Ten patients with simultaneous combined resection of tumor-bearing esophagus with the trachea and/or the aorta were clinically evaluated in terms of its application and indication on the basis of a result of our clinical experience. 1) All the patients were in advanced disease stages with far extending nodal involvement. 2) Cancer recurrence at bronchial anastomosis occurred in one year after surgery. It is warned that the extent of a resection should be sufficient. 3) The circumferential resection of the aortic wall and replacement with artificial vascular graft were made with the aid of temporary bypass constructed in the same operation field of esophagectomy. However, there was no experience with grave complications such as postoperative infection. 4) The surgical outcome is not satisfactory but the necessity of proper early cares is required for keeping away from an operative death. In addition, multimodality adjuvant therapy is needed for avoidance of distant metastases

Akoskin Santiago

Ayabe Hiroyoshi

Kawahara Katsunobu

Tomita Masao

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Acta Med. Nagasaki 35:43-47Simultaneous Combined Resection of Adjacent Involved     Organs for Carcinoma of Thoracic EsophagusMasao TOMITA, Hiroyoshi AYABE, Katsunobu KAWAHARA               and Santiago AKOSKINFirst Department of Surgery, Nagasaki University School of MedicineReceived for publication, February 14, 1990ABSTRACT : Ten patients with simultaneous combined resection of tumor-bearing esophagus with the trachea and/or the aorta were clinically evaluated in terms of its application and indication on the basis of a result of our clinical experience. 1) All the patients were in advanced disease stages with far extending nodal involvement. 2) Cancer recurrence at bronchial anastomosis occurred in one year after surgery. It is warned that the extent of a resection should be sufficient. 3) The circumferential resection of the aortic wall and replacement with artificial vascular graft were made with the aid of temporary bypass constructed in the same operation field of esophagectomy. However, there was no experience with grave complications such as postoperative infection. 4) The surgical outcome is not satisfactory but the necessity of proper early cares is required for keeping away from an operative death. In addition, multimodality adjuvant therapy is needed for avoidance of distant metastases.       INTRODUCTION  The thoracic esophagus lies adjacent to the aorta, trachea and left main bronchus in the mediastinum. It is anatomically characteristic of the devoid of the serosa which acts as a barrier to extension of cancerous infiltration and a help the anastomotic sites heal satisfac-torily enough to avoid occurrence of anasto-mosis insufficiency. It is accepted that carcinoma of the thoracic esophagus is found at advanced disease stages because a symptom of dysphagia is caused by considerable narrowing of over three fourth in its lumen.  Therefore, surgery is indicated for patients with advanced cancer stage of carcinoma of the thoracic esophagus. Some have impending symptoms which threatens life. It is often experienced that surgical treatment for patientswith advanced cancers may as well be indicated to alleviate their urgent catastrophe unless oncologic curability is not necessarily ensured.  The aim of this study is to verify merits of aggressive surgery for advanced carcinoma of the thoracic esopohagus on the basis of a result of the treatment for our clinical advanced cancer of the thoracic esophagus.     MATERIAL AND METHOD  Ten patients with a resection of carcinomas involving the aort and trachea were eligible for this study.  During past 16 years from January 1973 to December 1988 in The First Department of Surgery, Nagasaki University School of Me-dicine, five patients underwent resections of the trachea or main bronchus, the other 4 had resections of the wall of the aort and theTable 1. patients with concurrent combined resection with the trachea          and the aortacase age sex location length histology vascular lymphnode                                           invasion metastasis  1 66 M luCe 7.5 sq well ly+ v+ n2  2 68 M lulm 9.5 sq well ly- v- na  3 65 M IM 8.0 sq well ly+ v- ns  4 65 F ImIu 9.0 sq well ly+ v- n,  5 64 M ImIu 9.0 sq well ly+ v+ n2  6 54 M Im 6.5 sq mod. ly+ v- n4  7 58 F Im 5.0 sq undiff. ly+ v+ n4  8 53 M Min 10.0 sq mod. ly+ v- n2  9 65 M Ei 7.8 sq well ly+ v+ ns 10 46 M Imlu 10.0 sq mod. ly+ v- n4Fig. 1. operative method schema regarding esopha-      gectomy with combined resection with the       aorta and