Ann Thorac Surg 2004;78:298-302
© 2004 The Society of Thoracic Surgeons
Original article: general thoracic
Influence of esophageal carcinoma operations on gastroesophageal reflux
Jian Hu, MDa*,
Renyuan Li, MDa,
Li Sun, MDb,
Yiming Ni, MDa
a Department of Thoracic and Cardiovascular Surgery, First Hospital, College of Medicine, Zhejiang University, Hangzhou, China
b School of Medicine, Hangzhou Normal College, Hangzhou, China
Accepted for publication November 25, 2003.
* Address reprint requests to Dr Hu, Department of Thoracic and Cardiovascular Surgery, First Hospital, College of Medicine, Zhejiang University, No 261 Qingchun Rd, Hangzhou, 310003, Zhejiang, China
e-mail: hjsl{at}mail.hz.zj.cn
 |
Abstract
|
|---|
BACKGROUND: Gastroesophageal reflux occurs more easily after esophageal carcinoma operations. Our objective was to compare the influence of three kinds of esophageal carcinoma operations on reflux.
METHODS: From May 1999 to May 2002, esophageal carcinoma operations were performed on 30 consecutive patients through left thoracotomy, including 10 cases completed with supraaortic, ante-aortic gastroesophageal anastomosis, 10 cases with subaortic gastroesophageal anastomosis, and 10 cases with apicothoracic retro-aortic gastroesophageal anastomosis. A 24-hour esophageal pH was recorded for every patient 3 months after the operation.
RESULTS: The number of reflux episodes per 24 hours (No. of episodes), the number of reflux episodes greater than or equal to 5 minutes per 24 hours (No. 
5 min), the time in minutes of the longest reflux episode recorded (longest episode) and the cumulative time of the esophageal pH less than 4 (total time that pH < 4) are all beyond normal limits. The difference in number of episodes between supraaortic, ante-aortic, and subaortic gastroesophageal anastomosis groups is not significant; but the other indexes are higher in the supraaortic, ante-aortic anastomosis group with significance (p < 0.05). The difference in number of episodes between supraaortic, ante-aortic, and apicothoracic retro-aortic gastroesophageal anastomosis groups is not significant while the other indexes are much higher in the supraaortic, ante-aortic anastomosis group with significance (p < 0.05); the difference in number of episodes between apicothoracic retro-aortic and subaortic gastroesophageal anastomosis groups is not significant while the other indexes are lower in the apicothoracic retro-aortic anastomosis group with significance (p < 0.05).
CONCLUSIONS: Gastroesophageal reflux occurred after all three types of esophageal carcinoma operations. The reflux is less severe in the apicothoracic retro-aortic anastomosis group than in the other two groups. The esophageal carcinoma operation with apicothoracic retro-aortic gastroesophageal anastomosis has more advantages to alleviate postoperative gastroesophageal reflux.
|
Introduction
|
|---|
There is clear evidence that patients with esophageal carcinoma have relatively good outcome when treated with resection only, especially through a thoracic incision in which it is easy to remove the regional lymph nodes and to carry out the whole operation [1–3]. Multimodality treatment with neoadjuvant chemotherapy or chemoradiotherapy was recommended for esophageal carcinoma by some studies but recently the results have been debated by other studies due to poor outcome [4–6]. Surgical therapy is considered the major method for treatment of operable esophageal cancer [1, 2]. Yet, there are still many postoperative complications such as gastroesophageal reflux, leaks, and stricture, which affect the esophageal function and quality of life, as well as the long-term survival of the patients [7–10].
