Ann Thorac Surg 2006;82:1849-1856
© 2006 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Lung Volume Reduction Surgery Allows Esophageal Tumor Resection in Selected Esophageal Carcinoma With Severe Emphysema
Qun-You Tan, MDa,
Ru-Wen Wang, MDa,*,
Yao-Guang Jiang, MDa,
Shi-Zhi Fan, MDa,
Michael K.Y. Hsin, MDb,
Tai-Qian Gong, MDa,
Jing-Hai Zhou, MDa,
Yun-Ping Zhao, MDa
a Division of Thoracic Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
b Division of Cardiothoracic Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
Accepted for publication May 16, 2006.
* Address correspondence to Dr Wang, Division of Thoracic Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Road Branch, Chongqing 400042, China (Email: tanqy001{at}yahoo.com).
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Abstract
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BACKGROUND: Esophageal carcinoma patients with coexisting severe emphysema are high risk surgical candidates. We hypothesize that simultaneous unilateral lung volume reduction surgery (LVRS) allows us to offer esophageal tumor resection to patients previously considered inoperable.
METHODS: Twenty-one patients with esophageal carcinoma were recruited. All patients had severe emphysema with impaired respiratory function and health-related quality of life (HRQL). Esophageal tumor resection with gastroesophagostomy in the thorax and then unilateral LVRS were performed at the same anesthesia. Dyspnea index, exercise capacity, pulmonary function, and HRQL were assessed at baseline and every three months up to one year postoperatively.
RESULTS: There was no perioperative death or significant morbidity. Clinical improvements were observed at 3, 6, and 12 months, in terms of dyspnea index, forced expiratory volume in 1 second, residual volume, partial pressure of oxygen, arterial, partial pressure of carbon dioxide, arterial, 6-minute walking distance, dysphagia, and odynophagia (p < 0.01 or p < 0.05). The Karnofsky Performance Status score improved from baseline 36 ± 3 to 53 ± 3 at 3 months, 67 ± 5 at 6 months, and 63 ± 8 at 12 months (p < 0.01). Significant improvement was seen in all the Short-Form 36-item Health Survey HRQL domains at 3 months (p < 0.01 or p < 0.05). These improvements remained significant for up to 6 months, and for up to 12 months for physical functioning and general health. The Psychosocial Adjustment to Illness Scale score and all the scales were improved after surgery (p < 0.01).
CONCLUSIONS: Our study shows that in selected patients with esophageal carcinoma who suffer from severe emphysema, simultaneous unilateral LVRS renders esophageal tumor resection safe and effective. Also, these patients may experience early improvement in pulmonary function and HRQL.
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Introduction
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Carcinoma of the esophagus is one of the most commonly occurring cancers and the leading causes of cancer death in the developing world, including China [1, 2]. Among treatment methods currently available, radical resection assures the best chance for cure, while alternative treatment strategies, including radiation therapy with or without chemotherapy, have yielded comparatively poor results [3, 4]. Approximately 550 to 700 esophageal carcinoma cases are diagnosed annually in our hospital, and most of them are the middle-aged or the elderly with concurrent chronic obstructive lung disease, including emphysema. The patients with severe emphysema are at high operative risk for esophageal resection, and the opportunity to undergo curative surgery may be denied owing to their impaired respiratory function [5].
Lung volume reduction surgery (LVRS) has been shown to improve respiratory function, dyspnea symptoms, and quality of life for up to 3 to 5 years in selected patients with end-stage emphysema [6]. In selected lung cancer patients whose emphysema would have otherwise precluded surgical resection, recent studies have demonstrated that, by combining LVRS and lung cancer resection, these patients may benefit significantly in terms of perioperative risks, quality of life, and long-term survival, thus also increasing the resection rate of lung cancer [7, 8]. Health-related quality of life (HRQL) is one of the primary outcome measures in evaluating LVRS and has become increasingly important in postoperative health care [9, 10]. We previously reported our early experience in treating esophageal and cardiac cancer patients with coexistent severe emphysema by combining gastroesophagostomy with simultaneous LVRS, with favorable outcome [5]. To date, we have found no other publication in the English language reporting this strategy. We now report our experience over an eight year period, by evaluating changes in HRQL, dyspnea index, exercise capacity, and pulmonary function at three monthly intervals after surgery. In this study, the effect of simultaneous unilateral LVRS to allow esophageal tumor resection in selected esophageal carcinoma patients with severe emphysema was investigated.
