Impact of fluid balance and opioid-sparing anesthesia within enchanced recovery pathway on postoperative morbidity after transthoracic esophagectomy for cancer

Background

Enhanced Recovery After Surgery (ERAS) protocol for esophagectomy may reduce the high incidence of postoperative morbidity and mortality. The aim of this study was to assess the impact of properly conducted ERAS protocol with specific emphasis on fluid balance and opioid-sparing anesthesia (OSA) on postoperative major morbidity and mortality after esophagectomy.

Methods

Patients undergoing elective esophagectomy for esophageal cancer at the Hospital for Digestive Surgery, University Clinical Center of Serbia, from December 2017 to March 2021, were included in this retrospective observational study. Patients were divided into two groups: the ERAS group (OSA, intraoperative goal-directed therapy, and postoperative “near-zero” fluid balance) and the control group (opioid-based anesthesia, maintenance mean blood pressure ≥ 65 mmHg, and liberal postoperative fluid management). The primary outcome was major morbidity within 30 days from surgery and 30-day and 90-day mortality. Multivariable analysis was used to examine the effect of the ERAS protocol.

Results

A total of 121 patients were divided into the ERAS group (69 patients) and the control group (52 patients). Patients in the ERAS group was received less fentanyl, median 300 (interquartile range (IQR), 200–1,550) mcg than in control group, median 1,100 (IQR, 650–1750) mcg, p < 0.001. Median intraoperative total infusion was lower in the ERAS group, 2000 (IQR, 1000–3,750) mL compared to control group, 3,500 (IQR, 2000–5,500) mL, p < 0.001. However, intraoperative norepinephrine infusion was more administered in the ERAS group (52.2% vs. 7.7%, p < 0.001). On postoperative day 1, median cumulative fluid balance was 2,215 (IQR, −150-5880) mL in the ERAS group vs. 4692.5 (IQR, 1770–10,060) mL in the control group, p = 0.002. After the implementation of the ERAS protocol, major morbidity was less frequent in the ERAS group than in the control group (18.8% vs. 75%, p < 0.001). There was no statistical significant difference in 30-day and 90-day mortality (p = 0.07 and p = 0.119, respectively). The probability of postoperative major morbidity and interstitial pulmonary edema were higher in control group (OR 5.637; CI95%:1.178–10.98; p = 0.030 and OR 5.955; CI95% 1.702–9.084; p < 0.001, respectively).

Conclusion

A major morbidity and interstitial pulmonary edema after esophagectomy were decreased after the implementation of the ERAS protocol, without impact on overall mortality.

Does the computed tomography perfusion imaging improve the diagnostic accuracy in the response evaluation of esophageal carcinoma to the neoadjuvant chemoradiotherapy? Preliminary study

PURPOSE

To estimate whether the computed tomography (CT) perfusion imaging could be useful to predict the pathological complete response (pCR) of esophageal cancer to the neoadjuvant chemoradiotherapy (NACRT).

METHODS

Twenty-seven patients with the advanced squamous cell esophageal carcinoma, who were treated with concomitant CRT (CIS/5-FU/LV and 45-50 Gy total radiation dose), were re-evaluated using CT examination, which included the low-dose CT perfusion study. CT perfusion series were analysed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE), and color parametric maps of the blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface area product (PS) were displayed. All patients were operated and histopathological analysis of the resected esophagus considered the gold standard for pathologic complete response (pCR).

RESULTS

BFpost-NACRT, BVpost-NACRT, and PSpost-NACRT were significantly lower, and MTTpost-NACRT significantly higher in the pCR group. Mean (±SD), or median perfusion parameter values in the pCRs (11 patients) vs non-pCRs (16 patients) were: BFpost-NACRT- 21.4±5.0 vs 86.0±29 ml/min/100 g (p<0.001), BVpost-NACRT- 1.3 vs 3.9 ml/100 g (p<0.001), MTTpost-NACRT- 5.5 vs 3.7 s (p=0.018), and PSpost-NACRT- 5.9 vs 9.8 ml/min/100 g (p=0.006). ROC analysis revealed that BFpost- NACRT (AUC=1.000), BVpost-NACRT (AUC=0.932), MTTpost-NACRT (AUC=0.801), and PSpost-NACRT (AUC=0.844) could predict the pCR (p<0.01), while maximal esophageal wall thickness could not (AUC=0.676, p=0.126). If we set a cut-off value of BFpost-NACRT<30.0 ml/min/100 g, pCR was predicted with sensitivity and specificity of 100%.