Generally, the destruction of physiologic antireflux structure is inevitable during an esophageal carcinoma operation. Thus, gastroesophageal reflux occurs more easily after the operation. In our study, postoperative gastroesophageal reflux was surveyed in three groups of patients, on whom esophageal carcinoma operations were performed using different gastroesophageal anastomosis techniques. The difference of reflux among the groups was analyzed.
|
Patients and methods
|
|---|
Patients and preoperative examination
From May 1999 to May 2002, esophageal carcinoma operations were performed on 30 consecutive patients (22 males, 8 females, age 40 to 67 years old), including 10 cases completed with supraaortic, ante-aortic gastroesophageal anastomosis, 10 cases with subaortic gastroesophageal anastomosis, and 10 cases with apicothoracic retro-aortic gastroesophageal anastomosis. Thirty patients consented to participate in the study and were subjected to clinical examination and laboratory tests. Approval from the Committee on Clinical Research of the hospital was obtained. All patients were diagnosed by esophagoscopy and biopsy. A barium swallow test confirmed that the cancer length was 3 to 6 cm. No lung or liver metastases were detected by radiography and(or) computed tomographic (CT) scan of the chest and ultrasonography of the upper abdomen. Supraclavicular lymph nodes were not involved by physical examination in all patients. All patients assessed by pulmonary functional test were fit for thoracotomy.
Surgical technique
The operations were completed through left muscle-sparing thoracotomy with removal of sixth or seventh rib. Isolation of the stomach was achieved through a left diaphragm incision. Gastroesophageal anastomosis was made by the assistance of an EH40 string suture clamp and 25#CDH curved intraluminal stapler (Ethicon Endo-Surgery Co, Ltd, Cincinnati, OH). Subaortic anastomosis was adopted for lower segment esophageal carcinoma, while middle segment esophageal carcinoma was assigned randomly to the supraaortic, ante-aortic anastomosis group (Figs 1–6),
or the apicothoracic retro-aortic anastomosis group. In the latter two groups, the proximal segment of esophagus was pulled out superior to the aortic arch after the resection of tumor. The "mushroom head" of the stapler was set into the proximal end of the esophagus. The string suture was fastened. In the apicothoracic retro-aortic anastomosis group, the proximal end of the esophagus, together with the mushroom head was then set back to the esophageal bed, posterior to the aortic arch, before the anastomosis was made. In that case, the gastroesophageal anastomosis located superior and posterior to the aortic arch, near the top of the thoracic cavity, while the stomach located mainly in the mediastinal esophageal bed. Anastomosis was covered and suspended by a mediastinal pleura flap, which provided a better condition for the anastomosis to heal and thus reduced the possibility of anastomotic leakage. In the supraaortic, ante-aortic anastomosis group, the gastroesophageal anastomosis was made directly anterior to the aortic arch. Esophageal carcinoma is verified by pathologic diagnosis for all cases.
Postoperative management and follow-up
After the operation, all patients were treated routinely by thoracic drainage, nutrition support, and antibiotics. All patients were evaluated clinically by their general condition, eating habits, and swallowing ability. During the follow-up of 3 months, no anastomotic leakage or stenosis was found. Antacid and(or) antiemetic was applied for 3 patients of the supraaortic, ante-aortic anastomosis group and 1 patient of the subaortic anastomosis group due to sustained gastric regurgitation. The patients with acid regurgitation were treated with omeprazole 20 mg per day within 14 to 28 days. The patients with symptoms of nausea received omeprazole 20 mg twice daily for 14 days. Regular postoperative follow-up was organized in 1, 3, 6, 12, and 24 months, with laboratory screening, chest roentgenogram, CT, or endoscopic checking of the anastomosis.
Twenty-four-hour esophageal pH monitor
Esophageal 24-hour pH monitoring was checked for every patient, 3 months after the operation. Esophageal pH monitoring was surveyed by a portable automatic pH recorder (Digitrapper MKIII, CTD-Synectics, Sweden). One reflux episode is defined as pH lower than 4 for more than 15 seconds. The electrode was placed 3 cm above the anastomosis by fluoroscopy. During surveillance, a routine life of the patient was followed except that acid food (pH < 4) was forbidden. The recorder was then connected to computer after surveillance and the datum was analyzed statistically.
Index of monitoring [11]
- The number of the reflux episodes per 24 hours (No. of episodes).
- The number of reflux episodes greater than or equal to 5 minutes per 24 hours (No. 5 min).
- The time in minutes of the longest reflux episode recorded (longest episode).
- The cumulative time of the esophageal pH less than 4 (total time that pH < 4).
