Abstract
OBJECTIVE To determine the ideal method of surgical preoperative treatment for perforation. with esophagea carcinoma.
METHODS 36 cases of perforation, with esophageal carcinoma were treated surgicaly in, this series. Perforations occurred into the right lung in 14 cases, the mediastinum, in 17 cases and trachea in 5 cases. Open thoracic, surgery was performed in 34 cases, in which the right thoracic approach using a 3-incision method was applied in 16 cases, and operation. by stages in 15 cases. Of the 34 cases, retrosternal substitution of the esophagus with stomach or colon was performed in 26 cases.
RESULTS Surgery was successful tn 31 cases and operative death occurred in 3 cases. The postoperative follow up study was from 3~72 months. Of these cases 15 were alive at 7~12 months, 2 at 24 months, and 1 at 72 months. The results can be considered satisfactory.
CONCLUSION The therapeutic results of surgical treatment of perforation with esophageal carcinoma were markedly superior to that of conventional conservative treatment. The authors suggest that surgical intervention without delay should be undertaken for patients having a perforation with carcinoma of the esophagus. A right thoracic approach with a 3-incision method (retrosternal replacement of esophagus with stomach or colon) or operation by stages is preferable.
keywords
Perforation with esophageal carcinoma is a severe condition that threatens the patient’s life. It often occurs in the late stage of progressive esophageal carcinoma or the late stage of radical radiotherapy for esophageal carcinoma, as well as from iatrogenic esophageal perforation resulting from dilation by a medical instrument of the narrow part of an esophageal carcinoma.[1] Once perforation occurs, the patient’s symptoms become significantly severe involving infections difficult to control or threatening symptoms, such as mediastinal abscess, lung abscess or esophago-tracheal fistula, etc. The patient will die immediately if the carcinoma perforates into adjacent large blood vessels. We treated 36 cases surgically of esophageal carcinoma perforation in this series from December, 1986 to March, 2001. The results were satisfactory.
Materials and Methods
Clinical data
Among the 36 cases, there were 24 male patients and 12 female. Their ages ranged from 39 to 72, with a mean of 53; 14 cases were more than 60 years old (38.8%). The length of their carcinomas were 4~6 cm in 16 patients and 7~8 cm in 15 patients, with the longest one being 9 cm. Pathological diagnoses after operation: squamous carcinoma was found in 30 cases, among which 20 cases were complicated with metastasis to the upper mediastinal lymph nodes or subcarinal lymph nodes (71.4%). Four cases demonstrated fibrosis after radiotherapy of squamous carcinoma. The tumors all were located in the upper or middle part of the esophagus.
In this series, 28 patients underwent radiotherapy before perforation. In 22 patients (78.5%) the irradiation dose was more than 60 Gy. The times between the termination of radiotherapy and perforation were as follows: 4~9 months for 16 cases and 12 months for 6 cases. The other 7 cases suddenly developed a perforation during radiotherapy and then received a surgical operation.
Size of perforations
The 36 patients all received an esophageal barium meal or an iodipin examination. The results demonstrated that contrast medium flowed into the mediastinum in 17 cases and into the right lung in 14 cases. In the other 5 cases contrast medium flowed into the trachea demonstrating a significant esophago-tracheal fistula.
In 11 of the 36 patients, the diameter of the perforation was less than 1 cm, 1~2 cm in 20 cases and more than 2 cm in 5 cases. Thirty cases had been perforated prior to hospitalization, and the other 6 cases perforated 2~11 days after hospitalization.
