Tutorial of CARCINOMA OF THE CARDIA

Tutorial of CARCINOMA OF THE CARDIA

Esophagogastrcctomy. The approach to cancers of the cardiac end of the stomach is governed primarily by the known paths of spread from these growths as differentiated from the squamous-cell cancers of the esophagus. Extension to the liver by the portal system is common and may occur early in the disease. Lymph node spread takes place, in order of frequency, in the following directions: the nodes along the left gastric vessels, the nodes along the superior border of the pancreas, the splenic hilar nodes, the greater curvature nodes, and the periduodenal nodes. There may be contiguous extension to neighboring structures, such as the diaphragmatic hiatus, the body and tail of the pancreas, and the edge of the left lobe of the liver. Extension upward along the esophageal mucosa is very common, and the extent of this inspread can be determined by preoperative esophagoscopy (Figs. 48, 49, 50, 51). This information guides the surgeon in choosing the appropriate interspace for adequate exposure of the thoracic esophagus. It becomes obvious, therefore, that the initial part of the operation is concerned with determining operability. This is accomplished by an abdominal incision (Fig. 52). The demonstration of a resectable tumor calls for extension of this incision into the left side of chest, thus creating an abdominothoracic exposure. This combined incision has simplified markedly the operation of esophagogastrectomy, as well as total gastrectomy, with a resultant significant decrease in postoperative morbidity and mortality rates. Important, also, has been the decreased operating time. In my view, these are all important factors when the surgeon is faced with so large a proportion of patients in the older age groups.

The Surgery Technique of CARCINOMA OF THE CARDIA:

The patient is placed on the operating table so that the right side is tilted at a 30 degree angle from the horizontal (Fig. 52).

carcinoma of the cardia

Fig. 48. Roentgenogram of esophagus and stomach indicating a carcinoma of the cardia with growth up the esophagus.

A kidney rest against the sacrum helps to stabilize this position. The right knee is bent to a right angle beneath the extended left leg, and a pillow is placed between to prevent venous compression. For added security of position, a broad strip of adhesive may be stretched across the pelvis at the iliac crest. The draping exposure includes the entire abdomen and left thorax. The abdominal incision is made first, extending it transversely across the upper abdomen midway between umbilicus and ensiform process. The abdominal exploration should be thorough and orderly. The liver is palpated first for metastases.

involving the lower esophagus

Fig. 49. Another example of a carcinoma originating at the cardia and involving the lower esophagus.

 

The undersurface of the diaphragm should be in eluded in this exploration. Next the pelvis is explored for nodules in the cul-de-sac. As the exploring hand is drawn upward, the omentum is palpated and brought out for inspection. The cardial lesion is now examined for size, mobility, and peripheral extent, such as fixation to the diaphragm, liver, pancreas, or retroperitoneal areas. The celiac, peripancreatic, splenic hilar, gastric, and periduodenal lymph nodes should now be carefully palpated for gross involvement.

Carcinoma of the cardia

Fig. 50. Carcinoma of the cardia with the major growth in the lower third of the esophagus.

 

Tutorial Alimentary Tract Surgery online:

The decision to continue with radical surgery will depend largely on the extent of peripheral spread, the feasibility of carrying out a good cancer operation for possible cure, and the judgment of the surgeon based on previous experience. What may appear inoperable to one surgeon may be considered resectable by another more experienced surgeon. On the contrary, the inexperienced might attempt a radical procedure in a situation which would deter the experienced surgeon with sounder judgment.

Roentgenogram of the stomach depicting a carcinoma

Fig. 51. Roentgenogram of the stomach depicting a carcinoma in the so-called silent area in the beginning of the greater curvature with the characteristic fingerlike projections frequently noted in this region.

To attempt a radical resection in the presence of pelvic implants and nodules in the great omentum is, in my view, a foolhardy gesture. Patients with extensive hepatic spread do not tolerate this operation. But I can see every justification forundertaking a palliative resection in the presence of a few hepatic nodules. Removal of the distal half of the pancreas to accomplish a radical resection should be done without hesitation. Splenectomy is carried out routinely.

abdominothoracic

Fig. 52. Recommended abdominothoracic incision for carcinoma of the cardiac end of the stomach. The position of the patient is indicated. The incision starts in the upper abdomen in the transverse direction for abdominal exploration and continues onto the chest when the tumor is found to be resectable.

