starting laparoscopic cholecystectomy by introducing the laparoscope.

One-year follow-up after laparoscopic Heller-Dor operation for esophageal achalasia

BACKGROUND

The Heller-Dor operation has recently been proposed for the treatment of esophageal achalasia even via a laparoscopic approach.

METHODS

To measure the medium-term effectiveness of this new minimally invasive technique, an evaluation of pre- and postoperative symptoms, esophagogram, endoscopic findings, esophageal manometry, and pH monitoring was prospectively designed in 43 patients with primary esophageal achalasia. The mean clinical follow-up for all the patients is 12 months (range 3-43), while the mean radiological follow-up is 11 months (range 1-23). Endoscopic data 1 year after surgery are currently available for 27 patients (63%), whereas a 12-month (range 1-26) functional follow-up (including manometric and pH-monitoring studies of the esophagus) is currently available for 35 patients (81.4%).

RESULTS

No dysphagia was reported in 38 cases (88.4%); two (4.6%) complained of occasional swallowing discomfort which regressed spontaneously; two (4.6%) had persistent dysphagia which regressed with pneumatic dilatation. One patient (2.8%) reported mild occasional dysphagia after a 1-year asymptomatic period. Preoperatively, esophagograms showed an average maximum diameter of 40.6 +/- 9.1 mm which decreased to 24.1 +/- 6.0 mm after operation. Mean lower esophageal sphincter (LES) resting and residual pressures decreased significantly from 28.6 +/- 10.7 mmHg to 8.8 +/- 4.1 mmHg and from 17.0 +/- 9.7 mmHg to 4.7 +/- 4.0 mmHg, respectively (p < 0.0001). These effects on esophageal diameter and LES function seem to persist over time. The complete absence of any peristaltic contractions recorded preoperatively in all cases remained unchanged after surgery in all but four patients. However, this rare recovery of peristalsis proved to be transient, and patients revealed a manometric impairment of their esophageal body function, but without complaining of dysphagia. Twenty-four-hour pH monitoring showed abnormal gastroesophageal reflux episodes in two (5.7%) of the 35 patients who were monitored: one was asymptomatic; the other had heartburn and endoscopically demonstrated grade II esophagitis.

CONCLUSIONS

Laparoscopic Heller-Dor operation achieves excellent medium-term results which, together with the already-demonstrated advantages of a minimal surgical trauma and rapid convalescence, validate the use of such a minimally invasive approach to treat patients with primary achalasia of the esophagus.

Esophageal motor function in primary Sjögren's syndrome: correlation with dysphagia and xerostomia

The incidence of dysphagia in patients with primary Sjogren's syndrome (pSS) has been underestimated and all too often ascribed to xerostomia, without considering the possible presence of esophageal motor abnormalities affecting other nonscleroderma connective tissue diseases. Esophageal and salivary functions were prospectively evaluated in 27 females who met the four criteria proposed by Fox for the diagnosis of pSS, using esophageal manometry after wet swallows and Saxon's test, respectively. Dysphagia was graded using a standard symptoms questionnaire and results were compared with those obtained in a group of 21 healthy controls. Seven patients with pSS (26%) had no swallowing discomfort, 2 (7.4%) had mild dysphagia, 7 (26%) had moderate dysphagia, and 11 (40.6%) had severe dysphagia. Saxon's test revealed an overall decrease in the salivary flow rate compared to controls, with no difference between patients with or without dysphagia. Esophageal manometry demonstrated the absence of any lower or upper esophageal sphincter function abnormalities in all patients. In the patients with pSS as a whole, manometric study of the esophageal body showed a motor pattern comparable with that of controls, with no difference between patients with and without dysphagia. Defective peristalsis, ie, the presence of simultaneous contractions in more than 30% of wet swallows was detected, however, in the distal tract of the esophagus of six patients (22.2%) and in the proximal tract of three (11.1%). All these patients had severe dysphagia and the modified Saxon's test revealed a salivary secretion comparable with that of patients with a normal peristalsis. Dysphagia is a very common complaint in patients with pSS and does not seem to correlate with xerostomia, which is a constant and typical finding of the disease. About one third of patients with pSS have an abnormal esophageal peristalsis that is responsible for severe dysphagia, whereas decreased salivary outflow exacerbates the swallowing discomfort. This has to be taken into account and justifies the routine use of esophageal manometry in patients with pSS. The cause of dysphagia in pSS patients without peristaltic disorders of the esophagus has to be investigated.