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Patients and Methods
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This prospective study was approved by the Human Studies Committee and Ethics Committee in the Third Military Medical University, and all patients signed a detailed and study-specific consent form outlining the rationale, potential benefits, and potential drawbacks of participation.
Patient Population
Between June 1998 and January 2006, 34 patients with esophageal cancer and coexisting severe emphysema presented to Daping hospital, Third Military Medical University. After detailed preoperative evaluation, and having obtained informed consent, 21 patients were eligible for our study of combined gastroesophagostomy and LVRS, on the basis of our selection criteria detailed in Table 1. For esophageal carcinoma, inclusion in the study was limited to patients with a potentially curable disease, namely stage T1 
3N0 1M0 (The International Union Against Cancer 1997 staging system), with the tumor located in the thoracic segment of the esophagus and deemed resectable. We excluded patients with advanced tumor (ie, patients with esophageal carcinoma invading paraesophageal organs or even malignant effusion [T4] or intrathoracic or extrathoracic metastasis [M1]); esophageal carcinoma patients with coexisting cancer were also excluded. We also excluded patients who had undergone preoperative adjuvant treatment aimed at the cancer, including chemotherapy and radiation therapy. For emphysema, inclusion criteria were the following: patients with shortness of breath on routine daily activities despite maximal medical therapy, whose forced expiratory volume in one second (FEV1) is less than 40% predicted, and whose residual volume is more than 250% predicted. By conventional criteria, these patients would be considered very high-risk candidates for surgery on the basis of their pulmonary function. We excluded patients whose FEV1 was less than 25% predicted, residual volume was more than 350%, partial pressure of carbon dioxide (PaO
2) less than 60 mm Hg (room air), or PaCO
2 more than 55 mm Hg. We also excluded patients who had an active bronchitis or pulmonary infection or a pulmonary hypertension (more than 45 mm Hg in pulmonary arterial systolic pressure or more than 35 mm Hg in mean pulmonary arterial pressure). The distribution of the emphysema should be heterogenous with predominance of the disease on one side more than the other. Preoperative evaluation for clinical tumor, node, metastasis staging of esophageal cancer included routine physical examination, chest roentgenogram, total body spiral computed tomography, upper gastrointestinal endoscopy, upper gastrointestinal endoscopic ultrasound, and upper gastrointestinal barium swallow. All patients were rigorously assessed preoperatively for the extent of the emphysema by means of imaging studies, including lung spiral computed tomography and radionuclide imaging with technitium 99 macroaggregated albumin, and functional studies including postbronchodilator spirometry, plethysmography, and arterial blood gas analysis. Echocardiography was performed for the cardiac functions, including assessment of pulmonary arterial pressures. Fiber optic bronchoscopy examination of the airway was systematically performed preoperatively for tumors of the upper and middle third esophageal carcinoma to confirm respectability regarding the tumor invasion of the trachea, and bronchi and to provide material for bacteria culture. All patients were enrolled in a preoperative period rehabilitation program after having obtained full informed consent. Pulmonary rehabilitation was started when the patients were clinically stable and continued for at least four weeks until the scheduled operation. The mean duration of preoperative pulmonary rehabilitation was 4.6 ± 1.1 weeks. Postoperative pulmonary rehabilitation was also performed until discharge to help their recovery from surgery. The pulmonary rehabilitation program consisted of exercise training, such as walking and cycle ergometry, and also included breathing-pattern training (pursed lips and diaphragmatic breathing), thoracic-mobility exercises, stress management, and educational sessions using videotapes (medication, oxygen therapy, nutrition, and health preservation). All patients were started on preoperative nutrition supplement for at least two weeks.