Once resection is decided upon, the surgeon prolongs the outer end of the transverse abdominal incision across the rib margin into the eighth interspace as far as the angle of the ribs posteriorly (Fig. 53). The thoracic musculature is divided in the line of incision with complete hemostasis as the incision progresses. By dividing the rib cartilages between the eighth and ninth ribs, the surgeon obtains enough spreading to incise the intercostal muscles exactly midway between the ribs throughout the length of the thoracic incision. Both sides of the incision are now completely covered with moist towels which remain in place until the end of the operation. Complete wound protection during all operations is the best insurance against wound contamination and infection. By incising the peripheral part of the left diaphragmatic leaf, it becomes possible to insert a rib-spreader at the site of the divided cartilages. As the spreader is opened gradually, the diaphragm is incised in a radial direction toward the hiatus. During this process, the vessels coursing through the diaphragm should be accurately ligated. The phrenic nerve is pinched. Wide separation of the blades of the rib spreader effects a magnificent exposure of the entire field of operation.

requires transection of the costal cartilage

Fig. 53. Extension of the abdominal incision into the seventh or eighth interspace which requires transection of the costal cartilage. The intercostal muscles are divided midway between the ribs. In this way injury to the intercostal vessels and nerves is avoided. With radial division of the left leaf of the diaphragm after the chest is entered, a wide exposure is obtained with a judicious use of a large rib spreader.

This alone permits the surgeon to perform the operation with a minimum of trauma and a corresponding markedly reduced postoperative morbidity and mortality.

Examination of the tumor area and the regional nodes will indicate to the surgeon what the extent of the operation should be. In the majority of cases, I do not think it is necessary to perform a total gastrectomy in order to effect a radical removal for cure. However, the operation should include an en masse removal of the greater omentum, the spleen, almost the entire lesser curvature, the posterior parietal peritoneum and areolar tissue up to the diaphragm, and, not infrequently, the distal half of the pancreas. The left gastric vessels are ligated and divided as they arise from the celiac axis. The importance of preserving intact the distal two thirds of the gastroepiploic arch should be stressed again. Most of the gastrohepatic ligament should be removed with the specimen. Before mobilizing the stomach, the surgeon is advised to free the esophagus from the lower portion of the mediastinum and occlude its lumen with an encircling stout ligature well proximal to the upper edge of the tumor. The importance of this maneuver has already been stressed. Mobilization of the stomach may be initiated by separating the spleen from its posterior peritoneal attachments and entering the lesser sac from this direction. The surgeon is admonished to avoid injuring the adrenal gland which lies in the immediate vicinity. As the stomach is brought forward, the posterior peritoneum and areolar tissue are peeled away as far as the neck of the pancreas. In fact, the entire area cephalad to the pancreas and up to the diaphragm should be similarly treated. Because of fixation, it may be necessary to excise part of the hiatus during the process of tumor removal.

After ligation of the left gastric vessels previously described, the stomach is now ready for transection. After setting up a “dirty field,” the surgeon now places a long narrow-bladed clamp across the stomach in such a manner as to remove most of the lesser curvature and the proximal third of the greater curvature, well beyond the tumor-bearing area. The remaining stomach now assumes the shape of an elongated tube. The divided end is closed in two layers by the technique previously described. The technique of esophagogastric anastomosis is exactly the same as described in the section on supra-aortic anastomosis. I might stress again the importance of avoiding the slightest tension on the suture line. The esophagus should be transected at least 2 inches proximal to the upper edge of the tumor. The more proximal, the better!

The transplanted stomach is now placed in the posterior mediastinum and fixed to the mediastinal pleura on each side with sutures of fine silk. The hiatus is now closed securely about the stomach as already described. Repair of the diaphragm is accomplished by using 00 interrupted silk sutures placed with accuracy and care. Removal of the rib-spreader facilitates the placing of these sutures. The insertion of an underwater drainage tube through a subjacent intercostal space posteriorly follows the repair of the diaphragm. The chest wound closure is expedited by the use of a pair of Bailey rib approximators. As mentioned before, in closing the intercostal space, I suture only the external intercostal muscle. In this way, the intercostal neurovascular bundle is avoided. As a result, intercostal neuralgia has been all but eliminated. The thoracic musculature is repaired in layers up to the divided cartilaginous costal arch. By excising a small segment of the cartilage on each side, one is able to bring the arch together snugly with the help of one or two No. 1 chromic catgut sutures passed through each side. I would counsel against the use of nonabsorbable suture material for this purpose. Persistently draining sinuses may result. The abdominal portion of the incision may be closed quickly and effectively by interrupted figure-of-eight 30 gauge steel wire sutures which include peritoneum, muscle, and fascia. Expulsion of any trapped air through the underwater drainage tube completes the procedure.

