Cancer of the esophagus and cardia: does age influence treatment selection and surgical outcomes?

BACKGROUND: Some physicians believe that an aggressive surgical approach for the management of cancer of the esophagus and cardia is unwise in elderly patients because of allegedly higher rates of mortality and morbidity and lower rates of survival than those associated with younger patients. We have long advocated an aggressive surgical approach regardless of the patient's age and have reviewed our experience to determine whether age was a factor influencing treatment and outcomes. STUDY DESIGN: From January 1, 1970 to January 1, 1997, 505 patients with cancer of the esophagus or cardia underwent operations by one surgical team using standard surgical techniques. One hundred forty-seven patients (29.1%) were 70 years of age or older and 358 patients (70.9%) were under 70 years of age. Their records and clinicopathologic features were reviewed and compared. RESULTS: The two groups were similar regarding the location of tumors. Tumor cell types were similar except for adenocarcinomas in Barrett's esophagus, which were less common in the older group (15.6% versus 24%; p=0.046). Surgical procedures were similar, as were the rates of resectability and the percentages of R0 resections. The hospital mortality rate was higher in the elderly patients but not significantly so, and the rates of major and minor complications combined were comparable. The differences in postresection pathologic staging were not significant. Satisfactory palliation of dysphagia was comparable between the groups, as were actuarial 5-year survival rates (24.1% of the elderly patients versus 22.4% of the younger patients). CONCLUSIONS: Age should not be a limiting factor in using an aggressive surgical approach for the management of cancer of the esophagus or cardia in patients aged 70 years or older. Such an approach can be performed as safely as in younger patients, with comparable rates of palliation and survival.

Neurofibroma of the esophagus.

Benign esophageal tumors occur infrequently, with leiomyomas accounting for approximately 70% of cases. Benign neural tumors of the esophagus account for 200 cases reported in the literature and rarely require operative resection. The case of a 58-year-old woman with a 4-month history of progressive dysphagia and odynophagia is presented. A large intramural esophageal mass was resected through a right thoracotomy, and the esophagus was primarily repaired. Histologic examination revealed a neurofibroma.

Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and results after standard resection in three consecutive eight-year intervals with improved staging criteria.

OBJECTIVE: A review of findings and results after standard resection for carcinoma of the esophagus and cardia without neoadjuvant therapy was done to provide a basis for comparison with current reports of radical resection and neoadjuvant therapy. METHODS: A 24-year experience on one surgical service with 454 operations for carcinoma of the esophagus and cardia was reviewed. A comparison of findings and results in three consecutive 8-year intervals was analyzed, and new staging criteria were developed and compared with those currently favored by the American Joint Committee on Cancer. RESULTS: From January 1, 1970, to January 1, 1994, 454 patients with carcinoma of the esophagus or cardia underwent operation, of whom 408 (90%) had esophagogastrectomy with a 30-day mortality rate of 2.5% and an additional hospital mortality rate of 1.2%. Of the 121 complications (30.7%), 71 (18%) were major and 50 (12.7%) were minor. Cardiovascular complications predominated. The overall 5-year survival was 24.7%, with a 33.7% survival after complete resections in the most recent interval under study. Palliation of dysphagia was achieved in nearly 80% of patients who survived the operation. During the three intervals under review, resectability, mortality, and complication rates remained constant. The percentages of left thoracotomies and transhiatal resections increased, and there was a decrease in thoracoabdominal incisions. The percentages of patients with Barrett's esophagus and stage 0 and I tumors increased. The percentage of complete resections (R0) increased, whereas that for resections with residual microscopic tumor (R1) decreased, and there was no change in the percentage of patients with residual gross tumor after resection (R2). Modified WNM staging criteria are proposed that provide better prognostic stratification of the disease than those currently favored by The American Joint Committee on Cancer. CONCLUSIONS: Standard esophagogastrectomy is applicable in 90% of patients with operable carcinoma of the esophagus or cardia, with consistently low mortality and morbidity rates and satisfactory palliation of dysphagia. The 5-year survival (24.7% overall) remains suboptimal, but the current figure for complete resections (33.7%) is encouraging. There is a need for revision of the current American Joint Committee on Cancer staging criteria.

Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients.