Procedure
All procedures were carried out under general anesthesia and intubation with a double-lumen endotracheal tube. The surgical approach was selected according to the location of the esophageal tumor and the side having more emphysematous lung in order to facilitate tumor resection and intentional unilateral operation (Fig 1). Nine patients underwent right thoracotomy. They all had severe emphysema with target areas for resection in the right lung. The tumor location was as follows: upper third of the esophagus, two cases; middle third, five cases; and lower third, two cases. With the patient in the left 45-degree lateral position, an anterolateral approach through the fourth intercostal space was performed to resect the esophageal tumor and dissect all the suspicious malignant lymph nodes in the mediastinum. Then, an upper median laparotomy was performed and the stomach was dissected free. A gastroesophagostomy in the right thorax was carried out with a circular stapler (Ethicon; Johnson & Johnson Company, Cincinnati, OH). A flexible plastic feeding tube, with a length of 45 cm and a luminal diameter of 3 mm, was then introduced through a nostril, past the gastroesophageal anastomosis, and into the descending part of the duodenum for postoperative nutrition. After cancer removal and alimentary tract reconstruction were completed, unilateral LVRS was performed under the same anesthesia. The "target regions" were selected using preoperative imaging and intraoperative findings, and the severe emphysematous lung parenchyma (mainly located in the upper and lateral parts of the upper lobe, except one case with lower-lobe predominance) was resected using the TLC75 stapling gun (Ethicon; Johnson &Johnson Company, Cincinnati, OH). The removal of the pulmonary tissues damaged by emphysema was about 25% to 30% volume of the total lung parenchyma and adjusted for the volume of the intrathoracic part of the stomach. All staple lines were buttressed with bovine pericardial strips. Then, fibrin sealant ([FS]; provided by Guangzhou Bioseal Biotech Co, Ltd, Guangzhou, China) was insufflated to reduce air leak. Four intercostal nerves around the incision were anesthetized with –60°C by a carbon dioxide freezing system (K520, Beijing, China) in case of postoperative pain. Two chest tubes were placed in the apical and basal positions. The remaining 12 patients had severe emphysema on the left side. The approach was through a left posterolateral thoracotomy in the full lateral decubitus position. They underwent tumor and malignant lymph lode removal, intrathoracic gastroesophagostomy above (6 cases) or below (6 cases) the aortic arch, and left-side LVRS. This group did not receive laparotomy and the stomach was lifted into the thorax through an incision in the left diaphragm. Simultaneous unilateral LVRS was performed similar to the procedure described previously except for one patient who had a left upper lobectomy because the disease had caused significant destruction of the lobe. Other treatment was the same as that in the right thoracotomy group. Perioperative complications and performances of all the patients were observed and recorded in detail. At the time of discharge, patients were given the contact information for the enrolling physician. Participants in the study were invited to contact the hospital for any advice or assistance at any time after the study. Follow-up was weekly for the first month and then once monthly thereafter.
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Fig 1. A decision tree for choosing different operative approaches according to the location of the esophageal tumor and the side having more emphysematous disease.
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Outcome Measures
The Karnofsky Performance Status (KPS) was evaluated by coordinators using a scale of 0 to 100 to assess functional rehabilitation of surviving patients [11]. The HRQL was assessed by using the Medical Outcome Study Short-Form 36-item Health Survey (SF-36) [12]. The survey consists of 36 multiple-choice questions that cover eight health concepts: physical functioning, social functioning, role physical, role emotional, vitality, bodily pain, mental health, and general health perception. Responses were scored using the computer algorithm that imputed missing values when appropriate, and transformed scale scores to 0 (worst) to 100 (best). Given the dominance of physical dimensions covered by the SF-36 and the need to provide expanded emphasis on psychosocial domains, we used the Psychosocial Adjustment to Illness Scale (PAIS), a 46-item questionnaire, to assess the functional, emotional, and social dimensions of HRQL [13]. All tests were performed during periods of clinical stability.
Because the KPS, SF-36, and PAIS are all generic measures of health, and not specific to patients with impaired respiratory function, a complete battery of pulmonary function tests was performed at our institution during the postoperative follow-up periods. Accordingly, we also included, as integrated clinical outcome measures, FEV1 and forced vital capacity (FVC; for airway obstruction), residual volume by means of helium dilution (for lung hyperinflation) six-minute walking distance (6MWD; for exercise capacity), modified Medical Research Council dyspnea index score (for the degree of subjective dyspnea), and arterial blood gases on room air (for the combination of pulmonary ventilating and diffusing capacity). In addition, because these patients had suffered from esophageal carcinoma, two symptom scales pertaining to the information of dysphagia and odynophagia were added to the questionnaire and a high score meant a greater severity of symptoms [3]. The HRQL and other outcomes were detected in all patients before surgery and at 3, 6, and 12 months after surgery.
