[Esophageal carcinoma: 2-stage operation for preventing mediastinitis in high risk patients]

Strict patient selection, standardization of the surgical technique and advances in peri- and postoperative management have in experienced centers resulted in a decrease in postoperative mortality after esophagectomy and reconstruction to less than 5% in recent years. The previously common and potentially lethal pulmonary and cardiac complications have lost their impact on outcome. Today, septic complications, which usually arise from the reconstruction phase, constitute the major morbidity and mortality factors in the surgical therapy of esophageal cancer. These complications pose a particular problem for patients with compromised organ function and patients after neoadjuvant combined radiochemotherapy. In these situations a surgical safety concept with a two-stage procedure, i.e., delay of reconstruction after resection for 8-10 days, can markedly reduce the otherwise substantial postoperative mortality. A two-stage procedure thus offers patients a chance of a potentially curative surgical therapy who would otherwise be excluded from resection.

Extensive sampling improves preoperative bronchoscopic assessment of airway invasion by supracarinal esophageal cancer: a prospective study in 166 patients

BACKGROUND

The utility of fiberoptic bronchoscopy in the preoperative assessment of patients with esophageal cancer has not been thoroughly investigated. More accurate staging could improve the design of clinical trials and avoid inappropriate surgical decisions in individual patients.

STUDY OBJECTIVE

To evaluate the utility of bronchoscopy in the preoperative assessment of airway invasion by supracarinal esophageal cancer.

DESIGN

We prospectively analyzed 220 bronchoscopies in 166 consecutive patients with supracarinal esophageal cancer and correlated the findings with operative results and survival.

RESULTS

In 126 bronchoscopies (57.3%), no abnormal findings could be seen in the airways. Compared with histologic and cytologic results, the normal macroscopic appearance of the airways had a negative predictive value of 94.4%, but the positive predictive value of all macroscopic abnormalities for the diagnosis of airway invasion was low, particularly after radiation therapy. Endoluminal tumor mass, protrusion of the posterior tracheal wall, and signs of mucosal invasion were visible in 5.9%, 28.6%, and 4.1% of the bronchoscopies, respectively. However, in only 8.6% of the 220 bronchoscopies, cancer invasion was proved by biopsy or cytology. Bronchoscopy with biopsies and brush and washing cytology examinations was the sole decisive staging procedure, enabling the exclusion from surgery because of airway invasion in 18.1% of otherwise potentially operable patients, with an overall accuracy of 93.3% (95% confidence interval, 86.7 to 97.3%). The results of bronchoscopy were falsely negative in six patients, who all underwent surgery after neoadjuvant therapy.

CONCLUSIONS

Fiberoptic bronchoscopy with systematic multiple biopsies and brush and washing cytology examinations is an accurate procedure in evaluating the possible invasion of supracarinal esophageal cancer into the airways. Macroscopic findings alone are not reliable; errors in sole bronchoscopic inspection would have resulted in operations that would be unlikely to help the patients or would have inappropriately excluded patients from surgery.

New aspects of prognostic factors in adenocarcinomas of the small bowel

BACKGROUND/AIMS

Primary small bowel tumors are rare and the prognosis is generally considered to be poor. Histologically chiefly adenocarcinomas are reported. The surgeon is challenged in their treatment, because of the infrequency, unspecific symptoms and delay in diagnosis. Retrospectively we investigated the surgical therapy, combined morbidity, survival rates and prognostic factors in a large series of primary adenocarcinomas of the small bowel at a single surgical center.

METHODOLOGY

Between 1985 and 1998, 94 patients with a primary tumors of the small bowel (malignant n = 62 [65.9%], benign n = 32 [34.1%]) were operated on. The subgroup of the adenocarcinomas (n = 22) were considered for this study.

RESULTS

The median follow-up is 8.4 years (range: 0.9-14.2 years). Sixteen patients had a follow-up more than 5 years. The main surgical procedure was a small bowel segment resection. Morbidity was 13.6% (only in patients with a duodenal tumors) and the 30-day mortality 5.6%. The estimated 2-year-survival rate was 66%, the 5-year-survival rate 45%. Univariate analysis identified the presence of the residual tumor (R-status) (P = 0.004), tumor stage according to the UICC (P = 0.01), lymph node metastasis (P = 0.007), distant metastasis (P = 0.001), lymphangiosis carcinomatosa (P = 0.001) and vascular invasion (P = 0.0008) as prognostic factors.