Statistical analysis
Statistical analysis was performed with SPSS for windows 10.0 (SPSS Inc., Chicago, IL). Results are expressed as mean ± standard error (SD). Since variables do not follow the normal distribution, before parametric tests, the transformation technique was applied where the measured values were transformed as log. Differences in each variable among the three groups were analyzed by analysis of variance (F test). Differences between two groups were examined for significance with the Student-Newman-Keuls (SNK) test. A p value below 0.05 was considered significant.
|
Results
|
|---|
As shown in Table 1,
all of the variables are above the normal limit in the three groups. The difference of No. of episodes between the supraaortic, ante-aortic gastroesophageal anastomosis (supraaortic group) and the subaortic gastroesophageal anastomosis (subaortic group) is not significant, while the other indexes are higher in the former group with significance (p < 0.05). The difference of No. of episodes between the supraaortic group and the apicothoracic retro-aortic gastroesophageal anastomosis (retro-aortic group) is not significant, while the other indexes are higher in the former group with significance (p < 0.05). The difference of number of reflex episodes per 24 hours (No. of episodes) between the retro-aortic group and the subaortic group is not significant, while the other indexes are higher in the latter group with significance (p < 0.05).
|
Comment
|
|---|
With regard to social and economic development in China, patients pay more and more attention to the quality of life after operations. It becomes a hot topic for surgeons to improve a patients' quality of life without sacrificing the effect of the operation. For several years, single muscle-sparing left thoracotomy has been adopted routinely in our institute for esophageal carcinoma operations [12]. Through this access, esophageal carcinoma resection and gastroesophageal anastomosis can be completed with satisfaction.
Gastroesophageal reflux is one of the main factors that decrease the quality of life of patients after an esophageal cancer operation [12–16]. The symptoms of gastroesophageal reflux vary from patient to patient. In the atypical symptoms, gastroesophageal reflux becomes more difficult to diagnose. A 24-hour esophageal pH recording is the most sensitive, objective, and valuable method used to diagnose gastroesophageal reflux. In other words, it is the "gold standard" [17]. There are some reasons that make gastroesophageal reflux inevitable after an esophageal cancer operation. First, there exists no effective antireflux anastomosis technique. Second, the normal antireflux mechanism of the esophagus is damaged by radical operation. For example, the damage of the sphincter effect of the abdominal esophagus and the lower end of the esophagus, disappearance of the diaphragm peduncle and the His angle, and so on. Third, a common space is formed by the esophagus and stomach, which makes gastric content enter into the esophagus freely according to pressure gradient. At last, the decrease of gastric emptying capability and the existence of thoracic negative pressure worsen the situation.
Some researchers believe that the apicothoracic retro-aortic anastomosis technique can alleviate reflux through the following mechanism [18, 19]: first, the heart beats rhythmically on the stomach to accelerate gastric emptying; second, the aortic arch blocks the stomach in some degree, forming a natural stenosis to prevent reflux. Besides, we think the gastric content relatively decreases when the stomach is set in the esophageal bed with apicothoracic retro-aortic anastomosis. Thus, on one hand it alleviates the compression of the stomach on the lung, which decreases the loss of pulmonary function and, on the other hand, it alleviates the compression of the lung on the stomach, which decreases the incidence of gastroesophageal reflux, especially during deep respiration or severe cough.
Our data show that gastroesophageal reflux exists in all three groups. But there is a statistic difference among the groups. As to esophageal pH monitoring, all indexes are significantly lower in the apicothoracic retro-aortic group than in the other groups, except the number of the reflux episodes per 24 hours. According to the severity of gastroesophageal reflux, it should be arranged as: the supraaortic, ante-aortic group more than the subaortic group more than the apicothoracic retro-aortic group, although the anastomosis location of the apicothoracic retro-aortic group is the highest.