BACKGROUND: The role of noninvasive carotid artery screening in relation to other clinical variables in identifying patients at increased risk of stroke after coronary artery bypass grafting was examined. METHODS: Preoperative, intraoperative, and postoperative clinical data were prospectively collected for 1,835 consecutive patients undergoing first-time isolated coronary artery bypass grafting between March 1990 and July 1995, 1,279 of whom had screening carotid ultrasonography. All patients with postoperative neurologic events were identified and reviewed in detail. Average patient age was 65.3 years (range, 33 to 92 years), and 9.3% (171 patients) had a prior permanent stroke or transient ischemic attack. Hospital and 30-day mortality was 2.2% (41 patients). Forty-five patients (2.5%) had a transient or permanent postoperative neurologic event. The data were analyzed by stepwise logistic regression to determine the independent predictors of both significant carotid stenosis and stroke. RESULTS: On multivariate analysis, the clinical predictors of significant carotid stenosis were age (p < 0.0001), diabetes (p = 0.0123), female sex (p = 0.0026), left main coronary stenosis greater than 60% (p < 0.0001), prior stroke or transient ischemic attack (p = 0.0008), peripheral vascular disease (p = 0.0001), prior vascular operation (p = 0.0068), and smoking (p < 0.0001). When all variables were evaluated for those patients who underwent noninvasive carotid artery screening, the independent predictors of postoperative neurologic event were prior stroke or transient ischemic attack (p < 0.0001), peripheral vascular disease (p = 0.0037), postinfarction angina pectoris (p = 0.0319), postoperative atrial fibrillation (p = 0.0014), carotid stenosis greater than 50% (p = 0.0029), cardiopulmonary bypass time (p = 0.0006), significant aortic atherosclerosis (p = 0.0054), postoperative amrinone or epinephrine use (p = 0.0054), and left ventricular ejection fraction less than 0.30 (p = 0.0744). CONCLUSIONS: The etiology of postoperative stroke is multifactorial. Selective use of carotid ultrasonography is of value in identifying patients who are at greater risk of postoperative stroke independent of other variables and should be considered before coronary artery bypass grafting, particularly in patients with a history of neurologic event or peripheral vascular disease.

Applications of statistical quality control to cardiac surgery.

BACKGROUND: Although originally developed for use in manufacturing statistical quality control techniques may be applicable to other frequently performed, standardized processes. METHODS: We employed statistical quality control charts (X- s, p, and u) to analyze perioperative morbidity and mortality and length of stay in 1,131 nonemergent, isolated, primary coronary bypass operations conducted within a 17-quarter time period. RESULTS: The incidence of the most common adverse outcomes, including death, myocardial infarction, stroke, and atrial fibrillation, appeared to follow the laws of statistical fluctuation and were in statistical control. Postoperative bleeding, leg-wound infection, and the summation of total and major complications were out of statistical control in the early quarters of the study period but showed progressive improvement, as did postoperative length of stay. CONCLUSIONS: The incidence of morbidity and mortality after primary, isolated, nonemergent coronary bypass operations may be described by standard models of statistical fluctuation. Statistical quality control may be a valuable method to analyze the variability of these adverse postoperative events over time, with the ultimate goal of reducing that variability and producing better outcomes.

Timing of surgery after acute myocardial infarction.

OBJECTIVE: We wished to determine if timing of surgery, when other co-morbid variables are controlled, influenced outcome after operations for acute myocardial infarction. DESIGN: Between 3/20/1990 and 6/17/1994, data was prospectively collected on 338 patients undergoing operation for either evolving infarcts (n=73) or up to 21 days after infarction (mean 7.9 days). SETTING: Tertiary hospital referral center. PATIENTS: Infarction was diagnosed by CK enzymes or EKG Q-waves preoperatively in 338 patients undergoing surgery. The mean age of the patients was 66.1 years (SD+/-10.5 years), 76 had emergency operations immediately after catheterization (50 following PTCA complications), 223 had urgent operations, and 39 were elective. INTERVENTIONS: Seventy-three had preoperative ballon pumps, and 259 had one or more mammary artery bypasses with a mean of 3.27 (SD+/-1.0) distal anastomoses. RESULTS: In-hospital and 30-day survival rate was 95.6% (323/338). Of the 73 variables evaluated by step-wise logistic regression analysis, the multivariate independent preoperative predictors of death were: aortic valve regurgitation, chronic pulmonary disease, preoperative diuretic administration, preoperative balloon pump, preoperative inotropes, and the need for additional concomitant noncardiac surgery. Including the operative variables, the predictors were: preoperative balloon pump, preoperative inotropes, the presence of left main stenosis, preoperative renal failure, chronic pulmonary disease, valve disease, ischemic arrhythmia, pump perfusion time, valve surgery, and homologous blood transfusion volume required. When the postoperative variables were included, the predictors were: preoperative inotropes, postoperative balloon pump, postoperative epinephrine, postoperative permanent stroke, and postoperative acute renal failure. The time between infarction and operation was not an independent prediction (p>0.4) in any of the logistic regression models. CONCLUSION: Early operation after acute infarction is not in itself a risk factor, rather comorbid disease and preoperative hemodynamic status determine outcome after surgery.

