Malignat tumors of the esophagus

Malignat tumors of the esophagus

Despite recurring reports in the literature during the past decade which depict a rather bleak outlook for surgical therapy, the problem of malignancy of the esophagus remains a most important one in the overall consideration of diseases of the gastrointestinal tract. In this section, I will try to indicate how certain misconceptions have crept into the present viewpoint of a large number of American surgeons and make an effort to clarify many controversial features with a view to reaching a more rational approach to this difficult problem.

Although of different origin and different histological morphology, it has become customary to consider cancer of the esophagus and cancer of the cardiac end of the stomach under the same heading. I would like to emphasize that these two forms of malignancy have different biological characteristics, different anatomical extensions, and, very often, differ in their symptomatology and clinical course. For these reasons, they should be treated as separate entities. For purposes of clarification, however, both will be considered in this chapter, but under separate headings.

ESOPHAGEAL MALIGNANCY

Aside from rare exceptions, the overwhelming majority of malignant tumors are squamous-cell carcinomas. Occasionally, one may encounter primary adenocarcinoma of the organ arising, apparently, from either ectopic gastric mucosa or from the deeper cell layers of the esophageal mucosa. In our overall series of patients, we have had seven such examples. In one the tumor was located above the aortic arch. An almost total esophagectomy was performed with transposition of the stomach as far as the upper cervical espohagus. For the record, this patient is alive and quite well nine years later. There is no evidence whatsoever of esophageal inflammation in the remaining small segment. Swallowing is normal, but the patient must sleep on three pillows to prevent regurgitation of gastric contents (Fig. 24).

Malignat tumors

Fig. 24. Roentgenogram of patient referred to in the text, nine years after resection of the esophagus for primary adenocarcinoma of the esophagus behind the aortic arch. The esophagogastric anastomosis is in the cervical region.

Other rare malignant tumors of the organ are nonepithelial in origin. These comprise the leiomyosarcomas and the still rare melanocarcinomas and carcinosarcomas. I have had one of each in our group of patients. The leiomyosarcoma arose from the middle third of the organ and projected downward like a thick sausage toward the cardia (Fig. 25). Because the pedicle was infiltrated with tumor cells, a radical esophagectomy with supra-aortic gastroesophageal anastomosis was performed in 1946. This woman is alive and well 18 years later without any evidence of regurgitant esophagitis. The patient with the melanocarcinoma was reported in the Annals of Surgery for August 1955. She is alive and well 10 years after operation. It was suggested at the time of publication that these organ melanomas arise only from the melanoblast (the dendritic cell) and that primary melanocarcinoma of the esophagus arises from melanoblasts ectopically located in the esophagus.

Malignat tumors

Fig. 25. Roentgenogram of a large leiomyosarcoma arising in the middle third of the esophagus. Patient is alive and well 18 years after operation.

Malignat tumors

Fig. 26. Roentgenogram of a carcinoma at the cardiac end of the stomach in a long-standing hiatus hernia.

Although one may find mention in surgical textbooks of many factors which could be considered as predisposing to the development of cancer of the esophagus, I believe that most of them can be discarded because of lack of any confirmatory evidence. A few would seem to possess some significance. For instance, I have noted a tremendous preponderance of esophageal cancer among the Chinese and Japanese, who ingest their rice piping hot. Again, I have had 11 instances of cancer of the cardia in long-standing hiatus hernia, approximately 8 percent of the total series of this variety of hernia (Figs. 26 and 27). On the other hand, I have seen only one example of squamous-cell cancer of the lower esophagus occurring seven years after a Heller operation for achalasia, the patient being symptom free during the intervening years.

Malignat tumors

Fig. 27. Roentgenogram of a small carcinoma at the cardiac end of the stomach producing symptoms of obstruction for six weeks prior to operation. The hiatus hernia had been present for some years.

Malignat tumors

Fig. 28. Gross specimen of resected esophagus showing the scirrhous or infiltrating variety of squamous cell carcinoma.

From the standpoint of therapeutic approach, the esophagus may be divided into four segments: 1, the cervical portion, extending from the pharyngoesophageal junction to the superior thoracic aperture; 2, the retro-aortic and superior mediastinal segment, stretching from the superior aperture to the under edge of the aortic arch; 3, the infra-aortic portion, extending from the inferior border of the aortic arch halfway to the diaphragm; and 4, the distal segment which ends at the hiatus of the diaphragm. In order of frequency, cancers of the organ occur in segments 3, 4, 1, and 2. The gross appearance of these tumors conforms to a loosely defined classification of three main types, in order of frequency: 1, scirrhous or infiltrating variety (Fig. 28); 2, the ulcerating form (Fig. 29); and 3, the fungating polypoid type (Fig. 30). A few years ago Wu-Ying-Kai of Peking presented a tentative gross pathological classification at a meeting of the International Society of Surgery. It has not been generally adopted.