Summarily, among all the three kinds of esophageal carcinoma operations, the operation with apicothoracic retro-aortic gastroesophageal anastomosis alleviates gastroesophageal reflux, which maybe benefit the postoperative quality of life. Further follow-up data on a larger scale are needed to verify the long-term status of the patients. Nevertheless, we believe it is one of the promising selections for treatment of the middle segment, especially for earlier stage upper-middle segment esophageal carcinoma.
|
Acknowledgments
|
|---|
We wish to acknowledge the valuable instruction of the Academician of the Chinese Academy of Engineering, Professor Zheng ShuSen, for this manuscript.
|
References
|
|---|
- Simchuk E.J., Alderson D. Oesophageal surgery. World J Gastroenterol 2001;7:760-765.[Medline]
- Law S., Fok M., Chow S., et al. Preoperative chemotherapy versus surgical therapy alone for squamous cell carcinoma of the esophagus: a prospective randomized trial. J Thorac Cardiovasc Surg 1997;114:210-217.[Abstract/Free Full Text]
- Miller J.D., Jain M.K., de Gara C.J., et al. Effect of surgical experience on results of esophagectomy for esophageal carcinoma. J Surg Oncol 1997;65:20-21.[Medline]
- Bosset J.F., Gignoux M., Triboulet J.P., et al. Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. N Engl J Med 1997;337:161-167.[Abstract/Free Full Text]
- Stein H.J., Sendler A., Fink U., et al. Multidisciplinary approach to esophageal and gastric cancer. Surg Clin North Am 2000;80:659-682.[Medline]
- Urba S.G., Orringer M.B., Turrisi A., et al. Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma. J Clin Oncol 2001;19:305-313.[Abstract/Free Full Text]
- Whooley B.P., Law S., Alexandrou A., et al. Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer. Am J Surg 2001;181:198-203.[Medline]
- Swisher S.G., Hunt K.K., Holmes E.C., et al. Changes in the surgical management of esophageal cancer from 1970 to 1993. Am J Surg 1995;169:609-614.[Medline]
- Urschel J.D. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995;169:634-640.[Medline]
- McLarty A.J., Deschamps C., Trastek V.F., et al. Esophageal resection for cancer of the esophagus: long-term function and quality of life. Ann Thorac Surg 1997;63:1568-1572.[Abstract/Free Full Text]
- Vandenplas Y. Esophageal pH monitoring: methodology, indication and interpretation. Eur J Pediatr Surg 1991;1:67-72.[Medline]
- Jian H., Yuxing Z., Dinsheng Y. Radical operation of esophageal carcinoma with apico-thoracic retro-aortic anastomosis. Chinese J Oncology 2002;24:197-198.
- Jian H., Renyuan L., Hongdi Y., et al. A comparison study of long-term respiration function after the different type of resection of esophageal cancer. Chinese J Oncology 2003;25:356-357.
- Chen J.h, Wei G.Q., Shao L.F., et al. Evaluation of effect and life quality after esophageal carcinoma operation with jugular and thoracic anastomosis. Chinese J Oncology 1996;18:131-133.
- El-Serag H.B., Hepworth E.J., Lee P., et al. Gastroesophageal reflux disease is a risk factor for laryngeal and pharyngeal cancer. Am J Gastroenterol 2001;96:2013-2018.[Medline]
- Ye W., Chow W.H., Lagergren J., et al. Risk of adenocarcinomas of the esophagus and gastric cardia in patients with gastroesophageal reflux diseases and after antireflux surgery. Gastroenterology 2001;121:1286-1293.[Medline]
- Wang QZ. Gastroesophageal reflux disease. Tianjin Science and Technology Press, 1994:126–39
- Yang L., Zhang R.G., Mao Y.S., et al. Intra-esophageal bed supra-aortic gastroesophageal anastomosis for treatment of lower, and middle segment esophageal carcinoma. Chinese J Oncology 1996;18:37-40.
- Zuo D.G., Xin Y.L., Yang S., et al. Gastroesophageal reconstruction inside esophageal bed after resection of esophageal carcinoma (197 cases report). Chinese J Thoracic Cardiovasc Surg 1988;4:27-30.
This article has been cited by other articles:
|
|
|
|
 
J. Hu, R. Li, L. Sun, and Y. Ni
Comparison of influence of esophageal carcinoma operations on pulmonary function
Eur. J. Cardiothorac. Surg.,
July 1, 2005;
28(1):
16 - 18.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