Objective assessment of gastroesophageal reflux after short esophagomyotomy for achalasia with the use of manometry and pH monitoring.

The role of an antireflux procedure as an adjunct to esophagomyotomy for achalasia remains a subject of controversy. Little objective documentation exists of this operation's effect on sphincteric competence and the degree of postoperative gastroesophageal reflux. This report of esophageal manometry and 24-hour pH monitoring on 14 patients with esophageal achalasia whom we had previously treated by a short esophagomyotomy without an antireflux procedure provides such documentation. Esophagomyotomy reduced lower esophageal sphincter pressure by 12% to 71% (mean 41%) from a preoperative mean of 26.7 mm Hg to a postoperative mean of 14.6 mm Hg. The number of postoperative episodes of acid reflux per patient in 24 hours was fewer than 29 (normal < 49) in 13 patients, with a median of 12 episodes for the entire group. Esophageal acid exposure, measured as percentage of total time with pH less than 4.0 (normal < 4.5%), was below 4.5% in 10 patients, six of whom had values less than 1%. Among the four patients with values greater than 4.5%, only one had a temporal correlation of symptoms with an episode of acid reflux. Multivariate analysis showed that esophageal acid exposure time correlated only with the level of residual lower esophageal sphincter pressure during the relaxation phase of deglutition. A pressure less than 8 mm Hg was predictive of normal acid contact time (p < 0.001). Mean lower esophageal sphincter pressure, percent reduction in lower esophageal sphincter amplitude, postoperative vector volume, and length of the lower esophageal sphincter did not significantly correlate with amount of esophageal acid exposure. We conclude that a short esophagomyotomy without an antireflux procedure results in a competent lower esophageal sphincter in most patients. Increased esophageal acid exposure, when it occurs, is due to slow clearance of esophageal acid from relatively few reflux episodes and is more likely to occur when there is a high residual pressure during deglutition after myotomy. These findings suggest that the addition of an antireflux procedure to a short esophagomyotomy would not be expected to improve clinical results.

Current status of cricopharyngeal myotomy for cervical esophageal dysphagia.

OBJECTIVE: We have reviewed our experience with cricopharyngeal myotomy for a variety of conditions causing cervical esophageal dysphagia to clarify its indications and results as well as to determine what, if any, ancillary procedures are indicated. METHODS: Eighty-three patients underwent cricopharyngeal myotomy between January 1970 and January 1995, 54 of whom had a pharyngoesophageal diverticulum. The remainder suffered from a variety of motor disorders of the upper esophageal sphincter. Clinical follow-up evaluation was obtained in 71 of the 83 patients (86%). RESULTS: Good or excellent results were obtained in 87% of the patients with pharyngoesophageal diverticula, 100% after myotomy plus diverticulectomy, 87% after myotomy plus diverticulopexy and 67% after myotomy alone. Of patients with hypertensive upper esophageal sphincter, 100% had good or excellent results, whereas only 60% with nonspecific esophageal motor disorders were so evaluated. None of the patients with bulbar palsy or miscellaneous conditions had good or excellent results. CONCLUSIONS: We recommend cricopharyngeal myotomy for all patients with a pharyngoesophageal diverticulum coupled with diverticulopexy for the majority, reserving diverticulectomy for those with recurrent pouches or extremely large pouches (6-8 cm in diameter). Good or excellent results can be expected after myotomy in patients with a hypertensive upper esophageal sphincter. Myotomy is rarely indicated for patients with dysphagia secondary to bulbar palsy. The role of cricopharyngeal myotomy for patients with non-specific esophageal motor disorders remains controversial.

The role of coronary revascularization in recipients of an implantable cardioverter-defibrillator.

The impact of adjuvant coronary revascularization was studied in a group of 138 recipients of an implantable cardioverter-defibrillator, all of whom had ischemic heart disease as the cause of their arrhythmias. Patients chosen for revascularization had more severe anatomic, symptomatic, or physiologic evidence of active ischemia. There were no operative deaths among 23 patients who actually underwent coronary artery bypass combined with cardioverter-defibrillator implantation; however, operative mortality by the intention-to-treat principle was 8% (2/25). Total cardiac survival was better for patients who underwent revascularization than for those patients who had "high-risk" characteristics and did not undergo revascularization. Stratified subgroup analysis demonstrated significant survival advantages favoring revascularization in patients with three-vessel or left main coronary artery disease, class III or IV angina, and an ejection fraction greater than 25%. Multivariate analysis revealed that low ejection fraction and left main coronary artery disease were independent predictors of decreased survival.