CONCLUSION

CT perfusion imaging enables accurate prediction of pCR of esophageal carcinoma to neoadjuvant chemoradiotherapy.

Pharyngolaryngoesophagectomy in a patient with an aberrant right subclavian artery: report of a case

We report a case of carcinoma of the hypopharynx and cervical esophagus in a patient with an aberrant right subclavian artery. Barium esophagography, endoscopy, and computed tomography showed a resectable tumor in the hypopharynx and cervical esophagus, coexistent with an aberrant right subclavian artery. We performed pharyngolaryngoesophagectomy with bilateral neck dissection and gastric pull-up through cervical, right thoracic, and abdominal incisions. We also partially resected the aberrant right subclavian artery with reimplantation in the right common carotid artery. To our knowledge, this is the first report of pharyngolaryngoesophagectomy with transposition of an aberrant right subclavian artery.

Bloodless esophageal replacement in children with corrosive esophageal strictures--report of two cases

BACKGROUND

Esophageal replacement is major procedure with high risk for perioperative allogeneic blood transfusion (ABT), especially in pediatric patients due to nutritive deficiency, anemia, small body weight and blood volume. Autologous blood policy is particularly important in female children.

METHODS

We present treatment strategy with the aim of avoiding ABT, that have been applied in two female pediatric patients with caustic stricture of thoracic esophagus. The patients were 7 and 8 years old, with body weight 34 and 23.5 kg, respectively. Protocol was based on the stimulation of haematopoetic system with erythropoietin, iron therapy and preoperative autologous blood donation (PABD). In the first patient, with a history of previous retrosternal bypass esophagocoloplasty and extraction of necrotic colonic graft, delayed reconstruction--transhiatal subtotal esophagectomy and gastric pull-up with cervical anastomosis were performed. In the second patient, repeated ineffective dilatations of esophageal stricture were reason for retrosternal left colon interposiotion and exclusion of native esophagus.

RESULTS

No adverse events were attributed to preoperative blood donation period. No allogenic blood products were used during perioperative period. Both patients had uneventful postoperative course.

CONCLUSION

In specialized institutions for esophageal surgery, PABD with administration of erythropoietin and iron therapy, enable bloodless esophageal replacement, even in children.

Minimally invasive surgery in the treatment of gastric cancer

Unlike benign pathology, progress of laparoscopy in performing cancer surgery has been slow because of fear of safety and oncological adequacy. However, the initial fear has been replaced by optimism as the results from a numerous studies have shown equivalent if not superior results to open surgery. Laparoscopic gastrectomy is safe and oncologic adequate, but time consuming and technically demanding procedure. Laparoscopic surgery has gained wide acceptance in the treatment of early gastric cancer, especially of the distal stomach. The use of laparoscopic surgery for the treatment of advanced gastric cancer remains controversial. Another open question that need complete evaluation is cost-effectiveness analysis of minimally invasive and open approach.

[Delayed MDCT in preoperative analysis of the hypopharyngeal postcricoid carcinomas]

INTRODUCTION

Determination of borders of the postcricoid tumors is of great significance during preoperative analysis, because it can be of considerable influence on operative treatment and its planning. Therefore, exact demarcation, delineation and opacification of tumor zone on CT analysis is crucial.

MATERIAL AND METHOD

Late CT scan delay of 150 sec and slow vein flow of contrast agents of 1 ml/sec is radiological method of choice in preoperative evaluation of carcinoma of the post-cricoid region. For our purposes we used modern MSCT Light Speed GE 64, with slice thick of 2.5 mm (retro recon of 0.625) with software postprocesing.

