Ann Thorac Surg 2004;78:702-705
© 2004 The Society of Thoracic Surgeons
Case report
Successful treatment of esophageal cancer with transhiatal esophagectomy after heart transplantation
Dipin Gupta, MDa,
Mahender Macha, MDb,
Valentino Piacentino, III, PhDb,
Arun K. Singhal, MD, PhDb,
Harvey F. Sasken, MDc,
Satoshi Furukawa, MDb,
Daniel T. Dempsey, MDa*
a Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
b Division of Cardiac and Thoracic Surgery, , Temple University School of Medicine, Philadelphia, Pennsylvania, USA
c Department of Anatomic Pathology, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
Accepted for publication June 19, 2003.
* Address reprint requests to Dr Dempsey, Department of Surgery, Temple University School of Medicine, 3rd Floor, Parkinson Pavilion, 3401 N Broad St, Philadelphia, PA 19140, USA
e-mail: daniel.dempsey{at}temple.edu
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Abstract
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A 55-year-old heart transplant recipient with reflux esophagitis presented for routine endoscopic surveillance of an area of Barrett's metaplasia initially seen 3 years previously. Esophagogastroduodenoscopy revealed adenocarcinoma at 33 cm from the incisors. The preoperative clinical stage was T1N0M0 by endoscopic ultrasound. Transhiatal esophagectomy was performed with R0 resection of the cancer, and the patient recovered uneventfully. Pathologic examination confirmed esophageal adenocarcinoma (T1N0M0) in Barrett's mucosa. The patient is doing well, and has no evidence of disease after 18 months.
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Introduction
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As heart transplant recipients achieve increasing survival, they are at greater risk for development of carcinoma. Whereas lymphoproliferative disorders and carcinomas of the skin predominate, visceral tumors are rare. Esophageal cancer, in particular, is quite unusual in this population, and has been reported only 16 times in the heart transplant registry [1]. This population often has distorted mediastinal anatomy from adhesions after previous cardiotomies. Furthermore, therapy of potential postoperative complications such as pneumonia, wound infection, mediastinitis, or anastomotic leakage is more challenging in the setting of necessary immunosuppression.
A 55-year-old female heart transplant recipient was transferred to our institution for management of an esophageal carcinoma. She had initially undergone esophagogastroduodenoscopy (EGD) during her immediate posttransplant course after an episode of gastrointestinal bleeding. At that time, she was found to have severe acute esophagitis with columnar-type intestinal epithelium, but no dysplasia. She was treated with acid suppression and followed with annual endoscopy.
Thirty months after transplantation, routine endoscopy revealed a large hiatal hernia and a new polypoid, bilobed, sessile fungating mass arising from the metaplastic epithelium at 33 cm from the incisors. Pathologic slides were reviewed at our institution and confirmed esophageal adenocarcinoma in a background of high-grade dysplasia involving Barrett's mucosa (Fig 1A, B). Computerized tomography showed esophageal wall thickening but no evidence of metastasis.
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Fig 1. (A) Esophageal mucosa is present at the left edge of the field. Dysplastic epithelium as well as intramucosal carcinoma are also apparent. Invasion below the muscularis mucosa is not present (hematoxylin & eosin stain, original magnification, x25). (B) A solid region of well-differentiated adenocarcinoma is demonstrated with cribiform and abortive gland formation, and focal necrosis and leukocytic infiltration (hematoxylin & eosin stain, original magnification, x200).
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At abdominal exploration, there was no evidence of visceral or nodal metastasis, and transhiatal esophagogastrectomy was performed in the standard fashion. The posterior mediastinum appeared to be anatomically normal, and blunt dissection was carried out in the tissue plane between the esophagus and posterior pericardium in the usual manner (Fig 2). During mediastinal dissection, the patient remained hemodynamically stable. A stapled side-to-side cervical esophagogastrostomy and temporary feeding jejunostomy were created, and pyloroplasty was performed.
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Fig 2. Lateral view of transhiatal mobilization of the esophagus. Note close proximity of posterior pericardium to plane of dissection. (Reprinted from Baue AE, et al, Glenn's thoracic and cardiovascular surgery, 6th ed, Stamford, CT, McGraw-Hill Education, 1991, p 801, with permission.)
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Postoperatively, immunosuppression was maintained parenterally. The patient was extubated on postoperative day 2 and recovered uneventfully. A contrast-swallowing study performed on postoperative day 7 was normal (Fig 3). After this time, the patient's diet was advanced gradually. The patient was discharged on postoperative day 12.
Pathologic review showed a 2.5 x 1.4 x 1-cm mass in the distal esophagus. Margins were free of tumor and all 25 resected lymph nodes had no evidence of carcinoma. Pathologic staging was T1N0M0.
Repeat endoscopy performed 6 months later was grossly unremarkable and yielded biopsies free of tumor. An anastomotic narrowing was successfully dilated at that time with 40F bougienage. The patient is doing well, with no evidence of disease at 18 months postoperatively.
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Comment
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In this report, we summarize the successful surgical therapy of esophageal carcinoma after heart transplantation. The transhiatal esophagectomy technique, in particular, permitted us to treat this high-risk, immunosuppressed patient in a manner that minimized perioperative risk, provided a good oncologic result, and limited the risk for postoperative complications. The posterior mediastinal tissue planes were normal after orthotopic heart transplantation, and the patient tolerated the operation without hemodynamic instability.