Critique of Other Procedures. The statement has been made frequently in the literature that the stomach is a poor substitute for the esophagus when it is used to reestablish esophagogastric continuity following esophagectomy for cancer. This has given rise to a flood of substitute procedures utilizing various segments of the colon and jejunum. I am afraid that this frequently voiced opinion is not in accord with clinical experience, laboratory studies, and long-term follow-up observations.

It seems to me that the confusion engendered by these statements can be attributed to the complete lack of differentiation between benign and malignant diseases of the esophagus. There is no disagreement with the thesis that reflux esophagitis frequently follows the operation of esophagogastrectomy for benign disease of the esophagus, such as stricture after an unsuccessful Heller operation for achalasia or stricture associated with a hiatus hernia. The physiological reason for this is the persistence of free acid in the stomach in spite of complete vagectomy. With cancer of the cardia and esophagus, the opposite is true. Practically every patient in our series has been anacid prior to surgery. In 1952, Dreiling, Druckerman, and Hollander reported from my service (Gastroenterology, Vol. 20, April 1952) the results of their study of pancreatic function after complete vagectomy which necessarily accompanied esophagectomy for cancer of the cardia and esophagus. During this study, it was determined that all of these patients, with one exception, were completely anacid. The exception had an insignificant amount of free acid. In our entire series, there has been only one instance of reflux esophagitis following esophagogastrectomy for cancer of the cardia, and this occurred 10 years after operation following this prolonged period of complete anacidity. The esophagitis was mild in degree and responded quickly to antacid therapy. This patient is still alive, 17 years after operation, and free of symptoms; he represents the curious physiological fact of return of gastric acidity after a 10 year period of anacidity.

Because of these frequently repeated observations, it seems to me that the argument advanced against the use of the stomach that there is a grave risk of subsequent reflux esophagitis is a specious one. The proponents of this objection must look elsewhere for reasons against the operation of esophagogastrectomy for cancer. It may be that their operative experience has been none too happy from the standpoint of leakage at the suture line, necrosis of areas of the upper stomach, and other complications of a technical nature. That these are of no small moment cannot be denied. But again, in the adoption of preventive measures, I would emphasize the importance of every technical detail of the operation and the rigidly controlled postoperative care of the patient. There certainly can be little objection to the employment of other organ substitutes provided that there is a concomitant acceptable morbidity and mortality rate and, at least, the same incidence of late survival.

Although the use of a loop of jejunum would be preferable for physiological reasons, there are so many inherent dangers to its routine employment that the surgeon must look elsewhere for a substitute organ. The main objection to the jejunal loop is the ever-present problem of adequate blood supply. Yudin was the greatest exponent of the use of jejunal loops, and he had a remarkably low incidence of necrosis postoperatively during his extensive experience in the surgical correction of lye strictures. But, in the hands of the average surgeon who attempts the occasional operation, blood supply problems loom large because of the relative shortness of the jejunal mesentery and the configuration of the vascular arcades. It becomes necessary to use more convoluted loops than are needed to bridge the defect, thereby creating a space problem as well as the probability of obstruction. For these reasons, surgeons have come to place greater reliance on sections of the colon for substitute interposition. The greater length of mesentery, the presence of the marginal artery which assures intercommunication between all the major colic vessels and the greater ease of using a straight segment of bowel instead of a convoluted loop are all factors which have increased the popularity of the colon for esophageal replacement or bypass. Experimental observations have demonstrated without question that when a segment of jejunum or colon is interposed between the esophagus and the stomach, it must be placed in an isoperistaltic direction, i. e., the proximal end at the upper anastomosis and the distal end at the lower anastomosis. Reversal of the segment to produce an antiperistaltic direction results in all sorts of motor difficulties which can be corrected only by a reversal of the loop.