CONCLUSIONS

A complete macroscopic and microscopic tumor resection including a systemic lymph node dissection has to be the aim of any curative surgical approach in patients with adenocarcinoma of the small bowel.

Experimental evaluation of the safety and biocompatibility of a new antireflux prosthesis

Previous studies have shown that encircling of the esophagogastric junction by a semiabsorbable scarf effectively prevents gastroesophageal reflux. The present study was performed to assess the long-term safety and biocompatibility of this type of scarf. The semiabsorbable scarf was implanted into 20 dogs either laparoscopically or via laparotomy. Pre- and post-operatively, contrast radiography, esophageal manometry, and upper gastrointestinal endoscopy were performed. No cases of perforation, stricture formation or other adverse effects were found after 1 and 2 years. It is concluded that the new type of scarf is without any adverse side-effects. Functional evaluation in reflux patients appears to be warranted.

Predictors of tracheobronchial invasion of suprabifurcal oesophageal cancer

BACKGROUND

Factors possibly predicting airway invasion of oesophageal cancer in the absence of frank oesophagotracheal fistulas have not been studied.

OBJECTIVES

To identify possible predictors of airway invasion by oesophageal cancer that are readily accessible in the preoperative setting.

METHODS

We prospectively investigated 148 patients with newly diagnosed oesophageal cancer located at or above the level of the tracheal bifurcation and without any evidence of oesophago-respiratory fistulas or distant metastases. Demographic variables, respiratory parameters, results of bronchoscopy and other staging procedures (oesophagoscopy, swallow oesophagography, endosonography, CT and histology) and findings at surgery were compared between the patients with (n = 30) and without (n = 118) proven airway invasion and entered into a stepwise logistic regression model to evaluate their independent predictive roles.

RESULTS

Univariate analysis indicated that the incidence of airway invasion increased with the presence of suspect CT findings, the presence of respiratory symptoms, tumour length, T stage on endoscopic ultrasonography, and histopathologic grading of the primary cancer. A multivariate logistic regression model indicated that suspect CT findings (odds ratio, 4.4; 95% confidence interval 1.7-11.1, p = 0.002) and maximal tumour length >8 cm (odds ratio, 3.7; 95% confidence interval 1.4-9.6, p = 0.007) were associated independently with airway invasion. The accuracy of predicting airway invasion was 82.5% with both variables combined.

CONCLUSIONS

The high incidence of airway involvement by oesophageal cancer and the difficulty to predict it accurately with clinical data or other staging procedures justifies the routine use of bronchoscopy in all patients with the tumour located at or above the level of the tracheal bifurcation. A particular effort to objectively prove or exclude airway invasion should be made in patients with tumours longer than 8 cm and/or with CT findings suggesting airway invasion.

Fibrovascular esophageal polyp as a diagnostic challenge

Fibrovascular polyps are rare benign esophageal tumors that usually arise from the proximal third of the esophagus. We present the case of a 48-year-old man with a history of dysphagia and 7-kg weight loss over a period of 2 months. A barium swallow showed a distended esophagus with a tumor extending from the upper esophageal sphincter to the cardia. On a thoracic computed tomographic scan, a homogeneous intramural mass with a density of 22 Hounsfield units was seen, which extended throughout the entire esophagus. Fiberoptic endoscopy confirmed the presence an intramural tumor beginning at the upper esophageal sphincter and reaching to the cardia. The tumor was completely covered with mucosa, except for an ulcerated area at its distal end, which herniated into the stomach. On endoscopic ultrasound, the tumor appeared to grow submucosally and to respect the muscularis propria. Endoscopic biopsies from the ulcerated distal aspect of the tumor suggested a leiomyoma. None of the imaging modalities used revealed evidence of a polyp or intraluminal esophageal tumor. Rather, a potentially malignant extensive intramural tumor was suspected, and an esophagectomy was performed. Only at the time of removal of the specimen did it become evident that the tumor mass was located intraluminally with a pedicle in the region of the upper esophageal sphincter. The final pathological diagnosis was a giant fibrovascular polyp of the esophagus.