RESULTS AND DISCUSSION

In our study, we have detaily analized 25 patients with clinically proved carcinoma of hypopharynx, of which 8 had the hardest form of tumor. Control group were patients to whom CT scan was done by standard protocol and CT time scan of 50 sec. With all 8 of them, scanned by protocol of delay time of 150 sec, was proved a statistically important validity of interpretation and demarcation of tumors.

CONCLUSION

Delay time on CT scanning is proved to be efficient protocol for visualization of neck soft tissues which includes the walls of hypopharynx.

Colon interposition for pharyngoesophageal postcorrosive strictures

BACKGROUND/AIM

Aim of this paper is to report a 40 years experience in performing colon interposition for pharyngoesophageal caustic injury.

METHODOLOGY

In the period between 1965 and 2005, 83 colon interpositions were performed due to the pharyngeal and high esopahageal injuries. Patients were classified according to the uppermost level of stricture in 3 groups: supraglotic, hypopharyngeal and esophageal ostium. In most of the patients (89.1%) an extrapleural retrosternal by-pass colon interposition was performed, while in the remaining 10.9% a colon interposition with esophagectomy had to be done. Long-term follow-up results were obtained in the period between one and up to 30 years.

RESULTS

Early postoperative complications occurred in 16.8% of patients, among which anastomotic leakage was the most common. Overall intrahospital mortality rate was 6%, while late postoperative complications were present in 14.4% of patients. Long-term follow-up was obtained in 84.2% of patients, with excellent functional results being present in 86.7% of them.

CONCLUSION

Colon graft is an excellent esophageal substitute for patients with pharyngoesophageal corrosive strictures, and used by experienced surgical team it provides low postoperative morbidity as well as mortality rate, and a long time good and functional quality of life.

Primary esophageal diffuse large B-cell lymphoma: report of a case

Primary esophageal lymphoma is very rare, with fewer than 25 cases documented in the English-language literature. We report a case of primary diffuse large B-cell lymphoma of the esophagus in a 42-year-old woman. Barium esophagogram revealed almost complete esophageal obstruction at the level of the cervical esophagus, and flexible endoscopy showed a circumferential submucosal tumor covered with intact mucosa. Neck magnetic resonance imaging (MRI) showed a wide cervical mass circumferentially encompassing the lumen of the cervical esophagus. Biopsies taken with multiple forceps during flexible and rigid esophagoscopy were nondiagnostic. Finally, external esophageal wall biopsies taken during neck exploration provided information that helped us establish the diagnosis. Pathohistological findings confirmed non-Hodgkin's lymphoma of the diffuse large B-cell type. The patient was treated with combined immunochemotherapy, consisting of rituximab plus cyclophosphamide, vincristine, adriablastin, and prednisone (CHOP), followed by irradiation. A complete response was achieved, and 3 years after diagnosis and treatment the patient was disease-free.

[Treatment of gastrointestinal hemorrhage manifestation induced by nonsteroidal anti-inflammatory agents]]

INTRODUCTION

The risk of upper gastrointestinal tract bleeding in the patients taking NSAID estimates 1% per year. Bleeding stops spontaneously in approximately 80% of all cases. Persistent and repeated bleeding (expecialy during the initial hospitalization) still represent the serious clinical problem. In this group of patients, mortality rate is between 6-10%, which in the USA counts 10-20000 patients per year.

AIM OF THE STUDY

The purpose of this review is to update the current knowledge of the use of different therapeutic strategies in patients with NSAID induced upper gastrointestinal bleeding.

RESULTS

Proton pump inhibitors (PPI) therapy is effective as a prevention of NSAID induced acidopeptic lesions, and also represents the first and best therapeutic option for the treatment of complications, such as upper gastrointestinal bleeding. In the last three decades use of early flexibile (diagnostic and therapeutic) endoscopy, agressive acidosupression (PPIs), and surgical treatment in restrictive indications, resulted in decreasing of the mortality rates from 25-35% to 6-10%. When PPIs and flexible endoscopy are not sufficient in the control of upper gastrointestinal bleeding, use of systemic hemostatic drugs could be taken into consideration.