Malignat tumors

Fig. 29. Typical appearance of the ulcerating form of carcinoma of the esophagus with sharply defined overhanging edges and excavated base.

The scirrhous infiltrating type of esophageal cancer possesses a marked tendency to grow peripherally, involving at an early stage the hilus of the left lung or the wall of the descending thoracic aorta. Attempts to separate the tumor from these sites have often resulted disastrously. I remember, in the early days of our experience, attempting to separate a tumor from the undersurface of the aortic arch. In my youthful enthusiasm, I did not realize the significance of this tumor invasion and was soon left with a hole in the aorta plugged by my left index finger in the manner of the famed Dutch boy and the dike. When aortic grafts were unknown, repair of the hole was impossible because of carcinomatous infiltration. The ulcerating type may also extend peripherally, but not nearly as frequently. This variety resembles the gross appearance of a skin epithelioma with an ulcerated base and raised hard overhanging edges. There is usually considerable pulling inward toward the ulcerated tumor of the remaining circumference of the esophagus at this site resulting in a marked narrowing of the esophageal lumen.

Malignat tumors

Fig. 10. Roentgenogram of the esophagus disclosing the presence of large epiphrenic diverticulum. There is also present a traction diverticulum in the middle of the organ.

A long incision is made over the left eighth interspace. The musculature is severed and all divided vessels are carefully ligated. With operative incisions of this size, I have always employed an all-silk technique. The reason for this is that, with the myriad of ligatures that are required for complete hemostasis, there is practically no accumulation of serum postoperatively as compared with the appreciable collections that follow the use of similar quantities of catgut. I am certainly not favorably impressed with the appearance of such wounds that electrocoagulation is used for hemostasis instead of ligatures. The routine use of the Bovie machine for hemostasis has always suggested innate laziness on the part of the surgeon.

The incision in the interspace should be exactly between the contiguous ribs. This avoids injury to the intercostal vessels and preserves the intercostal muscles for later closure. The wound edges are covered with thick toweling, and a rib – spreader is inserted. If the surgeon now opens the spreader gradually over a period of eight to ten minutes, one notch at a time, he will obtain a wide opening of the chest without breaking the eighth or ninth ribs. If he does it hurriedly, one or both ribs will invariably be fractured. This makes for a more painful convalescence. The inferior pulmonary ligament is divided and the lung retracted cephalad. An incision is now made in the mediastinal pleura overlying the lower esophagus, which is then bluntly mobilized from the mediastinum. A Penrose tube is placed about it for traction purposes. The sac is now grasped and gradually separated from its areolar attachments until it emerges from the esophagus at the broad neck. Injury to the vagus nerves should be avoided.

The pleural cavity and wound are now covered with moist towels to set up a “dirty field.” The sac is removed piecemeal from one end of the neck to the other in exactly the same manner as described for Zenker’s diverticulum. The mucosal sutures are inverted toward the lumen (Fig. 11). A firm muscle repair is essential. However, these sutures should not be tied too tightly because it is easy to cut through the musculature in this region. The “dirty field” is discarded after the mucosal closure is completed. The cut edges of the mediastinal pleura are now loosely approximated over the esophagus, and the chest wound is ready for closure. A soft rubber tube is inserted into the chest through a stab wound in a subjacent intercostal space. The eighth and ninth ribs are approximated with two Bailey clamps, and the anesthetist is instructed to inflate the lung until it hugs the rib cage. I discarded the use of periscostal approximating sutures years ago because of the appreciable incidence of postoperative intercostal neuralgia. Instead I place interrupted 00 silk sutures in the external intercostal muscles, thus avoiding any injury or suturing of the intercostal nerves. Since the adoption of this technique, intercostal neuralgia has all but disappeared. I am emphasizing this point of technique because it is not generally appreciated. The Bailey approximating clamps are now removed, and the thoracic musculature is repaired carefully in layers. During the closure of the chest wound, the anesthetist maintains expansion of the lung until the dressing is applied. Underwater drainage through the intercostal chest tube is maintained until its removal on the sixth or seventh day. It need hardly be emphasized that this tube should be securely fastened to the water bottle to prevent inadvertent displacement during the postoperative period.

Postoperative care of the patient follows the same routine as described in the previous section. I never use an indwelling Levin tube because its presence in the vicinity of an esophageal suture line may produce pressure necrosis. As a matter of record, I saw two examples of this complication in consultation not too many years ago. In each instance, postmortem examination disclosed the Levin tube resting in a trough of necrotic tissue at the suture line following esophagectomy for carcinoma. I purposely leave the underwater drainage tube for five to seven days as a vent for possible suture line leakage. The appearance of gastric contents in the drainage calls for immediate exploration of the mediastinum. However, this should rarely, if ever, occur following the operation just described.

Malignat tumors

Malignat tumors

Fig. 11. Diagrammatic representation of the method of excision of an epiphrenic diverticulum and repair of the esophagus in two layers.

Malignat tumors

Malignat tumors

 

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