Carcinoma of the esophagus

Carcinoma of the esophagus

Carcinoma of the esophagus continues to have a low 5-year cure rate despite advances in radical surgery and super-voltage radiation. Neither patient education nor newer diagnostic techniques have improved survival. The reported operative mortality is 4 to 30% for esophagogastrostomy and 10 to 44% for colon interposition. Average survival time with surgery is 11 to 28 months and 5 to 11 months with irradiation. Local recurrence is high (33 to 76%) with irradiation. The reported 5-year survival rate with preoperative irradiation followed by surgery is higher (14 to 25%). Recent reports have concentrated on improving functional rehabilitation rather than improving cure rates. Palliative surgery is more acceptable because of lowered operative morbidity and mortality and the high complication rate with radiation therapy for far advanced disease. New approaches of interest include fundoplication added to esophagogastrostomy, substernal gastric bypass with anastomosis in the neck, reversed gastric tube (Heimlich operation), the addition of postoperative rather than preoperative irradiation in patients with potentially curable lesions, the use of preoperative hyperalimentation, and the potential application of immunotherapy.

The creation of autologous substitute organs with stapling instruments

After partial or total esophagectomy, total gastrectomy, pancolectomy, and urinary cystectomy, it becomes necessary to reestablish continuity and/or replace function by the creation of a substitute organ obtianed from the various portions of the gastrointestinal tract. Ideally, the creation of the substitute organ should be undertaken at the same operation in which the original organ is excised. At times, however, the surgeon may elect a two-stage approach by replacing the afflicted organ during a separate operation either prior to or after excision, as dictated by the circumstances surrounding each individual patient. The use of stapling instruments has greatly facilitated the precision, neatness, and speed with which substitute organs can be constructed. This is especially spectacular in those patients in whom a one-stage procedure is elected.