the left main bronchusremained one received the resection of both the trachea and the arota (Fig-1). The patients comprised 8 men and 2 women whose age ranged from 53 to 68 years. The locaitons of the tumors were lu Ce in one, IuIM in 5, Im in 3 and Ei in one respectively. The length of shadow defect on esophagogram showed 5.0cm to 10.0cm and the patterns of shadow defect were the serratus type in one, the funnel type in one and the spiral type in 7. The types of the lesions at endoscopy were the ulcerative one in 9 and the protrusive in one. The vascular invasion of ly (+) was seen in 9 and that of v (+) in 4 and ly (+) v (+) in 4. Nodal involve-ment was shown in 3 of n4, in 4 of n3, in 3 of n2, none in no. The resection of the trachea and bronchus in 5 comprised of a resection of laryngotrachea in one (Fig. 2), left and rightFig. 2. Operative method schema regarding the        tracheal or broncheal resection and recon-       structionTable 2. Comparison in surgical outcome between with and         without combined resection with aorta and trachea                                    ( )%               AORTA TRACHEA   outcome without with without with               resection resec ion resection resec ion                 n=13 n=5 n=8 n=5 operative 6(46 .1) 1(20.0) 2(25.0) 2(40.0)    death   hospital 8(61 .5) 3(60.0) 6(75.0) 4(80.0)    death   survival   patients 7(53.8) 4(80.0) 6(75.0) 3(60.0)   over 1 m    alive 1 1 2 1    died 6 3 4 2    mean survival time 4.1+3.1 3.0+2.1 3.3+1.8 6.5+5.5   monthsmain bronchus in 2, the treachea in one and the membranous portion of the trachea in one respectively. The oncological curability (Ci) of surgery was ensured in all 5 patients. The suruvial time of the 5 patients ranged from 12 days to 12 months and 3 died within one month after surgery.  On the other hand, the resection of the wall of the aorta in 5 comprised of segmental resection in 4 in whom one had in combination with partial resection of thoracic vertebrae and combined reseciton of the aorta with left main bronchus in one. The oncological curability of C, was achieved in all 4 but one. The survival time ranged from 6 days to 6 months, one still surviving one month after surgery.          RESULTS  The surgical outcome after combined re-section with the tracheobronhus and aorta for the treatment of carcinoma of the thoracic esophagus was compared as shown in Table 2. High feasibility rate of a combined resection with the tracheobornchus was shown as com-pared with that of the aorta. The hospital death was almost the same, although it was exces-sively high. The patients who survived following surgery were a few in both groups but it was clearly shown that even a few patients survived, reflecting the effectiveness of op-erations on alleviating severe complaints andfacilitating a high quality of life.  However, the operative death was still high in both groups. The cause of early death follwing surgery were tracheal bleeding due to DIC, biliary peritonitis caused by purulent cholecystitis, respiratory failure, acute renal failure and bronchial fistula associated with operative technical error. There were mainly based on grave operation insult. In the ten patients. oncological curability was ensured in 8. Surgical curability tends to be ensured easier in case with a resection of the tracheobronchus rather than that of the wall of the aorta. In 2 patients who underwent a resection of the wall of the aorta, cancer residue was found at the site of the bornchial wall. It was shown that cancer infiltration used to be widely extended when the aorta had been involved.         DISCUSSION  Application of combined resection with involved adjacent organs for the treatment of carcinoma of thoracic surgry is still required in spite of detecting an early stage patients according to advances in diagnostic techniques. It is because dysphagia does not appear until the esophagus has obstructed over three fourths of its lumen. Aggressive surgery accompanying combined resection with the aorta, trachea and bronchus in still indicatd for far advanced cancer patients as far as the patient's conditionmay permit to alleviate life-threatening symp-toms and facilitate radicality to surgical oncology. The findings of CT and MR help us decide preoperativel indication of aggressive operation for carcinoma of the thoracic esophagus.  