CONCLUSION

Multidisciplinary approach, precise diagnostic and therapeutic critearia would probably result in better outcome of patients with active upper gastrointestinal bleeding.

[Gastrointestinal stromal tumors (GIST) of the stomach as a cause of upper gastrointestinal bleeding]

Gastrointestinal stromal tumors (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. GIST is currently defined as a gastrointestinal tract mesenchymal tumor containing spindle cells (less commonly epitheloid cells or rarely both) and showing CD 117 (c-kit protein) positivity in more than 95% of cases. Although they may arise throughout the gut, the commonest site are stomach (60-70%), small intestine (20-30%), colorectum (5%) and esophagus (up to 5%). Rarely, GISTs develop in the retroperitoneum, omentum or mesentery. GIST originates from the intestinal cell of Cajal (ICC). ICCs are located in and around the myenteric plexus and are thought to function as intestinal pacemaker cells. Historicaly, GIST were often misclassified as leiomyomas or leiomyosarcomas. Subsequently, it has been determined that GISTs have distinct ultrastructural features and immunophenotypical markers compared with smooth muscle and smooth muscle tumors. GIST predominantly occur in middle aged and older patients, with no significant difference in the sex incidence. Data from the recent population study suggest an incidence of about 10-22 cases per million persons per year. Clinical presentation of GIST varies widely, and depends on tumor size and location. GISTs that caused symptoms tended to be larger with an average size of 6cm versus 2cm for asymptomatic GISTs. Symptoms are most commonly related to mass effect or bleeding. GISTs can grow very large before producing symptoms. Commonest symptom of gastric GIST is manifest or occult bleeding. Abudant, life-threateting bleeding that require urgent surgery is rare. For patient with primary, localized, nonmetastatic GIST, complete surgical resection represents the only chance for cure. Lymhadenectomy is not necessary, because lymph node metastasis is very rare. The 5 year survival rate in patients with resected primary GISTs ranges from 48-65%. Conventional chemotherapy and radiation therapy is ineffective in the treatment of GIST. Imatinib mesilate (a tyrosine kinase inhibitor) was confirmed to be effective against metastatic or unresectable GISTs.

[Dieulafoy's lesion: rare cause of massive upper gastrointestinal bleeding]

Dieulafoy's lesion is an unusual and potentially life-threatening cause of massive, recurrent gastrointestinal bleeding. Its reported incidence as a source of upper gastrointestinal bleeding ranges from 0.3-6.7%. Dieulafoy's lesion is most commonly located in the proximal stomach (75% of cases). Lesion typically occur within 6 to 10 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Similar lesions have been identified in the esophagus, duodenal bulb, jejunum, ileum, colorectum, anal canal, even in bronchus. Detection and identification of the Dieulafoy's lesion as the source of bleeding can often be difficult, especially because most present with massive bleeding. Because of intermittent nature of bleeding, initial endoscopy is diagnostic in 60% of the cases, so repeated endoscopies are often necessary. If the lesion can be endoscopically documented, attempts should be made to achieve hemostasis using one or a combination of several endoscopic modalities. Success has been reported with multipolar electrocoagulation, heater probe, noncontact laser photocoagulation, injection sclerotherapy, endoscopic hemoclipping and band ligation. Surgery is reserved for lesions that cannot be controlled by endoscopic techniques. When localized, a wide wedge resection of entire area traversed by the large submucosal artery is recomended because rebleeding has been described after simple coagulation and ligation.