Ischemic spinal cord syndrome after transthoracic esophagectomy: two cases of a rare neurologic complication

Anterior spinal artery syndrome (ASAS) is a rare complication after surgery of the thoracic or abdominal aorta. The sulco commissuralis syndrome represents a partial or incomplete ASAS. We report two cases of ischemic spinal cord syndromes after transthoracic esophagectomy. This represents a prevalence of this syndrome of 0.2% in more than 1000 consecutive esophagectomies performed at our institution. Patient 1 developed an ASAS on the first day after esophagectomy. Patient 2 showed the pathognomonic clinical signs associated with sulco commissuralis syndrome after an asymptomatic window. In both patients, the extent of the neurologic symptoms initially improved but then remained unchanged for the rest of the follow-up of 9 and 12 months. Although the prognosis of neurologic syndromes resulting from spinal cord infarction is poor, preoperative tests to identify patients at risk appear not to be justified because of the very low incidence of these syndromes after esophagectomy and the poor sensitivity and specificity of currently available diagnostic modalities. However, the possibility of ischemic spinal cord syndrome should be kept in mind when patients present with neurologic symptoms after esophagectomy.

Quality of life before and after laparoscopic Nissen fundoplication

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common disorder in the Western world. The acute disease can usually be managed by medical therapy. To prevent relapse, many patients require lifelong medication. In these patients, laparoscopic antireflux surgery offers a good alternative. The aim of this study was to evaluate the postoperative results and compare pre- and postoperative quality of life after laparoscopic Nissen fundoplication.

METHODS

Clinical investigations, including esophageal manometry, pH monitoring, and endoscopy, and a previously validated Quality of Life Index, were performed before and a median of 41 month after antireflux surgery in 75 patients.

RESULTS

After laparoscopic Nissen fundoplication, the percentage of total time with pH <4 decreased from 10.4% to 3.2% on 24-h pH monitoring. The mean pressure of the lower esophageal sphincter improved from 8.1 to 12.3 mmHg. Esophagitis healed in 63 of 66 patients in whom it was present prior to surgery. The overall Quality of Life Index improved significantly from 86 +/- 16 to 116 +/- 16.

CONCLUSION

Laparoscopic fundoplication provides effective and durable relief of reflux in patients with GERD. The Quality of Life Index showed significant improvement after surgery.

Individualized surgical strategies for cancer of the esophagogastric junction

Due to their borderline location between the stomach and esophagus the optimal surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial. Irrespective of the surgical approach a complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of surgical treatment of such tumors. Based on the experience with surgical resection of more than 1000 patients with adenocarcinoma of the esophagogastric junction we recommend an individualized surgical strategy guided by tumor stage and topographic location of the tumor center or tumor mass. This requires detailed preoperative staging and classification of tumors arising in the vicinity of the esophagogastric junction into adenocarcinoma of the distal esophagus (AEG Type I Tumors), true carcinoma of the gastric cardia (AEG Type II Tumors) and subcardial gastric carcinoma infiltrating the esophagogastric junction (AEG Type III Tumors). In patients with Type I Tumors transthoracic esophagectomy offers no survival benefit over radical transmediastinal esophagectomy, but is associated with higher morbidity. In patients with Type II or Type III tumors an extended total gastrectomy results in equal or superior survival and less postoperative mortality than a more extended esophagogastrectomy. In patients with early tumors, staged as uT1 on preoperative endosonography, a limited resection of the proximal stomach, cardia and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment allows a complete tumor removal with adequate lymphadenectomy and offers excellent functional results. Multimodal treatment protocols with neoadjuvant chemotherapy or combined radiochemotherapy followed by surgical resection appear to markedly improve the prognosis in patients with locally advanced tumors who respond to preoperative treatment. With this tailored approach extensive preoperative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept.

Neoadjuvant therapy of esophageal squamous cell carcinoma: response evaluation by positron emission tomography

OBJECTIVE

To evaluate the use of positron emission tomography using [(18)F]-fluorodeoxyglucose (FDG-PET) to assess the response to neoadjuvant radiotherapy and chemotherapy in patients with locally advanced esophageal cancer.

SUMMARY BACKGROUND DATA

Imaging modalities, including endoscopy, endoscopic ultrasound, computed tomography, and magnetic resonance imaging, currently used to evaluate response to neoadjuvant treatment in esophageal cancer do not reliably differentiate between responders and nonresponders.

METHODS

Twenty-seven patients with histopathologically proven squamous cell carcinoma of the esophagus, located at or above the tracheal bifurcation, underwent neoadjuvant therapy consisting of external-beam radiotherapy and 5-fluorouracil as a continuous infusion. FDG-PET was performed before and 3 weeks after the end of radiotherapy and chemotherapy (before surgery). Quantitative measurements of tumor FDG uptake were correlated with histopathologic response and patient survival.