Clinical manifestations
Sixteen cases presented with fever after perforation (44.4%); 30 cases presented with intensified chest or back pain (83.3%) and 32 cases presented with a significant elevation in blood leucocyte count (88.8%). Chest X-ray examinations showed a broadened shadow of the mediastinum in 12 cases and a shadow of the lung in 14 cases; among them 1 case had dysphagia and chest pain again 5 months after radiotherapy and the X-ray examination showed “recurrence after esophageal radiotherapy with perforation”. But another X-ray examination in our hospital 6 days later showed there was vomica of about 10.0 × 4.5 cm in size in the right lung, showing a typical manifestation of lung abscess. One case demonstrated a narrow anastomotic stoma after an esophagogastrostomy for esophageal carcinoma in another hospital. This was followed by an esophago-tracheal fistula 1 year after treatment with a membrance-covered self-expending metallic stent.
RESULTS
Operation technique
In the 36 patients, 16 received a right thoracic anterolateral approach with a 3-incision method. Of these patients, 4 underwent substitution of the esophagus with stomach via the esophageal bed; 10 were treated with retrosternal substitution of esophagus with stomach; 1 received retrosternal substitution of the esophagus with the colon; and 1 underwent esophageal exteriorization with gastric stoma. Eighteen patients received retrosternal esophageal carcinoma removal, left cervical esophageal outlay and gastric stoma. Of these 15 were treated in stages which meant that 1~2 months after the operation, a retrosternal substitution of the esophagus with stomach (or colon) was performed to reconstruct the digestive tract. Two patients (including 1 esophago-tracheal fistula) only asked to receive a gastrostomy because of expense and then were discharged. Four cases of esophago-tracheal fistula (Fig. 1) received closure of their tracheal fistula by using the same-side intercostal muscle with blood vessels. Of these, 3 cases received filling of the surrounding tracheal fistula by using large omentum with a blood vessel pedicle.
Barium meal showed a tracheoesophageal fistula post esophageal stennt.
Dealing with infection focus inside the chest
In this series, carcinoma invaded into the right lung in 14 cases; 6 showed a lung abscess (Fig.2). For the smaller vomica, we performed an incision and drainage. We did not suture the abscess wall for those without an obvious air leakage. We performed a pulmonary segment resection or pulmonary lobectomy for bigger vomica (Fig.3).
Barium meal showed a perforation in esophageal carcinoma inducing a right lung abscess.
Large perforation in middle of esophageal carcinoma during radiotherapy. Diameter of the perforation was 5.0 cm.
Carcinoma invaded into the mediastinum in 17 cases (Fig. 4). For small perforations, we removed the mediastinal abscess when removing the carcinoma (Fig. 5). For bigger abscesses or if the abscess invaded into important organs such as part of the aorta or trachea, then part of the abscess wall remained and was washed and fiilgurized during the operation.
Barium meal after operation by stages showed: anastomosis stoma between the esophagus and colon in the neck is unobstructed.
Barium medium entered into the mediastinum.
For infections of the pleural cavity, we soaked and washed the area with 1000 ml of 0.05% iodophor liquid, then washed it repeatedly 6~8 times with physiological saline, using 1000 ml each time.
Complications
Operative complications occurred in a total of 16 cases, which was much higher than that for ordinary esophageal carcinoma operations. Among them, 2 cases had thoracic empyema, 1 a tracheo-pleural fistula, 1 grave pneumonia with renal failure, 3 a cervical stoma fistula complicated with upper gastrointestinal hemorrhage, 7 a simple cervical stoma fistula, 1 an intestinal obstruction and 1 hepatitis C transmitted by a blood transfusion.
In this series, 3 cases died; 1 case presented with severe pneumonia 4 days after the operation and died from a complication with renal failure 8 days later; 1 case died from a massive hemorrhage of the upper gastrointestinal tract complicated with pneumonia of the right lung; 1 case was discharged voluntarily with a tracheo-pleural fistula 10 days after the operation (regarded as death).
Follow-up
The cases were followed-up for 3~72 months after operation. Of these patients, 2 cases survived for 3 months (7.2%), 8 cases for 6 months (28.5%), 2 for 24 months (7.2%) and 1 for 72 months (3.6%).
