Wilford B. Neptune

Transthoracic versus Extrathoracic Esophagectomy: Mortality, Morbidity, and Long-term Survival

Extrathoracic esophagectomy for carcinoma is an acceptable substitute for transthoracic resection if it can be shown to have comparable or superior safety and no adverse effect on long-term survival. To test this hypothesis, we employed extrathoracic esophagectomy in 30 consecutive patients with carcinoma of the esophagus from January, 1978, to July, 1984. During this period, 65 comparable patients underwent transthoracic resection through a left thoracotomy for lower esophageal lesions or a right thoracotomy and laparotomy for upper thoracic lesions. Only patients with carcinoma limited to the gastric cardia were excluded from the study. Overall morbidity was higher in the extrathoracic than in the transthoracic group (13 of 30 or 43.3% versus 15 of 65 or 23.1%; p = 0.05), but the differences in hospital mortality (4 of 65 or 6.2% for the transthoracic group versus 4 of 30 or 13.3% for the extrathoracic group) and duration of hospital stay (17.4 +/- 11.7 days for the transthoracic group versus 20.5 +/- 13.4 days for the extrathoracic group) were not statistically significant. Considering all patients who either died or sustained a postoperative complication, we found significant differences favoring transthoracic resection in those subgroups of patients who were able to undergo primary reconstruction at the time of resection (12 of 57 or 21.1% versus 15 of 28 or 53.6%; p = 0.004), those with advanced Stage III lesions (11 of 47 or 23.4% versus 12 of 20 or 60%; p = 0.006), those with tumor of the lower esophagus (8 of 35 or 22.9% versus 6 of 10 or 60%; p = 0.04), and those with tumor that could be resected through a left thoracotomy (2 of 18 or 11.1% versus 17 of 30 or 56.7%; p = 0.002). Actuarial survival curves for all transthoracic and extrathoracic resections and separate analysis for Stage I and Stage III tumors revealed no statistically significant differences between these two techniques.

Pancoast tumors: improved survival with preoperative and postoperative radiotherapy

Long-term survival after treatment of Pancoast tumors has been limited in most series to those patients without positive lymph nodes or residual tumor. In our series of 18 consecutive patients treated with preoperative irradiation and resection, 14 underwent supplemental postoperative radiotherapy because of positive lymph nodes, tumor at the resection margin, or both. No hospital deaths occurred. Eight patients subsequently died, 6 because of metastatic disease; only 2 deaths were secondary to local recurrence. Ten patients are alive at 6 months to 13 years after resection, and 9 of the 10 have no evidence of tumor recurrence. The overall five-year observed survival (Kaplan-Meier) for the entire series was 56.1 +/- 12.7% (+/- standard error). Although the number of patients is small, the addition of postoperative radiotherapy for those with unfavorable operative findings resulted in long-term survival comparable to that of patients with negative nodes and margins.

An aggressive approach to marginally resectable lung cancer.

Between July 1968 and December 1974, 53 patients with lung cancer were planned for preoperative irradiation and surgery. All patients were considered clinically marginally resectable because of advanced local disease, 4 Stage II patients, with limited pulmonary reserve and 49 Stage III patients. Most patients received 3000 to 4000 rad followed in two weeks by thoracotomy. Forty‐six patients were explored and 38 were resectable. Twelve patients are alive with a median follow‐up of 48 months. The cumulative 5‐year survival of all resectable patients is 27%. The survival of patients with marginally resectable lung cancer treated by accelerated radiotherapy followed by aggressive surgery approaches the survival experience of patients with primary resectable lung cancer and is superior to such patients treated with radiation therapy alone.

Primary Cancer of the Lung: A 42-Year Experience

Between April, 1932, and July, 1974, 3,808 patients with primary lung cancer were studied and 1,848 underwent resection. Among untreated patients, 95% were dead with a year. Unresected cancer of the lung is so lethal that efforts to streamline surgical management should not be neglected. In good-risk patients with isolated lesions the approach can be direct. If surgical excision is indicated, regardless of a positive or negative sputum cytology, bronchoscopic biopsy, or brush biopsy, such investigations become superfluous. Needle biopsy is also inconclusive and in addition is hazardous. Preoperative investigation should focus on cardiopulmonary reserve more than on ways to obtain tissue for verification. With the passage of time, the extent of resection has become more conservative. The value of palliative resection is now better appreciated in terms of quality of life, its prolongation, and, for some, a possibility for cure.