Since Thompson') first reported in 1973 a successful case with a combined resection of the esophagus with lower trachea and carinal resection, a few reports have shed some light on the extension of surgical indication for a combined resection with the trachea and bronchus 5)  The obvious disadvantage in a combined resection of the esophagus with the trachea and bronchus is that the trachea and bronchus loose suporting tissues of the esophagus and the feed-ing vessels into the lateral wall of the trachea cause damage or injury at surgery.  It is a main cause of anastomosis insuffi-ciency at the site of tracheo-and bronchoplasty. Furthermore, wrapping at anastomosis is needed for avoidance of occurring broncho-pulmonary artery fistula. Applicaiton of pedicled pleura is not adequate as a selection of wrapping material. The pedicled pectoral or latissimus dorsi muscles and the omentum which abound in tissues containing rich vessels are the wrapping material of choice6>.  There is some limitation of surgical indication for combined resection of the esophagus and the aorta. However, it is no doubt that patients with impending symtoms will set benefit by an aggressive operation to relieve a life-threatening risk. It is well known that cancer infiltration on the wall of the aorta causes obstruction of vasa vasorum which nourish the wall of the aorta. Subsequent ischemic change of the wall of the aorta is particularly prone to occurrence of a catastrophe of rupturing epispde. the question arises regarding a postoperative complication of catastophic episode of rupturing caused by postoperatie infection. Whenever a surgeon may try to surgically resect carcicnoma of the esophagus involving thr aorta, it should be known as to how deep cancer infiltraiton reaches on the wall of the involved aorta and as to whether the adhesion to the wall of the aorta is caused by inflammation or cancer infiltration. The indication of aggressive surgery should be considered on the basis of the standpoint of oncological radicality. In this series, adhesion over one half of the circumference of the aortic wall meat a presence of cancer infiltration extending the lamina elastica externa.  As a rule, it is defiend whether the margin of the aortic wall on CT finding is clear or not to define the depth of cancer infiltration into the aortic wall.  At present, a combined resection of the esophagus with the aorta is technically feasible and it is possible to make the risk minimized by improved surgical technique and proper pre-and postoperative cares.  On the other hand, there is one major ques-tion to be answered that temporary bypass constructed in the same operation field is justified for a postoperative complication of infection, and also extraanatomic bypass prior to a decision of resectability is valid. It apprears to be of no use unless aggressive operation is indicated. And the major problem is to improve the surgical outcome. It is recommended on the basis of a result of this study that postoperative complications be avoided by appropriate early cares to prevent the postoperative complcation such as acute renal failure and suppurative cholecystitis and complete node dissection including removal of the tumor be made. Surgeons should be aware of the fact that palliative operation to reduce an operation trauma is of no value to salvage the patients with advanced cancer and also postoperative full course of adjuvant chemotherapy is of help to prolong the survival time.         REFERENCES 1) Thompson DT : Lower tracheal and carinal    resection associated with subtotal esopha-   gectomy for carcinoma of esophagus involv-   ing trachea. Thorax 28: 257, 1873. 2) Tomita M, Ayabe H, Kawahara K : Combined    resection of the esophagus with the bronchus.   Except a Medica 40:105, 1986. 3) Obitsu R, Iwatsuka Y, Ikeda T et al: A case   with combined tracheal resection with esopha-   gectomy for the treatment of caricnoma of   thoracic esophagus. Shuzutsu 36:975, 1982 (in   Japanses).4) Kawahara H, Fujita H, Hidaka M et at:    Intrathoracic application of latissimus dorsi    muscle flap for extended radical esophagectomy    Jap. J. Assoc. Thorac. Surg. 85:300, 1984. 5) Tomita M et al: Surgical consideration of    esophagectomy combined with tracheo broncho-   plastic procedure for the treatment of    esophageal cancer. Acta Medica Nagasaki. 31  143, 1986.6) Kimino K : Experimental study on healing    process in bronchial anastomosis : Especially    availability of omental wrapping and pericardial    covering. Acta Medica Nagasaki. 30: 34, 1985.

Simultaneous Combined Resection of Adjacent Involved Organs for Carcinoma of Thoracic Esophagus

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Simultaneous Combined Resection of Adjacent Involved Organs for Carcinoma of Thoracic Esophagus

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