RESULTS

After neoadjuvant therapy, 24 patients underwent surgery. Histopathologic evaluation revealed less than 10% viable tumor cells in 13 patients (responders) and more than 10% viable tumor cells in 11 patients (nonresponders). In responders, FDG uptake decreased by 72% +/- 11%; in nonresponders, it decreased by only 42% +/- 22%. At a threshold of 52% decrease of FDG uptake compared with baseline, sensitivity to detect response was 100%, with a corresponding specificity of 55%. The positive and negative predictive values were 72% and 100%. Nonresponders to PET scanning had a significantly worse survival after resection than responders.

CONCLUSION

FDG-PET is a valuable tool for the noninvasive assessment of histopathologic tumor response after neoadjuvant radiotherapy and chemotherapy.

[Therapy of esophageal diverticula]

Diverticula of the esophagus can be divided into two categories. Pulsion diverticula result from an increased pressure gradient through the upper esophageal sphincter resulting in herniation of the mucosa through a weak point of the muscle layer. There are two types: hypopharynx (Zenker) diverticulum and epiphrenic diverticulum. Traction diverticula result from inflammatory reactions in neighboring lymph nodes or as a result of embryonic malformation and are composed of all layers of the esophageal wall. The presence of a Zenker diverticulum in a symptomatic patient represents always an indication for surgical therapy. A successful procedure contains a diverticulectomy combined with cervical myotomy. For the treatment of epiphrenic diverticula the underlying motility disorder, determined by preoperative manometry, plays a crucial role in the length of the myotomy. In order to prevent postoperative reflux a partial fundoplication should be added. Independent of location or size surgical therapy of diverticula of the esophagus has a success rate of more than 90 percent.

[Endoluminal therapy of neoplastic changes in the gastrointestinal tract: Barrett esophagus--from the viewpoint of the surgeon]

The need for radical subtotal esophagectomy and extensive lymphadenectomy in patients with early Barrett cancer, i.e. T1 tumors, is increasingly questioned. Based on the principles of surgical oncology, the precancerous nature of Barrett esophagus, and the high rate of lymph node metastases in patients with T1b tumors, the minimal extent of the procedure for early Barrett cancer must include the entire segment of the distal esophagus covered by intestinal metaplasia and a regional lymphadenectomy. In adequately selected patients this can be achieved by a limited surgical procedure with transhiatal resection of the distal esophagus and jejunum interposition, but not by endoscopic mucosal ablation or endoscopic mucosa resection. The high recurrence rates after endoscopic interventions does not support the use of these techniques in operable patients.

Limited resection for early adenocarcinoma in Barrett's esophagus

OBJECTIVE

To assess the extent of disease in patients with pT1 esophageal adenocarcinoma and to evaluate the feasibility and outcomes of a limited surgical approach.

SUMMARY BACKGROUND DATA

Radical esophagectomy with systematic lymphadenectomy is widely advocated as the treatment of choice in patients with early adenocarcinoma of the distal esophagus. This approach, however, is associated with substantial complications and long-term side effects. The extent of resection necessary to achieve cure in such patients is not clear.

METHODS

Seventy-one patients with pT1 adenocarcinoma of the distal esophagus underwent transmediastinal or transthoracic esophagectomy with two-field lymphadenectomy. Twenty-four patients with uT1N0 tumors underwent a limited resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic pedicled jejunal segment. The two groups were compared for extent and multicentricity of the primary tumor and associated high-grade dysplasia, pattern of lymph node metastases, complications, deaths, and outcome of surgical treatment.

RESULTS

Multicentric tumor growth or associated high-grade dysplasia was observed in 60.6% of the resection specimens. Complete resection of the tumor and the entire segment with intestinal metaplasia was achieved in all patients, irrespective of the surgical approach. Patients undergoing limited resection had fewer complications. Lymph node metastases or micrometastases were present in none of the 38 patients with tumors limited to the mucosa (pT1a) versus 10 of the 56 (17.9%) patients with tumors invading the submucosa (pT1b). Distant lymph node metastases occurred only in patients with more than three positive regional lymph nodes. Lymph node metastases were prognostic, but the pT1a/pT1b category and the surgical approach were not. The mean Gastrointestinal Quality of Life Index after limited resection did not differ from that of healthy controls: 20 of the 24 patients were completely asymptomatic.