Benign lesions mimicking malignant tumors of the esophagus

Three cases of benign lesions which mimicked malignant tumors of the esophagus are described. In all three cases, two inflammatory pseudotumors and one case of diffuse leiomyomatosis, the clinical presentations, radiologic features, and gross pathologic findings led to the mistaken diagnosis of carcinoma at thoracotomy. The benign nature of the processes was recognizable only on microscopic examination. Although most benign tumors of the esophagus are localized solitary lesions that are easily distinguished from carcinoma, occasionally benign conditions may present as infiltrative, ulcerated mass lesions. Inflammatory pseudotumor and diffuse leiomyomatosis should be included in the differential diagnosis of esophageal malignancies.

Intraaortic Balloon Pump Morbidity: A Comparative Analysis of Risk Factors Between Percutaneous and Surgical Techniques

We reviewed our concurrent experience with percutaneous insertion versus surgical placement of the intraaortic balloon pump over a two-year period both to compare morbidity and to provide guidelines for the choice of method in particular patient groups and clinical settings. The effects on morbidity of sex, age, emergency placement, coexisting peripheral vascular disease, and duration of counterpulsation were determined. Sex was a highly significant factor, with low complication rates (3/29 or 10.3%) for percutaneous insertion in men and an inordinately high morbidity (12/17 or 70.6%) in women (Fisher exact test: p = 4.611 X 10(-5)). This difference may be due to the smaller size of the femoral artery in women. We conclude that percutaneous insertion is the preferred technique for most men but that direct exposure of the femoral artery should be employed in women. Given the serious morbidity encountered with each technique, there is no justification to broaden the indications for intraaortic balloon counterpulsation.

Pulmonary metastases from ceruminous adenocarcinoma (cylindroma) of external auditory canal.

This is a report of a patient with ceruminous adenocarcinoma (cylindroma) arising from the external auditory canal who developed pulmonary metastases. Cylindromatous adenocarcinoma of the head and neck region is an uncommon tumor but may give rise to distant metastases. Routine roentgenograms of the chest should be done in all suspected cylindromas of the head and neck, and follow‐up x‐rays should be made biannually thereafter.

Esophagectomy without thoracotomy for carcinoma of the esophagus

During the past 2.5 years, 13 patients underwent esophagectomy for carcinoma of the esophagus without the use of a thoracotomy. During the same period, 81 operations on the esophagus or cardia were performed, 73 of which were esophagogastrectomies. Two patients died, for a hospital mortality rate of 2.7 percent. Of the 13 patients, there were 7 women and 6 men with an average age of 59.7 years. The lesion was located in the cervical esophagus in two, the upper thoracic esophagus in eight and the lower esophagus in three. One patient died on the 12th postoperative day, for a hospital mortality rate of 7.7 percent. Satisfactory relief of dysphagia was accomplished in all surviving patients, five of whom have died from the disease, for an average survival of 13.1 months. Seven are currently alive, with the longest period of survival 20.5 months. Esophagectomy without thoracotomy can be carried out with low mortality and morbidity rates. It is most applicable to patients with early lesions, particularly those in the cervical esophagus and the upper thoracic esophagus.

Surgical management of chest wall tumors.

A new technique for reconstruction of the chest wall providing immediate chest wall stability was employed in six patients who required extensive chest wall resection for a variety of neoplasms. Despite preoperative impairment of pulmonary function, early extubation was possible in all patients. Pulmonary function was well preserved on follow-up examination.

Symptomatic Carotid Stenosis Secondary to an Intraluminal Web—A Case Report

A thirty-four-year-old man presented with symptoms of carotid occlusive disease. Work-up revealed 90% stenosis of the left internal carotid artery, which was found to be caused by a heretofore undescribed web of the carotid artery. The patient was treated with operative excision of the web and patch angio plasty of the carotid artery.