Statistical Analysis
Group descriptive statistics were presented as means ± standard deviation, otherwise specified. Categorical data were expressed as counts and proportions. The correlation between the clinical variables and HRQL variables was also examined by the Pearson product moment correlation analysis. A p value less than 0.05 was considered statistically significant. The statistical analysis was performed using the Statistical Package for Social Sciences PC software package (Systat 11.0 for Windows; SPSS Inc, Chicago, IL).
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Results
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A total of twenty-one patients underwent the resection of esophageal cancer and suspicious mediastinal lymph nodes; intrathoracic gastroesophagostomy and simultaneous unilateral LVRS were evaluated. There were 17 men and 4 women with a median age of 60.3 ± 8.7 years (range, 51 to 69 years). All patients fulfilled our inclusion criteria for this combined surgery. In particular, all cases had emphysema graded as severe and asymmetric with disabling symptoms despite maximized medical therapy, while no patient had isolated giant bullous emphysema. One patient was known to have lower-lobe predominance with lower- lobe target areas. Nine of the 21 patients used chronic oral corticosteroids with a daily dose of less than 10 mg before surgery.
At the operation, radical esophageal carcinoma resection was carried out in all 21 patients (2, 11, and 8 cases were in the upper, middle, and lower third of the esophagus, respectively) (Fig 1). The amount of resected emphysematous pulmonary tissues damaged weighed 62.3 ± 9.1 g (range, 46 to 71 g). Standard LVRS was performed in 20 patients and left upper lobectomy in one patient where severe emphysematous change in the lobe. All patients were extubated in the operating room or shortly thereafter in the postanesthesia recovery area. Only one patient (4.8%) required immediate reintubation and was ventilated overnight, with successful extubation on the following morning. There was no hospital mortality or reoperation, and there was no significant perioperative morbidity. All patients reported satisfactory postoperative pain control. All patients received supplementary oxygen, which was weaned off in all patients within one week. The most common complications were prolonged air leak for longer than 7 days in 6 patients (28.6%), pneumonia in 3 patients (14.3%) (one combined with air leak), atelectasis in 1 patient (4.8%), and transient cardiac arrhythmia in 2 patients (9.5%) (one combined with air leak). There were no additional cardiac, vascular, gastrointestinal, urinary, or wound complications; and especially, no esophageal-related problems including anastomosis fistula or stenosis. Postoperative hospital stay averaged 17.6 ± 4.9 days (range, 14 to 26 days). The length of postoperative hospital stay in ten patients with complications (20.1 ± 7.4 days) was much longer than that of the remaining patients who did not have complications (15.3 ± 3.2 days) (p < 0.01). Pathologic staging showed nine T2N0M0, four T2N1M0, seven T3N0M0, and one T3N1M0 tumors. Histology revealed that all the esophageal tumors were squamous cell carcinoma. Ten patients received adjuvant treatment for the cancer including 7 with chemotherapy, 2 with radiation therapy, and 1 with both.
All 21 patients had complete vital status assessment throughout the entire study period. Follow-up averaged 10.4 ± 2.6 months (range, 3 to 12 months), 21 patients at 3 months, 19 at 6 months, and 17 at 12 months after the operation. The completion rate of answered questions in the SF-36 questionnaire was satisfactory (96%).There were 2 postoperative late deaths attributed to respiratory failure secondary to pulmonary infection, including 1 death at the fifth month and 1 death at the eighth month. Each of the two patients had a heavy cold and did not come to the hospital in time.
The degree of subjective dyspnea, exercise capacity, pulmonary function test, dysphagia, and odynophagia results are shown in Table 2
and demonstrate the typical degree of improvement in all parameters compared with the preoperative values. Early clinical improvement was observed at 3 months regarding dyspnea index, FEV1, residual volume, PaO
2, PaCO
2, 6MWD, dysphagia, odynophagia (p < 0.01 or p < 0.05). At 6 and 12 months, all the variables previously described and FVC were still much better than baseline. When we compared these postoperative data at 3 months, 6 months, and 12 months, there was no significant difference noted for all variables except for FVC (p < 0.05). This would suggest that the corresponding improvement compared with baseline in the parameters may be related to the effects of LVRS. The FVC at 3 months was significantly different from those at 6 and 12 months, but no difference between 6 and 12 months was found. This may represent the time necessary for the benefits of LVRS, such as chest wall mechanics, to become measurable.