CONCLUSIONS

In patients with early adenocarcinoma in the distal esophagus, resection of the distal esophagus and esophagogastric junction, with regional lymphadenectomy and jejunal interposition, is an attractive limited surgical alternative to radical esophagectomy.

II. Vinzenz Czerny (1842-1915): grand seigneur of oncologic surgery--life, influence, and work of the Second Congress President of the ISS/SIC. International Society of Surgery/Société Internationale de Chirurgie

Vinzenz Czerny, chairman and professor of surgery in Freiburg im Breisgau and in Heidelberg, Germany, is the typical example of a prominent surgeon with an elegant technique, who was also a keen observer and scientist at the turn of the nineteenth into the early twentieth century. Starting his career in Vienna, Austria, he can be looked upon as the most important disciple of Theodor Billroth. Whereas Billroth may be regarded as the father of modern gastrointestinal surgery, Czerny can be considered the father of modern surgery for intestinal malignancies and multimodal treatment. The early history of visceral cancer therapy is linked with his career. He became a surgeon of the highest rank, with great clinical skill, rare judgment, and vision who contributed essentially to the development of modern surgery. From his early education he maintained a lifelong affection for the natural sciences and was an excellent physiologist and pathologist. During his professional life he successfully built up a well deserved reputation for general and cancer surgery and for the introduction of radio- and chemotherapy into the treatment of tumors. Czerny founded and chaired the first experimental Institute for Cancer Research in Germany. Two years later, in 1908, he presided at the 2nd Congress of the International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC) in Brussels, a congress that was almost entirely devoted to the etiology of visceral cancer and the progress and achievements of its treatment. Czerny left a clear legacy of opinion and methods on which the modern era of surgical cancer treatment is based.

Comparison of loss of heterozygosity and microsatellite instability in adenocarcinomas of the distal esophagus and proximal stomach

Adenocarcinoma of the gastroesophageal junction is rapidly rising in incidence. It has been proposed that these tumors be classified as three different types: distal esophageal (AEG I), cardia (AEG II), and subcardia (AEG III). Using comparative genomic hybridization (CGH) analysis, one recent study reported that the 14q chromosomal arm showed a significantly higher rate of deletion in esophageal than in cardia adenocarcinoma. Using a microsatellite analysis technique, we analyzed this area and regions in the vicinity of the APC, DCC, and p53 genes. Tumor and normal tissues were microdissected from 54 cases (27 AEG I and 27 AEG III). DNA was extracted and then amplified using seven fluorescent-labeled microsatellite markers, one pair each on 5q, 18q, and 17p and four on 14q. The results were analyzed for loss of heterozygosity (LOH) and microsatellite instability (MSI). LOH varied from 20% to 30% at each locus except for the 17p locus, where it was slightly above 50% in both groups. No significant differences in LOH or MSI were found between the esophageal and gastric tumors, including the 14q chromosomal arm. These results fail to confirm the finding that abnormalities on the 14q chromosomal arm distinguish between distal esophageal and proximal gastric tumors.

[New therapy approaches in tumors of the upper gastrointestinal tract (esophagus, stomach)]

Despite numerous phase-II and phase-III studies investigating neoadjuvant treatment in esophageal and gastric cancer, the value of multimodal therapy in these tumors is not clearly defined yet. One reason are the different study entry criteria and different staging modalities in the investigations published so far. Concerning esophageal cancer, neoadjuvant chemotherapy does not yet have a definite role after several phase-III studies. It may be that this treatment should only be inaugurated in innovative protocols. Furthermore, in esophageal cancer it is proven that chemoradiation is superior to radiation alone in the neoadjuvant setting. Following neoadjuvant chemoradiation, there is a distinct trend in favor of multimodal therapy. In the case of locally advanced squamous cell carcinoma of the esophagus, neoadjuvant chemoradiation offers 30%-60% of the patients the possibility for a complete resection (UICC-R0); however, this is accompanied by increased postoperative morbidity and mortality. In gastric cancer, neoadjuvant chemotherapy is still an experimental approach. Intraperitoneal chemotherapy has failed to show any benefit in Western trials. Clinically related research is concentrating on the problem of distinguishing responder from non-responder at the beginning of the therapy. First results indicate that with molecular markers, response might be predicted before therapy. Using 18-FDG PET, it could be possible that the response can be recognized after only 1 week of treatment, opening the door to early response evaluation. New therapeutics like monoclonal antibodies for adjuvant therapy, which is again under discussion in gastric cancer, are only in phase-I studies.