[Upper gastrointestinal bleeding as a surgical complication of primary gastric lymphoma]

Primary gastric lymphomas are of the extranodal non-Hodgkin type. The gastrointestinal tract is the most common site of extranodal non-Hodgkin lymphomas and accounts 30-45% of all extranodal lymphomas. Gastrointestinal lymphomas occurs in the stomach in 55-70% of cases. Primary gastric lymphoma is relatively rare tumor accounting 1-7%, of all gastric malignancies. An increased incidence has been documented recently. The median age of diagnosis is approximately 60 years old, and disease affects an equal number of men and women. The initial symptoms may be vague and nonspecific leading to delayed establishment of diagnosis up to several years. Many patients came down late with advanced disease and complications such as upper gastrointestinal bleeding. Twenty to thirty percent may present with occult bleeding or hematemesis et melena while gastric obstruction and perforation are less common. Gastric bleeding can also occur as a complication of chemotherapy. The incidence of gastric bleeding in patients receiving chemotherapy is up to 11%. In most cases surgical resection is necessary to achieve hemostasis. Given the rate of surgical complications, especially gastric bleeding, there is still an important role for surgeon in the multimodal treatment of patients with primary gastric lymphoma.

[Systemic hemostatic drugs]

Understanding the haemostatic changes is crucial in developing strategies for the management of haemorrhage syndroma. In recent years, the revised model of coagulation ("cell based" model) provided a much more authentic description of the coagulation process. Pharmacological intervention, especially desmopresin, antifibrinolytics (synthetics and nature) and increasingly recombinant activated factor VII are being used in prevention and therapeutically to control bleeding of variety etiologies. Skillfull surgery combined with blood saving methods and careful management of blood coagulation will all help in sucessfull haemorrhage prevention and treatment, and reduce unnecessary blood loss and transfusion requirements and its attendant risks. Among the all avalaible tests, the use of thromboelastography has allowed for more detailed dynamic assessment of the various steps of hemostasis.

[Less frequent causes of upper gastrointestinal bleeding]

Upper gastrointestinal (GI) bleeding represents emergency which despites modern advances in treatment still carry substantial mortality. Mortality remained relatively constant in the last 50 years at approximately 12%. Peptic ulcers remain the most common cause of upper GI bleeding and account approximately 50% of all cases. Next leading causes are esophageal and gastric varices, and gastroduodenal erosions. Mallory Weiss tears, angiodysplasia and gastric antral vascular ectasia (GAVE)-Watermelon stomach are less frequent but important causes of upper GI bleeding that contribute substantially to the overall morbidity and mortality. Recognition of such lesions is crucial to provide effective hemostasis. In most cases endoscopic therapy is procedure of choice which significantly improved the outcome of patients. In cases where endoscopic hemostasis is not effective, or patients rebleed after initial control surgical therapy may be required. This article will review recent advances in diagnosis and therapy of upper GI bleeding caused by Mallory Weiss tears, angiodysplasia or Watermelon stomach.

Iron deficiency anemia and its importance in gastroenterology clinical practice

Iron deficiency anemia (IDA) is a universal problem involving individuals of all ages and both sexes and is a common cause of referral to medical departments. This anemia is one of the most common types of anemia. IDA impairs growth and intellectual development in children and adolescent. In women IDA is most common in reproductive period because of menstrual and pregnancy iron losses. IDA affects roughly 10-30% of all pregnancies and, among others morbidities, may contribute of developing postpartum depression. Among other adult patient, chronic occult gastrointestinal bleeding is the leading cause of IDA. Approximately, one third of patients with anemia have iron deficiency and up to two thirds of patients with IDA have serious gastrointestinal lesions detected with esophagogastroduodenoscopy and colonoscopy, including 10-15% with malignancy. However, in practice not all anemic patients undergo appropriate diagnostic tests to detect iron deficiency. Furthermore, a substantial proportion of patients with IDA do not undergo endoscopic evaluation. The approach to its investigation and subsequent therapy depends upon a comprehensive understanding of iron metabolism and heme synthesis. Once diagnosis of iron deficiency or IDA is established, evaluation for the cause of anemia must be appropriate performed and treatment must include corrective replenishment of body stores.