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Table 2. Dyspnea Status, Exercise Capacity, Respiratory Function, Dysphagia, and Odynophagia Data at Different Points
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Repeated measures analysis of variance demonstrated that the KPS score improved for all patients from baseline 36 ± 3 to 53 ± 3 at 3 months, 67 ± 5 at 6 months, and 63 ± 8 at 12 months (p < 0.01). Significant changes in all the SF-36 HRQL domains at 3 months, including physical functioning (p = 0.002), role physical (p = 0.005), bodily pain (p = 0.028), vitality (p = 0.002), social functioning (p = 0.007), role emotional (p = 0.006), mental health (p = 0.005), and general health (p = 0.001). These improvements remained significant for up to 6 months for all the domains above, and for up to 12 months for physical functioning and general health only. Remembering that lower scores show improvement, the Psychosocial Adjustment to Illness Scale global score and all the scales were improved after surgery (p < 0.01). The pattern is thus similar to the KPS and SF-36 data but not as pronounced (Table 3). Similar to the pulmonary function, when the values of all the domains about HRQL at 3, 6, and 12 months were compared no significant difference was found (p > 0.05). Meanwhile, there was no difference in all the HRQL domains between the two groups, with and without postoperative adjuvant therapy (p > 0.05).
Although these patients, suffering from esophageal carcinoma and coexisting severe emphysema, presented a correlation between odynophagia and the KPS, SF-36 physical functioning, general health, and the Psychosocial Adjustment to Illness Scale global scores, the difference was not significant (p > 0.05). While dyspnea index, FEV1, FVC, residual volume, PaO
2, PaCO
2, 6MWD, and dysphagia showed significantly correlative when analyzed with the domains about HRQL (p < 0.05 or p < 0.01; Table 4). That might mean all the domains described above contributed to HRQL except odynophagia.
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Table 4. Correlation of KPS, PF, GH, and PAIS (Before Operation) With Respiratory Function, Dysphagia and Odynophagia
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Comment
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Esophageal carcinoma is one of the most common malignancies in China. Mass screenings for esophageal cancer conducted from 1959 through 1981 showed that the age-adjusted annual mortality rate of this cancer in the 40- to 69-year-old population group was 470/105 [2], and radical resection is still the mainstay of treatment for early stage cancer. Transthoracic en bloc resection of the esophageal tumor, followed by intrathoracic esophageal reconstruction with the stomach, is the strategy of choice for most thoracic surgeons in China. The alternative, a transhiatal esophagectomy, is not universally accepted because of concerns of adequacy of lymph node dissection and a higher incidence of anastomotic complications and recurrent laryngeal nerve lesions [14]. Unfortunately, most esophageal carcinoma patients are middle-aged or elderly, a percentage of whom have coexistent severe emphysema. These patients are often denied the opportunity of surgical treatment or if offered esophageal resection, result in poor postoperative HRQL and delayed postoperative adjuvant therapy [5, 7, 8]. Rehabilitation exercise can improve the pulmonary function of these patients to a certain extent; however, not all patients are able to undertake the exercises or complete the program. Indeed, the intervening period imposes a delay to the intended surgical treatment of the malignant disease. Moreover, the respiratory rehabilitation is expensive and time consuming, and the improvement in pulmonary function is sometimes inadequate for the requirements of esophageal resection [15]. Therefore, the patients in our study were asked to complete a short-period rehabilitation program lasting just four to six weeks.
The most important finding of our study is that simultaneous unilateral LVRS may be performed in combination with esophageal resection in rigorously selected esophageal carcinoma patients with coexisting end-stage emphysema, with acceptable morbidity and without mortality. Emphysematous patients with poor pulmonary function are at significant risk of morbidity and mortality after major surgery. Lung volume reduction surgery is an effective surgical procedure for severe emphysema. After esophageal carcinoma resection and intrathoracic gastroesophagostomy, part of the thoracic cavity will be occupied by the pulled-up stomach, which will lead to further impairment of respiratory motion and poorer pulmonary function. Although the jejunum can be used to reconstruct the digestive tract, the stomach is usually regarded as the substitute of choice by most thoracic surgeons. Moreover, the incidence of anastomosis fistula of the esophagus and stomach in the thorax (especially with a stapler) is lower than that in the neck [16].