Transvenous versus transthoracic cardioverter-defibrillator implantation. A comparative analysis of morbidity, mortality, and survival.

The hypothesis that transvenous implantation of a cardioverter-defibrillator is associated with less morbidity than use of a transthoracic approach was investigated in a retrospective series of 146 patients. None of these patients had concomitant heart procedures, and the preoperative characteristics of the two groups were similar. When analyzed by actual technique used (transvenous, 57 patients; transthoracic, 89 patients) and by the intention-to-treat method (transvenous, 65 patients, 8 of whom actually underwent thoracotomy; thoracotomy, 81 patients), transvenous implantation was associated with a lower incidence of postoperative respiratory complications and atrial fibrillation. Total cardiac mortality and freedom from sudden cardiac death in the transvenous and transthoracic groups were comparable at 2 years.

Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions.

BACKGROUND: A study was undertaken to compare the efficacy of short term tube thoracostomy drainage with standard tube thoracostomy drainage before instillation of tetracycline for sclerotherapy of malignant pleural effusions. METHODS: The study consisted of a randomised clinical trial in a sequential sample of 25 patients with malignant pleural effusions documented cytopathologically. Fifteen patients were randomly assigned to group 1 (standard protocol) and 10 to group 2 (short term protocol). Patients in group 1 had tube thoracostomy suction drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was < 150 ml/day, before tetracycline (1.5 g) was instilled. The chest tube was removed when the amount of fluid drained after instillation was < 150 ml/day. Patients in group 2 also had suction drainage, but the tetracycline (1.5 g) was instilled when the chest radiograph showed the lung to be re-expanded and the effusion drained, which was usually within 24 hours. The chest tube was removed the next day. RESULTS: The response to tetracycline sclerotherapy in the two groups was the same (80%) but the duration of chest tube drainage was significantly shorter for patients in group 2 (median two days) than for those in group 1 (median seven days). CONCLUSIONS: The duration of chest tube drainage before sclerotherapy for malignant pleural effusions need not be influenced by the amount of fluid drained daily but by radiographic evidence of fluid evacuation and lung re-expansion. Shorter duration of drainage will reduce the length of hospital stay without sacrificing the efficacy of pleurodesis.

Papillary fibroelastoma of the mitral valve.

A case report of a 73-year-old woman with mitral regurgitation secondary to papillary fibroelastoma and prolapse of the mitral valve is described. The tumor was excised, and the valve repaired with a Duran annuloplasty ring. The clinicopathologic features and the surgical management of this rare tumor are reviewed.

Infection of implantable cardioverter defibrillator systems: a preventable complication?

In a consecutive series of 164 patients undergoing primary implantation of an implantable cardioverter defibrillator (ICD), two patients died in the hospital (1.2%) and early system infection developed in one patient requiring explantation of the device (0.61%). Late infection developed in one additional patient (0.61%) 7 months after transvenous ICD implantation, and was thought to be due to a recent intravascular catheterization. Symptomatic generator pocket hematomas developed in three patients, two of which were treated by simple evacuation and one with temporary generator explanation and subsequent reimplantation of the unit in a new pocket. No infection developed in these three patients during follow-up. Generator erosion without obvious system infection developed in a fourth patient. Guidelines for the prevention of infection in ICD systems are presented.

Paraesophageal hiatal hernia: is an antireflux procedure necessary?

Between January 1970 and October 1992, 119 patients underwent 126 repairs of a paraesophageal hiatal hernia at the Lahey Clinic. Seven patients with a recurrent hernia required reoperation. Of the procedures, 19 (15%) included an antireflux procedure because of severe reflux symptoms and objective evidence of reflux demonstrated by grade 2 esophagitis on endoscopy, manometric evidence of a hypotensive lower esophageal sphincter pressure (< or = 10 mm Hg), positive results on 24-hour pH monitoring, or all three methods. Follow-up ranged from 6 months to 18 years with a median of 61.5 months, and the results of 115 operations were analyzed. Symptomatic results were good to excellent after 96 (83.5%) of these 115 operations. Thirteen symptomatic paraesophageal hernias recurred in 12 patients (one recurrence per 58 patient-years of follow-up). Severe reflux symptoms accompanied by endoscopic evidence of esophagitis developed in 2 patients who had not undergone an antireflux procedure at the time of repair of the hernia. We conclude that an antireflux procedure is rarely required in patients undergoing repair of a paraesophageal hiatal hernia and should be employed only when objective evidence of reflux is seen preoperatively.