Frequency and clinical impact of lymph node micrometastasis and tumor cell microinvolvement in patients with adenocarcinoma of the esophagogastric junction

BACKGROUND

Tumor involvement of regional lymph nodes has a crucial impact on the prognosis of patients with adenocarcinoma of the esophagogastric junction (AEG). Although additional tumor cell deposits can be detected by sensitive methods (e.g., immunohistochemistry and polymerase chain reaction), their prognostic significance is uncertain.

METHODS

Using immunohistochemistry for cytokeratins (AE1/AE3 antibody), the authors studied 3987 regional lymph nodes from 145 patients with completely resected adenocarcinoma of the esophagus (AEG I; n = 46 patients), cardia (AEG II; n = 79 patients), and subcardial region (AEG III; n = 20 patients). The newly detected cells were categorized with tumor cell microinvolvement (TCM) or with micrometastases (MM) based on tumor size and histology.

RESULTS

Of the 75 pathologic lymph node negative (pN0) patients, 3 of 30 patients in the AEG I group (10%) and 8 of 45 patients in the AEG II and III groups (18%) had TCM (no significant difference). MM was found in 2 of 30 tumors in the AEG I group (7%) and in 11 of 45 tumors in the AEG II and III groups (24%), a significantly lower rate that that in the AEG I group (P < 0.05). Neither TCM nor MM showed a significant prognostic impact in AEG I tumors (P > 0.05). For the AEG II and III tumors, MM (new lymph node positive [pN+] cases) had a prognostic impact similar to metastases found by routine methods, with reclassification based on MM resulting in improvement in the pN0 group from 72.8 months to 82.6 months, but almost no change was seen in the pN+ group (49.9-49.2 months). TCM had no adverse impact on survival in any tumor type.

CONCLUSIONS

These results highlight important differences between AEG I tumors and AEG II and III tumors and argue for different lymphadenectomy strategies for patients with these tumor types.

Frequency and clinical impact of lymph node micrometastasis and tumor cell microinvolvement in patients with adenocarcinoma of the esophagogastric junction

BACKGROUND

Tumor involvement of regional lymph nodes has a crucial impact on the prognosis of patients with adenocarcinoma of the esophagogastric junction (AEG). Although additional tumor cell deposits can be detected by sensitive methods (e.g., immunohistochemistry and polymerase chain reaction), their prognostic significance is uncertain.

METHODS

Using immunohistochemistry for cytokeratins (AE1/AE3 antibody), the authors studied 3987 regional lymph nodes from 145 patients with completely resected adenocarcinoma of the esophagus (AEG I; n = 46 patients), cardia (AEG II; n = 79 patients), and subcardial region (AEG III; n = 20 patients). The newly detected cells were categorized with tumor cell microinvolvement (TCM) or with micrometastases (MM) based on tumor size and histology.

RESULTS

Of the 75 pathologic lymph node negative (pN0) patients, 3 of 30 patients in the AEG I group (10%) and 8 of 45 patients in the AEG II and III groups (18%) had TCM (no significant difference). MM was found in 2 of 30 tumors in the AEG I group (7%) and in 11 of 45 tumors in the AEG II and III groups (24%), a significantly lower rate that that in the AEG I group (P < 0.05). Neither TCM nor MM showed a significant prognostic impact in AEG I tumors (P > 0.05). For the AEG II and III tumors, MM (new lymph node positive [pN+] cases) had a prognostic impact similar to metastases found by routine methods, with reclassification based on MM resulting in improvement in the pN0 group from 72.8 months to 82.6 months, but almost no change was seen in the pN+ group (49.9-49.2 months). TCM had no adverse impact on survival in any tumor type.

CONCLUSIONS

These results highlight important differences between AEG I tumors and AEG II and III tumors and argue for different lymphadenectomy strategies for patients with these tumor types.

