Showing papers by "J. R. Siewert published in 1993"

Endodissection of the thoracic esophagus. Technique and clinical results in transhiatal esophagectomy.

Abstract: OBJECTIVE: Transhiatal esophagectomy (THE), mostly performed in patients with adenocarcinoma of the esophagus, bears the risk of damage to mediastinal structures because the physician's vision is poor during esophageal dissection. The authors report a new endoscopic technique, which enables microsurgical dissection of the esophagus under visual control, that can be performed simultaneously to the abdominal approach. The clinical results in unselected patients with malignant esophageal disease were compared with those of patients undergoing conventional THE. METHODS: Thirty unselected patients (24 men and 6 women; median age, 60 years; age range, 35 to 80 years), mostly with adenocarcinoma of the esophagus, underwent endodissection between April 1991 and July 1992. Thirty patients, who underwent conventional THE between January 1986 and December 1990, were selected using a matched pair algorithm. RESULT: Three significant intraoperative complications were recorded during endodissection (one case of mediastinal bleeding; one case of postoperative bleeding; and one case of a lesion of the right main bronchus), and all were managed without further patient morbidity. The mortality rate (30 days) was 6.6% in the endodissection group (vs. 9.9% THE; not significant [NS]). The frequency of postoperative severe pulmonary complications was 13.3% in the endodissection group (vs. 30% in THE; p < 0.05). The rate of recurrent nerve palsy was only 6.6% in the endodissection group (vs. 13.3% in THE; NS). CONCLUSIONS: Endodissection is especially helpful during esophageal dissection at or above the trachea. It allows identification of mediastinal structures and controlled biopsy of mediastinal lymph nodes. This study showed that endodissection eliminates the "blind angle" during conventional THE, prevents recurrent nerve damage, and reduces pulmonary distress during transhiatal esophagectomy.

Barrett's esophagus: Pathogenesis, epidemiology, functional abnormalities, malignant degeneration, and surgical management

Abstract: Barrett's esophagus (i.e. columnar epithelial metaplasia in the distal esophagus) is an acquired condition that in most patients results from chronic gastroesophageal reflux. It is a disorder of the white male in the Western world with a prevalence of about 1/400 population. Due to the decreased sensitivity of the columnar epithelium to symptoms, Barrett's esophagus remains undiagnosed in the majority of patients. Gastroesophageal reflux disease in patients with Barrett's esophagus has a more severe character and is more frequently associated with complications as compared with reflux patients without columnar mucosa. This appears to be due to a combination of a mechanically defective lower esophageal sphincter, inefficient esophageal clearance function, and gastric acid hypersecretion. Excessive reflux of alkaline duodenal contents may be responsible for the development of complications (i.e., stricture, ulcer, and dysplasia). Therapy of benign Barrett's esophagus is directed towards treatment of the underlying reflux disease. Barrett's esophagus is associated with a 30- to 125-fold increased risk for adenocarcinoma of the esophagus. The reasons for the dramatic rise in the incidence of esophageal adenocarcinoma, which occurred during the past years, are unknown. High grade dysplasia in a patient with columnar mucosa is an ominous sign for malignant degeneration. Whether an esophagectomy should be performed in patients with high grade dysplasia remains controversial. Complete resection of the tumor and its lymphatic drainage is the procedure of choice in all patients with a resectable carcinoma who are fit for surgery. In patients with tumors located in the distal esophagus, this can be achieved by a transhiatal en-bloc esophagectomy and proximal gastrectomy. Early adenocarcinoma can be cured by this approach. The value of multimodality therapy in patients with advanced tumors needs to be shown in randomized prospective trials.

The surgical management of motility disorders.

Abstract: Surgical treatment is either the therapy of choice or a facultative procedure in various types of esophageal motility disorders. In achalasia, cardiomyotomy, frequently combined with fundoplasty, achieves good or excellent results in >80% of cases, and is, therefore, advised in cases when pneumostatic dilatation fails. Diverticulectomy and myotomy of the upper or lower esophageal sphincter are proven procedures to treat cervical and epiphrenic diverticula, leading to good/excellent results or at least an improvement in more than 95%. If, exceptionally, parabronchial diverticula require therapy, they should be excised transthoracically. Cervical myotomy is indicated in cases of cervical achalasia, when sufficient pharyngeal propulsion is preserved. In systemic diseases like scleroderma reflux induced complications may require surgical intervention in medically intractable cases. In these rather few cases, subtotal gastrectomy with a Roux-en-Y anastomosis is advised. In patients suffering from diffuse esophageal spasm or symptomatic “nutcracker” esophagus, extended esophageal myotomy can relieve symptoms. If a clear diagnosis is provided, about 75% of patients will have an improvement of symptoms.

pH monitoring: the gold standard in detection of gastrointestinal reflux disease?

