First-line chemotherapy improves the resection rate and long-term survival of locally advanced (T4, any N, M0) squamous cell carcinoma of the thoracic esophagus: final report on 163 consecutive patients with 5-year follow-up.
Journal - Annals of surgery (UNITED STATES )
OBJECTIVE: The objective of this prospective, nonrandomized study was to evaluate the immediate and long-term results of first-line chemotherapy and possible surgery in locally advanced, presumably T4 squamous cell esophageal cancer. SUMMARY BACKGROUND DATA: Locally advanced esophageal cancer is rarely operable and has a dismal prognosis. For this reason, neoadjuvant cytoreductive treatments are more and more frequently used with the aim of downstaging the tumor, increasing the resection rate, and possibly improving survival. Methods: From January 1983 to December 1991, 163 consecutive patients with a presumedly T4 squamous cell carcinoma of the thoracic esophagus (group A) received on average 2.5 cycles (range, 1-6) of first-line chemotherapy with cisplatin (100 mg/m2 on day 1) and 5-fluorouracil (1000 mg/m2 per day, in continuous infusion from day 1 through day 5). Chemotherapy was followed by surgery when adequate downstaging of the tumor was obtained. RESULTS: Chemotherapy toxicity was WHO grade 0 to 2 in 80% of cases, but 3 toxic deaths (1.9%) occurred. Restaging suggested a downstaging of the tumor in 101 of 163 patients (62%), but only 85 patients (52%) underwent resection surgery; it was complete or R0 in 52 (32%) and incomplete or R1-2 in 33. Overall postoperative mortality was 11.7% (10 of 85), morbidity 41% (35 of 85). Complete pathologic response was documented in 6 patients, and significant downstaging to pStage I, IIA, or IIB occurred in 25 more patients. The overall 5-year survival was 11 % (median, 11 months). After resection surgery, the 5-year survival was 20% (median, 16 months); none of the nonresponders survived 4 years after palliative treatments without resection (median survival, 5 months). The 5-year survival rate of the 52 patients undergoing an R0 resection was 29% (median, 23 months). Stratifying patients according to the R, pT, pN, and pStage classifications, the survival curves were comparable to the corresponding data obtained in the 587 group B patients with "potentially resectable" esophageal cancer who underwent surgery alone during the same period. Furthermore, the results were improved in comparison with 136 previous or subsequent patients with a locally advanced tumor who did not undergo neoadjuvant treatments (group C). In these patients, the R0 resection rate was 7%, and the overall 5-year survival was 3% (median, 5 months). CONCLUSION: Although nonrandomized, these results suggest that in locally advanced esophageal carcinoma, first-line chemotherapy increases the resection rate and improves the overall long-term survival. In responding patients who undergo R0 resection surgery, the prognosis depends on the final pathologic stage and not on the initial pretreatment stage.
|ISSN : ||0003-4932|
|Mesh Heading : ||Adult Aged Antineoplastic Combined Chemotherapy Protocols Carcinoma, Squamous Cell Cisplatin Combined Modality Therapy Esophageal Neoplasms Female Fluorouracil Humans Male Middle Aged Neoplasm Staging Palliative Care Prognosis Prospective Studies Survival Analysis Treatment Outcome mortality pathology surgery administration & dosage mortality pathology surgery administration & dosage|
|Mesh Heading Relevant : ||therapeutic use drug therapy drug therapy|
Esophageal achalasia: laparoscopic versus conventional open Heller-Dor operation.
Journal - American journal of surgery (UNITED STATES )
BACKGROUND: The laparoscopic treatment of esophageal achalasia has recently been introduced, and the occasional reports in the literature seem to indicate considerable advantages for patients in terms of surgical trauma, postoperative discomfort, and appearance. As yet, however, no studies have directly analyzed the benefits and shortcomings of the new surgical technique by comparison with the conventional open procedure. The objective of our study was to review recent experience with the laparoscopic Heller-Dor operation (LAP-HD) at the Department of Surgery of Padua University and compare it with the traditional open Heller-Dor procedure (OPEN-HD) to assess early effectiveness in patients with primary esophageal achalasia. PATIENTS AND METHODS: The records of 17 patients who had LAP-HD and a matched group of 17 patients who had OPEN-HD were retrospectively reviewed. The duration of procedures, morbidity, several aspects of the postoperative course, and hospital costs were recorded and compared. Results of clinical follow-up and of manometric and pH-monitoring studies performed 6 months postoperatively were also evaluated in both patient groups. RESULTS: LAP-HD took longer than OPEN-HD (mean 178 versus 125 minutes). There was no mortality or major morbidity in either group. Postoperative pain and ileus and need for IV nutrition lasted a shorter time for LAP-HD patients (P < 0.0001). Consequently, the median postoperative hospital stay and the median interval before returning to normal activity were also shorter (4 and 14 days for the LAP-HD group versus 10 and 30 days for the OPEN-HD group, P < 0.0001). During follow-up, dysphagia recurred in 1 patient of the LAP-HD group and gastroesophageal reflux was registered in 1 patient of the OPEN-HD group. Lower esophageal sphincter pressure decreased significantly after both procedures. CONCLUSIONS: Laparoscopic management of achalasia leads to short-term results comparable to those of the well-established open technique. In view of the less severe surgical trauma and lower hospital cost, the laparoscopic approach is preferable, but long-term studies are needed.
|ISSN : ||0002-9610|
|Mesh Heading : ||Adult Aged Esophageal Achalasia Female Hospital Costs Humans Length of Stay Male Middle Aged Postoperative Complications Retrospective Studies economics|
|Mesh Heading Relevant : ||Laparoscopy surgery|
Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia.
Journal - Surgical endoscopy (GERMANY )
The technique of Heller laparoscopic myotomy with associated Dor anterior fundoplication for the treatment of esophageal achalasia is described. This operation was performed on three patients with clinical, radiologic, and manometric diagnoses of achalasia. Complete relief of dysphagia and modifications of radiological and manometric patterns were achieved in all patients 1 month after surgery. Laparoscopic treatment of achalasia is technically feasible, reduces surgical trauma, and may be considered a valid alternative to open surgery.
|ISSN : ||0930-2794|
|Mesh Heading : ||Adult Cardia Esophageal Achalasia Esophagus Female Gastric Fundus Gastroesophageal Reflux Humans Laparoscopy Male Manometry Middle Aged surgery physiology surgery|
|Mesh Heading Relevant : ||surgery prevention & control methods|