The significance of lymphonodal micrometastasis in the patients with gastric adenocarcinoma

Micrometastasis is defined as microscopical deposit of malignant cells, less than 2mm in diameter, separated from the primary tumor. This does not include discontinous growth in peritumoral region, but include microinolvement of regional lymph nodes. The literature on micrometastases, with special resperct to nodal micrometastasis, and their implications in gastric adenocarcinoma have been reviewed. Immunohistochemical detection offer the best accuracy for detection of nodal micrometastasis. Molecular techniques are more sensitive than method of immunohistochemical detection, but methods are compromised with false positive results caused by various sources of biological contamination. It is more than obvious that there is no definite agreement neither about risk factors, nor definitive clinical significance of micrometastatic node involvement in the patients with gastric adenocarcinoma. At present, the role of occult lymph node involvement proved its significance in two major fields: defining criteria for limited surgical dissection in the patients with early (sm) carcinoma in respect to detection of micrometastatic tissue in sentinel lymph node, and distinguishing the category of pN0 (Mi+) patients with potential benefit of postoperative adjuvant therapy.

Surgical treatment and clinical course of patients with hypopharyngeal carcinoma

In the period between 1 January 1978 and 1 January 2004, 85 patients with hypopharyngeal squamocellular carcinoma were admitted at the Department of Esophagogastric Surgery in Belgrade. Among them, only 46 patients (54.1%) had radical surgical en-block resection and functional neck dissection, and they were included into an historical cohort study. In 40 patients a pharyngolaryngoesophagectomy was performed using for reconstruction, stomach tissue in 29 and colon tissue in 11 patients. Since 1996, in six patients with localized hypopharyngeal carcinoma pharyngolaryngectomy was performed with resection of cervical esophagus and free jejunal graft interposition. The overall incidence of morbidity was 50.0% and the overall mortality rate was 13.0% (6 patients). Mean hospital stay was 35 days (range, 18-78 days). The median survival of patients was 26 months, and overall 5-year survival rate was 26.5%. At present, surgery seems to be the appropriate therapeutic choice for patients with advanced hypopharyngeal carcinoma, providing a definitive palliation of dysphagia and relatively good long-term survival. At our Institution, after pharyngolaryngoesophagectomy, reconstructive method of choice is gastric 'pull-up', and the colon is used only when stomach tissue is not available, that is, previous gastric resections, inappropriate blood supply, synchronous gastric carcinoma and so on. Recently, pharyngolaryngectomy and free jejunal transfer has become the standard technique in patients with small carcinomas (up to 3 cm) confined to the hypopharynx in the absence of synchronous esophageal and/or gastric carcinoma.

Intraoperative endoscopy in obstructive hypopharyngeal carcinoma

AIM: To demonstrate the necessity of intraoperative endoscopy in the diagnosis of secondary primary tumors of the upper digestive tract in patients with obstructive hypopharyngeal carcinoma.

METHODS: Thirty-one patients with hypopharyngeal squamous cell carcinoma had been operated, with radical intent, at our Institution in the period between 1978 and 2004. Due to obstructive tumor mass, in 7 (22.6%) patients, preoperative endoscopic evaluation of the esophagus and stomach could not be performed. In those patients, intraoperative endoscopy, made through an incision in the cervical esophagus, was standard diagnostic method for examination of the esophagus and stomach.

RESULTS: We found synchronous foregut carcinomas in 3 patients (9.7%). In two patients, synchronous carcinomas had been detected during preoperative endoscopic evaluation, and in one (with obstructive carcinoma) using intraoperative endoscopy. In this case, preoperative barium swallow and CT scan did not reveal the existence of second primary tumor within esophagus, despite the fact that small, but T2 carcinoma, was present.

CONCLUSION: It is reasonable to use intraoperative endoscopy as a selective screening test in patients with obstructive hypopharyngeal carcinoma.