In vitro decalcification of aortic valve leaflets with the Er:YSGG laser, Ho:YAG laser, and the Cavitron ultrasound surgical aspirator.

This study was designed to compare the efficacy of the erbium:yttrium-scandium-gallium-garnet (Er:YSGG) laser and the holmium:yttrium-aluminum-garnet (Ho:YAG) lasers in debriding calcium from freshly explanted aortic valve leaflets and to compare the Er:YSGG laser with the Cavitron ultrasonic surgical aspirator (CUSA). Aortic valve leaflets were freshly explanted from patients undergoing aortic valve replacement for aortic stenosis. Initially, 4 leaflets each were debrided with the Er:YSGG and the Ho:YAG lasers to attempt removal of calcium deposits while preserving the underlying integrity of the leaflets and minimizing thermal damage. The Er:YSGG laser was more effective in doing so with less thermal and photoacoustic damage when compared with the Ho:YAG laser. Twelve more leaflets each were then debrided with the Er:YSGG laser and the CUSA. The Er:YSGG laser again proved less injurious to the underlying leaflet. The CUSA-treated leaflets demonstrated shattering and disruption of adjacent tissue as well as collagen fiber exposure. These changes were not seen with the Er:YSGG laser. Because of these properties, the Er:YSGG laser merits further evaluation as a tool for aortic valvuloplasty procedures in selected patients with senescent calcific aortic stenosis.

Pulmonary venous infarction.

Pulmonary venous infarction, although rare, can develop in patients with the various pathologic conditions outlined. The triad of cough, dyspnea, and hemoptysis should raise clinical suspicion. The venous phase of pulmonary arteriography is the best way to document pulmonary venous obstruction, although MR imaging may also prove useful in the future. Treatment of patients with pulmonary venous infarction should be determined on the basis of the obstructing pathologic findings. Antibiotic therapy is important, as evidenced by the early experimental experience with this condition. It may be the only treatment available to patients with idiopathic fibrosing mediastinitis. Pulmonary resection, however, can be accomplished when a localized obstructing lesion is identified.

Pulmonary venous infarction secondary to squamous cell carcinoma.

This type of pulmonary venous infarction has not been previously reported, namely: pulmonary vein obstruction from squamous cell carcinoma. Furthermore, this case is unique in that the characteristic pathologic vascular changes observed with pulmonary venous infarction were contrasted with a noninfarcted upper lobe that was removed from the same patient one year later.

Current concepts concerning the nature and treatment of Barrett's esophagus and its complications.

Current concepts regarding the nature and the treatment of Barrett's esophagus and its complications are reviewed. The columnar-lined lower esophagus is being increasingly recognized as an acquired condition caused by gastroesophageal reflux. Many patients are asymptomatic. Barrett's esophagus occurs in about 10% to 15% of patients with reflux esophagitis. The diagnosis depends on endoscopy and biopsy. Complications are common and include ulceration, stricture, dysplasia, and adenocarcinoma. Esophagitis, ulceration, and stricture can usually be treated medically. Surgical approaches are discussed for patients whose condition is refractory to medical therapy. The premalignant nature of Barrett's epithelium is well recognized, and strategies for surveillance and resection are discussed. Survival after resection of adenocarcinoma in Barrett's esophagus is not appreciably different from that of other carcinomas. Surveillance with endoscopy offers the best chance for early detection and cure.

Subfascial implantation of implantable cardioverter defibrillator generator.

The automatic cardioverter defibrillator generator is a relatively large unit, which has most often been implanted in a subcutaneous pocket. In a consecutive series of 120 primary implantations, we employed a subrectus fascia pocket that has resulted in a cosmetically superior result with a 0.8% incidence of system infection. The technique of subfascial implantation is described.

Mediastinal goiters. The need for an aggressive approach.

We reviewed the cases of 52 patients with substernal goiters to examine clinical presentation, workup, technique of removal, malignancy, and outcome. Half of the patients were asymptomatic; half had at least one compressive symptom. Chest film was the most used; computed tomography or magnetic resonance imaging was by far the most useful study. Thyroid scans often failed to show the intrathoracic goiter. Fine-needle aspiration was not helpful because of the gland's inaccessibility. Seventeen percent (nine) of the thyroids showed malignancy, 21% (11) including incidental papillary carcinomas. These were not identified by duration of goiter, symptoms, or fine-needle aspiration. Except for lymphomas, prognosis was good after resection. Removal was almost always accomplished via cervical incision, with low morbidity and no deaths. The threat of compression, the substantial chance of malignancy, and the safety of resection mean that the presence of substernal goiter is an indication for surgery.