Another finding of this study is that after simultaneous unilateral LVRS with esophageal tumor resection, these patients with severe emphysema also report improvement in HRQL by all three measures and this improvement is observed for up to 12 months. Comparing with the baseline scores, the KPS values improved significantly for all patients after surgery at 3 months, at 6 months, and at 12 months. Significant changes are observed in all the SF-36 HRQL domains at three months. As far as HRQL domains were concerned, the greatest improvements were in "physical functioning" and "general health" in all patients. Moreover, these improvements remained significant for up to 6 months for all the domains above, and for up to 12 months for physical functioning and general health. The PAIS global score and all the scales were noticeably improved after surgery, similar to the KPS and SF-36 data.
Our results show that clinical improvements regarding dyspnea index, FEV1, FVC, residual volume, PaO
2, PaCO
2, 6MWD, dysphagia, and odynophagia remain improved compared with baseline up to 12 months. Moreover, in this cohort we were able to demonstrate a significant correlation between parameters such as dyspnea index, FEV1, FVC, residual volume, PaO
2, PaCO
2, 6MWD, and dysphagia with quality of life parameters; namely the KPS, physical functioning, general health, or the PAIS global scores. Our data suggest that by performing simultaneous unilateral LVRS, our patients not only benefit in the perioperative period but also experience improvement in their HRQL.
This strategy of combined surgery carries significant risks because of the combined diseases and the older age of the patient, although Meyers and colleagues [17] recently reported encouraging results of LVRS in patients meeting a National Emphysema Treatment Trial high-risk criterion. In our study, significantly, there are no esophageal-related problems or mortality and the two postoperative late deaths were not related to the operations; however, there are 12 nonfatal complications in 10 patients. Therefore, we emphasize the importance of selecting appropriate patients for this combined surgery. In our opinion, patients with less than 25% of predicted FEV1, hypercapnia with more than 55 mm Hg PaCO
2, pulmonary hypertension with more than 35 mm Hg mean pulmonary arterial pressure, or evidence of active pulmonary infection should be excluded. Nor do we feel that it is appropriate to offer this treatment to patients with less than one-year expected survival. We suggest that the rigorous preoperative assessment is of paramount importance, and this includes routine physical examination, chest roentgenogram, total body spiral computed tomography, upper gastrointestinal endoscopy, upper gastrointestinal endoscopic ultrasound, and upper gastrointestinal barium swallow. Fiber optic bronchoscopy examination of the airway should be performed for tumors of the upper and middle third esophageal carcinoma to confirm resectability. During the operation, the removal of the pulmonary tissues damaged by emphysema is often about 25% to 30% volume of the total lung parenchyma; however, it should also take into account the volume of the part of the stomach within the thorax because the ascended stomach occupies a part of the thoracic cavity. The operating time should be minimized for these patients with impaired pulmonary function. The team should be proficient at performing both esophageal and pulmonary operations. We did not employ video-assisted thoracoscopic surgery as this is more time-consuming than open thoracotomy for esophageal operation. Meanwhile, adequate postoperative analgesia management and nutrition supply are essential. In our study, intraoperative intercostal nerve freezing (rehabilitation of the paralysis starts from two weeks after surgery) reduces postoperative pain. The nutrition tube is convenient for early nutritional support. Furthermore, if indicated, postoperative adjuvant therapy should be considered because it does not adversely affect the HRQL.
In summary, this is a detailed report on simultaneous unilateral LVRS, which enables esophageal resection in selected esophageal carcinoma patients with severe emphysema, and which confers improvement of HRQL. By a rigorous preoperative assessment protocol and a combined surgical strategy, including transthoracic en bloc resection of carcinoma, gastroesophagostomy, and unilateral LVRS based on emphysema morphology, resection of the tumor can be achieved with acceptable morbidity and mortality, with improvements in pulmonary function and HRQL. A larger multicenter and randomized study with long-term follow-up is warranted to evaluate further this strategy.
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Acknowledgments
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This study was partially supported by the Science and Technology Committee of Chongqing (20033301) and the Scientific Research Foundation of the Third Military Medical University (2001).
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References
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Abstract
Introduction