Reference has already been made to the two-stage operation which, occasionally, may be adopted when the surgeon is confronted with complicating factors which could adversely alfect the patient’s recovery. Another variation is that reported by Luna and Ernst of Dallas, Texas. This method, a three-stage procedure, has been utilized by others. A loop of colon is inserted retrosternally connecting the cervical esophagus and the stomach without attacking the cancer. The second stage is the administration of the cobalt therapy to the tumor, and finally as a third stage, the thoracic esophagus is resected. However, if a radical esophagectomy is done at the first sitting, I see no reason why the stomach should not be used instead of the colon. It is certainly a more easily consummated operation and more physiological.

Another problem which merits special attention is concerned with the most desirable therapeutic approach to the obviously inoperable squamous-cell esophageal cancer. The increasing dysphagia and the constant regurgitation of large quantities of saliva are the two distressing symptoms which have led many surgeons to undertake heroic procedures, such as bypass operations, most often utilizing segments of the colon. Experience has shown that, in the obviously inoperable patient, these operations are followed by a prohibitive mortality. In fact, I know a number of surgeons who have discarded this approach because of the high mortality rate associated with it. I went through this phase some years ago and quickly learned my lesson. With the advent of high-voltage radiation therapy, especially radioactive cobalt, a new modality of greater potential became available. Now, instead of ill-advised bypass operations, these inoperable tumors are referred for radiation therapy. Not infrequently, in the early phase of such treatment, edema in and about the tumor-bearing area may increase the dysphagia and necessitate the passage of a fine plastic Levin tube by esophagoscopic control. This is left in place for feeding purposes until the lumen enlarges to a degree which allows for its removal. The palliation afforded by this therapy has often been quite astonishing. Frequently, the radiologist is unable to locate the original site of tumor by subsequent barium x-ray examination (Fig. 54). The average period of palliation varies between 12 and 18 months, and the treatment is free of mortality. I recently had the unusual experience of operating on a patient who had had radiation therapy for a mid-esophageal cancer two and one half years before. Because of return of dysphagia, relief was sought. At operation, an easily resectable tumor was encountered. This is certainly an unusual set of circumstances.

The problem with inoperable cardial cancers is different. These tumors are radioresistant. I have never seen one instance of response to high-voltage therapy. Occasionally a bypass anastomosis can be effected between the greater curvature of the stomach and the lower esophagus by a side-to-side anastomosis. But usually in the inoperable patient, there is such extensive involvement that nothing can be done. Here also the use of sections of colon for bypass purposes carries a very high initial mortality. Perhaps the newer cancericidal drugs may prove to be effective, but I must state that, with the drugs available today, I have not encountered the slightest beneficial effect.

Another variation in operative approach is that practiced by Mr. Andrew Logan of the Royal Infirmary in Edinburgh. He recently reported his technique and results at a meeting of the American Association for Thoracic Surgery. In the main, the operation encompasses a more radical removal of surrounding tissues than is usually practiced by those with extensive experience in this field of surgery. Apparently his operation is confined to tumors in the lower third of the esophagus and cardia. In dissecting out the thoracic esophagus, he creates an encircling envelope of tissue consisting of adventitia of the aorta and both the right and left mediastinal

Esophagram of a patient

Fig. 54. Esophagram of a patient who was found to be inoperable at exploration. The x-ray on the left shows the extent of the tumor and the x-ray at the right shows the effect of cobalt therapy. This salutary response has been noted frequently.

pleura. This dissection is continued into the abdomen through the diaphragm, with extensive removal of the posterior peritoneum and subjacent tissues, a good portion of the pancreas, the spleen, a large section of stomach, and part of the diaphragm. The gastroesophageal anastomosis is always located below the aortic arch. Let us examine the facts to determine whether this extra effort is worthwhile. In the first place, Logan makes no differentiation between adenocarcinoma of the cardia and squamous-cell cancers of the esophagus. It is well known that they are biologically different tumors, behave differently, and have different directions of spread. In the second place, the line of transection of the esophagus is too distal to exclude intramural lymphatic spread. Third, his operative mortality is 30 percent, a figure generally considered prohibitive. Fourth, Logan reports a very high incidence of suture line leaks which undoubtedly have their origin in difficulties related to the blood supply. In the fifth place, no distinction is made between operations for cure and operations for palliation. And, finally, the end results in terms of long-term survival are no better than those reported by other surgeons who perform less radical operations. For these reasons, I am not impressed by the more extended operation as reported by Logan.

 

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