Abstract: Gastroesophageal reflux disease (GERD) is one of the most frequent benign diseases of the gastrointestinal tract and in some cases the diagnosis may be very difficult. There are many diagnostic procedures but none of them could prove or definitely exclude the disease. The 24-h pH-monitoring is the “gold standard” for detection of gastroesophageal reflux and in many patients the reflux correlates with the GERD. The evaluation of a diagnostic method has to be done in a similar manner to the evaluation of therapeutic study (phase 1 to phase 4). For the definition of the “gold standard” for detection of a special diagnosis (e.g., the gastroesophageal reflux disease), the results of phase 3 studies for different methods had to be compared. The method with the best values for sensitivity and specificity is yet to be discovered. Until now, pH monitoring has been the gold standard for the diagnosis of GERD. However, there are many problems connected with using this method in clinical practice.

The place of esophageal manometry in the diagnosis of dysphagia

Abstract: Esophageal manometry allows to quantify intraluminal pressure changes as the basis of normal or abnormal esophageal motility. It is a complementary diagnostic procedure which should only be performed after endoscopic and fluoroscopic examinations and may be helpful in the detection of various motility disorders like diffuse esophageal spasm, nutcracker esophagus and vigorous achalasia. Manometry is recommendable for therapy control after medical and surgical therapy, and mandatory prior to surgical reflux therapy.

[Is cholecystectomy a risk factor for colorectal cancer? A meta-analysis].

Abstract: Durch die Einfuhrung der laparoskopischen Cholezystektomie ist die Frage nach dem Einflus der Gallenblasenentfernung auf die Entstehung von kolorektalen Karzinomen (CR-Ca) erneut aktuell geworden. Bisher vorliegende Studien zeigen widerspruchliche Ergebnisse. Durch eine Metaanalyse getrennt nach Studienart (prospektiv, retrospektiv) wurde die Hauptfragestellung „Wird das Risiko an einem kolorektalen Karzinom zu erkranken durch die Cholezystektomie erhoht?” untersucht. In den prospektiven Matched-pairs-Studien wurden 1 158 Patienten mit Cholezystektomie (CHE) mit 1 222 Kontrollen (Ko) verglichen. Das relative Risiko (RR) war mit 1,48 nicht significant erhoht. In 4 prospektiven Kohortenstudien wurde die Haufigkeit des CR-Ca von 22 783 Patienten mit CHE verglichen mit der zu erwartenden Haufigkeit (RR = 0,99). In den retrospektiven Studien wurde die Haufigkeit einer vorhergehenden CHE bei 11 797 Patienten mit CR-Ca mit der Haufigkeit bei 33 940 Kontrollen ohne CR-Ca verglichen. Die berechnete „odds ratio” (O. R.) der Metaanalyse betrug 1,15, was eine signifikante aber klinisch nichtrelevante Risikoerhohung darstellt. Ahnliche Werte ergaben sich fur die getrennte Auswertung nach Geschlecht sowohl in der Analyse der prospektiven Studien mit einem RR von 0,99 fur Frauen and 1,00 fur Manner und fur die retrospektiven Studien mit 1,17 (p 0,001).

Combined Modality Treatment for Locally Advanced Squamous Cell Esophageal Carcinoma Located at or Above the Level of the Tracheal Bifurcation

Abstract: Despite the advances of en bloc esophagectomy and lymph node dissection, the results of surgical resection alone in patients with advanced squamous cell esophageal cancer remain disappointing [1, 2]. Complete macroscopic and microscopic tumor removal, i.e., an RO resection according to the UICC 1987 definition [3], provides the only chance for long-term survival in this situation [4, 5]. Due to the close anatomical relation between the esophagus, trachea, and main stem bronchi, complete macroscopic and microscopic tumor removal is particularly difficult in patients with tumors in the proximal half of the esophagus [4]. Consequently, surgical resection in patients with locally advanced squamous cell esophageal carcinoma located at or above the level of the tracheal bifurcation is usually palliative and the prognosis is dismal [4].