[Strategy in the treatment of hypopharyngeal and cervical esophageal carcinoma]

In the period between January 1st, 1978 and January 1st, 2003, 82 unselected patients with hypopharyngeal and cervical esophageal squamocellular carcinoma were treated at the Department of Esophagogastric Surgery, First University Surgical Hospital, Clinical Center of Serbia. In 43 (52.4%) patients operated with curative intent, radical surgical en-block resection and functional neck dissection has been performed. In 26 (60.5%) patient reconstruction was performed with stomach, in 11 (25.6%) left colon, and 6 (14%) free jejunal transfer. The overall 2-year and 5-year survival rate were 55.88% (19 patients) and 26.47% (9 patients), respectively. No patient undergoing nutritive gastrostomy and radiotherapy was alive after two years. At present surgery looks like the treatment of choice for hypopharyngeal and cervical esophageal carcinoma, providing a definitive palliation of dysphagia and better long-term survival. Free jejunal transfer has become the standard technique for reconstruction of the pharynx and hypopharynx especially with proximal lesions, whereas, gastric tube interposition is the technique of choice for reconstruction of the hypopharynx and cervical esophagus when the resection extends below the thoracic inlet or when there is a presence of synchronous carcinoma of theesophageal.

[Prevalence and importance of nodal micrometastasis in patients with gastric adenocarcinoma]

Micrometastasis is a microscopic (less than 2 mm) deposit of malignant cells separated from the primary tumor. The incidence and importance of occult perigastric lymph node involvement were analyzed in 26 pN0 patients using the prospective method. The occult lymph node involvement was detected by immunohistochemical method using the anticytokeratin 8/18 antibody. Prevalence of clinically significant occult lymph node involvement (Mi+) was statistically significant, and found in 38.5% of pN0 patients. Out of tumor characteristics analyzed as possible predictors of occult lymph node involvement, the histological grade (GH) and the involvement of lymphatic vessels within gastric wall (pL1) had significant effect on the respective evaluation. The patients with histological grade 3 and 4 had occult lymph node involvement more often than those with grade 1 and 2 (p<0.05). More than 60% of pL1 patients had occult lymph node involvement LN (Mi+). Due to high prevalence of micrometastatic lymph node involvement, detection with specific immunohistochemical or molecular biology techniques should be a part of routine specimen examination in patients with pN0 gastric cancer.

[Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery]

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.

Modified stapling technique of esophagojejunal anastomosis

The most dangerous complication of total gastrectomy, often causing postoperative death, is dehiscence of esophagojejunal anastomosis. After analyzing more then 300 patients undergoing surgery for gastric and/or cardiac carcinoma at our department in the period 1992-96, we concluded that the main cause of anastomotic dehiscence was a technically insufficient anastomosis, and the main risk factor was hypertrophied muscular layer of the esophagus (predominantly in advanced cardiac carcinoma). In this paper we discuss indications for, and the surgical technique of, our own modification of mechanical esophagojejunal anastomosis. In the period between 1 January 1997 and 1 March 2001, 148 procedures were performed using the modified anastomotic technique. In only two patients (1.35%) were radiological signs of small anastomotic leakage observed. The described modification of mechanical esophagojejunal anastomosis is safe and is not a time-consuming procedure. It is highly recommended in the treatment of the obstructive cardiac carcinoma with a compensatory hypertrophied muscular layer of the esophagus.

[History of surgery of stomach and cardial carcinoma]

Despite the marked decline in incidence during last 50 years, gastric cancer remains significant cause of mortality and morbidity worldwide. According to data in 1984. incidence in Yugoslavia was 35 per 100,000. In the United States, where incidence is not high, 24,000 new cases and 13,300 deaths had been estimated for the year 1992. Despite fact that modern diagnostic and surgical concept changed perspective for significant number of the patients with gastric carcinoma, most authors agree that Gastric cancer may be the most seriously mismanaged malignancy from a surgical perspective in the USA ... (Paul H. Sugarbaker, M.D, April 1999.) Analyzing medical literature, with special respect to domestic literature, authors analyzed historical data of gastric cancer surgery.

