Michihiko Kitamura

Long-term evaluation of patients treated by radical operation for carcinoma of the thoracic esophagus

During the past 19 years, resection has been performed on 457 (72.9%) of 627 patients with carcinoma of the thoracic esophagus; curative resection was done in 388 patients. Among the 259 (57%) patients who underwent reconstruction through the retromediastinal space, thoracic esophagogastrostomy accounted for 181 and interposition of jejunal segments between the thoracic esophagus and the stomach accounted for 78 patients. Among the 171 (37.4%) patients who underwent reconstruction through the retrosternal space, there were 110 with esophagogastrostomy, 57 with interposition of jejunal segments, and 4 with colonic segments between the esophagus and the stomach. Comparing the reconstructive organs or the reconstructive routes used, there were no significant differences in the incidences of pulmonary complication, leakage, or operative death.Among the patients who tolerated curative surgery, the 5-year and 10-year survival rates were 31% and 23.1%, respectively. Comparing operative procedures, there were no significant differences in survival rates. Reconstruction was also performed in postgastrectomized patients using jejunal segments.There was a considerable number of complaints of passage failure and reflux esophagitis such as heartburn among patients who underwent esophagogastrostomy performed in the thoracic cavity, even 5 years after surgery.The performance status of patients in whom jejunal segments were used was better than that of patients in whom gastric tubes were used.RésuméAu cours des 19 dernières années, 457 résections (72.9%) ont été pratiquées chez 627 malades atteints de cancer de loesophage dont 388 opérations à visée curatrice. Deux cent cinquante neuf interventions (57%) ont été conduites par voie rétromédiastinale soit 181 oesophago-gastrostomies sans interposition et 78 avec interposition dune anse jéjunale après résection de la tumeur. Pendant la même période, cent soixante et onze (41%) ont été menées par voie rétro-sternale comprenant 110 oesophago-gastrostomies sans interposition dun segment intestinal, 57 avec interposition dun segment colique. La fréquence des complications pulmonaires, des fistules, des décès a été identique quelles quaient été la voie dabord empruntée et la méthode suivie pour rétablir la continuité digestive. Le taux de survie des opérés qui franchirent le cap de lintervention fut de 31% à 5 ans et 23.1% à 10 ans. Aucune différence du taux de survie en fonction des diverses opérations pratiquées na été enregistrée. En revanche, un grand nombre de troubles postopératoires tels que difficultés de transit du bol alimentaire et brûlures rétro-sternales dues à une oesophagite par reflux ont été notés quand la résection tumorale avait été éffectuée par voie intra-thoracique. De même il a été remarqué que létat des opérés était plus satisfaisant quand un segment de jéjunum était interposé entre loesophage et lestomac au lieu dun tube constitué à laide de lestomac.ResumenEn el curso de los últimos 19 años se ha realizado resección quirúrgica en 457 (72.9%) de 627 pacientes con carcinoma del esófago torácico; resección curativa fué posible en 388 casos. En 259 casos (57%) reconstruídos a través del espacio retromediastinal, la esofagogastrostomía torácica fué realizada en 181 casos y la interposición de segmentos yeyunales entre el esófago torácico y el estómago en 78 casos. Entre 171 casos (41%) reconstruídos a través del espacio retroesternal, hubo 110 casos de esofagogastrostomía, 57 de interposición de segmentos yeyunales y 4 de interposición de segmentos de colon entre el esófago y el estómago. Al comparar los órganos o la vía utilizados para la reconstrucción, no se hallaron diferencias significativas en la incidencia de complicaciones pulmonares, escapes anastomóticos o mortalidad operatoria.En los pacientes que toleraron le circugía curativa se encontraron tasas de supervivencia a 5 años y a 10 años de 31% y 23.1% respectivamente. Al comparar los procedimientos operatorios no se encuentran diferencias significativas en las tasas de supervivencia. La reconstrucción también fué realizada en pacientes postgastrectomizados utilizando segmentos de yeyuno.Hubo un número considerable de quejas de fallas en deglución y esofagitis de reflujo, tales como pirosis, en los pacientes sometidos a esofagogastrostomía realizada en la cavidad torácica, aún 5 años después de la circugía. El estado funcional de los pacientes en quienes se utilizaron segmentos yeyunales fué mejor que el de los pacientes en quienes se utilizaron tubos gástricos.