Therapie des fortgeschrittenen Magenkarzinoms: Multiviszeral oder multimodal?

Abstract: Zu den wenigen zweifetsfrei belegten Fakten in der Chirurgie des Magenkarzinoms geh6rt, dab ein operativer Eingriff nur dann ffir den Patienten einen prognostischen Gewinn bringt, wenn er zur lokalen Tumorfreiheit ffihrt. Diese Aussage gilt im Prinzip gleichermagen ffir frfihe und ffir fortgeschrittene Magenkarzinome. Dieser Situation wird in der hoffentlich bald verbindlichen Nomenklatur der UICC als ,,no residual tumor= RO\" Rechnung getragen; der Begriff kurativ wird bewuBt vermieden, denn nicht Heilung, sondern lediglich Prognoseverbesserung ist erreicht. RO im Sinne der UICC meint lokale Tumorfreiheit in allen 3 Dimensionen (oral, aboral und in der Tiefe), sollte abet auch die Tumorfreiheit in den Lymphabflul3wegen (freie Grenzlymphknoten) beinhalten. Um dieses Ziel der lokalen Tumorfreiheit zu erreichen, ist auch eine Operationserweiterung vertretbar oder anders herum ausgedrfickt: Nur wenn dieses Ziel erreicht wird, ist eine Operationserweiterung vertretbar. Dies gilt sowohl ffir die radikale Lymphknotendissektion als auch ffir die multiviszerale Resektion [3]. Will man Argumente fiir multiviszetale Resektionen vorlegen, mfissen diese Fakten klar aufgezeigt werden. Entschliel3t man sich zu einer multiviszeralen Resektion, gilt es natfirlich sorgf/iltig das Risiko und den Nutzen eines derartigen Eingriffs gegeneinander abzuw/igen. Der zu erreichende Prognosegewinn, d.h. also der Nutzen, ist um so geringer, je fortgeschrittener das Tumorstadium ist. Dies bezieht sich nicht nut auf die T-Kategorie, sondern insbesondere auf die N-Kategorie, die die Prognose des Patienten am nachhaltigsten beeinflul3t [1]. Das bedeutet, dab eine multiviszerale Resektion bei einem T4Tumor mit beginnender oder wenig fortgeschrittener Lymphknotenmetastasierung (N1 -N2) mehr erreicht als bei weit fortgeschrittener Lymphknotenmetastasierung (mehr als N2) [3]. Die Tatsache sollte sorgf/iltig bei der Indikationsstellung bedacht werden. Konsequenterweise ist ein intraoperatives Staging ffir die Indikation zur multiviszeralen Resektion hilfreich. Die postoperative Morbidit/it wird in erster Linie durch eine etwaige Pankreasresektion in der Regel handelt es sich um eine Pankreaslinksresektion gepr/igt.

Lymphadenectomy in Esophageal Cancer Surgery

Abstract: In general, lymphadenectomy is indicated as a surgical treatment of esophageal carcinoma. It is also proven that lymphadenectomy is necessary for precise tumor staging. Adjuvant and additive therapy a

Adenocarcinoma of the Esophagus: Results of Surgical Treatment

Abstract: Adenocarcinoma of the esophagus is of special importance because it has been showing an increasing frequency, especially in Europe and North America [1]. This tumor is mostly attributed to a malignant degeneration of the columnar cell-lined lower esophagus. The results of surgical treatment of adenocarcinoma of the esophagus were prospectively analyzed and are reported in comparison to the long-term results after resection of squamous cell cancer of the esophagus, cardia cancer, and subcardial carcinomas.

Verlauf der Serumspiegel von TNF-α, IL-6 und CRP bei der postoperativen septischen Komplikation

Abstract: Postoperative septische Komplikationen, wie Peritonitis und Pneumonie, stellen die haufigste Ursache fur die Letalitat in der Abdominalchirurgie dar. Auch in der Unfallchirurgie sind es bei standig verbesserten Therapiemoglichkeityen des initial hamorrhagisch-hypovolamischen Schocks heute hauptsachlich septische Spatkomplikationen, ausgehend von Weichteilen und Knochen oder vom Respirationstrakt, die fur einen letalen Ausgang verantwortlich zu machen sind. Bei protrahiertem Verlauf oder nicht ausreichender chirurgischer Sanierung des septischen Fokus kommt es zu den bekannten Folgen der Sepsis wie akuter renaler Tubulusnekrose, mesenterialer Ischamie oder ARDS mit konsekutivem Multiorganversagen.