Influence of simultaneous neoadjuvant radiotherapy and chemotherapy on bronchoscopic findings and lung function in patients with locally advanced proximal esophageal cancer

To assess the bronchoscopic and lung function changes induced by preoperative radiochemotherapy (30 Gy radiation and 5-fluorouracil) in patients with proximal esophageal cancer, we prospectively compared the findings in 77 consecutive patients before and after the therapy. All patients completed the radiochemotherapy protocol; toxicity was minimal. Sixty-four patients underwent surgery, 48 had total gross removal of disease, and six had a complete histologic response. Of the 13 patients who developed apparent direct macroscopic signs of tumor invasion into the airways during therapy, histologic proof of cancer was obtained in only one of the abnormalities. Bronchoscopy was falsely negative in six patients in whom airway invasion of the cancer was found at surgery. Neoadjuvant therapy led to no systematic changes in the appearance of the uninvolved tracheal mucosa; microscopically, an increase in postinflammatory changes, hyperplasia, and metaplasia was found. There was no significant change in the values of lung function parameters after the therapy. No patient developed symptoms suggestive of radiation-induced lung changes, although in one of them, subtle radiologic features consistent with radiation pneumonitis were found. No patient died of postoperative pulmonary complications. The interpretation of bronchoscopy in the assessment of airway invasion of esophageal cancer after radiochemotherapy is more difficult than at baseline staging; the positive predictive value of macroscopic abnormalities without microscopic proof of cancer is low, and even with extensive sampling for histology and cytology, the procedure was falsely negative in 9.4%. Neoadjuvant therapy did not induce radiation pneumonitis or changes in lung function that could be of concern at the following operation.

Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients

OBJECTIVE

To assess the outcome of surgical therapy based on a topographic/anatomical classification of adenocarcinoma of the esophagogastric junction.

SUMMARY BACKGROUND DATA

Because of its borderline location between the stomach and esophagus, the choice of surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial.

METHODS

In a large single-center series of 1,002 consecutive patients with adenocarcinoma of the esophagogastric junction, the choice of surgical approach was based on the location of the tumor center or tumor mass. Treatment of choice was esophagectomy for type I tumors (adenocarcinoma of the distal esophagus) and extended gastrectomy for type II tumors (true carcinoma of the cardia) and type III tumors (subcardial gastric cancer infiltrating the distal esophagus). Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor types, focusing on the pattern of lymphatic spread, the outcome of surgery, and prognostic factors in patients with type II tumors.

RESULTS

There were marked differences in sex distribution, associated intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, and stage distribution between the three tumor types. The postoperative death rate was higher after esophagectomy than extended total gastrectomy. On multivariate analysis, a complete tumor resection (R0 resection) and the lymph node status (pN0) were the dominating independent prognostic factors for the entire patient population and in the three tumor types, irrespective of the surgical approach. In patients with type II tumors, the pattern of lymphatic spread was primarily directed toward the paracardial, lesser curvature, and left gastric artery nodes; esophagectomy offered no survival benefit over extended gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophagogastric junction into type I, II, and III tumors shows marked differences between the tumor types and provides a useful tool for selecting the surgical approach. For patients with type II tumors, esophagectomy offers no advantage over extended gastrectomy if a complete tumor resection can be achieved.

Prognostic factors in resected primary small bowel tumors

We report a retrospective analysis of 71 patients, operated for primary small bowel tumors (SBT): 47 malignant (66.2%) and 24 benign (33.8%) tumors. Of the malignant tumors, adenocarcinomas predominated (38.3%), followed by neuroendocrine tumors (31.9%), Non-Hodgkin lymphomas (NHL) (12.8%), leiomyosarcomas (10.6%) and other rare entities (6.4%). Morbidity of surgical treatment was 16. 9%, 30-day mortality 7%. The estimated 5-year survival rate in malignant lesions was 31.8%. Univariate analysis identified the presence of distant metastasis and the resection status (R status) as prognostic factors (p = 0.034 and p = 0.001). There was no influence of T, N status or grading on survival. A complete macroscopic and microscopic tumor resection has to be the aim of any curative surgical approach in patients with SBT.

The relationship between gastroesophageal reflux, intestinal metaplasia and adenocarcinoma of the esophagus

Currently available data indicate a clear and probably causal relationship between long-lasting gastroesophageal reflux disease, the development of long segments with specialized intestinal metaplasia in the distal esophagus and subsequent progression to adenocarcinoma. To a lesser degree, this also appears to be the case for short segments of specialized intestinal metaplasia in the distal esophagus. In contrast, epidemiological data and classic parameters for the diagnosis of gastroesophageal reflux disease do not currently support a causal role of gastroesophageal reflux in the pathogenesis of specialized intestinal metaplasia at the gastric cardia. Despite its high prevalence and malignant potential, many questions about the prevention and management of intestinal metaplasia in the distal esophagus remain unsolved. In patients with chronic gastroesophageal reflux, current modes of medical therapy do not appear to prevent the development of intestinal metaplasia, while effective anti-reflux surgery seems to have a protective effect. Formal studies with adequate follow-up are, however, still lacking. Neither acid-suppression therapy nor anti-reflux surgery, with or without mucosal ablation, can reliably prevent the malignant degeneration of established intestinal metaplasia of the esophagus. Close endoscopic surveillance with extensive biopsies, therefore, remains mandatory in such patients, irrespective of the treatment modality.

