Subtotal esophagectomy with extended 2-field lymph node dissection for thoracic esophageal cancer

OBJECTIVE

To examine the efficacy of the Ivor Lewis esophagectomy with extended 2-field lymph node dissection for thoracic esophageal carcinoma we reviewed our experience.

METHODS

We analyzed the cases of 147 consecutive patients who underwent subtotal esophagectomy with extended 2-field lymph node dissection through Ivor Lewis approach for esophageal cancer from January 1996 through December 2000. Eighty-six patients were operated on for cancer of the midthoracic esophagus, 48 for cancer of the lower thoracic esophagus, and 13 for cancer of the aortal segment of the esophagus. No patient had received chemotherapy or radiotherapy before operation.

RESULTS

There were 113 men (76.9%) and 34 women. Median age was 57 years (range 51-65 years). Postsurgical pathological studies revealed squamous cell carcinoma in 139 patients (94.6%), adenocarcinoma in five (3.4%), and adenosquamous carcinoma in three (2%). Positive abdominal and/or mediastinal lymph nodes were found in 122 patients (82.9%). At mean 43 nodes (range from 32 up to 75) were studied for each patient. Even in T(1)-T(2) tumors mediastinal or abdominal lymph nodes are involved in up to 80% of cases. However, in T(3)-T(4) stages the frequency of lymph node involvement is significantly higher (P<0.05). Postsurgical staging was as follows: stage I in three patients (2%), stage IIa in 20 (13.6%), stage IIb in 29 (19.7%), stage III in 54 (36.8%), and stage IV in 41 (27.9%). All distant metastases were lymphogenous. The operative mortality rate was 6.1%, and complications occurred in 62 patients (42.1%). The overall 5-year survive rate was 28.8% (median survival 36.1 months). The 5-year survival rate for patients in stage IIa was 59%; for those in stage IIb, 39.5%; for patients in stage III, 26.7%; and 0% for patients in stage IV.

CONCLUSIONS

Subtotal esophagectomy with extended 2-field lymph node dissection through Ivor Lewis approach for esophageal cancer is a safe operation. Long-term survival is stage dependent. Effective multimodality treatment may be helpful for patients with advanced disease.

Surgical treatment of esophageal carcinoma complicated by fistulas

OBJECTIVES

The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant esophageal fistulas is about 13%. The range of treatment modalities proposed by different authors varies from palliation to active and, if possible, radical surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas.

METHODS

Thirty-five patients (aged 28--67) with malignant esophageal fistulas of different localizations were operated over a period from 1990 to 2000. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and 11 cases, respectively. The malignant fistula with the mediastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, two, five, four and three cases, respectively. Subtotal esophagectomy and esophagogastroplasty were performed in 18 patients; subtotal esophagectomy with intrapleural coloesophagoplasty was performed in one case; proximal gastric and lower thoracic esophageal resection from the left-side abdominothoracic approach was performed in three cases. Esophagogastric bypass anastomoses were formed in ten patients. Gastrostomy was performed in three patients.

RESULTS

The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resection, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3--31), the 2-year survival rate was 21% after combined esophagectomies.

CONCLUSIONS

The goal of surgery for esophageal cancer with various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymphadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surgery or gastrostomy. We consider that en-bloc combined resection of esophageal cancer complicated by fistula can be done with a low mortality.

Eleutherococcus senticosus (Rupr. & Maxim.) Maxim. (Araliaceae) as an adaptogen: a closer look

The adaptogen concept is examined from an historical, biological, chemical, pharmacological and medical perspective using a wide variety of primary and secondary literature. The definition of an adaptogen first proposed by Soviet scientists in the late 1950s, namely that an adaptogen is any substance that exerts effects on both sick and healthy individuals by 'correcting' any dysfunction(s) without producing unwanted side effects, was used as a point of departure. We attempted to identify critically what an adaptogen supposedly does and to determine whether the word embodies in and of itself any concept(s) acceptable to western conventional (allopathic) medicine. Special attention was paid to the reported pharmacological effects of the 'adaptogen-containing plant' Eleutherococcus senticosus (Rupr. & Maxim.) Maxim. (Araliaceae), referred to by some as 'Siberian ginseng', and to its secondary chemical composition. We conclude that so far as specific pharmacological activities are concerned there are a number of valid arguments for equating the action of so-called adaptogens with those of medicinal agents that have activities as anti-oxidants, and/or anti-cancerogenic, immunomodulatory and hypocholesteroletic as well as hypoglycemic and choleretic action. However, 'adaptogens' and 'anti-oxidants' etc. also show significant dissimilarities and these are discussed. Significantly, the classical definition of an adaptogen has much in common with views currently being invoked to describe and explain the 'placebo effect'. Nevertheless, the chemistry of the secondary compounds of Eleutherococcus isolated thus far and their pharmacological effects support our hypothesis that the reported beneficial effects of adaptogens derive from their capacity to exert protective and/or inhibitory action against free radicals. An inventory of the secondary substances contained in Eleutherococcus discloses a potential for a wide range of activities reported from work on cultured cell lines, small laboratory animals and human subjects. Much of the cited work (although not all) has been published in peer-reviewed journals. Six compounds show various levels of activity as anti-oxidants, four show anti-cancer action, three show hypocholesterolemic activity, two show immunostimulatory effects, one has choleretic activity and one has the ability to decrease/moderate insulin levels, one has activity as a radioprotectant, one shows anti-inflammatory and anti-pyretic activities and yet another has shown activity as an antibacterial agent. Some of the compounds show more than one pharmacological effect and some show similar effects although they belong to different chemical classes. Clearly, Eleutherococcus contains pharmacologically active compounds but one wishes that the term adaptogen could be dropped from the literature because it is vague and conveys no insights into the mechanism(s) of action. If a precise action can be attributed to it, then the exact term for said action should obviously be used; if not, we strongly urge that generalities be avoided. Also, comparison of Eleutherococcus with the more familiar Panax ginseng C.A. Meyer (Araliaceae), 'true ginseng' has underscored that they differ considerably chemically and pharmacologically and cannot be justifiably considered as mutually interchangeable. Accordingly, we recommend that the designation 'Siberian ginseng' be dropped and be replaced with 'Eleutherococcus'. In the case of both Eleutherococcus and true ginseng, problems inherent in herbal preparation use include inconsistencies not only in terms of indications for use, but in the nomenclature of constituent chemical compounds, standardization, dosage and product labeling. (ABSTRACT TRUNCATED)