Endoscopic Esophagectomy: A Better Way to Atraumatic Surgery?

Abstract: This paper describes the technique and clinical results of endoscopic dissection (endodissection) of the thoracic esophagus during transhiatal esophagectomy (THE). The method eliminates the ‘blind angle’ of conventional THE and reduces intraoperative traction on mediastinal tissues. Mediastinal structures such as the trachea, main bronchi and mediastinal nerves can be identified, and bleeding from minor mediastinal vessels can be controlled under vision. The mortality rate of the first 30 patients operated on was 6.6%, and only two major intraoperative complications occurred (one lesion of the right main bronchus, 2 bleedings). The rate of recurrent nerve palsy in these patients was low (6.6%).

Staging of Esophageal Cancer—Preoperative Prediction of LN-Metastases

Abstract: The therapeutic decision in esophageal cancer is decisively influenced by the preoperative staging especially the depth of wall infiltration of the primary tumor, lymph node metastases, and localization. Recent reports have clearly pointed out that radical lymphadenectomy is able to contribute to an improvement of prognosis especially in patients with early stages of lymph node metastases. In patients with an advanced stage of metastases, however, no improvement of survival can be effected by lymphadenectomy [1]. In addition, the radicality of lymphadenectomy also influences postoperative mortality and especially morbidity [2–4].

Gastroösophageale Funktionsstörungen beim Endobrachyösophagus

Abstract: Als Endobrachyosophagus oder Barrett-Osophagus wird heute allgemein der Ersatz des Plattenepithels in der distalen Speiserohre durch Zylinderepithel als Folge von chronischem gastroosophagealen Reflux bezeichnet [1]. Die Grunde, warum es nur bei etwa 10%-20% der Patienten mit pH-metrisch nachgewiesenem Reflux zum Zylinderepithelersatz in der distalen Speiserohre und dem damit verbundenen Risiko der malignen Entartung kommt, sind jedoch unklar. Als mogliche pradisponierende Faktoren werden eine verlangerte Expositionszeit und erhohte Aggressivitat des Refluates, ein inkompetenter unterer Osophagussphinkter und eine gestorte peristaltische oder Clearance-Aktivitat der tubularen Speiserohre diskutiert [1, 2]. In der vorliegenden Studie verglichen wir osophageale Saureexposition, Kompetenz des unteren Osophagussphinkters, Clearance-Funktion der tubularen Speiserohre und Magensaftsekretion bei Patienten mit Endobrachyosophagus, Patienten mit Refluxosophagitis ohne Endobrachyosophagus und normalen Probanden.

Swallowing Function Before and After Esophagectomy for Treatment of Esophageal Cancer

Abstract: A total or subtotal esophagectomy represents the main therapeutical step in esophageal cancer when cure is desired or also as a palliative measure. Surgeon’s goals are not only tumor radical resection, but also to allow survival under acceptable conditions.

Grenzen chirurgischen Handelns: Pfortaderresektion beim Pankreaskopftumor

Abstract: In an attempt to achieve complete tumor removal a tangential or segmental resection of the portal vein was performed in 17/210 patients who had a partial pancreatoduodenectomy. Although there was no postoperative mortality median survival time was 6 months only in the 15 patients with an adenocarcinoma while the two remaining patients (acinus cell carcinoma and cystadenocarcinoma) are alive 47 and 14 months after the procedure. These data indicate that portal vein resection, although safe in experienced hands, does not prolong survival in patients undergoing pancreatoduodenectomy for an adenocarcinoma.

Transmediastinal Esophagectomy: Comparison of Cardiopulmonary Performance After Anterior Versus Posterior Reconstruction

Abstract: Cardiopulmonary complications remain one of the leading factors in postoperative morbidity and mortality following esophagectomy. To reduce these complications, new surgical methods like limited transmediastinal resection [1], endodissection of the esophagus [2] or transthoracic resection with delayed reconstruction have been evaluated [3].