Long-term Survival After Curative Resection of Carcinoma of the Thoracic Esophagus

Since Torek first successfully performed radical surgery for esophageal carcinoma in 1913, the results of esophageal surgery have been somewhat disappointing. A high operative mortality rate and a low 5-year survival rate were consistent features of surgery for esophageal cancer for a long time. The results of surgery, however, have shown marked improvement in Japan in the last 15 years. In the 12-year period from 1969 to 1980,10113 cases of esophageal carcinoma were registered in Japan. Among these cases, resection was carried out on 6130, and re-sectability was 67%. The operative mortality rate was 8.0%. Of these cases, 1953 survived 5 years or more after surgery, and the 5-year survival rate was 23.7% (Table 1).

Changes in the Plasma ADH Level During and After Surgery for Esophageal Cancer

It is well known that surgical stress produces hypersecretion of antidiuretic hormone (ADH) and oliguria [1, 2]. However, there has been little study of the relationship between plasma ADH level and urine volume under surgical stress. The purpose of this study is (1) to analyze the factors causing the elevation of plasma ADH level during surgery and (2) to investigate the relationship between plasma ADH level and urine volume by measuring plasma ADH level of patients undergoing surgery for esophageal cancer and gastric cancer.

Significance of Active Nutritional Support for Maintenance of Immunopotentiation in the Surgical Treatment of Esophageal Cancer

The correlation between nutrition and immunological potentiation on patients with cancer of the esophagus was investigated in preoperative and postoperative periods. Preoperative immunological status: These patients were already suffering from malnutrition, because of the impossibility of peros intake. Natural killer (NK) cell activity and interleukin-II inducing activity of peripheral mononuclear cells in the above patients were clearly lower than such activities of cells in the patients with breast cancer whose nutritional condition was as normal as that of healthy people. These two immunological parameters in the majority of the patients were improved by active total parenteral and enteral nutrition. However, there were a few patients whose nutritional status could not be improved. Postoperative immunological status: The movement of peripheral lymphocyte subpopulation was successively checked with several kinds of monoclonal antibodies such as OKT-3 (anti-T cells), Leu-7 (anti-NK cells), OKIa-1 (anti-B cells), OKT-4 (anti-inducer and/or suppressor T cells) and OKT-8 (suppressor and/or cytotoxic T cells). In nutritionally controlled patients, the population of OKT-3, Leu-7 and OKIa-1 showed a pattern similar to the preoperative value, but in undernourished patients, that population was disturbed soon after the operation. Patterns of OKT-4 and OKT-8 showed a converse correlation. Nearly two weeks after operation, all these five kinds of population had changed. Moreover, nitrogen balance recovered from negative to positive. The time of is thought to be the turning point of surgical metabolism and the immunological status.

Renal dysfunction following surgery for carcinoma of the thoracic esophagus.

X過去10年間の胸部食道癌277例のうち術後の腎機能障害 (血清クレアチニン2.0mg/dl以上) は15例 (5.4%) に発生した. 15例中9例は第1病日に異常値を示した. 70歳以上と未満 (10.9: 4.3%), 高血圧の既往の有無 (8.0%: 3.7%) について発生率に約2倍の差がみられた. 術前の腎機能では, 血清クレアチニンが1.5mg/dl以上と未満 (35.7%: 3.8%, p<0.01), PSP試験15分値が20%以上と未満 (20.7%: 3.0%, p<0.01), Fishberg尿濃度試験で500mOsm/kg以上と未満 (17.4%: 4.0%, p<0.05) についてそれぞれ発生率に有意差がみられた. 腎機能障害の原因となった合併症の治療が困難であった3例を除き, 他の12例では保存的治療により腎機能障害は回復した.