DISCUSSION
Benefit of operations
Perforation associated with esophageal carcinoma usually occurs in late-stage carcinoma, and is often complicated with thoracic infections. Therefore the condition is often very serious. Conventional conservative treatment includes esophageal exteriorization, enteral or parenteral nutritional support,[2] and stent placement under the endoscope.[3,4] But conservative treatment can neither eliminate the carcinoma nor control the thoracic infection completely. The mortality soon after perforation is fairly high with a mean survival time of only 11-16 weeks.[5] Surgical operations produce the following benefits: (1) resection of the carcinoma (or partially, the remaining small part might be directly fulgurized and then marked for post-operation radiotherapy); (2) elimination of infection inside the chest; (3) washing the thoracic cavity repeatedly with large amount of physiological saline during the operation, thus decreasing greatly the colony count of infectious bacteria inside the chest. Therefore, favorable conditions are created for controlling the infection. So operations should be conducted as long as there is indication for surgery.[6,7]
Selection of operation time
Benign esophageal perforation is often the result of accidental damage to the esophagus. The mediastinum and pleural cavity are infected immediately after being contaminated by the contents of the digestive tract. The patient might present with toxic shock within a short time period, even endangering life.[8] Perforation from esophageal carcinoma occurs in the course of the carcinoma invading outward, so mediastinal infection is often blocked by the surrounding tissues, and lung infections might turn into an abscess. Thus, the operation need not be urgent, and the preoperative preparation may be enough. In this series, of the 34 cases receiving open thoracic surgery, the times between operation and the perforations were as follows: 24 h for 2 cases, 48 h for 4 cases, 72 h for 8 cases, and 72 h for 20 cases (the longest time was 11 days). One case of perforation with esophageal carcinoma with a right lung abscess received an operation on the 9th day and the result was satisfactory with primary healing.
Comparisons of surgical approaches
In routine operations for esophageal carcinoma, the substituting organs (stomach or colon) for esophagus pass through the esophageal bed, being consistent with physiological characteristics. In surgical operations for perforation with esophageal carcinoma, the preferable method for substituting organs for the esophagus is via a retrosternal (or subcutaneous) approach. In this series, only 4 cases were through the esophageal bed. Thoracic empyema occurred in 2 cases and multiple encapsulated effusions inside the chest occurred in 1 case because the stomach locates in the right esophageal bed and it is disadvantageous for drainage of the mediastinal bed. For the 26 cases through the retrosternal approach, 21 cases resulted in primary healing and only 5 cases had local effusion and healed after puncturing.
In recent years, operation by stages often has been performed, providing these advantages: (1) the incision locates in the post-lateral side of the right chest, and it is beneficial for removing the esophageal tissue and tumor; (2) the first operation time is shortened and the recovery is comparably quick; (3) the second stage operation is not through the pleural cavity and post-operative recovery is easy.
Characteristics of post-operative care and therapy
Perforation in esophageal carcinoma usually occurs in the middle or late stage of radical radiotherapy for this cancer. Large-dose radiotherapy is especially harmful to the cardiopulmonary system after open thoracic surgery, often complicating with heart or lung failure, arrhythmia or hypoxemia after operation.[9] Our main measures for this are: (1) myocardial preservation fluid is routinely infused intravenously to promote the reserve of myocardial cells; (2) strict control of the amount and speed of post-operative fluid replacement. The amount is limited to 40-45 ml/kg, and the speed is limited to about 2.0 ml/min; (3) for patients with hypoxemia, diuresis and dehydration, a certain dosage of cortisone is given in time to improve the permeability of alveolar basement membrane and to promote the diffusion of oxygen; (4) if necessary, assisted respiration is applied using a nasal intubation breathing apparatus for patients with severe hypoxemia. Patients do not require the apparatus after 2-3 days.
- Received January 25, 2006.
- Accepted March 24, 2006.
- Copyright © 2006 by Tianjin Medical University Cancer Institute & Hospital and Springer
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