Protective effect of superoxide dismutase and polyethylene glycol-linked superoxide dismutase against renal warm ischemia/reperfusion injury

The protective effect of oxygen free radical scavenger superoxide dismutase (SOD) against the warm ischemic damage that occurs in kidneys harvested from non-heart-beating donors is controversial because of its short half-life. In this model, we compared the protective effect of SOD and two longer lasting polyethylene glycol (PEG)-linked forms of SOD in a model of renal ischemia induced by 60 min of arterial clamping in rats. Rats treated with PEG1-SOD and PEG2-SOD had a better renal function than controls, with significantly lower serum creatinine levels throughout the follow-up period and a significantly higher creatinine clearance on postoperative days 1, 2, and 4. In native SOD treated-rats, serum creatinine was lower than in controls, though not significantly so, and creatinine clearance was significantly higher on postoperative day 4. Our results indicate that the protective effect of SOD against renal warm ischemia can be enhanced by prolonging its half-life by binding the enzyme to PEG.

Esophageal motor function in patients with myotonic dystrophy

To investigate pharyngeal and esophageal motor function in myotonic dystrophy (MD), and its relationship to esophageal symptoms, we used low-compliance, high-fidelity esophageal manometry and videofluorography to evaluate 14 consecutive MD patients. Patients exhibited a consistent, typical motor pattern, involving a marked reduction in resting tone of both the upper and lower esophageal sphincters, and a reduction in contraction pressure in the pharynx and throughout the esophagus. Radiology showed hypotonic pharynx with stasis and a hypo- or amotile, often dilated, esophagus. These findings were nonspecific, however, being present in patients both with and without dysphagia, which suggests that MD patients have valid compensatory mechanisms. Dysphagia only correlated to the pharyngeal impairment at manometry. Furthermore, the results of our study suggest that not only the proximal, striated part of the gullet, but also the distal part (in which smooth muscle dominates) is involved in the disease. The latter leads to the impairment of the LES resting tone and competence, highlighting the risk of gastroesophageal reflux disease in these patients.

Functional and morphological study of the cricopharyngeal muscle in patients with Zenker's diverticulum

Pharyngo-oesophageal function was investigated in 12 patients with Zenker's diverticulum before and after cricopharyngeal myotomy with or without diverticulectomy using low-compliance, high-frequency oesophageal manometry. Nine healthy volunteers served as controls. The amount of muscle and connective tissue in the cricopharyngeal muscle was also measured by computerized morphometry and compared with findings in cadavers with no history of dysphagia. Preoperative manometry in patients with Zenker's diverticulum showed an incomplete relaxation of the upper oesophageal sphincter (UOS) (the residual UOS pressure at swallowing was 7.9 (range 1-20)mmHg in patients versus 0.2 (-12.5-14) mmHg in controls; P < 0.001) and increased pharyngeal intrabolus pressure (21 (range 0-52) versus 9 (range 0-16) mmHg; P < 0.01), with no pharyngo-oesophageal coordination abnormalities. Both parameters significantly decreased after myotomy. Patients with Zenker's diverticulum had significantly fewer muscle fibres in the cricopharyngeus and the muscle:connective tissue ratio was significantly lower (0.94 (range 0.8-1.4) in patients versus 1.5 (1.4-3.6) in controls; P < 0.05). This study supports the theory that Zenker's diverticulum is caused by an increased intrapharyngeal pressure at swallowing due to incomplete cricopharyngeal muscle relaxation resulting from localized sclerosis.

Mediastinal cyst involving the oesophagus: diagnosis and results of surgical treatment

OBJECTIVE

To describe our experience with mediastinal cysts involving the oesophagus.

DESIGN

Retrospective study.

SETTING

University hospital, Italy.

SUBJECTS

11 patients who presented to our department with a mediastinal cyst from 1976-1994.

INTERVENTIONS

Excision of the mass through a posterolateral thoracotomy (n = 10) or by video-assisted thoracoscopy.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

8 patients presented with retrosternal or epigastric pain, three of whom had mild dysphagia. In the remaining 3 the tumour was asymptomatic and an incidental finding on a chest radiograph. Endoscopic ultrasonography and computed tomography (CT) allowed preoperative diagnosis of an extramucosal cyst in 5 of the 7 patients investigated by both tests. Masses were excised through a formal thoracotomy (n = 10) or by video-assisted thoracoscopy. Histological examination confirmed a benign cyst in all cases. There was no operative morbidity and nine patients are free of symptoms after a median follow-up of 2.3 years.

CONCLUSION

Excision, preferably by thoracoscopy, is the treatment of choice for mediastinal cysts that involve the oesophagus. Special attention should be paid to the vagal nerves, and as many as possible of the muscular layers of the oesophagus should be preserved.