With recent refinements in organ preservation, transplantation techniques, and immunosuppressive regimens, transplant recipients are achieving increased survival. Longer survival exposes this population to more complications of transplantation and immunosuppression, such as infection, graft rejection, and the development of carcinoma.
Review of the Organ Procurement and Transplantation Network (OPTN) database [1] yields only 16 reported cases of esophageal cancer in heart transplant recipients between 1989 and 2002 (Table 1). Resection was attempted in 9 patients. Despite therapy, 8 patients had progressive disease and 6 suffered death due to tumor.
Our management strategy was influenced by several factors. The decision to proceed to esophagectomy in an immunosuppressed heart transplant recipient rather than lesser therapy with endoscopic treatment or chemoradiotherapy was based on improving survival rates after esophagectomy [2–6], especially with early-stage tumors. Bousamra and associates [7] recently reported a median survival of 20 months in 90 patients after esophagectomy for malignancy. This group also reported only one postoperative death (during hospitalization or less than 60 days after discharge) out of 115 consecutive patients. Couetil and colleagues [8] reported a patient who developed a midesophageal tumor less than 1 year after transplant who was treated with radiotherapy alone and died within 4 months. Endoscopic therapy of an esophageal tumor using only Nd:YAG laser in a high-risk immunosuppressed patient was reported by Sharma [9]. This patient developed recurrence 36 months after initial complete response.
The choice of the transhiatal technique was based on evidence of lower perioperative morbidity, fewer postoperative complications, and equivalent long-term survival when compared with more radical operations. Gluch and associates [10] performed a retrospective analysis of 98 esophagectomies in which they found that those patients undergoing transthoracic esophagectomy had longer operative times, longer postoperative hospital stay, and more respiratory complications than those undergoing transhiatal esophagectomy. Hulscher and associates [11] performed a meta-analysis comparing results of transhiatal esophagectomy and transthoracic esophagectomy. They reported higher perioperative blood loss, higher risk of pulmonary complications, higher rate of chylous leak, and more wound complications after transthoracic esophagectomy. They also found a higher rate of anastomotic leakage and vocal cord paralysis after transhiatal esophagectomy, but equal overall survival between the two procedures. Orringer and associates [12] reported the results of 1,085 transhiatal esophagectomies in which they describe 5 (0.5%) patients requiring thoracotomy for control of mediastinal bleeding, 24 (2.2%) patients with persistent (duration > 12 weeks) vocal cord paralysis, 18 (1.7%) patients with chylothorax, 17 (1.6%) patients with clinically significant atelectasis or pneumonia prolonging the hospital stay, and 146 (13%) patients with leakage from the cervical esophagogastric anastomosis. All but 9 of their 146 patients (94%) with anastomotic leaks were successfully treated with conservative therapy (wound opening and local care). Orringer and associates have more recently reported a 3% leakage rate with the use of the side-to-side stapled anastomosis [3] used in our patient. Multiple prospective evaluations [4–6] of transthoracic esophagectomy and transhiatal esophagectomy yielded no differences in long-term mortality. Macha and Whyte [13] consider all patients with esophageal cancer to be candidates for transhiatal esophagectomy.
Based on this experience, we do not consider previous heart transplantation to be a contraindication to transhiatal esophagectomy in patients with resectable esophageal carcinoma.
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References
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- Organ Procurement and Transplantation Network Database, 2002
- Orringer M.B., Marshall B., Iannettoni M.D. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 1999;230:392.[Medline]
- Orringer M.B., Marshall B., Iannettoni M.D. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119:277-288.[Abstract/Free Full Text]
- Goldminc M., Madder G., Le Prise E., et al. Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial. Br J Surg 1993;80:367-370.[Medline]
- Chu K.M., Law S.Y., Fok M., et al. A prospective randomized comparison of transhiatal and transthoracic resection for lower-third esophageal carcinoma. Am J Surg 1997;174:320-324.[Medline]
- Hortsmann O., Verneet P.R., Becker H., et al. Transhiatal oesophagectomy compared with transthoracic resection and systematic lymphadenectomy for the treatment of oesophageal cancer. Eur J Surg 1995;161:557-567.[Medline]
- Bousamra M., Haasler G.B., Parviz M. A decade of experience with transthoracic and transhiatal esophagectomy. Am J Surg 2002;183:162-167.[Medline]
- Couetil J.P., McGoldrick J.P., Wallwork J., English T.A. Malignant tumors after heart transplantation. J Heart Transplant 1990;9:622-626.[Medline]
- Sharma P. Laser, and Multipolar Electrocoagulation ablation of early Barrett's adenocarcinoma: long-term follow-up. Gastrointest Endosc 1999;49:442-446.[Medline]
- Gluch L., Smith R.C., Bambach C.P., Brown A.R. Comparison of outcomes following transhiatal or Ivor-Lewis esophagectomy for esophageal carcinoma. World J Surgery 1999;23:271-276.
- Hulscher J.B., Tijssen J.G., Obertop H., van Lanschot J.B. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surgery 2001;72:306-313.[Abstract/Free Full Text]
- Orringer MB, Marshall B, Ianettoni MD. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease. World J Surgery 2001;25:196–203
- Macha M., Whyte R.I. The current role of transhiatal esophagectomy. Chest Surg Clin North Am 2000;10:499-518.[Medline]
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Abstract
Introduction