[Correction of failed primary surgical interventions in benign lesions of the esophagus]

In an retrospective analysis of documentation and printed paper in period between 1964-1998 168 patients required reoperations in benign esophageal lesions. Failed initial interventions were found in 66 (39.28%) pts. operated in our clinic and 102 (60.71%) pts operated in other institutions in our country. The corrective procedure was possible in 140 (83.33%) pts and impossible in 11 (6.54%). Post-operative mortality was 7.73% so the definitive failed corrections were 14.27%. The main cause of failure were: Defective operative technique, wrong preoperative diagnosis and indications including inadequate initial procedure. Among the 168 pts undergoing corrective surgery, more than a half of pts had obstructive lesions requiring resections and reconstructions. Dilatation of the stricture was possible in 16% followed by total diversion, particularly in previous gastric surgery. Malignant degeneration of benign lesions were found in 10.71%. Only 4 pts (2.3%) refused suggested operations. Satisfactory long-term results especially in patients undergoing esophageal corrective reconstructions for benign diseases were good to excellent in regular yearly postoperative routine control examination.

[Surgical strategy in the treatment of primary lymphoma of the stomach]

Primary gastric lymphoma has been traditionally accounted for only 1-7% of all malignancies of the stomach. During the period 1980-1996 in Department of Esophagogastric Surgery of University Surgical Hospital in Belgrade 41 patients have been operated due to primary gastric lymphoma. Radical surgery is the only therapeutic procedure in more then 45% of patients. It is also a safe procedure with specific complication rate less then 22%, and specific mortality rate less then 5%. In our experience, total gastrectomy with systematic lymphadenectomy is a therapy of choice in most patients with primary gastric lymphoma.

[Reconstruction of the hypopharynx and cervical esophagus using a free jejunal graft]

Extensive malignant tumors of the hypopharynx and cervical esophagus continue to challenge surgeons in respect to both type and extent of resection as well as type of reconstruction. In the period between November 1st, 1996 and November 1st, 1998, at our Department, five patients have been operated due to squamocellular carcinoma of the hypopharynx using a free jejunal graft reconstruction method. The first free jejunal graft operation due to hypopharyngeal carcinoma, at the same time the first operation of this kind ever done in our Country, was performed on November 13th, 1998. There were 4 female and one male patient, average age 47.75 years. Disfagia for solid foods was a leading symptom in all patients (mean duration of 3.5 months) and was always accompanied with weight loss (average of 8 kg for two months). In all patients barium swallow, endoscopy, CT as well as intraoperative endoscopy was performed. Radical surgical procedure was always accompanied with the bilateral modified lympf node neck dissection. As a arterial donor vessel superior thyroid artery was used in all patients. As a venous drainage in three patients a external jugular vein was used and in two facial vein. Reconstruction using a free jejunal graft of approximately 25 cm long was performed in all patients creating upper, oropharingeal, anastomosis end to side and distal, esophageal, end to end (in only one patients side to end) using 3/0 apsorbable sutures. Mean duration of the operation was six hours. The postoperative course in all patients was uneventful. On the 9th postoperative day gastrografin and three days later barium swallow radiography was performed as a standard control study. Regular check ups were done on three, six, nine months, year and two years. On all controls all patients were symptom free and feeling well. It is our opinion that in the patients with isolated carcinoma of the hypopharynx due to low morbidity and mortality rate, free jejunal graft method is the surgical procedure of choice.

[Surgical treatment of cardial carcinoma]

In the period from 1970 to 1996, in the Departmenf of Esophagogastric Surgery, Belgrade, Yugoslavia 562 have been operated with curative intent due to cardiac carcinoma. Since 1970 until 1985, in 182 patients a distal esophagectomy and proximal gastrectomy followed by eosphagogastro anastomosis had been performed. In the period between 1982 and 1996, a distal esophagectomy with total gastrectomy and radical or extended radical dissection and intrathoracic esophagojejuno anastomosis in 380 patients (192 hand sewn 3/0 interrupted sutures and 188 spapled anastomosis) had been performed. In our opinion for the majority of patients with advanced cardiac carcinoma distal esophagectomy and total gastrectomy, via the left thoracoabdominal approach, with D2 pancreas preserving splenectomy and dissection of lymph nodes in stations 16a1 and 16a2 is a surgical therapy of choice. Overall complications of such a procedure not differ in type and number from those after standard total gastrectomy and D2 dissection.