Anatomic dilatation of the cardia and competence of the lower esophageal sphincter: a clinical and experimental study

Anatomic and clinical data suggest that the gastroesophageal junction or cardia in patients with gastroesophageal reflux disease GERD) may be dilated. We hypothesized that anatomic dilatation of the cardia induces a lower esophageal sphincter dysfunction that may be corrected by narrowing the gastroesophageal junction (i.e., calibration of the cardia). We measured the perimeter of the cardia during surgery in control subjects and patients with GERD and Barrett's esophagus. We then tested our hypothesis in a mechanical model. The model was based on a pig gastroesophageal specimen with perpendicularly placed elastic bands around the cardia simulating the action of the "sling" and "clasp" fibers. "Dilatation" of the cardia was induced by displacing the sling band laterally and decreasing its tension. "Calibration" of the cardia was performed by reapproximation of the sling band toward the esophagus but maintaining the same tension as the dilated model. In the "basal," "dilated," and "calibrated" states, the perimeter of the cardia was noted and rapid mechanized pullback manometry with a water-perfused catheter was performed. The opening pressure was determined, and three-dimensional sphincter pressure images were analyzed. The average cardia perimeter was 6.3 cm in control subjects, 8.9 cm in GERD patients, and 13.8 cm in patients with Barrett's esophagus. The arrangement of the bands in the experimental model generated a manometric high-pressure zone similar to that in the human lower esophageal sphincter. Dilatation of the cardia resulted in a decrease in the resting pressure, length, and vector volume of the high -pressure zone, and reduced the opening pressure. Calibration restored the resting and opening pressure, and normalized the three-dimensional pressure image. In patients with GERD and Barrett's esophagus, the cardia is dilated. Our model supports the hypothesis that lower esophageal sphincter function is compromised by anatomic dilatation of the cardia and can be restored by approximation of the "sling" fibers toward the lesser curvature "clasp" fibers). This provides evidence for a correlation between gastroesophageal sphincter dysfunction in reflux disease and its correction by antireflux surgery.

Bronchoscopy in the preoperative staging of oesophageal cancer below the tracheal bifurcation: a prospective study

Oesophageal cancer located above the level of the tracheal bifurcation is frequently complicated by its spread into the airways and by the simultaneous occurrence of malignant bronchial tumours. Although bronchoscopy is an essential procedure in identifying malignant tumoral invasion of the airways and detection of primary airway tumours in patients with suprabifurcal oesophageal cancer, its role in patients with infrabifurcal oesophageal cancer is not clear. This study aimed to assess the value of fibreoptic bronchoscopy in the preoperative staging of oesophageal cancer located below the level of the tracheal bifurcation. In a prospective protocol, bronchoscopic findings were correlated with the results of other staging procedures, operative results and survival in 51 patients with oesophageal cancer located below the level of the tracheal bifurcation. One unsuspected primary bronchial cancer in a patient with squamous cell oesophageal cancer and one case of lower lobe invasion of an oesophageal adenocarcinoma were found. By excluding from surgery these two patients in whom curative resection was not possible bronchoscopy was the sole decisive staging investigation in 6.5% of potentially operable and 3.9% of all patients. Suspect macroscopic abnormalities were shown in 15.7% of the patients at bronchoscopy. Taking bronchoscopic biopsy as the gold standard the positive predictive value for all macroscopic abnormalities was only 25% (95% confidence interval (CI) 3.2-65.1%). The overall accuracy of bronchoscopy with biopsy and brush and washing cytology in proving or excluding airway invasion in otherwise potentially operable patients was 100% (95% CI 89.4-100%). Bronchoscopy is useful in the preoperative staging of oesophageal carcinoma located below the level of the tracheal bifurcation, particularly if the oesophageal cancer is of the squamous cell type.